CEolumbta Ittttterstig in % GItig of New fark (Bolide nf Physicians att& §>urar mts jFrotn tl?^ ffitbraru, of OWjurrlylH (ftarmalt, IK. S- $JrsHimiea by; tij? Extern* r intestines, a no1 infrequent occurrence shortly after birth, but of varying degrees of intensity. 36 DISEASES OF THE NEW-BORN INFANT. Symptoms : These gastro-enteric hemorrhages begin usually during the first few days of life. The blood is light colored when passed fresh, or dark when partially digested. Asso- ciated with this hemorrhagic diathesis there may be bleedings under the skin, into the kidneys, or from the vagina or navel, or any of these forms may occur independently. Prognosis : This is serious, but not always fatal, depending on the extent of the bleeding and the vitality of the child. Of late there is some evidence of this condition also being an infection, and entering through the digestive tract. Melaena — treatment : Ergot is the drug recommended, but its efficacy is doubtful. Special attention to the general nutrition is more important, and washing the bowels and stomach with a cleansing astringent solution should be tried. External hemorrhages are treated by local astringents. PEMPHIGUS. This form of bullous eruption is often found on new-born babies. There are two general varieties which are very important to differentiate : First, the form occurring as one of the manifestations of congenital syphilis. The diagnosis rests on the presence of other lesions of the disease, on the presence of bulla? on the palms and soles, and on the history of the parents. Second, there is a form consisting almost entirely of bullce located on various parts of the body, the trunk especially, which seems to be infectious in its nature. This latter form heals well under the application of drying antiseptic powders and cleanliness. GRANULOMA OF UMBILICUS. This is a little lump of granulations left after the slough- ing of the cord, and causing a purulent discharge. At times there may be associated with it a patent urachus leading to the bladder, and hence a few drops of urine may ooze from the navel. UMBILICAL HERNIA— SCLEREMA. 37 Treatment : It is best snipped off by scissors and the base touched with solid nitrate of silver. UMBILICAL HERNIA. This form of rupture usually appears through the opening in the linea alba for the umbilical vessels, and before the vessels, and before the third month of life. It varies in size from a simple convexity of the navel to a tumor large enough to become strangulated. Umbilical hernia — treatment : A mechanical application is usually all that is required, the main care being to prevent the formation of a rupture by wearing an abdominal band during the first four months. If the hernia is present, it is best held back by rubber strapping around the abdomen with an ordinary wooden button over the ring, acting as a pad to prevent protrusion. If this is worn constantly for three to six months, the hernia is regularly cured. MASTITIS. A slight degree of inflammation of the breasts is fairly common in new-born infants of both sexes. Symptoms : These are pain, tenderness, and secretion of small quantities of a milky fluid. Etiology : Traumatism and lack of cleanliness. Treatment : Apply cool, clean compresses, and do not rub nor squeeze the breasts. They may be painted with tincture of belladonna if the inflammation is severe. SCLEREMA. This is a condition of hardening of the skin and subcu- taneous tissues in circumscribed areas, or more generally. It occurs in feeble, badly nourished babies, and is usually fatal. The condition is associated with marked lowering of the cutaneous temperature of the body, and is probably the result c\' the hardening of the subcutaneous fat, duv to this low temperature. There is no pitting on pressure. Treatment: Artificial heal and proper nutrimenl are all we can do tor these cases. Use of the incubator is indicated. 38 DISEASES OF THE NEW-BORN INFANT. HYDROCEPHALUS. Varieties : This condition, of water on the brain, is of two varieties, external and internal. The former, in which the fluid is between the brain and dura mater, in the arachnoid, is quite rare. The latter, with the fluid in the cerebral ventricles, is the common form. The condition may be congenital, or more rarely acquired. Hydrocephalus — etiology : The cause is a mechanical one, producing exudation by pressure, or is due to a chronic in- flammation of the lining membrane of the ventricles. The fluid resembles cerebro-spinal fluid in character, and may be present in quantities up to two quarts or more. The ven- tricles are dilated, and the brain is thinned by pressure, at times to a mere shell. Hydrocephalus — symptoms : The cranial sutures are widely open, even those at the base in marked cases. The fontanelles are open and bulging, the head is enlarged, the forehead is high, and the face seems small. Fluctuation and even translucency can be obtained in marked cases. The head cannot be held up, the mental condition is dull, and there is a general lax state of the muscles, although there may be localized rigidity. Nystagmus, strabismus, and inability to close the upper lid over the eyeball are often present. Con- vulsions may occur. When the head enlarges greatly in utero birth may be im- possible without perforation. Prognosis : Recovery is rare. When the process ceases and the child grows up some mental defect is usually present. Hydrocephalus — treatment : This is very unsatisfactory. Iodide of potassium to cause absorption may be tried. Various operative procedures have been used, and aspiration is probably the best of them ; but all are of doubtful value. MENINGOCELE. Definition: This means a protrusion of some part of the membranes of the brain through a hole in the cranial wall, usually in the location of a suture or fontanelle. The tumor SPINA BIFIDA— HARELIP— CLEFT PALATE. 39 is filled with fluid communicating with that in the brain, and frequently brain-elements are also present. Symptoms : The tumor fluctuates, and is most often seated in the occipital region or at the root of the nose. The child usually has other deformities associated. Meningocele — treatment : Aspiration and the injection of tincture of iodine should first be tried. A plastic operation may be necessary. SPINA BIFIDA. Definition : This is a protrusion of the spinal meninges through the unclosed lamina? of one or more of the vertebrae. In the sac of membranes is usually some portion of the spinal cord. The tumor is covered by skin to near the apex, when the covering becomes parchment-like and easily ulcerates. Spina bifida — symptoms: The tumor is present at birth, and usually is situated in the lumbar region. It fluctuates ; and if the baby cries, as the intracranial pressure is increased it enlarges. If the cord-elements are in the sac, paralysis of legs and of the bladder and rectum is present. The tumor has a tendency to grow, and eventually to ulcerate and burst, when death from infection usually follows. Prognosis : If no paralysis coexist, complete recovery may occur. If paralysis is present, the prognosis is bad. Spina bifida — treatment : Protect the tumor from pressure and trauma. Attend to the rectum and bladder. Aspiration with injection of tincture of iodine is the best operative pro- cedure. A plastic operation may be made. HARELIP CLEFT PALATE. Definition : This abnormality is due to imperfect closure of the maxillary and intermaxillary processes in embryonal life. The fissure may be single or double, and may involve the lip only, or the intermaxillary bono, or the soft or hard palate, or nil. The deformity is unsightly and prevents the infant sucking with ease. Harelip and cleft palate — treatment : H<> a) a is > a> <2 c C.5.C. <2° +J-fi Oh 2 5<£o o ~~' S -C.fi " S ^ a £ < H 10 1 10 10 2 H 15 10 2 2 20 10 2 2 1 25 8 2 si 26 8 2 3* 28 6 2 41 27 6 2 5 30 6 2 5i 33 6 2 6 J 36 6 2 6* 39 6 2 7 42 6 2 71 45 The bottle should be finished in twenty minutes; if not, take it away. Do not warm the remnant and give it again to the baby. By the time the tenth month is finished the average baby begins taking some other form of food as a substitute for one or more of the milk-feedings. In large, robust children somewhat larger quantities than the above averages are better; while in small, delicate chil- dren smaller quantities are prescribed. The stomach un- doubtedly bears some direct ratio in size to the weight of the infant, a point which should be remembered in deciding on the proper quantity of milk to be given a particular infant at a nursing. The regular weekly weighings are here of equal value as in breast-feeding as an index of whether the baby is being properly nourished, 62 FEEDING OF INFANTS. Artificial feeding — care of bottles and nipples : The best bottles are graduated, for ease in measuring the food ; and have wide neck and sloping shoulders, for ease in cleaning. They should be kept scrupulously clean of all evident signs of milk or foreign matter, and before being filled with the milk should be boiled. The best nipples are of black rubber, and large enough to fit over the neck of the bottle and to be turned inside out for cleaning. Those with a rubber tube connecting them to the bottle and running into the milk should not be used, as it is almost impossible to keep them clean. The nipple should be cleaned thoroughly after use, and kept in a borax solution when not in use. The hole in the nipple should be large enough to allow the milk to drop out, but not to run in a stream. Milk laboratories : There have been established in very recent years in many of the large cities of the United States milk laboratories for the exact modification of cows' milk to fit it for infant feeding. At these laboratories the milk is ordered by prescription exactly as drugs are ordered by pre- scription at the apothecary's. Each laboratory is a branch of the original Walker-Gordon laboratory founded in Boston under the supervision of Rotch. Each laboratory has its own herd of cows, which are fed and housed with great hygienic care, and are tested for tuberculosis regularly with tuberculin. The milk is milked and shipped to the labora- tory under aseptic precautions. At the laboratory it is sepa- rated in a centrifugal machine and a 16 per cent, cream obtained. The skimmed milk is used for the proteids, and a 25 per cent, solution of lactose for the sugar. The chemist at the laboratory knows the quantity of proteids and sugar in the 16 per cent, cream, and the quantity of proteids, fat, and sugar in the skimmed milk. With these and the definite solution of milk-sugar he can form modified milk of any definite strength of proteids, fat, and sugar. The physician in ordering the milk knows the requirements of his particular case, and on a prescription-blank prepared for this purpose writes the order for the modified milk to be delivered ready for feeding. ARTIFICIAL FEEDING. 63 The form of prescription-blank is as follows : 1^ Proteids, %. Alkalinity, %. Fat, %. No. of feedings, Sugar, %. Amount at each feeding, 5. Heat to ° F. This being filled out by the physician, as required,, is sent to the laboratory, and each day thereafter, until changed by the physician, a basket of the required number of bottles for twenty-four hours is delivered, each bottle containing the exact quantity of milk of the proper proportions ready for feeding. This should be kept in a cool place, and when a bottle is to be fed it should be warmed to the proper tem- perature for feeding (98° F.), the cotton stopper removed, and the nipple applied. Milk laboratories — their advantages : Food prescribed through the medium of the laboratory has the advantage of accuracy of percentage of constituents, of exact quantity at a feeding, of sterility of the milk, and of ease of changing the percentages gradually and exactly as conditions demand. Further, it is next to impossible for the family to make any change in the quality or quantity of this milk without the knowledge of the physician, a fact of value in dealing with difficult cases of digestion or nutrition. Artificial feeding — home modification : The great disadvan- tage of the milk laboratory is its expense, thus putting such milk out of reach of the masses of the people. With patients who cannot afford this milk, and in localities where there are no laboratories, home modification is our only resource. Modification at home can be done with some little trouble, and although exact percentages cannot, of course, be gotten, com- parative accuracy can be attained and a good substitute for laboratory-milk produced. Frequently, in cases requiring much care in feeding, laboratory-milk may lie used tempo- rarily until improvement begins, when home modification can be substituted, thus using the expensive milk lor a short time only. Home modification — Coit's decimal method: This is the 64 FEEDING OF INFANTS. simplest and easiest worked method of home modification yet suggested. It is based on the metric system, and all the calculations are made in decimals. Three solutions are required : 1. A decimal (10 per cent.) cream, or super-fatted milk for introducing the fat ; 2. A saccharated (10 per cent.) skimmed milk for introducing pro- teids not carried by the cream ; 3. A standard (10 per cent.) sugar solution for introducing the lactose not carried by the cream or the skimmed milk. Solutions 1 and 3 only are required when the proteid percentage is small. As the child grows older, and a higher proteid percentage is necessary, solution 2 is required also. Decimal cream is produced by allowing a quart of ordinary fresh milk from a mixed herd to stand on ice for fifteen hours, and at the end of this time one-fifth of it is taken from the top. This averages 15 per cent, of fat, and loses about \ per cent, each of sugar and proteids. If to this we add one-half its volume of water, a decimal cream is obtained, analyzing: 10 per cent, of fat, 2.33 per cent, of proteids, and 2.66 per cent, of sugar. From this the following for- mulae, showing the amounts of proteids and lactose coincidently introduced with any definite fat-percentage, are easily deduced : Decimal cream in introducing 4 per cent, of fat, also intro- duces 1 per cent, of proteids and 1 per cent, of lactose. Decimal cream in introducing 3.5 per cent, of fat, also introduces .8 per cent, of proteids and .9 per cent, of lactose. Decimal cream in introducing 3 per cent, of fat, also intro- duces .7 per cent, of proteids and .8 per cent, of lactose. Decimal cream in introducing 2.5 per cent, of fat, also introduces .6 per cent, of proteids and .7 per cent, of lac- tose. Decimal cream in introducing 2 per cent, of fat, also introduces .5 per cent, of proteids and .5 per cent, of lactose. Saccharated skimmed milk depends on the fact that skimmed milk analyzes 4 per cent, of proteids and 5 per cent, of sugnr. Five per cent, more of lactose is added simply for convenience of calculation. This means adding one ounce by weight of lactose to twenty ounces of skimmed ARTIFICIAL FEEDING. 65 milk. Our solution then analyzes : proteids 4 per cent, and lactose 10 per cent. If we wish to add 1 per cent, of pro- teids, we use one-fourth of the total food required from solution 2 ; if .5 per cent, of proteids, one-eighth, etc., al- ways remembering that we introduce coincidently two and one-half times as much sugar. The formulae here deduced are also plain : Amount of food in c.c. X| (saccharated skimmed milk) adds proteids .5 per cent, and lactose 1.25 per cent. Amount of food in c.c. X^ (saccharated skimmed milk) adds proteids 1 per cent, and lactose 2.5 per cent. Amount of food in c.c. Xf (saccharated skimmed milk) adds proteids 1.5 per cent, and lactose 3.75 per cent. Amount of food in c.c. X-§- (saccharated skimmed milk) adds proteids 2 per cent, and lactose 5 per cent. Standard sugar solution is prepared by dissolving 10 per cent, of lactose in sterile water, or two ounces by weight in twenty ounces of water. In calculating formulae four facts only are necessary : the quantity of food required ; the percentage-formulte required ; that the standards, except the proteids, are 10 per cent. ; and the quantity of other constituents introduced with the standards. With these facts in mind, all that is necessary further is to reduce the quantity expressed in ounces to cubic centimetres by multiplying by thirty, and to multiply this product by one- tenth of the constituent to be introduced. Examples with and without the introduction of extra proteids will be given : Single feeding : i^oLidf s~^. Quantity, %2. Formula desired, 2. .50 6. 52 x 30 = 60 c.c. x .2= 12 c.c., decimal cream, adds, 2. .50 .50 Leaves, 5M 32 x 30 = 60 c.c. x .55 = 33 c.c. sugar solution, adds, 5.50 Working formula — 12 c.c. decimal cream. 33 c.c. standard sugar solution. 15 c.c. water. 60 c.c. 5— D. C. 66 FEEDING OF INFANTS. One day's food : ^7~? e J ^, nt c ' ° Fat. Proteids. Sugar. Quantity, 535. Formula desired, 4. 1. 6.50 5 35 x 30 = 1050 c.c. x .4 = 420 c.c. decimal cream, adds, 4. 1 . 1 . Leaves, . 5.50 335 x 30 = 1050 c.c. x .55 = 577.50 c.c. sugar solution, adds, 5.50 Working formula — 420 c.c. decimal cream. 577.50 c.c. standard sugar solution. 52.50 c.c. water. Fat. 4. 4. —Per cent. > Proteids. Sugar. 1.50 7. 1. 1. .50 6. .50 1.25 4.75 4.75 1050.00 c.c. One feeding : Quantity, 5*5. Formula desired, ^5 x 30 = 150 c.c. x .4 = 60. c.c. decimal cream, adds, Leaves, 3*5 x 30 = 150 c.c. x -| = 18.75 c.c. skimmed milk, adds, Leaves, 5*5 x 30 =100 c.c. x .475 = 71.75 c.c. sugar solution, adds, Working formula — 60 c.c. decimal cream. 18.75 c.c. saccharated skimmed milk. 71.25 c.c. standard sugar solution. 15000 c.c. Other methods have been introduced by Holt and by West- cott, but require the memorizing of algebraic formulae or of certain combinations, while this method of Coit is the sim- plest of all, really requiring no memorizing, as the whole process can be deduced from the formula? for milk-con- stituents. In cities where milk with certain definite fat-percentages is sold a less exact method of home modification and one not admitting of gradual changes of the constituents, but still of practical use where precision is not specially requisite, is very easy to adopt. The so-called 8 per cent, milk analyzes : proteids, 3.9 per cent. ; fat, 8 per cent. ; sugar, 4.3 per cent. The so-called 12 per cent, milk analyzes : proteids, 3.8 per cent. ; fat, 12 per cent. ; sugar, 4.2 per cent. The changes in the sugar and proteids are so small that they can be almost overlooked, especially as we are not aim- ing at marked exactness. If we wish a milk of medium proteid strength, we choose the 12 per cent, milk, and dilute it with twice its volume of CONDENSED MILK. 67 sterile water. This mixture analyzes: proteids, 1.26 per cent.; fat, 4 per cent.; sugar, 1.4 per cent. If to this we add 5 per cent, of milk-sugar, we have a modified milk of fair average proportions. If we wish a milk of higher proteld strength, we choose the 8 per cent, milk, and dilute it with an equal quantity of sterile water. This mixture analyzes: proteids, 1.95 per cent. ; fat, 4 per cent. ; sugar, 2.15 per cent. Add to this 4 per cent, of milk-sugar, and we get a stronger milk than before. By making slight changes in the proportions of water and these milks we can modify the constituents still further. Here again the addition of sodium bicarbonate, one grain to the ounce, or of lime-water, 1 : 20, is used to alkalinize the milk. Cows' milk — methods of examination : The reaction and specific gravity should be taken and the amount of fat calcu- lated. Holt's cream-tube may be used; but it is not so accurate as in analyzing breast-milk. If used, the cream should be made to rise rapidly by standing the fresh milk on ice for about eight hours. The fat is now about one-fourth of the cream. The best optical test is the Feser lactoscope. It depends on the obscuring of dark lines seen through the milk diluted with more or less water. This test is only approximate, and depends too much on individual experience. The most accurate and quickest method is by means of Babcock's centrifugal machine, in which the milk is mixed with sulphuric acid and then revolved rapidly in the machine, the fat coming to the top of the narrow tube in five minutes and being read off. So far there is no clinical method for estimating the pro- teids, this requiring the work of a skilled chemist. The sugar is fairly uniform at 4.5 per cent. CONDENSED MILK. Condensed milk is made by evaporating fresh milk, which has been sterilized by heat, to about one-quarter its volume. 68 FEEDING OF INFANTS. After this it is preserved by adding about one-third its weight of cane-sugar before being sealed in the cans. In many cities fresh condensed milk, without the addition of sugar, is sold. The following table from Holt gives the composition of condensed milk, and of dilutions of it six, twelve, and eighteen times : Condensed Milk. Diluted 6 times. Diluted 12 times. Diluted 18 times. Fat a f Cane-, 40.44 Su S ar J Milk-! 10.25 • • Salts 6.94 8.43 50.69 1.39 31.30 .99 1.20 7.23 .17 90.49 .53 .65 3.90 .10 94.82 .36 .44 2.67 .07 96.46 Condensed milk as a food : The dilution of twelve parts is nearest that ordinarily used for infant-feeding. A study of its composition as diluted thus shows that the infant is getting almost no fat, a quite low proteid percentage, about the right quantity of sugar, and altogether too little salts. The total solids lack 7 per cent, of what they should be. Such a food is easy of digestion, but decidedly lacking in nutrition. Infants thus fed have as a rule little trouble, if any, with their digestion, and are fat and plump from the sugar, but invariably show signs of more or less rachitis, depending on the length of time the condensed milk is continued. This latter fact seems to depend on the lack of fat and salts, and possibly the proteids also. Further, these children although appearing healthy and well nourished, have very little resist- ing power and readily succumb to acute diseases. The addition of cream to condensed milk, or the coincident use of cod-liver oil, will prevent these bad symptoms from its prolonged use. Condensed milk has some marked advantages as a food : it is sterile, it is very easy and simple to prepare, and it is very cheap. As a temporary food to bridge over sickness, or to use in travelling, it is very valuable ; but it ought never to be used for any length of time unless other food is given with it. INFANT FOODS. 69 INFANT FOODS. Of recent years a large number of proprietary or patent or manufactured foods have been put on the market and widely advertised and largely used for feeding infants. They are mostly dried powders, intended to be dissolved in water for use. It is quite practical to divide them into two distinct classes at once : those free from, and those containing, un- changed starch. In the first class are malted milk and Mellin's food ; in the latter are all the rest, which, having raw starch as a constitu- ent, are manifestly unfit for infant feeding during the first nine or ten months of life. No further attention will be paid to these. Malted milk and Mellin's food contain no ingredient that is objectionable for feeding, but are lacking in one of the import- ant ingredients of milk — the fat, and contain a very large excess of sugar. Mellin's food is recommended to be dis- solved in fresh milk to overcome partially this defect. Analyses of these when dissolved in about the amount of water in milk are as follows : Malted Milk. Mellin's Food. Fat, 39 per cent. .04 per cent. Proteids, . . . 2.28 " 1.50 Sugar, .... 10.18 " 11.56 Salts, 5 " .45 Water, .... 86.65 " 86.45 Looking over these analyses we find about a normal per cent, of proteids, but of vegetable and not animal origin, vir- tually no fat, and a great excess of carbohydrates. As food they often produce, like condensed milk, fat, plump babies ; but these infants again are not resistant and succumb readily to acute diseases. These foods are often well digested, and are useful at times as temporary foods when it is desirable for any reason not t<> use cows' milk; but so many cases of both rick- ets and scurvy have been traced to dried foods as a cause that it is well never to use any of them lor any great length of 70 FEEDING OF INFANTS. time without using simultaneously some fresh food. The addition of cream to either does away with the lack of fat, and adds the element of freshness to the food, but what value the addition of the food to fresh cows' milk has, is as yet unknown. During the second yea?- of life they form a more useful addition to an infant's dietary. Peptonized milk : This is milk in which the proteids are changed to peptones, or, in other words, digested, by the addi- tion and action of pancreatic ferment. The process may be stopped when partially performed, giving a product of which the taste is not objectionable ; or may be carried on to com- plete peptonization, when the product has a very bitter, disa- greeable taste. Method : To peptonize milk partially, add to a pint of fresh cows' milk and four ounces of water five grains of pancreatic extract and fifteen grains of bicarbonate of soda. Allow this to stand at a temperature of 105° to 115° F. for five to twenty minutes, then bring to a boil to kill the ferment, or stand on ice to prevent its further action. If the milk is to be used at once, neither of these latter is necessary. To peptonize the milk completely, allow the process to con- tinue for one to two hours. After this time the addition of acid produces no coagulation. In infant feeding it is better to peptonize a modified than a whole milk. Peptonized milk is frequently very useful in feeding an infant with feeble digestive powers; but it is un- wise to continue its use over too long a period, as then the infant's stomach, being called on to do no work, becomes en- feebled from disuse and gradually unable to perform its proper function. Whey : By coagulating one pint of fresh milk by adding a teaspoonful of essence of pepsin, and allowing this to stand, a solid curd is formed swimming in a liquid — whey. This has the following composition : proteids, .86 per cent. ; fat, .32 per cent. ; sugar, 4.79 per cent. ; salts, .65 per cent. ; water, 93.38 per cent. This at times makes a very valuable food for infants in cases of gastric or intestinal disorder, where the use of milk INFANT FOODS. 71 must for a time be interdicted. Babies like it, it is very easy of digestion, and does not irritate the stomach. A little wine may be added if desired. Egg-water : This is made by mixing thoroughly the white of one egg with six ounces of water and adding a little salt. The addition of a few grains of sugar will make the child take it better, and adds also a food-element. Such a mixture is one of the best foods we have for tem- porarily feeding an infant with digestive disturbances when we wish for a time to stop temporarily all milk food. Beef-juice : Expressed beef-juice is obtained by slightly broiling a piece of lean beef, and then squeezing the juice from it by a lemon-squeezer. One pound of steak yields two or three ounces of juice. This is flavored with salt and given cold or warm. Do not heat enough to coagulate the albumin. This is very nutritious and usually well taken. It may be given at the rate of a tablespoonful three times a day. Scraped beef: This is another valuable and easily digested food. It is prepared by scraping with a dull knife some raw or rarely done lean beef. A tablespoonful of this salted is the amount usually given at a feeding. Broths : These are made by first soaking and then boiling one pound of lean beef, mutton, veal, or chicken, in one pint of water. They do not contain a large quantity of nourish- ment, but do have in them many extractives, and hence are stimulating rather than nutritious. Barley-, oatmeal-, or rice-water : These are made by boiling an ounce of barley, oatmeal, or rice in a quart of water to a pint, and straining before use. Feeding in the second year : During the second year a child should have five meals a day, about 7 and 10 A. M. and 1, 4, and 7 p. m., and nothing between meals. A sample diet is as follows : 7 a. m., a tablespoonful of some well-boiled cereal — wheat, rice, oatmeal, barley, or hominy, with cream and a little sugar if necessary; 10 a.m., a half pint of milk; 1 I". >F., tablespoonful of scraped beef, or soft-boiled egg, piece of dry bread, ;i half pint of milk ; 4 p. m., a half pint of milk; 7 P. m., a tablespoonful of cereal with cream 72 FEEDING OF INFANTS. and sugar; a little orange juice may be given from time to time. Feeding in the third and fourth years : During this time four daily meals are sufficient, at 7 and 10.30 a. m. and 1.30 and 6 p. m., and again nothing should be given between meals. A sample diet is as follows : 7 a. m., orange, cereal with cream and sugar, glass of milk ; 10.30 A. M., glass of milk or cup of broth and slice of stale bread or toast or zwiebach ; 1.30 P. M., piece of meat — steak, chop, or chicken — two vege- tables, potatoes and spinach, rice or bread pudding, or prunes, or apple sauce ; 6 p. m., bread and milk, or milk toast. CHAPTER VI. DISEASES OF THE DIGESTIVE SYSTEM. DISEASES OF THE MOUTH. CATARRHAL STOMATITIS. Definition : This is a simple catarrhal inflammation of the mucous membrane of the mouth, unaccompanied by ulcera- tion. Etiology : Irritants taken into the mouth, as too hot fluids, dirty teething-rings, sugar-teats, or substances the child may pick up from the floor, are active causes. It is at times started by excessive or rough efforts at cleanliness. It com- plicates the infectious diseases, as measles, scarlet fever, diph- theria, or influenza. The eruption of the teeth may at times produce it. Pathology : There is congestion, accompanied by desqua- mation of the buccal epithelium. This is followed by in- creased secretion of the mucous and salivary glands. Catarrhal stomatitis — symptoms : The mucous membrane of the mouth is red, swollen ; at first hot and dry, later bathed in a profuse secretion. The temperature is slightly elevated, the child is restless and fretful. The mouth is tender, as shown by marked evidences of pain when anything is put into the mouth or on examination. In severe eases the child refuses food. At times the inflammation may be severe enough to produce a slightly blood-stained secretion. The tongue is coated on the surface and reddened on the r(\o;c<. The neighboring lymphatic glands may be enlarged and tender. Prognosis: This is good. The duration depends on the cause. Catarrhal stomatitis — treatment: Remove the cause, if it 73 74 DISEASES OF THE DIGESTIVE SYSTEM. can be found. Attend to the general hygiene and diet. Use frequently gentle antiseptic cleansing of the mouth with cold washes of saturated solution of boric acid, or borax 2 per cent. In the severer cases a daily application of a 1 per cent, nitrate of silver solution will hasten the cure. FOLLICULAR STOMATITIS. Synonyms : This is also called aphthous and herpetic stom- atitis from the formation of small vesicles, which later form superficial ulcers. These ulcers at first are discrete, but may coalesce into larger ones. They, however, always remain superficial. Etiology : There seems to be a reflex nervous origin of this form of stomatitis, similar to that seen in connection with herpes elsewhere. Gastro-intestinal disorders and dentition seem to be factors of this sort. The cause is more frequently general than local. Pathology : On the mucous membrane of the cheeks or lips, or the edges of the tongue, but not in the gums, there are present pearl-colored vesicles, about the size of a pin's head, and later small ulcers formed by abrasion of the epithelial covering of these vesicles. More or less catarrhal stomatitis is always associated. Follicular stomatitis — symptoms : The symptoms resemble those of catarrhal stomatitis, but are more marked. There are fever, furred tongue, heat, redness, swelling, pain, and in- creased secretion. The mouth presents the appearance de- scribed of vesicles and superficial ulcers, and in addition general redness. The lymphatic glands of the neck are swollen and tender. Prognosis : This is good. It is a self-limited disease ; but if improperly managed, may go on to ulcerative stomatitis. Follicular stomatitis — treatment : Regulate the diet and general condition of the patient. Bathe the mouth frequently with solution of potassium permanganate, grains three to the ounce. Chlorate of potassium given internally, grains two every three hours, well diluted, has repute with some. Solid silver nitrate may be applied to the ulcers. ULCERATIVE STOMATITIS. 75 ULCERATIVE STOMATITIS. Definition : This form of stomatitis is only seen with the presence of teeth, and consists in an ulcerative process begin- ning in the mucous membrane of the gums around the teeth, and spreading from this point to the rest of the mouth. It is accompanied by a peculiar fetor of the breath. Etiology : Overuse of mercury, decayed teeth, improper food, bad hygiene, exhausting diseases, and scurvy are fre- quent causes. It is often a sequel of the infectious diseases. Pathology : The process begins around a tooth and involves the gum and the contiguous surfaces of the lips, cheek, and edges of the tongue. The mucous membrane is much swollen and of a deep livid hue. The ulceration may extend deeply to the periosteum and cause necrosis of the maxilla. The ulcerative process never extends beyond the mouth. Ulcerative stomatitis — symptoms : These are pain, fretful- ness, change in disposition, crying, and wakefulness. There is an increase in the buccal secretions, to which there is a foetid odor. The mouth and gums bleed frequently. On in- spection the gums are swollen, spongy, livid, and bleed easily. A line of ulceration, with a white necrotic appearance, will be found around one or more of the teeth. In severe cases the teeth may be loosened and sequestra of bone found. The submaxillary lymphatic glands are badly swollen and painful. The tongue is swollen, thickly coated, and shows the indenta- tion of the teeth on the edges. Prognosis: If left to itself, the disease progressively in- creases, the ulceration extending further and further until a frightful condition of the mouth results. Gangrenous stoma- titis may supervene. If properly treated in the early stages, a rapid cure results; and even when further advanced treat- ment is very efficacious. Ulcerative stomatitis — treatment : First remove the cause by stopping the use of mercury, improving the hygienic sur- roundings, and treating the scorbutus if present. Keep the mouth scrupulously clean by frequent washings with peroxide of hydrogen or permanganate of potassium. If there is much bleeding, a solution of alum is useful, [nternally, chlorate of 76 DISEASES OF THE DIGESTIVE SYSTEM. potassium is almost a specific, being excreted after absorption by the buccal mucous membrane. It is best given at the rate of two grains, largely diluted, every two hours. If under this form of treatment the ulcers do not heal, some of the teeth may need extracting, as a sequestrum is probably present. The ulcers may heal faster under daily pencillings with silver nitrate in stick-form. THRUSH. Etiology : This form of stomatitis is caused by the presence and growth in the mouth of a fungus called the saccharomyces albicans. It is a parasite of the class of yeast fungus. The fungus is the only cause, but it never grows except on a previously unhealthy mucous membrane. It develops spe- cially in feeble, badly nourished, and marasmic infants, and in those suffering from gastro-intestinal diseases. The use of improper food, uncleanliness of the mouth, fermentation of particles of food, or a previous catarrhal stomatitis favors its growth. Under favorable conditions the fungus will grow on any of the mucous membranes of the body. The spores are conveyed to the mouth usually by dirty nipples, sugar-teats, and such like, but may spread through the atmosphere. Pathology : The parasite consists, microscopically, of long threads (the mycelium) interwoven together, and, in their " meshes," oval bodies (the spores). The fungus lodges on the mucous membrane of the mouth and grows in little clumps of white between the epithelial cells, thence spreading to the surface. These white tufts may be scattered uniformly all through the mouth, and many may coalesce into larger lumps. They seldom produce pus. The mucous membrane of the mouth is the seat of catarrhal stomatitis. Thrush — symptoms : The subjective symptoms are very slight. The appearance of the mouth is very characteristic. The whole mouth, or only parts, is studded with little white feathery spots, seeming to rise above the surface of the mucous membrane, and which do not rub off with ease, but leave a bleeding spot behind. They appear first on the tongue and cheeks, but may spread to the lips, palate, tonsil, and pharynx, and at times to the oesophagus and stomach. GANGRENOUS STOMATITIS. 77 Each spot has the appearance of a little lump of coagulated milk, but is differentiated from this by the difficulty of removal. These cases usually have acrid, irritating stools with erythema of the buttocks. Prognosis : It is not in itself a serious disease, but so often appears in a much debilitated child that it is associated in the lay mind with severe cases. If properly treated in a child strong enough to withstand the original disease, thrush is always recovered from. Treatment : Thrush may almost always be prevented by thorough cleanliness of nipples, bottles, and mouth. If present, the disease is treated by the use of an antiseptic mouth-wash, the best of which is a solution of boric acid in glycerin, grains ten to. the ounce, applied four times a day with a soft rag or camel's-hair brush. Special attention should be paid to remedy any underlying condition. GANGRENOUS STOMATITIS. Definition : This disease is also called noma and cancrum oris, and consists essentially of a gangrene beginning in the mucous membrane of the gums, cheeks, or lips, spreading rapidly, and destroying all the tissue it attacks. Etiology : It is usually a secondary disease following measles, whooping-cough, chronic intestinal catarrhs, or general sepsis. It seems never to develop in previously healthy children. At times it supervenes on ulcerative stomatitis. Streptococci are found in most of the cases, but no specific germ has as yet been isolated. Pathology : The mucous membrane first presents a brawny induration, followed by a sloughing ulcer. This induration extending to the skin gives rise to a livid, glazed appearance in the integument, which later becomes black, and perforation of the cheek follows. The sloughing process may extend and involve the whole side of the face and the bones of the jaw. The vessels become thrombosed and hemorrhage is rare. A line of demarcation rarely forms, but the gangrene steadily spreads till death ensues. Symptoms : The constitutional symptoms of gangrenous 78 DISEASES OF THE DIGESTIVE SYSTEM. stomatitis are those of great prostration and sepsis, being more or less marked at the beginning, but rapidly increasing in severity as the disease progresses. The temperature runs from 102° to 105° F. The pulse is rapid and feeble, the appetite is lost, and a severe diarrhoea is frequent. Septic pneumonia frequently supervenes. Locally, in the early stages there is moderate pain, but it is never very marked. The typical appearance of the ulcera- tion spreads in all directions from its starting-point, and a gangrenous odor is present in the breath. The secretions of the mouth are increased in quantity, and soon become thick and sanious. The gangrene may involve the whole cheek, the eyelids, and even the eye. The appearance is one of the most repulsive ever seen. The duration of the disease is one to two weeks. Prognosis : This is very bad, fully three-fourth's of the cases dying. Gangrenous stomatitis — treatment : Support the patient's strength with nutritious food, stimulants, and tonics. Locally, the necrotic area, as soon as a diagnosis is made, should be freely destroyed, under the influence of an anesthetic, by the actual cautery. The cauterization should go well beyond the diseased into the healthy tissue. If new gangrenous spots appear, these should be treated in the same way. The wound should be dressed afterward with strong antiseptics and the mouth kept very clean by the use of peroxide of hydrogen. CROUPOUS STOMATITIS. Definition : This is the form of stomatitis in which the buccal mucous membrane undergoes an inflammatory process accompanied by the production of a false membrane. It is also called diphtheritic stomatitis. Etiology: Intense chemical irritants may rarely form a false membrane ; but the large majority of the cases are due to the growth on the buccal mucous membrane of the Klebs- Loffler bacillus. In the mouth it is almost invariably second- ary to the presence of diphtheritic membranes elsewhere, as ADHMSIA LINGUjE—RANULA. 79 on the tonsils or pharynx ; but the month may possibly be the primary seat. Pathology : There is a stomatitis affecting the lips and cheeks which is accompanied by the growth on these inflamed parts of a pseudo-membrane, which is firmly adherent to its seat. The symptoms of croupous stomatitis are usually those of the primary diphtheria, with the addition of sore, tender mouth. Diphtheria of the mouth always belongs to the severe cases of the disease. Croupous stomatitis — treatment : The primary diphtheria is to be treated as always, and the mouth by frequent and gentle cleansing with a saturated solution of boric acid. The mem- brane should not be forcibly removed. ADHMSIA LINGILE. This condition, commonly known as tongue-tie, consists of an abnormally short frsenum. It may interfere with suckling, and later may possibly affect the speech, but is not nearly so important as is commonly supposed. Treatment : Strip the frsenum near its attachment to the tongue with a pair of scissors, and then tear the cut deeper by a dull instrument, as the finger-nail. RANULA. Definition : This is a cyst, forming in the floor of the mouth on either side of the frsenum. It varies in size, but may be- come large enough to interfere seriously with the uses of the njouth. It is clue to occlusion of a mucous duct, or the duct of the sublingual gland. The cyst may be simple or multi- locular. Symptoms: This growth is painless, fluctuates, and is the color of the buccal mucous membrane. The fluid it contains is a glairy mucus. Ranula — treatment— Snip off the top of the cyst-wall, evacuate the fluid, and cauterize the interior of the sac with solid nitrate of silver or iodine. 80 DISEASES OF THE DIGESTIVE SYSTEM. ALVEOLAE ABSCESS. Definition : This is fairly common in children with teeth allowed to be kept in a state of decay or uncleanliness. It consists of an inflammation going on to the production of pus beginning around the roots of a tooth. The periosteum of the jaw may be involved, and, if neglected, necrosis of the jaw may result. Alveolar abscess — symptoms : There is pain in the affected part, with fever and other constitutional symptoms. The face is always badly swollen on the outside, and in the mouth is a similar condition. After the formation of pus fluctua- tion can be made out within the mouth. The pus may per- forate into the antrum, if in the upper jaw, or will discharge through the buccal mucous membrane or the skin, if left alone. Alveolar abscess — treatment : The teeth should be kept clean by the use of a tooth-brush, and decayed fangs should be extracted. If the abscess begins to form, it should be hastened by the use of hot applications in the form of poul- tices externally and hot washes in the mouth. As soon as pus is detected the abscess should be lanced from within the mouth (to prevent cutaneous scars), the pus evacuated, and the cavity well drained and packed. DISEASES OF THE THROAT. ACUTE PHARYNGITIS. Pathology : In this condition the whole pharynx and the tonsils are inflamed and red. It may be, and frequently is, a primary disease ; or it may be part of one of the infections, as scarlet fever, measles, diphtheria, or influenza. Etiology : It is most commonly caused by exposure to cold, but probably behind this is some bacterial invasion. The disease at times appears infectious. A rheumatic diathesis is frequently present. Certain individuals present a marked predisposition and have recurrent attacks. The symptoms of acute pharyngitis are pain in swallow- ing and dryness in the throat, with later an increase in the RETRO-PHARYNGEAL ABSCESS. 81 secretion. There is frequently an irritating purposeless cough. On examination the soft palate, uvula, tonsils, and pharynx are seen to be red and inflamed. The posterior sur- face of the soft palate is often attacked early and the whole naso-pharynx involved. The constitutional symptoms may be marked, with rise of temperature at times to 103 G F., and its accompanying symp- toms. Vomiting may be present. Diagnosis : This is easy from the inspection of the throat ; but we should never forget the possibility of the pharyngitis being the initial lesion of one of the infectious diseases. Acute pharyngitis — treatment : The bowels should be opened by fractional doses of calomel frequently repeated. Small doses of phenacetin given every three hours will re- duce the fever, ease the pain, and give general comfort to the patient. Locally, the throat should at short intervals be sprayed or swabbed, or the naso-pharynx washed out, according as the child is old enough to allow one or the other method of appli- cation. Some mild alkaline wash, such as Seder's solution, seems the best. Chronic pharyngitis : This is a rare condition in childhood, but may develop as the result of frequent attacks of the acute form. One of its common results is to produce an elonga- tion of the uvula. With this is associated an harassing cough, from the uvula tickling the base of the tongue by its con- stant presence. Treatment: Astringent local applications are useful in this condition, but amputation of the tip of the uvula may be required for cure. RETRO-PHARYNGEAL ABSCESS. Definition: In this disease a collection of pus makes its appearance in the posterior pharyngeal wall. In a general way there are two sources of this pus: either from a suppu- rative inflammation of the connective tissue, or of a lymphatic gland, of the posterior pharyngeal wall ; or from caries of the cervical vertebras. What is ordinarily understood by retro- 6— D. c. 82 DISEASES OF THE DIGESTIVE SYSTEM. pharyngeal abscess is the former variety — i. e., that without disease of the bone. Retro-pharyngeal abscess — etiology : The cause usually lies in an infection of the lymphatics from a precedent inflamma- tion of the nose or pharynx. The disease is regularly one of infancy, and infants are particularly prone to adenitis. The disease is most frequent in winter and spring, when diseases of the nose and throat are commonest. It may follow an attack of influenza, or more rarely scarlatina or measles. It is usually seen only in delicate children. Pathology: The simple form is primarily a suppurative in- flammation of one or more of the lymphatic glands lying just in front of the cervical vertebrae. The inflammation spreads to and involves the cellular tissue. Some few cases never go on to the formation of pus. In the form due to cervical caries a much more serious condition, with broken- down bone, is present. Retro-pharyngeal abscess — symptoms : The three symptoms of most importance are stiff neck, dysphagia, and dyspnoea. This dyspnoea may come on in sudden attacks and appear quite alarming. The temperature is raised to 102° F., and the child is usually sick for five or six days before the abscess develops. The diagnosis is made by a careful ocular and digital ex- amination. A fluctuating swelling is found directly in front of the bodies of the vertebras, but a little to one or the other side. The mucous membrane of the soft palate is usually red and swollen. There may be a tumor at the angle of the jaw r on the same side. Prognosis : The abscess, if left to itself, usually ruptures in the course of a week or two. The pus may be swallowed or expectorated. If rupture does not occur, the pus may burrow in the neck. Fatal cases may occur from stoppage of the respiration or the bursting of the abscess into the larynx. If properly treated, rapid recovery is the rule. The cases due to spinal caries, of course, take their progno- sis from this, the underlying factor. Retro-pharyngeal abscess — treatment : The formation of pus should be hurried by hot applications to the neck. As soon ADENOIDS OF THE NASO-PHARYNX. 83 as fluctuation is made out, prompt incision should be made. The child should be upright, and the abscess freely opened at its lowest point, the child's head being bent forward quickly to allow escape of the pus. The opening may be made by a protected knife, a pair of dressing-forceps, or the finger-nail. After-treatment is usually unnecessary. ADENOIDS OF THE NASO-PHARYNX. Definition : This is a hypertrophy of the so-called third or pharyngeal tonsil, a mass of adenoid tissue located in the naso-pharynx, just below the basilar portion of the occipital bone. Etiology : There seems to be a predisposition in some chil- dren to overgrowth of the lymphatic structures of the body. The diathesis is congenital, but the disease seems to be ac- quired. Delicate children are most frequently affected. Damp, changeable climates seem to predispose to it. It may follow attacks of the infectious diseases. Pathology : The growths are a simple hypertrophy of the natural tissue of the third tonsil due to folding in and over of the mucous membrane covering it. They are attached to the bone above and behind. The symptoms of adenoids are mainly the result of the accompanying chronic naso-pharyngeal catarrh, plus the mechanical obstruction of the growths to the breathing. The catarrh is evidenced mainly by a persistent discharge from the nose, growing better or worse with changes in the weather, but always persisting. There is great difficulty in blowing the nose and clearing out this discharge. Attacks of otitis are frequent and recurrent. Sleeping is interfered with and nervous symptoms are prominent, such as dreams, night- terrors, and somnambulism. The obstructive symptoms are mouth-breathing, snoring during sleep, a nasal voice, and deafness from occlusion of the Eustachian tubes. The persistent mouth-breathing pro- duces a typical shape of the face, with a pinched nose, and deflected septum, a prominent pointed upper jaw with mis- placed teeth; a high-peaked hard palate, and a deficient 84 DISEASES OF THE DIGESTIVE SYSTEM. lower jaw. The whole expression of the face is characteris- tic and very stupid. In fact, these children are stupid, their mental condition usually being below par. The chest is apt to be deformed or pigeon-breasted. Adenoids — prognosis: They have a tendency to increase till puberty, when a spontaneous atrophy seems to occur, the enlargement of the naso-pharyngeal space itself giving in- creased room for them. The deformities produced and the evils done by their presence, however, never disappear, but remain as a handicap for life. Patients with adenoids are prone to diphtheria, and have more severe attacks of it than normal children. The same is true of others of the infectious diseases. Adenoids — treatment : The only adequate treatment is operative removal of the growths. This is best done under full anaesthesia with the use of a mouth-jag, using the adenoid forceps first, and cleaning out the ragged remnants afterward by a Gottstein's curette. The head can be held so as to pre- vent blood from running down the trachea. There is no especial after-treatment, and the results of the operation are very brilliant. Recurrence is rare. The syrup of the iodide of iron may be given to build up the health afterward. ACUTE FOLLICULAR TONSILLITIS. Definition : This is the form of acute inflammation attack- ing and confined to the tonsils proper. It is called, wrongly, diphtheritic sore throat. Acute follicular tonsillitis — etiology : It is undoubtedly an infectious disease due to the presence in the tonsillar crypts of some form of streptococcus or staphylococcus. There is a very marked predisposition in some children to attacks of this disease. A rheumatic diathesis seems a predisposing factor. Those with chronic hypertrophy of the tonsils are often the victims. " Catching cold " is often the exciting cause. Pathology : The infection begins in the mucous membrane at the bottom of the tonsillar crypts. The crypt is soon filled with a whitish plug of pus, fibrin, and epithelium, which pro- PERITONSILLAR ABSCESS. 85 jects from the surface of the tonsil. The separate crypts being tilled the same way, give a white spotted appearance to the whole tonsil. The contents of one or more crypts may coalesce. The whole tonsil is much swelled and inflamed. The disease is bilateral. Acute follicular tonsillitis — symptoms : The disease begins suddenly with chilly sensations, a rapid rise of temperature to 102° to 104° F., and marked general malaise with head- ache and backache. Pain in the throat of quite a severe type follows, made worse by swallowing. The severe symp- toms last three or four days. The glands at the angle of the jaw are inflamed, swollen, and tender. On inspection, at first the tonsils appear red and swollen, but the characteristic white spots soon make their appearance. In differentiating them from diphtheria it is to be observed that these spots can be easily rubbed off with a swab, and when removed leave no bleeding spot behind as is the case in diphtheria. Tonsillitis is also much more sudden in its onset. The exudate in tonsillitis never appears elsewhere than on the tonsils. It may be necessary to make a culture to prove the presence or absence of Klebs-Loffler bacilli. Prognosis : This is good, as recovery occurs even without treatment. Acute follicular tonsillitis — treatment : A combination of small doses of phenacetin and sodium salicylate, five grains of each given every four hours, has a very comfortable effect, alleviating the fever and many of the unpleasant constitu- tional symptoms. Locally, a gargle or spray or swabbing with Dobell's or Seder's solution hurries the cure of the disease PERITONSILLAR ABSCESS. Synonyms : ( )ther names for this condition are phlegmonous, or suppurative tonsillitis and quinsy. Peritonsillar abscess — etiology : The direct cause is infection of the connective tissue in the neighborhood of the tonsil by pus-producing micro-organisms. Predisposing causes are chronic pharyngitis and hypertrophy of the tonsils. Certain individuals have a marked tendency to recurrent attacks. 86 DISEASES OF THE DIGESTIVE SYSTEM. Pathology : The peritonsillar connective tissue, and not the tonsil itself, is the part in which the lesion is located. The abscess is unilateral and tends to point through the anterior faucial pillar a little above the tonsil. Peritonsillar abscess — symptoms : The disease begins abruptly with somewhat the same general symptoms as follic- ular tonsillitis, but less marked : chilly sensations, fever, headache, and backache. The local symptoms are more pro- nounced, the pain in the throat being very severe and shoot- ing into the ear. Swallowing and moving the jaw for any purpose make the pain intense. After a few days the patient presents quite a characteristic appearance with immovable jaw, slightly opened mouth, thick nasal voice, and mucus and saliva drooling from the lips. The neck on the same side is quite swollen. On inspection the region around one tonsil is badly swollen and oedematous. The uvula is swollen and pushed to the opposite side. It seems impossible for the patient to open the mouth wide. On palpation a soft fluctuating swelling is detected just above and in front of the tonsil. Prognosis : Recovery is the rule. Death may occur from rupture of the abscess into the larynx. Peritonsillar abscess — treatment : The disease may possibly be aborted in the first stages by heroic dosing with sodium salicylate after the use of a saline purge, and local appli- cations of strong solutions of nitrate of silver. There is, however, always the question of doubt as to the diagnosis in the beginning. If we decide that the disease is going on to the formation of pus, the process may be hastened by hot applications to the neck and the frequent inhalation of steam by the mouth. These applications likewise give some relief to the pain. As soon as pus shows its presence a free incision should be made with a pointed bistoury in the fluctuating point. This will usually be above the tonsil at about the juncture of the hard and soft palates. If pus is well localized, the relief is imme- diate. After-treatment consists in washing out the sac and keeping the exit open. CHRONIC TONSILLITIS. 87 CHRONIC TONSILLITIS. Hypertrophy of the tonsils is the better name for this con- dition, as the essential lesion is a marked increase in the size of the glands. Etiology : This condition is part of the same so-called "lymphatism" as is seen in adenoids, a constitutional ten- dency to hypertrophy of lymphatic structures. They begin to enlarge very early in life, and are at times even congenital. Frequent acute attacks and climatic conditions probably pre- dispose. Pathology: There is a hyperplasia of both the connective- tissue stroma and of the lymphoid tissue of the tonsils. Either may predominate, producing a harder or softer variety of hypertrophy. Chronic tonsillitis — symptoms : Hypertrophied tonsils so frequently coexist with adenoids of the naso-pharynx that the symptoms of the two conditions are blended. They cause mechanical obstruction to nasal breathing, with snoring and nasal voice, and to swallowing. They predispose to attacks of acute tonsillitis. Deafness, mouth-breathing and its concomitants — change in the shape of the maxillary bones — follow. The blood being imperfectly aerated, these chil- dren suffer from disturbed sleep and night-terrors. Both the tonsils are affected, and remain in the same condition up to puberty, when they may shrink some, especially if they are of the soft variety. The enlargement of the throat at this times also gives them more room, and the local symptoms after this are less troublesome. The tonsils appear prominent, and project toward the median line, at times almost touching each other. Their sur- faces are full of deep excavations, the natural crypts. Chronic tonsillitis — treatment : Local applications and drugs arc of no value in these cases. The only satisfactory treat- ment is their surgical removal. This is best done by one of the instruments specially con- structed lor this purpose, of which MaeKenzie's is the least complicated. The tonsils can be removed quickly with very little pain, and the hemorrhage afterward is trifling in ehil- 88 DISEASES OF THE DIGESTIVE SYSTEM. dren. It is, however, always well to have some means for stopping bleeding at hand, as a few rare cases are reported where such means was needed. Styptics or digital compres- sion may be tried. If enough of the tonsil is removed, recur- rence is rare. If operation cannot be done, local astringents may be tried, and syrup of the iodide of iron given internally. After the operation a gray appearance is frequently seen on the stump, which may arouse suspicion of diphtheria, but is only the coating of the cut surface. ACUTE OESOPHAGITIS. Etiology : Inflammation of the mucous membrane of the oesophagus is most often caused by the passage of some hard substance, as metal or bone ; or some hot or corroding chemi- cal, as too hot food, or acid, or lye. Symptoms : Burning pain in the oesophagus, neck, back, and pericardium, with painful swallowing, intense thirst, retching, and vomiting are the regular symptoms. Ulcera- tions are almost always formed, and in three to six months symptoms of oesophageal stricture, due to cicatrization and cauterization of these ulcers, follow. Acute oesophagitis — treatment : This depends on the cause. If & foreign body is lodged in the gullet, attempts to remove it should be made. If a corrosive fluid has been swallowed, the proper antidotes should be given, followed by oils and demulcent drinks. Opium is necessary to relieve the pain. If stricture is forming, regular passage of oesophageal sounds should be practised. If stricture has formed, the treatment is surgical. CONGENITAL FISTULA OF THE NECK. In embryonic life the openings between the second and third branchial clefts may fail to close, leaving a small or large opening in the neck just above and a little outside of the sterno-clavicular joint. These openings usually com- municate with the oesophagus. They are not serious, but SWALLOWING FOREIGN BODIES 89 may be troublesome from being occasionally occluded, the secretion being dammed up behind and forming a cystic tumor. The discharge from the sinus may be bothersome. Treatment : This is entirely surgical. RETROESOPHAGEAL ABSCESS. Definition : This condition, as its name implies, is a collec- tion of pus behind the oesophagus and in front of the bodies of the lower cervical or upper dorsal vertebrae, lower than the retro-pharyngeal abscess. Etiology : There are three forms of this abscess : that due to simple suppuration of the lymph-glands in the posterior mediastinum ; that due to tubercular inflammation and break- ing down of these same glands ; and that due to caries of the body of one or more of the dorsal vertebras. Retro-oesophageal abscess — symptoms : These are vague, and a diagnosis is very difficult to make. The main symptoms seem to be dependent on irritation of one or the other of the pneumogastric nerves, which lie next to the oesophagus. Sudden attacks of dyspnoea, or of inhibition of the heart's action, are the commonest reported symptoms. Dysphagia seems not to be marked. Prognosis : This is bad, as. diagnosis is next to impossible, and hence treatment is out of the question. If the abscess ruptures spontaneously into the oesophagus, recovery may follow. SWALLOWING FOREIGN BODIES. Children are frequently brought to a physician with the story of having swallowed a foreign body of some kind, as coins, buttons, jackstones, tacks, pins, pieces of bone, and various other objects. Always investigate the history care- fully, to be sure of the fact. As a rule, these bodies pass into the stomach and through the intestines, and are dis- charged from the rectum without causing any disturbance. At times they lodge in the pharynx, or in the oesophagus, and may cause unpleasant symptoms from their presence. These symptoms are pain, dysphagia, retching, and cough. Some blood-stained mucus may be brought up. 90 DISEASES OF THE DIGESTIVE SYSTEM. The pharynx should be carefully inspected and palpated by the linger, and if the body can be found it should be re- moved. If it is lodged in the oesophagus, attempts to remove it with a probang or to push it down with a sound may be made. CEsophagotomy may be necessary. If the foreign body has passed into the stomach, do not give a purge or emetic, but give the child a good meal of potatoes or bread, to form a protective coating for the body during its passage through the intestines. DISEASES OF THE STOMACH. ACUTE GASTRIC INDIGESTION. Definition : In this condition the stomach is unable, through functional causes only, to perform temporarily its digestive duties. Etiology : The main causes are improper food, the too early use of solid food in infants, sudden weaning, and overload- ing the stomach. In other words, the use of food of an indi- gestible character for a child of the age to whom it is given. The stomach may itself be at fault in certain cases through general causes, as fatigue, or general depression, or excessive heat. Pathology : Two conditions may be present, a decrease in the gastric juice and a lack of muscular peristalsis. Inflam- mation is absent. Acute gastric indigestion — symptoms : The food remains in the stomach longer than normal, and excites pain in the epi- gastrium, nausea, vomiting, and a marked malaise. The ap- petite is lost, the patient has attacks of faintness, and a good deal of headache. After the stomach is completely emptied the symptoms, as a rule, rapidly disappear. In some cases there is fever up to 102° F., and symptoms of toxaemia, dul- ness and stupor ; or the opposite, restlessness and even con- vulsions, may develop. The pulse becomes weak, and pros- tration is pronounced. There is distention of the abdomen, and later usually diarrhoea. The shortness of the attack and ACUTE GASTRITIS. 91 the termination of the symptoms after thorough vomiting, differentiate the condition from gastritis. Acute gastric indigestion — treatment : If the stomach has not been thoroughly emptied, it should be cleaned out com- pletely, and this is best done by means of the stomach-tube. If unable to use lavage, large quantities of lukewarm water may be given, or an emetic, as ipecac. If vomiting is persis- tent, cracked ice, or lime-water, or soda-water, given in small quantities, will usually check it. Fractional doses of calo- mel, grain ^ , every hour for ten doses, will tend to quiet the stomach and to remove by the bowels any indigestible matter left behind. After cleaning the stomach stop completely the food which has been used, and, if possible, stop all food for some hours, giving the stomach absolute rest. If the demand for food is marked, egg-water mixture or whey given in small quantities is the best form of food for a day or two, when the original food may be gradually resumed. During the continuance of the pain hot applications to the epigastrium are very soothing. ACUTE GASTRITIS. Definition : Here there is an inflammatory change in the mucous membrane lining the stomach. Etiology : The causes are the same as of gastric indiges- tion : indigestible foods and the swallowing of irritants, drugs, and chemicals. Pathology : The gastric mucous membrane is in a condition of catarrhal inflammation, with congestion and swelling, and exudation of cells into the stroma, accompanied by marked increase of the mucous secretion of the membrane, and des- quamation of the epithelium. The changes are fairly well distributed throughout the stomach. The organ is full of undigested food and mucus. There may be slight blood ex- travasations. In rare cases a false membrane may form on the mucous membrane. In cases due to swallowing of chemi- cals ulcers may be found scattered irregularly around the organ, but usually on the greater curvature. Acute gastritis — symptoms: The disease begins, as does 92 DISEASES OF THE DIGESTIVE SYSTEM. gastric indigestion, with pain in the epigastrium, nausea, vom- iting, headache, faintness, loss of appetite, coated tongue, prostration, and fever. But these symptoms, instead of dis- appearing after the stomach has been emptied, persist, and vomiting of mucus continues even after all the food has been ejected. The temperature continues somewhat raised and thirst is very prominent. The pulse and respiration are like- wise quickened. Intestinal symptoms very commonly coexist or follow. The attacks last somewhat less than a week. Prognosis: Simple acute gastritis in a previously strong child is usually recovered from. In delicate children, or if improperly managed, serious results may follow, or the disease may be the forerunner of a severe gastro-enteritis. We must never forget that the attack may be the beginning of one of the infectious diseases, more particularly scarlatina. Acute gastritis — treatment : The stomach must be com- pletely emptied of any irritants, and this is best done by lavage. Warm water or ipecac may be used as emetics if lavage is unadvisable. Afterward give calomel, grain -^ every hour for ten doses, to remove any remaining portion of the irritant. Cracked ice, or bicarbonate of sodium, or bismuth will usually check the vomiting if it becomes per- sistent. Hot applications to the epigastrium are helpful. The dietetic treatment is very important, with complete stoppage of all food for as long as possible, and when begun again using small amounts of something very bland and easy to digest, as egg- water or whey. Gradual return to regular food should be made after the symptoms have subsided. If the gastritis is due to swallowing some chemical, the proper antidote should be given, and followed by demulcents. Opium may be needed for the pain. GASTRO-DUODENITIS. Definition : This is an acute inflammation of the stomach and duodenum, with an extension of the inflammatory proc- ess into the common bile-duct and resultant obstructive jaundice. Another name for it is catarrhal jaundice. Etiology : The causes are not well understood, but prob- CHRONIC GASTRITIS. 93 ably they are somewhat similar to those of acute gastritis — the use of improper food. There may be an infectious element. Pathology : T here is inflammation, with congestion, swelling, increased secretion, and desquamation of the epithelium from the mucous membrane of the pyloric end of the stomach, of the duodenum, and of the common bile-duct. The swollen mucous membrane of the duct causes its occlu- sion and subsequent obstruction to the blow of bile. Castro-duodenitis — symptoms : The attack begins rather suddenly, with pain in the neighborhood of the duodenum, nausea, vomiting, constipation, fever, rapid pulse, and general malaise. After a few days the typical symptom of the disease, jaundice, makes its appearance first in the conjunctivas, then in the skin. The urine will contain bile and the faeces be clay colored. The appetite is lost and the tongue thickly coated. After the jaundice has been present a short time the skin becomes itchy, and the pulse may be slow. The patient is languid, and good for nothing. The liver may show slight enlargement and some tenderness. Prognosis : The disease lasts about two weeks, and recovery is the regular outcome. In the treatment of gastro-duodenitis the diet should be restricted to milk or scraped meat, the fats and starches being specially excluded. Water should be given freely, and the bowels kept loose by fractional doses of calomel given on alter- nate days, and followed by some saline laxative, as phosphate of sodium. Hot applications to the epigastrium will relieve the pain. Alkalies or lavage may be needed to stop the vomiting in the early stages. CHRONIC GASTRITIS. Definition : This: is a chronic inflammatory change in the gastric mucous membrane, and a consequent interference, more or less marked, with the functions of the stomach. Etiology : The causes are the same as those producing acute gastritis, only being prolonged in their action. The use of improper, badly prepared, or indigestible food ; improper 94 DISEASES OF THE DIGESTIVE SYSTEM. quantities at a feeding; irregularity in feeding; rapid eating or imperfect mastication, if continued long enough, will pro- duce this condition. These causes apply equally to infants as to children on solid food. Bad teeth are a potent cause. Frequent attacks of acute gastritis predispose to the chronic form. The presence of anaemia, rachitis, tubercu- losis, syphilis, or malnutrition is also a predisposing factor. Chronic heart, liver, or kidney diseases, by producing venous engorgement, likewise are predisposing agents. Pathology : The lesions are in the mucous membrane, con- sisting of degeneration of the epithelium of the gastric tubules and increased production of mucus. If the process advances further, there is round-cell infiltration with produc- tion of new connective tissue, and consequent destruction of the glandular structure. In old cases the stomach becomes dilated and the mucous membrane is covered with a large quantity of sticky mucus. The symptoms of chronic gastritis are those of impaired digestion and failing nutrition. The appetite may be lessened or increased, belching of wind and nausea are regularly present, and vomiting occurs more or less frequently. The vomitus consists not only of undigested food, but also of large quantities of mucus. The younger the child the more marked is the vomiting. There are pain, uneasy sensa- tions, or a feeling of fulness in the region of the stomach. Headache, irritability, and disturbed sleep may follow. The bowels are apt to be constipated, but there may be diarrhoea from the passage of undigested food into the intestines. This is most common in infants. The tongue is coated, the breath smells badly, and there is a bad taste in the mouth on awaking. Signs of failure of nutrition follow, either a lack of gain or a loss in weight. The child grows anaemic and feeble, and loses its energy. Prognosis : In infants the disease is serious by interfering with the normal growth of the child and in predisposing to attacks of intestinal disturbance. In older children, if the cause is removed and proper treatment instituted, many re- cover ; but lacking these the disease tends to go on and grow DILATATION OF THE STOMACH. 95 worse as time advances in the presence of a continuously acting cause. Although these older children seldom die from the disease or its complications, they become the confirmed dyspeptics of adult life. Chronic gastritis — treatment : The dietetic care is most im- portant, and all the causative factors of this class should be investigated and errors corrected. The right food, in proper quantities, at regular intervals, correctly prepared, and thor- oughly masticated should be taken. If the teeth are faulty, they should be attended to. A hygienic life should be pre- scribed, with proper exercise, sleep, and bathing. Daily ivashing of the stomach with plain boiled water, or with warm water to which some alkali has been added, is the very best local treatment. It removes the mucus and undi- gested food, and stimulates the production of gastric juice and the muscular tone of the stomach. The drugs that are of value are either sodium bicarbonate, or hydrochloric acid, or mix vomica, or pepsin, alone or in various combinations ; but too much reliance must not be placed on any one of them. DILATATION OF THE STOMACH. Definition : A more or less enlarged stomach in infants is a fairly frequent condition, especially when fed artificially. Etiology : The most common cause is the almost universal habit of overfeeding artificially fed infants. The other causes which predispose are rickets and chronic gastritis. Pathology: The dilatation is usually symmetrical and may become enormous. In rare instances there may be a congeni- tal stenosis of the pylorus underlying the condition. Dilatation of the stomach — symptoms : The main symptoms are du ■ to the accompanying chronic indigestion. Vomiting attends the cases due t<> pyloric blockage. The diagnosis is made by physical examination, proving the presence of a dilated stomach after it lias been filled with gas or water. Prognosis : This is good except in cases of pyloric obstruc- tion. 96 DISEASES OF THE DIGESTIVE SYSTEM. Treatment : Remove the cause by regulating the meals. Improve the tone of the stomach by lavage and the use of nux vomica. If rickets is present, treat this. ULCER OF THE STOMACH. Gastric ulcer is found only rarely in children; but a few cases are reported from time to time. Etiology : Ulcers may be due to follicular gastritis or tubercu- losis, or belong to the same category as in adults — of unknown cause. Pathology : The ulcer may be single or multiple, and usu- ally involves only the mucous membrane. Its position on the stomach-wall is uncertain. Symptoms: Gastric pain increased by the ingestion of food, nausea, vomiting, and hrematemesis are the characteristic symptoms. Usually some gastritis is present, adding its symptoms. Prognosis : This is rather unfavorable. Ulcer of the stomach — treatment : If diagnosis is made, the child should be kept in bed and the stomach given absolute rest by withholding all food by mouth, the child being nour- ished by enemata of predigested food. The drugs used are silver nitrate, bismuth, and opium, but none is of much value. DISEASES OF THE INTESTINES. ACUTE IRRITATIVE DIARRHOZA. Synonyms : Other names for this condition are simple diar- rhoea, mechanical diarrhoea, and nervous diarrhoea. It is meant to include cases without anatomical changes in the in- testines, and without involvement of, or influence from, the stomach. The absence of a bacterial cause is shown by ref- erence to the etiology. Etiology : The exciting causes are various, but the same underlying predispositions exist as in all diarrhoeas. These are age, the first two years of life, unhygienic surroundings, malnutrition from any cause, and hot weather. ACUTE IRRITATIVE DIARRHCEA. 97 The active causes are excessive feeding ; the use of foods un- suitable to the age of the child, and which consequently act virtually as foreign bodies, such as green corn, cabbage, rad- ishes, partially cooked starches, fruits, and such stuff; the swallowing of foreign bodies ; ordinary drugs in susceptible infants used as laxatives; reflex nervous influences, as exhaus- tion, chilling the surface, excessive heat, fright, and rarely dentition ; eliminative efforts of nature to excrete toxic sub- stances from the body by the intestines, of which urcemic diarrhoea is the best example. Acute irritative diarrhoea — pathology : There is neither in- testinal fermentation nor intestinal inflammation. Increased peristalsis seems at the bottom of this form of diarrhoea, caused by local direct irritation or reflexly. With it some hyperemia of the intestinal mucous membrane and an in- creased secretion from its glands are present. If allowed to progress, an intestinal inflammation may supersede, or bacte- rial invasion and fermentation of the intestinal contents may follow. Symptoms : These usually begin suddenly with abdominal pain and diarrhoea. The first stools are soft faeces ; later they become thin and watery, averaging six to ten a day. The child is restless, somewhat weak and exhausted, and has a clammy perspiration. There is no vomiting and no fever. The stools are yellow or brown. Their odor is not bad. If due to irritating foreign bodies, these will appear in the stools. The abdomen is swollen and the increased peristaltic movements of the intestines are evident to the sight and touch. Prognosis : These cases regularly recover in a few days, nature removing the irritant from the bowels. Under un- favorable conditions the attack may lead to one of the more serious forms of diarrhoea. Acute irritative diarrhoea — treatment: Follow nature's lead and first give a cathartic, of which castor oil is the best. Calomel in divided doses may be used, bu1 is slower. This removes the irritanl completely from the bowel. Four to six hours later give the proper dose of opium ami repeal as occa- sion requires. This had best be given uncombined, and live t<> ten drop- of paregoric to a child a year <>M are the right 7—1). C. 98 DISEASES OF THE DIGESTIVE SYSTEM. sized dose. Food should be withheld as far as possible for a day, and when begun should be bland and given in small quantities. ACUTE FERMENTAL DIARRHCEA. Synonyms : This is the common diarrhoea of summer that is the cause of the high infantile mortality at that time. The names given it are almost as many as the authors writing of it. They are summer diarrhoea, acute dyspeptic diarrhoea, gastro-intestinal catarrh, infectious diarrhoea, gastro-enteric infection, and, very erroneously, cholera infantum. The name chosen expresses the condition as well as any — i. e., that of fermentation or decomposition of the intestinal contents by bacterial invasion. Etiology : The causes are summer heat, artificial feeding, bad habits of feeding, overfeeding, improper food, impure milk, bad hygienic surroundings, and residence in the city. The excessive heat of the summer combined with high humid- ity in the atmosphere seems the main predisposing factor. During long terms of hot weather this form of diarrhoea seems to sweep in epidemics through the infants in large cities. Behind all these causes, but acting as the direct ex- citants of the disease, are undoubtedly various forms of germ life, which are introduced with the food into the child's diges- tive tract, and for which the milk or other food taken acts as a culture-medium. Attempts are being made to isolate and separate the forms of micro-organisms responsible for these conditions, but as yet no very definite results have been reached. The probabilities are that there are many different varieties of germ life in each case, each contributing its share to the disturbance, and that no one form of germ is alone the cause of the disease. In a child previously unhealthy from any cause these fac- tors, germs, bad feeding, and heed, are far more likely to pro- duce this disease than in a perfectly well infant. Further, the great majority of these cases are seen in artificially fed children, breast-fed babies being rarely attacked, thus show- ing the necessity for the action of all three factors at once. ACUTE FERMENT AL DIARRHCEA. 99 Pathology : Essentially this disease is non-inflammatory, but is a putrefaction of the food-contents of the intestine due to the presence of bacteria of one kind or another. In a healthy child and with a short attack of the disease, virtu- ally no anatomical changes take place. If the child is non- resistent and the attack severe and lasting, early changes in the intestines are desquamation of the epithelium of the mu- cous membrane, going on if further continued to the changes seen in the inflammatory diarrhoeas. The gross appearances in the intestinal mucous membrane are almost none. Acute fermental diarrhoea — symptoms : The disease may begin gradually with slight looseness of the bowels, associated with symptoms of general malaise, some fever, restlessness, and fretfulness ; or more acutely with high fever, frequent vomiting, and marked diarrhoea. In the gradual form the diarrhoea is the main symptom. The stools are fairly frequent, eight to ten a day, yellow or more frequently green and thin, and contain masses of undigested food, curdled proteids, and fat. They may con- tain mucus and at times a little blood. At first the odor is sour only, but later becomes offensive. Anorexia is usually present. The tongue is coated white. Thrush frequently develops in the mouth. The child soon becomes pale, the muscles grow soft and flabby, and he loses flesh from week to week. The disease terminates under favorable circumstances by a gradual change to the normal in the stools, and by a gain in strength and flesh. Under unfavorable conditions the cases go on to a chronic intestinal fermentation which remains till the cold weather comes ; or it may develop suddenly, under tin' influence of very hot weather, into a case of genuine cholera infantum ; or it may be the starting-point of an entero- colitis. "\\ hen beginning acutely the symptoms usually continue acute. The fever keeps at about 102° F. ; there are marked restlessness, irritability, and often convulsions ; or, on the contrary, stupor and great prostration. The vomiting re- mains frequent, at first curdled milk being ejected, and later mucus, serum, and bile may follow. Any food or drink is 100 DISEASES OF THE DIGESTIVE SYSTEM. immediately returned. The appetite is gone, but thirst is marked and fluid food is eagerly taken to quench it. The bowels move frequently, in the beginning the stools being faecal, and later being thin, yellowish or greenish, with a great deal of gas and an offensive odor. There may be a dozen or more stools per day. The diarrhoea is characterized especially by the large amount of gas expelled and the very putrid odor of the stools. The abdomen is distended and tender, and the infant evidently suffers from intense colicky pains. After three or four days of these symptoms the tem- perature falls, the stools become less frequent, the vomiting stops, and under proper management the child will go on to complete recovery. Under less favorable circumstances — that is, a feeble child and continued bad feeding — an inflammatory entero-colitis supervenes. Others terminate in death during the acuteness of the attack. Diagnosis : This form of diarrhoea must be differentiated from cholera infantum, entero-colitis, and the beginning of several of the acute diseases, such as tonsillitis, scarlet fever, pneumonia, and malaria. The diagnosis may be difficult at first, but a few days of careful observation will usually clear up the case. Acute fermental diarrhoea — prognosis : In a previously healthy child, and with proper management, which means feeding, these cases usually recover. In institutions; in children suffer- ing from marasmus, rickets, and other nutritional disorders ; among unhygienic surroundings ; with previous chronic indi- gestion from wrong feeding ; and in very hot weather, the mortality from this form of diarrhoea is high. Prophylaxis : This is of great importance, as the majority of these cases of acute fermental diarrhoea may be prevented by proper attention to a few essentials. During the hot sum- mer such babies, as can, should be sent from the cities to the country, and those in a hot country to a cooler climate. If this is impossible, much may be done by keeping the child in the air and out of doors as much as possible both day and night. Frequent cool bathing both promotes cleanliness and assists in keeping the temperature of the surface lower. The ACUTE FERMENTAL DIARRHCEA. 101 diapers must be kept scrupulously clean, especially where in- fants are congregated. In any case of diarrhoea the diapers particularly should be disinfected. Feeding should be carefully regulated. Encourage breast- feeding in every way possible during the hot mouths, and postpone weaning till cool weather begins. If artificial feeding is necessary, this should be thoroughly regulated as to quality, quantity, and intervals. During hot weather special attention must be paid to the purity of the milk, and unless this can be assured some form of sterilization should be adopted. Foods unsuited to a child's digestion should be absolutely interdicted. Excessive feeding particularly should be avoided. Little and seemingly unimportant gastric or intestinal derangements should be promptly corrected, as these are often the beginnings of more serious disease. Acute fermental diarrhoea — treatment : First and most im- portant is attention to the food. In the rare cases occurring in breast-fed infants all food should be withheld for a short time, particularly until the tendency to vomiting is passed. Small quantities of water may be given instead to quench the thirst. As the breast is resumed, the quantity allowed at a nursing should be small and the return to full feeding gradual. In artificially fed children, among whom the vast majority of these cases occur, all milk food should be temporarily pro- hibited. As food during this abstinence from milk albumin- water is usually the best. Broths, rice- or barley-water, or one of the infant foods free from starch, made with water only, may be tried. The reason for the prohibition of milk during the acuteness of the attack is that this forms the best culture-medium for the germs whose action is causing the disease By depriving them of their food we starve them out. After the attack is ended we must return to a milk food very slowly, at first using a very dilute form, and gradually increasing the proportions of the solid ingredients to the proper limit for the child. Small quantities at a feeding should also be adhered to. In some of these eases, especially the very young, a wet-nurse must be secured for a time. 10'2 DISEASES OF THE DIGESTIVE SYSTEM. Milk given after such an attack is over should always be carefully sterilized. In a few cases peptonized milk is useful for a time until the stomach regains its tone. In older children on solid food this must be stopped, and only easily digested fluids used until the attack is over, and then the return to the regular diet should be gradual. Medicinally our first purpose is to clean out thoroughly from both stomach and intestine all the fermenting food-prod- ucts left behind. The stomach ordinarily will be cleaned of itself; but if vomiting is persistent, it may require our special attention. In these cases nothing is so efficacious as lavage. For an infant a No. 16, American scale, soft-rubber catheter, attached by rubber tubing to a funnel, is the best size. It is easily passed, the passage being facilitated by wrapping the child, arms and all, in a blanket, and the act of washing is quickly accomplished. Warm, boiled water is the best medium, although a little bicarbonate of sodium may be added. One washing is usually sufficient. The intestines should next be thoroughly emptied by a tea- spoonful or more of castor oil. This is undoubtedly the most efficient of the drugs of its class; but if the stomach is irri- table, it may be omitted. If the stomach-tube has been used, before removal the oil maybe given through this. Fractional doses of calomel (a tenth of a grain every half hour till ten or twelve doses are taken) have the advantage of ease of administration, do not irritate the stomach, and have some slight antifermentative action in the intestines. It is not so thorough and not so quick as castor oil, however. After the cathartic has acted, a thorough irrigation of the colon with warm saline solution through a long rectal tube cleans out the last remnants of decomposition. This may be repeated every day with advantage in most cases. After the whole alimentary canal has been thus thoroughly emptied the use of some antiseptic drug given regularly is in order. These drugs are many, but the best of them all is the old subnitrate of bismuth, as it may be given in large doses without fear of poisonous effects. It is best given in doses of ten to twenty grains every three or four hours. Other drugs of this class are salol, salicylate of sodium, salicylate of CHOLERA INFANTUM. 103 bismuth, subgallate of bismuth, calomel, bichloride of mer- cury, and creosote. Iu the more subacute and prolonged cases the use of one of the mineral acids is at times of value. The use of opium in these cases is indicated by marked pain and evident peristalsis. It should always be given by itself, and never combined with other drugs. Never use it until after the alimentary canal is thoroughly cleaned out. Paregoric may be used, five to ten drops ; or Dover's powder, one-fourth to one-half a grain. These doses may be repeated in two to four hours as needed. The vegetable astringents are often used, but are not very reliable, although the tannin in them does combine with the toxins to form insoluble compounds. Stimulants may be necessary in the cases with marked prostration. Brandy, or whiskey, or champagne may be used. Blackberry brandy answers the double purpose of a mild astringent and stimulant. Hot baths, mustard applications, etc., may be used in great weakness. In prolonged or convalescing cases there seems profit at times in the use of some of the digestive ferments. The hygienic care of these children is likewise important. The child should be given fresh air in abundance ; should be kept as cool as possible ; should be frequently bathed in cool water ; its clothing should be thin, and special attention should be paid to disinfection of the diapers. If possible, these children should be sent away from the hot cities to the country, especially when the disease shows any tendency to become protracted. CHOLERA INFANTUM. Definition: This disease is undoubtedly a specific infection of the milk \\>a\ as tool 1 by the infant affected. It is also called choleriform diarrhoea, and the name has been used wrongly as a generic term for all summer diarrhoeas of in- fancy. This name should be restricted, however, to the less common class of cases differing essentially from the form just described, and also from the inflammatory varieties. 104 DISEASES OF THE DIGESTIVE SYSTEM. Cholera infantum — etiology : This disease practically never occurs in an entirely breast-fed baby. It never occurs except in hot weather. Although careful researches have been made to find a specific micro organism in cholera infantum, as yet no such germ has been isolated. Various forms of bacteria, however, have been found ; but as yet it has not been proved to be caused by one special variety. The cause is invariably in the milk, and there may be enough of the toxic elements present in the milk as taken to produce the symptoms imme- diately on absorption ; or they may be manufactured from the milk by the bacteria in the digestive tract. Each case is one of poisoning by toxins generated in the milk by growth of bacteria in it. The disease is frequently grafted on a case of irritative or fermental diarrhoea, or occurs in a convalescent from some form of inflammatory diarrhoea. It may attack a previously healthy child, but this is far less common than the above. Cholera infantum — pathology : This again is not a diarrhoea with anatomical changes in the intestinal mucous membrane, but is purely a poisoning of the system by the swallowing, or manufacture in the digestive tract, of chemical toxins. In fact, the symptoms are due far more to absorption of poison- ous toxins into the blood than to the presence of the germs in the stomach and intestines. Cholera infantum — symptoms : In a previously healthy child, or in one already showing some mild intestinal disorder, there is a quite sudden attack of violent vomiting and purging. These two symptoms are the most characteristic of the dis- ease, and may continue uninterruptedly throughout. The vomiting is frequent, and follows every attempt to introduce food or drink into the stomach. At first curdled milk is ejected, and later mucus and serum and bile. The stools are frequent, fifteen to twenty a day, at first faecal, of yellow, brown, or green color, and later losing all color, and consist- ing simply of large quantities of serous fluid. These are the typical stools of the disease. They are acid in the beginning, but when they become serous are alkaline. They are usually without typical odor, but in some cases may have the putrid smell of those in fermental diarrhoea. Under the microscope CHOLERA INFANTUM. 105 they show epithelial and round cells and large numbers of bacteria. The child loses flesh and color very rapidly ; the eyes sink in their sockets, a marked pallor develops in the skin, and the flesh seems to disappear almost under our very eyes. The skin is cool and clammy, but the temperature from the first is high, 102° to 104° F., and often reaches 107° F. It is some- what in proportion to the severity of the attack. High tem- perature, as the disease progresses, points to a fatal termina- tion. The pulse is weak and rapid ; the respirations shallow and fast. The tongue is coated early, but soon becomes dry and red. -The abdomen, instead of being distended, is sunken. Thirst is intense, the child eagerly taking any fluid given it. The urine is almost suppressed, only very small quantities being secreted. The nervous symptoms are marked, the child crying or moaning, and throwing itself about in a very restless way. Delirium and convulsions may follow. Certain cases develop the opposite condition of stupor and later coma. They may pass into a condition like the algid stage of Asiatic cholera, with pinched features, subnormal temperature, collapse, de- pressed fontanelle, irregular respiration, and very feeble pulse. In some cases the gastro-intestinal symptoms subside, but the nervous symptoms become especially prominent, so much so as to suggest meningeal complications. Any actual changes in the brain or its membranes are, however, very rare. ('uses of cholera infantum either die or show marked changes for the better in two or three days. In those going on to recovery the vomiting usually stops first, then the stools become less frequent and lose their serous character, the nervous symptoms subside, the temperature falls, and the pulse and respiration regain their power. Convalescence i- likely to be quite slow. Diagnosis: If the picture of the disease is kept well in mind, it will scarcely be confounded with anything else. Tin' frequent vomiting, large serous stools, high temperature, marked prostration and collapse, great thirst, dry month and tongue, combined with the nervous symptoms of great rest- 106 DISEASES OF THE DIGESTIVE SYSTEM. lessness or stupor and coma, and the rapid, feeble pulse, sudden loss of weight, with pinched face and sunken fontan- elle, are characteristic of this disease only. In times of an epidemic of Asiatic cholera there might be some difficulty in differentiating these two conditions. Prognosis : This is distinctly bad. If the cases of real cholera infantum only are considered, the mortality is prob- ably 60 to 70 per cent. The younger and feebler the child the less are its chances of recovery. The severity of the infection is, however, of most importance in prognosis. Cholera infantum — treatment : Compare these cases with those of poisoning by some intense chemical irritant for pur- poses of treatment. Prompt and energetic action should be taken. First, not a particle of food is to be given for twenty- four hours at least. Immediately and thoroughly wash out both stomach and bowels with large quantities of boiled water, or normal saline solution. This will not exhaust the patient nearly so much as the constant vomiting and purging, and assists nature in her efforts to remove the poisons from the system. After washing, tannin may be thrown into the stomach and intestines to make insoluble compounds with any of the toxins that may be left behind. If the vomiting and purging recur, repeat the washings. There is very little value in any medication given by mouth as it is either ejected or not absorbed. Stimulants will be needed, and may be given in the form of whiskey diluted with cold water "by mouth, in small quantities fre- quently repeated ; or hypodermatically. To stimulate the heart, quiet the nervous manifestations, and inhibit the enormous excretion of serum from the intestinal bloodvessels, morphine grain y^-, and atropine grain -g-^-, given hypoder- matically, and repeated hourly to watch their effects, seem the very best combination yet suggested. This is contra- indicated only in the cases with stupor. To allay the great thirst and supply fluid to the tissues normal salt solution is to be injected slowly and in large quan- tities into the subcutaneous tissues. Giving large amounts of water by mouth only increases the irritability of the stomach. CHRONIC INTESTINAL INDIGESTION. 107 To combat the high temperature baths gradually cooled should be used. If the symptoms begin to abate and recovery seems probable, great care should be exercised as regards the return to food, and the strictest surveillance of the diet should be kept up for some weeks. Recurrences are fairly common after very slight dietetic errors. The same general rules should be followed as after recovery from fermental diarrhoea. In the cases of intense collapse with subnormal temperature applications of heat are decidedly indicated. CHRONIC INTESTINAL INDIGESTION. Synonyms : This common form of chronic functional dis- turbance of the intestines is also called chronic diarrhoea and chronic intestinal catarrh. Etiology: It is especially seen in institution-children and in those massed together for any cause. It is also an accom- paniment of general constitutional diseases, as rachitis, syphilis, and chronic pulmonary diseases. It is often seen in children who have been reduced by attacks of one of the acute infectious diseases. Unhygienic surroundings of any kind also predispose. It may occur at any season of the year, but is more serious during hot weather. It attacks both breast-fed and artifici- ally fed children, the latter, however, more commonly. In breast-fed infants the mother's milk is at fault in being in- digestible for her particular child. Such mothers are usually neurotic or anaemic, or run-down, or pregnant, or some of the constituents of her milk are present in abnormal quanti- ties. Lactation prolonged far beyond the normal time may produce this condition. In children on the bottle too frequent feeding, or overfeed- ing, or too concentrated food is usually the cause. A high proteid percentage seems the commonest factor. The prepared foods containing starch may cause this condition. In children on general diet overuse of carbohydrates seems t" lie the commonest cause. It occurs often in children whose feeding in early life ha- been faulty. Children allowed to 108 DISEASES OF THE DIGESTIVE SYSTEM. eat anything they wish — sweets, pastry, and fancy foods — are commonly affected. Pathology : There are really no lesions in chronic intestinal indigestion, as the condition is one of chronic indigestion, or lack of performance of function by the intestinal juices, and consequent fermentative changes in the undigested food- products. After the disease has existed for some time the constant irritation in the bowels will produce a mild form of chronic catarrhal inflammation, evidenced mainly by a hyper- plasia of the solitary and agminated follicles of the small and large gut, and by an increased production of mucus. Chronic intestinal indigestion — symptoms : A mild form of diarrhoea characterizes this condition. The stools seldom ex- ceed six or eight in the twenty-four hours, and are greenish, or yellowish, or gray, and after the diarrhoea has existed some time contain mucus and at times streaks of blood. They contain undigested food, lumps of coagulated casein, and unchanged fat. They are very dry, or semisolid in con- sistency, and the odor is very offensive, an evidence of albu- minous decomposition. The child is irritable, nervous, and sleeps badly. The ab- domen is markedly distended and tympanitic, and the veins on the abdominal wall are marked out in their course. The stomach is not regularly involved, and consequently vomiting is the exception. The tongue is red and dry, and thrush and stomatitis are frequent complications. The skin of the but- tocks is usually erythematous and excoriated. The tempera- ture may rise slightly and irregularly, but may be found sub- normal. The pulse grows rapid and feeble, and the respira- tion shallow. The appetite, instead of being lost, is regularly increased, the child taking its food with seeming pleasure. The patient loses flesh slowly but steadily, and, if the disease is prolonged, may waste to a mere skeleton. As this condi- tion of emaciation develops the patients lie in a semistupor, sucking their fingers and otherwise indifferent to their sur- roundings. The duration of the cases is very indefinite, exacerbations and remissions being common. In children on general diet the skin is pale and callow, the CHRONIC INTESTINAL INDIGESTION. 109 muscles are flabby, the whole body is thin, but the abdomen is protuberant and distended. These children are emotional, cross, and hard to control. Their sleep is restless and dis- turbed, and during sleep they frequently grind their teeth. The bowels may be constipated, with light-gray lumpy stools of a foul odor, and an excessive quantity of gas ; or diarrhoea may exist with four or five stools a day containing undigested food and with an offensive smell. They may at times con- tain mucus. Colicky pains are frequent. The appetite is variable, with a craving for indigestible articles of food. The tongue is thickly coated white and the breath is bad. There are many nervous symptoms, in addition to the emo- tional changes, as tetany, fainting-attacks, headache, dulness, stupor, and at times convulsions. There is often slight irregu- lar fever. Diagnosis : The history, with examination of the child and inspection of the stools, usually quickly establishes the diag- nosis. Special attention should be given to the other organs to prove the presence or absence of disease of any of them. Marasmus and tuberculosis especially must be differentiated. Prognosis : Without intelligent care cases of chronic intes- tinal indigestion continue to grow worse and die from ex- haustion or from some intercurrent acute diarrhoea, or pul- monary disease. If the disease is in a child with some constitutional disorder, or in an institution, the prognosis is bad. If the child is strong, and if intelligent treatment can be carried out by removing the cause, recovery should take place. The younger the child the fewer the chances for re- covery. The disease is more difficult to cure in the summer time than during cold weather. In children on general diet a fatal ending is not common, but a permanent relief of the symptoms is difficult to accomplish ; and these cases grow to adult life with digestive systems that are always troublesome. Chronic intestinal indigestion — treatment : The 2 yveven ^' n ' < ' treatment is most important, and consists in strict attention to the feeding on hygienic principles of all infants and young children. If the disease has started, the dietetic and hygienic manage- 110 DISEASES OF THE DIGESTIVE SYSTEM. ment is far more important than any drugs. Seek hard for the cause in the food the child is taking:. Have a chemical analysis of the milk, breast or cows', made to find what con- stituent is at fault. Inspect the stools to find what forms of food are most undigested. Regulate the quantity of food and the intervals of feeding, as well as the quality. If any constitutional ailments are present, treat them. Have the child properly clothed for the season of the year. If it is summer, insist on change of climate if possible. At any rate, have plenty of fresh air with sanitary surroundings. It is often helpful to put an artificially fed child on some non-milk food for some time, and whatever food is given should be well diluted. Egg-water, whey, broths, or one of the non-starchy proprietary foods may be tried. The pre- digested foods, peptonized milk, or peptonoids, find a useful field in these cases. It is better to underfeed than to over- feed these children. As regards drugs, none is very satisfactory. Opium and astringents are useless. The only cases wdiere opium is indi- cated are those in which the bowels move immediately on the introduction of food into the mouth. Here it counteracts the reflexly increased peristalsis. The intestinal antiseptics may be helpful : bismuth subnitrate in large doses, or salol, or salicylate of sodium. Dilute hydrochloric acid and pepsin given with each feeding are theoretically indicated. Calomel in divided doses, or castor oil, from time to time, are good adjuvants. An occasional thorough washing of the colon is advisable. As improvement begins tonics, as iron and arsenic, are indicated. In children on general diet results of treatment, if care- fully carried out, are brilliant. The regulation of the diet is here also of primary importance. A diet of beef-juice, or scraped beef, or partially peptonized milk, with avoidance of carbohydrate food and absolute prohibition of all indigestible and fancy foods, will accomplish wonders in these children. The proprietary foods here have a useful field. The meals should be given at regular intervals. As improvement occurs, a gradual return to the diet proper for a child of its age should be substituted. ACUTE ENTERO-COLITIS. Ill Calomel given from time to time aids our treatment, espe- cially in the constipated cases, and colon-irrigation may be helpful, particularly in the cases with mucus. Salol or sodium salicylate may aid in lessening flatulence. Tincture of mix vomica is a useful tonic. Regular exercise and fresh air, and a general sanitary life, must be included in our management. Relapses will follow slight indiscretions. ACUTE ENTERO-COLITIS. Definition and synonyms : So far, all the forms of diarrhoea described have been essentially without anatomical lesions, but depend rather on changes taking place in the food than in the intestinal walls. This form, on the contrary, is really an in- flammation of the intestinal mucous membrane. Other names by which it is known are ileo-colitis, enteritis, dysen- tery, and inflammatory diarrhoea. Acute entero-colitis — etiology: The causes are virtually the same as those of fermental diarrhoea : bad food, or bad habits of feeding, being of the greatest importance. Hot weather predisposes markedly to the disease, although in the fall, with exposure to cold, many cases develop. It is frequently the re- sult of one of the forms of functional diarrhoea which has been improperly cared for. It may complicate the infectious diseases. Bacterial life of some kind undoubtedly plays a prominent part in its etiology. It is far most frequent in artificially fed children, and the tendency to it exists even after general diet is allowed. Pathology : The lesions of acute entero-colitis are found in- volving, as a rule, both the ileum and the colon, spreading in both directions from the ileo-csecal valve. In a few cases the ileum only, in a larger number the colon only, is involved. The mildest cases show only a catarrhal inflammation of the mucous membrane, with swelling, congestion, and increased production of mucus. The veins are engorged, and large areas of the mucous membrane appear of a deep-red color. In places small hemorrhagic spots may be seen. In the protracted cases the entire intestinal wall is thickened, and the solitary follicles and I 'oyer's patches are swollen. 112 DISEASES OF THE DIGESTIVE SYSTEM. If this catarrhal inflammation is very severe and long con- tinued, small ulcers appear in the mucous membrane, due to desquamation of the epithelium. These are scattered irregu- larly through the colon. Several of these ulcers may coalesce, forming large irregular bare areas. By this process large amounts of the mucous membrane may be destroyed, and the gut present a worm-eaten appearance. Other cases present the lesions of inflammation and hyper- plasia, with subsequent breaking down of the solitary lymph- follicles. These changes are seen in both the ileum and the colon. Peyer's patches may also, but rarely, be involved. Seen with the naked eye the mucous membrane is studded with little rounded elevations, the enlarged follicles, and in the early stages the top of each presents a small pit. In more advanced cases the excavation is larger and the elevation smaller, the follicles having been entirely destroyed. The mucous membrane then presents a uniformly pitted appear- ance. The ulcers do not become large like those in catarrhal ulceration, but at times two or more small ulcers may run together and form an irregular figure. The mucous mem- brane is never so completely destroyed as in the former ulcera- tive condition. Another and the most severe form of entero-colitis shows the lesions of croupous inflammation. In this there are patches of false membrane adhering to the surface of the intestine. To the naked eye the intestinal wall is thick and stirrer than normal, and has a greenish appearance on its inner surface. It is difficult to strip off any large-sized pieces of the mem- brane from its base. The portions of gut uncovered by. pseudo-membrane are red and congested, with here and there hemorrhagic spots. The lesions are most marked in the colon, but some patches may be found above the ileo-csecal valve. Under the microscope a distinct layer of fibrinous exudate is seen growing on the intestinal mucous membrane. There is a large round-cell infiltration of the mucosa and submucosa. Necrosis and ulceration are very rare. There are many complicating lesions, as bronchitis, broncho- pneumonia, atelectasis, and acute degenerative nephritis. The ACUTE ENTERO-COLITIS. 113 mesenteric lymph-nodes are enlarged and inflamed in almost every case. Acute entero-colitis — symptoms : Some attempt may be made to connect certain symptoms with one or other of the groups of pathological lesions just described; but the cases vary excessively in their clinical picture, and such attempts are often proved ineffectual at the autopsy. The cases, except in the follicular form, which is more of a subacute process, begin suddenly with vomiting, diarrhoea, abdominal pain, and fever. The stools at first are fsecal, but soon become mixed with blood and mucus in considerable quantities. They are very frequent, each one small in amount, and are preceded by pain and followed by rectal tenesmus. There is very little disagreeable odor to these stools, the odor occurring in the late stools of prolonged cases. In the follicular variety the stools are less frequent and the presence of blood less com- mon. In the membranous variety mucus and blood are pres- ent in large quantities, and shreds of pseudo-membrane add a diagnostic feature to the case. After a few days, in all the cases, the stools gradually assume a dark-brown or greenish- brown color. Prolapsus ani frequently complicates the pro- tracted cases. The temperature at first averages 103° or 104° F. ; but as the disease progresses it falls some, but continues above nor- mal so long as the inflammatory process is present. In the beginning the patients are less prostrated than in the fer- mentative diarrhoeas; but as the case progresses the prostra- tion increases. There is anorexia, but increased thirst. The abdomen is distended, and usually tender along the line of the colon. The child gradually /o.sr.s flesh and strength, the pulse be- comes rapid and feeble, and the respirations irregular and shallow. The skin of the buttocks becomes excoriated, and bedsores may form. The tongue is coated, or red and glazed, and the mouth is frequently the seat of some variety of stom- atitis. Nervous symptoms in the early stages are of an active na- 8— D. C 114 DISEASES OF THE DIGESTIVE SYSTEM. ture : restlessness, irritability, twitchings, and convulsions. If the case lasts, stupor and coma often develop. The more acute cases die in a few days to a couple of weeks. The subacute cases may last three or four weeks, gradually losing ground till death. In cases of recovery the early symptoms of improvement are seen in the stools : the mucus and blood gradually disap- pear, the movements are less frequent, and the constitutional symptoms subside by degrees. Convalescence in all varieties is very slow and relapses are common. Diagnosis : The two diseases with which acute entero-colitis may be confounded are typhoid fever and intussusception. The former is rare in children, but must be remembered during an epidemic. The latter should always be thought of, as the symptoms of the two are similar : abdominal pain, tenesmus, bloody discharges, and vomiting. The fever of entero-colitis is not present in intussusception, and the subsequent consti- pation and presence of an abdominal tumor in the latter con- dition are differential points. The effort to separate the different pathological varieties of entero-colitis depends on the onset and severity of the symp- toms and the characters of the stools. Many cases cannot be classified even with all the helps. Prognosis : The prognosis of acute entero-colitis is always grave, but is worse in feeble or anaemic children, and in those already suffering from any form of constitutional or nutri- tional disorder, as rickets, syphilis, tuberculosis, or marasmus. The younger the child the more are the chances of an un- favorable end. Protracted cases and those occurring in hot weather have a bad prognosis. In a previously healthy child and under proper surroundiugs, with an intelligent carrying out of the physician's directions, many cases will recover. Never forget the possibility of a relapse occurring even when the child is seemingly improving rapidly. Acute entero-colitis — treatment: In the way of prevention, special attention should be paid to the careful feeding of all children during their years of liability to the disease. All the hygienic and sanitary surroundings of the children should be regulated to the best of our ability in each particular case. ACUTE ENTERO-COLITIS. 115 Prompt treatment of all the forms of functional diarrhoeas will prevent the development of many cases of these graver varieties. If a case has developed, a change of air to a cooler climate will often work marked and rapid improvement. The die- tetic regulations are most important and most difficult. In breast-fed babies, if no gross changes are evident in the milk, this form of feeding should not be interfered with. If a child has been recently weaned, a wet-nurse may be needed. In bottle-fed babies the milk should be made quite dilute or be peptonized, or stopped altogether, and meat-juice, broths, scraped beef, peptonoids, or egg-, rice-, or barley-water used instead. The point is to give food that leaves very little indigestible residue. These children have little appetite, and enough food must be given to keep up their nutrition. All food should be given at regular intervals, and not too often. As improvement occurs special care should be given to the diet to prevent relapses. In the beginning lavage, performed once, may be useful ; it will seldom require repetition. Irrigation of the colon is particularly valuable in this condition. The lesions are mostly colonic, and we can make our medication through local applications direct. A normal salt solution given warm with a high rectal tube, and in considerable quantities, injected once or twice a day is the safest solution. Tannin or starch may be added. It is unsafe to use the stronger antiseptics for fear of leaving some behind. If tenesmus is marked, starch-water with the addition of five or ten drops of lauda- num is very soothing. Cocaine suppositories, each containing one-fourth to one-half grain of the drug, may be needed. At the first, a good-sized dose of castor oil, one or two drachms, should be given if the stomach will retain it. Later, repeated doses of the same in small quantities, ten to fifteen minims, will often be found beneficial. Opium in one form or another will usually be needed after the purge has acted. It is always best given separately, in small doses, repeated as need requires to quiet the pain and tenesmus. Bismuth in large doses regularly repeated, fifteen to twenty grains every three or four hours, soothes and rests the inflamed mucous 116 DISEASES OF THE DIGESTIVE SYSTEM. membrane. Stimulants are almost always necessary to rouse the feeble circulation and combat the great prostration. Blackberry brandy, whiskey, or good old brandy may be used. Pepsin and the mineral acids are frequently given by mouth for assistance in more completely digesting the food. As convalescence is established, the mineral acids, nux vomica, arsenic, and iron are helpful tonics, local and general. After complete recovery in the digestive tract cod-liver oil is useful. CHRONIC ENTERO-COLITIS. Definition : These are prolonged uncured cases of the acute form of entero-colitis, which have lost their active character. The change from the acute to the chronic condition is slow and gradual, and the point of change is hard to set. Etiology : Bad management of acute cases of entero-colitis is usually the cause of the assumption of a chronic character. It is seen in the more hardy infants, who have managed to escape death during the summer months. Pathology : The main lesions found are a chronic catarrhal inflammation of the mucous membrane, with growth of new connective tissue, and destruction of the tubular glands of the intestine; or a chronic hyperplasia of the lymph-follicles with some small ulcerations over their summits and marked pigmentation in places. Ulcerative conditions are rare, as most of the patients with ulceration die during the acute stage. Chronic pulmonary complications are common — hypos- tatic congestion, broncho-pneumonia, or tuberculosis. Chronic entero-colitis — symptoms : There are no fever and no signs of active inflammation. Pain and tenderness have likewise disappeared. Food is taken readily as given ; but evidences of a desire for it are not common. The main symptoms are progressive emaciation and abnormal bowel- action. The child wastes from week to week, until there seems nothing to its body but the skeleton covered with loose skin. The face is thin and sharp, the eyes sunken, and the cheeks hollow. The fontanelle is much depressed. All the subcutaneous fat has disappeared, so that the skin hangs in loose folds. The abdomen is distended and tympanitic. CHRONIC ENTERO-COLITIS. Ill The lips, tongue, and mouth are usually dry, and may be covered with sordes. Various forms of stomatitis may be present. The teeth may decay rapidly, but dentition may proceed normally. Vomiting is rare. The stools average four to six per day ; they are thin, and contain mucus and biliary coloring-matter, being green or brown. They contain undigested food unless the diet is care- fully regulated. Blood is seldom present. They have a very offensive putrid odor. Prolapsus ani is rarer than in the acute variety of the disease. Colic and flatulence are regular accompaniments. The skin around the buttocks is erythem- atous and excoriated. The pulse is rapid and feeble, the circulation sluggish, and the extremities cold. These children are restless and irri- table, sleep poorly, and whine a great deal. At other times they are dull and stuporous. Convulsions may occur. The duration of the cases is a few months. Diagnosis : The main point to be determined is whether the symptoms are due only to the chronic entero-colitis, or whether there is some complicating disease. Rickets, syphilis, tubercu- losis, and marasmus must each be carefully examined for and excluded. Prognosis : This is very bad in young infants, in those pre- viously debilitated, in those in institutions ; and during hot weather. Under favorable circumstances, and when intelli- gent treatment can be followed, results are fair. Some of the most hopeless appearing cases recover. Chronic entero-colitis — treatment : The main reliance is on good hygiene, carefully regulated diet, and local treatment of the colon. An occasional dose of castor oil to clean out the entire intestinal tube; opium from time to time when the peristalsis is excessive; and stimulants judiciously used, are the only drugs of any special value. The sanitary points to be taken advantage of are abundance of fresh air, a change of climate, regular bathing, and cleanliness. The diet should be nourishing, suitable lor the age of (ho child, and cither very casv of digestion or predigested. Pep- tonized milk, beef-juice, scraped beef, peptonoids, and such 118 DISEASES OF THE DIGESTIVE SYSTEM. forms of highly nutritious food leaving little residue are specially useful. Attempt to keep up the child's nutrition without overfeeding. Astringent applications given regularly by means of ene- mata seem the most useful form of medication. They should be used daily, and such solutions as tannin, alum, boric acid, or silver nitrate may be employed. Changing the drug used in the enemata from time to time seems helpful. Bismuth may be given by mouth, as also pepsin ; but brilliant results need not be expected from either. CHRONIC TUBERCULAR ENTERITIS. Occurrence : This condition is found usually associated with tuberculosis elsewhere in the body, but in some few cases may be primary. The mesenteric lymph-glands are always coin- cidently involved. Etiology : The tubercle bacillus in the intestinal canal is the cause of this condition. The bacilli may be swallowed in sputum from the infected lung or in milk. Chronic tubercular enteritis — pathology : The lesions of chronic tubercular enteritis are usually found only in the small intestine, and consist of tubercular deposits in the solitary and agminated lymph-follicles, and of necrosis of these with formation of ulcers. These ulcers are irregularly shaped, and lie transverse to the length of the gut. They vary greatly in number and size. The lymph-glands are enlarged, and may caseate and form abscesses. Chronic tubercular enteritis — symptoms : There may be diarrhoea or constipation, the former being the more com- mon. Diarrhoea in general tuberculosis does not always have ulcers as its cause. If diarrhoea is present, it is very obstinate. Hemorrhages are rare, but may be serious. The stools are large, frequent, and brown. Abdominal pain may, or may not, be present. There are progressive wasting, and fever with its accompanying symptoms. Diagnosis : This depends on finding the tubercle bacillus in the stools. In any case of tuberculosis with diarrhoea the probabilities are in favor of ulceration being present. APPENDICITIS. 119 Prognosis : This is distinctly bad. As a complication it makes the fatal end of pulmonary tuberculosis more rapid, due to its interference with the nutrition. If primary, it will probably lead to infection elsewhere. Chronic tubercular enteritis — treatment : The diarrhoea is best treated by combinations of bismuth and opium. Intes- tinal irrigation is not used, as the lesions are seldom in the colon. Creosote is useful, as in all forms of tuberculosis. Stimulants will usually be necessary. APPENDICITIS. " Appendicitis " is now used to include all varieties of inflammation occurring in the region of the csecum, as they are all now believed to originate in the appendix vermiformis. Etiology : Appendicitis is commoner in males than in females, and is usualy seen in young adults. After the fourth year of life it is fairly frequent, although cases are reported from time to time even under four years, and one is recorded only seven weeks old. Predisposing causes are the anatomical peculiarities of the appendix, such as unusual length, abnormal position, and irregularities of the mesentery. These all tend to prevent the appendix from expelling its contents. Adhesions from previous inflammations act in the same way. Chronic con- stipation also acts as a predisposing cause. Exciting causes are usually mechanical — the presence of a faecal concretion or a foreign body in the appendix. Blows, falls, or strains, with the presence of such a foreign body, act as frequent causes. Undoubtedly there is a bacterial ele- ment of much importance in the etiology; but as yet its ex- act connection with each case is not well worked out. Each c;[M' \< probably due primarily to some mechanical cause in- terfering with the circulation in the appendix, followed by a germ infection made more easy by this stasis. Pathology: The appendix may be the seat of a simple catar- rhal inflammation only, with congestion and swelling of the mucous membrane, ami increased production of mucus. In these mild cases resolution takes place with few symptoms and a normal appendix. 120 DISEASES OF THE DIGESTIVE SYSTEM. If the inflammation is more severe, the appendix becomes distended with the inflammatory products, and the lumen of the tube closed up. In these cases the peritoneal coat is in- volved as well as the mucous membrane, and from this a localized or general peritonitis may arise by contact, and without perforation. The mucous membrane is likely to be ulcerated, even when no foreign body is present. In recovery from these cases, strictures of the lumen, bendings and thick- enings of the walls of the appendix, and peritoneal adhesions are left behind. Recurrences are frequent after such attacks. In still more severe cases the inflammation and swelling are so intense as to cause necrosis and sloughing in the wall of the appendix, with perforation at one or more points. These perforations lead to a localized abscess if adhesions are pres- ent, or to a general peritoneal infection if not. There is a form of appendicitis in which the entire appen- dix becomes rapidly gangrenous, with general peritonitis as an immediate complication. The whole appendix, or a por- tion, may become completely detached. Inflammation and ulceration caused by the typhoid or tubercle bacilli are found in the appendix at times. Appendicitis — symptoms : The disease usually begins with general abdominal pain, which sooner or later is localized in the region of the caecum. With the pain there are fever of a moderate degree, at times a chill, some rapidity of the pulse, and nausea or vomiting. The bowels are usually constipated, but there may be diarrhoea. On examination there is tenderness in the right iliac region, and this can usually be localized in one small area, called " McBurney's point," one-third of the distance on a line drawn from the right anterior superior spine of the ileum to the navel. The right rectus muscle offers some resistance to palpation. If more severe, and the whole appendix is inflamed, with some localized peritonitis, the symptoms are more marked, and on palpation fulness and an indistinct feeling of a mass in the right iliac fossa can be made out. If perforation with a localized abscess results, a distinct mass, dull on percussion, is found. APPENDICITIS. 121 The suddenly perforating and gangrenous cases may give no signs in the beginning different from the milder attacks, and may suddenly show all the symptoms of a diffuse peri- tonitis with general septic infection. There is very great difficulty in deciding in the early stages which are to be the mild and which the severe cases. No one symptom can be relied on to warn us of this, and hence the general picture of every case must be carefully and intelligently watched. Perforation and gangrene usually succeed to a few days of the milder symptoms ; but they may occur in the early stages. They are evidenced by a sudden increase in the pain, by vomiting, a rapid rise in the pulse, and the symptoms of intense shock. The temperature usually rises also. If the general peri- toneal cavity is shut off by adhesions, the acute symptoms gradually subside, and the patient is left with the presence of a circumscribed abscess. This abscess, if left alone, may perforate the colon, the bladder, or the peritoneal cavity, or may travel behind the peritoneum backward, upward, or downward. If no adhesions are present, the symptoms of shock are rapidly replaced by those of general peritonitis, and death follows in a few days. After recovery from a primary attack the patient may have more or less frequent recurrent attacks of exactly the same character as the first one. The symptoms and prognosis in these recurrences are the same as in the primary attack. Other cases have no more acute attacks, but suffer from a chronic disturbance, with pain and uneasiness, in the region of the appendix. Some of these patients tend to become chronic invalids. Diagnosis : Remember how almost impossible it is to decide what pathological condition exists in the appendix from the symptoms and physical signs in the early stages. Reliance cannot positively be placed on anything. In differentiating appendicitis from other conditions in chil- dren, ordinary colic and intussusception are most likely to cause confusion. In colic there is no fever and no tender- ness. On the contrary, pressure ordinarily relieves the pain. In intussusception there is no fever in the beginning, and the 122 DISEASES OF THE DIGESTIVE SYSTEM. resistance or tumor is in the upper portion, on the left side of the abdomen rather than the right. Further, the tenesmus and bloody discharges from the rectum are absent in appen- dicitis. Prognosis : This is always grave ; but many cases recover under both medical and surgical treatment. If the case can be properly treated before general peritonitis develops, the chances for cure are good. Localized abscesses are favorable for cure. General peritonitis is uniformly fatal. Appendicitis — treatment : The child should be kept abso- lutelv at rest in bed, put on a fluid diet, and an ice-bag applied continuously to the right iliac region. If ice is objectionable to the patient's sensations, hot poultices may be substituted. Opium may be given in small quantities, but enough to relieve the pain if the local applications fail to do so. No cathartics should be given, but enemata may be used as needed. It is wise for a physician and a surgeon to watch these cases together from the outset, as operation may be demanded at any time. When skilled surgical help is available there is less risk in operating on a doubtful case than in delaying the operation too long. The difficulty in deciding how a case will develop has much to do with the varying opinions of physicians and surgeons as to the place of operative inter- ference in dealing with these cases. If an abscess is present, an operation is indicated at once. COLIC. " Colic " is a name for a symptom only ; but it is so com- mon in infancy, and so often requires treatment of itself, that a separate description is usually accorded it. Etiology : Colic is a regular symptom of almost all the functional and inflammatory diarrhoeas, of appendicitis, of intussusception, and of worms. It may be present, however, without diarrhoea, vomiting, obstruction, or foreign bodies ; and in these cases is due to flatulent distention of the intes- tine and irregular peristalsis. The distending gases are formed by fermentative changes in the food-contents of the COLIC. 123 alimentary canal. It may occur in both breast-fed and arti- ficially fed babies ; but is commoner in the latter class. In either case the food contains some indigestible constituent, and this is usually the proteids. Starchy foods may be the cause, and also over-feeding. Chronic constipation is fre- quently present. Colic is most frequent during the early months of life. Pathology : The condition is one of painful muscular con- traction of the intestinal walls in the endeavor to remove the accumulated distending gases. Colic — symptoms : These are crying, which is sharp and per- sistent, drawing up of the legs, and in boys retraction of the scrotum. The abdomen is distended, and pressure or knead- ing usually relieves the pain and quiets the child. If the gas is expelled by the mouth or anus, the crying usually ceases at once. There is always difficulty in getting these children asleep and in keeping them so. The least noise or movement disturbs them. They will usually take food raven- ously, as if it temporarily relieved them, but in a few min- utes they are crying again with pain. In mild cases the infant is simply wakeful and fretful. If severe, there may be prostration and cold extremities. Very many infants have a chronic colic, and are continually crying and very restless. Diagnosis : This is usually easy ; but we must never forget the possibility of some grave intestinal disease being the cause of the colicky pain. Appendicitis and intussusception, and earache especially, must be excluded before calling the case a simple colic. Prognosis : This is good. Prolonged cases can be cured by proper care of the diet. Colic — treatment : During the attack, by mouth a little brandy and hot water, or ginger and hot water, or hot pep- permint-water, or soda and hot water, will assist in removing the gas from the stomach. To remove the intestinal gases an enema of warm water or a glycerin suppository is most efficient. Hot applications and massage to the abdomen are very soothing. Opium preparations should be avoided as much as possible. 124 DISEASES OF THE DIGESTIVE SYSTEM. To prevent recurrence of the colic the diet should be in- vestigated and any errors in it corrected. If any one of the food-constituents seems at fault, reduce its quantity in the food. If all the constituents seem normal, try reducing the total quantity of food given. Cure constipation if it exists. CONSTIPATION. Constipation is one of the most frequent disorders of in- fancy, and one of great difficulty in its satisfactory manage- ment. Etiology : The causes exist either in the child or in its food. Probably the latter causes are the more important. Of the former, feeble muscular power in the intestinal wall is of most importance. This may be due to the various forms of malnutrition, of which rachitis is the commonest. In older children, lack of attention to the desire to go to stool, and of the formation of a regular habit, is a prominent cause. Decreased, secretion of the intestinal fluids and of the bile is probably next in importance. Certain anatomical peculiari- ties are believed to play their part, as a very long sigmoid flexure, stricture of the gut — congenital or acquired — kinks and bends from adhesions, tumors inside and outside the gut, and painful fissures at the anus, producing a voluntary con- stipation. Of the latter class a deficiency in fat is probably of greatest importance. This occurs in babies fed on the breast and in those fed on the bottle. Next most common as a cause is the lack of enough total solids in the food to leave any residue. Here there is nothing to provoke the intestinal peristalsis. Other causes are ingestion of too little water, or excessive excretion of it by the skin or kidneys, leaving the faeces dry. Prolonged use of sterilized milk will often be the cause of constipation, as a return to fresh milk will frequently pro- duce regular movements again. Drugs given for other causes, and containing opium or astringents, are factors of impor- tance. In older children the lack of a proper variety to the diet, such as green vegetables and fruit, may produce constipation. CONSTIPA TION. 125 Constipation — symptoms : The local symptoms are usually all that are present. Constipation is a relative term, as the normal number of stools per day varies with different indi- viduals and with different periods of life. During the first year less than two stools per day is abnormal. After the first year the passing of any day without a stool is abnormal. But the character of the stool, and the ease or difficulty in its discharge, should be taken into consideration as well as the frequency. The other symptoms associated with constipation are flatu- lence and colic, and a tendency to piles and to hernia. The hard masses of faeces may irritate the rectum and anus, and be streaked with mucus and blood. Absorption of intestinal toxins may produce various gen- eral symptoms, as headache, languor, disturbed sleep, and some interference with nutrition. The tongue is furred, the breath is foul, and anorexia may be present. In some cases the hardened fasces may block up and irri- tate the rectum and thus set up a false diarrhoea, the fluid movements taking place around or through the solid masses, the patient presenting the signs of diarrhoea while really suf- fering from constipation. Prognosis : This depends on the cause and the possibility of its removal. Some cases are very stubborn to treatment. Constipation — treatment : More than the fact of the existence of constipation must be known. We must find the cause of the condition, and, if possible, the part of the intestine at fault. If we can do these, we can treat the cases far more intelligently. If structural or pathological conditions are present, such that we cannot remove them, we must content ourselves by treating the case symptomatically. In a breast-fed child have a chemical examination of the mother's milk made; and if some constituent is found ab- normally low, as, for instance, the fat, take measures to in- crease this. In bottle-fed babies modify the proportions of the milk-ingredients by adding fat, or diminishing the pr<>- teids, or increasing the total solids, until some combination is arrived at that will produce daily stools. In both give plain water or oatmeal-water freely. Cane-sugar instead of lac- 126 DISEASES OF THE DIGESTIVE SYSTEM. tose will at times assist, and maltose will often do better yet. Stopping the sterilization of the milk may also aid. In older children the addition of fruit and green vegeta- bles, as orange-juice, stewed prunes, baked or stewed apples, is of value. Massage of the colon and along its course will be a help in some cases. Muscular exercise is of value by increasing the tone of all the muscles. If rachitis or mal- nutrition exist, the proper treatment should be undertaken for the cure of these. When these modifications in diet and improvements in general condition fail to cure, our next resort is to specific treatment of the constipation itself. There are three general methods for this : suppositories, enemata, and drugs. If the seat of the constipation is in the rectum only, suppositories are of value. Soap, glycerin, and gluten are all used, and each works well ; but any of them, if too long continued, may produce rectal irritation. They should be greased before insertion. If enemata are used, plain water, or soap-suds, or sweet oil, or glycerin, may be injected. They produce a cleansing of the colon, and reflexly excite peristalsis in the small gut. It is best to use small quantities, so as not to dilate the intes- tine too much. Their effect gradually wears off, particu- larly if too large quantities of fluid are used. Drugs are very unsatisfactory for prolonged use. Calo- mel, castor oil, rhubarb, cascara, aloes, and phosphate of sodium are the best. In all cases attempt to form a regular habit of going to stool. In children who are old enough to be taught this, much good may be accomplished. INTESTINAL OBSTRUCTION. This means a mechanical obstruction to the passage of the contents of the intestinal canal. The varieties of the obstruc- tion in children are not so many as those in adults; but almost any form may occur, and one form particularly is a disease of childhood. The forms with rare causes will be mentioned, while the important variety — intussusception — will be described in detail. INTUSSUSCEPTION. 127 Rarer causes : Foreign bodies may be the cause of obstruc- tion. These may be objects swallowed, as solid substances; or masses of caked drugs, as bismuth. A lump of lumbri- coid worms rolled up together has been found as the cause. Volvulus, or the twisting of the gut upon itself, is a rare cause in children ; more common in adults. Strangulation, or kinking of the gut, by abnormal bands from previous peritonitis ; or from abnormal openings in the mesentery ; or by the remains of Meckel's diverticulum ; or by an adherent appendix, may likewise cause strangulation. Strangulated hernia as a cause of obstruction should never be forgotten. INTUSSUSCEPTION. All the above forms of obstruction are rare in childhood when compared with this condition. Definition : Intussusception, or invagination of the intestine, consists in one portion of the bowel passing into a succeed- ing portion, and through its mechanical presence and subse- quent swelling and bending by the attached mesentery, block- ing up the lumen of the bowel and causing the obstruction. Varieties : Intussusceptions may occur at any portion of the bowel, but are commoner in certain parts than in others. The commonest location is for the apex of the intussuscep- tum, or entering portion, to be formed by the ileo-ccecal valve. This draws in after it the colon, and is called the ileo-cceccd variety. A subvariety, the ileo-colic, is formed by the invagination of the ileum through the valve and into the colon, but without necessarily invaginating the colon. The enteric variety is rarer, and consists of the invagination of some part of the small gut into another part. The rarest variety of all, the colic, consists of the invagi- nation of some part of the colon into another part. Intussusception may occur in two places at once. It usu- ally takes place in the direction of the peristalsis — that is, downward ; but the reverse may occur rarely. .Except in the ileo-colic variety, the apex of the intnssus- ceptuni is fixed, the outer sheaths, or intussuscipiens, being 128 DISEASES OF THE DIGESTIVE SYSTEM. gradually infolded. In the ordinary variety a few inches to six or more feet of bowel may be involved. Mild forms of intussusception occur frequently just after death. They are usually multiple and enteric, always short, and usually upward. Etiology : There are no facts of any value in causation. It is most frequent from four to nine months of age, and in males. Most cases occur in previously healthy children. Previous intestinal disorder is present in a small proportion of the cases. Irregular peristaltic action of the intestinal walls seems the exciting cause. Intussusception — pathology : There is great congestion of the invaginated bowel ; and if long enough continued, this leads to gangrene and sloughing. The two peritoneal sur- faces in contact are liable to form adhesions to each other, and this, combined with the swelling and the dragging of the mesentery, makes reduction often very difficult. If adhe- sions form and the intussusceptum sloughs, it may be dis- charged entire or piecemeal through the bowel, and sponta- neous cure result. If adhesions do not form, the sloughing leads to perforation of the gut and infection of the perito- neum. Intussusception — symptoms : These regularly begin sud- denly, with severe abdominal pain. It is located in the neighborhood of the navel, and causes the child great agony. The pain is paroxysmal in character, and is almost at once accompanied by vomiting. The stomach first empties itself of its contents, and afterward ejects bile in large quantities ; later the vomiting may be stercoraceous. At first there are one or two loose faecal stools ; but afterward absolutely no faecal matter is passed, but only bloody mucus. With this is marked rectal tenesmus. Soon after the attack begins, on palpating the abdomen it is found relaxed ; and usually in the neighborhood of the transverse or descending colon a tumor is found. In a fair proportion of the cases rectal examina- tion discloses the apex of the advancing intussusceptum. In some this may protrude from the anus. As the case advances, tympanitic distention of the abdomen and tenderness develop. At first there is no fever. If in- INT USS USCEPTION. 129 flarnmatory signs appear in the intussusception, it may de- velop. There are intense prostration, feeble pulse, cold extremities, and pallor. A marked diminution in the quantity of urine secreted, or complete suppression, is frequently present. There are chronic cases with vague abdominal symptoms, but without complete obstruction. In these cases the pres- ence of the tumor makes the diagnosis. In the acute cases the disease lasts less than a week. Spon- taneous reduction probably occurs at times. Spontaneous cure by adhesions and sloughing may occur. Death is usually from shock ; or, if shock is survived, from peritonitis. In the chronic cases the duration may be from two weeks to a month. These usually die from exhaustion or the de- velopment of complications. Diagnosis : With a typical history, and a careful examina- tion showing the presence of a tumor, the diagnosis should be easy. Never neglect a rectal examination. In all cases of bloody and mucous discharges from the bowels think of intussusception as well as entero-colitis. They are easy to differentiate if both are in mind. In chronic cases the tumor is the diagnostic point. Prognosis : This is always grave. The younger the child and the more advanced the case the more serious is the prog- nosis. With early diagnosis and proper treatment many re- cover. Spontaneous recovery, while it does occur, is rare. Chronic cases seldom recover. Intussusception — treatment : As soon as the diagnosis can be made adopt energetic methods of treatment. Every hour's delay increases the dangers. Give absolutely no cathar- tics. These only increase the intestinal peristalsis and drive the intussusceptum farther in. On the contrary, keep the patient under the influence of opium. This fulfils two indi- cation.- ; it relieves the pain and decreases the peristalsis, thus preventing further advance of the invagination. Next, an attempt should at once be made to reduce the intussusception by means of mechanical devices. These are inflation by air and injection of fluids. Each lias its advo- cates. Either is bes< done under an anaesthetic. 9—1). C. 130 DISEASES OF THE DIGESTIVE SYSTEM. Inflation is performed with the patient on his back, and the air is pumped into the bowel through a rubber rectal tube attached to a Davidson syringe or to a small hand-bellows. This should be done quite slowly. While the air is being in- troduced the abdomen may be gently massaged upward over the tumor. From time to time the child may be inverted to aid reduction by the action of gravity. The amount of air introduced should be governed by the tension of the abdomi- nal walls. Sounds or physical signs may suggest reduction ; but to be sure of it the air should be let out and a careful examination for the disappearance of the tumor made. After complete reduction the symptoms should cease, and faecal movements or passage of gas begin. If inflation fails the first time, it may be repeated ; but more than two trials are useless. Injection of fluids may also be tried to reduce the intussus- ception. It may be tried first, or after the failure of in- flation. Again the child is anaesthetized, and a warm saline solution is introduced into the bowel, best by means of a foun- tain-syringe having an elevation of four to six feet. The abdomen may be massaged during the introduction of the fluid, and inversion may also be tried. A bandage rolled around the rectal tube prevents escape of the fluid. The fluid should be introduced slowly, with interruptions, and the amount will vary in individual cases. It is more difficult to decide whether reduction has been accomplished in these cases than when using air. Again the fluid must be let out and examination made for the tumor. If reduction is accomplished in either way, the child must be kept quiet, given little food, and held under the influence of opium for a few days, until the danger of recurrence has passed. Too much time must not be lost in trying to reduce by in- flation or injection. If both methods fail — and they often will — resort must be had to laparotomy, as otherwise we leave our patient to almost certain death. It is best to be prepared for operation while trying the mechanical devices for reduction ; and if they fail, operate before the patient recovers from the anaesthetic. Of late INTESTINAL PARASITES— BOUND-WORMS. 131 years many of the cases operated on during the first few days, and even in infants, recover. In chronic cases operative results are quite brilliant. INTESTINAL PARASITES. Varieties : There are three general forms of worm that com- monlv inhabit the intestines of children. These are the round-worm, ascarides lumbricoides ; the pin-worm, oxyuris vermicularis ; and two varieties of tapeworm, taenia medio- canellata and taenia solium. Worms, however, are very much less common than is ordi- narily supposed by the public at large. The life-history of each form of parasite is different, and as each requires a special treatment a separate description of each is necessary. ROUND-WORMS. Description : These worms, the ascarides lumbricoides, are from five to ten inches long, the female being the longer. They are cylindrical-shaped, taper at both ends, and are of a pinkish-gray color, being not unlike the ordinary angle-worm in appearance. The worms live in the small intestine, and rarely are single. Half a dozen to a hundred may be pres- ent. They frequently roll up into large masses. They have a curious tendency to wander from their natural home in the small gut, and may be found in the colon, stomach, oesopha- gus, and even in the nose and larynx. At times they escape into the peritoneal cavity through an intestinal perforation. They have been known to crawl into the common bile-duct and to block it up. The eggs arc oval in shape, and about T -J-g- of an inch long. The contents appear granular, and the coat thick. They are discharged in large numbers in the stools, and have great vitality outside the body. They are probably swallowed with the food or drink, and after entering the intestine develop into mature worms there. Round-worms — symptoms: There may be no symptoms at 132 DISEASES OF THE DIGESTIVE SYSTEM. all, and the finding of a worm in a stool may be the first suspicion of anything being wrong. In other cases there may be irregular abdominal pains and tympanites, with restlessness, poor sleep, grinding of the teeth, and picking of the nose. These symptoms are all more often due to some chronic indigestion than to the presence of the worms. Various nervous disturbances of an emotional character are often associated with the presence of worms, as headache, dizziness, hysterical symptoms, tetany, and even convulsions. Certain mechanical symptoms may be trouble- some, as the massing of large numbers of the worms in a ball somewhere in the intestine ; or due to their tendency to travel into undesirable situations. Diagnosis : No symptoms or set of symptoms can be relied on for a diagnosis. The only positive sign is by seeing the worms or their eggs in the stools. If one worm is found, the probability of others being present is strong. Round-worms — treatment : The drug of most value for kill- ing or benumbing the ascarides is santonin. This is best given after a few hours of fasting, and must be accompanied or followed by a cathartic, as in itself it does not remove the worms. It is well given rubbed up with calomel, and in divided doses. The dose for a child of five years is two to four grains. A dose of castor oil may be given afterward, if the calomel does not completely empty the canal. PIN-WORMS. Description : These are very small worms, called also thread- and seat-worms. The technical name is oxyuris ver- micularis. They are of about the diameter of thread or a pin, and are from one-sixth to one-third of an inch long, the female again being the longer. They are white in color, and taper to a point at the tail. The eggs are oval and small, with a thin coat. The worms live almost entirely in the rectum and colon, and are present in enormous numbers. They are propagated by the swallowing of the ova. The worms, and also the eggs, are passed in large numbers with the stools. They are frequently found alive in the folds of PIN-WORMS. 133 skin around the anus and genitals, and these act as a frequent source of reinfection to the patient. Pin-worms — -symptoms : The most important sign of the presence of the oxyuris is intense itching of the anus and genitals. This is usually worse when the child goes to bed. The scratching for relief may lead to eczema of the anus, or balanitis, or vulvitis. Masturbation and incontinence of urine are frequent results. The child's sleep is disturbed, and he becomes restless and wakeful. The worms irritate the colon, and much mucus is usually discharged with the stools. Reflex nervous symp- toms are much rarer than with the other varieties of worms. Diagnosis: Itching of the anus and genitals in children should always make us suspect seat-worms, but the only posi- tive diagnosis again rests on seeing the worms themselves or their ova. Examine the discharges and also the parts about the anus very carefully for either. Pin-worms — treatment : Scrupulous cleanliness of the pa- tient is the first thing of importance. He should be kept very clean, and his hands and the parts about the anus should be washed daily with some antiseptic solution, as the bichlo- ride of mercury 1 : 5000. The anus should be kept anointed with a 2 per cent, carbolic salve, to prevent itching and to kill any worms that emerge from the rectum. By mouth, salts should be given to produce watery move- ments and to wash the worms that are high up in the bowel down into the colon. Once a day the colon should be washed out thoroughly with a large quantity of water passed through a long rectal tube. This water should contain either soapsuds, or quassia, or alum, or salt. Bichloride of mercury, in 1 : 10,000 or 1 : 20,000 solution, is very useful for killing the worms; but there is danger of poisoning from some of the solution being lefl behind. The cure is slow, but, by persistent use of the above means over some length of time, can be effected. The clothing, toys, bedding, and even carpets should be thoroughly cleaned for fear of reinfect ion. 134 DISEASES OF THE DIGESTIVE SYSTEM. TAPEWORMS. Description : Tapeworms are from twenty to fifty feet long, of a white color, and composed of many flat segments. The segments are fairly uniform in size, but taper gradually to the head, where the newly formed segments develop. The head is a modified segment, the size of a pin's head, and contains suckers by which the worm fastens itself to the gut. Varieties : The commonest varieties of tapeworm found in this country are two, the beef tapeworm, or icenia mediocanel- lata, and the pork tapeworm, or tcenia solium. Each segment of each variety is a sexually mature individual, and ova are cast off continually by them. Segments from the tail end are also broken off from time to time and discharged from the bowel. New segments grow from the head-end to take their place. Cysticercus : The eggs from the tapeworm are swallowed by animals in their food, and passing into their stomachs the embryos are set free and are carried by the blood around the body and are deposited in various parts of the tissues, among others the muscles. Arrived here they form a little wall around themselves and take on a larval condition. They are then called cysticerci, and may live in this condition for some years. Each cysticercus is about the size of a pea. When the flesh of these animals is eaten by a human being, unless the cysticercus is destroyed by the heat of cooking, it is set free in the digestive tract, and attaches itself to the mucous membrane of the small intestine and grows there into an adult tapeworm. Habitat : The toznia mediocanellata lives in the bodies of cattle during its larval state, and hence is called the beef tape- worm. The tcenia solium lives during its larval state in the bodies of hogs, and hence is called the pork tapeworm. More than one taenia mediocanellata is frequently found in a patient at a time ; but the tsenia solium, as its name implies, is usually single. Tapeworms — symptoms : There may be no symptoms at all, the finding of segments in the stool being the first intimation of the presence of the worm. Irregular pains in the abdo- PRURITUS ANI. 135 men, large appetite, restlessness, and picking at the nose are observed in some cases. There may be diarrhoea. Probably these symptoms are all due more to disordered digestion than to the worm. Tapeworms — diagnosis : This is made entirely by finding segments of the worms in the stools. The physician should always examine these segments himself. Tapeworms — treatment : Preventive treatment consists in not eating underdone beef, or pork, or pork preparations. Thorough cooking will destroy the cysticerci. If the presence of the worm is proven, treatment should be begun at once by first starving the patient for some time. To increase this time the night may be taken advantage of in children. Have the child go to bed with a very light meal and a laxative. In the morning, after the stool (which may be assisted by an enema) and without any breakfast, give the specific drug. Follow this in an hour by a thorough purge, the best of which is a tablespoonful of castor oil. Practically only two drugs need to be remembered as tamiacides, male-fern and pomegranate. The first is given as oleoresina aspidii, in doses of half a drachm to one drachm, and made up in an emulsion with syrups, or in capsules, if these can be swallowed. It makes a nasty mixture, however, and in cases where expense need not be taken into account Tanret's pelletierine, made from the alkaloid of the pome- granate, is the nicest way of attacking the worm. Each bottle contains an adult dose. For a child a proportionate amount should be given. It also should be followed by a purge in an hour. To insure against recurrence the head must be removed. DISEASES OF THE ANUS AND RECTUM. PRURITUS ANI. Pruritus ani is at times seen in children, and is an intense itching in the neighborhood of the anus. Etiology: The itching may be due to pin-worms in the rectum, to pedieuli, to irritating Cecal discharges, to consti- 136 DISEASES OF THE DIGESTIVE SYSTEM. pation, or to eczema of the anus. The constant scratching tends to make it worse by setting up an artificial dermatitis. Treatment : If possible find the cause and remove it. Keep the parts absolutely clean by bathing them after every stool. After bathing anoint the anus with some such oint- ment as, Tfy. Acid, carbolic V([x. Ung. zinc, oxid 3j. PROLAPSUS ANI. Varieties : There are two varieties of this condition : 1, Where a portion of the mucous coat only of the rectum is prolapsed ; and 2, where the entire rectal wall is invaginated through the sphincter. Etiology : This condition is quite common in children in the second and third years. It is predisposed to by the ana- tomical fact of the very loose attachment of the submucous connective tissue of the rectum. Chronic intestinal disorders and constipation, by causing straining efforts at stool, are the common exciting causes. Phimosis, vesical calculus, and rectal polypus may be causa- tive agents. Prolapsus ani — symptoms : The characteristic symptom is the appearance during stool of a dark-red or purplish-colored tumor protruding from the anus. This is covered by mucous membrane, which may be in a condition of acute inflamma- tion. It may bleed freely. The mass often will return spon- taneously, or may be easily reduced. There is no pain con- nected with the protrusion. After prolapsing once, recurrence with each stool is common. Diagnosis : This condition must be differentiated from haemorrhoids and rectal polypi. After reduction the absence of any tumor on rectal examination excludes these conditions. More important is to diagnose it from intussusception, in which the presence of pain and obstruction are of most value. Prolapsus ani — treatment : Lay the child on its face, and, having oiled the mass, gentle pressure will usually easily HEMORRHOIDS— FISSURA ANI. 137 reduce it. If difficulty is found, the application of cold or the use of an anaesthetic may be called for. After reduction keep the child on its back for an hour to prevent recurrence, and before allowing it to move about a pad to the anus held in place by a T-bandage should be applied. After this the child should not be allowed to defecate in the ordinary sitting posture. He should be made to lie down on his back or side, and to use a bedpan. The bowels should be kept open by the use of laxatives. Any of the causes of the condition that may be present should be removed. A daily enema of some astringent solution, as alum or tannin, tends to contract the mucous membrane and to prevent recurrence. If these simple means fail, linear cauterization by nitric acid, made under an anaesthetic and followed by artificial con- stipation with opium for a few days will usually cure the cases permanently. The actual cautery may be used instead of nitric acid. HEMORRHOIDS. Definition : These are vascular tumors growing in the lower portion of the rectum, outside or inside the sphincter, from dilatation of the bloodvessels of the part. They are quite rare in childhood, and when they do exist are generally of the external variety. Etiology : Chronic constipation. Symptoms : Presence of the vascular masses around the anus, and pain at stool. Bleeding is rare in children. Haemorrhoids — treatment : Regulate the bowels. Some astringent ointment, as the unguentum galhe, may be used locally. Operative interference is rarely required ; but, if necessary, ligation is probably the best procedure. FISSURA ANI. In fissura ani a small ulcer is present at the anal margin, and usually extends over the area that is under the action of the sphincter. It is a fairly common affection of childhood, and is seen at times even in infant-. Etiology: The passage of hardened f;eces, scratching to re- 138 DISEASES OF THE DIGESTIVE SYSTEM. lieve pruritus, or traumatism from the nozzle of a syringe may cause the fissure. Symptoms : Pain at and after stool is the marked symp- tom of this condition. On examination, an ulcer with its long diameter parallel with the long axis of the bowel, and lying over the sphincter, will be seen. It has a grayish base, and often bleeds slightly. Fissura ani — treatment : Clean the parts and touch the base of the ulcer with silver nitrate stick. Keep the bowels open. If healing does not take place under this method, stretch the sphincter and keep the parts at rest, when cure will be rapid. ISCHIORECTAL ABSCESS. Definition : This is a collection of pus in the cellular tissue around the lower portion of the rectum. Etiology : Traumatism is an active cause. It may arise through infection of the cellular tissue from the rectum through either the lymph- or bloodvessels. Symptoms : A sense of fulness, intense and throbbing pain, and tenderness of the parts are the significant symptoms. Defecation causes great agony. Some fever with its con- stitutional symptoms is usually present. On examination, a tense, red, tender swelling will be found on one or the other side of the anus. Fluctuation may be obtained from the skin surface or from the rectum. Ischio- rectal abscess — treatment : Early and prompt incision through the skin, in a line radiating from the anus, should be made. The finger should be inserted in the wound, and any partitions broken down. The wound should be irrigated and packed to heal by granulation. FISTULA IN ANO. Fistula in ano is an unhealed ischio-rectal abscess. The sinus may lead from the rectum to the old abscess-cavity, or from the skin to the old abscess cavity, or be complete and lead from the rectum through the old abscess-cavity to the skin -surface. ACUTE PROCTITIS. 139 Etiology : There may be a history of an acute ischio-rectal abscess which has been untreated ; or the fistula may result without au attack of precedent acute and painful inflamma- tion. These chronic cases are more likely to be of a tuber- cular nature. Symptoms: There is no special pain in this condition, but the sign of suspicion is a discharge of pus or bloody fluid with the stools, through either the external or the internal opening. On examination, the opening will be found either on the skin-surface or in the rectal wall ; if complete, a probe can be passed through the fistula, or colored fluid or peroxide of hydrogen can be syringed through to locate the internal opening. Treatment: Any variety of incomplete fistula should first be made complete, by passing a director through from the skin-opening (an artificial one being made if necessary) into the rectum, and then bringing the point of the director out through the anus. Along this as a guide, cut through the intervening tissue, dividing the sphincter once only. If pockets exist, open into them freely from the first incision. Curette the tissue, pack with gauze, and let the wound heal by granulation. ACUTE PROCTITIS. "Proctitis" is applied to an inflammation of the rectum unaccompanied by inflammatory trouble higher up in the bowel . Etiology : Enemata, suppositories, traumatism from the nozzle of a syringe, thread-worms, and irritation from hard- ened feces are frequent causes. The inflammation may be due to infection by the germs of gonorrhoea, diphtheria, or scarlet fever. Pathology: The rectum may be the seat of a simple catar- rhal inflammation ; or superficial or deep ulcers may form ; or there may be an inflammation with the production of a false membrane. Acute proctitis — symptoms: There are mild constitutional symptoms only, the local signs being the most important. 140 DISEASES OF THE DIGESTIVE SYSTEM There are marked rectal tenesmus, and the frequent passage of very small stools each containing a large proportion of mucus and some blood. Prolapsus ani is a frequent compli- cation. Pruritus ani and excoriations of the neighboring skin are common. In ulcerative cases there are pus in the stools and marked pain. Acute proctitis — treatment : The patient should be put to bed, and on a proteid diet. The bowels should be moved by small doses of castor oil. Daily injections of some bland fluid should be employed to wash out the rectum and quiet the tenesmus. Starch-water and laudanum is a useful wash. Suppositories of opium or of cocaine may be used. If ulcers are present and can be seen, a solution of boric acid or nitrate of silver should be used as a local application. If any removable cause is present, it should be attended to. POLYPUS RECTI. Polypus is a much commoner condition in childhood than in adult life. No cause for the growth is known. Pathology : The polyp is a pedunculated body about the size of a hazelnut. Histologically it is of a myxo-fibroma- tous or adenomatous structure. There may be only one, or many tumors. In the early stages they may be sessile, but in time they always tend to become pedunculated. They are usually located in the lower segment of the rectum. Polypus recti — symptoms : The symptoms are bleeding from the rectum, associated with some rectal irritation and tenes- mus. They may lead to a mucous discharge and to prolapsus ani. As the pedicle grows long enough the tumor is often protruded during stool. On examination it appears the color of mucous membrane ; but if protruded and pinched, it has a purplish tint. It is found to be distinct from, but attached to, the general mucous membrane, thus differentiating it from prolapsus ani. Polypus recti — treatment : This consists in tying the pedicle off at its attachment, and cutting the tumor away beyond the ligature. If more than one polyp exist, each must be treated the same. JAUNDICE. 141 DISEASES OF THE LIVER. The liver in new-born babies and in early childhood is, pro- portionately to the body-weight, a larger organ than in adults. This should be remembered in estimating its size, as it will be found normally extending below the free border of the ribs. This comparatively large size has some relation to the direct connection of the liver with the placental circulation. Notwithstanding the large size of the gland, diseases of the liver in infancy and childhood are comparatively rare, and clinically the liver offers little of interest. JAUNDICE. Definition : Icterus neonatorum, the jaundice of early infancy, has already been described. This is a jaundice due to changes in the blood, hematogenous so called. Jaundice due to changes in the liver, hepatogenous, does, however, occur in children. It is also called simple and catarrhal jaundice. Under the term gastro-duodenitis an intense and more widespread form of the disease is recog- nized. There may, however, be only a catarrhal inflamma- tion of the bile-ducts present, and no involvement of the duodenum or stomach. This is the form under consideration. Jaundice — etiology : The mucous membrane of the com- mon or hepatic ducts is swollen, thus closing the lumen of these ducts. A plug of inspissated bile, a round-worm, or rarely a gall-stone may plug the duct. Errors in diet or exposure to cold may be the causative agent. In many cases there seems no exciting cause. Symptoms : The main sign of simple jaundice, and often the only one, is the yellow discoloration of the skin and mucous membranes. It varies from a quite pale lemon tint to a decided dark-yellow color. The urine is dark brown, and contains bile-pigment in abundance. The stools are white or "clay-colored," due to the absence of bile from the intestinal tract. The pulse is often slowed, and there may be itching of the skin, particularly if the jaundice lias been persistent. Urticaria may be present. The bowels are apt to be constipated. 142 DISEASES OF THE DIGESTIVE SYSTEM. Physical signs : On examination the liver is usually a little enlarged, and some tenderness over it is present. The gall-bladder may be found distended. Prognosis : This is good, as most of the cases recover rather rapidly, even if left alone. The duration is one or two weeks. When the common duct is plugged by a round-worm or other solid body the prognosis is not so good. Jaundice — treatment : The diet should be free from fats and sugars. The bowels should be kept open by calomel, or salines, or aloes. Phosphate of sodium is one of the best drugs to use with children, owing to its lack of taste. An excess of water should be given to drink. Large enemata of cold water have been found quite useful in the more obstinate cases. FUNCTIONAL DISORDERS OF THE LIVER. Functional disorders of the liver are most apt to be asso- ciated with disturbances of the functions of the stomach and intestines, but at times the liver alone may be involved. Either the bile-producing function of the liver may be dis- turbed, or the chemical changes which should normally take place in the blood passing through the liver are imperfectly performed. While this whole question is as yet in an unsettled state as regards exact knowledge, still much of the evidence points to disorders of the liver functions as being the basis of condi- tions which are variously styled, lithsemia, biliousness, uric- acid diathesis, and so on. Such conditions are fairly common in childhood, although they are undoubtedly often overlooked and ascribed to other causes. Etiology : Heredity seems to be the main predisposing cause. The exciting cause is the habitual eating of improper food, or of too large quantities of food ; and insufficient muscular exercise. Functional disorders of the liver — symptoms : Constipation, flatulence, headaches, bad breath, coated tongue, poor nutri- tion, and ansemia are the most marked symptoms. The ap- petite is apt to be capricious. The fseces are light colored ACUTE AND CHRONIC CONGESTION OF THE LIVER. 143 and have an offensive odor. The urine is of high specific gravity, and contains an excess of urates or phosphates. These children are apt to be neurotic, and irritable, and to have frequent regular or irregular nervous " explosions " of various sorts. These frequently develop at puberty. Functional disorders of the liver — treatment : This is fairly successful where the family compel the child to carry out the physician's directions. In the first place, the diet should be regulated. Sugars and fats should be avoided. An easily digested, mixed diet, given at regular intervals, and in not excessive quantities at a time, should be prescribed. Plenty of water should be given daily to keep the various fluids of the body dilute. Regular outdoor exercise should be enforced. As drugs, those that increase the production of bile are indicated, phosphate of sodium, aloes, podophyllin, and rhu- barb. After a course of such treatment extended over a considerable time the tendency to outbreaks of these disor- ders can usually be overcome. ACUTE CONGESTION OF THE LIVER. Varieties : The liver may be congested either actively or passively. The acute congestions are much rarer than the chronic. Etiology : It is the result of poisoning by malaria or phos- phorus ; may follow overeating of rich foods ; and be a com- plication of simple jaundice or gastro-duodenitis. Symptoms : These are very slight. Moderate jaundice may be present. The liver is moderately and uniformly enlarged, and may be slightly tender to pressure. Acute congestion of the liver — treatment : This consists simply in removing the cause, or rather in treating the Cott- le •• « . ~ , O dition giving rise to the congestion. CHRONIC CONGESTION OF THE LIVER. Etiology: This is the commoner variety of congested liver. It is never a primary disease, but is always secondary to con- ditions causing stasis of the blood-current. The commonest 144 DISEASES OF THE DIGESTIVE SYSTEM. cause is congenital or acquired heart-disease, and, next to this, chronic pulmonary conditions, as emphysema, pleurisy, or in- terstitial pneumonia. Pathology : The liver is enlarged, firm on pressure, and harder to cut than normal. The surface is dark, and on sec- tion the so-called nutmeg appearance is present, due to the dilatation of the central veins of the lobules. There is some increase in the connective tissue. Chronic congestion of the liver — symptoms : These are due rather to the primary disease than to the congested liver. There may be some slight jaundice and other symptoms in- dicative of interference with the functions of the liver, such as coated tongue, poor appetite, and constipation. On examination the lower edge of the liver is found to reach well below the costal border, and to be easily felt by palpation. The enlargement will be found uniform, and there will be no nodules. Diagnosis : This should be made from hypertrophic cirrho- sis and from the enlarged liver of leukaemia. The presence of the causative factor is of special value in congestion. Prognosis : This depends entirely on the importance of the primary disease. Chronic congestion of the liver — treatment : The removal or treatment of the cause is the rational method of caring for this disease. The occasional use of a saline laxative tends temporarily to reduce the congestion. SUPPURATIVE HEPATITIS. Varieties : There are two varieties of this condition in chil- dren, as in adults. In one there is a single circumscribed abscess; in the other there are multiple points of suppuration. Either form is rare in children. Etiology : Traumatism seems to have been present in many of the cases. Dysentery occasionally precedes the abscess. A suppurative inflammation of the portal veins is more com- monly found as a cause. This may arise from the umbilicus, from the appendix, or from typhoid ulcers. It may be a meta- static pyaemic abscess. In many cases no cause can be found. FATTY LIVER. 145 Suppurative hepatitis — symptoms : In the variety with mul- tiple suppurative points we usually have the preceding symp- toms of the inflammation, in the area drained by the portal veins, which is the cause of the hepatitis. The signs pointing to involvement of the liver are enlarge- ment, pain, and tenderness over that organ. More or less jaundice usually develops coincidently. Chills and irregular fever are present. After a time the typhoid state develops, with low muttering delirium, stupor, dry, brown tongue, and sordes on the lips and teeth. Diarrhoea soon begins, with thin, offensive, light-colored stools. The urine contains bile- pigment, and later albumin and casts. Rapid emaciation is regularly seen. In the variety with single abscess the symptoms are less acute. There are pain in the region of the loins, chills, sweating, irregular fever, loss of flesh and strength, and some jaundice. The typhoid state develops less rapidly. There are cases where the symptoms are entirely latent, and the abscess is discovered by accident. On examination the liver is tender and enlarged, and fre- quently the enlargement is irregular, the abscess being near the surface and pointing above or below. Diagnosis : The presence of hepatic symptoms, combined with irregular chills and fever, and a uniform or irregular enlargement of the liver, are the points for diagnosis. Withdrawal of pus through an exploring-needle, is the only positive evidence of abscess that we have. Failure to obtain pus on the first trial does not exclude its presence. Prognosis: In multiple abscesses the prognosis is almost surely fatal. In the single variety, although still grave, it is somewhat better. Suppurative hepatitis — treatment : This is purely surgical. II* the pus is so situated that it can be reached and freely evacuated, a good many cases will recover. FATTY LIVER. This condition is a fatty degeneration of the hepatic cells, and is, as ;i rule, secondary to some of the wasting diseases of 10—1). r. 146 DISEASES OF THE DIGESTIVE SYSTEM. children. Tuberculosis, marasmus, and chronic gastroin- testinal diseases are the usual primary conditions. It is fairly common in infants. Pathology : The liver is large, the surface is smooth, the color is yellow, much lighter than normal, and a cut section has an oily appearance. Under the microscope fat-globules are seen in the liver-cells. Symptoms : There are no subjective symptoms. A uniform enlargement of the liver is present. There is no pain and no tenderness. If the fatty degeneration is marked, some interference with the hepatic functions may be present, but not enough to give any marked symptoms. Fatty liver — treatment : This is entirely that of the original disease on which the liver condition depends. AMYLOID LIVER. Amyloid degeneration of the liver-cells is dependent on chronic suppurative disease in other parts of the body. Chronic bone-disease is the commonest precursor. Phthisis, empyema, and hereditary syphilis are less common primary causes. This condition is fairly common in childhood. The spleen and kidneys are likely to be similarly affected. Pathology : The liver is quite large, and symmetrically so. It has a smooth surface, with a gray waxy color. On section it is fairly firm. Iodine gives a mahogany color to the de- generated cells. Amyloid liver — symptoms : There are no special symptoms from the liver itself. In the presence of the original disease, a markedly enlarged liver, with no pain, no tenderness, and no jaundice, will usually be waxy. Slight interference with the liver-functions may occur, but the symptoms are so merged with those of the primary disease as to give them no value. The spleen is regularly enlarged, and the urine some- times shows the changes seen in amyloid kidneys. Amyloid liver — treatment: This is entirely that of the primary disease. In cases where the originating focus can be eradicated cure may be hoped for, but otherwise little can be expected. CIRRHOSIS OF THE LIVER. 147 CIRRHOSIS OF THE LIVER. Cirrhosis of the liver is quite rare in infancy and childhood, but from time to time cases in children under puberty are reported. Etiology : Alcoholism is a cause as in adults. Some chil- dren inherit an appetite for liquor; and to others it is given medicinally in such quantities and over such periods as to produce in the liver the degenerative changes of chronic alcoholism. Syphilis, malaria, and chronic ptomain-absorp- tion from the intestines are recognized as distinct causes. Pathology : There are two general varieties, the atrophic and the hypertrophic cirrhosis. The latter form is the rarer in children. In the atrophic form the liver is smaller than normal; its surface rough and yellowish ; it is firm and hard to the touch and cuts like cartilage. The liver-structure shows a marked increase of the connective-tissue stroma. The hepatic cells are atrophied and replaced by new connective tissue. The smaller veins and bile-ducts may be obliterated. In the hypertrophic variety the liver is enlarged, firm, and yellowish colored. The new growth of connective tissue begins around and follows the intralobular branches of the bile-duct, giving a more uniform distribution. The portal veins are less interfered with, while the bile-ducts are more apt to be destroyed. From this distribution of the connec- tive tissue the term biliary cirrhosis is often applied to this condition. Cirrhosis of the liver — symptoms : In the early stages the symptoms are mainly those of disturbance of the functions of the liver. Such symptoms as furred tongue, bad breath, bad taste in the mouth, capricious appetite, and constipation with foul stools are usually first noticed. After some time the more definite symptoms of the disease develop, as vomiting, hematemesis, slight ascites, enlarged spleen, diarrhoea, bloody stools, and haemorrhoids. Slight jaundice may occur. The patients lose flesh and strength, and become anaemic. On examination the liver is found to be small, the spleen 148 DISEASES OF THE DIGESTIVE SYSTEM. large, and the presence of fluid in the abdominal cavity can be demonstrated. There may be albuminuria. The hypertrophic form has somewhat the same symptoms, except for the presence of a marked and rather malignant form of jaundice, an enlarged liver, and usually not much ascites. Toward the end both varieties present some irregular fever, with low delirium and other cerebral symptoms. Prognosis : This is quite unfavorable. The course of the disease is slow, although seemingly less so than in adults. The hypertrophic form is more rapidly fatal. Cirrhosis of the liver — treatment : If any causative factor is present, remove it at once. A milk-diet is the best for this disease. Any tendency to congestion in the portal system should be relieved by the use of salines. The patient should be out of doors and should exercise freely. Plenty of water should be drunk daily. If syphilis is present, mercury and iodide of potassium are to be used, and may produce good results. Chloride of ammonium also seems to have some value in this disease. The ascites is to be relieved by diuretics, purging, or aspiration. HYDATIDS OF THE LIVER. Hydatids are rare in the United States, and especially rare in children. A few cases are reported from time to time. At any rate, children are not immune to the disease. Hydatids of the liver — etiology : They are produced by the development in the liver of the embryo of the tapeworm in its larval state. The eggs of a tapeworm are swallowed by the child, and the embryo, being set free in the stomach or intestines, travels through the walls of the viscus and is carried by the portal blood to the liver. Here it forms a wall about itself, and develops a so-called echinococcus-cyst. This cyst, growing gradually in size, is the hydatid. Pathology: The echinococcus is enclosed by a thick wall made up of connective tissue from the organ in which it is growing. The cyst is single (unilocular), or contains smaller cysts inside the larger ones (multilocular). The contents are an opalescent fluid, slightly albuminous, containing crystals of cholesterin and echinococcus hoohlets or scolices. BILIARY CALCULI. 149 Hydatids of the liver — symptoms : The cyst is usually latent for some time, until it grows large enough to cause symptoms by its mechanical presence. It grows very gradually, and often a good-sized cyst will be discovered by accident on ex- amination when no previous history has been present. Usually the first thing noticed by the patient is an enlarge- ment in the region of the loin, or of the whole abdomen. There is no pain and no tenderness. Jaundice is rare, only occurring when the cyst presses on the hepatic duct. Press- ure on the portal vein may produce ascites. The cyst may become infected and suppurate, giving the symptoms of en- capsulated, abscess. The cyst may rupture, usually as the result of trauma. This may take place into the stomach, or bowel, or pleural cavity, or lung, or peritoneal cavity, or ex- ternally. Hydatids of the liver — physical signs : The liver is found enlarged, and usually irregularly so. The mass may point upward to the lung, or downward to the pelvis, or forward to the abdominal wall. If the prominence can be palpated, it is found to fluctuate, and the so-called hydatid fremitus, a sort of tremor of the cyst, is felt. By aspiration, the typical fluid showing the presence of cholesterin and hooklets is obtained. Diagnosis : This is positively made, with the above symp- toms and physical signs, by the discovery of the scoliees in the aspirated fluid. Prognosis : If a diagnosis is made, and the tumor is accessi- ble to operation, the prognosis is good. If untreated, the disease is apt to be fatal. Hydatids of the liver — treatment : This is purely surgical. The cyst should be opened and the contents evacuated. K very bit of the contents, especially all the small "daughter? cysts," should be carefully removed to prevent recurrence. The cavity should be packed and allowed to granulate. BILIARY CALCULI. Gall-stones, although ran; in childhood, are found from time to time. Probably their presence is often overlooked on ac- count of their extreme raritv. 150 DISEASES OF THE DIGESTIVE SYSTEM. Etiology : They are caused by the precipitation from the bile of its solids. Cholesterin, bile-pigment, and lime are the main constituents. Probably catarrh of the bile-ducts enter into the etiology, by causing a desquamation of the epithelium. Pathology : The gall-stones may be single or multiple. In children the latter condition is the commoner. They are usually small and faceted from mutual pressure. They are rather friable and of a brownish color. They are found usually in the gall-bladder, but may be found in any part of the hepatic ducts. The mucous membrane of such a gall- bladder, or of the ducts around a stone, is in a state of mild catarrhal inflammation. The gall-bladder may be dilated. Suppurative inflammation of the gall-bladder or of the ducts may be present. Biliary calculi — symptoms : So-called biliary colic is the most characteristic symptom. This is due to the passage of a gall-stone from its place of rest, through the duct to the duodenum. The attack begins suddenly, with sharp agoniz- ing pain in the right hypochondrium, making the child cry vigorously and roll around in the bed. The screaming is incessant, and nothing seems to relieve the pain. The skin is pale and clammy, and vomiting soon begins. After some few hours of this suffering the temperature rises, and a chill may accompany this rise. In highly neurotic children con- vulsions may take place. The pain may continue for a day or more, and then usually ceases as suddenly as it began. By the second day some jaundice is usually present, with bile- pigment in the urine, and later the stools may be clay-col- ored. On examination there is some sensitiveness over the region of the liver. The liver itself may be slightly enlarged. The gall-bladder may be found distended. The above is the history of an attack in which the gall- stone passes completely through the common duct and into the duodenum. Instead of complete expulsion, the stone may become impacted in the cystic, or common, duct. If it remains in the cystic duct, the gall-bladder becomes painfully distended, and eventually the stone may be pushed BILIARY CALCULI. 151 out ; or the bile in the bladder may be absorbed and the bladder gradually contract and atrophy. In other cases the gall-bladder becomes the seat of an infectious inflammation, with formation of an abscess. If the stone is impacted in the common duct, the pain gradu- ally ceases, but the jaundice with white stools increases. Later the duct forms a dilatation around the stone, allowing the passage of bile around it, the jaundice disappears, and the bile again reaches the intestine. This impacted stone may thus produce no trouble ; but there is always danger of the ducts being infected, causing a suppurative inflammation which spreads to the liver and forms multiple abscesses in that organ. Biliary calculi — diagnosis : Sudden severe pain in the region of the liver, associated with jaundice and slight tenderness and enlargement of that organ, are the points for diagnosis. Ordinary intestinal colic, intussusception, and perforation of some abdominal viscus, must be thought of as causing similar attacks. Renal colic may simulate these cases closely. The faeces should be searched daily after such an attack, to en- deavor to find a calculus. Prognosis : The attack itself is rarely fatal. One attack is likely to be followed by others. Cases with persistent jaun- dice, or with infectious inflammation of the bile-passages, are very serious. Biliary calculi — treatment : The pain should be relieved by hot baths and the hypodermatic use of morphine. Large quantities of the latter are often needed, and care should be taken to consider the fact that children bear opium badly. Hot stupes sprinkled with chloroform may be applied to the liver region. At times it may be necessary to administer an amesthetic to control the pain. After the attack of pain is over treatment should be di- rected to the prevention of further formation of gall-stones. For this, the did should be regulated, sugars and fats being excluded, abundance of water should be drunk, and out-door exercises should be enforced. Doses of olive oil, of phos- phate of sodium, and of other salines should be used from time to time. 152 DISEASES OF THE DIGESTIVE SYSTEM. Of late years the surgery of the gall-bladder and ducts has made great strides, and all chronic cases should be given the benefit of surgical advice. DISEASES OF THE PANCREAS. PANCREATIC CYST. Diseases of the pancreas are rare under ail circumstances, and especially among children. The only disease of clinical importance is cyst. Etiology : This is due to blocking of the pancreatic duct and retention of secretion behind the point of obstruction. A larger or smaller cyst may result ; only the larger ones, however, being recognized. Pancreatic cyst — symptoms : There is nothing definite in the symptomatology. The presence of a fluctuating tumor in the epigastrium, with ill-defined signs of intestinal indiges- tion and with malnutrition, are suggestive of this condition. In some cases the urine may contain sugar. Exploratory puncture with a clean aspirating-needle, by withdrawing fluid having the digestive qualities of the pancreatic juice, is the only positive means of diagnosis. Treatment : This is purely surgical, viz., incision and drainage. DISEASES OF THE SPLEEN. The normal spleen of a child lies at the left extremity of the diaphragm, and extends along the ninth, tenth, and eleventh ribs. It cannot be easily percussed or felt when of normal size. If enlarged, the lower edge can be easily pal- pated, especially on deep inspiration, extending below the free border of the ribs. If much enlarged, it may be felt extending well down toward the ileum and often the notch on the anterior edge can be easily made out. The only pathological change that takes place in the spleen that is evident to us is its enlargement. This enlargement is always secondary to some general constitutional state, except in a few very rare cases of primary splenic tumor. ENLARGEMENT OF THE SPLEEN— ACUTE PERITONITIS. 153 ENLARGEMENT OF THE SPLEEN. The commonest of the causes of acute enlargement of the spleen are malaria, typhoid fever, and septicaemia. Any of the infectious diseases, however, may cause it to swell. Such swelling is due to congestion, and the spleen becomes very dark-red and soft. When the infection has disappeared, the spleen returns to normal. There are also a number of chronic conditions in which the spleen becomes hypertrophied. In these cases the chronic congestion of the spleen is succeeded by a growth of new connective tissue, so that the spleen becomes harder and more fibrous than normal. Such diseases are tuberculosis, syphilis, leukaemia, Hodgkin's disease, amyloid degeneration, cirrhosis of the liver, chronic endocarditis and rachitis. The other causes of enlarged spleen are primary new growths. Any of these are rare, but a few cases of sarcoma and of echinococcus have been reported. Enlargement of the spleen — treatment : This is dependent on the original cause. In some of the chronic cases extirpa- tion by surgery is advisable. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Definition : This is an acute inflammation of the serous membrane covering the abdominal viscera. The inflamma- tion may be local, confined to some small area of the peri- toneum, such as that covering one viscus ; or general, when it spreads over the whole peritoneum. A localized peritonitis is liable to become general. Etiology: Acute peritonitis occurs quite commonly among new-born infants, even being found in intra-uterine life. It is rarer after this until the child reaches about its fifth year. The cause- in early infancy arc such as take their origin from the umbilical cord and navel. In later childhood the common causes are abdominal traumatism, surgical operations on the abdomen, appendicitis, exposure to cold and wet, intussusception, strangulated hernia, 154 DISEASES OF THE DIGESTIVE SYSTEM. rupture of cysts or abscesses into the peritoneal cavity, ulcers, ruptures or perforations of the stomach or intestines, inflammations of the uterus, tubes, or ovaries, rupture or inflammation of the bladder, inflammation or abscess of the abdominal lymphatic glands, and diseases of the vertebra? or pelvic bones. It may complicate rheumatism, erysipelas, chronic nephritis, or the infectious diseases. Finally, so- called idiopathic cases occur in which no cause can be dis- covered. There are always found various micro-organisms which are the exciting causes of the peritonitis. The peritoneum is particularly sensitive to these. The staphylococci and strepto- cocci are commonly found. The pneumococcus and bacillus coli communis are also frequently present. Pathology : In the beginning the peritoneum is simply con- gested, its normal shining surface becomes dull, and the sub- peritoneal vessels are visibly enlarged. The surface becomes roughened, and an exudation of serum, or of serum and fibrin, or of pus, follows. Either form of exudate may be in excess, and very large quantities of any one of them may be present. Adjacent surfaces of inflamed peritoneum become loosely adherent, and small sacculated collections of the exudate may thus be formed. The intestinal walls are para- lyzed, and the intestines are distended with gas. If the disease lasts and recovery ensues, these adhesions become organized and permanent. The formation of these adhesions may be the means of saving the patient's life, by walling off the general peritoneal cavity and circumscribing the peritonitis. Acute peritonitis — symptoms : Abdominal pain usually begins early. At first it is localized over the inflamed area, but soon spreads and becomes general even when the inflam- mation may be fairly circumscribed. The abdomen is very tender, and all motion, even that of breathing, increases the pain. On this account the respiration is almost entirely costal. There is marked tympanitic distention of the abdo- men, and the patient lies on his back with the knees drawn up to relax the abdominal parietes as much as possible. Vomiting begins early in the disease and is quite intractable. ACUTE PERITONITIS. 155 The bowels are usually constipated, not even much gas being passed, but in some cases diarrhoea may be present. The temperature is moderately high with quite an irregular curve. The pulse is rapid and feeble and wiry. Respiration is rapid and superficial, the diaphragm being nearly immo- bile. The tongue is coated and the mouth dry. The face is drawn and shows the evidences of pain. The urine is scanty and may contain albumin. All the cases increase in severity as the disease advances, and the fatal cases usually end at the expiration of a week or less. The mind is usually clear throughout. Diagnosis : This disease may be confused with intestinal, renal, or hepatic colic ; acute gastritis, or entero-colitis, and with intestinal obstruction. A little care will soon clear up the differential points. It is not only necessary to diagnose the presence of peri- tonitis, but a careful attempt should be made to locate the point where the peritonitis began ; in other words, to find the causative factor. - The diagnosis of the cause of the peri- tonitis is of very great importance from the therapeutical standpoint. Prognosis : Localized peritonitis has a much less grave prognosis than the generalized form. The latter is a very fatal disease. Seemingly very sick cases, however, do re- cover. Acute peritonitis — treatment : If the cause of the attack can be found, it will influence the treatment markedly (mainly from a surgical standpoint). Where the case is seen earl)', and the evidence points to some localized area as the region of the inflammation, surgical interference should always be considered. An example is seen in the localized peritonitis accompanying appendicitis. If the appendix can be removed before the inflammation spreads to the general peritoneal cavity, the patient can usually be saved. In some few cases recovery has been recorded following operation even after general peritonitis had set in. Abscesses in the peritoneal cavity; perforation of any viscus; and intes- tinal obstruction causing peritonitis are definite indications for operation. 156 DISEASES OF THE DIGESTIVE SYSTEM. The medical treatment consists of rest in bed and con- tinuous cold applications to the abdomen. This may be accomplished by ice-bags or the cold coil. If for any reason the cold is very objectionable to the patient, hot applications may be substituted. Turpentine stupes — flannel cloths wrung out of hot water and sprinkled with turpentine — are also very good local applications. The question of diet is of great importance on account of the incessant vomiting. Food is very likely to be immedi- ately rejected. If any form can be retained, it must be pre- digested and given in very small quantities at a time. Pep- tonized milk, peptonoids, and koumyss are all allowable. At times gavage will assist in preventing vomiting. If the stomach rejects these, nutrient enemata of predigested foods must be used. Cracked ice and champagne by the mouth will usually be well retained, soothing the stomach and acting as a general stimulant. If the peritonitis is recognized in the very beginning, a saline purge, as Rochelle salts or citrate of magnesium, in small doses every hour until the bowels move, will frequently help. It acts by depleting the walls of the intestine, and so may cut short the attack. Any time later the saline is use- less, and will only irritate the stomach. From this time on opium should be used freely. There is probably no dis- ease in which such large quantities can be safely and profit- ably used as in acute peritonitis. It is best given hypoderma- tically, and in doses enough, and repeated frequently enough, to stop the pain absolutely, and to paralyze the intestinal peristalsis. Begin with about -^ of a grain of morphine for a five-year-old child, and repeat it in about two hours as con- ditions point the way. Atropine may be well combined with it, but care must be taken not to produce belladonna-poison- ing. Gas may be removed from the bowels by the intro- duction of a long soft-rubber rectal tube. As the disease advances heart-stimulants will be required, and had probably best be given by the rectum or hypodermatically. Alcohol, digitalis, or strychnine may be used. Special symptoms are to be treated as they arise. CHRONIC PERITONITIS. 157 CHRONIC PERITONITIS. Definition : This is a rare condition in children when com- pared with the tubercular variety ; but, undoubtedly, cases of simple chronic peritonitis do occur. Etiology : It may follow an attack of the acute variety, or be chronic from the outset. It may be the result of a chronic inflammation extending to the peritoneum covering some one of the abdominal viscera, the organ itself being inflamed. Trauma is given as a cause in many cases. In the largest number, however, no adequate exciting cause can be made out. Pathology : There is a general thickening of the peritoneum, due to the growth of new connective tissue. There are fre- quent adhesions between adjacent portions of the peritoneum, and threads and membranes, due to stretched adhesions, are seen in different places. There is a good deal of serum, which may be slightly purulent, scattered among the coils of intestine. Chronic peritonitis — symptoms : The symptoms begin very gradually, with some interference with the general health, slight digestive disturbances, and irregular colicky pains in the abdomen. The abdomen is distended, but is not tender; nor is steady pain a regular symptom. The bowels are apt to be constipated, but diarrhoea may occur. As the effusion takes place, the abdomen becomes more distended and the superficial veins become prominent. The appetite is fair, and the strength keeps up tolerably well. There is little or no fever, but the pulse gradually loses in strength. If the case continues to advance, a gradual, slow exhaus- tion supervenes, from which the patient may die, or some intercurrent disease carries him off. If recovery is to ensue, the fluid is gradually absorbed, the strength returns, and the various organs take on their normal functions. Chronic peritonitis — physical signs: The tympanitic disten- tion of the abdomen, together with a feeling as if the bowels might be matted together ; and, if fluid is present, dulness in the dependent parts of the abdomen, accompanied by a fluid wave, are the physical signs to be expected. Diagnosis: If fluid is present, various causes for this, such 158 DISEASES OF THE DIGESTIVE SYSTEM. as endocarditis, nephritis, and cirrhosis, must be eliminated. The difficulty lies in differentiating this condition from tuber- cular peritonitis. The main points are the absence of any evidences of tuberculosis elsewhere, and the more marked constitutional symptoms present in the tubercular variety. Prognosis : Recovery is rather to be expected, although some changes of a permanent nature are usually left behind, which may interfere with the functions of the intestines. Many cases gradually grow worse, and die emaciated and exhausted. Chronic peritonitis — treatment : The child should be kept at rest, with plenty of fresh air and sunshine, and under the best hygienic surroundings. The diet should be easily di- gestible and highly nutrit.ous. Milk, eggs, and meat should be the staples. Carbohydrates had best be limited. Hot applications, or chloroform stupes, or some irritant liniment, should be applied to the abdomen for some time each day. The syrup of the iodide of iron given internally seems a good tonic treatment to be used. If fluid is present, occa- sional saline purges or diuretics should be used. If it shows no tendency to absorption, the abdomen should be tapped. This may be repeated if the fluid reaccumulates. If, after repeated aspirations, the fluid continually returns, laparotomy is justifiable. TUBERCULAR PERITONITIS. Occurrence : The peritoneum is frequently infected by tuber- culosis in childhood. The disease may be primary in the peritoneum, and at autopsy no other portion of the body may be found involved ; but it is more frequently secondary to tuberculosis elsewhere. Etiology: The tubercle bacillus growing in the peritoneum is the only active cause of the disease. The bacilli may be carried there by the blood or lymph without involving other organs ; but usually the peritoneum is secondarily infected from the lungs, intestines, mesenteric, or other lymph-glands. Pathology: The peritoneum may contain few or numerous small miliary tubercles scattered irregularly over its surface, TUBERCULAR PERITONITIS. 159 and no other changes be present. In some cases a serous ex- udation accompanies this. In other cases the tubercles may be massed together into large nodules or plates. Many of these may be ensealing. With these are numerous adhesions between adjacent portions of the intestines, and a variable quantity of sero-fibrinous or purulent exudation. This effusion may be free or encapsu- lated, forming a cystic tumor. In advanced eases ulceration of the tubercular nodules oc- curs, with formation of small abscesses and intestinal per- foration. All these lesions may be mixed together in any one case, but usually one or the other pathological variety predomi- nates. In some cases the ascites is the main lesion, in others the adhesions, and in others the ulcerations. Tubercular peritonitis — symptoms : Tubercular peritonitis may run its course acutely or chronically ; or the same case at different times may show decided differences in the course of its symptoms. The tendency, however, is to be chronic. The ascitic cases are usually the more rapid. There are irregular fever with moderate rises, symptoms of indigestion, diarrhcea, and usually some abdominal pain or discomfort. The abdomen enlarges and shows the presence of some fluid, free or encapsulated, and the intestines give a feeling as of being matted together. The omentum may be thickened, and give a sensation of an indefinite tumor extending across the upper part of the abdomen. Tenderness is present, but is not marked. The child feels sick, is weak and prostrated, and loses flesh regularly. Vomiting is seldom present. In the variety villi adhesions, all the symptoms are more chronic and gradual in their development, but otherwise do not differ much from the above. In the variety with caseating nodules and ulceration, {\ww> are more marked and more serious constitutional symptoms. The temperature is higher, and often assumes a hectic course. Chills ami evidences of septic absorption are present. Diar- rhoea is marked, and blood and necrotic tissue are present in tin' stools. The abdomen presents irregular areas of dulness and tympanitic resonance, Tumor- of irregular size can be 160 DISEASES OF THE DIGESTIVE SYSTEM. felt on abdominal palpation. Encapsulated fluid can be often made out. The abdominal outlines are decidedly asymmetri- cal. In the neighborhood of the umbilicus, the abdominal wall may be affected by contiguity, and an abscess burst through and discharge itself. In all varieties the disease steadily progresses, the patient growing weaker and weaker, and the signs of the disease in- creasing, until death supervenes from exhaustion or tubercu- losis elsewhere. The cases last from two to twelve months, the longer ones being of the adhesive variety. Diagnosis : The ascites of tubercular peritonitis must be distinguished from that due to cirrhosis of the liver, to chronic endocarditis, to chronic nephritis, and to simple chronic peritonitis. The last is the hardest to differentiate. The points in favor of tubercular peritonitis are the family history, the presence of any evidences of tuberculosis else- where, and the more marked constitutional symptoms. If there is no ascites, the presence of evidences of matted in- testines, or of irregular masses scattered over the abdomen, is in favor of tubercular peritonitis. In many cases, how- ever, it will be almost impossible to do more than to suspect the presence of the disease. Prognosis : Many cases of the ascitic and adhesive variety recover, some without, and more with, treatment. The ulcer- ative form is quite fatal. The disease is very serious. Tubercular peritonitis — treatment: The constitutional treat- ment of the patient is that of general tuberculosis : rich, nourishing, easily digested diet, attention to the functions of the stomach and intestines, abundant fresh air, and the ad- ministration of creosote. Local applications are almost use- less. Aspiration is of little value. After many trials it has been found that laparotomy, with evacuation of any fluid present, and washing out of the whole peritoneal cavity with sterile water, will cure a large per- centage of the cases. Any variety except the ulcerative is amenable to this treatment. Tuberculosis elsewhere in the body is not a contraindication. The reason why this opera- tion is curative is not yet decided ; in fact, no satisfactory explanation has been offered. CHAPTER VII. DISORDERS OF NUTRITION. MALNUTRITION. This, in one form or another, is a very common occurrence in children. Malnutrition — etiology : The tendency to malnutrition may be inherited from delicate or unhealthy parents. Persons of highly neurotic constitution are often the parents of these children. Infants born before term, or of unusually light weight, are apt to be affected. But commoner yet, it is seen in children who in early infancy have been fed on diet entirely unsuitable to their age. Bad hygienic surround- ings, impure air, overheated houses, and lack of proper cleanliness are also causes. Other cases follow and seem the result of precedent acute disease, as the infections, broncho- pneumonia, or some form of intestinal disease. In many of the cases, two or more of the causative factors are active at the same time. Pathology: Nothing further is found than an anaemia of all the tissues, together with a flabby condition of all the organs. Malnutrition — symptoms : There is a great difference in the weigh! of these infants as compared with a normal child of the same age. Not only do they weigh less, but their gain in weighl is decidedly slower. The child also grows much more slowly, and is much shorter than he should be. The muscles are flabby and feeble, and sitting up, creeping, and walking arc very late in being attempted. Dentition may also be delayed. The child is anaemic, and the circulation poor. The various lymph-glands of the body enlarge easily under slight irritation. The digestive functions are | rly per- formed, and greai care is necessary to prevent digestive dis- order- from developing. The resistance of these children to 11-1'. C. ir,\ 162 DISORDERS OF NUTRITION. any acute disease is very small ; not only do they seem prone to these diseases, but if the disease once develops they have little power to withstand it. If these children grow up they usually are continuously cursed by the presence of these abnormal conditions. They frequently have in addition many nervous symptoms, and may develop one or other of the functional neuroses. Some never outgrow the condition, and in adult life exhibit similar symptoms. Diagnosis : In diagnosing such a disorder great care should be taken to rule out all organic disease of every kind. There are many latent states any one of which may produce just such a set of symptoms. Tuberculosis, syphilis, rickets, malaria, malignant disease, blood-diseases, and actual disease of any of the important organs must be excluded. Do not make the diagnosis of simple malnutrition until every one of the possible causes is eliminated. Prognosis : This depends on the ability to find and remove the cause. The cases with a bad heredity are the least favor- able for cure. When due to bad feeding, or bad hygienic surroundings, or even after some acute disease, they can usually be cured. Malnutrition — treatment : This rests on the proper diagnosis of the causative factor of the condition. If it is decided that the food is at fault, steps should be taken to remedy this. In very young children a wet-nurse will often be necessary. If this is out of the question, artificial feeding, begun" with a dilute modified milk which is gradually changed to one with higher percentages of constituents, is the best method. In children on mixed diet great care should be taken to have them fed only on such food as can be easily digested by the particular child ; and on one that is highly nutritious. We must remember that often in such children food suitable for the average child of the same age is often altogether un- suitable. They often require the regular diet of a much younger child. In every way the problem of feeding these children is a difficult one, and will require great intelligence and patience on the part of both physician and parent. If the sanitary surroundings are bad, these must be changed. MARASMUS. 163 Abundance of fresh air and the avoidance of overheated living- and sleeping-rooms should be insisted on. Daily cool baths stimulate the various functions and prevent " catching cold" by accustoming the child to changes of temperature. After the bath thorough rubbing of the surface before a warm fire should be indulged in. Regular habits of eating and sleeping should be enforced. In children able to walk outdoor exercises are to be encouraged. Habits of reading and studying and other sedentary occupations should be supervised. As internal treatment, nux vomica, iron, cod-liver oil, and wines are our main assistants. Moderation should be used in the amount of each given. Use doses only large enough to be assimilated easily by a child of the age at which it is given. This is of special importance as regards iron and cod-liver oil. MARASMUS. Definition: This common condition of wasting is also known as athrepsia, or infantile atrophy. Excessive emacia- tion is an accompaniment of many diseases of infancy, par- ticularly of tuberculosis and of those of the digestive tract; but in this condition of malnutrition it is understood that none of these well-known causative factors is present. In other words, marasmus is wasting without recognizable organic lesion. Marasmus — etiology : Marasmus is a disease of the first year of life, but cases are seen with some frequency even in the second year. It is seen in the large majority of cases in artificially fed infants, but at times a breast-fed baby is the victim. It occurs with special frequency among the poor and in institutions. It might almost be considered an institutional disease. Probably three factors enter into the causation of these cases: an inherited delicate comtitution, improper methods of feeding, and imhygienic surroundings. There is an inability to digest and assimilate the food given, which food is usually decidedly improper ; but in many cases is such as properly nourishes the average child of the same age. In fact, the 164 DISORDERS OF NUTRITION. two other elements, and possibly something further which is not yet recognized, enter into the case as well as the feeding. Pathology : After death the results of the marasmus are found rather than any changes which may be looked on as causes. The muscles are atrophied, all fat has disappeared from the body, and fatty degeneration of the kidneys and liver is often present. Some hypostatic pneumonia is fre- quently found along the posterior borders of the lungs. The stomach shows no special changes. The solitary and agmin- ated follicles of the intestines are usually enlarged and may be slightly pigmented. The mesenteric glands may likewise be enlarged. So many of these cases die of some intercurrent disease that other lesions due to those diseases are present, but in a pure case of marasmus nothing further is found. Marasmus — symptoms : The disease begins gradually and progresses gradually. Loss of weight and emaciation are the characteristic features. The regular infantile plumpness gradually disappears, the muscles grow soft and atrophy, the skin becomes wrinkled and dry, the face grows thin, pinched, and pale, the anterior fontanelle becomes depressed, while the abdomen grows prominent and distended. Eventually there seems nothing left but the skeleton covered by skin. There is marked ansemia, the haemoglobin often being only one-third of the normal. The temperature is usually subnormal, even when taken by rectum. The pulse is rapid and feeble, and the respirations inefficient. The tongue is coated, and the mouth is frequently the seat of thrush. The appetite is usually voracious, the call of the starved tissues for nutri- ment being strong and constant. The taking of food does not seem to satisfy this hunger, and naturally so, as the tissues do not receive it. Vomiting is rather frequent from the constant attempts made to satisfy the appetite. The stools may be fairly normal, but usually contain undigested food. They may be green, and of offensive odor, and are usually large in amount from the small absorption of the food. The buttocks are regularly excoriated and red, and bedsores develop on the occiput, sacrum, and heels. The child lies quietly, dozing a good deal of the time, and constantly sucking the fingers and hands. Restless sleep and MARASMUS. 165 fretfulness may be present, especially when the child is dis- turbed. Nervous symptoms, twitching, rolling of the eye- balls, and convulsions are frequently present. The neck is often retracted. The disease advances steadily to a fatal issue, which may result from exhaustion, from convulsions, or frequently from some intercurrent disease. Marasmus — diagnosis : The diagnosis rests on the exclusion of all forms of organic disease. The main diseases under this category are tuberculosis, congenital syphilis, and chronic digestive disturbances. Tuberculosis shows the physical signs in the lungs, and is associated with fever. The hypo- static pneumonia of marasmus may, however, give physical signs that are confusing. In inherited syphilis the child has snuffles, and has a dry skin showing some form of rash. The mouth and anus show mucous patches. In digestive dis- orders the history points to the diagnosis. Prognosis : The prognosis is very bad in young infants, in institutions, and among the poor and ignorant. Even under the best circumstances it is often difficult to start the nutrition on the up grade. Return to normal is complete when re- covery does occur. Marasmus — treatment : Attention should be paid to the three etiological factors. As yet we have no way of improv- ing the heredity, but the sanitary surroundings can be changed for the better. Plenty' of -fresh air should be given all infants, and especially should this be so in all institutions. The question of diet, the third factor, is of vast impor- tance. Wet-nursing will often be the only means of safely feeding these infants. If this is impossible, modified cow's milk given in small quantities and regularly is the best food. We must begin with a dilute milk for the age, and gradually increase the ingredients with the child's ability to digest them. Peptonized milk is of special value in many of these cases. The child should be bathed regularly, and the bath finished with :i cold douche to stimulate the respiration. Thrush, in- tertrigo, and bedsores must be treated in the ordinary way. Cod-liver oil is much used in this condition ; but its utility depends on its absorption, and in very many of the cases no absorption takes place. The children should be kept warm, 166 DISORDERS OF NUTRITION. especially when the temperature is subnormal. Special care should be used to prevent them from contracting any acute disease, as such diseases are very fatal. SCORBUTUS. Definition: This is commonly called scurvy. It is a con- stitutional disease, which in infants, until recent years, has often been called acute rickets, its exact classification being unrecognized. Etiology : " Infantile scurvy follows the prolonged employ- ment of some diet unsuitable to the individual child." While no one particular diet seems to be always at fault, in a gen- eral way " the farther a food is removed from the natural food of a child, the more likely is its use to be followed by the development of scurvy." The lack of the quality of freshness in the food seems to be the most marked single factor. The proprietary foods, condensed milk, and steril- ized milk seem to have the most cases assigned to them as a cause. A few cases fed on breast-milk, or on raw cow's milk, or on table diet, are reported. The disease occurs usually during the first two years of life. The largest proportion of the cases are seen in the better walks of life. It is not any more common in the city than in the country. Pathology : So few cases of scorbutus die that opportunity for pathological investigation is rare. The changes that are found are those due to hemorrhage. In an affected limb there will be present a large subperiosteal hsematoma. The perios- teum will be stripped from the bone, and in bad cases detach- ment of the epiphysis may be present. The bone, especially in the neighborhood of the epiphysis, will be quite congested. Scorbutus — symptoms : The patients are apt to be ansemic and show signs of malnutrition ; but these signs may be evi- dent only to a skilled observer, a layman considering the child well developed. Scurvy frequently develops in a rickety child, although there is no relation between the diseases. Usually the first symptoms that definitely point to scurvy are pain and tenderness. The pain may be present when the SCORBUTUS. 167 child is at rest, but usually is evident only on moving or handling the child. This tenderness may be so great as to cause the child to scream if anyone approaches him, or if the least movement is made that shakes him. On searching for the situation of the pain, it will usually be located in the limbs. Another symptom, which is a direct result of this tenderness, is a pseudo- or voluntary paralysis. The child holds the affected limb immobile, in order to prevent the pain which results from motion ; the limbs are apt to be kept in a flexed position. If now the extremities are carefully examined, there will usually be found a more or less marked fusiform swelling of one or more of the limbs. These swellings, which are due to the subperiosteal hemorrhages, will usually be found involv- ing the shafts of the long bones, more particularly the femur, tibia, or humerus, and extending into the epiphyseal area. In some cases the hemorrhages are confined to the epiphyses, and in these the case seems more like a joint-involvement, and is very likely to be mistaken for rheumatism. There may be some redness around these joints, but it is not regularly present. In the great majority of cases the gums are affected at the same time. They are swollen, spongy, and bleed easily. Ulcerative stomatitis may develop from these. These signs are more marked in cases when the teeth have erupted, but at times are seen in infants with no teeth. Purpuric and ec- chymotic spots are fairly frequent. They may occur anywhere on the body, but are quite regularly seen about the eyes. Hemorrhages from the mucous membranes may be present, such as those of the stomach, intestines, or nose. There is no regular fever in this disease, but slight elevations of tempera- ture may occur. Albuminuria at times is present. Cases are seen of all degrees of severity, from mild attacks of tender joints to very marked eases with hemorrhagic gin- givitis and large subperiosteal hemorrhages. Diagnosis: The three conditions most likely to be confused with scurvy are rheumatism, paralysis, and osteosarcoma. If scurvy is always kept in mind, it will be fairly easy to make the differential diagnosis. The prompt improvement on 168 DISORDERS OF NUTRITION. proper treatment offers a therapeutical proof of the diagnosis in cases of doubt. Prognosis: This is good. Recovery will be rapid under proper treatment. Scurvy occurring in a case of severe marasmus, or other condition of exhaustion, is naturally a more serious disease. Scorbutus — treatment : The child should be kept as quiet as possible to protect it from pain. If the epiphysis is sepa- rated, the limb should be put up in splints. An antiseptic mouth-wash may be used with advantage. A change in the diet is imperative. In a general way it may be said, stop all proprietary foods, condensed milk, and sterilized milk. Put the child on raw cow's milk and orange- juice. Beef-juice, and in older children potato, are also use- ful adjuncts. The symptoms may be confidently expected to improve greatly in three or four days, and cure may be expected in three to four weeks. After improvement begins steps should be taken to correct the malnutrition from which the child is usually suffering. This can be best accomplished by fresh air, iron, and cod-liver oil. RACHITIS. Rickets is a constitutional disease with its main pathologi- cal lesions located in the bones. It must be remembered, though, that almost all the organs of the body take part in the nutritional changes. Etiology : Rickets is far more frequent in the cities, among the ill-fed and badly housed. These conditions, together with the diet, are the actual causes. Prolonged feeding on a diet which does not contain all the proximate principles of milk in comparatively proper quantities is regularly a cause. The fat first and the proteids second are usually deficient. Condensed milk and the proprietary foods fulfil this con- dition of lack of fat and proteids, and the large proportion of cases will be found to have been fed on one or the other of these foods. Prolonged nursing at the breast, as when it is continued into the second year, and even breast-feeding 01 o 5 «5 » i ffl Q £ 3! (0 • 73 0> U4 — m 3 » 5" 3 a .-. to ** a ~ 3 £«* a 8) 9) T 3 IB to a — _ a 05 „ 3 ft >< 3 RACHITIS. 169 when the mother's milk is deficient in quality, will produce rickets. Two nationalities in this country, the negroes and Italians, seem especially prone to the disease. The age of greatest susceptibility seems to be from the sixth month to the end of the second year. Pathology : Although all the tissues of the body are in- volved by the nutritional changes, still the lesions evident to the naked eye are mostly in the bones. There is a general anasmia of the voluntary muscles, and of those of the heart. The lungs show the furrows from the depressed thorax. The stomach and intestines are dilated and show some evidences of chronic catarrhal inflammation. The spleen is enlarged. The liver and kidneys are negative. The lymphatic glands in different parts of the body are apt to be enlarged. In the bones are the constant signs of the disease. These changes take place in the regions of the bones where ossifica- tion is in progress. These regions are the cartilage between the epiphysis and the shaft, underneath the periosteum, and in the flat bones about the centres of ossification. The bones grow by the proliferation of the cartilage-cells in these loca- tions, which cartilage-cells have lime salts deposited in them, thus undergoing ossification. In rickets the proliferation of these cartilage-cells is stimulated to undue activity, while the deposit of lime salts in the same areas does not keep pace with the cartilaginous growth. The result of these abnormal changes is to produce a marked enlargement at the epiphyses of the long bones and at the centres of ossification of the flat bones. These bones become very soft and flexible owing to the deficiency of lime salts in them. The normal two-thirds mineral matter is reduced to one-third. This softness and flexibility explain the rachitic deformities, which are especially marked where the bones are subject to muscular action or to pressure, as in the femur, tibia, radius, ulna, or the ribs. A section through the epiphyseal junction of a rachitic bone shows a very vascular, bluish-colored condition, which is softer than normal when cut. In the shaft next to the perios- teum the bone is soft and thickened, but deeper it is hard. Sec- tion through thickened masses on the flal bones shows :i spongy vascular substance which is soft enough to be indented easily. 170 DISORDERS OF NUTRITION. Microscopical examination shows a marked increase of new cartilage-cells and increased vascularity of the proliferating zone. The areas which should be calcified show large quantities of cartilaginous tissue instead. The under layer of the periosteum is very vascular, and again there is a great excess of uncalcified cartilage. In the flat bones the bony trabecule are eroded, and their places taken by newly formed minute blood-vessels. When the rachitic process ceases and recovery begins, this excessive proliferation stops. Calcification and ossification of these tissues take place, the enlargements due to the hyperplasia are absorbed, and the bone returns to a normal condition save for any deformities that may have resulted during the activity of the rachitic process. Rachitis — symptoms : Rickets is a slow disease, with a very gradual onset and progression. It is difficult to say when the disease begins, as the early symptoms are not marked enough to attract much attention. A fully developed case of the dis- ease is easily recognized ; but it is of more practical value to be able to diagnose the beginning of rickets, so as to prevent its further development. At the first, we may expect to find some ancemia, marked sweating around the head and neck, especially during sleep, and slight beading of the ribs. The baby is restless in its sleep and is usually constipated. The hair will frequently be rubbed off the occiput by the continual rolling of the head in the pillow. As the disease advances the bony changes become more prominent, although the other symptoms still continue. The beading of the ribs, the so-called " rachitic rosary," increases until the little lumps are evident to the eye through the skin. In the early stages they are evident only to palpation. The "beads" are due to overgrowth of cartilage at the junc- tion of the ribs with the costal cartilages. They are found at the end of each rib, the row thus made running downward and outward to the costal margin. The same beading is found on the inner side of the thorax, but naturally only shows in this situation post mortem. The atmospheric press- ure exerted on these softened ribs causes in advanced cases RACHITIS. 171 a marked depression of the thorax in a line parallel with and on each side of the sternum, and just along the course of these beads. A second depression is also frequently present extending in a horizontal direction around the lower portion of the thorax, and is probably due to traction of the dia- phragm on the lower ribs. The sternum is apt to be pro- truded, or at times depressed, by this same action of the atmospheric pressure, causing the deformity known as pigeon- breast or funnel-breast. The vertebrce likewise are partially softened, and the weight of the head and shoulders on these causes a posterior or lat- eral bending of the spinal column. The kyphosis, or scoliosis, so produced, forms a long, regular curve, no sharp angles being found in rachitic spines. In the early stages these curvatures will disappear when the child lies down or is sus- pended, but in the long-standing cases the deformity becomes permanent. The changes in the cranium are well marked and charac- teristic. The head appears large and square, the forehead broad and projecting, the top is flattened, and the suggestion of two furrows crossing each other at the anterior fontanelle at right angles is often present. These appearances are due to the thickened masses of bone, called "bosses" which exist at the frontal and parietal eminences. These bosses often grow quite thick and prominent. In the occipito-parietal regions are frequently found soft spots in the bones. This condition is known as crauiotabes. ( J a pressure with the finger these small areas dent in, but spring out again when the pressure is removed. Crauio- tabes is seen in syphilis as well as in rickets. The sutures and fontanelles arc very late in closing; often the anterior fontanelle will be open at the end of the second or even the third year. The veins of the scalp seem large, and are plainly outlined through the thin skin. The teeth are cut quite late, are often irregular in the order of their appearance, and are subject to early decay. The various disturbances connected with dentition are more apt to be seen in rachitic children than in normal ones. Changes in the long bones of the limbs are seen early and 172 DISORDERS OF NUTRITION. constantly. The earliest is an enlarged, rounded knob, found at the epiphyseal junctions. The wrists, ankles, and knees show this change most commonly and in the order named. Other joints may be affected in the most severe cases. Later the long bones become bent into abnormal curves. These bendings are most marked in the leg, thigh, and forearm, but the upper arm may also be affected. In the forearm the bones are usually bowed backward, and in the upper arm outward. It is in the legs though that the deformities are most marked. The usual variety is bowing outward of the tibia;, and, in marked cases, of the femora also, producing the condition known as bow-legs or genu varum. In these patients, when the feet are put together, the knees are far apart. In others the opposite condition of knock-knee, or genu valgum, is present. In these the inner condyles of the femur are hypertrophied, so that when the knees are put together the feet are far apart, the legs making an obtuse angle with the thighs. In very severe cases the rachitic softening is so marked that irregular and very dis- tressing deformities in the long bones are produced. In the pelvic bones rickets causes certain changes that are of importance only from an obstetrical standpoint, since the deformity may interfere with the passage of the child through the pelvis. The usual deformity of rickets is a decided short- ening of the antero-posterior diameter of the pelvis, from pushing forward of the sacrum. The ligaments about all the joints are relaxed and weak- ened, thus assisting in the production of the deformities. The muscles also are flabby, small, and feeble, so that sitting and standing are difficult for these children. Walking is always learned late, and at times they are first brought to the physi- cian to know why they do not walk, the mother dreading paralysis. Children with rickets may be either fat and seemingly well nourished, or thin and suffering from malnutrition. Almost always they are anmmic. The abdomen is enlarged and tympanitic, for which there are two probable reasons : the pressing downward of the dia- phragm from the diminished chest-capacity, and the disten- RACHITIS. 173 tion of the stomach and intestines from the accompanying chronic indigestion. The pulse and temperature are about normal. A bruit may often be heard over the anterior fontanelle, but is of no special significance. The urine is negative. Rachitic children are quite prone to catarrhal inflammations of the gastro-intestinal tract or of the respiratory system. The reflex excitability of their nervous systems is highly ex- aggerated, and laryngismus stridulus, tetany, and general convulsions are frequent. The course of rickets is chronic, and the disease usually lasts for one or two years. Spontaneous recovery regularly occurs, as the child is put on a mixed and nourishing diet. Diagnosis : In a developed case the diagnosis is not diffi- cult, and hydrocephalus is the only disease with which it may be confused. A careful examination of the head, and the presence of rickety changes elsewhere, are the deciding points. In mild cases careful examination for beginning changes in the bones, at the epiphyses and costal cartilages, will usually settle the diagnosis. Any of the bony signs are sufficient to establish the presence of rachitis, when the child is supposed to be suffering only from an emia, debility, or even from paralysis. Prognosis : The disease is self-limited, and will usually re- cover spontaneously when the diet becomes such as to furnish the proper nutrition. Rachitis is seldom fatal in itself, but from its tendency to act as a predisposing cause of gastro- intestinal, respiratory, and nervous diseases, it is partially responsible for much infantile mortality. The bony deformities which have taken place during the disease are, as a rule, permanent throughout life. Rachitis — treatment: Proper attention to the hygienic sur- roundings and care with the food are the two general points to be followed both in the prevention and in the treatment of rachitis. The children should be kept in cool, dry, well-ventilated rooms. They should be given as much out-of-door life as possible, and particularly plenty of sunshine. Each day they should be given a cool bath to stimulate the respiration and 174 DISORDERS OF NUTRITION. circulation, and to accustom the system to changes in temper- ature, and thus do away with the tendency to " catching cold." The diet should be made to conform as nearly as possible to the normal for a child of the same age. Proprietary foods and condensed milk should especially be avoided. An abundance of fats and proteids should be given, while the carbohydrates should be diminished. Cream, beef-juice, and scraped beef fulfil these conditions admirably. As regards drugs, three are used quite regularly, and all rationally. They are cod-liver oil, phosphorus, and lime. Cod-liver oil is given more as a fat food than a drug, in just sufficient dosage to be absorbed easily and not to upset the digestion. Phosphorus is given in doses of ^-jro ^° Tiro °^ a grain three times a day. Thompson's solution, containing one-twentieth of a grain to the drachm, is the easiest way of giving it. Lime is best given as the hypophosphite of calcium. If the child is anaemic, iron as the syrup of the iodide is useful. During the active stage of the disease attention should be given to the prevention of bony deformities as far as possible, by keeping the child from making too much mechanical ex- ertion. Light supports and braces may often be used with advantage. If marked deformities are present after the cure of the disease, orthopaedic apparatus may be tried, but oste- otomy will usually be necessary to straighten the bones. DIABETES MELLITUS. Diabetes mellitus : This is a rare disease in children, and is probably as well grouped under the errors of nutrition as elsewhere, in the present state of our knowledge. It is a far more serious disease in childhood than in adults, its serious- ness being inversely to the age. Etiology : It is commoner in girls than in boys, and there is an hereditary element present in many of the cases. Other- wise nothing is known as to the causes. Pathology : There are no recognized pathological facts con- nected with diabetes other than the occasional association of pancreatic disease and diabetes. ACUTE RHEUMATISM. 175 Diabetes mellitus — symptoms : The symptoms are frequent urination, which is found to be due to increased secretion of urine, great thirst, increased appetite, and wasting. On examining the urine the specific gravity is high, and sugar is present in larger or smaller quantities. As the case advances albumin may also be found in the urine. Loss of weight is very rapid, the skin becomes dry, and constipation is apt to be present. Furunculosis may exist as a complication. Der- matitis about the genitals may develop from the irritation of the glycosuric urine on the skin. This is commoner in girls. The disease progresses rapidly, and a fatal termination usually comes before six months from the outset. Diabetic coma is the usual cause of death. A few die of pneumonia or tuberculosis. Diagnosis : This is based on the urinary analysis, a method of examination too seldom used in dealing with children. Prognosis : This is very bad, almost surely fatal, in child- hood. Diabetes mellitus — treatment : This differs in no wise from that in adults. The diet should contain as little carbohydrates as possible, milk, meat, and eggs being the staples. Good hygiene should be insisted on — fresh air, exercise, and bath- ing. As drugs, codeine given regularly seems the most valuable one. Arsenic and the salicylate of sodium have some reputation as being of value. ACUTE RHEUMATISM. Nature : We are still in the dark as to the true nature of rheumatism, and, as there is evidence as to its being due to faulty f issue-metamorphosis, it is hero classified mainly as a matter of expediency. In fact, rheumatism in childhood is inure of a diathesis with local evidences breaking out in various portions of the body, than distinctly ;i joint-disease as it is looked on in adults. Cases are seen with the joint- symptoms so very slight that they are entirely overlooked. Etiology: Nothing is as yet positively known on this point. There may be more than one exciting cause at work at the same time. There may be some poisonous substances, due to 176 DISORDERS OF NUTRITION. faulty metamorphosis of the tissues, floating in the body-fluids, which irritate and inflame the serous membranes ; or there may be specific micro-organisms at work as the cause. He- reditary influences play a certain part, and exposure to cold and damp undoubtedly acts as an assistant exciting cause. Acute rheumatism — pathology : The inflamed membrane, whether it be in a joint, the pericardium, or the endocardium, is congested, and may show slight hemorrhagic spots. There is an increased secretion of serum accompanying. The tissues in the neighborhood are swollen by inflammatory effusion, which may contain fibrin, leucocytes, and at times red cells. The articular cartilages are also swollen and inflamed. Sup- puration is very rare. Acute rheumatism — symptoms : Rheumatism in childhood is seldom of the very acute type so often seen in adults, but is more apt to be subacute in its manifestations. The general symptoms are those of more or less fever, which is regularly lower than 102° F., and which runs an irregular and rather short course ; and its accompaniments, malaise, anorexia, at times nausea and vomiting, some delirium, and a more or less free perspiration. At the same time one or more joints become painful and may appear a little swollen and red. These joint-symptoms may be so slight as to give no signs save a little tenderness on use. The urine is of high specific gravity and deposits urates on standing. The child may not feel sick enough to desire to go to bed. These attacks are often called " growing pains " by the family. The attack usually lasts only one or two weeks. In other cases no joint may be affected, but the rheumatic poison centres itself in some one of the muscles. The muscles most commonly affected are the deltoid, the trapezius, and sternomastoid, those of the lumbar region, or the intercos- tals. In such cases there are scarcely any constitutional symptoms, the only sign being pain on motion in the affected muscles, and at times some continuous spasm of the same. In other children, and unfortunately fairly often, with very slight joint or muscular signs, the poison especially attacks the pericardium or endocardium. This is, of course, far more serious. In fact, the heart is more frequently involved in ACUTE RHEUMATISM. 177 children than in adults, and at times the only way of feeling sure that the child has been suffering from rheumatism is by finding a murmur or a friction-rub. No case that is even suspicious of rheumatism should be allowed to go a day without a careful examination of the heart. Heart-compli- cations, as a rule, give no special symptoms, except a slightly rapid or irregular heart-action, or a little precordial pain if pericarditis develops. In other cases the rheumatic diathesis is evidenced by an outbreak of chorea, either with or without signs in the joints; and in others by an attack of acute tonsillitis, or by recurrent attacks of the same ; in others subcutaneous nodules are found developing on almost any of the fibrous structures of the body. They are mainly about the joints and in the sheaths of tendons, and vary in size from a pinhead to an almond. They seem particularly associated with cardiac disease. They are not tender and not permanent. Cutaneous eruptions, either erythematous or even purpuric, are often developed by the rheumatic diathesis. Rheumatism, no matter in what variety it manifests itself objectively, is always accompanied by a rapidly developing ancemia. Acute rheumatism — diagnosis : The slightness of the joint- affection makes the diagnosis difficult at times. Previous similar attacks, or attacks of tonsillitis, or a rheumatic family- history assist. Signs of pericarditis, or of endocarditis, or rash, or fibrous nodules, or chorea, are the best evidence. Scurvy, rachitis, tuberculosis, and pyaemia are to be differ- entiated. By care no confusion need exist. Acute rheumatism — prognosis : This is good in every way except as regards the development of heart-lesions. The heart-lesions become permanent; but the changes in the joints and muscles, the chorea, the fibrous nodules, and the tonsillitis are curable. A bad point in the prognosis is the tendency for further attacks to develop after the first. Acute rheumatism — treatment: A child with any of the rheumatic manifestations should be an object of care for the prevention of heart-lesions. He should be kept at rest in bed, and in an equable temperature, till all signs have disap- peared. After an attack is over lie should be constantly 12—1). c. 178 DISORDERS OF NUTRITION. under supervision to prevent subsequent attacks. He should wear flannel underclothing and should be kept from all damp surroundings, and especially from wet feet. During the attack the inflamed joint or muscle should have hot local applications made to it, and should be rubbed gently with chloroform liniment. Internally the salicylate of sodium or the oil of wintergreen should be given in fairly large doses. In some cases citrate of potassium in doses large enough to keep the urine alkaline should be used. It may be profitably combined with the salicylate. During the fever the best diet is milk ; later it may be more varied. Water should be drunk freely. After the attack iron is indicated to combat the ansemia. The heart-lesions and chorea are treated as usual. CHAPTER VIII. DISEASES OF THE CIRCULATORY SYSTEM. DISEASES OF THE HEART AND PERICARDIUM. CONGENITAL HEART-DISEASE. All abnomalities found in the heart at birth are classified under this head. Some form of congenital heart-lesion is found with moderate frequency. Congenital heart-disease — etiology : The causes are well grouped under three headings: 1. Non-closure of openings existing normally in foetal life. These are the foramen ovale leadino; from the right to the left auricle, and the ductus arteriosus connecting the pulmonary artery with the descend- ing aorta. 2. Actual developmental areas. These are par- tial or complete absence of the septa, between the auricles or ventricles; transposition of the great vessels; atresia or absence of one of the valves. 3. Endocarditis occurring during foetal life. This is capable of producing any of the lesions which follow endocarditis of post-natal life. Pathology: The commonest lesions found are absence or defects of the ventricular septum, patent foramen ovale, stenosis of the pulmonary artery, persistent ductus arterio- sus, and abnormalities in the origin of the great vessels. Many lesions are found connected with the valvular open- ing-, both stenoses and insufficiencies, but in nowise differing from the same lesions as seen in ordinary endocarditis, excepf that the right side of the heart is more often involved than the left. A large number of the cases have more than one lesion existing at the same time, as if when a defect occurred a partial endocarditis was engrafted on it. The heart is ordinarily hypertrophied, as the result of the extra work thrown on it by these anomalies. 179 180 DISEASES OF TEE CIRCULATORY SYSTEM. Congenital heart-disease — symptoms : Cyanosis and the presence of a murmur are the characteristic signs of this con- dition. The cyanosis is present continuously in most of the cases, but may be developed only by exertion, as crying, coughing, or vomiting. At any rate, it is always intensified by such action. The blueness is due to imperfect oxygenation of the blood, and is present in all the tissues. The mucous membranes, as the lips and tongue, appear very purplish. The murmur heard over the heart is usually rough and loud, and systolic in time. It may be heard loudest at the base or apex. Murmurs synchronous with the other heart- sounds are rare. It is, however, impossible to diagnose the form of lesion by the variety of murmur, as many different pathological changes produce the same murmur. There are cases of undoubted congenital heart-disease with absolutely no murmur, the cyanosis being the only symptom present. Hemorrhages from the nose and elsewhere are fairly com- mon. A result of the chronic congestion of the tissues is seen in the clubbed fingers and toes which these children pre- sent. The last phalanges become enlarged and thick, and the nails somewhat deformed. Dyspnoea, increased on exertion, is a marked symptom and is always troublesome. Dropsy in the limbs and serous membranes may supervene. Diagnosis : In the presence of cyanosis and a murmur the diagnosis is made. In the absence of a murmur other causes, which are mainly pulmonary, of cyanosis must be excluded. Nothing more than a guess as to the variety of abnormality in the heart can be made. Prognosis : This is bad. Most of the cases die before they are twenty, and during their life they are in a state of con- tinual danger and discomfort. Their functions are badly per- formed, they are delicate, and bear badly any acute disease, particularly in the respiratory system. The more marked the cyanosis the worse the prognosis. Congenital heart-disease — treatment : There is nothing to do for the abnormalities themselves. Good hygiene and pre- vention of colds and exertion are necessary. Otherwise we can only treat symptoms as they arise. ACUTE PERICARDITIS. 181 ACUTE PERICARDITIS. Etiology : This is a quite rare disease in infancy, but is as common in older children as in adults. The principal cause is rheumatism. It may complicate pneumonia, or pleurisy, or scarlet fever. General sepsis may involve the pericardium. Direct injury and extension of the inflammation from a neighboring organ are frequent causes. Pathology : The pericardium may be the seat of a dry inflammation in which the membrane is swollen and rough and coated with fibrin ; or, more commonly, there is at the same time an effusion of serum in greater or less quantity in the sac. In children the serous variety is commoner than in adults. In other cases there is a distinct purulent character to this effusion. Rarely it is hemorrhagic. After recovery the fluid is absorbed, but the fibrin becomes organized, leaving adhesions between the two layers of pericardium. Acute pericarditis — symptoms: The subjective symptoms are few and slight. There may be a little precordial pain, and some interference with the heart's action. If effusion embarrasses the heart, there may be some dyspnoea and a weak, irregular pulse. The other symptoms are those of the primary disease. Pericarditis lasts usually two or three weeks. Acute pericarditis — physical signs : In dry pericarditis there is heard a superficial to-and-fro friction-sound directly over the heart and uninfluenced by inspiration. It is loudest in the third and fourth spaces just to the left of the sternum. In the serous variety the area of cardiac dulness is increased in all directions, this dulness extending further to the left than the apex-beat, There is usually a small area of dul- ness extending to the right of the sternum. The heart- sounds are heard feebly, and a preceding friction-sound will disappear. Diagnosis : This depends entirely on the physical exami- nation of the heart. The use of an exploring-needle to cor- roborate the diagnosis of effusion and to decide on the kind of fluid present is always allowable. Prognosis: The younger the child the more serious the 182 DISEASES OF THE CIRCULATORY SYSTEM. prognosis. While pericarditis is always a serious disease, and always adds a bad element to the condition which it complicates, still it is frequently recovered from. The pres- ence of fluid aggravates the danger as it increases in quantity. Purulent pericarditis is the most dangerous form. The adhesions left after recovery are often the source later of serious trouble. Acute pericarditis — treatment : Absolute rest in bed should be enforced from the first. Locally, hot applications, or mild counter-irritation, or an ice-bag with a layer of flannel between it and the skin, seem to have some power of limiting the inflammation. The diet should be easily digestible and in moderate quan- tity, so as not to overload the stomach. The primary disease to which the pericarditis is secondary should be treated thoroughly. Probably the best drug to use is opium to quiet the patient and the heart. Aconite or digitalis may be used to slow an overacting heart. The latter is especially good if the heart's action becomes feeble. If effusion is present, counter-irritation and some diuretic, as caffeine, will usually remove it. If it is persistent and interferes with the heart by its mechanical presence, aspira- tion done in the fifth intercostal space just to the left of the sternum is advisable. If the effusion is purulent, it is best removed by incision. After the attack is over renewal of physical exertion should be gradual, and tonic treatment is indicated. CHRONIC PERICARDITIS. Pathology : This condition is mainly the result of one or more attacks of acute pericardial inflammation. At times it is tubercular. The main lesions are a thickening of the pericardium and the presence of permanent connective-tissue adhesions be- tween the visceral and parietal layers. Symptoms : There are usually no subjective symptoms, unless some feeling of interference about the heart and dyspnoea on exertion. ACUTE ENDOCARDITIS. 183 Chronic pericarditis — physical signs : The heart is usually enlarged, the apex being displaced to the left and downward. The only characteristic sign is retraction of a small spot of the chest-wall during the systole of the heart. This is pres- ent, though, in but a small percentage of the cases. Prognosis : The lesion is permanent, but is compatible with long life. Chronic pericarditis — treatment : There is no special treat- ment for the disease. Good hygiene and attention to the body-functions comprise the therapeutics. ACUTE ENDOCARDITIS. Inflammation of the endocardium, especially that part enter- ing into the formation of the valves, is quite as frequent in childhood as in adult life. In foetal life usually the right heart is affected ; after birth the left heart, as in adults. Etiology : Rheumatism is the most frequent cause of the disease. Scarlet fever, septicaemia, and, less frequently, the other infectious diseases, are complicated by endocarditis. Pathology : The endocardium is swollen only and remains smooth, or there is an extensive growth of new connective- tissue cells in its substance. This produces warty excres- cences on the surface of the endocardium involved, and on these excrescences fibrin coagulates from the blood and organizes, exaggerating the changes. The valve becomes deformed, the chordae tendinese shortened, and, the new con- nective tissue being deficiently vascularized, tends to break down and ulcerate. Portions of these "vegetations," as they are called, may be broken off and carried by the blood- current to different parts of the body, where they lodge, and are called emboli. The vessel in which they are caught is stopped up, and the process is called embolism. Acute endocarditis — symptoms : There may be no rational symptoms at all, or the endocarditis may show itself by some fever, malaise, disturbed heart-action, and restlessness. The pulse is usually rapid and not very strong, and there may be venous congestion of the body with dyspnoea. Delirium or stupor may be present. 184 DISEASES OF THE CIRCULATORY SYSTEM. At times the signs of an embolism in some portion of the body is the first symptom, suggesting a heart-lesion. If the embolus goes to the brain, hemiplegia is the usual result ; to the lungs, sharp dyspnoea ; to the kidneys, haematnria ; to the liver and spleen, local pain and enlargement ; to the mesen- tery, diarrhoea ; to the limbs, obstructed circulation. An attack of acute endocarditis lasts two or three weeks, and ends in recovery or death, or often becomes the starting- point for a chronic endocarditis. Acute endocarditis — physical signs : Regular physical ex- amination of the heart will often show the presence of an acute endocarditis during an attack of rheumatism or scarlet fever when no subjective symptoms of any kind are present. The physical signs depend on the changes in the valves — in- sufficiency, or roughening, or stenosis. According to the valve involved, and the lesion of this valve, will be the form of murmur present. With mitral regurgitation we hear a systolic murmur, loud- est over the apex ; with mitral stenosis, a presystolic murmur, heard loudest over the mitral area ; with aortic regurgitation, a diastolic murmur, heard over the aortic valve and carried down the sternum ; with aortic roughening, a systolic murmur, heard loudest over the aortic valve. The valves of the right side, and combinations of valves, give their distinct murmurs also. Diagnosis : This depends on the physical signs rather than on the symptoms. Pericarditis is differentiated by its friction- sound, which is superficial and not connected with valvular closure. Functional or anaemic murmurs are at times diffi- cult to exclude. They may be heard over the apex, but are most frequent over the pulmonary valve — the second left in- terspace. The second pulmonic sound will not be accentu- ated in anaemic murmurs. An old valvular lesion being present and not before recognized, may raise the suspicion of an acute endocarditis when none exists. Prognosis : Recovery without some change left behind in the valves is rare, but at times all murmurs and all evident signs of heart-lesion do disappear permanently. In some cases the valves remain without undergoing further change MALIGNANT ENDOCARDITIS. 185 throughout life. In others, slow changes continue and the case becomes one of chronic endocarditis. Recurrent attacks are common. Very few die in the acute stage. Acute endocarditis — treatment : If any suspicion of a rheu- matic diathesis is present, anti-rheumatic treatment should be instituted. The salicylates, combined with the citrate of potassium, in large enough doses to render the urine alkaline, is the best form to give this. Absolute rest in bed is of primary importance. If the heart's action is exaggerated and tumul- tuous, aconite or opium is indicated to quiet it. If the heart's action is feeble and rapid, digitalis is the best drug. After the acute stage has passed, rest should be insisted on for some time, and exertion should be resumed very grad- ually. Iron and tonics are to be used freely during this stage. Efforts should be made to prevent subsequent attacks of rheumatism in these patients. MALIGNANT ENDOCARDITIS. This is often called ulcerative endocarditis, and in childhood occurs most always after the tenth year. Hence it differs in no respect from the same condition when seen in adults. Etiology : The disease is a cardiac sepsis, combined with an inflammation of the endocardium. It occurs with rheuma- tism, pneumonia, erysipelas, scarlet fever, gonorrhoea, and septicaemia. Streptococci, staphylococci, and pneumococci are found in the endocardium. Probably, it is never a primary condition. Pathology : The endocardium is swollen, infiltrated with round cells, and often ulcerated. The surface is coated, in patches, with a thin or thick layer of fibrin and micrococci. Vegetations and ulcerations form in the cavities and on the valves. Portions of these vegetations being detached are car- ried by the blood to distant parts of the body and lodge as emboli, causing not only the mechanical results of embolism, but setting up an infectious inflammation at the same spot. Malignant endocarditis — symptoms : The disease is very irregular in its symptomatology, and really presents nothing characteristic. The symptoms are those of a genera/ septicoe- 186 DTSEASES OF THE CIRCULATORY SYSTEM. mia. Fever of an irregular variety and often quite high, ac- companied by an occasional chill, is regularly present. Fre- quent sweats, marked prostration, anorexia, vomiting, and diarrhoea, are usually found. The so-called typhoid state develops rather rapidly, with dry tongue, sordes on the lips, rapid emaciation and alternating stupor and delirium. Pete- chial eruptions and the signs of embolism in various parts of the body may exist. The heart and pulse may not be much disturbed, or may be rapid and feeble, or may be irregular. Dyspnoea, more or less marked, may supervene. The disease lasts from a week to ten days in the more rapid cases, to a month in the slower ones. Death is usually due to exhaustion. The physical signs of malignant endocarditis depend on the development of a murmur. This murmur is most apt to be that of mitral insufficiency. Aortic regurgitation may develop with its characteristic murmur. In some cases no murmur may be detected, when after death there may be marked evidence of valvular disease. The spleen is regularly enlarged. Albuminuria may be present. Diagnosis : The presence of symptoms of septicaemia or pyaemia, together with a heart-murmur, are the points for diagnosis. Typhoid fever and general tuberculosis are to be differentiated by their special symptoms. In many cases the diagnosis is impossible, but the possibility of malignant endo- carditis in all obscure cases of a septic type must be remem- bered. Prognosis : This is almost uniformly fatal. Malignant endocarditis — treatment : Nothing more, can be done than to nourish the patient properly and to use alcoholic stimulants. CHRONIC ENDOCARDITIS. Definition : This is a slowly developing, insidious disease, usually leading to marked deformities of the valves of the heart. Etiology: Rheumatism is the most frequent etiological factor. Many of the cases are secondary to acute endocar- ditis. Some cases develop during scarlet fever or chorea. Syphilis is at times a cause. CHRONIC ENDOCARDITIS. 187 Pathology : The inflammation involves oftenest the endo- cardium of the mitral or aortic valves. The endocardium of the tricuspid or pulmonary valves, or of the ventricles or auricles, is less often affected. The endocardium is thickened by the infiltration of new cells and the growth of new con- nective tissue in its substance. Little beaded vegetations may form on its surface, thickening and roughening the valves. In other cases the surface of these vegetations becomes ulcerated and roughened, and thrombi form on them or lime- salts are deposited in them. These changes occurring, as they do, most markedly in the neighborhood of the valves, cause them to be contracted, thickened, and deformed. After this the valves cannot be opened or closed properly, and this causes stenosis or insufficiency of the valvular opening. In insufficiency the valves cannot be shut properly, and some blood is forced back by the contraction of the heart. In stenosis the valvular opening is so small that the blood is pumped through it with difficulty. More than one form of lesion may be present at the same time. Complicating lesions are always present : dilatation of the ventricles, hypertrophy of their walls, and disturbances in the circulation in other organs of the body. Due to this venous obstruction, we get congestion of the lungs, liver, spleen, and brain. Dropsy of the serous cavities and of the subcutaneous tissues is also often found. Chronic endocarditis — symptoms : The pathological changes take place so slowly, and the interference with the valvular action is so gradual, that the heart-muscle accommodates itself to the extra work required to pump the blood with the valves diseased. This accommodation of the heart is called compen- sation and lasts up to a certain point only, after which the compensation is lost and the heart becomes unable to perform its functions in full. During the time of full compensation there are virtually no symptoms from the endocarditis, and often the discovery of a murmur is the first intimation the patient has of any trouble with his heart. This condition of compensation may last many years, or may give way in a short time. Much depends on the endocarditis becoming stationary or advanc- 188 DISEASES OF THE CIRCULATORY SYSTEM. ing, and on the general condition of health and the habits of life of the patient. Marked deformities of the valves, acute illness, or chronic malnutrition, or excessive muscular exertion tends to destroy compensation. Usually the earliest symptom of chronic valvular disease is dyspnoea on exertion, and this may be present even during fair compensation. Palpitation of the heart may be felt at times, but is not constant. Pain around the heart is rare. As compensation begins to fail the rational symptoms of the disease appear. They are mainly due to venous congestion of the various tissues of the body. In the brain the conges- tion produces headache, vertigo, stupor, delirium, at times convulsions ; in the lungs, dyspnoea, orthopnoea, cough, haemoptysis, chronic bronchitis, the pneumonia of heart-dis- ease, and oedema of the lungs ; in the pleural cavity, hydro- thorax ; in the stomach and intestines, indigestion, vomiting, at times hsematemesis ; in the liver, enlargement and func- tional disturbances ; in the peritoneum, effusion ; in the kid- neys, scanty urine and albuminuria ; in the limbs, dropsy. The pulse is usually rapid, feeble, and often irregular. It has different characteristics in different lesions of the valves, which are described under physical signs. Emboli from the heart may be carried to any part of the body, and produce their characteristic symptoms there : in the brain, paral- ysis ; in the lungs, dyspnoea ; in the mesentery, bloody stools ; in the spleen or liver, pain ; in the kidneys, hema- turia ; in the limbs, thrombosis and oedema. The symptoms gradually increase in severity until death, or periods of greater or less improvement occur, to be followed by a re- turn of the symptoms later. The disease may last for many years. Chronic endocarditis — physical signs : These depend on the valve affected. In aortic stenosis, which is the rarest lesion of the left heart, a systolic murmur is heard with its greatest intensity over the second right intercostal space quite near to the sternum, and is transmitted upward into the great ves- sels of the neck. A similar murmur is caused by simple roughening of the valves, and also in ansemia ; but in stenosis there is decided hypertrophy of the left ventricle, with dis- CHRONIC ENDOCARDITIS. 189 placement of the apex to the left and downward. The pulse is small and usually regular. In aortic insufficiency there is a diastolic murmur heard loudest over the sternum at about the level of the third rib, and transmitted down the sternum and to the apex. The left ventricle is greatly hypertrophied and dilated. The pulse in all the arteries is exaggerated, and distinct throbbing is present in the larger ones. This is often felt quite un- pleasantly by the patient. The pulse on palpation is quite characteristic, and is called "water-hammer," or " Corri- gan." The upstroke is very sudden and the collapse equally so. The arteries are almost empty in the interval. Raising the arm brings out the characteristics of this pulse. In mitral stenosis a presystolic murmur is heard over a limited area directly over the location of the mitral valve. This murmur is not transmitted. On palpation a distinct thrill is felt with each systole of the heart. The left auricle and right ventricle became dilated and hypertrophied in this condition, displacing the apex to the left, but not markedly downward. The pulse is small, feeble, and apt to be irregular. In mitral regurgitation a systolic murmur is heard with maximum intensity over the apex, and is transmitted around the subaxillary space into the back. The second pulmonic sound is accentuated. The left ventricle becomes dilated and hypertrophied. The pulse is small, weak, and apt to be irregular. The right-sided lesions are rare and difficult to diagnose, but tricuspid insufficiency may develop as a secondary lesion to mitral valve disease. It gives a systolic murmur heard mainly over the ensiform cartilage. The great veins of the neck are apt to pulsate with the systole of the heart. Various combinations are often present, giving two or more murmurs at the same time. Chronic endocarditis — diagnosis : This depends on the physi- cal signs. The only thing to be remembered is the possibility of the murmurs being functional. No functional murmurs have associated the changes of hypertrophy and dilatation, which nre present with actual valvular disease. Prognosis: On the whole, the prognosis in children is not 190 DISEASES OF THE CIRCULATORY SYSTEM. so good as in adults. At the time of puberty, particularly, the extra strain put on the heart is apt to destroy compensa- tion. Aortic stenosis and mitral insufficiency are the least serious varieties of endocarditis. Mitral stenosis is the more serious, and aortic insufficiency the most serious of all. Absolute recovery from the disease is exceedingly rare, and the presence of endocarditis always increases the danger from attacks of other diseases. Long life is compatible with valvular lesions under some circumstances. Chronic endocarditis — treatment : If compensation is present, all treatment directed to the heart is useless. During this period the patient's general hygiene should be carefully under regulation. The diet should be varied and easily digestible, and moderated outdoor exercise should be carried out, with avoidance of all great and sudden strain. Daily bathing, proper sleeping, and regulation of the bowels are important. Measures should be taken to prevent all forms of acute dis- ease, especially rheumatism and the infections. The child's nutrition should be particularly watched, and iron, cod-liver oil, and tonics given if there are evidences of anaemia or mal- nutrition. If compensation fails, then is the time for treatment directed to the heart proper. The first and most important factor in this is absolute rest in bed for a considerable length of time. This at once makes the work of the heart much less, and allows it to recover its strength. Combined with this, the drug of most value is digitalis. It should be given alone if the arteries are soft ; and should be used with nitroglycerin, or chloral, or iodide of potassium, if the arteries are tense. At the same time the general venous congestion is reduced by diuretics and saline purges, either of which class of drugs removes much water from the system. The diet had best be reduced to milk only for a time during this stage. As the heart improves, return to solid and highly nourishing diet, and the use of strychnine and iron are indicated. The special symptoms as they arise require special treat- ment. Dropsy of the serous cavities may be removed by diuretics and purges ; but tapping may be necessary. The oedema of the limbs had best not be interfered with surgically ACUTE MYOCARDITIS. 191 from the danger of infection. Intense dyspnoea and orthop- noea are relieved by nitroglycerin and opium. Sleeplessness is relieved by trional. ACUTE MYOCARDITIS. Definition: This is an inflammation of the muscular wall of the heart. Etiology : It is secondary to the infectious diseases — diph- theria, scarlatina, typhoid fever, and septicaemia. It is rather commoner in children than in adults. Some cases are asso- ciated with pericarditis, and others with endocarditis. Pathology : The inflammatory changes may be diffuse or circumscribed, and may be interstitial or parenchymatous. In the interstitial form the heart-wall is infiltrated with inflammatory products, round cells, sero-fibrin, and even blood-cells. At times the process may be so intense in spots as to form a small abscess. The heart is flabby and softened, and of a mottled yellowish color. In the parenchymatous form there is a distinct fatty degen- eration of the muscle-fibers. The two varieties are apt to be associated at the same time in the same heart. These hearts are regularly dilated. Acute myocarditis — symptoms : There are no typical symp- toms or physical signs of this disease. The heart's action may be too slow or too rapid, or feeble or irregular. The attacks of cardiac failure, slow or rapid, coming on in the course of the acute infections are apt to be due to this disease. The physical signs depend entirely on the enlarge- ment of the heart from the dilatation. Diagnosis : It is impossible to make a sure diagnosis. The association of these symptoms with one of the infectious diseases makes the diagnosis probable. Prognosis : Recovery is possible, but death is the rule. Acute myocarditis — treatment: Careful nursing, absolute rest, and proper nourishment during the course of an infec- tious disease tend to prevent this condition from developing. Strychnine by mouth or hypoderraatically is the best drug we have for use in this disease. It should be used in large 192 DISEASES OF THE CIRCULATORY SYSTEM. doses, and often up to the physiological limit. In imminent cases hypodermatics of some rapidly diffusible stimulant, such as ether, brandy, or camphor, are useful. Iron and tonics are needed during convalescence. CARDIAC NEUROSES. These are rather rare in children, as most of the causative factors are usually the developments of adult life. Etiology : Gastro-intestinal disorders are the commonest provoking cause of these neuroses. A neurotic heredity is usually present. Sudden fright, grief, and other emotions may cause them. The early use of tobacco in excess, as in cigarettes, and the use of tea and coffee are other causes. Anosmia and malnutrition are often present. Pathology : There is no known lesion present in these con- ditions. They are undoubtedly due to some reflex influence acting on the nervous supply of the heart. Possibly the absorption of toxins from the digestive tract may explain the functional derangements. Cardiac neuroses — symptoms : These are palpitations, irregu- larities in rhythm, excessively rapid or slow rate, and attacks of syncope. Respiration is liable to be hurried along with the change in the heart-rate. Normally in children some irregularity of the heart's rhythm is fairly common, and occasions no disturbance. Especially is this so during sleep. Most of these conditions are paroxysmal. They come on in attacks lasting a short time, and disappear equally quickly. The physical examination of the heart in these cases is nega- tive other than to show its rate and rhythm. Diagnosis : The only point in diagnosis is absolutely to exclude all forms of organic heart-disease, pericardial, endo- cardial, and myocardial. This in some cases can be done only after repeated careful examinations of the heart, and observation of the child for some time. Prognosis : This is good. The neuroses are never fatal in the attack, and with proper treatment and removal of the cause the tendency to the attacks can be cured. Certain cases with marked hereditary predisposition are least amenable to treatment. CHRONIC ENDARTERITIS. 193 Cardiac neuroses — treatment : The cause should be care- fully searched for and removed. Gastro-intestinal derange- ments should be corrected. Attention to the diet is of great importance. Tea, coffee, and tobacco should be stopped. Proper exercise, fresh air, and regular sleeping hours should be enforced. If the child is at school, supervision of its studies should be undertaken. Anaemia and malnutrition should be treated in the usual manner. During attacks digitalis, strophanthus, aromatic spirits of ammonia, valerian, and the bromides are the most useful drugs. Between attacks no special treatment for the heart proper is indicated. DISEASES OF THE ARTERIES AND VEINS. CHRONIC ENDARTERITIS. Inflammations of the arteries are rare in children, as they are regularly the result of senile changes. Etiology : Syphilis or tuberculosis is the usual cause. Pathology : The arterial wall undergoes hyperplastic in- flammation and a subsequent degeneration of the new tissue, with weakening and giving way of the wall. Chronic endarteritis — symptoms: The development of an aneurism in this weakened wall is the typical symptom of this condition in children. Aneurisms are quite rare, but they have been found in the abdominal aorta, the iliac, femoral, and cerebral arteries. The presence of a pulsating tumor in the line of an artery over which a systolic bruit is heard ; and the mechanical symptoms due to its pressure, are the regular sinus of the disease. Endarteritis in patches, without aneu- rism, can scarcely be diagnosed. Prognosis: This is bad, as the disease is apt to appear in subjects in bad general health. Chronic endarteritis — treatment: This is the same as in adults. Antisyphilitic treatment should be used in the pres- ence of a specific history. Surgical intervention in external aneurism is always advisable. 13— d. c. 194 DISEASES OF THE CIRCULATORY SYSTEM. ACUTE PHLEBITIS. Definition : This is an acute inflammation of the walls of a vein. Etiology: Injury of the vein, extension of inflammation from neighboring structures, the presence of an infective embolus, and exposure to cold act as actual causes. It also complicates the infectious diseases, particularly typhoid fever and septicsemia. In some cases anaemia seems to be the only cause. Pathology : The wall of the vein is the seat of an acute inflammation with swelling and infiltration by inflammatory products. The internal surface becomes roughened, and the lumen of the vein diminished, thus favoring coagulation of the blood in the vein. The inflammation may be so intense as to cause minute abscesses in the wall of the vein. Throm- bosis, or clotting of the blood in the vein, may be the result or the cause of the phlebitis. Acute phlebitis — symptoms : There are pain and tenderness along the course of the affected vein, and, if it is a superficial vein, a red swollen line follows its course. Thrombosis of the blood inside occurs, and the parts below, that are drained by this vein, are swollen and oedematous. There are usually slight fever and some general malaise. In infective cases abscesses may form in the course of the vein. The disease may last but a couple of weeks, with cessation of the inflammation, absorption of the thrombus, and return of the vein to normal ; or it may run a chronic course, and in some cases the vein remain permanently blocked, all signs of acute inflammation, however, disappearing. Diagnosis : In the veins of the limbs the diagnosis is fairly easy, and rests on the presence of signs of inflammation over the vein and thrombosis. In the trunk the symptoms are mainly those of thrombosis and blocking of the circulation, and the diagnosis is more difficult. Prognosis : This is fairly good unless the disease occurs in the veins of some one of the vital organs, as for instance the brain, or unless it is part of a general septic process. Acute phlebitis — treatment : Rest and the avoidance of all NMVUS, 195 unnecessary movement in the part containing the affected vein are of primary imj)ortance. This is to reduce the chance of breaking off a piece of the clot, and the formation by it of an embolus elsewhere. Hot applications, lead and opium wash, and in the chronic stage mild counter-irritation, as by iodine, assist in absorption of the clot. The bowels should be kept freely open and the patient fed on nourishing diet. No drugs are of any special value. DISEASES OF THE CAPILLARIES. Definition : This condition, which is also called angioma, is one of the commonest congenital disfigurements of childhood. Etiology : Noevi are probably always congenital. At times they may be so small at birth as not to be noticed, and then grow distinctly after birth. In olden times they were erro- neously ascribed to maternal impressions. Pathology : There are two general varieties : the capillary, with a great increase in the number and size of the capilla- ries ; and the cavernous, in which there is a form of erectile tissue, the blood circulating in irregular anastomosing spaces without distinct vascular walls. Nsevus — symptoms : When superficial, the so-called cuta- neous nrevus, it forms the well-known port-wine stain, or " mother's mark." These are purplish blotches on the skin of irregular shape and size. They may be situated anywhere on the surface. In the subcutaneous variety there is a soft, irregular tumor of varying size under the skin. It is increased in volume by crying, coughing, or exertion. The skin over it may be normal or bluish, or be so thin that the tumor shows the bl 1 color through it. Pressure reduces its size, but it fills again on removing the pressure. As a rule no other symptoms than the presence of a mark or a tumor arc found ; but in certain localities pain, or the displacemenl of certain organs, may be caused by the nsevus. This is seen, for instance, in the orbit. Hemorrhage, which 196 DISEASES OF THE CIRCULATORY SYSTEM. may be dangerous, may occur from them. They are most often found around the head and neck. They may occur in the viscera, as the liver, spleen, or kidneys, but are only diagnosed at autopsy. Diagnosis : The cutaneous form is simple. The subcutane- ous may be mistaken for other tumors, and especially for lipomata. The increase in size on exertion and decrease on pressure are the points in favor of nsevus. Prognosis : They rarely disappear spontaneously. Usually they remain stationary and are only disfigurements. They may grow, however, and become not only very unsightly, but even disabling. They are not dangerous. Nsevus — treatment : This is based on replacing the vascular tissue by cicatricial tissue, which may be brought about by the local application of caustics, the actual cautery, or electroly- sis. Diffuse scarification may be tried in large port-wine stains. In the subcutaneous variety any of the above meth- ods may be tried ; or injections of coagulating fluids, or liga- tion by passing a thread around the tumor and strangling it. DISEASES OF THE BLOOD. The blood in early infancy : During the first week or two of extra-uterine life, and in premature infants, the blood differs considerably from that of adults. The specific gravity and the proportion of haemoglobin are high, the number of red cells exceeds the normal five millions per cubic millimetre, and there are present nucleated erythrocytes or hsematoblasts in considerable numbers, and also many red cells with the haemoglobin dissolved out. The leucocytes are also present in larger number than the normal ten thousand per cubic millimetre. They may increase to twenty or even thirty thousand. In other words, leucocy- tosis is a normal condition during this stage. The five different varieties of leucocytes, small mononu- clear cells, large mononuclear cells, mononuclear cells with nucleus undergoing transition, polynuclear neutrophile cells, and eosinophile cells, are found as in adult blood, and in ap- proximately the same proportions. Within a short time all SIMPLE ANEMIA. 197 the elements gradually take on the proportions of adult blood, except that for a year or two the haemoglobin is lower than the normal 100 per cent, of adult life. Otherwise the blood in childhood differs very little from that of maturity. In health, within certain rather definite limits, the propor- tion of the different constituents remains constant. In dis- ease, diminished production or increased destruction of one or another element produces marked changes in their relative proportions, and gives us our only means for the classification of diseases of the blood. SIMPLE ANEMIA. This is also called primary anaemia, and when it occurs in young girls about the time of puberty it is called chlorosis, from the greenish appearance produced in the skin. Etiology : The disease is commonest in girls and during the second decade of life. Confining occupations, impure air, lack of exercise, improper food, and constipation all act -as causes. The last probably acts through absorption of poi- sonous substances into the blood, which should be excreted with the stools. Pathology: On examining the blood the haemoglobin is found far below normal, often being down to 30 or 40 per cent. The red cells and leucocytes are not diminished. In other words, each red cell has lost a certain proportion of its haemoglobin. Simple anaemia — symptoms : The patient is languid, feeble, and incapable of exertion. There are headache, dyspnoea on exertion, vertigo, palpitation of the heart, attacks of syncope, constipation, anorexia or capricious appetite, and amenorrhoea, one or all in almost every case. The skin and mucous mem- branes are pale, and the muscles flabby, but the subcutaneous fat is not diminished. The disease comes on gradually, and without treatment lasts an indefinite length of time. Simple anaemia — physical signs: The blood-changes de- scribed under pathology are most important. There is usually a systolic murmur heard over the heart, with its maximum in- tensity over the pulmonic area, although it may be loudesl at 198 DISEASES OF THE CIRCULATORY SYSTEM. the apex. There is a loud venous hum heard over the great vessels in the neck. Diagnosis : This, in the presence of the typical symptoms, depends on the blood-examination. Prognosis: This is good. It is not a fatal disease, and under proper treatment recovery is rapid. Simple anaemia — treatment: The treatment is very simple and very satisfactory. The bowels should be kept open, daily exercise in the fresh air should be prescribed, and iron should be given regularly. Blaud's pills, grains three or five, three times a day after meals, give most excellent results. Other forms, as the tincture of the chloride or the bitter wine, may be used when it is impossible to swallow pills. SECONDARY ANEMIA. Definition: This disease is not due to any fault of the blood-making apparatus, but is secondary to general consti- tutional states which increase the normal wear and tear on the blood. Etiology : It is a common disease of infancy and childhood, and is seen complicating and after such conditions as rheu- matism, tuberculosis, syphilis, acute and chronic digestive disorders, rachitis, hemorrhages, the infectious diseases, ne- phritis, prolonged suppuration, malaria, marasmus, improper food and insufficient air, prolonged fevers, and malignant growths. In some cases very rapid bodily growth seems to be the only discoverable cause. Pathology: Aside from the lesions of the primary disease, the changes in the blood are all that we expect to find. There is a moderate decrease in the quantity of haemoglobin and in the number of red cells in the blood. The diminu- tion in each is fairly proportionate — that is, the cells are decreased in number, and those that are left behind have less than their proportion of haemoglobin. The decrease is sel- dom as great as it often becomes in simple anaemia. There is no increase in the leucocytes. Secondary anaemia- — symptoms : It is difficult to separate the symptoms due to the anaemia from those of the primary PERNICIOUS ANMMIA. 199 disease. The skiu and mucous membranes are pale and blanched. The muscles are flabby. The extremities are apt to be cold. There are disinclination to exertion, dyspnoea on motion, attacks of palpitation of the heart and of syncope, poor appetite, general restlessness, and disturbed sleep. The patients tire easily, and, if old enough, complain of headache. Anaemic heart-murmurs are often present, but are less marked than in the essential form of the disease. Diagnosis : This depends on the blood-changes shown by examination in the presence of one of the primary diseases. The absence of any primary cause would point to a simple anaemia: The proportionate percentage of haemoglobin and cells in the two diseases differs also. Prognosis : This depends entirely on the primary disease. The anaemia itself is not a cause for special prognosis. Secondary anaemia — treatment: The cure of the primary disease is of first importance. All digestive disturbances particularly must be corrected. Good hygiene, proper food, and, above all, fresh air, must be insisted on. The drugs of most value directly to increase the richness of the blood are iron and arsenic. The former may be given as the bitter wine, the syrup of the iodide, or the pepto-manganate ; the latter as Fowler's solution. In children who can swallow pills, Bland's pill, with arsenic, is the best form. Cod-liver oil seems to assist the treatment in certain cases. PERNICIOUS ANEMIA. Definition : This is a primary disease of the blood which progresses regularly to a fatal end. Etiology : No real cause for the disease is known. It is of rare occurrence in childhood. Late researches point to the fact of the disease being due to an increased destruction of the red blood-cells in the liver, which may be brought about by the presence in the portal blood, fresh from the intestinal tract, of some tome principles. Some cases arc due to the presence of the anchylostoma du- odenale in the intestines. Such are rare in this country. Pathology: There is a fatly degeneration of the walls of 200 DISEASES OF THE CIRCULATORY SYSTEM. the heart, of the hepatic and renal cells, and of the walls of the arteries and capillaries. The blood shows a marked diminution in the red cells and in the haemoglobin. The cells that are left have a normal proportion of haemoglobin, but are of irregular shapes and sizes, and often are nucleated. The leucocytes are not absolutely increased, although they are so relatively to the number of erythrocytes present. Pernicious anaemia — symptoms : The symptoms develop slowly and insidiously. The skin and mucous membranes become pale, and later lemon tinted. The muscles grow flabby and soft, and progressively feeble. The disinclination to exercise is most marked. There are palpitation of the heart, dyspnoea on exertion, attacks of syncope, and a gradual muscular and mental enfeeble men t. The functions of the stomach and intestines are weakened, with the consequent symptoms of indigestion and malnutrition. There may be hemorrhages into the retina, or from the mucous membrane of the nose, mouth, stomach, or intestines, or even under the skin. In the later stages subcutaneous oedema may develop, but without albuminuria. Irregular fever is present at some time in the disease. A fair degree of nutrition — that is, of sub- cutaneous fat — is usually retained. Anaemic heart-murmurs are usually present. Toward the end the feebleness becomes so marked that the patient is absolutely bedridden. The cases regularly last some time, with intervals of seeming improve- ment. Diagnosis : This depends on the blood-examination showing both the great decrease in red cells and haemoglobin, and the morphological changes in the erythrocytes. By this means the other varieties of anaemia are differentiated ; and all dis- eases of other organs should also be excluded. Prognosis : This is distinctly bad, although periods of im- provement are to be expected. Pernicious anaemia — treatment : Rest, fresh air, a highly nutritious and easily digestible diet, and minute attention to all the functions of the stomach and intestine are very im- portant. No constipation should be permitted. The only drug from which any help can be expected is arsenic. It LEUKEMIA. 201 should be given in Fowler's solution, in gradually increasing doses, until full tolerance is reached. LEUKEMIA. Definition : This is a disease of the blood, characterized by a marked increase in the leucocytes; a diminution in the number of erythrocytes, and in the quantity of haemoglobin ; enlargement of the spleen and lymphatic glands ; and increase in amount of the marrow of the long bones. With the leu- cocytosis, which is always present, one or more of the other organs — spleen, glands, and marrow — may be involved. Etiology : Nothing definite on this point is known. It is seen with some frequency in children, and even in infants, and in boys more often than in girls. In some cases it seems to be secondary to malaria, or syphilis, or trauma over the spleen, or at times to starvation. Pathology : The essential lesions are in the blood, spleen, lymph-glands, and- bone-marron\ The blood is lighter col- ored than normal, and in advanced cases has a whitish puru- lent appearance. The number of red cells and the amount of haemoglobin are moderately diminished. The leucocytes are very much increased in numbers, at times being as many as the erythrocytes. This, of course, occurs in extreme cases only. The proportions of the different varieties of leucocytes present vary with the form of leukaemia present. In the lymphatic variety the small mononuclear cells are mainly in- creased. In the spleno-medullary variety the large mono- nuclear cells are mainly in excess, while the eosinophiles are also increased. The spleen is usually much enlarged, the changes being mainly those of a simple hypertrophy. The lymphatic glands are hypertrophied in various parts of the body, single <»r multiple groups being involved. These again undergo simply a hyperplasia of their normal tissue. New lymphoid tissue in the form of tumors may grow in the liver, kidnevs, or peritoneum. The marrow of* the hones is hyper- trophied, it- color may be yellow or red, and both its cells and stroma are regularly involved. All of the organs, blood, spleen, gland-, and marrow, may 202 DISEASES OF THE CIRCULATORY SYSTEM. be involved at once, or only the blood with the glands, when it is called lymphatic leukaemia ; or the blood with the spleen and marrow, when it is called spleno-medullary leukaemia. In any variety all the organs are usually somewhat involved, although certain ones are more markedly so. Leukaemia — symptoms : The disease usually begins insid- iously, but advances rather more rapidly in children than in adults. The child is pale, very weak and feeble ; has marked dyspnoea and attacks of fainting. Hemorrhages from the various mucous membranes, as into the retina or under the skin, are often seen quite early. These bleedings at times may be large enough to be quite serious. Enlargement of the abdomen from the hypertrophied spleen or of the various superficial or deep lymphatic glands soon begins, and at times is the earliest symptom. The heart's action is rapid and feeble, and there may often be irregular rises of temperature lasting over some days. There may be pains and tenderness in the bones from the changes in the marrow. As the disease progresses extreme feebleness, subcutaneous dropsy, headaches, failing sight, diarrhoea, and hemorrhages gradually bring on the fatal issue. The cases last from a few months to a year. Diagnosis : This is based on the blood-examination — that is, the increase in the number of leucocytes and the propor- tions of the different varieties. Prognosis : This is almost absolutely fatal, although a few cases of recovery have been reported. Leukaemia — treatment : Rest, a highly nourishing diet, and fresh air are of importance. Arsenic in gradually increasing doses is the best drug. Iron and phosphorus are often used as adjuvants. PSEUDOLEUKEMIA. Definition : This is often called Hodgkin's disease, malig- nant lymphoma, lymphatic anaemia, and splenic anaemia. It is characterized by anaemia and enlargement of the lymphatic glands of the body. Often the spleen is enlarged at the same time, and in some cases the spleen is involved without the PSEUDOLEUKEMIA. 203 glands. To this variety the term splenic ancemia is especially applicable. Etiology : The disease is more frequent in boys than in girls. Syphilis, tuberculosis, and malaria are possible predis- posing factors. Local traumatism may be assigned as the beginning. Very little is known, however, of the causes. Pathology : In the blood the red cells are decreased in number and the haemoglobin correspondingly in amount, but the white cells are unaltered. One or more groups of lymphatic glands are enlarged. The glands are simply hypertrophied, both the stroma and the cells being involved. They have no tendency to sup- purate uor caseate. The glands in the neck or axillse are usually first involved. In the spleen new growths of lymphoid tissue are often found. These may cause a uniform or irregular enlargement of that viscus. Similar growths of lymphoid tissue may be found in the liver, kidneys, and other organs, but much less commonly than in the spleen. The marrow of the bones in rare cases may be involved in this hyperplastic growth. Pseudoleukaemia — symptoms : The first symptom is regu- larly an enlargement, without known cause, of some set of superficial lymph-glands. Those in the neck are usually earliest involved. The axillary or inguinal glands may soon be affected, or even some of the deeper sets, as the thoracic or retroperitoneal. After some little time the constitutional symptoms of the disease appear. These are mainly the result of the ansemia, such as pallor, weakness, palpitation of the heart, dyspnoea on exertion, fainting 1 attacks, vertigo, and disordered diges- tion. Later, hemorrhages from the mucous membranes and into the skin, subcutaneous oedema,- fever, and marked loss of flesh and strength develop. Toward the end nervous symptoms, delirium, coma, or general convulsions may occur. As the glands grow in size pressure-symptoms become prominent. In the neck they produce dyspnoea, dysphagia, and interference with the blood-vessels or pneumogastric nerves; in the thorax they may press on the trachea, oesoph- 204 DISEASES OF THE CIRCULATORY SYSTEM. agus, or descending vena cava ; in the abdomen they may produce jaundice by pressure on the bile-duct, or ascites by pressure on the portal vein, or oedema of the lower extremi- ties by pressure on the ascending vena cava ; in the spleen they produce enlargement; in any position they may produce pain from pressure on sensory nerves. The glands are not tender and are freely movable. The disease progresses rapidly, with periods of improve- ment, and regularly lasts a number of years. Diagnosis : The disease must be differentiated from leu- kaemia, which is done by the blood-examination, and from tubercular adenitis. In the latter condition the glands are prone to fuse together, soften, and suppurate, all of which phenomena are rare in pseudoleukemia. In the splenic form splenic leukaemia is distinguished by the blood-exami- nation ; and other causes of splenic enlargement must be excluded before diagnosing splenic pseudoleukemia. Prognosis : Absolute recovery is rare, but temporary im- provements extending over many years are often seen. Where the deeper glands are involved the cases seem more serious. Pseudoleuksemia — treatment : The patient must be kept under strict hygienic surroundings, with good food, good air, and moderate exercise. Of drugs, arsenic seems the only one of much value ; it is given in gradually increasing closes. The iodides at times seem useful. The question of the operative removal of the enlarged glands has much to be said on both sides. At times, after operation, there seems to be a fresh outburst of the disease elsewhere. At other times good results follow. Operation is indicated when pressure-symptoms are causing trouble. ADDISON'S DISEASE. Definition : This is a disease characterized by anaemia, general languor and debility, feeble heart-action, irritability of the stomach, bronzing of the skin, and disease of the suprarenal capsules. Etiology : It is a rare disease under any circumstances, but especially so in children. A few cases are recorded under HAEMOPHILIA. 205 fifteen years of age, some being in mere babies. The causal conditions are not known. Pathology : The supra-renal capsules are usually the seat of a tubercular inflammation, with conversion of the glands into cheesy and fibrous tissue. At other times they are atrophied or absent. There is a deposit of pigment in the cutis vera. The blood shows a decrease in red cells and haemoglobin, but no change in the white cells. Addison's disease — symptoms : There is a slow, gradual loss of flesh and strength. The mind becomes dull and apathetic. The temper is often highly irritable. The action of the heart grows very rapid and feeble. Dyspnoea is present, increased by exertion. The stomach is upset ; there are pains, nausea, and vomiting. The typical bronzing of the skin is most evident on the face and hands, and in the regions where the skin is naturally most pigmented. Patches are also found on the various mucous membranes, as that of the mouth. Toward the end asthenia becomes most marked, and stupor, delirium, coma, or convulsions may occur. The disease is chronic, but progressive in its course, and with its periods of remission and exacerbation may last for years. Diagnosis : This is difficult except in cases where all the typical symptoms are present at the same time. Prognosis : This is bad, as almost all the cases die in a few years. General tuberculosis may develop. Addison's disease — treatment : Absolute rest and nourishing and digestible diet are of prime importance. Iron, arsenic, strychnine, and phosphorus are all recommended as useful drugs. HEMOPHILIA. Definition: This is a condition in which even after the slightest injury hemorrhage, which is very difficult to control, occurs. Such a person is called a "bleeder." Etiology: There is a marked hereditary tendency to the disease. It is transmitted through the female xid<- of a luemo- 206 DISEASES OF THE CIRCULATORY SYSTEM. philic family, but regularly appears in the male members. No real cause for the disease is known. Pathology : No marked changes either in the blood or in the bloodvessels are found. In a few cases the walls of the vessels seem to be very thin. In the other tissues nothing abnormal is found. Haemophilia — symptoms : As a rule, there is nothing in the appearance of the child to suggest that he is a " bleeder." The first sign is apt to be a prolonged hemorrhage from some trifling wound, or from some mucous membrane. Epistaxis is the commonest form of bleeding. The bleedings usually do not make their appearance before the second year. For instance, such hemorrhages from the umbilical cord are rare. The first hemorrhage is apt to be recovered from. The fatal ones, as a rule, are subsequent. Petechia? in the skin, or hematoma in the deeper parts, are apt to take place. In some cases there are swelling and inflammatory signs in the joints. Diagnosis : No way exists to tell that these children are " bleeders," except by experience with a wound in each indi- vidual case. Prognosis : A large proportion of these cases never reach adult life. They are in constant danger of death from hem- orrhage from a small or large traumatism. In the few women who are " bleeders," neither in menstrua- tion nor in parturition does the haemophilia seem to add to the dangers. Haemophilia — treatment : In case of bleeding the usual sur- gical measures — pressure, position, plugging, and ligaturing — should be followed. If a coagulum is formed, great care should be taken not to disturb it. After the bleeding is stopped measures should be taken to prevent further accidents. All minor operations and all trau- matisms should be avoided, vaccination and pulling of the teeth being among these. The child should be kept in the open air and given plenty of exercise and iron. There seems some value in giving lime salts over a considerable length of time. Girls in these families should not marry. PURPURA. 207 PURPURA. Definition : This term is used to include spontaneous hemor- rhages into the skin, mucous membranes, and internal organs. The different varieties have received different names ; but they all seem related except in degree, and hence will be grouped together. Such varieties are purpura simplex, in which purpuric spots are seen in the skin ; purpura hemorrha- gica, or Werlhof's disease, in which in addition free hemor- rhages appear from one or another of the mucous membranes ; and rheumatic purpura, or peliosis rheumatica, occurring in cases at the same time suffering from inflamed joints. Etiology : This is quite a common disease of children, as in them the bloodvessels are still immature. In very many cases no etiological factor can be made out. In others, such causes as cachexia from scurvy ; tuberculosis ; chronic pul- monary or intestinal disorders ; from malignant disease or infections from septicaemia, malignant endocarditis ; or the exanthemata, are active. Certain drugs, as quinine, the iodides, chlorate of potassium, and phosphorus, will produce it. A few cases are mechanical from venous stasis, as in endo- carditis, pertussis, and epilepsy. In others the rheumatic diathesis seems in some way to act as a cause. In others there is reason for believing that some form of micro-organism is the actual cause. This is especially true in Werlhof's disease. Pathology : In the blood itself no changes have as yet been demonstrated other than those of slight anaemia. In some cases the walls of the small arteries and capillaries, from which the hemorrhages regularly take place, are found in an abnormal condition, permitting free escape of the blood through them. In the variety with an infectious origin an infectious embolus followed by thrombosis and inflammation of the wall of the vessel is found. In the very acute hemorrhagic cases different forms of germs have been found, but no specific one. Hemorrhagic areas are found in the skin, the serous and mucous membranes, the joints, and the viscera. The spleen is usually enlarged. Purpura — symptoms : These vary a good deal with the form of purpura present. 208 DISEASES OF THE CIRCULATORY SYSTEM. In purpura simplex there may be no constitutional symp- toms at all, or slight fever with its accompanying malaise, anorexia, and headache, may be present. The local symp- toms are the occurrence of hemorrhagic spots or blotches sit- uated in almost any part of the skin. These spots are a dark red at first, later fading to a brown, and then to a yellow. They are not tender and do not disappear on pressure. After fading some pigmentation is left for a considerable time. In the course of two or three weeks the disease is over. In purpura hemorrhagica there are regularly present more or less marked constitutional symptoms, as fever, headache, prostration, and digestive disturbances. With these occur extravasations into the skin and free bleedings from the mu- cous membranes. These hemorrhages are from the nose, mouth, throat, stomach, lungs, intestines, or genito-urinary tract. In many cases the bleeding is severe enough to en- danger life. In other cases the hemorrhage may take place en masse in some internal portion of the body where the tis- sues are loose, as the orbit, producing exophthalmos. Some of the more severe cases of this variety run a very rapid fatal course, presenting the symptoms of an infectious disease with high fever and signs of general toxaemia. All of these hemorrhagic cases last several weeks, and, if recovery occurs, the patient is left anaemic and feeble. In purpura rheumatica the symptoms are those of acute rheumatism of one or more joints with the lesions of simple purpura added. They are probably not cases of actual rheu- matism, however. The joints are inflamed, red, hot, swollen, and tender. There are fever, with its accompaniments, and on the extremities purpuric spots scattered irregularly about. This form lasts several weeks and relapses are quite common. Diagnosis : Purpura being more of a symptom than a dis- ease, diagnosis in any variety is fairly easy. Scurvy is dif- ferentiated by its signs in the gums, the different locality of the hemorrhages, the etiology, and, if necessary, by the effects of treatment. Hemophilia is distinguished by the family history and the absence of constitutional symptoms. If possi- ble, the cause of the purpura must be diagnosed as well as the presence of the disease. PURPURA. 209 Prognosis : The large proportion of cases end in recovery. The fatal cases are the very severe ones of the hemorrhagic variety, with marked symptoms of infection, the so-called purpura fulminans. Relapses are common. Purpura — treatment : The patient should be put to bed and on a nourishing diet. The causal factor should be searched for and treated, if possible. Tonics, as iron and arsenic, are indicated. Stimulants should be used in the presence of fever and toxsemia. Fresh fruit-juice and vegetables should be tried on account of their value in the similar condition of scurvy. Of drugs, aromatic sulphuric acid, turpentine, ergot, tannic or gallic acid and calcium chloride have been used. In the rheumatic form the salicylates should be given. 14— D. c. CHAPTER IX. DISEASES OF THE KESPIRATORY SYSTEM. DISEASES OF THE NOSE. EPISTAXIS. Hemorrhage from the nose is quite a common occurrence in children. Etiology : Boys are more apt to surfer from nose-bleed than girls. It occurs especially in delicate children who are not accustomed to outdoor life. It is often a symptom of ade- noids and of rhinitis. It may begin without any exciting cause, but more often follows picking the nose, a slight blow on the nose, or other local injury. Severe exertion may bring on an attack. It occurs in cases of endocarditis and other conditions in which there is venous stasis of the blood. It may be an early symptom of typhoid fever, malaria, or almost any of the infectious diseases. It may be part of the hemophilic diathesis or a complication of almost any of the anaemias. Pathology : The source of the blood may be situated almost anywhere in the nasal fossae, but usually is in the anterior nares. Asa rule there is a small erosion of the mucous mem- brane, which may be situated over a fair-sized vessel, in which case the bleeding is more marked than when there is capillary oozing only. Epistaxis — symptoms : Bleeding from the nose is the only sign of any moment. The blood may come from one or both nostrils, or, if the bleeding point is posterior, it frequently will come through the pharynx, the blood being either spit up or swallowed. In some cases the bleedings maybe large enough to produce feelings of faintness and to leave the child 210 ACUTE RHINITIS. 211 anaemic. The hemorrhages as a rule last only a few minutes, but recurrences are common. Diagnosis : It is, of course, easy to make the diagnosis of epistaxis, but it is at the same time important to find the cause of the bleeding and its exact source. Prognosis : Ordinarily epistaxis is a simple, harmless trou- ble. In the various constitutional diatheses of which it is a symptom, as hemophilia and the anaemias, it is more serious. In conditions of venous stasis from any cause it is ordinarily helpful. Occurring in the late stages of the infectious dis- eases it indicates a serious form of the disease. Epistaxis — treatment : A child prone to attacks of epistaxis should be put under the best hygienic conditions, and by the use of daily cold baths and being kept in the fresh air should have his mucous membranes toughened so as to resist changes in temperature. If the epistaxis is due to any of the predisposing causes, as rhinitis, adenoids, venous congestion, or any of the hemorrhagic diatheses, these should be treated. In an attack the local application of cold to the nose externally, or to the back of the neck, or in the nostril, will usually stop the bleeding. If these are not effective, astrin- gent solutions may be applied to the nostrils, such as tannic acid, anti pyrin, or alum. In other cases the anterior nares may be plugged with cotton. In more severe cases the pos- terior nares had better be plugged at the same time. This may easily be done by passing a soft-rubber catheter, in which a piece of silk is threaded, through the nostril into the pharynx. The catheter is withdrawn, the silk being left in place by catching the end with a pair of forceps. With this silk a piece of cotton can be drawn into the naso-pharynx and tied there. After the hemorrhage has ceased it is wise to examine the nares carefully for the bleeding spot, and to touch this with silver nitrate. ACUTE RHINITIS. This is commonly called '' cold in the head," and technically coryza. Etiology: This very common disease of adull life is equally 212 DISEASES OF THE RESPIRATORY SYSTEM. often seen in babies and children. It is seen oftenest in chil- dren who are coddled too much, being dressed too warmly, and kept in overheated, un ventilated rooms, and never bathed in cool water. It follows exposure to draughts, sudden chilling of the sur- face while warm, wet feet, and cold to the abdomen. Prob- ably some form of micro-organism is also present as a co- existing cause. The disease certainly seems somewhat infec- tious. Coryza is an early symptom of measles. Pathology : The nasal mucous membrane is congested and swollen, and at first has a very scanty secretion, or at best only a watery one. Later, as the inflammation passes off, the mucous glands begin to secrete, and mucus and muco-pus are discharged in large quantities. Acute rhinitis — symptoms : The nose is stuffed up, necessi- tating mouth-breathing, and in infants causing difficulty in nursing. There is a feeling of fulness in the nose and frontal sinuses, and there may be decided aching in the same localities. There are slight fever and general malaise. Sneezing begins early. At first there is no discharge ; later there is a profuse acrid watery one, and later yet mucus and muco-pus in large amounts may be expelled by blowing. If the naso-pharynx is involved, the openings of the Eustachian tubes may be swollen, and ringing in the ears and deafness follow. The attack lasts a little less than a week, but the mucous discharge continues for some time longer. Complications, as excoriation of the upper lip, ear-ache from catarrhal otitis media, conjunctivitis from extension through the lachrymal duct, and cervical adenitis from absorption into the lymph- glands may be present. Diagnosis : The diagnosis of the rhinitis is easy enough ; but we must exclude the beginnings of measles, influeuza, or diphtheria, and the presence of congenital syphilis. Prognosis : This is good. Recovery regularly follows in about one week. Recurrences are frequent. Acute rhinitis— treatment : To cure the tendency to catch- ing cold, the children should be accustomed to sleeping in cool, well-ventilated rooms, and to being out of doors almost every day. They should be warmly and properly dressed, CHRONIC RHINITIS. 213 but not bundled up. Every day they should take a cool- water sponge or plunge after the cleansing bath. This tones up the vascular system, and keeps it more resistant to sudden temperature-changes. The nose and naso-pharynx should be examined for any chronic conditions, such as chronic rhinitis or adenoids, that may be present. To treat the coryza itself, the child should be kept indoors and in a uniform temperature. A purge should be given early, which will remove the congestion and hasten the in- flammatory process in the nose. After this there may be given internally some combination of quinine, belladonna, and camphor, as in "pill rhinitis;" or of quinine, ammonium chloride, camphor, belladonna, opium, and aconite, as in " pill coryza," in small doses suitable for the age of the child, and frequently repeated. The nostrils may be washed out two or three times a day by a cleansing solution, such as Seller'*', and then a little melted vaseline poured into them. If reduction of the congestion is necessary, a weak cocaine solution may be used cautiously. A blunt-pointed piston syringe, or a medicine-dropper, or aJBermingham douche, are better for these local applications than sprays or atomizers. CHRONIC RHINITIS. This is a chronic inflammation of the nasal mucous mem- brane in which there is neither hypertrophy nor atrophy. Etiology: Frequent attacks of the acute form are the com- monest cause. Adnoids in the naso-pharynx, foreign bodies in the nose, and nasal polyps are often found in these cases. Chronic rhinitis — symptoms: A mucous or muco-purulent discharge from the nostrils, of greater or less amount, is the early symptom of this disease. The edges of the nostrils and the upper lip may be excoriated by the discharge. The dis- charge can usually be easily removed by blowing. Diagnosis : A thorough examination of the anterior and posterior nares should be made when possible, to discover the condition of the nasal mucous membrane and the presence of any of the local causes. Prognosis: The disease may be cured by proper treatment; 214 DISEASES OF THE RESPIRATORY SYSTEM. but if left alone, it is apt to terminate in one of the more serious forms of chronic rhinitis, the hypertrophic, or more often the atrophic. Chronic rhinitis — treatment : The prophylactic treatment recommended for acute rhinitis must be followed. Local causes, if they exist, must be removed, such as adenoids, polypi, or foreign bodies. The nostrils should be thoroughly cleaned out once or twice a day by spraying or syringing with some mild alkaline solution, such as Seller's. A good home wash is a teaspoonful each of soda, salt, and borax to a quart of water. Always use nasal solutions warm. A useful and simple little instrument for this purpose is the Bermingham douche. After cleaning, some astringent such as sulpho- carbolate of zinc in 1 per cent, solution, or nitrate of silver in 1 or 2 per cent, solution, should be applied with cotton. HYPERTROPHIC RHINITIS. Definition : This is a form of chronic rhinitis in which the nasal mucous membrane is very much hypertrophied, block- ing up the nasal fossa? and interfering with the passage of air through them. Etiology : It is most commonly secondary to repeated at- tacks of acute rhinitis. Pathology: All the parts of the mucous membrane are hyperplastic. The vascular portion is particularly affected, the number of vessels being increased and their size enlarged. The membrane over the turbinated bones takes on the char- acteristics of erectile tissue. Hypertrophic rhinitis — symptoms : The two symptoms com- monly present are nasal discharge and obstructed nasal breathing. The discharge is more difficult of expulsion than that due to simple rhinitis, but is not so irritating to the upper lip. The nasal obstruction leads to mouth-breathing and to the so-called nasal tone of voice. This is not due to talking " through the nose," but to the inability to ventilate the naso-pharynx through the nose. Diagnosis : This is made by examining the anterior and posterior nares when possible. The turbinated bodies are seen ATROPHIC RHINITIS. 215 to be swollen, and red both in front and behind, and the space of the nostrils blocked by them so much that a probe is passed with difficulty. Prognosis : Much good can be accomplished by removing this hypertrophic condition by treatment. It is questionable if the inflammation can be completely cured. If untreated, the cases usually go on to atrophy. Hypertrophic rhinitis — treatment : The same prophylactic and cleansing measures should be used as in simple chronic rhinitis. The hypertrophied turbinates can be reduced by forming a linear horizontal scar along them by the applica- tion of nitric, glacial acetic, or chromic acid, or by the use of an electro-cautery. In some cases the mucous membrane is so hypertrophied that portions of it may be removed by a snare. ATROPHIC RHINITIS. Atrophic rhinitis is a somewhat rare condition in children. It is often called ozsena or foetid rhinitis. These terms are better reserved for cases with necrosis of the bones of the nose. Etiology : It is sometimes secondary to repeated attacks of acute rhinitis and to hypertrophic rhinitis. Other cases come without known cause. Pathology : There is a gradual atrophy of all the elements of the nasal mucous membrane. The submucous tissue with its glands and vessels disappears in time. Atrophic rhinitis — symptoms: The liquid discharge from the nostrils is small. On the contrary the secretions dry in the fossa?, and form crusts and scales which adhere more or less firmly to the mucous membrane. The nostrils are roomy and the passage of air through them free. If the crusts are allowed to accumulate, they begin to decompose and give a disagreeable odor to the air passing through the nostrils. From tin's arises the name foetid rhinitis. This foetor depends almost entirely on the lack of proper cleansing of the nostrils. The naso-pharynx and the pharynx are usually the scat of an atrophic inflammation at the same time. Diagnosis: Careful inspection of the anterior and posterior 216 DISEASES OF THE RESPIRATORY SYSTEM. nares, showing the free nasal cavities, the pale appearance of the mucous membrane, and the presence of crusts, usually settles the diagnosis. Prognosis : Cure is impossible, but amelioration of the symptoms can easily be brought about, and a little con- tinuous care afterward will prevent their recurrence. Atrophic rhinitis — treatment : This consists in cleanliness, and a stimulating application to the nose to keep the mucous glands secreting as much as possible. For purposes of clean- liness a nasal douche of warm water containing some alkali, as soda, salt, or borax, or Seller's solution, may be used daily. This may be given by the ordinary fountain-syringe to which a nasal nozzle is attached, or by the Bermingham douche. After washing, some stimulating oily solution should be applied, as menthol or thymol, about ten grains to the ounce of sweet oil. If the foetor is bad, listen ne may be added to the alkaline douche. Any crusts that cannot be washed out should be removed mechanically with a cotton-wrapped probe. MEMBRANOUS RHINITIS. This is nothing more nor less than diphtheria of the nose, and on account of its importance as a source of infection in others it should be so considered. Etiology : The Klebs-Loffler bacillus is the cause of almost all the cases of this disease. Pathology : The nasal mucous membrane is highly inflamed, and its surface coated with a layer of false membrane. If the inflammation extends backward into the naso-pharynx, the cervical lymph-glands will be enlarged and tender. Membranous rhinitis — symptoms : The local symptoms in the nose are the main ones, as, unless the inflammation spreads to the naso-pharynx, absorption is slight, and hence consti- tutional symptoms few. There are obstruction of the nares, and serous, or mucous, or bloody discharge from the nostrils, and usually excoriation of the upper lip. On examination the nostrils are choked up, and the gray or dirty white membrane is easily seen covering the whole of the inside of the nose. It can be SYPHILITIC RHINITIS. 217 removed only with difficulty, and leaves a bleeding place behind. The membrane may remain localized or may spread to the pharynx or larynx. In case it does not spread the membrane will come away piecemeal, or as a whole, in the course of a couple of weeks, and recovery will rapidly follow. Diagnosis : This depends on the presence of a false mem- brane in the nose, and should be accompanied by a bacterio- logical report as to the presence or absence of the Klebs- LSffler bacillus. Prognosis: As long as the disease remains localized in the nose, the prognosis is fairly good. If it spreads, the case takes on the characters of a general diphtheria. Membranous rhinitis — treatment: The patient should be isolated, and the nose washed out two or three times a day with a warm weak solution of bichloride of mercury, about 1 : 50,000 or 1 : 30,000. The question of giving antitoxin will depend on the same rules as in general diphtheria. Constitutional treatment of other kinds will seldom be needed. SYPHILITIC RHINITIS. This is seen with some frequency in infants the victims of inherited syphilis. Etiology : The disease is the result of a syphilis contracted in intra-uterine life, and manifesting itself during the first three or four months of extra-uterine life. Pathology : The lesions are those of a catarrhal rhinitis. In places, superficial ulcers, the so-called mucous patches, form in the nostrils. In other children the lesions are those of the tertiary stage of the disease, when gummata form and break down, with destruction of mucous membrane, cartilage, and bone. The septum may be perforated, the various bones may necrose, and marked deformities of the nose may follow. The ^ so- called " saddle-back " nose is the most typical, where the bridge is sunken and the nose becomes very broad. These tertiary lesions are seldom confined to the nose, but the hard and soft palates are usually affected coincident!}-. Alter syphilitic 218 DISEASES OF THE RESPIRATORY SYSTEM. ulceration, cicatricial healing regularly takes place, with con traction of the scar-tissue subsequently and increase of the deformity. Syphilitic rhinitis — symptoms : In the secondary form a coryza, or the so-called " snuffles," is the only symptom. The discharge from the nose is serous, or mucous, or bloody, and excoriates the upper lip. In the tertiary form the physical signs, as described under pathology, together with a very offensive odor and some dis- charge, are the symptoms. Diagnosis : The secondary form is differentiated from simple coryza mainly by its longer course and greater discharge. Other evidences of congenital syphilis should be looked for, and will usually be found. The family history will help at times. In the tertiary variety the signs are more characteristic, ulceration and scars being often seen side by side. Prognosis : This is that of syphilis in general, in children. Syphilitic rhinitis — treatment : Constitutional treatment for syphilis should be at once instituted. Locally, the nose should be kept clean by an alkaline wash, and afterward an appli- cation of bichloride of mercury in weak solution or insuffla- tions of calomel powder should be made. NASAL POLYPI. Nasal polypi occur only in older children, and are compar- atively rare even in them. Etiology : The causes are unknown ; but polyps seem to be always secondary to, or at least associated with, chronic in- flammatory conditions in the nose. Pathology : The polyps are usually composed of a mixture of mucous and fibrous tissue, one or the other predominating. They are covered with ciliated epithelium. They are regu- larly pedunculated, and of a round form and pink color. They originate usually from the middle meatus. Nasal polypi — symptoms : These are due mainly to the ac- companying rhinitis, and are discharge and interference with the passage of air through the affected nostril. There HAY FEVER. 219 may be headache and sneezing, and frequent attacks of acute coryza. Diagnosis : This depends on a careful examination of the nostrils and the discovery of the pale, soft pediculated growth. Frequently a number of polypi will be found at the same time. Prognosis : Polyps are not serious, but are troublesome ; and unfortunately, after removal, have a tendency to recur. Nasal polypi — treatment : The polyps are best removed by the cold-wire snare passed nround the pedicle and drawn tight. After removal the base, if it can be found, should be cauter- ized. The use of cocaine makes the operation easier. The accompanying chronic rhinitis should be carefully treated on the regular plan. HAY FEVER. Synonyms : This is also called rose cold, autumnal catarrh, and hay asthma. It is a condition of intense coryza, with which conjunctivitis is regularly, and asthma often, associated. Etiology : It is not common except in older children. The cause is not known, but it is believed to be a neurotic predis- position, and the presence in the atmosphere of some irritant arising from vegetation. The cases regularly begin in the fall months, and usually at a very definite time. Certain localities seem perfectly free from the disease, and a patient going to one of these will be cured almost at once. Pathology : The disease is functional ; there are no lesions, but the irritated mucous membranes are temporarily in a state of acute inflammation with inci^eased secretion. Hay fever — symptoms : The disease begins suddenly, at a rather definite time of year, with sneezing, obstructed nasal breathing, a watery irritating discharge from the nostrils, lachrymation, and injected conjunctivas. The nose itches ex- cessively and the sense of smell is much impaired. These symptoms continue throughout the attack'. In certain eases, in addition to the involvement of the nasal and ocular mucous membranes, the bronchial walls and lining are invaded and the patient suffers from attacks of coughing, with scanty expectoration, and from attacks of asthma. The 220 DISEASES OF THE RESPIRATORY SYSTEM. difficult breathing is continuous day and night, but is often exacerbated and may become very distressing. The attacks last for a month or six weeks, and usually disappear with the first frost. Diagnosis : The first attack may be a little difficult to recog- nize ; but, as a rule, even in this the character of the disease is shown. Subsequent attacks should be quickly diagnosed. Prognosis : It is not a serious disease ; but it is difficult to cure an attack, and equally so to prevent subsequent ones. Many cases of undoubted cures are, however, reported. Hay fever — treatment : During the attack much relief may be afforded by applications to the nose of atropine in 1 per cent, solution, or of cocaine in 2 per cent, solution. Some ointment, or even vaseline, applied to the nostrils prevents excoriations from the discharges. In cases with asthma combinations of belladonna and iodide of potassium given internally produce relief. The inhalation of smoke from stramonium cigarettes is often helpful. Between attacks the nostrils and naso-pharynx should be carefully searched for any abnormalities, and these, if found, should be thoroughly treated. If no amelioration can be effected, the child should be sent away regularly to a region free from the disease during the time of its prevalence. DISEASES OF THE LARYNX. SPASMODIC LARYNGITIS. This disease is also called laryngismus stridulus and spas- modic croup. Etiology : This disease is a neurosis of the internal laryngeal muscles. It is seen most often in rachitic children or in those suffering from any form of malnutrition. In these conditions all the reflexes are markedly increased. Children of a neurotic heredity are often affected. Local causes are frequently found, such as adenoids, hypertrophied tonsils, elongated uvula, or acute inflammations of the throat, nose, SPASMODIC LARYNGITIS. 221 or bronchi. Indigestion, exposure to draughts, excessive exertion, and great emotion will often excite attacks. Pathology : There are no lesions of this disease. The con- dition is a reflex spasm of the laryngeal muscles. The patho- logical changes of the predisposing diseases are found. Spasmodic" laryngitis — symptoms : The symptoms consist in sudden, unexpected attacks of interference with the passage of air through the larynx. The spasm seems at first to close the glottis completely, and during this time the child changes from a pale to a cyanotic color, throws back his head, and makes violent efforts to breathe. In about half a minute the spasm gradually relaxes, and this is shown by a noisy crowing or stridulous inspiration. Expiration is, however, more diffi- cult. This may be the end, but recurrences in a few minutes or hours are to be expected. There may be a great many paroxysms during the day. General convulsions and tetany are apt to complicate the attacks. There are all grades of severity to the paroxysm, from the mildest form which may be scarcely noticeable to a spasm so severe and prolonged as to endanger life. The tendency to recurring attacks lasts usually from a few weeks to a month or two. Diagnosis : The disease must be differentiated from ca- tarrhal laryngitis and from diphtheria of the larynx. The suddenness of the seizure and the intermissions in the attacks, together with the absence of fever and other signs of inflam- matory stenosis of the larynx, suffice for a diagnosis. The general condition of the child also assists. With a little care in following; the historv there should be no occasion to confuse the disease with whooping-cough. Prognosis : The prognosis is good, although fatal cases do occur. The presence of general convulsions, the general condition of the child, and the severity of the paroxysm must be taken into consideration in estimating the chances for recovery. Spasmodic laryngitis — treatment: To relieve the spasm, strong counter-irritation to the skin is quickly efficacious. This may be brought about by dashing cold water on the head and lace or by putting the patient in a hof bath. In 222 DISEASES OF THE RESPIRATORY SYSTEM. more severe cases chloroform-inhalations may be used, and at times intubation may be necessary. In the intervals between attacks antispasmodics should be given to prevent recurrences. The best drugs of this class are bromide of potassium, chloral, and antipyrin. They may be used separately or in combination, and should be given so as to keep up a continuous impression on the nervous system. To remove the tendency to attacks, all measures directed to improving the child's general health, particularly its nutrition and digestion, should be carefully followed out. Fresh air, cool bathing, and proper food should be insisted on. Rickets must be treated, if present. The nose, naso- pharynx, and throat should be carefully examined, and any abnormalities that are found should be properly treated. ACUTE CATARRHAL LARYNGITIS. This disease is also called catarrhal croup, and, in its milder or severer form, is the ordinary croup from which children so frequently suffer. Etiology : The disease commonly results from exposure to cold, or damp, or draught, in a child that is ordinarily too much protected from these influences. It occurs most com- monly before the third year, but is seen even in much older children. Certain children have a marked predisposition to the disease, attacks recurring with great persistency. It often complicates influenza, measles, scarlet fever, or others of the infectious diseases. Pathology : The mucous membrane of the larynx is hyper- semic and swollen, with — in the beginning — a diminished se- cretion, so that the membrane is dry. As the disease ad- vances the secretion increases until it eventually becomes abnormally large in q uantity . The swollen mucous membrane over the cords decreases the space of the glottis, and, as more or less muscular spasm usually accompanies the inflamma- tion, the stenosis becomes more marked. In the severe and prolonged form, the trachea takes part in the inflammatory process. Acute catarrhal laryngitis — symptoms : In the milder cases, ACUTE CATARRHAL LARYNGITIS. 223 which are the ones ordinarily seen, about the only symptoms are a change in the character of the voice. This becomes hoarse and at times metallic. In young infants it can only be noticed when crying, but in older children the spoken voice also shows it. At times aphonia may be present:. A cough of a dry, brassy character usually accompanies this. If the chink of the glottis is much narrowed, particularly if some adductor spasm is present, as so often is seen in these cases, there is more or less interference with the breathing, which is the alarming symptom of the-disease. The constitutional symptoms are slight, the temperature rising only a degree or two, and the child not feeling at all sick. These cases regularly have an exacerbation of the symptoms during the night, with remissions during the day. In the severe cases the symptoms due to the larynx are the same, but intensified ; a croupy voice and cough, no expectora- tion at first, and marked interference with respiration. The inspirations are stridulous and the child seems to be suffo- cating. The skin becomes somewhat cyanotic and dyspnoea is very marked. The suprasternal and infracostal spaces sink somewhat in inspiration, and all the signs of laryngeal stenosis are present. The constitutional symptoms are likewise marked. The temperature may be from 101° to 104° F., the pulse and res- piration are rapid, and the child seems sick and prostrated. The symptoms increase in severity for two or three days, and then gradually diminish as the mucous glands begin to secrete and the inflammation to be resolved. The cases usually last about a week or ten days, unless bronchial or pulmonary complications set in, when they are much prolonged. Diagnosis : Spasmodic laryngitis is distinguished by the ab- sence of fever and constitutional symptoms, by its occurring usually in rachitis, and by its paroxysmal character. The differentiation from membranous laryngitis is more difficult and more important. The dyspnoea in the membra- nous form is more constant, and does not show the daytime remissions seen in catarrhal croup. The presence of visible membranes elsewhere in the throat is almost certain proof of the membranous variety. Cultures can be made from the 224 DISEASES OF THE RESPIRATORY SYSTEM. pharynx and larynx for the Klebs-Loffler bacilli, even where no membrane can be seen. In doubtful cases where other children are exposed it is better to isolate the patient until the diagnosis can be made positive. Prognosis: This improves with the age of the child. Although most of the cases recover, still caution must be used in prognosing, as very severe symptoms may develop, and any case may turn out to be of the membranous variety. Acute catarrhal laryngitis — treatment : The child should be put to bed in a room with a uniform temperature, in which the air is artificially moistened by steam, and put on a lighter diet than it normally takes. The clothing should be suffi- ciently warm, and the neck should be rubbed with campho- rated oil or turpentine, and then bound up with flannel. A hot mustard foot-bath may also be given. The bowels should be opened by fractional doses of calomel given hourly. If the case is in any way severe, the child should be under a tent and breathe steam plain, or medicated with turpentine, creosote, or compound tincture of benzoin. Internally, the so-called expectorants are indicated, of which the best are ipecac and antimony. They are best given in doses just short of producing emesis, frequently repeated so as to keep up a continuous effect. A convenient method is by use of the tab- let containing t ^~q grain each of ipecac and antimony, or com- binations of the wines of ipecac and antimony with ammo- nium chloride may be used. At times there seems value in giving repeated doses of pilocarpine until the laryngeal mu- cous membrane begins to secrete. If the spasmodic element is marked, chloral, or the bromides, or antipyrin, are useful additions and are indicated. In very severe cases where medicinal measures do not relieve the stenosis, recourse must be had to intubation. To prevent future attacks these children should have the nose and naso-pharynx and pharynx carefully examined and any abnormalities found treated. Such lesions as adenoids or enlarged tonsils are often found, and act as predisposing causes. Each day the child should be given a cool bath, and it should be taken out of doors daily and accustomed to cool, fresh air. The clothing should be comfortably warm, but MEMBRANOUS LARYNGITIS. 225 not too heavy. The tendency to croup can be completely removed in these children by attention to these little details. MEMBRANOUS LARYNGITIS. Synonyms for this are true croup, or membranous croup, or laryngeal diphtheria. The latter particularly must be re- membered, as in the vast majority of the cases the whole disease is diphtheria with its lesion located in the larynx. Etiology: While infection by the Klebs-Lomer bacillus is, in the great mass of the cases, the cause of this disease, still pseudomembranes may rarely form in the larynx from irri- tation produced by the streptococci, and at times after intense chemical irritants, as lye. Pathology : There is an inflammation of the laryngeal mucous membrane so intense that a new false membrane is formed on its surface and attached quite intimately to it. The false membrane by its mechanical presence blocks up the opening between the cords, which is already diminished in size by the swelling. In this false membrane the Klebs- Loffier bacillus is easily demonstrated, together with colonies of streptococci. Membranous laryngitis — symptoms: The constitutional symptoms, particularly early in the disease, are quite secon- dary to the local symptoms from the larynx. The disease begins gradually with a steadily increasing diminution in the calibre of the glottis, but with very slight or no remissions, thus distinguishing the catarrhal variety. They have the croupy voice and cough, and the stridulous, noisy respiration. Later on aphonia may develop and the stenosis become marked enough to produce general cyanosis of the patient. In the meantime the fever is slight and the pulse only a little fast. The respiration is more rapid. As the dyspnoea increases restlessness and excitement and a struggle for air are prominent symptoms. There is no enlargement of the lymph-glands in the neck. All these signs presuppose the presence of pseudomembrane only in the larynx. If the resull is t<> be favorable, after four or five days the cough grows looser, the voice returns, the breathing is easier, and 15— D. C. 226 DISEASES OF THE RESPIRATORY SYSTEM. often fair-sized pieces of false membrane are spit np. If the end is fatal, all the dyspnceic symptoms increase in severity, and cerebral symptoms become especially prominent, as rest- lessness, delirium, and convulsions ; or stupor and coma. The cases are rapid in their course, recovery or death usually being certain by the end of a week. The spreading of the membrane to the lung, setting up bronchitis or pneumonia, adds an important element to the symptoms of the disease. Diagnosis: This is often quite difficult to make in the be- ginning. The presence of membrane elsewhere in the throat and the lack of general symptoms are of most importance. Bac- teriological examinations should be made in any doubtful case. Prognosis : This is very serious, but since the advent of antitoxin the mortality has been very considerably reduced. Membranous laryngitis — treatment : The child should be put to bed and isolated from other children and properly fed and stimulated. In preantitoxin days, emetics, steam inhalations, and calomel fumigations were used as the medical treatment of this disease. At the present time they may be used as aids to the specific antitoxin treatment, but are never to be relied on alone. Emetics that are of value are ipecac, or antimony, or turpeth mineral given in small doses repeated frequently until vomiting is produced. Plain or medicated steam inhalations are used in the same way as in catarrhal laryngitis, under a tent. Calomel fumigations are given by subliming ten to twenty grains of pure calomel over an alco- hol lamp, the calomel being placed in a porcelain receptacle. The child and the fumigating apparatus should be under a tent, and the only caution necessary is to prevent accidents by fire. Various forms of apparatus are sold for this pur- pose, but by a little ingenuity a simple and efficient home- made one may be devised. The fumigations are usually repeated every three hours, watching results. The antitoxin should be given early, in good-sized dose, and repeated in twelve hours, according to results. In cases of doubtful diagnosis it should be given without waiting for the case to develop to a certainty, as, should the case turn out to be some other form, no harm has been done. MEMBRANOUS LARYNGITIS. 227 Notwithstanding antitoxin and medical treatment, very many of these cases require mechanical help to overcome the laryngeal stenosis, and it is due to these only in many cases that the child is saved from absolute suffocation. Mechani- cal measures or operative procedures are indicated by a stead- ily increasing dyspnoea, restlessness, cyanosis, and retraction of the suprasternal and infracostal regions. It is always a matter of some anxiety to know when the time for operation is necessary, and there is no good rule to follow. It is, how- ever, better to perform it too early than too late, after the child is exhausted by its struggles for air and the tissues are poisoned, by the venous blood. Of the two operative meas- ures employed, intubation and tracheotomy, the evidence in favor of the former is steadily increasing, and tracheotomy is now very seldom used as a first recourse, but only in certain cases where intubation cannot be performed, or where it may have failed. Intubation has many advantages over trache- otomy. It is simple, it is more easy to obtain the parents' consent to an early operation ; it has no prejudicial effects on the throat in forming a wound for fresh infection ; if it fails, tracheotomy can be done as easily afterward as before, and there is no need of an anaesthetic. The only objections are the difficulty in feeding some children who are wearing tubes, and the rare accident of crowding false membrane into the trachea ahead of the tube and spreading the infection, and the possibility of not having the apparatus. Intubation consists in the passing into the larynx through the mouth, and leaving there, a tube through which the air passes in entering and leaving the lungs. The O'Dwyer apparatus is the best one for use. It consists of various sized tubes, an introducer, an extractor, a mouth- gag, a gauge for deciding the size of the tube required, and some strong silk. To insert the tube the child should be wrapped, arms and all, in a blanket or .-heel, and then held upright by the nurse with his head resting against her chest. The gag is inserted in the left side of the mouth. The operator holds the tube on the introducer in his right hand, the silk being first passed through an eye in the tube and tin.' ends held by the same 228 DISEASES OF THE RESPIRATORY SYSTEM. hand. He then passes his left index finger over the epiglot- tis, and thus locates the upper part of the larynx. With this finger as a guide he passes the end of the tube through the space between the cords and pushes the tube easily into place. The introducer is then removed, leaving the tube with its at- tached silk in situ. If the intubation has been successful, the relief to the dyspnoea is immediate, and some attempts at coughing are usually made. If unsuccessful, the tube is again affixed to the introducer and again introduced. After the child quiets down from the intubation and becomes accus- tomed to the tube, the silk may be removed. If it is left, it should be fastened to the cheek by adhesive plaster. After a successful intubation usually very few troubles arise. One is the coughing up of the tube. This is remedied by passing the next larger size. Feeding with the tube in place should usually be done with the head held lower than the body, or at least lying down ; and, if possible, semi-solid food rather than liquids should be used. If the tube becomes blocked, it is usually coughed up by the patient ; but if not, it must be quickly extracted. During the wearing of a tube the child should be carefully watched to prevent accidents, and the physician should be within easy call to replace a coughed-up tube or to remove an offending one. In removing a tube the child is held in the same way as in introduction. With the left index finger the head of the tube is located, and on this as a guide the extractor is passed into the lumen of the tube and the tube removed. The time for removal is difficult often to decide. Await the subsidence of the disease before trying it. Often after re- moval it will have to be reintroduced, and worn for a few days longer before it can be safely left out. Tracheotomy is sometimes necessary, and is performed in the way regularly described in all the text-books on surgery. CHRONIC LARYNGITIS. Chronic inflammations of the larynx are found with some frequency in infants and children. CHRONIC LARYNGITIS. 229 Etiology : Most of the cases follow attacks of acute laryn- gitis, and are apt to be associated with chronic catarrhal con- ditions elsewhere in the throat. Other cases are due to syphilis and others to tuberculosis. Pathology : In the simple catarrhal cases and in the early syphilitic ones, the mucous membrane is in a state of chronic inflammation, with at first an increased and later a decreased secretion, and hence abnormal dryness. The later syphilitic form attacks the deeper tissues of the larynx, producing ulcer- ation and deformity. The tubercular cases show thickening of parts of the larynx by tubercular infiltration, and later necrosis of this new tis- sue with ulceration. Chronic laryngitis — symptoms : These are hoarseness, a dry cough, more or less aphonia, and a thick, sticky, but not pro- fuse, expectoration. In the tubercular variety, tubercle bacilli may be found in the sputum, and there is severe pain on swallowing. Diagnosis : This depends on the above symptoms, in addi- tion to the physical signs seen on examination. Ulceration, with involvement of the arytenoid areas, usually means tuber- culosis. General ulceration with scar-tissue present at the same time usually means syphilis. Evidence of either dis- ease elsewhere assists the diagnosis. The simple variety sim- ply shows a general thickening of the cords, with often dried secretion on them. Prognosis : The simple form can usually be cured by re- moving the cause. The tubercular form usually complicates tuberculosis elsewhere, and the prognosis is that of tubercu- losis in general. The syphilitic form can be regularly cured ; but in the tertiary variety, after extensive ulceration, the larynx is apt to be left badly deformed. Chronic laryngitis — treatment: In the simple form, atten- tion to the whole pharynx is important. Any chronic condi- tions there must be treated. The larynx should he touched daily with astringent applications, or l>v weak solutions of nitrate of silver, inhalations of turpentine or of tar are 230 DISEASES OF THE RESPIRATORY SYSTEM. valuable. Internally, expectorants such as ammonia and ipecac may be given. In the syphilitic variety, the main reliance is to be placed on antisyphilitic treatment. Local applications of a cleansing nature often aid. With marked cicatricial contraction intu- bation is often necessary. In the tubercular variety, cleansing applications should be made, and the ulcers touched with nitrate of silver, or lactic acid, or dusted with iodoform. If pain on swallowing is marked, applications of cocaine give temporary relief. Spe- cial means should be taken to build up the general health, and to overnourish the child. PAPILLOMA OF THE LARYNX. Papilloma of the larynx is found with some frequency in children, and at times even in infancy. Nothing is known as to its causation. It consists of one or more warty growths from the neigh- borhood of the cords. The tumor is either sessile or pedun- culated, and presents a pinkish appearance. Papilloma of the larynx — symptoms: The symptoms are hoarseness, going on to aphonia, an irritating cough, and a gradually increasing dyspncea as the growth of the tumor blocks up the larynx. The symptoms progress slowly, as the tumor grows slowly. Diagnosis : This depends on direct examination with the laryngoscope if possible. If not, much can be learned by palpation of the larynx with the index finger. Prognosis : This is not good, as the tumor is apt to recur after removal, and seems at times to take on almost a malig- nant character. Papilloma of the larynx — treatment : In some older children they can be removed by endolaryngeal operations through the mouth. Most cases require thyrotomy and the excision of the growths. In some cases tracheotomy and leaving the growth entirely alone is all that can be done. FOREIGN BODY IN THE LARYNX. 231 (EDEMA GLOTTIDIS. Definition : By this is meant an effusion of serum into the submucous tissue of the larynx. Etiology : It is secondary to disease elsewhere, as nephritis, and occurs often as a complication of the exanthemata. It also results from intense local irritation, as the inhalation of hot vapors, the swallowing of corrosive liquids, and from ulceration and foreign bodies. Pathology : The cellular submucous tissue is infiltrated with serum and with new cells. The larynx, especially in the aryepiglottic folds, is intensely swollen. (Edema glottidis — symptoms : The characteristic symptom is inspiratory dyspnoea, expiration being comparatively easy. If any local inflammation is present, there is intense pain. The symptoms develop rapidly, and in a few hours the pa- tient may be in danger of death from suffocation. Diagnosis : A laryngoscopic, or digital, or at times a mere visual, examination will settle the diagnosis. Prognosis : With proper treatment this is good. Untreated, the mortality is high. (Edema glottidis — treatment : The oedematous tissues must be freely scarified, and ice must be given to swallow, and also packed externally around the throat. In some cases trache- otomy is necessary. Intubation is not, as a rule, very suc- cessful. FOREIGN BODY IN THE LARYNX. This occurs from time to time, usually as a result of a child laughing, <>r crying, or coughing, while holding some foreign body in its mouth. It may lodge in the larynx, or trachea, or drop down into a bronchus, usually the right one. Symptoms: Violent paroxysmal cough and dyspnoea, with often localized pain and haemoptysis, are the regular results of this accident. Diagnosis: This depends on the history and symptoms. In a few cases the object may be seen by the laryngoscope. Prognosis: In many cases the body is eventually expelled. It may remain and be encapsulated, causing no trouble ; but 232 DISEASES OF THE RESPIRATORY SYSTEM. in no case can a positive prognosis, good or bad, be given. There is always danger from its presence. Foreign body in the larynx — treatment : The patient should be inverted and shaken, and in some cases the body will be expelled. If impacted in the larynx or trachea, it may be removed by properly constructed forceps either through the mouth or after tracheotomy. DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. ACUTE BRONCHITIS. Definition : This very common condition in infants and children is an inflammation of the mucous membrane lining the smaller and larger bronchi. Etiology: It commonly follows exposure to cold and damp- ness. It occurs most often during the winter months, espe- cially when the changes of temperature are sudden and marked. Certain children seem predisposed to the disease, especially those who have frequent attacks of coryza and sore throat. It is often secondary to the infectious diseases, par- ticularly to influenza, measles, and whooping-cough. It is common in children suffering from any form of malnutrition, especially rickets. Micro-organisms undoubtedly play a prom- inent part in the causation of this disease. Pathology : The small or the large, or both kinds of tubes may be involved, and regularly those of both sides. The mucous membrane is congested and swollen, the superficial epithelium is shed, and the glands secrete an excessive quan- tity of mucus and muco-pus, due to the inflammatory exudate. Acute bronchitis — symptoms : The disease begins gradually, and frequently after a preceding coryza, with fever, cough, and malaise. The respiration is rapid, and the child is rest- less and fretful. In the milder cases these symptoms last about a week and recovery occurs. In more severe eases all the above symptoms are intensified, the temperature runs higher, the cough becomes distressing, and the respiration quite rapid and difficult, but its normal ACUTE BRONCHITIS. 233 rhythm is retained. The pulse is rapid and the child de- cidedly prostrated. In the early stages the secretion from the bronchi is scanty ; and later, when it increases, the child swallows what it coughs up into the throat. Expectoration is a habit formed later in life, the young child always swal- lowing its sputa. The appetite is commonly lost ; there may be vomiting and diarrhoea. In these severe cases the disease lasts for a couple of weeks, and may be protracted even over a longer time. Acute bronchitis — physical signs : In the very beginning there are often no physical signs, save the very rapid respira- tion and the movement of the ala? nasi. After a day or two both chests are full of sibilant and sonorous breathing. Later, as the secretion becomes loose, this breathing is replaced by very numerous fine or coarse rales. The kind of rale de- pends on the size of the bronchi in which it is formed. As the disease advances the rales grow looser and fewer, and gradually disappear. Diagnosis : This depends on the history and the physical signs. The only difficulty is in excluding broncho-pneumo- nia, and in many cases this may be impossible. Prognosis: — In children of good physique this is good. Delicate children, those the subjects of rickets or of the infectious diseases, and very young infants bear the disease badly. In young infants the mucus is very apt to block up the bronchi and to impede respiration seriously. Acute bronchitis — treatment : The child should be kept in the house in an equable temperature, and put on a light, easily digestible diet. It should be given first fractional doses of calomel repeated till the bowels move. The chest should be rubbed with some mild counterirritant, as camphorated oil, or mustard paste may be applied. Internally a prescription containing small doses of an expectorant, such as ammonium chloride and ipecac, may be given and repeated frequently. Inhalations of steam, containing turpentine or creosote, are often useful. Stimulants are frequently necessary, ami brandy "i - si rychnine may be used. ( )pium should be given sparingly in this disease. 234 DISEASES OF THE RESPIRATORY SYSTEM. In cases of sudden collapse, or of respiratory feebleness, nothing acts so quickly as a stimulant as a hot mustard bath. CHRONIC BRONCHITIS. Etiology : This condition is not so common in children as in adults. It regularly follows an attack of acute bronchitis in a patient who has a poor constitution, or is weak from some disease which the acute bronchitis complicated. Pathology : The bronchial mucous membrane is in a con- dition of chronic catarrhal inflammation, with an excessive production of mucus. Chronic bronchitis — symptoms : A troublesome, persistent cough, with the raising of a great deal of mucus, are the regular symptoms of this disease. The cough is apt to be worse in the morning and at night. There are no fever and no malaise, and very little interference with the general health. Chronic bronchitis — physical signs : These are simply the presence of coarse mucous rales scattered over both lungs. Diagnosis : This depends on the cough and the signs in the lungs. Tuberculosis must be excluded by the difference in the physical signs and the absence of tubercle bacilli from the sputum. Prognosis : This is good, as most of these children by intelligent treatment can be cured. Chronic bronchitis — treatment : General strengthening, con- stitutional treatment is of most importance. All measures to improve the child's general health should be carefully fol- lowed out. These children should not be confined to the house, but should have the freedom of the fresh air and sun- shine in good weather. A change of climate for a short time will often be very beneficial. As drugs, creosote, tar, or terebene seem of most value. Iron and cod-liver oil are especially helpful. FIBRINOUS BRONCHITIS. Definition : This rather rare disease consists in the forma- tion in the bronchi of false membranes, which form casts BRONCHO-PNEUMONIA. 235 of the tubes in which they occur. Some cases are un- doubtedly diphtheritic, but others are not so, and their etiology is unknown. Pathology : The trachea and large bronchi are usually involved, but the inflammation may reach down into the bronchioles. The mucous membrane is swollen and con- gested, and coated with a layer of coagulated fibrin, which may be free in the lumen, or attached to the surface of the bronchi. Fibrinous bronchitis — symptoms : The symptoms are those of a severe catarrhal bronchitis, acute or chronic, as the case may be. They differ mainly in the severity of the dyspnoea, which in the croupous variety is excessive. The physical signs are likewise the same. Diagnosis : This is made by the expulsion and recognition of the fibrinous casts of the tubes. Otherwise the diagnosis from ordinary bronchitis is impossible. Prognosis : This is bad, as considerably over half the cases die. Fibrinous bronchitis — treatment : This is the same as for the catarrhal variety. Inhalations of oxygen may be of service in the excessive dyspnoea. If the diagnosis of the fibrinous form is made, an emetic may assist in the expulsion of the membrane. With the possibility of the disease being diphtheritic anti- toxin might be used to aid in loosening the cast. BKONCHO-PNEUMONIA. Synonyms and definition : Other names for this common children's disease are catarrhal pneumonia, lobular pneu- monia, and capillary bronchitis. It is an inflammation involving both the terminal bron- chioles and the air-vesicles. There is consequently a lobular distribution to this inflammation. Etiology: This is the usual "pneumonia" of childhood, it maybe primary, as after exposure to cold, or damp, or draughts ; but is more commonly secondary to bronchitis, or measles, or whooping-cough, or diphtheria, or influenza. It 236 DISEASES OF THE RESPIRATORY SYSTEM. attacks previously healthy children, but more often those of feeble constitution. Micro-organisms of one form or another are the actual exciting cause. Pathology : The inflammation involves the entire thickness of the bronchial wall, and not the mucous membrane only. The terminal bronchi are those usually attacked, and the air- vesicles connected with them and those surrounding them are involved in the inflammatory process. The walls are thick- ened and infiltrated by new cells ; the air-vesicles are filled with exuded fibrin, pus, and epithelium, and in places this is changed into new connective tissue. Parts of both lungs are regularly involved. Catarrhal bronchitis, pleurisy, atelectasis, and diffuse consolidation of portions of the lungs are ordi- nary complications. This inflammation is such that resolu- tion is slow, and often it may become chronic. Broncho-pneumonia — symptoms : The disease, whether it be primary or follow a preceding inflammation elsewhere, begins gradually with a slowly rising temperature, an increasing rapidity of the pulse and respiration, and a cough. The tem- perature runs irregularly, with remissions and exacerbations, the highest point reached being ordinarily 103° or 104° F. The fever subsides gradually, by lysis. The pulse goes to 130 to 150 beats to the minute. The respi- ration is excessively rapid and shallow, and may reach 50 to 75 per minute. The respiratory rhythm is changed, so that the breath is held after inspiration, giving the so-called grunt- ing respiration. The pulse-respiration ratio is entirely lost. The cough is short and dry, and quite incessant. Later it is looser and easier, but expectoration is uncommon, the sputa being swallowed. The face and skin are suffused and cyanotic, the alee nasi are playing freely. The tongue is coated and dry. There may be vomiting and diarrhoea. All the cases are restless, and in some the nervous symptoms are especially marked, with delirium, or stupor and coma, and often convulsions. A good many cases are ushered in by general spasms. Prostration is marked in all the severe cases. If the case is to go on to recovery, a gradual improvement in all the symptoms occurs, but convalescence is extended over BRONCHO-PNEUMONIA. 237 a considerable time, and the duration of the attack is quite indefinite. In other cases the acute symptoms gradually subside, and the disease protracts itself into a chronic state. The bad cases increase in severity, and die exhausted, or from respiratory failure, or from convulsions, before the second week. Broncho-pneumonia — physical signs: If only the walls of the bronchi and of the air-spaces are involved, there will be no physical signs at all. If enough neighboring air-spaces are inflamed to produce patches of consolidation, we have areas of dullness on percussion, increased fremitus, and bron- chial voice and breathing. If a catarrhal bronchitis is present as a complication, which is very common, we find the fine or coarse mucous rales of this disease. The smaller and the finer the rales, the nearer to the air-vesicles they are made, and the more the probability, in the absence of signs of consolidation, of the presence of broncho-pneumonia. If any pleurisy is present, we find crepitant rales or a friction-rub. Diagnosis : In some cases the diagnosis must be made by the presence of fever, rapid breathing, cough, and prostra- tion. Catarrhal bronchitis often gives exactly the same signs, but broncho-pneumonia has more fever and more prostration. Without signs of areas of consolidation the differentiation cannot be positive. From lobar pneumonia the diagnosis is fairly easy, the history and physical signs of the two being quite different. The only important difficulty is in excluding tubercular broncho-pneumonia in the protracted cases. This should always be borne in mind, but often only time will decide the question. Prognosis : A serious prognosis must always be given. Cer- tain conditions add decidedly to the mortality-rate. These are age and previous condition of health. The younger the infant the worse the prognosis. Previous disease, as measles, pertussis, diphtheria, or influenza, or bad nutritional stales, 238 DISEASES OF THE RESPIRATORY SYSTEM. as rachitis, add to the dangers. The amount of lung in- volved and the presence of a large amount of bronchitis are elements to be considered in estimating any particular case. Broncho-pneumonia — treatment : As prophylaxis, measures should be taken in all cases of bronchitis and the infectious diseases to prevent the development of broncho-pneumonia. Proper attention to the air of the sick-room, and to the mouth and throat, and to the treatment of these diseases will pre- vent many cases of broncho-pneumonia. If the disease has developed, the child must be .put to bed in a room with an equable temperature of about 70° F., and kept on easily digestible but nutritious diet. Special atten- tion should be given not to overload the stomach. The child should not be allowed to lie in one position for any length of time, as this favors hypostatic congestion of the lungs. There seems to be some value in keeping the air in the room moist by allowing water to boil over a fire. The child's chest should be rubbed twice a day with cam- phorated oil or diluted turpentine, and then kept covered with a cotton jacket. If stronger counter-irritation is needed, repeated applications of mustard paste made with flour, in strength of 1 to 6 up to 1 to 2, may be used. In the beginning of the disease fractional doses of calomel, frequently repeated, should be given. Following this, doses of ammonium chloride and ipecac, in syrup of tolu, or simple elixir, should be given frequently enough to keep up a con- tinuous action on the bronchial mucous membrane but not to nauseate, throughout the disease. Inhalations of tar or of creosote seem to have some value. Stimulants will usually be needed after the disease lias run a few days. Alcohol and strychnine are the best. Atropine may be used to stimulate the respiration. The fever will seldom need any treatment ; but if it should, cool sponging should be our resource, rather than antipyretics internally. If the child is very restless and the nervous symptoms are marked, small doses of opium, or of bromide, may be used. As a rule, the less opium given in this disease the better. In sudden attacks of collapse, hypodermics of caffeine, or of camphor, or of nitroglycerin, may be used. LOBAR PNEUMONIA. 239 Immersion in hot water is, however, a quicker and more re- liable stimulant than drugs. If the disease becomes protracted, attention to the general health and a change of climate are our main resources. Iron, quinine, and cod-liver oil, as general tonics, are of most value. Creosote should also be given in slowly increasing doses. LOBAR PNEUMONIA. Definition: This disease is also called croupous or fibrinous pneumonia, and while broncho-pneumonia is the ordinary variety as seen in children, still the lobar form occurs with more frequency in them than is usually supposed. Etiology : The older the child the more frequent is this form of pneumonia. It is most frequent during the cold mouths of the year. It is due in the large number of cases to the presence of the diplococcus pneumoniae. The disease at times seems to be somewhat epidemic. Pathology : The lower lobe of one or the other lung is most often involved, although the upper lobe may be attacked. At times more than one lobe in the same lung is affected, or even parts of both lungs. The disease goes through the same stages as in adults, first that of congestion, in which in the affected lobe the air-cells contain the products of inflammation, and their walls are swollen and thickened. The second stage — of red hepatization — follows, in which the above process is simply so intensified as to cause a com- plete consolidation of the affected part. This is red, and re- sembles liver on cut section. During this stage the pleura over the affected lobe becomes inflamed and is coated with fibrin. This is followed by the third stage — that of gray hepatiza- tion— in which the inflammatory exudate begins to soften and break" down. The red color is changed to gray, but the con- solidation remains. Lastly conies the stage of resolution, in which the exudates become still softer and more liquid, and are gradually removed by absorption and expectoration. After this stage is passed the lung returns to its original condition. 240 DISEASES OF THE RESPIRATORY SYSTEM. Lobar pneumonia — symptoms : The disease begins quite suddenly with chilly sensations, a rapid rise in temperature, pain in the chest, and cough. In many cases the onset is announced by convulsions or vomiting. The temperature soon reaches about 105° F., and remains there with very slight remissions until the disease is over, when it falls quickly, by crisis. The respiration is acceler- ated to 40 or 50 per minute, and is usually painful. The pulse becomes rapid, 120 to 140 per minute, but should be strong and full. The appetite is lost, and the bowels may be loose or constipated. There is apt to be rather a lively delirium throughout the fever. The cough is persistent and frequently painful. In the beginning the expectoration, if not swallowed, is a stringy, sticky, blood-stained mucus ; later it grows looser, and consists of little yellowish lumps. Daring the whole course of the disease the child sleeps very little. The disease lasts with very little change in its character for a week or ten days, when the temperature rapidly drops to normal by the so-called crisis. With the fall in tempera- ture is a coincident drop in the rate of the pulse and respi- ration to nearly normal. In some cases is a pseudo-crisis with some fall of temperature and remission in the symptoms a day or so preceding the real crisis. It is just before the crisis that the sudden attacks of heart-failure, that are such a serious feature of lobar pneumonia, develop. Some cases, instead of defervescing at the regular time, go on with the same symptoms, this indicating usually a spreading of the disease to new portions of the lungs. Lobar pneumonia — physical signs : During the congestive stage there is slight dulness on percussion, while the breath- and voice-sounds are somewhat exaggerated. Over the same area a few crepitant rales are usually heard. During the stages of hepatization there is distinct dulness on percussion over the consolidated area. The vocal fremitus is markedly increased, and both the breathing and the voice are bronchial. Rales are usually absent. As the stage of resolution appears the dulness diminishes, the breathing and voice gradually take on their normal quality, and the crepitant rdle, the rdle redux, returns. Later, INTERSTITIAL PNEUMONIA. 241 coarser rales take their place, and are present until the lungs return to normal. Signs of dry pleurisy, or of fluid in the chest, or of peri- carditis, are often found as complications. Diagnosis : Broncho-pneumonia and pleurisy with effusion are the two diseases most likely to be confused with lobar pneumonia. The history and physical signs, if carefully fol- lowed, will usually prevent any error being made. Prognosis : The prognosis in children is much better than in adults. The great danger depends on failure of the heart, and in children this does not occur so readily as in adults. The height of the temperature and the extent of lung in- volved are of great importance in estimating the prognosis. The danger of post-pneumonic complications, particularly pleurisy with effusion and empyema, must be remembered. Lobar pneumonia — treatment: The child should be kept absolutely quiet in bed from the first. The food should be liquid, and given in small quantities frequently repeated. If there is pain in the chest, the application of mustard paste and a cotton jacket are of value. For the restlessness and cough, small doses of opium are allowable. For the tem- perature it is best to do nothing. If its height seems detri- mental to the child, cool sponging is the best way of bringing it down. If the heart's action is too excessive, small doses of aconite may be given. The main reliance must be put on heart-stimulants. They will always be necessary just before the crisis, and had better be used in moderation throughout the disease. The best of these are alcohol and strychnine. Digitalis is often used, but is not so reliable as the above. They should be used in full dose. The inhalation of oxygen is useful in certain cases of excessive clyspnaa. During con- valescence, general tonic treatment is indicated. INTERSTITIAL PNEUMONIA. Definition: This condition is also called chronic broncho- pneumonia and fibroid .phthisis. Clinically it is a rather in- definite disease and difficult of diagnosis. Etiology: It follows attack- of broncho-pneumonia, of 16— D, C. 242 DISEASES OF THE RESPIRATORY SYSTEM. chronic pleurisy, and of bronchitis. Its connection with a precedent cured tuberculosis is in doubt. It is a compara- tively rare disease of childhood. Pathology : The disease is regularly unilateral, and consists in a substitution of connective tissue for the normal pul- monary tissue throughout the affected lung. The pleura on the lung is thickened and adherent, and the lung is filled with bands of dense fibrous tissue. In fact, there is a growth of new connective tissue all through the lung. The walls of the bronchi are thickened or thinned, and in places the bronchi are much dilated, forming bronchiectases. Interstitial pneumonia — symptoms: Following the history of the acute disease is the persistence of the symptoms of cough, expectoration, dyspnoea on exertion, and at times pain in the chest. The patient does not gain in flesh or strength, but remains thin and feeble. The cough is troublesome and the expectoration usually profuse and muco-purulent. Haemoptysis may be present. Fever is ordinarily not pres- ent. The disease lasts for months and years. If only a small area of the lung is involved, the inflammation may stop, and the patient recover. If the whole lung is involved, the patient will probably die, exhausted, after a long time. Often a tubercular inflammation is engrafted on the inter- stitial change. Interstitial pneumonia — physical signs : These are not dis- tinctive. The chest is retracted. There is dulness on per- cussion, or flatness. The vocal fremitus is increased. The breathing-sounds are feeble, or bronchial, or cavernous in cases where bronchiectatic cavities are found. Various forms of rales are usually present. Diagnosis : The diagnosis of this disease from tuberculosis is of special importance, and is extremely difficult to make. The history and physical signs of the two diseases are almost identical. The diagnosis usually rests on frequent examina- tions of the sputa for tubercle bacilli. Prognosis: This is bad. Some cases with an involvement of only a small area of lung recover. Life may be prolonged over very many years. Interstitial pneumonia— treatment : Climatic and hygienic PULMONARY EMPHYSEMA— ASTHMA. 243 treatment are of special value, and the only ones on which we can place much reliance. The child should live where he can be out of doors most of the time. Cod-liver oil and creosote seem to have some value. PULMONARY EMPHYSEMA. Definition : The variety occurring regularly in children is the so-called vesicular emphysema, in which the air-spaces are abnormally dilated, but without any of the chronic inflam- matory changes seen in adult life. Etiology : The cause is either compensatory, in which por- tions of the lung are overdistended, because other parts are disabled ; or obstructive, where something mechanically pre- vents the lung from emptying itself properly. In other words, emphysema in children rarely exists unless compli- cated by some other form of disease in the lung. Pathology : The causative disease produces its lesions, and in the parts affected by emphysema the air-spaces are found dilated and their walls thinned. In some the walls are ruptured. Pulmonary emphysema — symptoms : There are no distinc- tive svmptoms of this disease, as those of the primary condi- tion completely conceal any slight ones that might be produced by the emphysema. Dyspnoea, persistent or in attacks, be- longs to this disease, but is regularly present before the em- physema develops. Pulmonary emphysema — physical signs : These arc likewise liable to be concealed by the primary disease. The emphysem- atous areas give a tympanitic percussion-note, with feeble breathing-sounds and prolonged, low-pitched expiration. Diagnosis: This is rarely made in dealing with children. Prognosis: If the original disease is cured, the emphysema is regularly recovered from also. Treatment: This is that of the original disease. There are no special measures for the emphysema itself. ASTHMA. Definition: This is also called bronchial or spasmodic asthma. It is a paroxysmal dyspnoea in which, (luring the 244 DISEASES OF THE RESPIRATORY SYSTEM. intervals between the paroxysms, no evidences of disease of the lungs are present. Etiology : The disease occurs with some frequency among older children, and seems specially to attack those of a gouty or neurotic heredity. The disease is looked on as a vaso- motor neurosis without lesion, but in certain cases the presence of some abnormality in some part of the respiratory tract seems to act as the exciting cause. Hypertrophied turbinates, adenoids, enlarged tonsils, elongated uvula, bronchitis, or en- larged bronchial glands are such causes. The inhalation of irritants as in hay-fever, and gastro-intestinal disturbances often provoke an attack. Asthma — symptoms : The attack regularly comes on sud- denly without warning, and often in the night. It consists of intense dyspnoea and air- hunger. The child sits up or stands bracing its arms, to bring into play the accessory mus- cles of respiration. The skin becomes bluish, the eyes promi- nent, and the alse nasi widely dilated. The skin may be cov- ered with perspiration. The respiration is noisy and wheezing, and the rate is rather under than above normal. The pulse is rapid and small, and the temperature ordinarily normal. After a few hours the attack gradually subsides and the respiration becomes regular and easy, and the patient drops to sleep exhausted. At times the attack lasts days instead of hours. Recurrences are to be expected. Asthma — physical signs : The chest is found fairly fixed. On percussion there is a rather hyperresonant note. The in- spiration is short and jerky ; the expiration is very prolonged and wheezing. The whole chest is full of sibilant and sonor- ous breathing. If bronchitis exists, moist rales are heard. Diagnosis : This is not difficult, After the attack is over a searching examination of the heart, kidneys, lungs, and upper air-passages should be made to determine the cause if possible. Prognosis : The paroxysm is almost invariably recovered from. The prognosis for complete recovery from the attacks is fairly good, especially if climatic treatment can be taken advantage of. Asthma — treatment : During the paroxysms the best treat- PULMONARY GANGRENE. 245 ment is the inhalation of the fumes of saltpetre paper, or of the smoke of stramonium cigarettes. A hypodermic of a small dose of morphine and atropine will cut short an attack, but had better not be used except under exceptional circum- stances. Between attacks the child should be put in the best hygienic condition and kept in a good climate. Any abnormalities in the respiratory tract should be carefully treated. As drugs, belladonna, iodide of potassium, and cod-liver oil are of most value. Antipyrine and chloral in small doses regularly seem to have a good effect in some cases. PULMONARY GANGRENE. This is a localized necrosis of the pulmonary tissue, and is rare under all circumstances, being rather commoner in chil- dren than in adults. Etiology : It is almost invariably secondary to pneumonia, septic infections, or some equally intense inflammation in the lung. It is seen usually in children of feeble constitution. Pathology : The process may be circumscribed or diffuse. The gangrenous patches are greenish-looking and emit an in- tensely foul odor. There is regularly found a thrombosis of the vessels leading to the necrotic mass, and this is conse- quently wedge-shaped. Putrefactive bacteria are present in large numbers. If the gangrene is on the surface, as it usually is, there is regularly present a complicating pleurisy. Pulmonary gangrene — symptoms : Those of the primary disease are always present and mask the symptoms of gan- grene. The distinctive features of this condition are the gangrenous odor of the breath and the expectoration of necrotic masses of tissue from the lungs. Irregular fever, sweating, cough, and emaciation are present, but do not point especially to gangrene. Physical signs: There may be only the signs of bronchitis, or of consolidated lung, or of a cavity — none of them dis- tinctive. Diagnosis: This is very difficult, and can only be surmised unless in the presence of the two characteristic; features of the 246 DISEASES OF THE RESPIRATORY SYSTEM. disease, the odor of the breath and the peculiar expectora- tion. Prognosis : This is bad. Death is the usual result. Pulmonary gangrene — treatment : Proper nourishment and stimulants of the alcoholic variety are the methods of value. The inhalation of the fumes of turpentine, or creosote, dis- guises the foul odor of the breath. PULMONARY ATELECTASIS. Definition : This is a condition in which from different causes the alveoli of the lung collapse and return to their foetal condition of non-aeration. Etiology : It occurs especially in feeble children, and in those suffering from the various congenital and acquired forms of malnutrition. The actual causes are compression or obstruction. Such conditions as effusions in the pleural or pericardial sacs, deformities of the spine or thorax, and tumors in the cavity of the chest may act to cause atelectasis from compression. The obstructive causes are those which occlude a small or large bronchus. The swollen mucous membrane, the increased mucous secretion, and the feeble breathing are all to be taken into account in this. Pathology : The collapsed areas may be scattered through the lung, but are usually situated in the posterior portion and near the spine. The area involved is darker than the rest of the lung, and is somewhat depressed below its surface. If put in water, it sinks. The surrounding alveoli are apt to take on a condition of compensatory emphysema. Symptoms : Dyspnoea and cyanosis are the ordinary symp- toms of pulmonary atelectasis, but as it usually occurs com- plicating some other condition, the symptoms of the two blend, and are not characteristic. The circulation is poor, the extremities are cold, and the child is usually in a con- dition of collapse. Pulmonary atelectasis — physical signs : The respiratory murmur over the affected area is feeble, and fine rales are usually heard in the neighborhood. On percussion, dulness is regularly present over the collapsed area if it is of any DRY PLEURISY. 247 size. The physical signs of the complicating condition must always be taken into consideration. Diagnosis : Except when a large continuous area of lung is involved, the condition is seldom recognized. Even if its presence be suspected, a positive diagnosis can seldom be made. Prognosis : This is serious, as it regularly occurs in feeble infants who are already suffering from another disease. Pulmonary atelectasis — treatment : In addition to the care of the primary disease, stimulants, fresh air, oxygen, and very hot baths seem of most service. DRY PLEURISY. This form of pleurisy is the simplest, and is accompanied by the exudation of fibrin only. Etiology : It follows exposure to cold and wet and injuries to the chest, and is secondary to various inflammations in the lung. Pathology: The inflammation may begin in the pulmonary or costal pleura, but regularly spreads to the opposite por- tion. The inflamed area, be it a small or large one, is swollen, red, and coated with fresh fibrin. Bands of this fibrin form adhesions between the opposite pleural surfaces. After the inflammation subsides the fibrin may be com- pletely absorbed, but permanent adhesions are usually left. Dry pleurisy — symptoms : There is a sharp, cutting pain over the affected area, made worse by pressure or by inspira- tion. There are also a dry, useless cough, and general malaise. The symptoms usually last about a week, when they completely disappear. Dry pleurisy — physical signs : Over the affected area is heard ;i friction-sound, or fine crepitant rdles. These sounds arc developed by full inspiration, and are unchanged by coughing. Diagnosis: This is easy with the history and physical signs. The presence of complications in the lungs must always be thought of. Prognosis: In uncomplicated cases this is good, although a damaged pleura is regularly lefl behind. 248 DISEASES OF THE RESPIRATORY SYSTEM. Dry pleurisy — treatment : Counter-irritation in the form of mustard paste, iodine, or even a blister, hurries on the proc- ess. Rest in the form of a firm bandage around the chest will often ease the pain. Opium may be needed. Some simple febrile mixture, as phenacetin, together with confine- ment to the house, is useful. PLEURISY WITH EFFUSION. Definition : In this form of pleurisy the side of the thorax involved contains more or less serum in addition to the fibrin. Etiology : It follows exposure to cold and damp. It is often secondary to pneumonia, rheumatism, or nephritis. It is frequently tubercular. Pathology : Only one pleural cavity is regularly involved, but cases are occasionally seen on both sides at once. The pleura is coated with fibrin, and bands of this material form fresh adhesions between the two surfaces. The cavity con- tains more or less serum, which may be quite clear, or slightly turbid, or at times sanguinolent. In the largest effusions the lung is compressed in the upper and posterior part of the chest. After the inflammation subsides the serum is regu- larly absorbed, but adhesions are apt to be left behind. Pleurisy with effusion — symptoms : If the disease is sec- ondary, the symptoms of the primary disease gradually merge into those of the pleurisy. If the pleurisy is primary, it at times begins acutely with high fever, pain in the chest, cough, and prostration. The regular onset, though, is gradual, with slight fever, general malaise, and often no symptoms at all pointing definitely to the chest. After any form of onset the disease regularly takes on a subacute course, the temperature only a little above normal, with some pain in the chest, and cough and dyspnoea on exer- tion. The patient feels sick, but often not enough to go to bed, and there are anorexia and loss of flesh and strength. The disease if left alone lasts weeks or months, and has a tendency to spontaneous recovery. Some few die from press- ure of a very large effusion. In some the effusion becomes PLEURISY WITH EFFUSION. 249 purulent, and the patient has empyema. In others, the pleu- risy being tubercular is not recovered from, and later the child shows evidences of tuberculosis elsewhere. Pleurisy with effusion — physical signs : Before the effusion is marked, and as it is absorbed, friction-sounds are heard over the inflamed pleura. After the fluid is present, we find beloiu its level flatness on percussion, diminished or absent breath- and voice-sounds, and loss of vocal fremitus. At the level of the fluid the voice has the tremulous quality known as a>,gophony. Above the fluid the resonance is exaggerated and the breath- ing is broncho-vesicular, due to the compressed lung. The chest containing the fluid does not move in respiration, the intercostal spaces bulge, the diaphragm is depressed, and when the fluid is on the left side the heart is displaced Irregular physical signs are frequently present ; and in many cases where the fluid is sacculated by adhesions they become very perplexing. Diagnosis : The physical signs in a typical case are very positive, but so often irregular signs are found that various forms of inflammation in the lungs may be confused with an effusion. From empyema the diagnosis can only be made by the use of an exploring-needle. Under any circumstances, the exploring-needle had better be used, in order to establish the diagnosis positively. Prognosis : Recovery is the rule. The two dangers are the possibility of the disease changing to an empyema, and of its being a tubercular pleurisy. Pleurisy with effusion — treatment : The patient should be put to bed, on a diet in which liquids are restricted, and some form of counterirritation should be applied to the chest. Dry cups or blisters are often very useful here. The bowels should be kept freely open, and by means of diuretics the kidneys should be kept secreting in abundance. The citrate • 'I' potassium and digitalis are good drugs for this purpose. If pain is excessive, opium may be used. The salicylate of sodium affects some cases favorably. If the effusion is so large as to embarrass the breathing, or if it does not decrease under the above treatment, aspiration of at least half the fluid in the chest should be performed 250 DISEASES OF THE RESPIRATORY SYSTEM. under aseptic precautions. A second and a third aspiration are sometimes necessary. After recovery, general tonic treatment, with a change of climate for a time, should be undertaken. EMPYEMA. Definition : This is a disease of some frequency in child- hood, and consists in an inflammation of the pleura with a purulent effusion. Etiology : Most of the cases are secondary to pneumonia. Some follow serous pleurisy. Others complicate the infec- tious diseases, or are part of a general sepsis. Trauma of the chest, or direct infection of the pleura from a necrotic rib or carious vertebra or suppurating gland, are other causes. One of three general varieties of bacteria are regularly found in the pus — the pneumococcus, the streptococcus, or the tuber- cle bacillus. Mixed infections are also found. Pathology : The whole of one pleura may be involved, or only a circumscribed portion. Rarely both pleural cavities may be simultaneously attacked. The pleura is inflamed and its surface coated with fibrin and pus, and the cavity is more or less filled with a purulent exudate. The pus settles to the bottom of the pleural sac, and floats the lung upward and toward the spine. Adhesions between opposing surfaces of the pleura are frequent, causing the pus to be sacculated. There is very little tendency to absorption ; and if un- treated, the pus tends to rupture into the lung, or externally through an intercostal space. Empyema — symptoms : Following the symptoms of the pre- cedent pneumonia or infectious disease, the temperature con- tinues high ; there may be sweats, the child has pain in the chest, dyspnoea, and cough. As the disease advances, the symptoms are mainly those of infection — irregular high fever, sweating, loss of flesh and strength, anorexia, diarrhoea, pros- tration, and a rapidly growing anaemia. The pulse grows rapid and feeble, and a typhoid condition is developed if the case is left alone. EMPYEMA. 251 The disease may run a slow course, with the above symp- toms more or less intensified ; and if untreated, the pus may rupture externally or through the lung, or the patient may die exhausted by the disease. Empyema — physical signs : These are identical with those of pleurisy with effusion, except that sacculation of the pus is more common, and therefore irregular physical signs more to be expected. Diagnosis : This is a very easy disease to overlook in chil- dren. Pleurisy with effusion, pneumonia, and phthisis are likely to be confounded with it. It is always advisable in suspected cases to make use of the exploring-needle. Prognosis : In the cases following pneumonia, under proper treatment, the prognosis is good. In the cases due to strepto- cocci the prognosis is much worse. In those due to tubercle bacilli the prognosis is that of tuberculosis in general. The younger the child and the longer the disease has been un- treated, the worse the prognosis. Some few cases recover spontaneously. The prognosis depends very decidedly on the treatment. Empyema — treatment : The child should be put on tonic stimulating treatment. The empyema requires surgical care and removal of the pus. Aspiration is unsatisfactory, and is best reserved for use as a temporary measure only. Simple incision through one of the lower intercostal spaces, with evacuation of the pus and drainage by a large-sized tube, will cure most of the cases. General or local anaesthesia may be used, and the dressings changed frequently. Irrigation had better not be employed. In cases where the ribs are close together, or where the pus is thick and fibrinous, a small piece of one rib had better he resected, and the subsequent treatment be carried out as after simple incision. Although this operation is more severe, success is more certain alter it than after any other method of treatment. In the few oases in which the lung will not expand after evacuation of the pus, and after lapse of some weeks, exten- sive operations with resection of many ribs may be necessary. 252 DISEASES OE THE RESPIRATORY SYSTEM. Pulmonary gymnastics should be advised to encourage the expansion of the lungs. ACUTE PULMONARY TUBERCULOSIS. This form of tubercular inflammation in the lung is also called acute or galloping consumption, or acute tubercular bron- cho-pneumonia. It is seen with some frequency in young children. Etiology : The causes are predisposing and exciting. The predisposition is often inherited from a tuberculous family. Bad hygienic surroundings, poor food, bad air, and wasting diseases produce a predisposition. The infectious diseases, particularly whooping-cough, measles, and la grippe, and simple inflammations in the lung, are marked predisposing causes. The exciting cause is infection by the tubercle bacilli of Koch, which in most cases gain access to the victim by way of the respiratory tract. In rarer cases they are taken in with the food or drink, and at times by direct inoculation. In only a very few cases has evidence of actual intra-uterine in- fection or of congenital tuberculosis been proved. In any pulmonary case the bronchial lymph-glands are regularly the seat of bacilli, and from them the pulmonary infection comes. Pathology : The lungs are more or less filled with miliary tubercles. These are scattered irregularly through the pul- monary tissue, and are also found on the surface. They are apt to have the distribution of an ordinary broncho-pneu- monia, but in places may be massed together in lumps. Some of the nodules, if the case is not too recent, caseate and break down with the formation of cavities. Catarrhal bronchitis, simple broncho-pneumonia, or even diffuse consolidation of the lung may exist as complications. The pleura is regularly involved if the tubercular process is near the surface. The bronchial glands will be found en- larged and caseous. Acute pulmonary tuberculosis — symptoms : The onset and symptoms of this disease are almost identical with those of ordinary broncho-pneumonia. There is fever of a somewhat ACUTE PULMONARY TUBERCULOSIS. 253 irregular character, and varying from 101° F. to 104° F. Sweats are not frequent. The child has a cough, with rapid respiration and pulse, appears quite sick, and shows a loss of flesh and strength somewhat more marked than in simple broncho-pneumonia. Expectoration, as always in children, is lacking. Some of the cases go on acutely with these symptoms and die within a month. Others take on a more subacute char- acter and last for two or three months, but the tendency in them all is to exhaustion and death. Acute pulmonary tuberculosis — physical signs : Here again the similarity with the signs of a simple bronchitis or broncho- pneumonia is most marked. If only scattered miliary tuber- cles are present, with the accompanying catarrhal bronchitis, we find scattered suberepitant or coarse rales. If areas of consolidation are present, we find dulness, increased fremitus, and broncho-vesicular or bronchial breathing and voice. In other words, there is nothing distinctive in the signs. Diagnosis : The history and physical signs are so nearly identical with those of simple broncho-pneumonia that a positive diagnosis is almost impossible. Unfortunately we have not the aid of finding tubercle bacilli in the sputum as in adults, as sputum is so hard to obtain. The family history, the preceding condition, and the surroundings of the child should all be carefully taken into consideration. Enlarged glands, or history of disease of the bones, are especially im- portant. The loss of flesh in tubercular pneumonia is more marked than in the simple form. The signs in the tubercular variety arc more often in the upper lobes or anterior portions of the lungs, while in the simple form they are more often posterior. Prognosis: This is bad. All the cases die in a short time, except the few which go on to the chronic condition. Acute pulmonary tuberculosis — treatment: To prevent the disease all children, and especially those with a hereditary predisposition, should be well led, well clothed, and kept most of the time in the fresh air. I (' consumptives are in the family, all their sputa must be carefully destroyed by chemi- cals or fire. These children should not sleep with nor kiss 254 DISEASES OF THE RESPIRATORY SYSTEM. tubercular people. All milk and meat should be carefully inspected before use. Tuberculous mothers should not nurse their children. All infectious diseases or pulmonary inflam- mations in these children should be most carefully treated with this end in view. If the disease has begun, the treatment consists in keeping the stomach and bowels in good condition, so that we will be able to over-nourish the child ; to allow an abundance of fresh air ; and to give creosote in full doses to tolerance. Special symptoms are to be treated as they arise. CHRONIC PULMONARY TUBERCULOSIS. Etiology : This form is seen mostly in older children, and differs very little from the same condition as seen in adults. The predisposing and actual causes are the same as in the acute variety. A good many of the cases follow an attack which began acutely, or are secondary to protracted simple inflammations of the lungs, or develop gradually from a latent tuberculosis of the bronchial glands. Pathology : The growth of miliary tubercles and of tuber- cular masses scattered through the lung, with the accompany- ing chronic bronchitis or broncho-pneumonia, are the begin- ning lesions of this disease. The same tendency to necrosis of this new-formed tissue, and subsequent formation of small cavities exists, as in adults. The apex is not so regularly the location of the early lesions as in older patients, this being more often in the neighborhood of the bronchial glands. In different parts of the lung are found bands of fibrous con- nective tissue, and the pleura is regularly thickened and adherent. The whole lung is irregularly consolidated. Chronic pulmonary tuberculosis — symptoms: The symptoms ordinarily follow those of some previous disease during its convalescence. They are cough, irregular fever, loss of flesh and strength, increasing pallor, and general prostration. Haemoptysis and expectoration are rare. The appetite is lost ; there may be vomiting and diarrhoea. The pulse is rapid and feeble, and the respiration is accelerated. As the disease progresses sweating is common and the temperature may CHRONIC PULMONARY TUBERCULOSIS. 255 take on a hectic course. The wasting becomes excessive and the strength very feeble. Tubercular diarrhoea and laryn- gitis may appear as complications, and toward the end a gen- eral oedema may develop, and the child dies after many months of excessive emaciation and exhaustion. Chronic pulmonary tuberculosis — physical signs : The expan- sion of the affected chest is limited. The vocal fremitus is apt to be increased. On percussion, irregularly placed areas of dulness or flatness may be found. On auscultation, exag- gerated voice- and breathing-sounds are found over these same areas, or there may be no change in the character of the breathing. There are always present, however, various kinds of adventitious sounds scattered irregularly over the lungs — fine and coarse rales, bubbling and whistling sounds — and if small cavities are present, cavernous breathing with moist gurgles may be heard. The signs are not nearly so distinctive as in adults, and are much more difficult to bring out. Diagnosis : The irregularity in the physical signs and the history are the main points of value in diagnosis. At times a simple chronic pneumonia will give precisely the same signs and symptoms, and differentiation will be almost impossible. If possible, a specimen of the sputum should be obtained and examination made for the tubercle bacilli. This is the only positive method of diagnosis. Prognosis : Reeoverv is possible when the cases are seen early and put under proper treatment. As more of the lung is involved and cavities form, and especially if the stomach fails, the prognosis becomes bad. Chronic pulmonary tuberculosis — treatment : The preventive treatment should be followed as is outlined for the acute variety. For the treatment of the disease itself, life in the fresh air, if possible in a elimatc that is dry and high, i- of most im- portance. Special attention should lie paid to the condition of the stomach and bowels, in order that the child may take and digesi and assimilate a large quantity of nourishing food. Food rich in fat should be taken especially, ami \'<. C. 274 DISEASES OF THE NERVOUS SYSTEM. to walk have an etiological relationship to it. Trauma and changes in temperature are also ascribed as causes. Some cases develop subsequently to the infectious diseases. There is some evidence that the disease itself may be of germ origin. Pathology : The lesion is an acute inflammation in the an- terior horns of the gray matter of the spinal cord. The cells in this area, which is usually a limited one, are destroyed in the inflammatory process, and after recovery the cord in this region shrinks in size. So few cases die in the acute stage that the lesions seen are mainly those due to the subsequent atrophy of that portion of the cord. The disease most often attacks the cervical or lumbar enlargements of the cord, and usually on one side only. Acute anterior poliomyelitis — symptoms : The disease regu- larly begins acutely, with fever of 101° to 104° F., vomiting, marked prostration, and pain in the limbs. Many cases also have one or more general convulsions. These acute symp- toms, similar to those of an infectious disease, last for a few days without any definite local signs developing, when one or more of the limbs are found to be paralyzed. Gradually the constitutional symptoms disappear, but the paralysis remains. The affected limb is regularly entirely involved at first, but as the weeks pass by some of the muscles regain their power, and eventually only one group, as for instance the anterior tibial, is left permanently paralyzed. In some cases more than one group, or different groups in different limbs, are permanently affected. After about three months whatever parts were to recover have done so, the paralysis in the other groups being perma- nent. After years this paralysis may lead to contractions and relaxations of joints, causing bad deformities, the limb being decidedly atrophied and feeble, the reflexes gone, and the reaction of degeneration to electricity being present. Diagnosis : In the early stages it may be mistaken for one of the infectious diseases or for meningitis. A few days' ob- servation will settle this point. Confusion may exist between it and cerebral paralysis, or peripheral neuritis. Cerebral paralysis may begin similarly, TRANSVERSE MYELITIS. 275 but the paralyzed limb is well nourished, the reflexes are in- creased, and its general condition is spastic rather than flaccid. Neuritis begins more gradually, and has pain along the af- fected nerves. In doubtful cases the diagnosis may be very difficult until some length of time elapses. Prognosis : As far as life is concerned, this is good. Death during; the acute stage is rare. Until three months have elapsed it is difficult to tell what the permanent damage will be. So long as the reaction of degeneration does not develop the prognosis for recovery in such muscles is good. Acute anterior poliomyelitis — treatment : During the acute stage, if the diagnosis is made, the child should be kept quiet in bed, and lying on its face or side rather than its back. The diet should be liquid, and the bowels emptied by repeated fractional doses of calomel. Counter-irritation to the spine by means of mustard applications, or by cups, or the use of continuous cold, is advisable. Mild, antipyretics answer for drugs. Ergot and bromides are theoretically indicated. After the acute stage is over, and only a paralyzed limb is left, the muscles in this limb should be regularly exercised by the use of electricity in the form that will produce con- tractions. Massage is a very useful adjunct. To prevent and to cure subsequent deformities various forms of orthopgedic apparatus are advisable. TRANSVERSE MYELITIS. Various forms of general myelitis are occasionally seen in children ; but this one, in which the lesion involves a com- plete cross-section of the cord of greater or less extent, is the only one of sufficient frequency to demand separate consider- ation. Etiology: This condition is regularly due to compression of the cord from the sharp angle formed in the spine in (tuberculous) vertebral disease, or from ;i chronic thickening of the meninges due to the same trouble. Tumors of the conl, ami fractures and dislocations of the spine produce the same lesions. Pathology : The carious bodies of the vertebrae collapse and 276 DISEASES OF THE NERVOUS SYSTEM. produce bends in the spine. In addition, the peritoneum and meninges undergo a chronic inflammatory process, with thick- ening of their tissues. The mechanical bending and the in- flammatory thickening together compress the cord and set up an interstitial myelitis, with gradual destruction of the cells and fibres, and with abolition of their function. Secondary degenerations, ascending and descending, from the involved region, are also frequent. The nerve-roots are usually affected coincidently. Transverse myelitis — symptoms : The essential symptom is a gradually increasing paralysis of the parts below the lesion, which paralysis is of the spastic variety and bilateral. The reflexes, superficial and deep, are increased, and there may be some anaesthesia. In old cases some atrophy may follow. If the myelitis is low down, bedsores and bladder and rectal difficulties are present. Pains radiating along the pinched nerves are an early and persistent symptom in many cases. The course of the disease is slow and chronic. Diagnosis : With a careful examination of the spine as to its flexibility and deformity, the diagnosis of this disease is easy. Prognosis : If the case is diagnosed early, and if under proper treatment of the spine the vertebral disease can be stopped, the cord will often return to normal. In the long- standing cases the prognosis is not so good, and many remain permanently paralyzed. Transverse myelitis — treatment : This is almost entirely that of the vertebral disease causing the myelitis. The child should be put at rest on its back, and kept on a highly nour- ishing diet. Extension of some sort should be applied to the spine. Special efforts should be made to prevent the forma- tion of bedsores, and the bladder must be watched. Iodide of potassium may be given internally with possible benefit. FRIEDREICH'S ATAXIA. Synonym : This disease of the spinal cord is also called hereditary ataxia. Etiology : It is distinctly a family disease, with often more PROGRESSIVE MUSCULAR ATROPHY. 277 than one child in the same family affected, and with an hered- itary history. Neurotic and alcoholic families are most often affected. Pathology : The lesion is a sclerosis of the posterior and lateral columns, and of the crossed pyramidal and direct cere- bellar tracts of the cord. Friedreich's ataxia — symptoms : There is an ataxic gait de- veloping very early in life, and later on ataxia of the upper extremities. The motions, however, are stiffer and more rigid than those of locomotor ataxia. All movements are ac- companied by a very coarse tremor. Actual paralysis is rare. Sensation is only slightly impaired. The reflexes are usually lost, or at any rate diminished. Bladder, rectal, and trophic symptoms occasionally occur. Contractures and deformities are frequent in the old cases. The disease progresses slowly upward, and finally the medulla is involved, by which time the child becomes help- less. Diagnosis : The two diseases most likely to be confused are locomotor ataxia and multiple sclerosis. Both are diseases of adult life, and both have many characteristic signs of dif- ference from Friedreich's disease. Prognosis : This is distinctly bad, although life is prolonged over many years, but the stage of complete helplessness surely approaches. Treatment : Care for the general health is all that can be done. PROGRESSIVE MUSCULAR ATROPHY. Definition : By this condition is understood a slowly pro- gressing atrophy of certain muscles in the body from disease of their "trophic centre" in the spinal cord. The causes are unknown. Pathology : The ganglion-cells in the anterior horns of the spinal cord in some cases have been found atrophied. Progressive muscular atrophy — symptoms : The disease begins slowly, and with no subjective symptoms save ;i gradual wast- ing and enfeeblement of certain muscles. It begins oi'tcnest 278 DISEASES OF THE NERVOUS SYSTEM. in the muscles of the ball of the thumb, or in those of the little finger. It involves the interossei, and often later the deltoid. In other cases the anterior tibial or peroneal groups are affected. The extreme wasting is accompanied by pro- portionate weakness and by persistent fibrillary contractions. The electrical reactions are unchanged in kind, but are very feeble. The course of the disease is slow and chronic. Diagnosis : This is rather easy, as no other disease simu- lates it. Prognosis : This is bad. The disease is incurable, but is consistent with a fairly long life. Treatment : General tonic treatment, with especial atten- tion to the nutrition is of most importance. PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. Synonym: This disease is also called muscular dystrophy, and is quite well recognized. Etiology : It is a disease of early childhood, and shows a distinct tendency to run in families. The parents are apt to be neurotic. Pathology : There is at first a true hypertrophy of the mus- cular fibres, but these soon undergo a fatty and then a fibrous degeneration, until finally all the muscle-fibres are replaced by connective tissue. The muscles on section appear yellow- ish. There are no lesions in the nervous system. Pseudo-hypertrophic muscular paralysis — symptoms : The be- ginning of the disease is very gradual and difficult to date. A gradually progressive weakness in the legs is first noticed. The child is uncertain on its feet, and has great difficulty in climbing steps, or in rising from a sitting posture. In rising upright from the floor the child goes through a characteristic series of motions which were first described by Gowers. He first rolls over on his face, then raises himself on all fours, and then bringing his hands to his feet uses them in climbing up his legs and thighs, thus lifting up the weight of his body. Similar weakness develops in other muscles — in the loins, producing a marked lordosis ; in the shoulder and neck, allow- ing the head to drop forward. These also produce a very protuberant abdomen. ACUTE MENINGITIS. 279 Succeeding this weakness is a symmetrical increase in bulk of the affected muscles, evident especially in the calves, glu- tei, deltoids, and infraspinati. As the disease progresses this hypertrophy is succeeded by a gradually increasing atrophy, until in the end all the affected muscles are wasted and flabby. The gait is swaggering, somewhat similar to the rolling gait of a sailor. There are no subjective symptoms, and no blad- der or rectal trouble. The reflexes are diminished or lost, and the electrical reactions are decreased. The course of the disease is gradually progressive to the stage of complete helplessness. There are three recognized types of the disease — that involv- ing the legs mainly ; that involving the shoulder-girdle, or Erb's type ; and that involving the face and shoulder-girdle, or the Landouzy-Dejerine type. Diagnosis : There is no other disease with which this may be easily confounded, if a careful history is taken and ex- amination is made. Prognosis : Recovery is impossible. Death is frequently due to intercurrent disease. Treatment : General constitutional treatment, with the use of strychnine, is all that can be done for these cases. ACUTE MENINGITIS. Acute meningitis, which is often called brain fever, may oc- cur sporadically without known cause ; is often secondary to inflammations about the head; and at times appears epidemi- catty, when it is called epidemic cerebrospinal meningitis. In these latter cases the membranes of the spinal cord are also regularly involved ; in the others, they may or may not be. Etiology: Injuries to the head, sunstroke, otitis, ethmoi- ditis, and other inflammations about the head are apt to cause meningitis. In the sporadic and epidemic eases the cause is probably the action of some form of coccus in the presence of bad air and bad hygienic surroundings. The pneumococcus is most frequently found. Other cases complicate the various infec- tion- diseases. 280 DISEASES OF THE NERVOUS SYSTEM. Pathology : The pia mater of the brain and of the cord is swollen and infiltrated with varying amounts of serum, fibrin, and pus. A distinct layer of these is usually found in the sulci and often over the convolutions. The ventricles are moderately dilated with purulent serum. The convolutions of the brain are somewhat flattened and their surface hyper- semic. Acute meningitis — symptoms : The disease usually begins rather abruptly with a rise of temperature ; at times a chill and intense headache. These are followed by vomiting of the cerebral type — that is, without nausea or reference to food — hyperesthesia all over the body, photophobia, and general pains. Convulsions are quite frequent in children. The fever runs an irregular course, tenderness and con- traction of the muscles of the neck develop, and the headache becomes extreme. Restlessness, sleeplessness, and wild deli- rium gradually succeed one another. Later stupor and coma replace the active brain-symptoms. The intelligence is soon lost, and muscular contractions, with inequality of the pupils and various forms of strabismus, are seen. The bowels are usually constipated and the abdomen retracted. In the epi- demic cases erythematous and petechial eruptions develop. The pulse at first is apt to be somewhat slow, but later becomes rapid and irregular. The cases regularly progress from bad to worse, and die in the course of one to three weeks. Some few recover with a gradual disappearance of the symptoms and probable absorp- tion of the exudate. In the cases which recover, a chronic thickening of the pia is frequently left, with a later develop- ment of hydrocephalus. Many of the cases run a much more subacute course than the above, even beginning more slowly. Diagnosis : In young children so many diseases have such marked cerebral symptoms suggesting meningitis that in the early stages we may frequently be in doubt over the diag- nosis. As the disease progresses, however, the diagnosis becomes more positive. The tubercular variety is differentiated by its slower course, and by the family and personal history. If a local cause TUBERCULAR MENINGITIS. 281 can be found for the meningitis, this also assists the diag- nosis. Prognosis : The mortality-rate is very high ; but some cases do recover permanently and completely ; in others various defects of the nervous system are left, as deafness, blindness, paralysis, and epilepsy ; in others hydrocephalus subsequently develops. Acute meningitis — treatment : The child should be put to bed, and kept on a fluid diet, in a quiet, darkened room. The hair should be cut short, and continuous cold applied to the head by a cold coil or by ice-bags. Counterirritation to the nape of the neck by repeated applications of iodine, or by a blister, may be used. The bowels should be kept freely open by the use of saline laxatives. Internally the bromides, ergot, and iodide of potassium are indicated ; the former to quiet the patient, the latter to relieve the cerebral congestion. If pain is severe, opium must be used. As the disease progresses alcoholic stimulation becomes necessary. Attention must be paid to the bladder to prevent retention. Restraint is often needed in the wild delirium. The sequela? are to be treated on general principles. TUBERCULAR MENINGITIS. Synonym : This is also called basilar meningitis, and is quite a common disease of childhood. Etiology : It is due to infection of the meninges by the tubercle bacillus. It is most apt to occur in children of a tuberculous heredity, or in those who have tuberculosis else- where in the body, as in the glands, the bones, or the lungs. It may develop a long time after the cure of glandular or bone-disease. Pathology: There are miliary tubercles, and inflammatory exudate of serum, fibrin, and pus in the meshes of the pia mate!'. They may be found anywhere in the brain, but are ino-i frequenl over the base. The ventricles are moderately dilated with serum, the ependyma contains small tubercles, and the surface of the brain is flattened. Tubercle bacilli 282 DISEASES OF THE NERVOUS SYSTEM. are found in moderate numbers. Tubercular lesions else- where are apt to be found. Tubercular meningitis — symptoms : In most of the cases there is a prodromic period lasting for a few days or weeks. The child during this time loses flesh and strength, and is less inclined to play. He is moody and irritable, sleeps badly, and may have a little evening fever with headache and a coated tongue. Sudden attacks of vomiting without apparent cause are rather characteristic of this stage. These symptoms vary a good deal, being more or less marked in the same case at different times. Gradually these indefinite symptoms change into undoubted evidences of cerebral disease. There are now present irregu- lar fever, intense headache, often convulsions, or alternating conditions of stupor and delirium. The child is restless, and sleeps badly, often crying out suddenly in his sleep. The bowels are constipated, and attacks of vomiting are fre- quent. Photophobia, general hyperesthesia, rigidity of different muscles, and transitory or permanent paralyses all develop. The pupils are dilated, or contracted, or unequal. There are stiffness of the neck, with some retraction, and at times opis- thotonos. The pulse is slow and irregular ; the respiration shallow, and also irregular. There may be retention of urine. As the disease progresses the delirious and irritative symp- toms gradually give place to stupor and coma and loss of all subjective sensation. The tongue and lips become dry and covered with sordes, and all intelligence and volition are finally destroyed. Toward the end there is inability to take food. The child dies in convulsions, or more often ex- hausted in coma. The temperature rises at the end. The disease lasts from a week to a month, and almost in- variably shows periods of distinct improvement, with amelio- ration of all the symptoms. Diagnosis : In the prodromal stages the diagnosis is very difficult, and is seldom made. As the real meningitic symp- toms develop, the disease becomes more definite, and a prob- able diagnosis is fairly easy. In certain cases, however, it is HYDR OCEPHAL US. 283 almost impossible positively to differentiate the simple and tubercular forms. From the cerebral types of non-meningitic diseases, after a few days' observation, the diagnosis is usually easily made. Prognosis : Probably the disease is universally fatal. In the few cases of reported recovery there may have been an error in diagnosis, the condition having been the simple form. Tubercular meningitis — treatment : This is precisely the same as for simple meningitis, and should be carried out with the possibility of an error in diagnosis having been made. HYDROCEPHALUS. This condition, called water on the brain, is of two varieties : external hydrocephalus, in which the exuded serum lies be- tween the dura mater and pia ; and internal hydrocephalus, in which the serum fills and distends the ventricles. The former condition is very rare. The latter, internal hydrocephalus, is the ordinary clinical form. Etiology : Most of the cases begin during intra-uterine life, and possibly congenital syphilis may be an etiological factor. More than one child in the same family may be affected. In some cases different causes are found which press on the open- ing to the fourth ventricle and cause a mechanical obstruction to the outlet of the ventricular fluid. Such cases are tumors of the brain, or chronic thickening of the meninges. In most cases there is no satisfactory cause found. Pathology : The ventricles are dilated, at times enormously, with thin scrum having the characteristics of cerebro-spinal fluid. The fluid may vary in quantity from a few ounces to over a quart. The brain-matter is markedly thinned, under- going pressure-absorption. The skull-bones are widely separated at the sutures and the fontanelles much enlarged. The ependvma may be normal or be somewhat thickened. Spina bifida is a rather frequent complication. Hydrocephalus — symptoms: In sonic eases the hydrocepha- lus is so developed a1 birth as to be a serious obstacle to de- livery, at times requiring puncture. 284 DISEASES OF THE NERVOUS SYSTEM. In other cases the symptoms develop soon after birth. The head is symmetrically enlarged, and increases in size often to extreme dimensions. The forehead overhangs the eyes and the face appears very small. The upper lid hangs so that the sclerotic shows between it and the iris. The sutures and fontanel! es are wide open, and bulge and pulsate. Fluctua- tion may be obtained. The infant has difficulty in support- ing its head, and its whole muscular system is flabby and feeble. In the severe cases the intelligence is more or less inter- fered with. Strabismus, changes in the pupil, nystagmus, blindness, deafness, and various forms of paralysis are pres- ent. Convulsions often occur. In the milder cases nothing except the enlarged head is to be noted. In some cases the exudation of fluid takes place after ossi- fication of the cranial bones is accomplished, and then no en- largement of the head follows. The course of the disease is slowly or rapidly progressive, and death regularly takes place before the development of puberty. Diagnosis : The only disease likely to cause confusion is rachitis. In this the other signs of rickets are of assistance, and the head does not increase in size so fast, nor do the sut- ures or fontanelles gape so widely. Prognosis : A few cases recover, but usually with a some- what impaired intelligence. The large majority, however, are incurable, and continue to grow worse. Hydrocephalus — treatment : There is nothing satisfactory to do. Attention to the general health should be strict. Mer- curial inunctions may be tried. Surgical measures, such as aspiration or incision, are not satisfactory. CEREBRAL ABSCESS. Notwithstanding the frequency in children of the main causes of abscess of the brain, it is in them a comparatively rare disease. Etiology : Suppurative otitis, with or without involvement of the mastoid cells, and traumatism to the head are the com- CEREBRAL ABSCESS. 285 monest causes of this disease. General sepsis and various inflammations of the scalp cause some cases. In a great many no cause is discoverable. Pathology : The abscess is usually single, varies in size, and may be situated almost anywhere in the brain, but is most common in the temporo-sphenoidal lobe or the cerebellum. There may be an encapsulated collection of pus, or only an irregular cavity containing a greenish pus with broken-down brain-tissue in it, and surrounded by inflamed brain-tissue. The abscess may rupture into the ventricles, or set up a meningitis, or cause a thrombosis of the lateral sinus. Cerebral abscess — symptoms: There are usually described three periods in abscess of the brain — an initial, a latent, and the terminal period. The initial symptoms may be mild or severe, and resemble those of acute meningitis, being fever, prostration, headache, general convulsions, vomiting, and delirium or stupor. The headache is apt to be localized to the affected area. After a variable time the symptoms gradually subside and the latent stage begins. During the latent period, which may be short or long, all the symptoms may disappear, or only the headache remain. If any local symptoms have developed, they also persist. After a variable time the terminal stage begins rapidly or gradually, the fever, headache, vomiting, optic neuritis, gen- eral convulsions, and delirium or stupor return. Various forms of paralysis and other local symptoms may now be present, and all the symptoms go from bad to worse. The first stage marks the development of the abscess, and death may take place during this. The latent period means the enrapsulation of the abscess. The final stage means its rupture into the ventricles, or its spread to fresh portions of the brain, or the development of a complicating meningitis. Dentli dikes place from convulsions or from exhaustion in coma. The disease m:i v last for a few weeks only, or, with a long latent period, may he prolonged over many months. Diagnosis: Tumors of the brain are distinguished by the lack of any signs of inflammation. From acute meningitis 286 DISEASES OF THE NERVOUS SYSTEM. the diagnosis is intensely difficult. Abscess is a slower dis- ease ; and, as a rule, shows more of the local and less of the general cerebral symptoms than meningitis. Prognosis : Without proper treatment all the cases die. A few are saved by surgical interference. Cerebral abscess — treatment : During the beginning stage it is that of acute meningitis — cold to the head, free purgation, and the use of bromides. As soon as the diagnosis of abscess can be made and its situation localized, it should be treated surgically. CEREBRAL TUMORS. Tumors of the brain of different kinds are fairly common in children. Etiology: No definite cause is known for any of them. Trauma is often assigned. Tubercular, sarcomatous, and car- cinomatous tumors are frequently secondary to similar growths elsewhere in the body. Pathology : The commonest varieties are the tubercular tumor, the glioma, the sarcoma, and the cyst. Carcinoma, gumma, and mixed growths are occasionally found. Tubercular tumors are often multiple, and are located most often in the substance of the cerebellum or cerebrum. The gliomata resemble the structure of neuroglia, are usually single, and also found most often in the cerebellum. Sarcomata may originate in the brain-tissue, the meninges, or the bones of the skull. Cysts are found anywhere in the brain ; they may be para- sitic or degenerative. Cerebral tumor — symptoms : These are best considered under two heads — the general symptoms, which are common to all intracranial growths ; and the local symptoms, which are due to the situation of the tumor. Under the general symptoms the first in importance is headache, which is regularly excessive and constant. It may be localized to one part of the head or be general. Repeated vomiting without cause and unaccompanied by nausea is quite a frequent symptom of brain tumor. Vertigo, either constant or paroxysmal, is often present. Optic neuritis, with CEREBRAL TUMORS. 287 more or less interference with vision, is an early symptom. General convulsions occur early, and are repeated as the tumor grows. Mental changes — irritability, loss of memory, and emotional excitement — are to be expected. Insomnia begins early; later, delirium may be present; and toward the end we find stupor and coma. The disease may last for many years before death. The local symptoms depend on where the tumor grows. In the frontal lobes, the emotional and intellectual functions are especially involved, but these local signs are vague. In the third left frontal there is motor aphasia. In the motor area — that is, around the fissure of Rolando — there are early seen convulsive twitchings, or spasms, of the leg, arm, or face of the opposite side, according to the region involved. Later there may develop complete paralysis of the same. This is the so-called Jacksonian epilepsy, and it is important to notice where the spasm starts and how it spreads, as this enables us to localize the site of the tumor more accurately. In the parietal lobes there may be some indefinite sensory symptoms on the opposite side of the body. In the occipital lobe there is developed a homonymous hemi- anopsia. In the temporo-sphenoidal lobe there is sensory aphasia : the patient can speak, but cannot understand what is spoken. On the base, in the anterior fossa we have inter- ference with smell. In the middle fossa there is atrophy of the optic nerves, or interference with the function of any of the first six pair. In the posterior fossa there will be inter- ference with the function of one or more of the last six pair of cranial nerves. In the cerebellum there is produced cere- bellar ataxia. In the substance of the cerebrum, and in the cms there are interference with the functions of the motor tract and hemiplegia of the opposite side. Diagnosis: Tumor must be diagnosed from abscess by the presence of fever and the absence of optic neuritis in the latter condition. From tubercular meningitis of .-low type the local symptoms of tumor arc of main value in diagnosis. It is also necessary to locate, if possible, the site of the tumor, and to decide its variety. The focal symptoms decide the former point, and the latter is helped by the presence 288 DISEASES OF THE NERVOUS SYSTEM. of tuberculosis or sarcoma elsewhere, or by a history of syphilis. Prognosis : It is a fatal disease. The symptoms progress steadily till death. If the tumor is a gumma, which is very rare in children, the prognosis is better. Cerebral tumor — treatment : If syphilis is suspected espe- cially, but under any circumstances in every case, give mer- cury and iodide of potassium a thorough trial. Otherwise surgery is our only recourse, and even with successful local- ization of the tumor the surgical results are not brilliant. Pain will require opium. INFANTILE CEREBRAL PALSIES. Classification : Clinically there are three general classes of patients to be described under this head : those suffering from hemiplegia, or paralysis of one side of the body ; those suf- fering from diplegia, or paralysis of both sides ; and those suffering from paraplegia, or paralysis of both lower limbs. Etiology and pathology: 1. Some of the cases are due to intra-uterine disease of the brain, which may be a congenital defect or a hemorrhage. Porencephalus and cysts are some- times found. In others there is an arrested development of the cortical cells. 2. More often the case results from some trauma inflicted on the brain during parturition. The lesion is regularly a meningeal hemorrhage, which is more often due to prolonged tedious labor than to the use of forceps. Asphyxia at birth is usually found in these cases. Secondary changes in the brain follow the hemorrhage, as a diffuse meningo-encepha- litis with atrophy and sclerosis of the cortex. Cysts are found in some cases. Secondary degenerations of the motor tract in the internal capsule and cord regularly follow in the older cases. 3. Other cases develop after birth, and may follow an injury to the head, or be subsequent to one of the infectious diseases. Severe whooping-cough is often assigned as a cause. General convulsions often leave behind some form of paralysis. There is found hemorrhage, thrombosis, or embo- INFANTILE CEREBRAL PALSIES. 289 lism in the brain. Subsequent meningoencephalitis, with atrophy and sclerosis, and descending degenerations in the motor tract are found. Infantile cerebral palsy — symptoms : The symptoms are a greater or less degree of spastic paralysis in different muscu- lar groups of the body. The distribution may be to one side, hemiplegia ; to two sides, diplegia ; or to the lower extremi- ties, paraplegia. The child is usually brought to the physician with the story that it cannot walk. Convulsions of an epileptic nature are fairly frequent. The child remains small and poorly de- veloped. The affected limbs are rigid, and resist quick efforts at moving them. The reflexes are markedly increased both in the affected limbs and all over the body. The muscles atrophy slowly from disease, and after some time contractures of the affected parts take place with the joints in flexion. Athetoid movements are also regularly present. Efforts at walking are usually associated with such a tendency to adductor contraction as to cross the legs over each other. The mental faculties are more or less impaired, sometimes to complete idiocy. Speech is usually imperfect, and hearing and sight may be defective. The acquired variety is apt to begin with a convulsion, fol- lowed by fever and symptoms like meningitis, but with hemi- plegia left behind. In these cases the mental condition is more nearly normal than in the congenital or birth palsies. Many of the congenital and birth cases give a history lending us to believe them acquired, as the mother thinks the child was normal for some months after birth, but more care- ful observation would decide otherwise. Diagnosis: Cerebral palsies differ from spinal paralysis by having rigid muscles, and not flaccid, atrophied ones. The reaction of degeneration is not present. The acquired form may suggest meningitis in its onset; but the quick recovery from the acute symptoms, with paralysis left, soon decides the diagnosis. 1 1 is well to discover, if possible, for the sake of prognosis, whether the case is congenital, due to birth-trauma, or ac- quired. 19—1). C. 290 DISEASES OF THE NERVOUS SYSTEM. Prognosis : This is better in the acquired hemiplegia than in the diplegias or paraplegias of congenital or birth-origin. None, however, recover completely without some mental im- pairment in addition to the physical deformity, and all are subject to epilepsy. Infantile cerebral palsy — treatment : During an acute attack treat as meningitis, by a purge, ice to the head, and bromides internally. After this, attend to the general health, and prevent de- formities by the use of proper apparatus. If deformity is present, perform tenotomies and apply braces. These chil- dren are fit subjects for education in institutions for the feeble-minded. In cases of epilepsy bromides and surgery are our recourse. IDIOCY AND IMBECILITY. The difference between an idiot and an imbecile is one of degree only. Both are permanent conditions due to changes in the cerebrum, which may be an arrest of development of a congenital nature ; or the result of inflammatory or trau- matic injury, or premature ossification of the skull. An idiot has his intellectual faculties completely impaired, and is really little more than an animal in human form. An imbecile is often called simply a feeble-minded person, and is really a high-grade idiot. His mental development is often fair, but his self-control and emotional faculties are very de- ficient. Idiocy and imbecility — symptoms : The main sign is the in- ability of the brain to receive, to utilize, and to produce mental conceptions. All varieties, from absolute lack of any mental action to simply an unbalanced mental deficiency, are seen. The least marked cases are the " backward " children in a family or in school. In many of them the moral nature seems absolutely lack- ing, although they may be bright and quick at most things. This is the class that furnishes a large number of the habitual criminals to society. In other words, they are degenerates. Deficient mental development may appear evident in chil- CRETINISM. 291 dren at a very early age, but the milder degrees are usually not discovered until much later. Physical signs are frequently seen which should attract our attention to the condition. Among these are a microcephalic or a misshapen skull, with a markedly receding forehead. The so-called stigmata of degeneration may be present, high arched palate, prognathism, irregularities in the teeth, mal- formations in the ears, anomalies in the fingers, and left- handedness. These children are apt to be restless, continually walking about, or keeping some limb in motion, and they go through various purposeless performances repeatedly. Diagnosis : A little observation of the mental and physical condition rapidly makes the diagnosis sure. It is well to at- tempt to find the origin of the condition, whether it is con- genital or acquired. Prognosis : This is absolutely bad as regards the mental defect. It has, however, no bearing on the prolongation of life. Idiocy and imbecility — treatment : Much can be accom- plished in developing any dormant intellect in these children by education in a thoroughly equipped institution. CRETINISM. Definition: This disease consists in the arrested physical and mental development of a child. It occurs endemically in certain portions of the world, and sporadically in our country, being fairly common now that it is more often looked for. Etiology : The condition is due to the loss of function of the thyroid gland. The gland may be congenitally absent, or its glandular structure may be replaced by other tissue, or the organ may have been removed by surgical means. Cretinism — symptoms : The characteristic signs of the dis- ease may appear during the first year of life, or nol until later. They develop rather slowly, but steadily become more marked. When well developed the appearance is unmis- takable. The child is short in stature, and light in weight for its age. The limbs and lingers and toes are short and 292 DISEASES OF THE NERVOUS SYSTEM. thick. The fontanelle is very late in closing, the nose is flat, broad and upturned, the alee being thick, and the nostrils wide open. The lips are much thickened, and the tongue is large and constantly protruded. The teeth are cut late, and are badly formed and irregularly placed. The hair is sparse, but coarse and straight. The skin of the entire body is thick and dry, but does not pit on pressure. In the supraclavicular regions there are regularly formed pads of fatty tissue, which give the neck a shortened, thickened appearance. The thyroid gland can usually not be felt unless it contains a tumor. The abdomen is large and prominent, and an umbilical hernia is frequently present. Walking and talking are learned late, and are very im- perfectly performed even then. The sexual functions are developed very late in life ; in fact, the infantile condition persists over many years. Constipation is often found, which seems to be directly due to the cretinoid condition, as it usually disappears quickly under treatment. The temperature is apt to be subnormal, and the mental condition is one of extreme apathy and dulness. Diagnosis : It is very important to make an early diagnosis, as when treatment is begun then the child may be brought back to virtually a normal state. By a little care, after one or two well-developed cases have been seen and their typical appearance well impressed on the mind, the condition should not be overlooked even in its ineipiency. Prognosis : If untreated, the cases grow worse and worse. Treatment begun early seems to be able to eradicate the effects of the disease. When begun late great improvement occurs, but probably the child will never become normal. The physical improvement is more marked than the mental. Under any circumstances " thyroids " have to be given in- definitely to prevent recurrence. Cretinism — treatment : Thyroid extract daily by mouth in doses of one to five grains replaces in the system the active principle of the normal thyroid gland. At the same time attention to the diet, exercise, fresh air, and the moral and mental education of the child are of the utmost impor- tance. 3 I o S- *4 CD ® O C 3 a ~ CONVULSIONS. 293 CONVULSIONS. Spasmodic contractions of the muscles are very common in infancy. They are often called eclampsia. They are to be looked on as a symptom of disturbance in the motor area of the brain due to various causes. Convulsions — etiology : The great predisposing cause is the markedly increased excitability of the lower reflex centers of the nervous system, and the poor development of the higher inhibitory centres in infancy. Nutritive disorders increase this tendency by interfering with the proper nutrition of the nervous centres. Rickets, ansemia, malnutrition, and intestinal diseases are of greatest importance as predisposing causes. An hereditary neurotic taint is also a great predisposer to convulsions. Exciting causes are various, and often seemingly unim- portant. All inflammations, injuries, and pathological lesions of the brain are apt- to be causes of convulsions. Irritation from trauma elsewhere on the body ; from renal, hepatic, or intestinal colic ; from undigested food ; from phimosis ; from foreign body in the ear, and probably from dentition and worms, may start a general convulsion. Finally, fever from any cause, as heat-stroke, or the beginning of an infectious disease, is a very frequent exciting cause. While in most cases some cause, direct or indirect, may be found ; still there are a good many that must be called idio- pathic. Pathology : The probable lesion is a hypersemic condition of the motor region of the brain. Convulsions — symptoms : There may be prodromal symp- toms of restlessness, twitchings of the facial muscles, grind- ing of the teeth, or rolling of the eyes. Usually, however, the general spasm comes on suddenly and unexpectedly. The eyes become fixed, the jaw clenched, the skin pale, the limbs rigid with a tendency to flexion in all the joints, and the neck retracted. Consciousness is abol- ished. This tonic contraction of the muscles may persist ; but it is usually followed by clonic contractions, with jerking move- 294 DISEASES OF THE NERVOUS SYSTEM. ments of all the limbs. There are then frothing at the mouth, working of the jaw, irregular rolling of the eyeballs, twitching of the facial muscles, and spasmodic action of the muscles of the trunk and extremities. Respiration is spas- modic, due to involvement of the diaphragm. The pulse is feeble and irregular. The skin and mucous membrane be- come cyanotic. Emptying of the bladder and rectum is common. These convulsions last from a few minutes to an hour, and leave the child in a condition of stupor. They may be re- peated after a short or long interval of quiet. Multiple re- currences extending over many days are fairly common, and even then may be followed by complete recovery. Death may take place during the first spasm or in the subsequent ones. Localized spasms of certain regions may occur at times without meaning permanent or organic focal lesion of the brain. Diagnosis : The only necessity in diagnosis is to discover as quickly as possible the cause of the spasm. All the etiologi- cal factors should be taken up in order and each one ex- cluded. In new-born babies the probabilities are in favor of meningeal hemorrhage or of tetanus. In older children gastro-intestinal irritations, or the beginning of one of the infectious fevers, are the commonest causes. The pulse and temperature should be taken, the fontanelles examined, the urine analyzed, and the history carefully investigated in every case. Prognosis : In fairly strong children, and except when actual brain-lesion is present, convulsions are not commonly fatal. Those from reflex irritation, and due to fever, are or- dinarily not dangerous. In very feeble children, and when they mark the beginning of intracranial disease, they are much more serious. The possibility of the convulsions being epileptic must be remembered, as this means recurrences during an indefinite number of years. Convulsions — treatment : The child should be kept as quiet as possible, and all rubbing and unnecessary manipulation forbidden. A warm mustard bath or pack may be given TETANY. 295 until the skin is reddened. If there is fever, a cool bath should be substituted. Ice applications to the head are always helpful. During the convulsion the child should be immediately put under the influence of chloroform, and kept so until the con- vulsive tendency has disappeared. While anaesthetized it should be given by rectum suitable doses, for its age, of chloral and bromide, which may be repeated hourly. If these drugs fail to prevent recurrences, it is quite justifiable to use morphine hypodermatically in proper dose. ^ In cases where the digestive tract is believed to be the offender the stomach and bowels should be emptied by wash- ing or drugs. In many cases a high rectal douche of warm water should be given. After the spasm is controlled hunt for the cause, and treat that condition to prevent recurrence. TETANY. Definition : This is a functional nervous disease character- ized by tonic spasms in certain groups of muscles, especially those of the hands and feet, and occurring in paroxysms. Etiology : It occurs almost always in infants who are suf- fering from rachitis, marasmus, or other forms of malnutri- tion, and from gastro-intestinal disorders. The irritation of cold and wet, or of indigestible food, reg- ularly excites an attack in those predisposed. Pathology : There are no lesions connected with the disease. Probably malnutrition of the nerve-centres increases their reflex excitability. Tetany — symptoms : The attack consists of tonic spasms in the extremities, and especially the hands and feet. It begins rather rapidly, and is continuous over some time. There are no loss of consciousness and no marked subjective symptoms. Pain is caused by efforts at overcoming the spasm, but is ordinarily not spontaneous. The typical position assumed in the affected limits is for the forearm to be pronated, the wrist flexed, the thumb turned in, and the lingers flexed at the metacarpo-phalangea 1 joints. In the feet the position of ecjuino-varus is assumed, with the plantar surface arched and 296 DISEASES OF THE NERVOUS SYSTEM. the toes bent. In the more marked cases the arms and legs are adducted, the spasm extending upward to the upper arms and thighs. The duration of the attack is from a few days to several weeks, and recurrences are quite common. Diagnosis : The lack of unconsciousness, the typical posi- tion taken by the extremities, and the presence of the predis- posing cause usually decide the diagnosis. Trousseau's symp- tom, the production or the augmentation of the spasm by pressure on the nerve or vessels of the affected limb, may be used as a diagnostic sign. Prognosis : It is not a serious disease, and recovery from the tendency to it, as well as from the attack, is to be expected. Tetany — treatment : Find and remove the cause, which is usually intestinal. During the spasm use chloral, bromides, and antipyrin internally. Attend to the patient's nutrition and digestion in order to prevent recurrences. EPILEPSY. Definition: This is a functional neurosis characterized by convulsions, which are accompanied by loss of consciousness. Etiology : The disease most commonly develops in children approaching puberty, although cases are seen much younger. A neurotic or alcoholic heredity predisposes to epilepsy. It develops often after convulsions occurring in infancy, and in children suffering from cerebral palsies. In a predisposed individual sudden fright, traumatism to the head, great emotional excitement, or excessive heat will develop the disease. Adenoids, phimosis, foreign bodies in the ear, menstrual disorders, masturbation, and intestinal tox- aemia are often causative factors. Pathology : There are no discoverable lesions of the disease. It must be looked upon as an explosion of energy in the cere- bral cortex. Epilepsy — symptoms : There are two distinct types of the disease, the grand mal and the petit mal. The grand, mal variety consists of a sudden attack of un- consciousness, the patient falling to the floor with a sharp cry, EPILEPSY. 297 the eyeballs rolling up, the jaw set, and all the muscles of the body in tonic spasm. The skin becomes cyanotic; the bladder and rectum may be evacuated. This condition is succeeded after a few seconds by the sec- ond stage, that of clonic spasms. During this stage the mus- cles alternately contract and relax violently. The jaw is moved up and down, the tongue is apt to be bitten, there is frothing at the mouth, and the head is twisted to one side. The extremities relax and then become rigid, the muscles of respiration again begin action, and the cyanosis passes off. This clonic stage gradually disappears, the patient regains consciousness for a moment, and then passes into a deep sleep of exhaustion lasting some hours. After awaking he has no recollection of what has happened. The petit mal variety consists essentially in a sudden, short loss of consciousness, coming on while the child is engaged in any action, lasting a few seconds ; and after it is over, im- mediate resumption of what was being done before, without recollection of the interruption. The child does not fall, but usually remains fixed in whatever position it occupied before the onset, while the eyes have a vacant stare. In either variety there is often preceding the attack a warning or premonition of its advent. This is called the aura, and when present it is usually the same before each convulsion, and may be motor or referred to any one of the senses. The seizures are repeated at irregular intervals, growing usually more frequent as time passes, and often recurring many times in the same day. They occur both by night and by day, and both types may be seen in the same individual. Diagnosis : Hysterical convulsions are to be excluded by differences in the character of the movements, and by the presence of consciousness and recollection of the event. Ureemic convulsions are proved by examination of the urine. Diseases of the brain produce more localized convulsions, and leave some evidence of their occurrence after they pass off. In cases suffering from petit mal only, observation must be 298 DISEASES OF THE NERVOUS SYSTEM. continued over some time before a diagnosis may be positively made. Prognosis : The danger to life consists in a serious accident happening to the child during the unconsciousness of the con- vulsion, as falling in the fire, or in front of a car, or from a height. If the cases are recognized early and a cause found that is removable, the chances of cure are fair. In the old cases treatment seems only to lessen the number of convulsions. Surgery has helped some of the cases where a local lesion was suspected in the skull. Epilepsy — treatment : During the attack simply prevent the child from injuring itself or biting its tongue. Epileptics should always have a companion. Discover, if possible, any cause, direct or reflex, and remove it, going systematically through the whole list of etiological factors. Regulate all the functions, particularly the digestive, in the most careful way. Insist on the proper amount of exercise, sleep, fresh air, proper clothing, proper food, regulation of the school- and play-hours, and on suitable domestic surroundings. As drugs, the bromides given in full doses over a consider- able length of time are the most valuable therapeutic help we have. In petit mal belladonna combined with the bromides seems helpful. In traumatic epilepsy, where a localized depression is found in the skull, cerebral surgery may be tried with some hopes of success. CHOREA. Definition : The ordinary name for this disease is St. Vitus' dance. It is a functional neurosis characterized by irregular rapid twitchings of a few or all of the muscles of the body. Etiology : It occurs most commonly from the seventh to the fourteenth year, and more often in girls than in boys. Children born of neurotic or alcoholic parents are predisposed to the disease. It often follows scarlet fever or other of the infectious diseases. Many cases develop in ana?mic children. Of all causes, however, the rheumatic diathesis is most often present in the subjects of chorea. CHOREA. 299 The exciting cause of an attack is often a great fright, or overwork at school, or the presence of adenoids, worms, or phimosis. The early evidences of beginning menstruation are often exciting factors. Pathology : The pathological condition present is probably some disturbance in the nutrition of the nerve-centres in the motor areas in the brain. Chorea — symptoms : The attack usually develops gradually, with clumsiness on the part of the child in making voluntary movements with the extremities to be affected. Twitching of the facial or trunk muscles may be first noted. Soon the typical, irregular, spasmodic movements of these muscles de- velop, until the child can only with difficulty use the limbs, the chronic jerkings interfering with the normal, intentional motions. The less observed and quieter the child keeps the less marked are the movements. When noticed, or when de- siring to make some muscular movement, the chorea becomes worse. The same is true under efforts to control them. The movements usually cease during sleep. The affected muscles are weak, and the mental condition of the child one of extreme irritability. The speech is regu- larly involved and at times very difficult to understand. On examining the heart, in a large majority of the cases, a soft systolic murmur is heard over the mitral or pulmonic area. In many children this disappears after recovery, in which case it was probably anaemic; but in others it remains permanent, when it was probably a rheumatic endocarditis. These children are regularly anaemic, with poor appetites and disturbed sleep, and other evidences of disturbed nutrition. The attacks last ordinarily from two to three months. Some become chronic and may last for years. Recurrences arc rather to be expected even after complete recovery. Diagnosis: This is usually easy. Tic convulsif, due to irritation of the fifth nerve, may be mistaken for chorea, but is never found outside the distribution of this nerve. Prognosis: Chorea may be so severe as to endanger life in itself, or from endocarditis, but this is rare in childhood. Recovery is usually complete in the ordinary cases, the heart- lesion of the rheumatic diathesis being the only serious re- 300 DISEASES OF THE NERVOUS SYSTEM. mainder. Recurrences after some months or about an even year may be looked for. Chorea — treatment : The child should be taken from school, and kept comparatively quiet in one room, and should not be allowed to see too many visitors. The diet should be simple and easy to digest, and the room kept properly ventilated. If there are evidences of rheumatism present, salicylate of sodium should be used. For the chorea itself, arsenic, given in the form of Fowler's solution in gradually increasing doses to tolerance, is almost a specific. Iron in some easily assimi- lable form is advantageously combined with it. In cases where the spasmodic movements are very excessive bromides, or chloral, or both, may be given at the same time to dull the reflex irritability of the nervous system. HYSTERIA. Hysteria, while rare in childhood, is still seen at times in certain of its phases. Etiology : The disease is seldom seen before the tenth year, and occurs as often in boys as in girls. A neurotic or alco- holic heredity is usually present. Malnutrition and improper school and home education and surroundings are most im- portant etiological factors. The modern forcing forward of children is responsible for much of it. Some sudden ex- ternal irritation to the nervous system awakes the attack. Pathology : There are no known pathological changes in this disease. Hysteria — symptoms : Almost any of the varied symptoms of disease may be simulated by hysteria. Sensory disturbances are quite common, hyperesthesia of almost any of the superficial or deep structures of the body being often present, such as headaches, joint-pains, and ab- dominal tenderness. Blindness and deafness may also occur. Anaesthesia is less frequent, but is also found. In the motor sphere various forms of paralysis are com- mon. Aphonia, monoplegia, or even paraplegia may develop. Various contractures in the extremities are quite common. The most frequent motor symptom, however, is the hysterical HYSTERIA. 301 convulsion. The child screams, or laughs, or cries, and rolls around, throwing the limbs in irregular purposeless move- ments. Opisthotonos is frequent, but the patient never hurts himself as in epilepsy. Consciousness is retained, and there is present afterward a remembrance of the fit. Psychical symptoms are often seen — morbid appetite, refusal of food, craving for sympathy, increased self-consciousness, and depressed states bordering on melancholia. In others there are great excitability and fits of ungovernable passion. Hallucinations, night-terrors, and disturbed sleep are fre- quent. Symptoms of more than one variety are often seen in the same patient. Diagnosis : Observation over a prolonged period of time is often necessary before organic disease can be excluded. The possibility of the two conditions being present at the same time must not be forgotten. Eventually the diagnosis becomes quite easy and positive. Prognosis: This is not very good. Periods of improvement are seen, but relapses are common, and later in life these patients usually become highly neurotic. Hysteria — treatment : Everything possible should be done to improve the general health and nutrition of these children. Fresh air, proper exercise, regulation of the bowels, easily digested and simple food; regulation of the work and the recreation ; avoidance of novels, theatres, and unsuitable as- sociates, are all points for medical supervision. Often a great deal is accomplished by removing them from family and friendly influences, and putting them under the charge of a suitable individual who will treat them with firmness and tact. In other words, the treatment is entirely hygienic and moral. Hysterical symptoms as they arise may call for treatment, and some rather unpleasant variety should be tried for each symptom, ;i- counter-irritation, electricity, cold douches, and other similar therapeutical means, any one of which will ap- peal to the child from the standpoint of suggestion. 302 DISEASES OF THE NERVOUS SYSTEM. HEADACHES. Headaches are fairly common in children, especially in girls approaching puberty. In infants they are rare, except as a symptom of organic disease of the brain. Etiology : The commonest causes are anaemia and other forms of malnutrition ; constant breathing of impure air charged with carbonic acid gas and other impurities ; chronic indigestion and constipation, with absorption of products of intestinal decomposition ; uraemia, malaria, the rheumatic diathesis ; and, reflexly, diseases and anomalies of the eyes, nose, and ears. A large class includes the so-called nervous headaches, in which there seems simply a tendency for the brain to ache under some unknown circumstances. These are usually children of a neurotic heredity. Another class are the sick headaches, in which nausea and vomiting accompany the pain. These are probably due to a toxaemia from an excess of the end-products of proteid metamorphosis in the blood. Pathology : The changes in the brain that cause pain are probably entirely circulatory. Headaches — symptoms: Pain in the head is the symptom. It may be localized or diffuse. It may be one-sided or on both sides. It may be accompanied by symptoms elsewhere, as nausea and vomiting, or rheumatism, or other sign point- ing to the etiology. Diagnosis : The only point in diagnosis is to discover the cause. Go carefully through all the possibilities, and observe the child closely, excluding one cause after another, and even- tually it can be decided in most cases to what the headaches are due. Headaches — treatment : To cure the attack, phenacetin and caffeine are the main drugs of value. They may be combined with cold applications to the head and hot mustard foot-baths. After the attack is over treat the cause if it can be found. Enrich the blood, improve the nutrition, regulate the diet and the bowels, remove malarial, rheumatic, or lithsemic tenden- cies, see that the kidneys secrete properly, correct errors of refraction in the eyes, and cure nasal, nasopharyngeal, and ear affections. SPEECH-DISORDERS. 303 SPEECH-DISORDERS. We are frequently consulted for advice about the various functional difficulties of speech which are so common in chil- dren. Varieties : The main forms are late development of speech, lisping, stuttering, and aphasia. Late development of speech : Most children should learn to talk during the second year of life. Much depends, how- ever, on efforts made to teach them. In children with no training, or in those who have been seriously debilitated by sickness, the function of speech may be much delayed even when there is no brain-defect. Time and a little attention will quickly remedy this. Very late speech is suspicious of cerebral anomaly. Lisping : This consists in an inability to articulate clearly the hissing sounds. It may be simply a habit; but at times it seems almost impossible to place the tongue and teeth and lips in such a position as perfectly to form these sounds. It is never a serious defect, and can usually be overcome by proper training begun early before the habit becomes too fixed. Stuttering : Stammering is a term also used almost inter- changeably with this. It is rare before the second dentition, and consists in an inability to connect consonants and vowels together into a continuous word. Certain consonants seem especially hard to enunciate. Singing is often done with no hesitation. Stuttering is likely to develop in children of neurotic hered- ity, in those who are overworked at school, and in the badly nourished. In some it is an imitative habit. Removal of the cause and improvement of the general health will often cure the habit. In the older eases a process of careful training in enunciation and use of the voice, by a person skilled in such work, should be undertaken. Aphasia: By this is meant a temporary functional hiss of speech, not the form due to disease of the third left frontal convolution. It is -ecu ;it times after severe attacks of ill- ness, as typhoid fever, and after marked emotional excite- 304 DISEASES OF THE NERVOUS SYSTEM. ment. It usually recovers spontaneously in a comparatively short time. SLEEP-DISORDERS. There are frequently found in children disturbances of sleep. The two of most importance are marked restlessness, amounting almost to insomnia, and night-terrors. The two conditions may be treated together, as they seem to depend on similar causes and to differ in degree only. Etiology : The commonest causes are derangements of the digestive tract, due to improper feeding in some way, either over-feeding or under-feeding, or the giving of unsuitable forms of food. This leads to colicky pains, to chronic indi- gestion, and to absorption into the blood and circulation through the brain of intestinal toxins. Earache, obstructed respiration (the result of adenoids or other causes), and general nervous irritability from excessive fatigue, reading or hearing exciting stories, and improper home-surroundings, are the common causes of many cases. Sleep-disorders — symptoms : There may be only a restless, disturbed sleep, with frequent waking ; or an actual insomnia. This latter is comparatively rare in children. In night-terrors the child suddenly awakes from his sleep in great fright, half remembering some dreadful dream. At first he is bewildered ; but gradually his mind becomes clear, and after a time he goes off to sleep again. Recurrences are frequent. Diagnosis : This is fairly easy. The night-terrors might be confused with nocturnal epilepsy ; but a little careful observa- tion will usually settle the diagnosis. Prognosis: This is good, as by proper treatment the con- dition can be cured. Sleep-disorders — treatment : Find the cause, if possible, and remove it. Regulate the diet, the bowels, the exercise, the reading of books, and listening to stories. Improve the general health in every way. Give no drugs, if possible to dispense with them. If necessary, use trional or bromides, given at bedtime. BAD HABITS. 305 BAD HABITS. The two bad habits that are most often seen in children are sucking and masturbation. The former may lead to the latter. Sucking : This is very common. It consists in sucking of the fingers, or toes, or some foreign substance, such as a rub- ber-nipple. Often the fingers will be sucked so constantly as to produce distinct maceration of the skin. In addition to its being a bad habit, probably the baby sucks some wind into its stomach by its persistent efforts. Great pains should be taken in the beginning to prevent the formation of the habit before it becomes so fixed as to be hard to cure. Often the fingers will have to be bandaged and tied. Masturbation : Masturbation, it must not be forgotten, is quite common among small children of both sexes, and is even seen in babies of a year old. It may result from local irritation of the genitals, as from phimosis, worms, vulvitis, itching skin-diseases, or irritating urine. Other cases are taught by forms of play or exercise in which friction is made on the genitals ; and still others by playmates or nurses. It may be performed by use of the hands, or by rubbing the thighs together, or by friction against some external object. Children the subject of this habit are apt to be anaemic and poorly nourished and irritable. Locally the genitals are relaxed, and there may be slight redness of the prepuce or vulva. Careful observation extended over some time is necessary to detect these cases. The younger the child, and the sooner the habit is discovered, the more apt will we be to break the indulgence. Masturbation — treatment : Intelligent moral care from the parents is of most value. Any local cause of irritation should be removed. The general health particularly should be im- proved in every way. Mechanical restraints may help in very young children, but are useless in older ones. The child's companions should be carefully selected. Hypnotism has been of value in some cases. Corporal punishment will not often be of much use, except in individual cases where the child's temperamenl is such as to be much influenced by this kind of treatment. Many of the cases arc very difficult to handle. 20— 1). C. CHAPTER XII. DISEASES OF THE LYMPH-NODES. ACUTE ADENITIS. Definition : This is an acute exudative inflammation of the lymphatic glands. It is exceedingly common in children. Etiology : This is probably always secondary to an abrasion or inflammation, of one kind or another, of the skin, or mucous membrane of the area drained into the inflamed glands. The original lesion may be so inconspicuous as to be overlooked. The commonest causes are rhinitis, naso-pharyn- gitis, stomatitis, dentition, otitis, eczema, diphtheria, scarlet fever, measles, and influenza. From these the cervical glands are affected. The axillary glands are involved from vacci- nation, paronychia, trauma to the hand or arm, or skin-erup- tions on the same. The inguinal glands inflame from lesions about the genitals, anus, or feet. Adenitis is most frequent during the first two years of life, the absorptive power of the lymphatics seeming most active then. It occurs in both healthy and delicate children, but seems most frequent among those in institutions. Pathology : The glands are swollen, infiltrated with the products of exudation, and the surrounding tissues are usually involved. If the infection is severe enough, there is such an excessive emigration of white cells as to cause the glands to break down and form abscesses. The milder cases go on to resolution with absorption of the inflammatory products. Acute adenitis — symptoms : Most of the cases have some fever, which may reach 102° F. or more, with its accompany- ing malaise. The inflamed glands are swollen, a little pain- ful, and usually quite tender. When under the sterno-mas- toid muscle a voluntary torticollis is often caused. When only the gland is involved the skin retains its normal color; but if the surrounding tissue becomes inflamed, the skin 306 CHRONIC ADENITIS. 307 reddens. These are the cases apt to suppurate. Only one, or a number of neighboring glands, may be affected, and in some cases groups in separate locations are involved simul- taneously. The tumor may reach the size of an egg. It remains hard and regular, unless it suppurates, when soft spots may be felt on its surface. In cases complicating infectious fevers the local swelling and tenderness are all that can be recognized during the symptoms of the original disease. In cases in which there is suppuration softening usually occurs by the second week, fol- lowed by bursting externally. After evacuation, natural or artificial^ healing is usually rapid and complete. In non-sup- purative cases the acute stage passes away, and the swelling gradually is absorbed, requiring a month or two. Diagnosis : Knowledge of the location of the superficial lymphatic glands, and the fact that the swelling is only of short duration, cover every point in diagnosis. Prognosis: This is good except in seriously debilitated children. Recovery is usually rapid. Some few become chronic and are later infected by the tubercle bacillus Acute adenitis — treatment : In all infectious diseases care- ful and frequent cleansing of the mouth, and nose, and naso- pharynx will prevent infection of the glands. If adenitis has begun, search the drained area, and treat any inflammation or abrasion there. Wash the mouth, nose, and naso-pharynx with some alkaline solution ; syringe the ear, care for skin-diseases, and so on. Apply cold to the in- flamed gland to retard the inflammatory process, or heat if suppuration seems inevitable. As soon as softening occurs lance the abscess, as thus a smaller scar is left than when it is allowed to burst itself. In cases going on to resolution daily applications of a 10 to 20 per cent, ichthyol ointment seem to assist the process. CHRONIC ADENITIS. Definition: In this condition it is understood that the glands arc in a state of chronic inflammation of a simple character, thai is, neither tubercular Dor syphilitic. 308 DISEASES OF THE LYMPH-NODES. Etiology : This is also fairly common in children. It often remains after an attack of acute adenitis ; but usually is the result of chronic inflammations of the skin or mucous mem- branes in the region drained. Some children seem especially prone to such conditions. Pathology : The glands undergo a true hyperplasia, with an increase of both their cellular and connective-tissue ele- ments. The latter, however, are usually in excess. Chronic adenitis — symptoms : The only symptom is the en- largement of the glands. This is usually moderate in amount, and tenderness and other signs of acute inflamma- tion are absent. There is very little tendency for the glands to increase in size, and softening and suppuration are almost unknown. More than one group is usually involved, and hypertrophied tonsils and adenoids are apt to be present in the same case. Diagnosis : The important point is to be able to exclude tubercular and syphilitic enlargements of the glands. The finding of a local cause of irritation is of main value. Sim- ple enlargement occurs in younger children, and shows no tendency to involve contiguous tissues nor to suppurate. A gland enlarged from a simple inflammation may later become tubercular. The diagnosis in many cases is very difficult. Prognosis : This is very good, as the curing of the cause usually hastens absorption of the inflammation. Chronic adenitis — treatment : Hunt carefully over the drained area for the cause of the inflammation, and treat it. If diseases of the scalp, or discharges from the ear, or ade- noids, or naso-pharyngitis are present, treat them as usual. Improve the child's health in every way by iron, cod-liver oil, nourishing diet, and fresh air. Locally, applications of iodine or of ichthyol may hasten absorption, and can do no harm. TUBERCULAR ADENITIS. This common condition, before the knowledge of the tubercle bacillus, was called scrofula. Etiology : The lymphatic system seems particularly prone to tuberculosis, and this condition is seen oftenest in children TUBERCULAR ADENITIS. 309 over three years old. Those with a tubercular family history are specially subject to it. At the same time, with this pre- disposition there is usually present some local irritant, as chronic inflammation of the skin or mucous membranes in the drained area. Other cases follow attacks of one or other of the infectious diseases. In addition to these causes there is always present infection by the tubercle bacillus. The pharynx seems the usual place of infection, as the cervical glands are those oftenest involved. Pathology : The glands are swollen and the seat of a simple and tubercular inflammation at the same time. The cellular and connective-tissue elements are both increased, and the gland studded more or less thickly with miliary tubercles and tubercular masses. In the older cases these tubercular masses undergo a caseous degeneration, and break down into tubercular abscesses. The surrounding tissues first become adherent to the inflamed glands, and later are involved in the same inflammatory process. Neighboring glands be- come likewise fused together into one mass. Tubercular lesions may or may not be found in other organs of the body. Tubercle bacilli are present in the glands in moderate numbers. Tubercular adenitis — symptoms : There is a slowly growing enlargement of one or more groups of glands. Those of the neck are most often affected ; those in the axilla or groin less often. Groups in two or more places may be involved coin- cidently. The increase in size continues, and fusing of the separate glands occurs until a large mass is present in which the original outlines of the glands cannot be made out. Then the surrounding tissues become adherent to the mass and likewise involved. By this time areas of softening occur which approach the surface, the skin becomes discolored, and an abscess bursts externally, discharging thick, curdy pus with bacilli. Throughout there are very seldom any pain or tenderness of the inflamed glands, or any signs other than those of their presence. The process usually extends over many months or years from the first appearance of enlargement to the time of sup- puration. The general health may be somewhat depreciated, 310 DISEASES OF THE LYMPH-NODES. the child becoming anaemic and poorly nourished. After bursting, the discharge may continue for an indefinite length of time with a permanent sinus, or may stop and healing occur. Under any circumstance, irregular, large disfiguring scars are left. Diagnosis : The diagnostic points are the tendency to con- glomeration of the glands, their caseation, and the character of the discharged pus in which tubercle bacilli may be found. The child's family history is also an aid. The enlarged glands of simple chronic adenitis, or of Hodgkin's disease, do not suppurate. Syphilitic enlargement usually has the history to help us. The difficulty of diagnosis is great in the early stages. Prognosis : Most of these cases get well ; some after many years of discharging sinuses. A very few develop tubercu- losis elsewhere and die of this condition. Tubercular adenitis — treatment : The main points in treat- ment are the cure of local conditions in the skin, nose, throat, or elsewhere that originally caused the glands to enlarge. After this everything should be directed to the general health of the child — fresh air, exercise, nourishing diet, and change of climate if possible. Internally, iron, arsenic, and cod- liver oil are very helpful. The former is best given as the syrup of the iodide. If, after some months of this treatment, no impiovement is seen, and particularly if suppuration threatens, the case should be put under surgical care. Operation, if undertaken, should be thorough, and the scars left by this are far less dis- figuring than those after spontaneous evacuation. CHAPTER XIII. DISEASES OF THE SKIN. LENTIGO. The common name for this affection is freckles. It con- sists of small pigmented spots, occurring in groups on sur- faces that are ordinarily left uncovered. Etiology : It occurs oftenest in children over five years old, and in blondes with a tendency to red hair. There seems some connection between it and exposure to sunlight. Lentigo — treatment : Apply a 1 per cent, solution of cor- rosive sublimate on a piece of lint to the aifected region for three or four hours. This raises a blister, which should be pricked and dressed with dry powder. When the raised skin desquamates the new epidermis is free from pigment. The treatment is somewhat painful. ICHTHYOSIS. This is a congenital deformity of the skin characterized by the formation all over the surface of dry scales, and with a lack of the normal cutaneous secretions. Etiology : The only point known is that the disease occurs in families. Pathology : It consists in an excessive growth of the epi- dermal cells. Ichthyosis — symptoms : The dry, scaly condition of the skin is the only symptom. These scales desquamate freely, and long crack- form through the skin at flexures, which may be painful. Perspiration is absent. The sense of touch is much interfered with. Except in the very worst cases the disease is not dangerous. These children are frequently exhibited as freaks, being called fish- or alligator-boys. 311 312 DISEASES OF THE SKIN. Prognosis : The condition is incurable, but is ordinarily compatible with long life. Ichthyosis — treatment : Internally, the use of the fatty foods is to be recommended. Locally, daily warm baths should be taken, with plenty of soap to remove the loose scales, and then the whole skin should be thoroughly rubbed with lanoline or vaseline, to keep it as soft and pliable as possible. SEBORRHEA. This condition of thick, dry crust-formation, is very com- mon on the heads of infants. Etiology : It is caused by an excessive production of the secretions of the sebaceous glands, which are allowed to dry on the scalp and become mixed with dirt. Seborrhoea — symptoms : The vertex of the head presents a large patch of dirty, yellowish, greasy secretion. On exami- nation it is found to consist of epithelial cells, granular mat- ter, fat, and dirt. The skin under it is ordinarily normal and shows no signs of inflammation. Seborrhoea — treatment : Keep a vaseline poultice on the scalp over night, held in place by a nightcap or a bandage. Next morning the free use of warm water and soap will re- move most of the crusts easily. Repeat this successive nights until the condition is gone. Afterward apply daily an oint- ment containing 10 grains of resorcin to the ounce of vaseline. MILIARIA. This is commonly called prickly heat, and is a very common condition in childhood. Etiology : It is regularly caused by intense heat, with ex- cessive production of irritating perspiration. Pathology : This is an acute inflammation of the sweat- glands, resulting in damming up of the minute ducts and the formation of small papules with minute vesicles on their sum- mits. When the inflammation is very slight it is called sudamina, and consists of the minute vesicles only. FUR UNCULOSIS. 3 1 3 Miliaria — symptoms : The symptoms are this widely spread red rash, consisting of the minute vesiculated papules, which may become infected and turn into pustules, associated with intense smarting and burning. It is usually most marked on the trunk and head, but may be universal. Diagnosis : This is easy. A careful inspection of the rash, the history of the case, and the state of the atmospheric tem- perature are the points for consideration. Miliaria — treatment : During hot weather the child should be lightly dressed, with cotton next the skin, should be fre- quently bathed in cold water, and the skin kept dusted with some dry non-irritating powder, such as the stearate of zinc, which acts very nicely. If the eruption is present, these measures should be con- tinued ; and, in addition, the bowels should be opened, the diet should be light, and internally some mild diuretic, such as sweet spirits of nitre, given. The zinc and calamine lo- tion — zinc oxide, sss ; pulv. calamine, 3ij ; glycerin, |j ; liquor calcis, ad gviij — should be applied freely. One per cent, of carbolic acid may be added, if there is any tendency to infection. Under this treatment the case should recover in a few days. FURUNCULOSIS. A boil is an intense localized inflammation occurring about a hair-follicle or a gland of the skin. Etiology : Boils are probably due to a direct infection of the follicle by micro-organisms. Pus from one boil will in- fect another follicle, and in this way successive crops are formed. Local injury of a slight nature often opens the way for infection. Boils are fairly common in children, but never seem so deep-seated, indurated, and painful as they heroine in adults. Furunculosis — symptoms: A boil begins as a small red papule, but the surrounding skin rapidly becomes indurated and lender. A small whitish top soon forms over it, but on removing this no pus escapes. The pain is severe and throb- bing, and the neighboring Lymphatics may become inflamed 314 DISEASES OF THE SKIN. and tender. There may be some constitutional symptoms in the worst cases. After a week or ten days pus collects in considerable quan- tity in the boil, and on evacuating it the centre of the boil shows the presence of a large white necrotic mass — the core. This core is the remnant of the dead follicle or gland. After its removal a little cavity is left to fill by granulation, and with this the parts soften and the pain and tenderness disap- pear. Diagnosis : There is no reason for confusing this condition with any disease. Furunculosis — treatment : Improve the general health by the use of arsenic and the hypophosphites. When a boil is beginning put over it a wet dressing of carbolic acid in 2 per cent, solution. As soon as it begins to point incise freely and continue this wet carbolic dressing. By this means we rapidly heal up any boil present and prevent the formation of others. Very careful cleaning of the skin, and subsequent applications of 1 : 1000 bichloride of mercury, or of 1 : 40 carbolic acid, will prevent the formation of additional boils. IMPETIGO CONTAGIOSA. This is an infectious disease of the skin characterized by the formation of vesicles and pustules. Etiology : The disease occurs almost always in children, is contagious, and hence is seen oftenest in a number of children in the same family, or among the poor, living in the same tenements. Probably some as yet unknown form of bacterial infection is the actual cause. Impetigo contagiosa — symptoms : There are often a little fever and malaise with 'the outbreak of the eruption. This begins as isolated vesicles, the contents of which soon become pustular, and then a dry, yellowish scab forms on the surface. After this crust drops the surface is red, but no depression is left. The eruption is usually confined to the hands and face. The lesions may remain discrete or may coalesce, and usually heal in a couple of weeks. Fresh crops from auto-inocula- tion may prolong the attack indefinitely. ECZEMA. 315 Diagnosis : Pemphigus and chickenpox are most apt to be confused. The points are the distribution of the lesions, their contagious character, and the isolated vesico-pustules. Prognosis is very good. Treatment : Remove the crusts, wash the parts carefully, and apply an antiseptic ointment, as unguentum hydrargyri ammoniati. ECZEMA. Definition : This very common skin disease of infancy and childhood is a dermatitis, characterized by itching, redness, infiltration, moisture, and crusting. It may be acute or chronic, and presents a boundless variety of lesions. Etiology : While the disease is especially frequent in child- hood, it presents no essential differences from the eczema of adult life. The skin in most children is very susceptible to irritation both from outside and inside, but in certain ones there seems to exist an especial predisposition to inflammatory action. This tendency is at times inherited. The parents are often subjects of a gouty or rheumatic diathesis. Chil- dren brought up amid unhygienic surroundings, being im- properly nourished and unaccustomed to good air, are often the subjects of eczema. On the other hand, very frequent examples of the disease are seen in children seemingly in the best of health, with their nutrition above the normal, and their skin pink and healthy. These latter seem especially prone to facial eczema. The exciting causes acting from within the organism are oftenest connected with digestion and elimination. It is seen in both breast- and bottle-fed babies, but more often in the latter because they are oftenest the subjects of digestive de- rangements. Indigestion from over-feeding, from excessively high percentages of fat, or proteids, or sugar in the milk, or from ton early use of starch, is a frequent cause. On the oilier hand, mother's milk or artificial food in which the nutritive value is far below normal may be responsible. Improper articles of diet for the age of the child are often causative ; as are also constipation and deficient action of the Liver or kidneys. 316 DISEASES OF THE SKIN. Reflex irritation, acting through the nervous system, un- doubtedly may be a partial cause at least of certain cases, as in dentition. External irritants which may cause an outbreak are cold, heat, irritating soap, powders, excessive bathing, and clothing of a rough texture. Discharges from the nose, ear, eyes, genitals, or rectum, and wet diapers will frequently start the disease. Parasites, as pediculi, acari, and trichophyta, will produce it. In most cases there is more than one cause acting. The disease is not contagious. Eczema — symptoms : In infants eczema is more often seen about the head and face than elsewhere. Any of the various lesions — erythema, papules, vesicles, or pustules — may be pres- sent singly or combined in the individual case. There is always intense itching, and the child's scratching adds mechanical lesions to those of the original inflammation. The inflamed surface discharges a serous secretion which dries on the skin and forms yellow crusts. Scratching these causes bleeding, so that many of them become dark brown. Many of the lesions become infected, and the eczema then takes on the pustular form. This pustular variety is most frequent in the scalp. Each variety has its own particular name, but there is no special advantage in these subdivisions. The lesions spread usually from one neighborhood to another, until finally a large portion of the skin becomes involved. It is quite common for the lymphatic glands to be inflamed, and to swell, and even to form abscesses. In the groin, and other regions where two surfaces of skin come into close contact, intertrigo or erythematous eczema develops quite regularly. All varieties of eczema are subject to frequent relapse, and all require great care and perseverance in treatment. The reader is referred to special books on the subject for more detailed description as to lesions. Diagnosis : Scabies and syphilis cause lesions most likely to be confused with eczema. Remember the characteristics of eczema : multiform lesions, serous discharge or " weeping," crusting, and itching. Scabies itches badly, but is usually found in other members of the family, and on special locali- ECZEMA. 317 ties, as the webs of the fingers, the flexures of the wrists and elbows, and around the genitals. With care the burrows of the acarus may usually be found. Syphilis gives multiform lesions, but does not itch. The eruption is dark colored and the child usually shows general cachexia. Prognosis : It is a slow, tedious disease. With proper care most cases can be cured ; but relapses are common, and the patience of the physician and of the family will be tried to the utmost in the meantime. Eczema — treatment : Search into every possible external, internal, and reflex cause of the condition ; if anything is found wrong, correct it, and regulate the child's life accord- ing to the most approved hygienic rules. This means special attention to the condition of the stomach, intestines, liver, and kidneys. The most painstaking care should be taken in these lines, and no little thing must be neglected. Intelli- gent co-operation on the part of the mother and nurse is very important. All local irritants must be removed, and irritat- ing discharges cured. Water should not be applied to eczem- atous surfaces. It has a specially irritating effect on them. A bland oil may be used for purposes of cleanliness, and the parts mopped dry afterward. Prevent scratching, if neces- sary, by confining the child's hands. During the acute stage some soothing ointment should be applied and kept in place by a bandage or mask. The plain oxide of zinc ointment, or this with 1 per cent, of carbolic acid added to allay the itching, answers the purpose well. In the more subacute cases a stimulating ointment, as one con- taining tar in some form, is of most value. Another useful formula is Lassar's paste, with ten grains of salicylic acid to the ounce of ointment. In the various text-books on dermatology will be found in- numerable form like for the different stages. Here it is nee- essary to emphasize principles only : remove causes, prevent washing and scratching, apply soothing remedies to acute cases, and stimulating ones to chronic eases. All applica- tions should be kept persistently in contact with the inflamed skin. 318 DISEASES OF THE SKIN. URTICARIA. This is also called hives and nettle-rash. It consists of suddenly appearing, elevated, irregularly shaped blotches in the skin, called wheals. They are usually paler than the sur- rounding skin, but may be pink. They disappear equally quickly, and leave no trace behind. Etiology : Local irritants, such as coarse underclothing, bites of insects, and some vegetable poisons, will produce the wheals. A large number are due to gastro-intestinal irrita- tion, as indigestion from any source ; but certain special arti- cles of diet always produce attacks in certain individuals. Strawberries, fish-food, and oatmeal are among such articles. Certain drugs, as quinine, will sometimes cause it. Urticaria — symptoms : The wheals are quite characteristic in their onset, appearance, and manner of disappearing. They itch intensely, and scratching will often develop new crops. As the attack begins some fever may accompany it, with general malaise. No other skin disease has any special resemblance to it. Prognosis : This is perfectly good, but individuals who once have the disease are very apt to have subsequent at- tacks. Urticaria — treatment : Find the cause, if possible, and re- move it. All local irritants should be taken away. As the digestive system is so frequently at fault, it is always well to clean it out thoroughly at once. This is best done by a dose of a saline cathartic. After this regulate the diet. Locally, an alkaline bath is always good to allay the itch- ing, or a solution of menthol, gr. x to the ounce. Nothing further is necessary except so to regulate the food and cloth- ing as to prevent subsequent attacks. SCABIES. This disease is called commonly the itch. It is not very frequent in this country. Etiology : It is due to the boring under the skin of the female acarus scabiei for the purpose of laying her eggs. The male parasite remains on the surface. The little furrow TINEA TRICHOPHYTINA. 319 made by the acarus is a pigmented, irregular line, which is the characteristic diagnostic point of the disease. At the ex- tremity of the burrow the minute insect will usually be found. Pathology : Around the itch-mite in the burrow will be a zone of inflammation, which is either a papule, a vesicle, or a pustule. In fact, the lesions of scabies are quite multi- form. Scabies — symptoms : The acarus chooses places to burrow where the skin is thin, and hence the lesions are found most frequently in the webs of the fingers, on the folds of the wrists, about the breasts and genitals. The burrows, to- gether with the multiform lesions and the intense itching, are the main symptoms. To relieve the itching the scratching is incessant, and the mechanical lesions of this are added. This probably explains the frequent presence of lesions about the genitals. In infants the face may be involved from in- fection from its mother's breast. Diagnosis: From simple eczema the finding of the burrow and the acarus decides the diagnosis. Prognosis : This is good. Cure is comparatively easy. Scabies — treatment : The child should first be given a soap and hot-water bath, the soap being very thoroughly applied in regions where lesions are found. After this a sulphur ointment should be well rubbed in over all the affected parts. This should be repeated two or three times, and until the acari are killed. All clothes and night-dresses should be sterilized by boiling. TINEA TRICHOPHYTINA. This is commonly called ring-worm, and is frequently seen iu children on the skin, general surface, or scalp. Etiology: This disease Is due to the growth in the skin of the trichophyton fungus. It is a vegetable parasite consisting of mycelial threads and spores. Tinea trichophytina — symptoms: The disease begins as a slightly red scaling spot. If in the scalp, the hairs in this spot become broken oil' and point in all directions. The 320 DISEASES OF THE SKIN. infection spreads from this point in a circle, the centre begins to heal, and eventually by this process of peripheral spread- ing and central healing, a ring is produced, which gives the name to the disease. Two or more points may be infected at the same time, and the rings formed from each may cut into one another, forming irregular figures. In the scalp, a common location in children, the hairs become brittle, lose their lustre, and give quite a " moth- eaten " appearance to the aifected area. Often ring- worm in the scalp gets infected, and pustules form in the hair-follicles. If such a case becomes chronic, we get the condition known as kerion, where the whole area becomes boggy from the infection. The disease does not produce much itching nor any other subjective symptoms. Diagnosis : Syphilis, eczema, and psoriasis all may form circinate figures, but by taking the other lesions into consider- ation usually no error need be made. By microscopical examination of scrapings taken. from the lesions the fungus may be easily found. Prognosis : In the skin it is easy to cure. In hairy areas it is more difficult, but perseverance brings it to an end here also. Tinea trichophytina — treatment : On the skin daily appli- cations of tincture of iodine will cure the case rapidly. In the scalp the hair should be clipped close, and the lesions thoroughly cleaned with soap and hot water. After this an ointment of white precipitate should be rubbed thoroughly into the aifected regions. This treatment, cleans- ing and anointing daily, should be continued till all signs of the disease are gone. There are many valuable ointments, for which reference should be made to the special text-books. In the very persistent chronic cases epilation may be necessary. CHAPTER XIV. DISEASES OF THE EAR. ACUTE OTITIS. Inflammations of the middle ear are excessively common in infancy and childhood. Etiology : It is usually secondary to inflammation in the naso-pharynx, such as cold in the head, adenoids, enlarged tonsils, and pharyngitis complicating the infectious diseases. The commonest of these are scarlet fever and influenza. It may occur after measles, diphtheria, or typhoid. Picking at the ears, foreign bodies in the ears, and boxing the ears are also causes. Pathology : The inflammation in the pharynx spreads through the Eustachian tube, swelling the mucous membrane and causing an increased secretion of mucus, which may become purulent. This inflammation may be confined to the mucous membrane of the Eustachian tube, or may spread to that lining the middle ear. In the middle ear the inflam- mation may be the milder catarrhal variety, or the more severe purulent form with the presence of the germs of sup- puration. Acute otitis — symptoms : Following the symptoms of the primary disease, the child has the two symptoms of otitis: fever and pain. The fever may be only 100° F. ; or may be much higher, reaching often 104° F. The pain, or earache, is quite a prominent sign, and the one that leads us to sus- pect the ear as the cause of the fever. The pain is acute and severe, and in young infants who cannot talk is evidenced by restlessness, crying, and tenderness on pressure about the ear. The crying from earache is apt to be incessant and con- tinuous. In infant- eases do occur, however, in which the pain and tenderness seem very slight. With the fever there 21— D. c. 321 322 DISEASES OF THE EAR. are general malaise, anorexia, headache, and constipation. The symptoms last a day or two to a week, and gradually cease with the subsidence of the inflammation ; or more quickly in case the otitis leads to rupture of the drumhead, with free exit to the inflammatory exudate. In the latter case the discharge from the ear is rather profuse at first, but gradually becomes less in quantity, and finally ceases with healing of the rent in the membrane. In the purulent variety mastoid abscess, thrombosis of the lateral sinus, meningitis, or cerebral abscess may develop from extension of the inflammation to these parts. Diagnosis : Fever of unknown origin, combined with pain or evidences of tenderness about the ear, is usually sufficient for diagnosis. Infants who have long crying attacks are very apt to be suffering from earache. If possible, an examination of the ear should be made through a speculum. The mem- brane will be found red and congested, and bulging if secre- tions are behind it. A discharge and a perforation may be found. Prognosis : In the catarrhal form the prognosis for recovery without impairment of hearing is good. In the purulent form, after recovery there is apt to be either partial or com- plete deafness in that ear, while there are many cases of serious disease, and even of death, following the complications. Acute otitis — treatment : In the early stages the local appli- cation of heat by a hot-water bag, a Japanese stove, or by prolonged douching with hot water by a fountain-syringe, will relieve the pain and hurry the inflammation through. At the same time touching the naso-pharynx with some astrin- gent, as silver nitrate, is good. The bowels should be opened by broken doses of calomel, and the child kept in a warm room with an equable temperature. If the pain continues, it is justifiable to put a few drops of a solution of atropine, 1 per cent., and cocaine, 4 per cent., in the external meatus. If the membrane is found to be bulging and tense, it is better to perform paracentesis than to wait for the membrane to rupt- ure spontaneously. After spontaneous or artificial perfora- tion of the drum-membrane, the ear must be kept scrupu- lously clean and dry. CHRONIC OTITIS. 323 CHRONIC OTITIS. This means really a chronic otorrhoea. Etiology : It usually follows repeated attacks of the acute disease in delicate, poorly nourished children. It often is due to neglect of proper treatment. Pathology : There is a chronic purulent inflammation in the middle ear, with rupture or destruction of the drum-mem- brane, and a constant purulent discharge from the external meatus. Chronic otitis — symptoms : The main symptom is the dis- charge, which is often quite free and creamy, and is apt to have a very characteristic, disagreeable odor. This discharge may cause eczematous eruption of the external ear, and with it may be associated a cervical adenitis. Diagnosis : This is made by the presence of the chronic dis- charge, and the examination of the drum-membrane, if it can be performed. Prognosis : While these cases are often obstinate, they can usually be cured by perseverance. Chronic otitis — treatment : Excessive cleanliness of the meatus, syringing twice a day with a boracic acid solution, and then drying the parts carefully, will usually heal them. Peroxide of hydrogen has a useful field here. At the same time any inflammatory condition in the naso-pharynx should be attended to, and the child's general health brought as near normal as possible. CHAP TEE XV. DISEASES OF THE BONES. ACUTE ARTHRITIS. Definition : This is a suppurative disease of the extremities of the bones, occurring with some frequency in infancy. It is also called acute epiphysitis. Etiology : It is an infection of the extremity of the bone by pyogenic organisms, which may gain entrance through almost any lesion of the skin or mucous membrane. Trau- matism of the joint is probably a partial cause. Pathology : The inflammation usually begins at the epiphy- seal junction, and spreads into the joint and to the shaft. It is really an osteomyelitis, modified by the anatomical condi- tion of the epiphysis in infancy. It is very apt to go on to the production of an abscess either subperiosteally or in the joint. Secondary abscesses elsewhere are common, when the true pysemic nature of the disease becomes apparent. Acute arthritis — symptoms : The disease begins suddenly with a chill, and fever of a remittent type. General prostra- tion and other symptoms of fever accompany this. The affected joint becomes swollen, red, painful, and very tender, so much so as. to produce a voluntary paresis. If pus forms, signs of deep fluctuation are present, and burrowing may be extensive or rupture externally may take place. Death may occur from the intensity of the infection in a few days ; or resolution may take place with a gradual disappearance of the symptoms ; or, after rupture of the abscess, recovery with a damaged joint may occur. Diagnosis : The disease is most likely to be confused with acute rheumatism, but in infancy rheumatism seldom assumes such marked local symptoms. 324 POTT'S DISEASE. 325 Prognosis : Death takes place in about 10 per cent, of the cases. Very few recover without some disability of the joint. Acute arthritis — treatment : The child's nutrition should be well kept up, and alcoholic stimulants will usually be neces- sary. Pain should be relieved by drugs and by local appli- cations. As soon as signs of suppuration occur, or even earlier, free incision with drainage should be used and the case treated on surgical principles. POTT'S DISEASE. Definition : This is a tubercular inflammation of the bodies of two or more of the vertebra?. Etiology : The tubercle bacillus seems particularly prone to invade the bones in children during the period after they learn to walk. Previously healthy children, with no tuber- cular family history, may be attacked; but it is much more common in delicate children with a bad heredity. It may fol- low attacks of one of the infectious diseases, but is usually the primary tubercular focus. Traumatism is often ascribed as a cause, but simply offers a locus minoris resistevtice for attack by the bacillus. Pathology : The bodies of the vertebrae are gradually in- vaded by the tuberculous tissue, which, having poor vitality, breaks down, producing caries of the bone. With this comes formation of tubercular abscesses, which may remain local- ized at the spot, or may burrow and appear at the surface at considerable distances. The intervertebral disks are de- stroyed by the same process. The weight of the body above the disease causes the carious vertebra? to yield, with the pro- duction of the characteristic deformities of the disease. If only one or two vertebra? are diseased, the bend is quite an acute angle ; if more, the curve is more general. The meninges, the roots of the spinal nerves, and even the cord itself, may be involved by the inflammatory process. Pott's disease — symptoms: The disease begins very gradu- ally. The child seems out-of-sorts, tires easily, is stiff in his movements, and has restless nights. The first definite symp- tom is pain, which is more often referred to the abdomen 326 DISEASES OF THE BONES. than to the back. This is probably due to irritation of the nerve-roots, and the case is often treated for indigestion. Later, there are noticed a rigidity of the spine and the vol- untary assumption of certain postures which relieve the pain. About this time a beginning deformity of the spine at the seat of the lesion may be noted, or in others paralysis from pressure on the cord. Later yet, abscesses form and remain localized at the seat of trouble, or burrow and burst at remote points. The general health may remain fairly good ; but usually the child becomes anaemic, emaciated, and feeble. The disease may attack the cervical, dorsal, or lumbar spine, giving localized symptoms according to the region in- volved. The dorsal vertebrae, however, are attacked much oftener than the others. The deformity produced is an antero-posterior bending, or kyphosis. Lateral curves are rare. Abscesses in the cervical region point in the pharynx ; those in the lower dorsal and lumbar travel down the sheath of the psoas muscle and point in the groin. The course of the disease is essentially chronic, lasting over a number of years, and death may take place from exhaus- tion, or from the development of tuberculosis elsewhere. In the cases going on to recovery the inflammatory process ceases, new bone is deposited in the carious vertebra?, and ankylosis with permanent deformity takes place. Diagnosis : This is made by rigidity of the spine, which is shown by having the child go through various movements in which the spine is necessarily bent ; by pain and tenderness in the diseased area ; by the attitude assumed, which is often char- acteristic ; by the presence of the typical deformity of the spine ; by paraplegia, and by abscesses. Rachitic deformities are more gradual in their curve, and, instead of mere rigidity of the spine, there may be greater mobility. Prognosis : In the lumbar and cervical regions the prog- nosis is better than in the dorsal. About one -fourth of the cases die from the disease sooner or later. Death occurs most often from one of the many complications that are likely to arise during the slow course of the disease. In the cases which recover some deformity is almost certain ; but its HIP DISEASE. 327 extent depends mainly on the kind of treatment and the stage at which it was begun. Pott's disease— treatment : The general treatment ot the patient is of great importance, as in all varieties of tubercu- losis. The nutrition should be carefully attended to, fresh air . /. Strc]>tococci, X 1000. Diphtheria Bacilli and Streptococci. DIPHTHERIA. 345 degeneration of the essential cells of various organs of the body. These are commonest in the kidneys, heart-muscles, peripheral nerves, liver, and spleen. Other complications are due to coincident infection by various streptococci, among which are adenitis and broncho- pneumonia. Incubation-period : This is from two to ten days. Diphtheria — symptoms : The symptoms are local, due to the inflammation of the mucous membrane ; and general, due to absorption of the toxins of the Klebs-Loffler bacilli into the system. The cases vary greatly both in severity of the con- stitutional symptoms and in the amount and location of false membrane formed. The local symptoms are the presence on ordinarily some part of the respiratory mucous membrane of the characteristic whitish patches of this disease. These patches may be seen on the tonsils only, or on other parts of the pharynx, and may be continuous or with intervals between them. The pseudo-membrane is white, or gray, or black ; it cannot be removed without leaving a raw, bleeding ulcer behind, and the surrounding mucous membrane is swollen, red, and in- flamed. The parts are painful and tender to the touch, and dysphagia is present. The glands under the jaw are coinci- dently inflamed, being swollen and tender. From day to day the pseudo-membrane is often seen to spread and involve neighboring parts. The first membrane may appear in the nose, or naso- pharynx, or larynx and out of sight. In the two former locations its presence is shown by a severe rhinitis, with irri- tating discharges from the nose, and in the last by the symp- toms of croup. These false membranes may be thin or thick ; and, since the use; of bacteriological diagnosis in this disease, we know that there may be true diphtheria, as shown by the presence of the Klebs-Loffler bacilli, without any pseudo- membrane, the throat being simply in the stale of catarrhal inflammation. The membrane in any one location is gradu- ally loosened from its base, and is discharged on an average in about seven days. 346 THE INFECTIOUS DISEASES. The constitutional symptoms in some cases are absolutely- absent, or so slight as to be overlooked. The disease, however, ordinarily begins with a chill or chilly sensations, accompanied by a rise of temperature. The fever continues throughout the disease, but is usually of only mod- erate severity — 101° to 102° F. Temperatures over 104° F. are very rare. With this are prostration, headache, vom- iting, and diarrhoea. The heart's action is ordinarily rapid and feeble, and diphtheria is pre-eminently the disease in which attacks of serious heart-failure are to be dreaded. These attacks may arise suddenly when the child is in his ordinary condition, or may develop more slowly, venous con- gestion, dyspnoea, and rapid feeble pulse being the signs of the failure. Probably in most cases these attacks are due to degeneration of the vagus nerve by the diphtheria toxins. Diphtheria — abnormal cases: There are cases without very high fever and with no large quantity of membrane, in which the child seems to suifer, and usually dies from an intense septic infection or toxaemia. The main symptoms here are great prostration and feeble heart-action. There are others where the only symptoms are those of a laryngitis, the membrane being confined to the larynx. These are described under Membranous Laryngitis. Complicating lesions add their symptoms to those of the disease proper, as obstructed respiration in laryngeal cases; rapid breathing, cough, and increased prostration in broncho- pneumonia ; diminished urine and oedema in nephritis. Pseudo-diphtheria : Since the introduction of the systematic bacteriological examination of cultures from most cases of diphtheria, it has been proved that there is such a thing as clinical diphtheria, differing scarcely from the true form, ex- cept that there are no Klebs-Loffler bacilli in the pseudo- membrane, but instead there are streptococci only as its cause. This variety has been called pseudo- or streptococcus-diphthe- ria. Clinically it is well to consider the two forms alike, although the Klebs-Loffler diphtheria is the more serious dis- ease of the two. Diphtheria — sequelae : There occur frequently after diph- theria paralyses of groups of muscles. These are due to de- Diphtherial infection of uvula and anterior pillars of fauces, show- ing the disappearance of the membrane after injection of antitoxic serum. (a, 18 hours; b, 24 hours, and c, 36 hours after injection.) (Williams.) DIPHTHERIA. 347 generation or inflammation of the peripheral nerves, due to the toxins of the disease. The muscles most commonly in- volved are those of the soft palate, of the pharynx, of the larynx, of the eyes, of the extremities, and of respiration. Except when involving the last set of muscles, they are not dangerous to life. After considerable time the power gradually returns to the paralyzed muscles as the nerves are regenerated. If the respiratory muscles are affected, death is quite likely to occur. Diagnosis: Clinically, the presence of general symptoms of an infectious disease, combined with the characteristic false membrane, are the points for diagnosis. This membrane is not easily wiped away, as are the spots in follicular tonsillitis. A sanious nasal discharge points to membrane in the nose, and laryngeal symptoms to its presence in the larynx. It is practically impossible to separate the cases of true from those of false diphtheria positively by the appearance alone. Of recent years our diagnosis is made more certain by the aid of bacteriological methods. A swab culture is made from the throat, and this allowed to incubate for twelve to eighteen hours. At the end of this time the little colonies are stained and examined under the microscope, and the presence or absence of the Klebs-Loffler bacilli proved. This is of special assistance in laryngeal and nasal cases where no mem- brane is visible. Prognosis : This is very uncertain, as the age of the patient, the virulence of the infection, the location and extent of the membrane, and the presence of complications all enter into the prognosis. The younger the child the more dangerous the disease When the membrane remains confined to the tonsil only, the prognosis is quite good. Rapidly spreading membrane is serious. Laryngitis and broncho-pneumonia are very dangerous complications. The cases with marked evi- dences of toxaemia are always severe. The mortality of pseudodiphtheria is far less than that of the real form. Diphtheria — treatment: The same preventive measures should be taken as in all infectious diseases. The patienl should be closely isolated ; the attendants should gargle their throats frequently; the outside clothing worn in the room 348 THE INFECTIOUS DISEASES. should be changed before going elsewhere ; discharges from the child's mouth and nose should be received in a strong solution of mercuric chloride ; the clothing and bedding of the patient should be soaked in the same solution or burned ; the hangings of the room should be removed before putting the child in it. After the disease is over the walls of the room should be washed with bichloride, and a public funeral should not be allowed. Nowadays, in addition to the old practice of swabbing out with an antiseptic the throats of children who have been exposed to the disease, a small immunizing dose of antitoxin should be given, averaging from 100 to 500 units, according to the age of the child. For this purpose there seems as much value in administering the serum by mouth as subcutaneously. For the actual care of the disease, the child should be kept absolutely quiet in bed, and on a highly nourishing diet, mainly of milk, and other easily digested soft foods. Gavage is often very helpful in feeding these cases when they will not take sufficient nourishment. The room should be well venti- lated and kept at an equable temperature. Internally there seems some value in giving small doses of bichloride of mercury every four hours. As stimulants, whiskey is to be given in rather large doses frequently repeated. It not only stimulates the heart, but also seems to neutralize the toxaemia. In cases of failing heart strychnine is our most useful remedy. Locally, the inflamed parts should be kept clean. If the membrane is only on the tonsils and pharynx, frequent gentle swabbing with weak bichloride solution is helpful. If the naso-pharynx or nose is involved, the nostrils should be washed out frequently each day with Seiler's solution. This is best done by a simple piston- or a fountain-syringe. The solution should go in one nostril and out the other. Laryn- gitis is treated locally and mechanically as described under membranous laryngitis. In addition to these measures, all cases should be treated, as soon as seen, by injecting antitoxin. The initial dose should be 1000 to 3000 units, or even more, according to the age of the child, the dose being repeated in about eighteen hours if no local or general improvement is manifest. It WHO OPING- CO UGH 349 may be given a third or a fourth time at the same interval if needed. Use the most concentrated serum, as the size of the dose is smaller, and the earlier it is given the better the result. It is given by a large-sized hypodermic syringe, under aseptic precautions, and may be inserted under the skin of the back or the side. Signs of improvement after antitoxin are seen in the diminution of the fever and con- stitutional symptoms, and in the stopping of the spread and the loosening of the membrane. These must not be expected before eighteen hours. Some days after the injection in certain cases erythema, urticaria, and joint-pains are noticed, but they usually quickly subside. The results of the use of antitoxin have been most grati- fying, particularly in the laryngeal cases, intubation and tracheotomy being less often required, and when used, saving more lives. Complications are treated as always ; post-diphtheritic neu- ritis by massage, electricity, and strychnine. Convalescence requires the use of iron, combined with good diet and plenty of fresh air. WHOOPING-COUGH. Definition : This disease, also called pertussis, is an infec- tious neurosis, characterized by inflammation of the respira- tory tract and a peculiar paroxysmal cough. Etiology: While whooping-cough is probably due to some germ, as yet efforts to isolate it have not been successful. The poison seems to be given off in the breath, to float in the air, and to be inhaled. Children are quite susceptible to the dis- ease, and more «o than are adults. One attack regularly pro- duces immunity. The disease exists endemically in most cities, but epidemics occur from time to time. Pathology: Catarrhal inflammations of the larynx, trachea, ;ind bronchi are regularly found. Broncho-pneumonia exists as a frequent complicating lesion. Incubation-period: This is probably about two weeks, but cannol be stated positively. Whooping-cough — symptoms: The invasion begins with a catarrh of the larynx, trachea, or bronchi. This lasts for 350 THE INFECTIOUS DISEASES. from ten days to two weeks ; but instead of the cough im- proving, toward the end of this period it grows worse. This catarrh is of varying degrees of severity, but regularly the cough seems disproportionate to the physical signs to be found in the chest. There is scarcely any fever or malaise. Toward the end of this period of invasion the cough begins to assume the typical character which has given its name to the disease. This cough comes in 'paroxysms, during which the child coughs continuously for some seconds, at the same time holding his breath, and at the end of the paroxysm taking a long stridulous inspiration, which produces a sound like the word " whoop." Daring this attack he becomes blue in the face, the eyeballs become prominent and suffused, the veins stand out, and the child presents the appearance of suffocation. This paroxysm is apt to be repeated two or three times, the inspiratory whoop being given at the end of each, until some tenacious mucus is expelled or vomiting is produced. It may be some hours before another set of paroxysms begins. The child grows to know when the attacks are coming, and will stand for support against some stationary object, and usually with his hands braced on his knees. Epistaxis is often an accompaniment of a severe paroxysm, and after an attack the child is very exhausted and often in a profuse perspiration. These paroxysms are usually more frequent by night than by day, and may be repeated many times in the twenty-four hours. They vary both in intensity and frequency very much. Exercise, shouting, crying, draughts, eating, drinking, or excitement will often develop a paroxysm. The general health of the patient suffers mainly from the interference with sleep, and from the inability to retain sufficient nourishment on the irritable stomach. Owing to this, many of these children grow very emaciated. This paroxysmal stage lasts from three to six weeks, but often is continued over a much longer period. In some cases a whooping-habit seems to be developed, which lasts many months. This disease ordinarily disappears very gradually, WHOOPING-COUGH. 351 the paroxysms becoming less frequent and less severe until they stop. Whooping-cough — physical signs : In uncomplicated cases auscultation of the chest gives no physical signs. If bron- chitis is present, as is so frequently the case, the coarse rales and sibilant and sonorous breathing of this disease are found. If broncho-pneumonia complicates the disease, we find the characteristic signs of this lesion. Complications : Bronchitis and broncho-pneumonia are the commonest and most serious complications of pertussis. Hemorrhages from the nose or mouth, into the conjunctiva, or into the meninges, are seen from time to time. The frsenum of the tongue is apt to be torn by the persistent coughing. The vomiting after the paroxysms may be looked on as a complication when it is so severe as to interfere with the child's nutrition. Convulsions and various forms of cerebral paralyses may complicate some severe cases in infancy. Hernia and prolapsus ani may result. A latent tuberculosis may be started up by the disease. Diagnosis : The typical whoop is the diagnostic test of this disease ; but in children with a persistent cough without adequate physical signs to account for it, and especially if it appear paroxysmal and accompanied by vomiting and suffusion of the eyes, a fairly probable diagnosis may be made. The presence of pertussis in the neighborhood, or a history of exposure to the disease, aids in making our diagnosis. Prognosis : Whooping-cough is a disease frequently occur- ring in very young infants, and in these cases it is an extremely fatal malady, as it is apt to be complicated by broncho-pneumonia, which in itself is necessarily fatal during the first two years of life. In older children, and without complications, it is not much to be dreaded. Infancy and complications are the dangerous sides of this disease. Whooping-cough — treatment: Children with pertussis should not be allowed to attend school nor to mix with other children. This is a point in which great carelessness exists in every community. In good weather the sick child should be kept out of doors a great deal, if lie lias no pulmonary coinplica- 352 THE INFECTIOUS DISEASES. tions, but the habit of taking such children on street-cars and into places where other children are exposed, is to be condemned. If the weather is bad, or if pulmonary compli- cations prevent the child being out of doors, care should be taken to keep the rooms in which he lives well ventilated ; but every precaution should be followed to prevent his " catching cold." The child's diet should be carefully attended to, and only the most nourishing and easily digesti- ble food should be given. If vomiting is excessive and in- terferes with the child's nutrition, the food should be pre- digested. Often by feeding a little of this food immediately after a paroxysm accompanied by vomiting, it will be re- tained. In some cases alcoholic stimulants will be useful. If any of the drugs given for the cough seem to irritate the stomach, they should be stopped. There seems some value in the child's breathing the vapor from creosote or carbolic acid. This may be brought about by wearing a respirator for some time each day, on which a few drops of the medicament are placed, or by having the air of the child's room contain the vapor of the drug. A so-called vapo-cresoline lamp is useful for this purpose, but either drug may be vaporized in an ordinary tea-kettle quite as well. Local applications made directly to the larynx are of little value. In very severe paroxysms with threatening convul- sions chloroform may be used. Internally almost all the drugs of the pharmacopoeia have been given. Only a few are of value, and in some cases even these fail. Belladonna in increasing doses until the early poisonous symptoms of the drug appear is often very useful. Antipyrin seems the next most valuable drug. It often controls the paroxysms like magic. Bromoform in two- drop doses four times a day is a newer remedy of some value. In some cases quinine in fairly large doses helps. It is often helpful to produce good sleep by the use of a hypnotic, such as bromide, chloral, trional, or sulfonal, which likewise quiet the reflex excitability of the child. Complications in the lungs should be treated in the usual way. MUMPS. 353 MUMPS. This disease, also called infectious parotitis, is characterized by constitutional symptoms and inflammation of the salivary glands. Etiology : The disease is contagious from person to person, but does not seem to attack infants quite as readily as adoles- cents. No specific germ has as yet been isolated. One attack protects against subsequent ones. Pathology : Only one, or both, parotids are involved. The submaxillary glands mayor may not be coincidently inflamed. The inflammation only goes to the point of congestion, with swelling and obstruction of the ducts. Suppuration is very rare, and as the inflammation subsides the gland returns to normal. Incubation-period : This varies from two to three weeks. Mumps — symptoms: The constitutional symptoms begin early and last three to five days. They are fever, headache, irritability, anorexia, nausea, and prostration. The tem- perature is from 100° to 102° F. ; but in severe cases may reach 104° F. Coincidently the glands become painful, swollen, and tender, and the mouth dry. Moving the jaw, as in talking or eating, is very painful, and the presence of any food in the mouth pungent enough to excite the flow of saliva increases the pain. This is the reason acids were used as an old test for mumps. One gland is usually inflamed a day or two before the other, but at times it may be some days before the second gland becomes swollen. The submaxillary glands may be inflamed coincidently or later. After two to three days the swelling of the glands reaches its height, and then gradually disappears. The disease lasts one or two weeks, asthe glands become inflamed together, or subsequently. Complications: In infants these are rare. In adolescents, inflammations of the testicles, breasts, or onirics are seen in a fail- proportion of cases. This inflammation usually subsides without injury to the organ. Diagnosis: An idiopathic inflammation of the parotid or submaxillary gland-; is usually mumps. II the parotid is swollen, the lobe of the ear stands <>ui from the head. He 23 — J>. C. 354 THE INFECTIOUS DISEASES. sure the swelling is not due to some of the cervical lymph- glands. Prognosis: This is almost invariably good, as recovery is to be expected in a few clays to a week. Mumps — treatment : The child should be kept in the house and fairly quiet. The diet should be liquid and without much flavor, so as not to excite the salivary glands to activity. If fever is high, a little phenacetin should be given. If the glands are painful, hot applications are soothing. Broken doses of calomel are well given at the beginning of the attack. LA GRIPPE. Definition : This disease, also called epidemic influenza, and catarrhal fever, is an infectious malady, characterized by fever, pains, prostration, and catarrhs of the mucous mem- branes. Etiology : It is pretty well proven now that grippe is due to a specific germ, the bacillus of Pfeiffer. The disease occurs epidemically over large areas of territory, and also endem- ically after the epidemic feature has passed. The germ seems to be disseminated in the atmosphere, and to attack the victims mainly in the winter and spring. Infants and children seem equally prone to the disease with adults. One attack does not confer immunity to subsequent ones. Pathology: Catarrhal inflammations of the eyes, nose, throat, ears, larynx, bronchi, or intestines are found. Com- plicating lobar or broncho-pneumonia may be present. Incubation-period : This is probably short, from a few hours to a few days, but cannot be decided positively. La grippe — symptoms : The disease usually begins rather suddenly with fever, headache, pains in the back and limbs, and marked evidences of prostration. The fever runs from 100° to 104° F., but very seldom higher. It lasts from two days to a week, and is accompanied by anorexia, nausea, vomiting, and often diarrhoea. In infants convulsions may be present, and restlessness, insomnia, and irritability are quite common. All the symptoms gradually disappear in about a week in the uncomplicated cases. LA GRIPPE. 355 La grippe — complications : Very few cases run their course without some complication. The commonest of these are in the respiratory system. Few cases occur without some in- volvement of the nose and pharynx, a severe rhino-pharyn- gitis being almost always part of the disease. The mucous membrane of the frontal sinuses is likewise inflamed, and thus severe frontal headaches are produced. A frequent complication is involvement of the middle ear, and an acute otitis media, with its symptoms of earache, deafness, and a discharge, follows. In children especially, the cervical lymph-glands are very often inflamed, and frequently go on to suppuration. The larynx, trachea, and larger bronchi are likewise usually involved in the catarrhal process, producing an irritating, croupy cough, with substernal pain, but very little expectora- tion. All the above inflammations seem to be almost a necessary part of the attack of grippe, and very few cases escape with- out more or less severe evidences of these. More unusual, and more serious complications are broncho- pneumonia and lobai- pneumonia. One or the other variety of inflammation of the lung is seen in a fair proportion of the cases of influenza. They both run a rather irregular course, the toxic symptoms of each being very prominent, the duration prolonged, and the mortality high. In some children the gastro-enteric system seems to be par- ticularly vulnerable to the influenza bacillus, and vomiting and diarrhoea are the prominent symptoms of the disease. This complication, however, is seldom very severe, and recovery is the rule. Diagnosis: During an epidemic the diagnosis is rather easy. Tn sporadic eases the diagnosis is best made by excluding Other conditions by the absence of physical signs. Malaria is differentiated l>v the enlarged spleen and plasrnodia; pneu- monia, by the physical signs in the chesl : meningitis, by the retracted head and ocular palsies; typhoid fever, l>\ the tym- panites, rose spots, and Widal reaction. Prognosis: When uncomplicated mo-t all of die children recover. Pulmonary complications are apt in be serious, 356 THE INFECTIOUS DISEASES. especially broncho-pneumonia. Latent tuberculosis is often developed by an attack of la grippe. La grippe — treatment : The child should be put to bed and kept there so long as the fever continues. The diet should be nutritious and easily digestible. The bowels should be moved by fractional doses of calomel. For the aching and fever, nothing is so useful as phenacetin and salicylate of sodium, given in doses suitable to the child's age. Quinine may be added in some cases with advantage. Where the depression is extreme, alcoholic stimulants should be used freely. The respiratory complications are best treated by the ammonium salts combined with inhalations. Convalescence should be carefully watched, and general tonic treatment followed until full strength returns. TYPHOID FEVER. Definition : This is an infectious disease due to a specific germ, and characterized by a rather typical course of fever with its attendant symptoms, and lesions in the lymphatic glands of the intestines. Etiology : The direct cause of typhoid is infection by Eberth's typhoid bacillus. This is usually taken into the digestive tract along with some form of food or drink, water and milk being the most usual carriers of the germ. It exists and multiplies in the contents of the intestines, in the intestinal lesions, the lymphatic glands, the spleen, liver, kidneys, and the blood. They are discharged from the body with the faeces, and can live outside the body for a considerable time. The disease is very rare in infants, as they are so univers- ally fed on sterile food. In children it occurs more com- monly, but even in them is rarer than in young adults. One attack of typhoid regularly produces immunity for life. Pathology : There is swelling, followed, in the severer cases, by necrosis and ulceration of the solitary and agminated glands of the ileum and colon. There is also an associated catarrhal enteritis. The lymphatic glands of the mesentery are swollen and inflamed, but rarely go to suppuration. The spleen is enlarged considerably and soft. There is a degener- TYPHOID FEVER. 357 ation 01 the essential cells of the liver and kidneys. The heart-muscle is soft and flabby. Complicating inflammations may be found in the lungs, meninges, peripheral nerves, and veins, but all are rather rare in children. Incubation-period : This averages from one to two weeks. The first symptoms of the fever are so indefinite that it is hard to set a positive period of incubation. Typhoid fever — symptoms : The course and natural history of the disease in childhood follow fairly well the type as seen in the adult, except that all the symptoms seem less severe. The disease begins gradually with lassitude, slight head- ache, anorexia, and often attacks of diarrhcea ; or more rarely rather suddenly with a quick rise of temperature and pros- tration. The fever lasts usually three weeks ; during the first week, each day showing a little more temperature than the preceding day ; during the second week the temperature remaining fairly uniform ; and during the third week, declin- ing day by day to reach normal after the twenty-first day. The average temperature is from 102° to 104° F., but in more marked cases it reaches 105° to 106° F. It often shows marked variations in its course, complications of an inflam- matory nature tending to increase it, while hemorrhages and perforation cause it to fall. It may be prolonged for a con- siderable time beyond the three weeks, remaining at 99^° to 101° F., or even after a period of apyrexia it may rise again and remain up without a distinct relapse. The heart's action grows more rapid as the fever progresses, but in this disease is always somewhat slower than a like amount of fever from another cause would produce. The pulse retains its power, but is apt to become dicrotic toward the height of the fever. The tongue is coated down the centre, but the tip and edges remain dean and the tip pointed. The mouth, becomes dry and glazed, and sordes develop around the lips and teeth. Anorexia is a regular symptom. The bowi Is are more often constipated than loose, but when diarrhcea exists the discharges partake of the "pea-soup" character seen in adults. The abdomen becomes moderately distended ami tympanitic .-it some time during the course of 358 THE INFECTIOUS DISEASES. the fever, due to accumulation of gas in the intestines. Tenderness and gurgling in the right iliac region are unim- portant signs. The spleen is regularly enlarged, so as to be felt on palpa- tion extending some inches below the border of the ribs. There seems some connection between enlargement of this organ and absorption from the intestinal lesions. During the second week of the fever the characteristic erup- tion of the disease appears in the shape of isolated, rose- colored, lenticular spots, slightly elevated, and disappearing on pressure. They are usually few in number, appearing on the abdomen and chest, and coming in successive crops which last about three days each. The nervous symptoms are rather marked in children : head- ache, restlessness, irritability, and later stupor and apathy. Picking at the bed-clothes and subsultus tendinum are not very common. In some cases delirium, hyperesthesia, stiff- neck, and ocular symptoms may be severe enough to suggest meningitis. The children usually feel quite sick, and prostration is enough to make them glad to stay in bed. As the disease progresses, emaciation becomes extreme, and bedsores are very liable to develop over bony prominences. Intestincd hemorrhages are not very common, but do occur toward the end of the second or the beginning of the third week. They may be single or repeated. They add a danger to the disease in showing the presence of rather deep ulcera- tions, but in themselves are rarely fatal. The blood is usu- ally dark, and mixed with fsecal matter. Intestinal perforation is very rare. It is accompanied by all the symptoms of intense shock, and a fatal ending is soon to be expected. Retention of urine is quite a common symp- tom at some time in the course of the disease. Relapses may occur at any time for two weeks after the subsidence of the fever. They are always shorter in duration and milder in their course than the original fever, but usually all the signs and symptoms of the first attack are reproduced. Typhoid fever — complications : Slight albuminuria is usually present in typhoid, due to a degeneration of the kidney-cells. TYPHOID FEVER. 359 More or less bronchitis is rather common, but is usually con- fined to the larger tubes. Broncho-pneumonia is a much rarer as well as more serious complication of typhoid. Otitis media is fairly common if attention is not paid to cleanliness of the mouth and throat. Phlebitis and venous thrombosis develop in many of the cases, most often in the legs. Diagnosis : This needs for its confirmation the typical fever, tympanites, enlarged spleen, and the eruption. In addition, the Widal reaction should be found in the blood : if to a culture of typhoid bacilli a drop of blood from a patient suffering from, or lately recovered from, typhoid fever, be added, the bacilli undergo a peculiar agglutination, which does not take place when normal blood, or blood from other diseases, is added. This test, while not absolute, if positive, is confirmatory. Malaria is differentiated by the presence of plasmodia in the blood ; tuberculosis by local signs of that disease ; menin- gitis by ocular and pupillary signs ; and the various forms of enteritis by the more marked intestinal symptoms. Prognosis: This is better than in adults, as the disease is usually milder in children. Typhoid fever — treatment : The child should be put to bed and kept there at least two weeks after the fever has reached normal. The diet should be milk, or milk derivatives only, if possible; but if an idiosyncrasy exists against this, broths and eggs may be used. If constipation is present, the bowels should be moved in the beginning by calomel, and afterward, at least every other day, by enema. If diarrhoea is not ex- cessive, it should be left alone. If necessary, it may be checked by bismuth and opium. All discharges from the bowels should be received into vessels containing 1 : 1000 bichloride of mercury solution, and allowed to remain in it at least an hour before being thrown out. All bedding and cloths which are soiled by the faecal discharges should be soaked in the same solution, or boiled thoroughly by them- selves. The fever had besl not lie treated by any drugs of any nature given internally. They simply control the symptoms without doing any good. If the temperature is 102^-° F. or 360 THE INFECTIOUS DISEASES. over, cool sponging, or cold packs, or cold bathing should be systematically used ; being guided by the height of the tem- perature and the reaction of the child as to the choice of methods. As temperature-reducers, they are valuable in- versely in the order given. The temperature of the water should be about 80° to 85° F. in either form. The mouth and tongue should be carefully cleaned three or four times a day, a mixture of lemon-juice and glycerin being very useful for this purpose. There seems some value in giving dilute hydrochloric acid in five-to-ten drop doses three times a day, throughout the course of the fever. If the tympanites is severe, use turpen- tine stupes to the abdomen or pass a rectal tube. If the child is very restless and sleepless, or delirious, bromides may be used as needed. Stimulants in the shape of whiskey or strong wine, are usually needed in the last week of the fever. For intestinal hemorrhage we give opium and apply cold to the abdomen. Intestinal perforation is treated by morphine. Prevent bedsores in the usual way, and be on the watch for retention of urine. Care must be taken after the subsidence of the fever in returning to a normal diet, and this should take place very gradually. Strychnine and iron are valuable during the convalescent stage. MALARIA. Definition : This is an infectious disease due to the presence in the blood of a specific organism belonging to the protozoa, and characterized by fever, enlarged spleen, and cachexia. Etiology: The organism causing the disease was first de- scribed by Laveran in 1880, and named the plasmodium ma- larias. It exists in the blood and destroys the red blood-cells. We do not know in all cases how it enters the blood ; nor is its habitat outside the human species exactly located. There seems, however, strong proof in some cases that cer- tain species of mosquito contain the plasmodium and act as the infecting agent. The plasmodium is an amoeboid body growing in the red corpuscle, absorbing the pigment from the red cell into itself, MALARIA. 361 and, as a paroxysm approaches, segmenting into a number of smaller bodies, each of which probably makes its way into another red cell to go through a similar series of changes when its cycle is through. Different varieties of malarial poisoning are due to some- what different species of plasmodia, the organism of inter- mittent fever showing some morphological differences from that of remittent or sestivo-autumnal fever. Malaria attacks persons of all ages — children as well as adults. It exists endemically in certain parts of the country which are usually low-lying marshy places, and is especially prevalent after the country has been flooded or when new ground has been turned up. In moist Southern climates it is especially frequent. It occurs most commonly in the spring and fall, being rare in the winter. Incubation-period : The poison of the disease may produce symptoms shortly after infection, or remain latent over such considerable periods of time that it is impossible to decide on a definite time of incubation. Malaria — varieties : There are two fairly distinct types of malarial fever seen — the intermittent and the remittent or ces- tivo-autumnal form. Intermittent fever begins suddenly with a severe chill, fol- lowed by a rapid rise of temperature to often as high as 104° or 106° F., and after a few hours this falls equally as quickly to normal with a profuse drenching perspiration. During the fever there are intense headache, backache, prostration, and often nausea and vomiting. In infants general convulsions quite commonly occur with the rise of temperature. This paroxysm is repeated daily at about the same hour in the quotidian form or on alternate days in the tertian. Between the paroxysms the child feels perfectly well and has no symp- toms. In children one or the other stage of the paroxysm is often wanting, the attack seldom being quite as typical as in the adult. Remittent fever : In this form the disease may begin sud- denly or gradually, or may follow one or more paroxysms of the intermittenl type. The fever ha- daily remissions in its course, but naver reaches normal. It lasts an Indefinite 362 THE INFECTIOUS DISEASES. length of time, depending on treatment and on the patient's remaining in the malarious country. With the fever the child suffers from headache, backache, marked prostration, and often nausea and vomiting. The tongue is coated white, the pulse is rapid, and the patient fre- quently passes into the so-called " typhoid state." In chil- dren delirium, restlessness, sleeplessness, and often convul- sions are present. These cases are often mild, but they frequently, especially in the South, pass into the pernicious form of fever, with an accession of all the symptoms, and often with a fatal ending. After either form of malarial infection has lasted for a suffi- cient length of time, the so-called malarial cachexia develops. In other cases it is seen in children living in a malarious country, even with no signs of preceding fever. This cachexia is due to the rapid destruction of the red blood-corpuscles by the plasmodia. The children are pale, feeble, languid, and emaciated., They have headaches and digestive disturbances. An examination of the blood will show the presence of a high degree of secondary ansemia, and of plasmodia in the red cells. Malaria — diagnosis : In intermittent fever the paroxysm is so characteristic as to settle the diagnosis easily. In the re- mittent form the diagnosis from typhoid is very difficult. In all varieties we expect to find the spleen enlarged enough to be easily palpated, and in addition a careful searching of the blood for plasmodia will usually find them, and thus settle the diagnosis positively. The therapeutic test with quinine is always helpful. Be careful not to overlook other conditions by carelessly calling them malaria. Prognosis : This is good if the disease is recognized early and properly treated. Removal from a malarious district adds much to a good prognosis. Malaria — treatment : During a chill hot applications should be made externally and a good dose of hot whiskey be given. After the chill is over the bowels should be opened by a dose of calomel, and then quinine be given in properly sized doses for the severity of the infection and the age of the child. SYPHILIS. 363 Children bear quinine well, and should be given relatively large doses. If the malaria is in the form of well-marked intermittent fever, a couple of large doses at an hour's inter- val, and the last one about five hours before the expected paroxysm, is the best way of giving it. In the irregular attacks and in the remittent forms it should be given regularly in good-sized dose three times a day. It should be continued in gradually decreasing doses for several days after all evidences of the infection are gone, and the en- largement of the spleen has disappeared. For children who can swallow capsules, this is the best method of giving quinine. If it must be given in solution, it is best disguised by the syrup of yerba santa. When small doses only are required, the chocolate quinine tablets may be used, each tablet containing one grain of the tannate. If it cannot be given by mouth, it may be given by rectum, either in enema or by suppository, a double dose of the bisulphate being used. In malarial cachexia arsenic should be given with the qui- nine. SYPHILIS. Definition : This is a chronic infectious disease, probably due to some specific germ ; but as yet none has been isolated and proven to be the real cause. Forms: In infancy and childhood the disease maybe ac- guired in many ways just as in adult life, but is more often inherited, and is then called hereditary or congenital syphilis. Acquired syphilis differs in no respect from the disease as seen in adults, and so will receive no separate description. In inherited syphilis the symptoms seem somewhat modi- fied from the regular course and require special consideration, and iu this article, when using the term syphilis, the congen- ital variety will l»e understood. Etiology: The disease may originate in the foetus from the father, the mother, or from both parents. Parents in the secondary stage of the disease are almosi certain to transmit the taint. If in the tertiary stage, ox after prolonged and proper treatment, the danger is rather slight. There seems 364 THE INFECTIOUS DISEASES. less danger of transmission from a syphilitic mother than from a syphilitic father. If the mother is infected late in her pregnancy, the child will often escape. Pathology : The lesions in babies dying of syphilis are not by any means always characteristic. There are usually found in the viscera certain changes of the nature of a new growth of connective tissue, which replaces the proper structure of the organ involved. For instance, there may be fibroid changes found in the spleen, liver, lung, or kidneys, giving these organs the characteristic whitish color and tough con- sistency which are always found in interstitial hyperplasia. The capsules of these organs are thickened and adherent, and the whole organ is usually enlarged. In the bones the lesions are quite characteristic and more regularly found. There is usually an inflammatory process present at the junction of the shaft of the long bones with the epiphysis. This consists of congestion and greatly in- creased proliferation of cartilage-cells. This may be found in only one or in many of the bones, and may lead to separa- tion of the epiphysis and diaphysis. These changes are often found in the metatarsal and metacarpal bones and in the phalanges, producing syphilitic dactylitis. In the late cases there are found osteophytic growths on the shafts of the long bones, due to a chronic periostitis, with the formation of new bone-tissue under the periosteum. This produces great enlargement and thickening of the aiFected bone. These thickenings may be uniform or in nodes. Syphilis — symptoms : According to the virulence of the in- fection and the period of incubation in the individual foetus, depends the condition of the child at birth. We must bear in mind that what corresponds in the acquired disease to the first period of incubation, (until the appearance of the initial lesion ;) and to the second period of incubation, (until the ap- pearance of the secondary symptoms), takes place during intra- uterine life in the inherited form. In other words, the infant is ordinarily born during the second period of incubation ; and, more rarely, after the secondary symptoms have begun to appear. Accordingly, abortion may take place, and fre- quently does ; or a dead, premature, or full-term child may be SYPHILIS. 365 born ; or a living child with skin lesions and other evident signs of the disease may come into the world ; but most com- monly a living child is born with no external evidences of disease. In infants born with evident syphilis present the symptoms are a marked degree of malnutrition, with wasted body, wrinkled skin, and senile appearance. In addition, the baby regularly has various kinds of skin eruption present. The eruption may be papular or pustular, but the characteristic form is that of pemphigus, and this is usually found on the palms and soles. Many of the bullae dry and form yellow crusts on different parts of the body. These infants usually live but a short time. In the ordinary case the infant appears healthy at birth. During the first month these children show some aneemia and other evidences of malnutrition. By the second month, usu- ally the first signs of the disease develop. These are a per- sistent coryza, called " snuffles," and the eruption. As in all syphilitic eruptions this is multiform, and may be a simple erythema or roseola, or may consist of macules, papules, ves- icles, or pustules. It may develop anywhere on the body, but is most apt to appear in regions where irritation is great- est, as around the buttocks. Associated with these skin erup- tions are the frequent occurrence at the muco-cutaneous junc- tions of ulcers, fissures, mucous patches, and condylomata. These form the rhagades about the lips and nostrils, and the ulcers and warts around the anus. During this time more or less inflammation about the nails is also common. The epiphysitis occurring at this time produces [tain, tender- ness, and often swelling about the joints. From this comes a voluntary immobility of the joint — a pseudo-paralysis. Anaemia and marasmus go on increasing during the course of the disease, and from time to time fever may be present. The spleen and liver are regularly enlarged, but not the lymphatic glands, as in the acquired form. The child frequently dies of marasmus or of some intercur- renl trouble during the course of the disease ; but if the in- fection is mild or if treatment i- given, tie- evidences of active disease, the secondaries as they really are, gradually disappear. 366 THE INFECTIOUS DISEASES. Later, often about the tenth year, signs of late syphilis or what might be called the tertiary stage of the disease, de- velop in many of these surviving children. These signs are seen most frequently in the teeth, eyes, ears, and bones. The teeth belonging to the permanent set take on the char- acteristics known as Hutchinson's teeth. In this condition the upper central incisors are deeply notched by a crescentic de- pression in their cutting-edge, and the teeth themselves are shaped like a peg or the end of a screw-driver. In the eye the cornea undergoes an interstitial inflammation with the production of opacities. In the ear there is a gradual loss of hearing without signs of inflammatory action. In the bones, the changes due to chronic periostitis are seen, with the production of enlargements and thickenings of the long bones, as the tibia?, and the growth of nodes on the flat bones — those of the cranium. Gummata may form anywhere in the skin or mucous mem- branes. If untreated, they break down and form ulcers when in the skin ; but when in the mucous membranes of the nose and hard palate, as they break down they produce destruction of the nasal and palate bones, with perforations and deformi- ties of these parts. Gummata may likewise form in the vis- cera, but are usually not diagnosed in these situations. Syphilis — diagnosis : In well-marked cases this is not diffi- cult. If an eruption only is present, it is more difficult ; and the mother's history must be taken into consideration as to previous abortions, birth of dead children or of children with eruptions. The coryza, fissures about the lips, condy- lomata about the anus, signs of epiphysitis, eruption, and malnutrition are the points to be looked for. In the tertiary stage, Hutchinson's teeth, interstitial kera- titis, deafness, deformities of the nose and palate, and enlarge- ments of the tibiae are typical signs. Prognosis : This is a more dangerous disease in infants than in adults, as the malnutrition so interferes with their growth. The earlier after birth the symptoms develop the worse the prognosis. Much depends on the way treatment is carried out in estimating the prognosis. SYPHILIS. 367 Syphilis — treatment: All the ordinary means for the pre- vention of syphilis should be carried out. If a mother be- comes pregnant with what may be a syphilitic child, she should be vigorously treated throughout her pregnancy. Just as soon as a diagnosis is made the child should be put under mercurial treatment. It is best given by inunction, using about one scruple of blue ointment daily. The place of rubbing should be changed from day to day to avoid irri- tating the skin. Internally, gray powder in grain doses three times a day, or bichloride of mercury, gr. -£$, three times a day, may be given. Salivation is rare in children, but diar- rhoea may be started. Locally, calomel powder or a calomel ointment is the best application for fissures, ulcers, and condylomata. In the tertiary stage large doses of iodide of potassium are to be given. Through all treatment special care should be given to hygiene and food,, and the use of iron from time to time is to be recommended. INDEX. A. Abdomen at birth, 19 Abscess, alveolar, 80 ischio-rectal, 138 peritonsillar, 85 retro-oesophageal, 89 retropharyngeal, 81 Addison's disease, 204 diagnosis of, 205 etiology of, 204 pathology of, 205 prognosis of, 205 symptoms of, 205 treatment of, 205 Adenitis, acute, 306 diagnosis of, 307 etiology of, 306 pathology of, 306 prognosis of, 307 symptoms of, 306 treatment of, 307 chronic. 307 diagnosis of, 308 etiology of, 308 pathology of, 308 prognosis of, 308 symptoms of, 308 treatment of, 308 tubercular, 308 diagnosis of, 310 etiology of, 308 pathology of, 309 prognosis of, 310 symptoms of, 309 t real menl of, 310 Adenoids of naso-pharynx, 83 Adhsesia linguse, 7:» treatmenl of, 79 Amyloid liver, 1 16 pathology of, 1 16 symptoms of, 1 16 treatment of. 1 Hi Anemia, pernicious, 199 diagnosis of, 200 $ 21-D. C, Anaemia, pernicious, etiology of, 199 pathology of, 199 prognosis of, 200 symptoms of, 200 treatment of, 200 secondary, 198 diagnosis of, 199 etiology of, 198 pathology of, 198 prognosis of, 199 symptoms of, 198 treatment of, 199 simple, 197 diagnosis of, 198 etiology of, 197 pathology of, 197 physical signs of, 197 prognosis of, 198 symptoms of, 197 treatment of, 198 Anus, diseases of, 135 acute proctitis, 139 fissura ani, 137 fistula in ano, 138 hemorrhoids, 137 ischio-rectal abscess, 138 prolapsus ani, 136 pruritus ani, 135 Appendicitis, 119 causes of, 119 diagnosis of, 121 etiology of, 119 pathology of, 119 prognosis of, 122 symptoms of, 120 treatment of, 122 Arteries and veins, diseases of, 193 acute phlebitis, L94 Chronic endarteritis, 193 Arthrii is, acute, 324 diagnosis of, 32 1 etiology of, 324 pathology of, 324 prognosis of, 325 symptoms of, 324 369 370 INDEX. Arthritis, acute, treatment of, 325 Asphyxia in the new-born, 31 treatment of, 31 Asthma, 243 diagnosis of, 244 etiology of, 244 physical signs of, 244 prognosis of, 244 symptoms of, 244 treatment, of, 244 Autumnal catarrh, 219 B. Balanitis, 270 etiology of, 270 symptoms of, 270 treatment of, 270 Bladder, extrophy of, in the new-born, 41 treatment of, 41 stone in, 358 Biliary calculi (see Calculi, Biliary). Blood, diseases of, 196 Addison's disease, 204 haemophilia, 205 leukaemia, 201 pernicious anaemia, 199 pseudoleukemia, 202 purpura, 207 secondary anaemia, 198 simple anaemia, 197 in early infancy, 196 Bones, diseases of, 324 acute arthritis, 324 hip disease, 327 knee-joint disease, 329 Pott's disease, 325 tubercular dactylitis, 330 Brachial paralysis in the new-born, treatment of, 34 Bronchi, diseases of, 232 Bronchitis, acute, 232 diagnosis of, 233 etiology of, 232 pathology of, 232 physical signs of, 233 prognosis of, 233 symptoms of, 232 treatment of, 233 chronic, 234 diagnosis of, 234 etiology of, 234 pathology of, 234 physical signs of, 234 prognosis of, 234 Bronchitis, chronic, symptoms of, 234 treatment of, 234 fibrinous 234 diagnosis of, 235 pathology of, 235 prognosis of, 235 symptoms of, 235 treatment of, 235 Broncho-pneumonia, 235 diagnosis of, 237 etiology of, 235 pathology of, 236 physical signs of, 237 prognosis of, 237 symptoms of, 237 treatment of, 238 c. Calculi, biliary, 149 diagnosis of, 151 etiology of, 150 pathology of, 150 prognosis of, 151 symptoms of, 150 treatment of, 151 renal, 267 diagnosis of, 268 prognosis of, 268 symptoms of, 267 treatment of, 268 Capillaries, diseases of, 195 Caput succedaneum, 19 Cardiac neuroses, 192 Catarrhal croup, 222 fever, 354 Cephalhematoma, treatment of, 33 Cerebral abscess, 284 diagnosis of, 285 etiology of, 284 pathology of, 285 prognosis of, 286 symptoms of, 285 treatment of, 286 hemorrhage in the new-born, 32 symptoms of, 32 treatment of, 33 palsies, infantile, 288 diagnosis of, 289 etiology of, 288 pathology of, 288 prognosis of, 290 symptoms of, 289 treatment of, 290 tumors, 286 . diagnosis of, 2S7 INDEX. 37 J Cerebral tumors, etiology of, 286 pathology of, 286 prognosis of, 288 symptoms of, 286 treatment of, 288 Chicken-pox, 334 Cholera infantum, 103 diagnosis of, 105 etiology of, 104 pathology of, 104 prognosis of, 106 symptoms of, 104 treatment of, 106 Chorea, 298 diagnosis of, 299 etiology of, 298 pathology of, 299 prognosis of, 299 symptoms of, 299 treatment of, 300 Circulation at birth, 17 Circulatory system, diseases of the, 179 Cirrhosis of liver, 147 etiology of, 147 pathology of, 147 prognosis of, 148 symptoms of, 147 treatment of, 148 Cleft palate in the new-born, 39 Club-foot, 40 Colic, 122 diagnosis of, 123 etiology of, 122 pathology of, 123 prognosis of, 123 symptoms of, 123 treatment of, 123 Congestion, acute, of liver, 143 symptoms of, 143 treatment of, 143 chronic, of liver. 1 13 symptoms of, 144 treatment of, 144 Constipation, 124 etiology of, L2 1 prognosis of, 125 symptoms of, L25 treatmenl of, 125 ( Ion vulsions, 293 diagnosis of, 294 etiology of, 293 pathology of, 293 prog Qosis of, 29 1 symptoms of, 293 treatment of, ~'94 Cretinism, 291 diagnosis of, 292 etiology of, 291 prognosis of, 292 symptoms of, 291 treatment of, 292 Croup, catarrhal, 222 membranous, 225 Cryptorchidism in the new-born, 41 treatment of, 41 Cysts, pancreatic, 152 etiology of, 152 symptoms of, 152 r>. Decimal cream, 64 Coit's, 63 Diabetes insipidus, 259 diagnosis of, 259 etiology of, 259 pathology of, 259 I>rognosis of, 260 symptoms of, 259 treatment of, 260 mellitus. 174 diagnosis of, 175 etiology of, 174 pathology of, 174 prognosis of, 175 symptoms of, 175 , treatment of, 175 Diarrhoea, acute fermental, 98 diagnosis of, 100 etiology of, 98 pathology of, 99 prognosis of, 100 prophylaxis, 100 symptoms (if, 99 treatment of, 101 irritative, 95 etiology of, 96 pathology of, 97 prognosis of, 97 symptoms of. 97 treatmenl of. 97 Dig< -i ive sj stem, diseases of. 7:; Dilatation of stomach, diagnosis of, 95 i-i iology of, 95 pal hologj of, 95 prognosis of, 95 symptoms of. 96 treatment of. 96 Diphtheria, 31 1 abnormal cases, '■'• 16 372 INDEX. Diphtheria, diagnosis of, 347 etiology of, 344 incubation-period, 345 pathology of, 344 prognosis of, 347 pseudo-, 346 sequelae of, 346 symptoms of, 345 treatment of, 347 E. Ear, diseases of, 321 acute otitis, 321 chronic otitis, 323 Eczema, 315 diagnosis of, 316 etiology of, 315 prognosis of, 317 symptoms of, 316 treatment of, 317 Empyema, 250 diagnosis of, 251 etiology of, 250 pathology of, 250 prognosis of, 251 symptoms of, 250 treatment of, 251 Endarteritis, chronic, 193 etiology of, 193 pathology of, 193 prognosis of, 193 symptoms of, 193 treatment of, 193 Endocarditis, acute, 183 diagnosis of, 184 etiology of, 183 pathology of, 183 physical signs of, 184 prognosis of, 184 symptoms of, 183 treatment of, 185 chronic, 186 diagnosis of, 189 etiology of, 186 pathology of, 187 physical signs of, 188 prognosis of, 189 symptoms of, 187 treatment of, 190 malignant, 185 diagnosis of, 186 etiology of, 185 pathology of, 185 physical signs of, 186 prognosis of, 186 Endocarditis, malignant, symptoms of, 185 treatment of, 186 Enteritis, chronic tubercular, 118 diagnosis of, 118 etiology of, 118 pathology of, 118 prognosis of, 119 symptoms of, 118 treatment of, 119 Entero-colitis, acute, 111 diagnosis of, 114 etiology of, 111 pathology of, 111 prognosis of, 114 symptoms of, 113 treatment of, 114 chronic, 116 diagnosis of, 117 etiology of, 116 pathology of, 116 prognosis of, 117 symptoms of, 116 treatment of, 117 Enuresis, 257 diagnosis of, 257 etiology of, 257 prognosis of, 257 symptoms of, 257 treatment of, 257 Epilepsy, 296 diagnosis of, 297 etiology of, 296 pathology of, 296 prognosis of, 298 symptoms of, 296 treatment of, 298 Epispadias in the new-born, 40 Epistaxis, 210 diagnosis of, 211 etiology of, 210 pathology of, 210 prognosis of, 211 symptoms of, 210 treatment of, 211 Erb's paralysis, 34 Erysipelas, 342 complications of, 343 diagnosis of, 343 etiology of, 342 pathology of, 342 prognosis of, 343 symptoms of, 343 treatment of, 343 Eyes at birth, 21 infection of, 21 INDEX. 373 F. Facial paralysis in new-born, ment of, 34 Fatty liver, 145 symptoms of, 146 treatment of, 146 Fissura ani, 137 etiology of, 137 symptoms of, 138 treatment of, 138 Fistula in ano, 138 etiology of, 139 symptoms of, 139 treatment of, 139 congenital, of neck, 88 Fontanelles at birth, 19 Friedreich's ataxia, 276 diagnosis of, 277 etiology of, 276 pathology of, 277 prognosis of, 277 symptoms of, 277 treatment of, 277 Functional albuminuria, 260 diagnosis of, 260 etiology of, 260 pathology of, 260 prognosis of, 260 symptoms of, 260 treatment of, 260 Furunculosis, 313 diagnosis of, 314 etiology of, 313 symptoms of, 313 treatment of, 314 G. Gastritis, acute, 91 etiology of, 91 pathology of, 91 prognosis of, 92 symptoms of, 91 I reatment of, 92 chronic, 93 etiology of, 93 pathology of, 94 prognosis of, !»l symptoms of, 91 t real men I of, 95 Gasl ro-duodenil is, 92 etiology of, 92 pathology of, !•:'• prognosis of, 93 treat- Gastro-duodenitis, symptoms of, 93 treatment of, 93 Genito-urinary system, diseases of, 257 acute degeneration of kidneys, 261 diffuse nephritis, 263 exudative nephritis, 261 balanitis, 270 chronic diffuse nephritis, 264 diabetes insipidus, 259 enuresis, 257 functional albuminuria, 260 perinephritis, 268 phimosis, 269 polyuria, 259 pyelitis, 266 renal calculi, 267 tumors of kidney, 265 vesical calculus, 258 vulvo-vaginitis, 270 German measles, 337 H. Hemoglobinuria, epidemic, 35 Haemophilia, 205 diagnosis of, 206 etiology of, 205 pathology of, 206 prognosis of, 206 symptoms of, 206 treatment of, 206 Hare-lip in the new-born, 39 Hay asthma, 219 fever, 219 diagnosis of, 220 etiology of, 219 pathology of, 219 prognosis of, 220 symptoms of, 219 treatment of, 220 Head at birth, 19 Headaches, 302 diagnosis of, 302 etiology of, 302 pathology of, 302 symptoms of, 302 treatment of, 302 Hearing, normal development of, 28 Heart disease, congenital, 179 diagnosis <>r, 180 etiology of, 179 pathology of, I T«> prognosis of, l B0 symptoms of, 180 374 INDEX. Heart disease, treatment of, 180 and pericardium, diseases of, 179 acute endocarditis, 183 myocarditis, 191 pericarditis, 181 cardiac neuroses, 192 chronic endocarditis, 186 pericarditis, 182 malignant endocarditis, 185 Hemorrhoids, 137 etiology of, 137 treatment of, 137 Hepatitis, suppurative, 144 diagnosis of, 145 etiology of, 144 prognosis of, 145 symptoms of, 145 treatment of, 145 Hernia, umbilical, in the new-born, 37 Hip disease, 327 diagnosis of, 329 etiology of, 327 pathology of, 327 prognosis of, 329 symptoms of, 328 treatment of, 329 Hives, 318 Hodgkin's disease, 202 Hydatids of liver, 148 diagnosis of, 149 etiology of, 148 pathology of, 148 physical signs of, 149 prognosis of, 149 symptoms of, 149 treatment of, 149 Hydrocephalus, 283 diagnosis of, 284 etiology of, 283 pathology of, 283 prognosis of, 284 symptoms of, 283 treatment of, 284 Hypospadias in the new-born, 40 Hysteria, 300 diagnosis of, 301 etiology of, 300 pathology of, 300 prognosis of, 301 symptoms of, 300 treatment of, 301 Ichthyosis, 311 etiology of, 311 Ichthyosis, pathology of, 311 prognosis of, 312 symptoms of, 311 treatment of, 312 Icterus, 31 Idiocy and imbecility, 290 diagnosis of, 291 difference between, 290 prognosis of, 291 symptoms of, 290 treatment of, 291 Imperforate rectum, 40 Impetigo contagiosa, 314 diagnosis of, 315 etiology of, 314 prognosis of, 315 symptoms of, 314 treatment of, 315 Indigestion, acute gastric, 90 etiology of, 90 pathology of, 90 symptoms of, 90 treatment of, 91 chronic intestinal, 107 diagnosis of, 109 etiology of, 107 pathology of, 108 prognosis of, 109 symptoms of, 108 treatment of, 109 Infant at birth, 17 abdomen of, 19 bathing of, 20 circulation, 17 clothing of, 21 examination of, for abnormalities, 21 eyes of, 21 food of, 22 head of, 19 intestines of, 19 kidneys of, 20 length of, 18 mouth of, 21 premature and delicate, 22 respiration, 17 skin, 18 sleep of, 22 temperature, 18 thorax of, 19 umbilical cord of, 20 weight of, 19 feeding of, 43 artificial, 58 care of bottles and nipples, 62 home modifications, 63 INDEX. 375 Infant, feeding of, artificial, prepa- ration of cows' milk for, 59 rules for, 60 during fourth year, 72 second year, 71 third year, 72 mixed, 53 foods, 69 barley-water, 71 beef-juice, 71 broths, 71 egg-water, 71 malted milk, 69 Mellins' food, 69 oatmeal-water, 71 peptonized milk, 70 rice-water, 71 scraped beef, 71 whey, 70 new-born, diseases of, 31 asphyxia, 31 cephalhematoma, 33 cerebral hemorrhage, 32 cleft palate, 39 club-foot, 40 cryptorchidism, 41 epidemic hemoglobinuria, 35 epispadias, 40 extrophy of bladder, 41 granuloma of umbilicus, 36 hare-lip, 39 hydrocephalus, 38 hypospadias, 40 icterus, 31 imperforate rectum, 40 mastitis, 37 rnelrena, 36 meningocele, 38 obstetrical paralysis, 33 ophthalmia, 32 pemphigus, '■'><> sclerema, 37 sepsis, 34 spina bifida, 39 tetanus, ::•""> umbilical hernia, 37 normal Meningitis, acute. 279 diagnosis of, 280 etiology of, 279 pathology of, 280 prognosis of, 281 Bymptome of, 280 treatmenl of, 281 tubercular, 281 diagii'i- ; - -'- ' etiology of, 281 Meningitis, tubercular, pathology of, 281 prognosis of, 283 symptoms of, 282 treatment of, 283 Meningocele, of the new-born, 38 symptoms of, 39 treatment of, 39 Mellins' food, 69 Middle ear, inflammation of, 321 Miliaria, 312 diagnosis of, 313 etiology of, 312 pathology of, 312 symptoms of, 313 treatment of, 313 Milk, age of, 52 condensed, 67 as a food, 68 cows', 54 care of, 56 chemical composition of, 55 comparison of, with woman's, 55 fat in, 55 germ-life in, 56 method of examination of, 67 pasteurization of, 57 method of, 58 proteids of, 55 salts in, 56 sterilization of, 57 methods of, 57 sugar in, 55 laboratories, 62 advantages of, 63 malted, 69 peptonized, 70 quantity of, causes affecting, 53 saccharated skimmed, 64 woman's, 43 characteristics, 43 chemical composition, 43 clinical analysis of, l!» Holt's test, 49 colostrum, 45 fat in, 44 ingredients in, changing of, 50 proteids of, 43 quantity of, daily, 45 salts in, 44 sugar in, 44 water in, 44 Mouth at birth. :.'! diseases of, 73 adhresia linguae, 79 alveolar abscess, 80 378 INDEX. Mouth, diseases of, catarrhal stoma- titis, 73 croupous stomatitis, 73 follicular stomatitis, 74 gangrenous stomatitis, 77 ranula, 79 thrush, 76 ulcerative stomatitis, 75 Mumps, 353 complications of, 352 diagnosis of, 353 etiology of, 353 incubation-period of, 353 pathology of, 353 prognosis of, 354 symptoms of, 353 treatment of, 354 Muscular atrophy, progressive, 277 diagnosis of, 278 pathology of, 277 prognosis of, 278 symptoms of, 277 treatment of, 278 paralysis, pseudo-hypertrophic, 278 diagnosis of, 279 etiology of, 278 pathology of, 278 prognosis of, 279 symptoms of, 278 treatment of, 279 Myelitis, transverse, 275 diagnosis of, 276 etiology of, 275 pathology of, 275 prognosis of, 276 symptoms of, 276 treatment of, 276 Myocarditis, acute, 191 diagnosis of, 191 etiology of, 191 pathology of, 191 prognosis of, 191 symptoms of, 191 treatment of, 191 N. Nsevus, 195 diagnosis of, 196 etiology of, 195 pathology of, 195 prognosis of, 196 symptoms of, 195 treatment of, 196 Nasal polypi, 218 diagnosis of, 219 Nasal polypi, etiology of, 218 pathology of, 218 prognosis of, 219 symptoms of, 218 treatment of, 219 Naso-pharynx, adenoids of, 83 etiology of, 83 pathology of, 83 prognosis of, 84 symptoms of, 83 treatment of, 84 Neck, congenital fistula of, 88 Nephritis, acute diffuse, 263 diagnosis of, 263 etiology of, 263 pathology of, 263 prognosis of, 263 symptoms of, 263 treatment of, 263 exudative, 261 diagnosis of, 262 etiology of, 261 pathology of, 261 prognosis of, 262 symptoms of, 262 treatment of, 262 chronic diffuse, 264 diagnosis of, 261 etiology of, 264 pathology of, 264 prognosis of, 265 symptoms of, 264 treatment of, 265 Nervous system, diseases of, 272 acute anterior poliomyelitis, 273 meningitis, 279 bad habits, 305 cerebral abscess, 284 palsies, infantile, 288 tumors, 286 chorea, 298 convulsions, 293 cretinism, 291 epilepsy, 296 Friedreich's ataxia, 276 headaches, 302 hydrocephalus, 283 hysteria, 300 idiocy and imbecility, 290 peripheral neuritis, 272 progressive muscular atrophy, 277 pseudo-hypertrophic muscular paralysis, 278 sleep-disorders, 304 speech-disorders, 303 INDEX. 379 ■Nervous system, tetany, 295 transverse myelitis, 275 tubercular meningitis, 281 Nettle-rash, 318 Neuritis, peripheral, 272 diagnosis of, 272 etiology of, 272 pathology of, 272 prognosis of, 273 symptoms of, 272 treatment of, 273 Neuroses, cardiac, 192 diagnosis of, 192 etiology of, 192 pathology of, 192 prognosis of, 192 symptoms of, 192 treatment of, 193 Nose, diseases of, 210 acute rhinitis, 211 atrophic rhinitis, 215 chronic rhinitis, 213 epistaxis, 210 hay fever, 219 hypertrophic rhinitis, 214 membranous rhinitis, 216 nasal polypi, 218 syphilitic rhinitis, 217 Nursing women, diet for, 49 drugs for, 50 exercise for, 50 Nutrition, disorders of, 161 acute rheumatism, 175 diabetes mellitus, 174 malnutrition, 161 marasmus, 163 rachitis, 168 scorbutus, 166 o. (Edema glottidis, 231 diagnosis of, 231 el iology of, 231 pathology of, 231 prognosis of, 231 symptoms of, 231 treatmenl of, 231 < Ksopliagitis, acute, SS etiology of. ss symptoms of, 88 treatmenl of, 88 Ophthalmia, 32 symptoms of, '■'•'' t reatmeni of, 32 Otitis, acute, 321 Otitis, acute, diagnosis of, 322 etiology of, 321 pathology of, 321 prognosis of, 322 symptoms of, 321 treatment of, 322 chronic, 323 diagnosis of, 323 etiology of, 323 pathology of, 323 prognosis of, 323 symptoms of, 323 treatment of, 323 Otorrhcea, chronic, 323 P. Pancreas, diseases of, 152 Pemphigus in the new-born, 36 Pericarditis, acute, 181 diagnosis of, 181 etiology of, 181 pathology of, 181 physical signs, 181 prognosis of, 181 symptoms of, 181 treatment of, 182 chronic, 182 pathology of, 182 physical signs of, 183 prognosis of, 183 symptoms of, 182 treatment of, 183 Perinephritis, 268 diagnosis of. 269 etiology of, 268 pathology of, 268 prognosis of, 269 symptoms of, 269 treatment of, 269 Peritoneum, diseases of, 153 acute peritonitis, 153 chronic peritonitis, 157 tubercular peritonitis, 158 Peritonitis, acute, 153 diagnosis of, 155 etiology of, 153 pathology of, 154 prognosis of, 155 symptoms of, 154 treatment of, 155 chronic, 157 diagnosis of, 157 el iology of, 157 pathology of, 157 prognosis of, 158 380 INDEX. Peritonitis, chronic, symptoms of, 157 treatment of, 158 tubercular, 158 etiology of, 158 pathology of, 158 prognosis of, 160 symptoms of, 159 treatment of, 160 Peritonsillar abscess, 85 etiology of, 85 pathology of, 86 prognosis of, 86 symptoms of, 86 treatment of, 86 Pharyngitis, acute, 80 diagnosis of, 81 etiology of, 80 pathology of, 80 symptoms of, 80 treatment of, 81 local, 81 chronic, 81 treatment of, 81 Phimosis, 269 symptoms of, 270 treatment of, 270 Phlebitis, acute, 194 diagnosis of, 194 etiology of, 194 pathology of, 194 prognosis of, 194 symptoms of, 194 treatment of, 194 Pleura, diseases of, 232 Pleurisy, dry, 247 diagnosis of, 247 etiology of, 247 pathology of, 247 physical signs of, 247 prognosis of, 247 symptoms of, 247 treatment of, 248 with effusion, 248 diagnosis of, 249 etiology of, 248 pathology of, 248 physical signs of, 249 prognosis of, 249 symptoms of, 248 treatment of, 249 Pneumonia, broncho-, 235 lobar, 239 diagnosis of, 241 etiology of, 239 pathology of, 239 physical signs of, 240 Pneumonia, lobar, prognosis of, 241 symptoms of, 240 treatment of, 241 interstitial, 241 diagnosis of, 242 etiology of, 241 pathology of, 242 physical signs of, 242 prognosis of, 242 symptoms of, 242 treatment of, 242 Poliomyelitis, acute anterior, 273 diagnosis of, 274 etiology of, 273 pathology of, 274 prognosis of, 275 symptoms of, 274 treatment of, 275 Polypus recti, 140 pathology of, 140 symptoms of, 140 treatment of, 140 Pott's disease, 325 diagnosis of, 326 etiology of, 325 pathology of, 325 prognosis of, 326 symptoms of, 325 treatment of, 327 Proctitis, acute, 139 etiology of, 139 symptoms of, 139 treatment of, 140 Prolapsus ani, 136 diagnosis of, 136 etiology of, 136 symptoms of, 136 treatment of, 136 Pruritus ani, 135 etiology of, 135 treatment of, 136 Pseudoleukemia, 202 diagnosis of, 204 etiology of, 203 pathology of, 203 prognosis of, 204 symptoms of, 203 treatment of, 204 Pulmonary atelectasis, 246 diagnosis of, 247 etiology of, 246 pathology of, 246 physical signs, 246 prognosis of, 247 symptoms of, 246 treatment of, 247 INDEX. 381 Pulmonary emphysema, 243 diagnosis of, 243 etiology of, 243 pathology of, 242 physical signs of, 243 prognosis of, 243 symptoms of, 243 treatment of, 243 gangrene, 245 diagnosis of, 245 etiology of, 245 pathology of, 245 physical signs of, 245 prognosis of, 246 symptoms of, 245 treatment of, 246 Pulse at birth, 18 Purpura, 207 diagnosis of, 208 etiology of, 207 haemorrhagica, 208 pathology of, 207 prognosis of, 209 rheumatica, 208 symptoms of, 207 treatment of, 209 Pyelitis, 266 diagnosis of, 267 etiology of, 266 pathology of, 266 prognosis of, 267 symptoms of, 267 treatment of, 267 R. Rachitis, 168 diagnosis of, 173 etiology of, 168 pathology of, 169 prognosis of, 173 symptoms of, 170 treatment of, 173 Banula, 7!> symptoms of, 79 i reatment of, 79 Rectum, diseases of, 135 acute proctitis, 139 fissura ani, 137 fistula in aim, 138 hemorrhoids, 137 ischio-rectal abscess, 138 prolapsus ani, L36 pruritus ani. 135 imperforate, 40 Remittent fever, :'.';i R< i j . 1 1 calculi see < 'alcitli, Ilcnal). Respiration at birth, 17 aids to, 17 how established, 17 rate of, 17 Respiratory system, diseases of, 210 Retro-cesophageal abscess, 89 etiology of, 89 symptoms of, 89 Retro-pharyngeal abscess, 81 diagnosis of, 82 etiology of, 82 pathology of, 82 prognosis of, 82 treatment of, 82 Rheumatism, acute, 175 diagnosis of, 177 etiology of, 175 pathology of, 176 prognosis of, 177 symptoms of, 176 treatment of, 177 Rhinitis, acute, 211 diagnosis of, 212 etiology of, 211 pathology of, 212 prognosis of, 212 symptoms of, 212 treatment of, 212 atropine, 215 diagnosis of, 215 etiology of, 215 pathology of, 215 prognosis of, 216 symptoms of, 215 treatment of, 216 chronic, 213 diagnosis of, 213 etiology of, 213 prognosis of, 213 symptoms of, 213 treatment of, 214 hypertrophic, 214 diagnosis of, 214 etiology of, 214 pathology of, 214 prognosis of, 215 symptoms of. 214 treatment of, 215 membranous, 216 diagnosis of, 217 etiology of, •.'in pathology of, 216 prognosis of, 217 symptoms of, 216 treatment of, 217 syphilitic, 217 382 INDEX. Ehinitis, syphilitic, diagnosis of, 218 etiology of, 217 pathology of, 217 prognosis of, 218 symptoms of, 218 treatment of, 218 King-worm, 319 Rose cold, 219 Rotheln, 337 diagnosis of, 337 etiology of, 337 incubation-period of, 337 prognosis of, 337 symptoms of, 337 treatment of, 337 Rubella, 337 S. Scabies, 318 diagnosis of, 319 etiology of, 318 pathology of, 319 prognosis of, 319 symptoms of, 319 treatment of, 319 Scarlatina, 337 < Scarlet fever, 337 complications of, 339 diagnosis of, 340 etiology of, 338 incubation-period of, 338 patbology of, 338 prognosis of, 341 symptoms of, 338 treatment of, 341 Sclerema in the new-born, 37 treatment of, 37 Scorbutus, 166 diagnosis of, 167 etiology of, 166 pathology of, 166 prognosis of, 168 symptoms of, 166 treatment of, 168 Seborrhcea, 312 etiology of, 312 symptoms of, 312 treatment of, 312 Sepsis in the new-born, 34 symptoms of, 34 treatment of, 34 Sight, normal development of, 28 Skin at birth, 18 desquamation of, 18 lanugo, 18 Skin at birth, vernix caseosa, 18 diseases of, 311 eczema, 31") furunculosis, 313 ichthyosis, 311 impetigo contagiosa, 314 lentigo, 311 miliaria, 312 scabies, 318 seborrhcea, 312 tinea trichopliytina, 319 urticaria, 31« Sleep-disorders, 304 diagnosis of, 304 etiology of, 304 prognosis of, 304 symptoms of, 304 treatment of, 304 Smell, normal development of, 29 Spasmodic contractions, 293 Speech-disorders, 303 varieties of, 303 late development, 303 lisping, 303 stuttering, 303 aphasia, 303 Speech, normal development of, 29 Spina bifida, 39 symptoms of, 39 treatment of, 39 Spleen, diseases of, 152 enlargement of, 153 treatment of, 153 Stomach, diseases of, 90 acute gastric indigestion, 90 acute gastritis, 91 chronic gastritis, 93 dilatation of, 95 gastro-duodenitis, 92 ulcer of, 96 Stomatitis, croupous, 78 etiology of, 78 pathology of, 79 symptoms of, 79 treatment of, 79 catarrhal, 73 etiology of, 73 pathology of, 73 prognosis of, 73 symptoms of, 73 treatment of, 73 follicular, 74 etiology of, 74 • pathology of, 74 prognosis of, 74 symptoms of, 74 INDEX. 383 Stomatitis, follicular, treatment of, 74 gangrenous, 77 etiology of, 77 pathology of, 77 prognosis of, 78 symptoms of, 77 treatment of, 78 ulcerative, 75 etiology of, 75 pathology of, 75 prognosis of, 75 symptoms of, 75 treatment of, 75 Strabismus in infant at birth, 21 Sucking, 25 Sugar solution, 65 Syphilis, 363 diagnosis of, 369 etiology of, 363 forms of, 363 pathology of, 364 prognosis of, 366 symptoms of, 364 treatment of, 367 T. Taste, normal development of, 29 Teeth, early, 27 milk, 26 second, 27 Temperature at birth, 18 Tetanus in the new-born, 35 symptoms of, 35 treatment of, 35 Tetany, 295 diagnosis of, 296 etiology of, 295 pathology of, 295 prognosis of, 296 symptoms of, 295 treatment of, 296 Thorax at birth, 19 Throat, diseases of, 80 acute follicular tonsillitis, 84 oesophagitis, 88 pharyngitis, 80 adenoids of naso-pharynx, 83 chronic pharyngitis, 81 tonsillil is, B7 congenital fistula of neck, 38 peritonsillar abscess, 86 retro-oesophageal abscess, 89 rel ro-pharyngeal abscess, -l foreign bodies in, B9 Thrush, 76 Thrush, etiology of, 76 pathology of, 76 prognosis of, 77 symptoms of, 76 treatment of, 77 Tinea trichophytina, 319 diagnosis of, 320 etiology of, 319 prognosis of, 320 symptoms of, 319 treatment of, 320 Tonsillitis, acute follicular, 84 etiology of, 84 pathology of, 84 prognosis of, 85 symptoms of, 85 treatment of, 85 chronic, 87 etiology of, 87 pathology of, 87 symptoms of, 87 treatment of, 87 Tonsils, hypertrophy of, 97 Touch, normal development of, 28 Treatment of acute adenitis, 307 anterior poliomyelitis, 275 arthritis, 325 bronchitis, 233 catarrhal laryngitis, 224 congestion of liver, 143 degeneration of kidneys, 261 diffuse nephritis, 263 endocarditis, 185 entero-colitis, 114 exudative nephritis, 262 fermental diarrhoea, 101 follicular tonsillitis, 85 gastric indigestion. 90 gastritis, 92 irritative diarrhoea, 97 meningitis, 281 myocarditis, 191 oesophagitis, 88 otitis, 322 pericarditis, 182 peritonitis, 155 pharyngitis, 81 phlebitis, 191 proctitis, 1 10 pulmonary tuberculosis, 253 rheumal ism, 177 rhiiiii is, •.'I'.' ill' Addison's disease, 205 hi' adenoids of naso-pharynx, 84 nl' adhsesia linguse, 79 ill' amyloid liver, 1 16 384 INDEX. Treatment of appendicitis, 122 of asphyxia in the new-born, 31 of asthma, 244 of atrophic rhinitis, 216 of balanitis, 270 of biliary calculi, 151 of brachial paralysis in the new- born, 34 of broncho-pneumonia, 238 of cardiac neuroses, 193 of catarrhal stomatitis, 73 of cephalliEematonia, 33 of cerebral abscess, 286 hemorrhage in the new-born, 33 palsies, infantile, 290 tumors, 288 of cholera infantum, 106 of chorea, 300 of chronic adenitis, 308 bronchitis, 234 congestion of liver, 144 diffuse nephritis, 265 endarteritis, 193 endocarditis, 190 entero-colitis, 117 gastritis, 95 intestinal indigestion, 109 laryngitis, 229 otitis, 323 pericarditis, 183 peritonitis, 158 pharyngitis, 81 pulmonary tuberculosis, 255 rhinitis, 214 tonsillitis, 87 tubercular enteritis, 119 of cirrhosis of liver, 148 of cleft palate, 39 of colic, 123 of constipation, 125 of convulsions, 294 of cretinism, 292 of croupous stomatitis, 79 of cryptorchidism, 41 of diabetes insipidus, 260 of mellitus, 175 of dilatation of stomach, 96 of diphtheria, 347 of dry pleurisy, 248 of eczema, 317 of empyema, 251 of enlargement of spleen, 153 of enuresis, 257 of epilepsy, 298 of epistaxis, 211 of erysipelas, 343 Treatment of extrophy of bladder in the new-born, 41 of facial paralysis in the new-born, 34 of fatty liver, 146 of fibrinous bronchitis, 235 of fissura ani, 138 of fistula in ano, 139 of follicular stomatitis, 74 of foreign bodies in larynx, 232 of Friedreich's ataxia, 277 of functional albuminuria, 260 disorders of liver, 143 of fiminculosis, 314 of gangrenous stomatitis, 78 of gastro-duodenitis, 93 of granuloma of umbilicus in the new-born, 37 of haemophilia, 206 of hare-lip, 39 of hay fever, 220 of headache, 302 of hemorrhoids, 137 of hip disease, 329 of hydatids of liver, 149 of hydrocephalus, 38, 284 of hypertrophic rhinitis, 215 of hysteria, 301 of ichthyosis, 312 of impetigo contagiosa, 315 of interstitial pneumonia, 242 of intussusception, 129 of ischio-rectal abscess, 138 of jaundice, 142 of knee-joint disease, 330 of la grippe, 356 of lentigo, 311 of leukaemia, 202 of lobar pneumonia, 241 of malaria, 362 of malignant endocarditis, 186 of malnutrition, 162 of marasmus, 165 of mastitis in the new-born, 37 of masturbation, 305 of measles, 336 of melaena in the new-born, 36 of membranous laryngitis, 226 rhinitis, 217 of meningocele of the new-born, 39 of miliaria, 313 of mumps, 354 of naevus, 196 of nasal polypi, 219 of oedema glottidis, 231 of ophthalmia, 32 INDEX. 385 Treatment of papilloma of larynx, 230 of perinephritis, 269 of peripheral neuritis, 273 of peritonsillar abscess, 86 of pernicious anaemia, 200 of phimosis, 270 of pin-worms, 133 of pleurisy with effusion, 249 of polypus recti, 140 of Pott's disease, 327 of progressive muscular atrophy, 278 of prolapsus ani, 136 of pruritus ani, 136 of pseudo-hypertrophic muscular paralysis, 279 of pseudo-leukEemia, 204 of pulmonary atelectasis, 247 emphysema, 243 gangrene, 246 of purpura, 209 of pyelitis, 267 of rachitis, 173 of ranula, 79 of renal calculi, 268 of retropharyngeal abscess, 82 of rotheln, 337 of round worm, 132 of scabies, 319 of scarlet fever, 341 of sclerema in the new-born, 37 of scorbutus, 168 of seborrhoea, 312 of secondary anaemia, 199 of sepsis in the new-born, 34 of simple anremia, 198 of sleep-disorders, 304 of spasmodic laryngitis, 221 of spina bifida, 39 of suppurative hepatitis, 145 of syphilis, 367 of syphilitic rhinitis, 218 of tapeworms, 135 of tetanus in the new-born, 35 of tetany, 296 of thrush, 77 of tinea trichophytina, 320 of transverse myelitis, 276 of tubercular adenitis, 310 dactylitis, 331 meningitis, 283 peritonitis, 160 of tumors of kidney, 266 of typhoid fever, '■'>'>'■> of ulcer of stomach, 96 of ulcerative stomatitis, 75 25- D. C. Treatment of umbilical hernia in the new-born, 37 of urticaria, 318 of vaccination, 333 of varicella, 334 of vulvo-vaginitis, 271 of whooping-cough, 351 Tubercular dactylitis, 330 diagnosis of, 330 prognosis of, 330 symptoms of, 330 treatment of, 331 enteritis, chronic, 118 symptoms of, 118 treatment of, 119 Tuberculosis, pulmonary, acute, 252 diagnosis of, 253 etiology of, 252 pathology of, 252 physical signs of, 253 prognosis of, 253 symptoms of, 252 treatment of, 253 chronic, 254 diagnosis of, 255 etiology of, 254 pathology of, 254 physical signs of, 255 prognosis of, 255 symptoms of, 254 treatment of, 255 Typhoid fever, 356 complications of, 358 diagnosis of, 359 etiology of, 356 incubation-period of, 357 pathology of, 356 prognosis of, 359 symptoms of, 357 treatment of, 359 u. Ulcer of stomach, 96 etiology of, 96 pathology of, 96 prognosis of, 96 symptoms of, 96 treatment of, 96 Umbilical cord, 20 ligation of, 20 pulsation of, 20 hernia in the new-born, 37 Umbilicus, granuloma of, in the new- born, 36 treatment of, 37 386 INDEX. Urticaria, 318 etiology of, 318 prognosis of, 318 symptoms of, 318 treatment of, 318 V. Vaccination, 332 abnormalities of, 333 complications of, 333 method of performance of, 332 symptoms of, 333 time for performance of, 332 treatment of, 333 Varicella, 334 complications of, 334 diagnosis of, 334 etiology of, 334 incubation-period of, 334 prognosis of, 334 symptoms of, 334 treatment of, 334 Vesical calculus, 258 diagnosis of, 259 etiology of, 258 prognosis of, 259 symptoms of, 258 treatment of, 259 Vulvo-vaginitis, 270 diagnosis of, 271 Vulvo-vaginitis, etiology of, 270 symptoms of, 271 treatment of, 271 w. Weaning of infant, 54 Wet-nursing, 51 Whey, 70 Whooping-cough, 349 complications of, 351 diagnosis of, 351 etiology of, 349 incubation-period of, 349 pathology of, 349 physical signs of, 351 prognosis of, 351 symptoms of, 349 treatment of, 351 Worms, pin-, 132 diagnosis of, 133 symptoms of, 133 treatment of, 133 round, 131 diagnosis of, 132 symptoms of, 131 treatment of, 132 tape, diagnosis of, 135 habitat, 134 varieties, 134 CATALOGUE OF PUBLICATIONS OF LEA BROTHERS & COMPANY, ~.Oii, 708 & 710 Sansom St., Philadelphia. 1H Fifth Ave. (Cor. 18th St.), New York. The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the United States, on receipt of the printed prices. INDEX. ANATOMY. Gray, p. 11 ; Treves, 30 ; Gerrish, 11; Brockway, 4. DICTIONARIES. Dunglison, p. 8 ; Duane, 8 ; National, 4. PHYSICS. Draper, p. 8 ; Eobertson, 24 ; Martin & Eockwell, 20. PHYSIOLOGY Foster, p. 10; Chapman, 5; Schofield, 25; Collins & Eockwell, 6. ■ [Luff, 19 ; Eemsen, 24. CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Martin & Eockwell, 20; PHARMACY. Caspari, p. 5. [Bruce, 4 : Schleif, 25. MATERIA MEDICA. Culbretb, p. 6 ; Maisch, 19 ; Farquharson, 9 ; DISPENSATORY. National, p. 21. THERAPEUTICS. Hare, p. 13 ; Fothergill, 10 ; Whitla, 31 ; Hayem & Hare, 14 ; Bruce, 4 ; Schleif, 25 ; Cushny, 6. PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Malsbary, 20. DIAGNOSIS. Musser, p. 21 ; Hare, 12; Simon, 25; Herrick, 15; Hutchi- son & Rainey, 16 ; Collins, 6. CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. NERVOUS DISEASES. Dercum, p. 7 ; Gray, 11 ; Potts, 23. MENTAL DISEASES. Clouston, p. 5 ; Savage, 24 ; Folsom, 10. BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy, 30; Senn's (Surgical), 25. Park, 22 ; Coates, 6. [Vale, 21. HISTOLOGY. Klein, p. 17 ; Schafer's, 25 ; Dunham, 8 ; Nichols & PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Nichols & Vale, 21 SURGERY. Park, p. 22; Dennis, 7; Eoberts, 24; Ashhurst, 3; Treves, 29; Cheyne & Burghard, 5 ; Gallaudet, 10. SURGERY— OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. SURGERY— ORTHOPEDIC. Young, p. 31 ; Gibney, 10. SURGERY— MINOR. Wharton, p. 30. [Ballenger & FRACTURES and DISLOCATIONS. Stimson, p. 27. [Wippern, 3. OPHTHALMOLOGY. Norris & Oliver, p. 21; Nettleship, 21 ; Juler,17; OTOLOGY. Politzer, p. 23; Burnett, 5; Field, 9; Bacon, 4. LARYNGOLOGY and RHINOLOGY. Coakley, p. 6 ; DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri- can System, 2 ; Coleman, 6; Burchard 4. URINARY DISEASES. Eoberts, p. 24 ; Black, 4 ; Morris, 20. VENEREAL DISEASES. Taylor, p. 28 ; Hayden, 14 ; Cornil, 6 ; Likes, 19. SEXUAL DISORDERS. Fuller, p. 10 ; Taylor, 29. DERMATOLOGY. Hyde, p. 16 ; Jackson, 16 ; Pye-Smith, 24 ; Mor- ris, 20 ; Jamieson, 16 ; Hardaway, 12 ; Grindon, 12. GYNECOLOGY. American System, p. 3 ; Thomas & Mnnd6, 29 Emmet, 9 ; Davenport, 7 ; May, 20 ; Dudley, 8 ; Crockett, 6. OBSTETRICS. American System, p. 3 ; Davis, 7 ; Parvin, 22 ; Play- fair. 23 ; King, 17 ; Jewett, 17 ; Evans, 9. PEDIATRICS. Smith, p. 26 ; Thomson, 29 ; Williams, 31 ; Tuttle, 30. HYGIENE. Egbert, p. 9 ; Richardson, 24 ; Coates, 6. MEDICAL JURISPRUDENCE. Taylor, p. 28. QUIZ SERIES, POCKET TEXT-BOOKS and MANUALS. Pp. 18, 25 and 27. 9.1.9 2 Lea Beothees & Co., Philadelphia and New Yoek. ABBOTT (A. O.). PRINCIPLES OF BACTERIOLOGY: a Practical Manual for Students and Physicians. New (5th) edition thoroughly revised and greatly enlarged. In one handsome 12mo. vol. of 585 pages, with 109 engrav., of which 26 are colored. Just ready. Cloth, $2.75, net. One of its most attractive charac- cessfully. 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Handsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.75, net. Lea Brothers & Co., Philadelphia and New York. 7 DAI/TON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, $5 ; leather, $6. DOCTRINES OF THE CIRCULATION OF THE BLOOD. In one handsome 12mo. volume of 293 pages. Cloth, DAVENPORT (P. H.). DISEASES OF WOMEN. A Manual of Gynecology. For the use of Students and Practitioners. New (3d) edition. In one handsome 12mo. volume of 387 pages, with 150 illustrations. Cloth, $1.75, net. Just ready. DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR STUDENTS AND PRACTITIONERS. In one very handsome octavo volume of 546 pages, with 217 engravings and 30 full-page plates in colors and monochrome. Cloth, $5; leather, $6. This work must become the prac- titioner's text-book as well as the student's. It is up to date in every respect. — Va. Med. Semi-Monthly. A Avork unequalled in excellence. — The Chicago Clinical Review. 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It is worthy of the position which surgery has attained in the great Republic whence it comes. — The London Lancet. It may be fairly said to represent the most advanced condition of American surgery and is thoroughly practical. — Annals of Surgery. No work in English can be con- sidered as the rival of this. — The American Journal of the Medical Sciences. DERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON NERVOUS DISEASES. By American Authors. In one handsome octavo volume of 1054 pages, with 341 engravings and 7 colored plates. Cloth, $6.00; leather, $7.00. Net. Representing the actual status of The work is representative of the our knowledge of its subjects, and | best methods of teaching, as devel the latest and most fully up-to-date of any of its class. — Jour, of Amer- ican Med. Association. The most thoroughly up-to-date tnalise that we have on this subject. — American. Journal of Insanity. oped in the leading medical colleges of this country.— Alienist and Neu- rologist. The best text-book in any lan- guage.— The Medical Fortnightly. DE SCHWEnSTITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. Their Classification, History, Symptoms, Pathology and Treatment. Very handsome octavo, 240 pages, 46 engravings, and 9 full-page plates in colors. Limited edition, de luxe binding, $4. Net. 8 Lea Brothers & Co., Philadelphia and New York. DRAPER (JOHN C). MEDICAL PHYSICS. A Text-book for Stu- dents arid Practitioners of Medicine. In one handsome octavo volume of 734 pages, with 376 engravings. Cloth, $4. DRUITT (ROBERT). THE PRINCIPLES AND PBACTICE OF MODERN SURGERY. A new American, from the twelfth London edition, edited by Stanley Boyd, F. R. C. S. In one large octavo volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. DUANE (ALEXANDER). THE STUDENT'S DICTIONARY OF MEDICINE AND THE ALLIED SCIENCES. New edition. Com- prising the Pronunciation, Derivation and Full Explanation of Medi- cal Terms, with much Collateral Descriptive Matter. Numerous Tables, etc. Square octavo of 658 pages. Cloth, $3.00 ; half leather, $3.25 ; full sheep, $3.75. Thumb-letter Index, 50 cents extra. convenience and thoroughness. — Medical Record. The best student's dictionary. — Canada Lancet. Far superior to any dictionary for the medical student that we know of. — Western Med. and Surg. Reporter. The book is brought accurately to date. It is a model of conciseness, DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF GYNECOLOGY. Handsome octavo of 652 pages, with 422 illustra- tions in black and colors. Cloth, $5.00, net; leather, $6.00, net. Just ready. tice of modern gynecology. — Inter- national Medical Magazine. The book can be safely recom- mended as a complete and reliable exjtosition of the principles and prac- DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1.50. DUNGL.ISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- ENCE. Containing a full explanation of the various subjects and terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By Robley Dtjnglison, M. D., LL. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. Edited by Richard J. Dunglison, A. M., M. D. Twenty-first edition, thor- oughly revised and greatly enlarged and improved, with the Pronuncia- tion, Accentuation and Derivation of the Terms. With Appendix. In one magnificent imperial octavo volume of 1225 pages. Cloth, $7 ; leather, $8. Thumb-letter Index for quick use, 75 cents extra. The most satisfactoiy and authori- , scarcely be measured. — Med. 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Lea Brothers & Co., Philadelphia and New York:. 9 EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- TATION. In one 12mo. volume of 359 pages, with 63 illustrations. Just ready. Cloth, Net, $2.25. It is written in plain language, ligence. The writer has adapted it and, while primarily designed for to American conditions, and _ his physicians, it can be studied with suggestions are, above all, practical. profit by any one of ordinary intel- — The New York Medical Journal. ELLIS (GEORGE VTNER). DEMONSTRATIONS IN ANATOMY. Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25 ; leather, $5.25. EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 150 original engravings. Cloth, $5 ; leather, $6. ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- GERY. Eighth edition. In two large octavo volumes containing 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American Text-Books of Dentistry, page 2. EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. In one handsome 12mo. volume of about 300 pages, with many illustra- tions. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallaitdet, M. D. See page 18. PARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth American from fourth English edition, revised by Frank Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. FEELD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75. It is just such a work as is needed by every general practitioner. — American Practitioner and News. To those who desire a concise work on diseases of the ear, clear and practical, this manual com- mends itself in the highest degree. FLINT (AUSTEV). A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE. Seventh edition, thoroughly revised by Frederick P. Henry, M.D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5.00 ; leather, $6.00. The work has well earned its lead- I medicine in the medical schools. — ing place in medical literature. — Northwestern Lancet. Medical Record. The best of American text-books _,,,,. . , . t on Practice. — Amer. Medico-Surgical The leading text-book on general j^ u n e n n A MANUAL OF AUSCULTATION AND PERCUSSION ; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M.D. In one handsome 12mo. volume of 274 pages, with 12 engravings. A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE HEART. Second edition enlarged. In one octavo volume of 550 pages. Cloth, $4. A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- EASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. MEDICAL F.SSA VS. In one 12mo. vol. of 210 pages. Cloth, $1.38. ON PHTHISIS: ITS MORBID ANATOMY ETIOLOGY, ETC. A Series of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50. 10 Lea Bbothers & Co., Philadelphia and New Yoek. FOLSOM (C. P.). AN ABSTRACT OF STATUTES OF U. S. ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. Cloth, $1.50. With Clouston on Mevtal Diseases (new edition, see page 6) $5.00, net, for the two works. FORMULARY, POCKET, see page 32. FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New (6th) and revised American from the sixth English edition. In one large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; leather, $5.50. Unquestionably the best book that I This single volume contains all can be placed in the student's hands, i that will be necessary in a college and as a work of reference for the I course, and all that the physician busy physician it can scarcely be , will need as well. — Dominion Med. excelled. — The Phi la. Polyclinic. j Monthly. FOTHERGELL (J. MILNER). THE PRACTITIONER'S HAND- BOOK OF TREATMENT. Third edition. In one handsome octavo volume of 664 pages. Cloth, $3.75 ; leather, $4.75. To have a description of the normal physiological processes of an organ and of the methods of treat- ment of its morbid conditions brought together in a single chapter, and the relations between the two clearly stated, cannot fail to prove a great convenience to many thought- ful but busy physicians. The jDrac- tical value of the volume is greatly increased by the introduction of many prescriptions — New York Med. Jour. POWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- bodying Watts' Physical and Inorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and 1 colored plate. Cloth, $2.75; leather, $3.25. PRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. In one handsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75 ; leather, $4.75. FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- GANS IN THE MALE. In one very handsome octavo volume of 238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. It is an interesting work, and one which, in view of the large and profitable amount of work done in this field of late years, is timely and well needed. — Medical Fortnightly. The book is valuable and instruc- tive and brings views of sound pathology and rational treatment to many cases of sexual disturbance whose treatment has been too often fruitless for good. — ■ Annals of Surgery. FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and Treatment. From second English edition. In one 8vo. volume of 475 pages. Cloth, $3.50. GALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR- GERY. In one handsome 12mo. volume of about 400 pages, with many illustrations. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text- booh, edited by Bern B. Gallaudet, M. D. See page 18. GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75. GD3BES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. GD3NEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- tioners and Students. In one 8vo. vol. profusely illus. Preparing. Lea Bbothebs & Co., Philadelphia and New Yoek. 11 GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. By American Authors. Edited by Frederic H. Gerrish, M. D. In one imp. octavo volume of 915 pages, with 950 illustrations in black and colors. Just ready. Clth, $6.50; flexible waterproof, $7; leath.,$7.50, net. In this, the first representative treatise on Anatomy produced in America, no effort or expense has been spared to unite an authoritative text with the most successful anatomical pictures which have yet appeared in the world. The editor has secured the co-operation of the professors of anatomy in leading medical colleges, and with them has prepared a text conspicuous for its simplicity, unity and judicious selection of such anatomical facts as bear on physiology, surgery and internal medicine in the most compre- hensive sense of those terms. The authors have endeavored to make a book which shall stand iu the place of a living teacher to the student, and which shall be of actual service to the practitioner in his clinical work, emphasizing the most important subjects, clarifying obscurities, helping most in the parts most difficult to learn, and illustrating everything by all available methods. GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. New and thoroughly revised American edition, much enlarged in text, and in engravings in black and colors. In one imperial octavo volume of 1239 pages, with 772 large and elaborate engravings on wood. Price of edition with illustrations in colors : cloth, $7 ; leather, $8. Price of edition with illustrations in black : cloth, $6 ; leather, $7. This is the best single volume upon Anatomy in the English language. — University Medical Mag- azine. Gray's Anatomy affords the student more satisfaction than any other treatise with which we are familiar. — Buffalo Med. Journal. The most largely used anatomical text-book published in the English language. — Annals of Surgery. Particular stress is laid upon the practical side of anatomical teach- ing, and especially the Surgical Anatomy. — Chicago Med. Recorder. Holds first place in the esteem of both teachers and students. — The Brooklyn Medical Journal. The foremost of all medical text- books. — Medical Fortnightly. Gray's Anatomy should be the first work which a medical student should purchase, nor should he be without a copy throughout his pro- fessional career. — Pittsburg Medical Review. GRAY (LANDOX CARTER). A TREATISE ON NERVOUS AND MENTAL DISEASES. For Students and Practitioners of Medicine. New (2d) edition. In one handsome octavo volume of 728 pages, with 172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75. An up-to-date text-book upon uervous and mental diseases com- bined. A well-written, terse, ex- plicit, and authoritative volume treating of both subjects is a step in the direction of popular demand. — The Chicago clinical Review. "The word treatment," Says the author, "has been construed in the broadest sense to include not only medicinal and non-medicinal agents, but also those hygienic and dietetic measures which are often the physi- cian's best reliance."— The Journal of the American Medical Association. The descriptions of the various diseases are accurate and the symp- toms and differential diagnosis are set before the student in such, a way as to be readily comprehended. The author's loir.' experience renders his views on therapeutics of great value. — The Journal of Nervous and Men- tal Disease. 12 Lea Brothers & Co., Philadelphia and New York. GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND MORBID ANATOMY. New (8th) American from the eighth London edition. In one handsome octavo volume of 582 pages, with 216 engravings and a colored plate. Cloth, $2.50, net. Just ready. A work that is the text-book of probably four-fifths of all the stu- dents of pathology in the United States and Great Britain stands in no need of commendation. The work precisely meets the needs and wishes of the general practitioner.— The American Practitioner and News. Green's Pathology is the text-book of the day — as much so almost as Gray's Anatomy. It is fully up-to- date in the record of fact, and so pro- fusely illustrated as to give to each detail of text sufficient explanation. The work is an essential to the prac- titioner — whether as surgeon or phys- ician. It is the best of up-to date text-books.— VirginiaMed. Monthly. GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- ISTRY. For the Use of Students. Based upon Bowman's Medical Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- EASES, INJURIES AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND AND THE URETHRA. Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN DISEASES. In one handsome 12mo. volume of 350 pages, with many illustrations. Shortly. Cloth, $1.50, net. Lea's Series of Pocket Text-books, edited by Bern B. Gallatjdet, M. D. See page 18. HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN Second American from the third English edition. In one octavo vol- ume of 554 pages, with 11 engravings. Cloth, $3.50. HALL (WINFIELD S.) TEXT-BOOK OF PHYSIOLOGY. Octavo about 500 pages, richly illustrated. In press. HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR DESCRIPTION AND TREATMENT. Second and revised edition. In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. HARD AW AY (W. A.). MANUAL OF SKIN DISEASES. New (2d) edition. In one 12mo. volume of 560 pages, with 40 illustrations and 2 plates. Cloth, $2.25, net. Just ready. The best of all the small books to recommend to students and practi- tioners. Probably no one of our dermatologists has had a wider every- day clinical experience. His great strength is in diagnosis, deselections of lesions and especially in treat- ment. — Indiana Medical Journal. HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New (4th) edition. In one octavo volume of 623 pages, with 205 engravings and 14 full-page colored plates. Cloth, $5.00, net. Just ready. It is unique in many respects, and the author has introduced radical changes which will be welcomed by all. Anyone who reads this book will become a more acute observer, will pay more attention to the simple yet indicative signs of disease, and he Avill become a better diagnosti- cian. This is a companion to Prac- tical Therapeutics, by the same author, and it is difficult to conceive of any two works of greater practical utility. — Medical Review. Lea Brothers & Co., Philadelphia and New York. 13 HARE (HOB ART AMORY). A TEXT-BOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Reme- dial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. New (7th) and revised edition. In one octavo volume of 776 pages. Cloth, $3.75, net; leather, $4.50, net. Its classifications are inimitable, and the readiness with which any- thing can be found is the most won- derful achievement of the art of in- dexing. This edition takes in all the latest discovered remedies. — The St. Louis Clinigue. The great value of the work lies in the fact that precise indications for administration are given. A complete index of diseases and remedies makes it an easy reference it can be readily used in connection with Hare's Practical Diagnosis. For the needs of the student and general practitioner it has no equal. — Medical Sentinel. The best planned therapeutic work of the century. — American Prac- titioner and Ncivs. It is a book precisely adapted to the needs of the busy practitioner, who can rely upon finding exactly what he needs. — The National Med- work. It has been arranged so that I ical Review. HARE (HOBART AMORY) ON THE MEDICAL COMPLICA TIONS AND SEQUELiE OF TYPHOID FEVER. Octavo, 276 pages, 21 engravings and two full-page plates. Just ready. Cloth, $2.40, net. A very valuable production. One , read with great profit.— C/c re land of the very best products of Dr. Journal of Medicine. Hare and one that every man can) HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- TICAL THERAPEUTICS. In a series of contributions by eminent practitioners. In four large octavo volumes comprising about 4500 pages,with about 550 engravings. Vol. IV., just ready. For sale by sub scription only. Full prospectus free on application to the Publishers Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8 Price Vol. IV. to former or new subscribers to complete work, cloth $5 ; leather, $6 ; half Russia, $7. Complete work, cloth, $20; leather $24 ; half Russia, $28. The great value of Hare's System of Practical Therapeutics has led to a v. idespread demand for a new volume to represent advances in treatment made since the publication of the first three. More than fulfilling ibis request the Editor has secured contributions from practically a new corps ol equally eminent authors, so that entirely fresh and original matter is ensured. The plan of the work, which proved so successful, has been fol- lowed in ibis new volume, which will be found to present t be latest devel- opments and applications of this most practical branch of the medical art. The entire System is an unrivalled encyclopaedia on the practical parts of ttiedioine, and merits the great success it has wou for that reason. 14 Lea Brothers & Co., Philadelphia and New York. HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages, with 144 engravings. Cloth, $2.75 . A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- gravings. Cloth, $1.50, net. Just ready. It is practical, concise, definite and of sufficient fulness to be satis- factory. — Chicago Clinical Review. This work gives all of the prac- tically essential information about the three venereal diseases, gon- orrhoea, the chancroid and syphilis. In diagnosis and treatment it is par- ticularly thorough, and may be relied upon as a guide in the man- agement of this class of diseases. — Northwestern Lancet. It is well written, up to date, and will be found very useful. — Inter- national Medical Magazine. HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- tricity, Modifications of Atmospheric Pressure, Climates and Mineral Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume of 414 pages,with 113 engravings. Cloth, $3. This well-timed up-to-date volume is particularly adapted to the re- quirements of the general practi- tioner. The section on mineral waters is most scientific and prac- tical. Some 200 pages are given up to electricity and evidently embody the latest scientific information on the subject. Altogether this work is the clearest and most practical aid to the study of nature's therapeutics that has yet come under our obser- vation. — The Medical Fortnightly. For many diseases the most potent remedies lie outside of the materia medica, a fact yearly receiving wider recognition. Within this large range of applicability, physical agencies when compared with drugs are more direct and simple in their results. Medical literature has long been rich in treatises upon medical agents, but an authoritative work upon the other great branch of therapeutics has until now been a desideratum. The section on climate, rewritten by Prof. Hare, will, for the first time, place the abundant resources of our country at the in- telligent command of American practitioners. — The Kansas City Medical Index. HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See Student's Series of Manuals, page 27. HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- book of the Methods for Determining the Physiological Actions of Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. volume of 199 pages, with 32 engravings. Cloth, $1.50. Lea Brothers & Co., Philadelphia and New York. 15 HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome 12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. Excellently arranged, practical, concise, up-to-date, and eminently well fitted for the use of the prac- titioner as well as of the student. — Chicago 3Ied. Recorder. This volume accomplishes its ob- jects more thoroughly and com- pletely than any similar work yet published. Each section devoted to diseases of special systems is pre- ceded with an exposition of the methods of physical, chemical and microscopical examination to be em- ployed in each class. The technique of blood examination, including color analysis, is very clearly stated. Uranalysis receives adequate space and care. — New York Med. Journal. We commend the book not only to the undergraduate, but also to the physician who desires a ready means of refreshing his knowledge of diag- nosis in the exigencies of professional life. — Memphis Mediial Monthly. HTT.T, (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. HELIilER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition. In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25. HIRST (BARTON C.) AND PDERSOL (GEORGE A.). HUMAN MONSTROSITIES. Magnificent folio, containing 220 pages of text and illustrated with 123 engravings and 39 large photographic plates from nature. In four parts, price each, $5. Limited edition. For sale by subscription only. HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. In one 12mo. volume of 520 double-columned pages. Cloth, $1.50 ; leather, $2. HODGE (HUGH L..). ON DISEASES PECULIAR TO WOMEN. INCLUDING DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. HOFFMANN ( FREDERICK) AND POWER (FREDERICK B. ). A MANUAL OF CHEMICAL ANALYSIS, as Applied to the Examination of Medicinal Chemicals and their Preparations. Third edition, entirely rewritten and much enlarged. In one handsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25. HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- ciples and Practice. A new American from the fifth English edition. Edited by T. PICKERING Pick, F.R.C.S. In one handsome octavo vol- ume of L008.pages, with 428 engravings. Cloth, $G; leather, $7. — A SYSTFM (»F SFRGERY. With notes and additions by various American authors. Edited by John If. PACKARD, M.D. In three very handsome 8vo. volumes containing 3137 double-columned pages, with 979 engravings and 13 lithographic plates. Per volume, clotn, $6 ; leather, $7 ; half Russia, $7.50. For tale by tubacription only. 16 Lea Brothers & Co., Philadelphia and New York. HORNER (WILLIAM EL). SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320 engravings. Cloth, $6. HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2.50. HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL METHODS. A GUIDE TO THE PRACTICAL STUDY OF MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- ings and 8 colored plates. Cloth, $3.00. A comprehensive, clear and re- markably up-to-date guide to clinical diagnosis. The illustrations are plentiful and excellent. As exam- ples of the more recent additions to medical knowledge which receive recognition, we mention Widal's test for typhoid and the Neuron theory of the nervous system. — Montreal Medical Journal. HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. See Series of Clinical Manuals, p. 25. HYDE ( JAMES NEVINS). A PRACTICAL TREATISE ON DIS- EASES OF THE SKIN. New (4th) edition, thoroughly revised. In one octavo volume of 815 pages, with 110 engravings and 12 full- page plates, 4 of which are colored. Cloth, $5.25 ; leather, $6.25. This edition has been carefully re- vised, and every real advance has been recognized. The work answers the needs of the general practitioner, the specialist, and the student. — The Ohio Med. Jour. A treatise of exceptional merit characterized by conscientious care and scientific accuracy. — Buffalo Med. Journal. A complete exposition of our knowledge of cutaneous medicine as it exists to-day. The teaching in- culcated throughout is sound as well as practical. — The American Jour- nal of the Medical Sciences. It is the best one-volume work that we know. The student who gets this book will find it a useful investment, as it will well serve him when he goes into practice. — Vir- ginia Medical Semi- Monthly. A full and thoroughly modern text-book on dermatology. — The Pittsburg Medical Review. It is the most practical hand- book on dermatology with which we are acquainted. — The Chicago Med- ical Recorder. JACKSON (GEORGE THOMAS). THE READY-REFERENCE HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. In one 12mo. volume of 637 pages, with 75 illustrations and a colored plate. Just ready. Cloth, $2.50, net. As a student's manual, it may be considered beyond criticism. The book is singularly full. — St. Louis Medical and Surgical Journal. Without doubt forms one of the best guides for the beginner in der- matology that is to be found in the English language. — Medicine. JAMD3SON (W. ALLAN). DISEASES OF THE SKIN. Third edition. In one octavo volume of 656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Cloth, $6. Lea Bbothebs & Co., Philadelphia and New York. 17 JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume of 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25. Just ready. An exceedingly useful manual for student and practitioner. The au- thor has succeeded unusually well in condensing the text and in arrang- ing it in attractive and easily tangi- ble form. The book is well illus- trated throughout. — Nashville Jour, of Medicine and Surgery. THE PRACTICE OF OBSTETRICS. By American Authors. One large octavo volume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored plates. Just ready. Cloth, $5.00, net; leather, $6.00, net. A clear and practical treatise upon I the book abounds. The work is obstetrics by well-known teachers of sure to be popular with medical the subject. A special feature of ! students, as well as being of extreme this work would seem to be the I value to the practitioner. — The excellent illustrations with which | Medical Age. JONES (C. HANDF1ELD). CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Second American edi- tion. In one octavo volume of 340 pages. Cloth, $3.25. JUIiER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND PRACTICE. Second edition. In one octavo volume of 549 J ages, with 201 engravings, 17 chromo-lithographic plates, test-types of aeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, $5.50 ; leather, $6.50. The volume is particularly rich in | color blindness, etc. The sections matter of practical value, such as j devoted to treatment are singularly directions for diagnosing, use of full and concise. — Medical Age. instruments, testing for glasses, for | KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, $2.50. From first to finish it is thoroughly cyclopedias. The well-arranged practical, concise in expression, well i index renders the book useful to illustrated, and includes a statement ! the practitioner who is in haste to of nearly every fact of importance ' refresh his memory. — Virginia discussed in obstetric treatises or ! Medical Semi-Monthly. KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome octavo of 700 pages, with 751 illustrations. Just ready. See American Text-Books of Dentistry, page 2. We have only the highest praise f tempted. We can heartily recom- for this valuable work. It is replete mend it to the profession.— Tin in every particular, and surpasses OMo Dental Journal. anything of the kind heretofore at- KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one 12mo. volume of 506 pages, with 296 engravings. Just ready. Cloth, $2.0u, net. See Student's Series of Manuals, page 27. It is the most complete and con- This work deservedly occupies a cise work of the kind that has yet first place as a text-book on his- emanated from the press. — The Med- tology. — Canadian Practitioner, ical Age. 18 Lea Brothers & Co., Philadelphia and New York. LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. LA ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 pages. Cloth, $7. LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- BOOK OF OPHTHALMIC SURGERY. Second edition. In one octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. LEA'S SERIES OF POCKET TEXT-BOOKS, edited by Bern B. Gallaudet, M. D. Covering the entire field of Medicine in a series of 16 very handsome cloth-bound 12mo. volumes of 350-450 pages each, profusely illustrated. Compendious, clear, trustworthy and modern, and issued at the very moderate price of $1.50, net, per volume. The following volumes constitute the series. Coates' Bacteriology and Hygiene. Beockway's Anatomy. Collins and Rockwell's Physiology. Martin and Rockwell's Chemistry and Physics. Nichols and Vale's Histology and Pathology. Schleif's Materia Medica, Therapeutics, Medical Latin, etc. Mals- bary's Practice of Medicine. Collins' Diagnosis. Potts' Nervous and Mental Diseases. Gallaudet's Surgery. Likes' Genito- urinary and Venereal Diseases. Geindon's Dermatology. Ballen- ger and Wippeen's Diseases of the Eye, Ear, Throat and Nose. Evans' Obstetrics. Ceockett's Gynecology. Tuttle's Diseases of Children. For separate notices see under various authors' names. LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION AND INDULGENCES IN THE LATIN CHURCH. In three octavo volumes of about 500 pages each. Per volume, cloth, $3.00. CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMIN ATI - THE ENDEMONIADAS ; EL SANTO NlftO DE LA GUARDIA ; BRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2.50. FORMULARY OF THE PAPAL PENITENTIARY. In one octavo volume of 221 pages, with frontispiece. Cloth, $2.50. SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Fourth edition, thoroughly revised. In one hand- some royal 12mo. volume of 629 pages. Cloth, $2.75. STUDIES IN CHURCH HISTORY. The Rise of the Temporal Power — Benefit of Clergy — Excommunication. New edition. In one handsome 12mo. volume of 605 pages. Cloth, $2.50. 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In one very handsome 12mo. volume of 512 pages, with 285 engravings. Just ready. Cloth, $2.50, net. Used as text-book in every college of pharmacy in the Qnitea States and recommended in medical col- leges. — Amrriran Therapist. Noted on both sides of the Atlantic and esteimed as much in Germany as in America. The work has no equal. Dominion ilrne handsome 12mo. volume of alioui 150 pages. I loth, $1.50, net. Shortly. Lea's Series of Pocket Textbooks, edited hy Bern B. Gallaudet, M. I). See paw 18. PROGRESSIVE MEDICINE, see page 32. PURDY (CHARLES WA BRIGHT'S DISEASE AND ALLIED AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 pages, with 18 engravings. Cloth, $2. 24 Lea Brothkes & Co., Philadelphia and New York. PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. QUIZ SERIES. See Student's Quiz Series, page 27. RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See Student's Series of Manuals, page 27. RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- TICE OF OBSTETRIC MEDICINE AND SURGERY. In one imperial octavo volume of 640 pages, with 64 plates and numerous engravings in the text. Strongly bound in leather, $7. REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. In one handsome octavo volume of about 800 pages, richly illustrated. Preparing. REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- ISTRY. New (5th) edition, thoroughly revised. In one 12mo. vol- ume of 326 pages. Cloth, $2. A clear and concise explanation of a difficult subject. We cordially recommend it. — The London Lancet. The book is equally adapted to the student of chemistry or the practi- tioner who desires to broaden his theoretical knowledge of chemistry. — New Orleans Med. and Surg. Jour. The appearance of a fifth edition of this treatise is in itself a guarantee that the work has met with general favor. This is further established by the fact that it has been trans- lated into German and Italian. The treatise is especially adapted to the laboratory student. It ranks unusu- ally high among the works of this class. This edition has been brought fully up to the times. — American Medico-Surgical Bulletin. RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI- CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. New (2d) edition. In one octavo volume of about 800 pages, with about 500 engravings. Shortly. THE COMPEND OF ANATOMY. For use in the Dissecting Room and in preparing for Examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. ROBERTS (SIR WDLLIAM). A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth American from the fourth London edition. In one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. See Student's Series of Manuals, page 27. ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, with 184 engravings. Cloth, $4.50 ; leather, $5.50. SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, with 18 fc typical engravings. Cloth, $2. See Series of Clinical Man- uals, page 25. Lea Brothers & Co., Philadelphia and New York. 25 SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- OGY. DESCRIPTIVE AND PRACTICAL. For the use of Students. New (5th) edition. In one handsome octavo volume of 359 pages, with 392 illustrations. Cloth, $3.00, net. Just ready. Nowhere else will the same very- moderate outlay secure as thoroughly useful and interesting an atlas of structural anatomy. — The American Journal of the Medical Sciences. 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See page 27. SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- SCOPICAL AND CHEMICAL METHODS. New (2d) edition. In one very handsome octavo volume of 530 pages, with 135 engravings and 14 full-page colored plates. Cloth, $3.50. Just ready. This book thoroughly deserves its In all respects entirely up todate. success. Itisa very complete, authen- — Medical Record. tic and useful manual of the micro- The chapter on examination of scopical and chemical methods the urine is the most complete and which are employed in diagnosis, advanced thai we know of in the Very excellenl colored plates illus Kniclish language. — Canadian Prac- trate this work. — X< n- York Medical titioner. Journal. 26 Lea Brothers & Co., Philadelphia and New York. SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory Work for Beginners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. New (6th) edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 plates showing colors of 64 tests. Cloth, $3.00, net. Just ready. It is difficult to see how a better < the covers of this book. — The North- book could be constructed. No man western Lancet. who devotes himself to the practice Its statements are all clear and its of medicine need know more about ! teachings are practical. — Virginia chemistry than is contained between j lied. Monthly. SL.ADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. SMITH (EDWARD). DIABLE STAGES. CONSUMPTION; ITS EARLY AND REME- In one 8vo. volume of 253 pp. Cloth, $2.25. SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- FANCY AND CHILDHOOD. Eighth edition, thoroughly revised and rewritten and much enlarged. In one large 8vo. volume of 983 pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; leather, $5.50. The most complete and satisfac- tory text-book with which we are acquainted. — American Gynecologi- cal and Obstetrical Journal. It truly is the most evenly bal- anced, clear in description and thorough in detail of any of the books published in this country on this subject. — Medical Fortnightly. A treatise which in every respect can more than hold its own against any other work treating of the same subj ect. — American Medico-Surgical Bulletin. A safe guide for students and phy- sicians. — The Am. Jour, of Obstetrics. For years the leading text-book on children's diseases in America. — Chicago Medical Recorder. SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- oughly revised edition. In one octavo volume of 892 pages, with 1005 engravings. Cloth, $4 ; leather, $5. dium for the modern surgeon. — Be ton Medical and Surgical Journal. One of the most satisfactory works on modern operative surgery yet published. The book is a compen- SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- TOLOGY. In one handsome octavo volume of 462 pages, with en- gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. Just ready. A clear and lucid summary of what is known of climate in relation to its influence upon human beings. — The Therapeutic Gazette. The book is admirably planned, clearly written,and the author speaks from an experience of thirty years as an accurate observer and practical therapeutist. — Maryland Med. Jour. Every practitioner of medicine should possess himself of a copy and study it, and we are sure he will never regret it. — St. Louis Medical and Surgical Journal. STDLLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- MENT. In one 12mo. volume of 163 pages, with a chart showing routes of previous epidemics. Cloth, $1.25. THERAPEUTICS AND MATERIA MEDICA. Fourth and revised edition. In two octavo volumes, containing 1936 pages. Cloth, $10; leather, $12. 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Recommended most highly for the amount of information contained in physician, and invaluable to the this work is made available is indi- druggist. — Therapeutic Gazette. cated by the twenty-five thousand It is the official guide for the Med- references in the two indexes. — Ves- ical and Pharmaceutical professions, ton Medical and Surgical Journal. — Buffalo Med. and Bur. Jour. Should be recognized as a national The readiness with which the vast standard. — North Am. Practitioner. STTMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 engravings. Cloth, $3.75. A useful and practical guide for all students and practitioners. — Am. Journal of the Medical Sciences. The book is worth the price for the illustrations alone. — Ohio Medical Journal. STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND DISLOCATIONS. In one handsome octavo volume of 831 pages, with 326 engravings and 20 plates. Just ready. Cloth, $5.00, net; leather, $6.00, net. Preeminently the authoritative j Taken as a whole, the work is the text-book upon the subject. The ; best one in English to-day. — St. vast experience of the author gives Louis Medical and Surgical Journal. to his conclusions an unimpeachable Pointed, practical, comprehensive, value. The work is profusely il- exhaustive, authoritative, well writ- lustrated. It will be found indis- ten and well arranged. — Denver pensable to the student and the prac- Medical Times. titioner alike. — The Medical Age. STUDENT'S QUIZ SERD3S. Thirteen volumes, convenient, author- itative, well illustrated, handsomely bound in cloth. 1. Anatomy (double number); 2. Physiology; 3. Chemistry and Physics ; 4. Histol- ogy, Pathology, and Bacteriology; 5. Materia Medica and Thera- peutics ; 6. Practice of Medicine ; 7. Surgery (double number); 8. Genito- urinary and Venereal Diseases ; 9. Diseases of the Skin; 10. Diseases of the Eye, Ear, Throat and Nose; 11. 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STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25. SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE OVARIES AND FALLOPIAN TUBES. Including Abdominal Pregnancy. In one 12mo. volume of 513 pages, with 119 engravings and 5 colored plates. Cloth, $3. TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL SURGERY. In two handsome octavo volumes. Vol. I. contains 546 pages and 3 plates. Cloth, $3. TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- EASES OF PREGNANCY. From the second English edition. In one octavo volume of 490 pages, with 4 colored plates and 16 engrav- ings. Cloth, $4.25. TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New American from the twelfth English edition, specially revised by Clark Bell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54 engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50. Just ready. To the student, as to the physician, we would say, get Taylor first, and then add as means and inclination enable you. — American Practitioner and News. It is the authority accepted as final by the courts of all English- speaking countries. This is the im- portant consideration for medical men, since in the event of their being summoned as experts or wit- nesses, it strongly behooves them to be prepared according to the princi- ples and practice everywhere ac- cepted. The work will be found to be thorough, authoritative and modern. — Albany Law Journal. Probably the best work on the subject written in the English lan- guage. The work has been thor- oughly revised and is up to date. — Pacific Medical Journal. — ON POISONS IN RELATION TO MEDICINE AND MEDI- CAL JURISPRUDENCE. Third American from the third London edition. In one octavo volume of 788 pages, with 104 illustrations. Cloth, $5.50 ; leather, $6.50. TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- MENT OF VENEREAL DISEASES. New (2d) edition. In one very handsome octavo volume of about 700 pages, with about 200 en- gravings and 6 colored plates. In press. Notices of previous edition are appended. diseases that has in recent years ap- peared in English. — American Jour- By long odds the best work on venereal diseases. — Louisville Medi- cal Monthly. In the observation and treatment of venereal diseases his experience has been greater probably than that of any other practitioner of this con- tinent. — New York Medical Journal. The clearest, most unbiased and ably presented treatise as yet pub- lished on this vast subject. — The Medical News. Decidedly the most important and authoritative treatise on venereal nal of the Medical Sciences. It is a veritable storehouse of our knowledge of the venereal diseases. It is commended as a conservative, practical, full exposition of the greatest value. — Chicago Clinical Review. The best work on venereal dis- eases in the English language. It is certainly above everything of the kind. — The St. Louis Medical and Surgical Journal. Lea Brothers & Co., Philadelphia and New York. 29 TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- UAL DISORDERS IN THE MALE AND FEMALE. In one 8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. Cloth, $3. Net. the female is presented in an exhaus- tive manner, all of the causes pro- ducing it being described. The author has presented to the profes- sion the ablest and most scientific work as yet published on sexual disorders, and one which , if carefully followed, will be of unlimited value to both physician and patient. — Medical Nexus. It is a timely boon to the medical profession that an observer of Dr. Taylor's skill and experience has written a work on this hitherto neglected and little understood class of diseases which places them on a scientific basis and renders them so clear that the physician who reads its pages can treat this class of patients intelligently. Sterility in A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 213 beautiful figures on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 pages of text. Complete work now ready. Price per part, sewed in heavy embossed paper, $2.50. Bound in one volume, half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Address the publishers. Specimen plates by mail on receipt of ten cents. TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for the use of Senior Students and others. In one large 12mo. volume of 802 pages. Cloth, $3.75. THOMAS (T. GAELIiARD) AND MUNDE (PAUL P.). A PRAC TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth edition, thoroughly revised by Paul F. MundE, M. D. In one large and handsome octavo volume of 824 pages, with 347 engravings. Cloth, $5 ; leather, " The best practical treatise on the subject in the English language. It will be of especial value to the general practitioner as well as to the specialist. The illustrations are very satisfactory. Many of them are new and are particularly clear and attrac- tive. — Boston Med . and Sur. Jour. This work, which has already gone through five large editions, and has been translated into French, Ger- man, Spanish and Italian, is the most practical and at the same time the most complete treatise upon the subject. — The Archives of Gynecol- ogy, Obstetrics and Pediatrics. THOMPSON (SIR HENRY). CLINICAL LECTURES ON DIS- EASES OF THE URINARY ORGANS. Second and revised edi- tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA AND URINARY FISTULA. From the third English edition. In one octavo volume of 359 pages, with 47 engravings and 3 lithographic plates. Cloth, $3.50. THOMSON (JOHN). DISEASES OF CHILDREN. In one crown octavo volume of 350 pages, with 52 illus. Cloth, $1.75, net. Just ready. TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. TREVES (FREDERICK). OPERATIVE SURGERY. In two 8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. A SYSTEM OF SURGERY. In Contributions by Twenty-five English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 487 engravings and 2 colored plates. Complete work, cloth, $10.00. 30 Lea Beothees & Co., Philadelphia and New Yoek. TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. In one 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See Student's Series of Manuals, page 27. TUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES OF CHILDREN. In one handsome 12mo. volume of about 300 pages, with many illustrations. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-hooks, edited by Been B. Gallaudet, M. D. See p 18. VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, or the Chemical Factors in the Causation of Disease. New (3d) edition. In one 12mo. volume of 603 pages. Cloth, $3. The work has been brought down to date, and will be found entirely satisfactory. — Journal of the Ameri- can Medical Association. The most exhaustive and most re- cent presentation of the subject.— American Jour, of the Med. Sciences. The present edition has been not only thoroughly revised throughout but also greatly enlarged, ample consideration being given to the new subjects of toxins and antitoxins. — Tri-State Medical Journal. VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. Four styles : Weekly (dated for 30 patients); Monthly (undated for 120 patients per month) ; Perpetual (undated for 30 patients each week); and Perpetual (undated for 60 patients each week). The 60- patient book consists of 256 pages of assorted blanks. The first three styles contain 32 pages of important data, thoroughly revised, and 160 pages of assorted blanks. Each in one volume, price, $1.25. With thumb-letter index for quick use, 25 cents extra. Special rates to advance-paying subscribers to The Medical News or The Ameeican Jotjenal of the Medical Sciences, or both. See p. 32. WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. A new American from the fifth and enlarged English edition, with additions by H. Haetshoene, M. D. In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR TO WOMEN. Third American from the third English edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- ING. New (4th) edition. In one 12mo. vol. of about 600 pages, with about 500 engravings, many of which are photographic. Shortly. Notices of previous edition are appended. We know of no book which more thoroughly or more satisfactorily covers the ground of Minor Surgery and Bandaging. — Brooklyn Medical Journal. Well written, conveniently ar- ranged and amply illustrated. It covers the field so fully as to render it a valuable text-book, as well as a work of ready reference for sur- geons. — North Amer. Practitioner. The part devoted to bandaging is perhaps the best exposition of the subject in the English language. It can be highly commended to the student, the practitioner and the specialist. — The Chicago Medical Recorder. Lea Beothees & Co., Philadelphia and New Yobk. 31 WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR THERAPEUTIC INDEX. Including Medical and Surgical Thera- peutics. In one square octavo volume of 917 pages. Cloth, $4. WILLIAMS (DAWSON). THE MEDICAL DISEASES OF CHIL- DREN. In one 12nio. volume of 629 pages, with 18 illustrations. Just ready. Cloth, $2.50, net. The descriptions of symptoms are j diagnoses, prognosis^ complications, full, and the treatment recommended | and treatment. The work is up to will meet general approval. Under I date in every sense. — The Charlotte each disease are given the symptoms, I Medical Journal. WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and revised American from the last English edition. Illustrated with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; leather, $5. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In one 12mo. volume. Cloth, $3.50. WTNCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. Translated by James R. Chadwick, A. M., M. D. With additions by the Author. In one octavo volume of 484 pages. Cloth, $4. WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated from the eighth German edition, by Ira Remsen, M. D. In one 12mo. volume of 550 pages. Cloth, $3. YEAR-BOOK OF TREATMENT FOR 1892, 1 893, 1896,1897 and 1898. Critical Reviews for Practitioners of Medicine and Surgery. In con- tributions by 25 well-known medical writers. 1 2mos., about 500 pages each. Cloth, $1.50. In combination with The Medical News and The American Journal of the Medical Sciences, 75 cents. YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. Cloth, $2.50. See Series of Clinical Manuals, page 26. We doubt whether any book on work of Dr. Yeo's. The value of dietetics has been of greater or more widespread usefulness than has this much-cjuoted and much-consulted the work is not to be overestimated. ■New York Medical Journal. A MANUAL OF MEDICAL TREATMENT, OR CLINICAL THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. YOUNG ( J AMES K.). ORTHOPEDIC SURGERY. In one 8vo. volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. In studying the different chapters, surgical specialty and every page one is impressed with the thorough abounds with >•'■- d prac- ness of the work. The illustrations ticality. [t is the clearest and i are numerous— the book thoroughly modern work upon this grow ing de- practical— Medical News. partmenf The Ch It is a thorough, a very compre- Clinical Review, bensive work upon this Legitim PERIODICALS. PROGRESSIVE MEDICINE. A Quarterly Digest of New Methods, Discoveries, and Improvement): in the Medical and Surgical Sciences by Eminent Authorities. Edited by Dr. Hobart Amory Hare. In four abundantly illustrated, cloth bound, octavo volumes, of 400-500 pages each, issued quarterly, commencing March 1st, 1899. Per annum (4 volumes), $10.00 delivered. THE MEDICAL NEWS. Weekly, $1.00 per Annum. Each number contains 32 quarto pages, abundantly illustrated. crisp, fresh weekly professional newspaper. THE AMERICAN JOURNAL OP THE MEDICAL SCIENCES. Monthly, $4.00 Per Annum. Each issue contains 128 octavo pages, fully illustrated. The most advanced and enterprising American exponent of scientific medicine. THE MEDICAL NEWS VISITING LIST. Four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 120 patients per month) ; Perpetual (undated, for 30 patients weekly per year) ; and Perpetual (undated, for 60 patients per year). Each style in one wallet-shaped book, leather bound, with pocket, pencil and rubber. Price, each, $1.27. Thumb-letter index, 25 cents extra. THE MEDICAL NEWS POCKET FORMULARY. Containing 1600 prescriptions representing the latest and most ap- proved methods of administering remedial agents. Strongly bound in leather ; with pocket and pencil. Price, $1.50, net. COMBINATION RATES: American Journal of the Alone. In Combination. Medical Sciences, .... $ 4.00 ] a,,,-,*") Medical News 4.00 } $7.50 ( $15 00 Progressive Medicine .... 10.00 J Medical News Visiting List . . . 1.25 Medical News Formulary . . . 1.50 net, In all $20.75 for $16.00 First four above publications in combination . . . $15.75 All above publications in combination .... 16.00 Other Combinations will be quoted on request. Full Circulars and Specimens free. LEA BROTHERS & CO., Publishers, 706, 708 & 710 Sansom St., Philadelphia. Ill Fifth Avenue, New York.