Columltta Winihtv&it^ in tl^e Citp of J5etD |9orfe CoUese of ^fip&imn& anb ^urseon£( 3^ef erence l^itirarp Is ^ t PLATE I Mottled eruption from the arm of same case. Severe Case of Scarlet Fever, showing eruption at its lieight. For strawberry tongue ot same case, see Plate XXVIll. (Original.) (Painted from a case in tlie Riverside Hospital.) DISEASES OF INFANCY AND CHILDHOOD THEIR Dietetic, Hygienic, and Medical Treatment A TEXT-BOOK DESIGNED FOR PRACTITIONERS AND STUDENTS IN MEDICINE. BY LOUIS FISCHER, M.D. ATTENDING PHYSICIAN TO THE VTII^LARD PARKER A^•D RIVERSIDE HOSPITALS OF NEW YORK CITY; CHIEF ATTENDING PEDIATRIST TO THE ZION HOSPITAL OF BROOKLYN; ATTEND- ING PEDIATUIST TO THE SYDENHAM HOSPITAL; FORMER INSTRUCTOR IN DISEASES OF CHILDREN AT THE NEW YORK POST-GRADCATE MEDICAL SCHOOL AND HOSPITAL, ETC.; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE. SEVENTH EDITION WITH THREE HUNDRED AND FIVE ILLUSTRATIONS, SEVERAL IN COLORS, AND FORTY-THREE FULL-PAGE HALF- TONE AND COLOR PLATES PHILADELPHIA F. A. DAVIS COMPANY, Publishers English Depot: Stanley Phillips, London 1917 COPYRIGHT, 1907, F. A. DAVIS COMPANY COPYRIGHT, 190S, F. A. DAVIS COMPANY COPYRIGHT, 1910, F. A. DAVIS COMPANY COPYRIGHT, 1911, F. A. DAVIS COMPANY COPYRIGHT, I9I4, F. A. DAVIS COMPANY COPYRIGHT, 1915, F. A. DAVIS COMPANY COPYRIGHT, 1917,, F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved. V~ 5 2_ Philadelphia, Pa., U. S. A. Press of F. A. Davis Company 1914-16 Cherry Street TO SIMON FLEXNER, M.D., DIRECTOR OF THE ROCKEFELLER INSTITUTE FOR SCIENTIFIC RESEARCH, NEW TORE, THIS VOLUME IS MOST AFFECTIONATELY INSCEIBED AS A SLIGHT TRIBUTE TO AN EARNEST AND DEVOTED STUDENT, BY THE AUTHOR h- Digitized by the Internet Archive in 2010 with funding from Open Knowledge Conimons http://www.archive.org/details/diseasesofinfancOOfisc PREFACE TO SEVENTH EDITION. Since the last edition appeared research in pediatrics has enriched our knowledge regarding the cause of the deficiency diseases, such as scurvy and rickets. It has been experimentally proven that these diseases are caused by a lack of vitamines in the food. In the chapters on nutrition, therefore, an article on Vitamines has been added. The value of blood transfusion as a therapeutic measure is described and illustrated by clinical cases. D^Espine's sign has been described. Its importance as an aid in the detection of tuberculosis in its earliest stage, before the lung-tissue is destroyed, has been established. Tuberculides, a skin manifestation of tuberculosis in many young children, has been illustrated; so also the Schick reaction, which is of great value in showing the susceptibility to dijihtheria, especially in crowded institutions. Vaccine therapy has been revised with especial reference to dosage. Likewise the dosage of diphtheria antitoxin has been modified according to our latest. views at the City Hospital for Diphtheria. The recent epidemic of poliomyelitis (summer of 1916) in New York City and State has given a vast opportunity for the study of the pre- paralytic stage, and to judge of the results of the serum treatment. Other additions to the present volume are: The complement devia- tion test in suspicious cases of pertussis. The use of adrenaline in serum rashes. The use of thromboplastine in the chapter on hemorrhages. The treatment of dropsy and suppression of urine in nephritis, with especial reference to the diet and the stimulation of the kidneys, and a new article on Erb's Palsy. Minor corrections have been made. Early statistics and useless cuts have been discarded to give space for more important clinical data. The aim of the book has been to present, in a concise manner, prac- tical points in the diagnosis and treatment of infantile diseases, for the benefit of the teacher as well as the general practitioner. Louis Fischer. 155 West Eighty-fifth -Street, New York City. (^) CONTENTS. PAKT I. DEVELOPMENT AND HYGIENE OF THE INFANT. DIAGNOSTIC SUGGESTIONS. CHAPTER PAGE I. — Infancy and Ciiiluhood 1 The new-born infant; infancy, childhood. II. — The Development of the Various Senses 2 Eeflex actions; sighing; urine; suckling or nursing; supporting the head; sitting; playing; stamping with] the feet; the first attempts at walking; laughing; kissing; tears; memory; taste; touch; voice sounds; very late speaking; sudden loss of speech due to paralysis. III. — The Development of the Body 5 Growth and height; dentition. IV. — Diagnostic Suggestions 9 The pulse-rate; respirations; temperature; eye; gestures; cry; tongue; throat; sleep; prognosis; infant mortality; the value of X-ray in diagnosis. V. — General Hygiene of the Infant 17 Hygiene of the mouth and teeth; management of the navel; the um- bilical cord; vernix caseosa; bathing the baby; clothing; the nur- sery; ventilation; when to take an infant out-of-doors; the nurse- maid; method of heating the nursery; light; furniture; bed and pillow; proper training of bowels and bladder; hygiene of the nervous system; physical exercise. PART 11. ABNORMALITIES AND DISEASES OF THE NEMT^Y BORN. I. — Premature Infants 26 Management of a premature infant; method of feeding; premature birth; artificial feeding. II. — ^Prophylaxis and Treatment of the Eyes in the New-bobn 34 III. — Diseases and Malformations of the Umbilicus 35 Granuloma; diphtheritic omphalitis; dangers incident to careless- ness in handling the navel; septic omphalitis; Meckel's diverticulum; congenital obliteration of the bile ducts. IV. — ^Hemorrhagic Diseases of the Newly Born 39 Spontaneous htemorrhage; umbilical haemorrhage; haemoglobinuria neonatorum; acute fatty degeneration of the new-born; gastro- intestinal hfemoiThage. (vii) viii CONTENTS. CHAPTER PAGE V. — Injuries of the New-boen 43 . Fractures; obstetrical paralysis. VI. — ^Asphyxia Neonatokum 45 VII. — FcETAL Ichthyosis 50 VIII. — Inflammatory and Non-infla5«:matoey Conditions 52 Icterus neonatorum; sclerema neonatorum; mastitis neonatorum; erysipelas in the new-born; tuberculosis in the new-born; peritonitis in the new-born; pemphigus neonatorum. IX. — Abnokmauties and Congenital Mali^oemations 57 Angeioma; harelip; cleft palate; tongue-tie; congenital adenoids; protrusion of the ears; abnormalities of the air passage; congenital stenosis of the larynx; prominent sternum; depressed sternum; haematoma of the sterno-mastoid ; cephalhsematoma ; caput succeda- neum; congenital cyst of the kidney; congenital sacral tumor; con- genital malformations of the rectimi. PAKT III. NUTRITION. 1. — The Infantile Stomach : Beeast-milk and Wet-nuesing 65 Colostrum; breast-milk; the mammary glands; maternal feeding; scanty breast-milk requiring mixed feeding; disturbances during breast feeding; immunity conferred by breast-milk; additional foods during the nursing period; diet of a nursing mother; wet-nurse; weaning and feeding from one year to fifteen months; management of woman's nipples; protein indigestion; weight and development. II.— Cows' Milk 114 Certified milk; adulteration; raw milk; chemical examination; fat; sugar; protein; mineral salts; starch; alkalies; cream. III. — Home Modifications of Milk 150 Bottle-feeding or hand-feeding; pasteurization; diet for a child from one year to fifteen months; diet for a child from eighteen months to three years; diet for a child from the third to the tenth year; feed- ing of delicate or sick children; substitute feeding; feeding bottles; nipples; caloric method of infant-feeding. . IV. — Percentage Feeding 170 V. — Other Substitute Foods 173 Goats' milk; buttermilk feeding; Bulgarian milk; Lahman's vege- table milk; Horlick's food; condensed milk. VI. — Proprietary Infant Foods 181 Nestle's food; Horlick's malted milk; cereal milk; Wampole's milk food; Imperial Granum; Eskay's albuminized food; Mellin's food; Mammala; Just's food; Benger's food; peptogenic milk powder. VII. — Concentrated Preparations of Albumin 194 VITI. — Additional Nutrients and Stimulants 198 CONTENTS. ix PAET IV. DISEASES OF THE MOUTH, CESOPHAGUS, STOMACH, INTESTINES, AND RECTUM, AND DISORDERS ASSOCIATED „, ^^„ WITH IMPROPER NUTRITION. „,^„ CHAPTER PAGE I. — Diseases of the Mouth 205 Stomatitis; stomatitis catarrhalis; stomatitis aphthosa; Bednar's aphthae; parasitic stomatitis; croupous stomatitis; syphilitic stoma- titis; stomatitis gangrsenosa; epithelial desquamation; congenital hypertrophy of the tongue; bifid tongue; bifid uvula; glossitis; ranula; alveolar abscess; angina Ludovici. II. — Diseases of the CEsophagus 217 Acute oesophagitis; croupous or diphtheritic oesophagitis; retro- oesophageal abscess; foreign bodies in the oesophagus. III. — Diseases of the Stomach 219 Acute gastric catarrh; pyloric obstruction caused by spasm of the pylorus; hypertrophic pyloric stenosis; gastro-duodenitis; chronic gastritis; acute dilatation of the stomach; gastroptosis; ulcer of the stomach; cyclic vomiting; dyspeptic asthma. IV. — Diseases of the Intestines 2.37 Infant stools; bacteria of the intestines; diarrhoea; insolation; dys- entery; pellagra; intoxication; summer diarrlioea; constipation; Hirschsprung's disease; intestinal colic; chronic intestinal indiges- tion; appendicitis; pseudo-appendicitis; intussusception; umbilical hernia; worms; uncinariasis. V. — Diseases of the Rectum 294 Fissure of the anus; simple cataiThal proctitis; croupous proctitis; ulcerative proctitis; hsemorrhoids ; ischio-rectal abscess; pi'olapsus ani; rectal polypi. VI. — Deficiency Diseases and Disorders Arising from the Improper As- similation of Nutrition whereby Faulty ^Metabolism Results. 298 Faulty metabolism; scurvy; rachitis; decomposition. PAET Y. DISEASES OF THE HEART, LWER, SPLEEN, PANCREAS, PERITONEUM, AND GENITOURINARY TRACT. I. — Introductory 32.'5 II. — Diseases of the Heart 330 Reflex symptoms of the heart, tachycardia, bradycardia; pulmonary stenosis; persistence of the ductus arteriosus Botalli; endocarditis; malignant endocarditis; pei'icarditis; tuberculosis of the pericar- dium; hydropericardium; myocarditis. III. — Diseases of the Liver 346 Jaundice; acute congestion of the liver; gall-stones; functional dis- orders of the liver; displacement of the liver; descended liver; amyloid degeneration; fatty liver; cirrhosis; focal necrosis; subphrenic abscess. X CONTENTS. CHAPTER PAGE IV. — "Diseases of the Spleen and Pancbeas 352 v.— Diseases of the Peritoneum 354 Acute peritonitis; clironic peritonitis; tuberculous peritonitis: ascites. VI. — Diseases of the Genital Organs Stil Hernia; hydrocele; adherent prepuce; phimosis; paraphimosis; hypo- spadias; epispadias; cryptorchidism; orchitis; vulvo-vaginitis ; simple vaginitis; gpnorrhceal vaginitis; vicarious menstruation; menstruation prsecox. VII. — Diseases of the Kidney and Bladder 370 Acute nephritis; secondary nephritis; perinephritis; pyelitis; ectopia vesicae congenitalis; indicanuria ; acetonuria; diacetonuria ; pyuria; lordotic albuminuria; hsematuria; heemoglobinuria ; glycosuria; diabetes insipidus ; diabetes mellitus ; colicystitis ; vesical calculi ; acute cystitis; chronic cystitis; enuresis. PAKT VI. . DISEASES OF THE RESPIRATORY SYSTEM. I. — Diseases of the Nose and Tkeoat 391 Acute nasal catarrh; naso-pharyngeal catarrh; influenza; foreign bodies in the nose; tonsillitis; follicular tonsillitis; croupous ton- sillitis; ulcero-membranous tonsillitis; phlegmonous tonsillitis; chronic hypertrophic tonsillitis; tuberculosis of the tonsils; adenoid vegeta- tion; pharyngitis; retropharyngeal abscess; spasmodic laryngitis; foreign bodies in the larynx; coughs of reflex origin. II. — Diseases of the Bronchi, Lungs, and Pleura 423 Bronchitis; bronchial asthma; broncho-pneumonia; pleurisy; dry pleurisy; pleurisy with effusion; empyema; chronic empyema; tuber- cular empyema. PAET YII. THE INFECTIOUS DISEASES. I. — Fever. Bacterial Vaccines ' 445 II. — Pertussis (Whooping-cough ) 455 III. — Pneumonia 460 IV. — Tuberculous Broncho-pneumonia : Pulmonary Gangrene 479 V. — Acute Tuberculosis 483 VI. — Diphtheroid. Pseudo-diphtheria. Acute Diphtheria. Chronic Diphtheria. Intubation. Tracheotomy 500 VII. — ^Rubella (German Measles). Duke's Disease (Fourth Disease) ... 577 VIII. — Measles (Morbilli, Rubeola) 584 IX. — Scarlet Fever ( Scarlatina) 599 X. — ^Varicella ( Chicken Pox ) 633 CONTENTS. xi CIIAPTEU PACK XI. — Variola and Vaccination 638 XII. — Typhoid Fever 646 XIII. — Erysipelas 658 XIV.— JIal^vria 662 XV. — Syphilis 672 PAET VIII. DISEASES OF THE BLOOD, GLAl^DS OR LYMPH-NODES, AND DUCTLESS GLANDS. I. — Introductory G8.3 II. — DiSKiVSES OF THE BlOOD 691 Anaemia; splenic antemia; secondary anfemia; pernicious anaemia; leukaemia; pseudo-leukcemic anaemia; chlorosis. III. — Acute Rheumatism 698 Muscular rheumatism; torticollis; pui-pura; purpura rheumatica; Henoch's purpura; lithaemia; haemophilia. IV. — Diseases of the Glands or Lymph Nodes 711 Status lymphaticus ; acute adenitis; chronic adenitis; tubercular adenitis; mumps. V. — Diseases of thei Ductless Glands 719 Cretinism; exophthalmic goiter; acute thyroiditis; abnormality of the thyroid; diseases of the thymus gland; diseases of the adrenal glands; Addison's disease. - . . PAET IX. DISEASES OF THE NERVOUS SYSTEM. I. — Fontanel 733 Percussion of the skull; the brain; reflexes. II. — Convulsions 739 Headaches; spasmus nutans; speech defects; chorea; hysteiia; multiple neuritis; pavor nocturnus; masturbation. III. — Tetany 756 Spasmophilia; tetanus; epilepsy; myelitis; spina bifida; hereditary ataxy; poliomyelitis; hydrocephalus; meningocele; encephalocele ; Cyclops ; porenceplialy. IV. — Tubercular Meningitis 779 Cerebro-spinal meningitis; pachymeningitis; cerebral paralysis; pleu- roplegia; pseudohypertrophic paralysis; facial paralysis; cerebral abscess; alalia idiopathica; idiocy and imbecility; infantile amaurotic family idiocA'; concussion of the brain. Xii CONTENTS. • PAET X. DISEASES OF THE EAR, EYE, SKIN, AND ABNORMAL GROAVTHS. CHAPTER PAGE I. — Diseases of the Ear 812 Acute catarrhal otitis media; mastoid operation; sinus thrombosis; foreign bodies in the ear. II. — Diseases oe the Eye , 819 Acute catarrhal conjunctivitis; pink eye; pneumococcus ophthalmia; purulent ophthalmia; membranous conjunctivitis; granular ophthal- mia; blepharitis; hordeolum; phlyctenular conjimctivitis. III. — Diseases of the Skin 827 Eczema; eczema rubrum; eczema intertrigo; urticaria; herpes zoster; chloasma; psoriasis; impetigo; pediculosis; miliaria papulosa; miliaria rubra; sudamina; lentigo; seborrhoea; furuncle; chronic pemphigus; erythema; nsevus; tinea tonsurans; verruca; burns; gangrene; scabies. IV. — ^Malignant and Non-maugnant Growths 842 Spindle-cell sarcoma; carcinoma; hypernephroma; lipoma; enchon- dromata; angeioma; malignant and non-malignant papillomata; granulomata. PAET XI. DISEASES OF THE SPINE AND JOINTS. Diseases of the Spine and Joints 848 Pott's disease; flat foot; scoliosis; morbus coxarius; congenital dislo- cation of the hip; knee-joint disease; diseases of the ankle-joint and tarsus; wrist-joint and elbow-joint disease; acute arthritis. Hypodermic medication. PAET XII. MISCELLANEOUS. I. — Dietary 868 II. — The Examination of the Gastric Contents ; 875 III. — Urine " 877 IV. — Bacteriological Memoranda 888 v.— Anaesthetics in Children 890 VI. — Disinfection 894 VII. — The Administration of Drugs 895 VIIL— Local Remedies 896 IX. — Rectal Medication 898 X. — Prescriptions for Various Diseases 900 XL — Table of Doses 909 LIST OF ILLUSTRATIONS. FIGURE PAGE 1. A, Tympanic cavity. B, Otic ganglion. C, Tooth. D, Internal carotid. E, Tympanic branch. F\ Auriculo-temporal nerve. G, Auricular branch of auriculo-temporal nerve. The dotted line connecting B and C repre- sents the inferior dental nerve ' 6 2. Two middle lower incisors. Nine to sixteen months 8 3. Four upper incisors. Nine to sixteen months 8 4. Two lateral lower incisors and four molars. Thirteen to seventeen months. 8 5. Four canines. Sixteen to twenty-one months 8 6. Twenty milk teeth. Twenty-three to thirty-six months 8 7. Proper-shaped shoe for infant , 21 8. Incubator 27 0. Feeder for premature infants 31 10. Funnel and catheter for forced feeding. .'. 31 11. Weight chart 32 12. Case of omphalocele 36 13. Appearance of abdomen four weeks after treatment 36 14. Diagram illustrating effects of persistence of the omphalomesenteric dvict, and the formation of the so-called diverticulum tiuuor 37 15. Eibemont's tube for inflating the lungs 47 16. Infant pxilmotor 48 17. A case of angeioma 57 18. Harelip nipple 58 19. Congenital cystic kidney 62 20. Congenital sacral tumor 63 21. Infant's stomach. Actual size. From a case of malnutrition 69 22. Infant's stomach. Actual size. Died suddenly from convulsions 69 23. Infant's stomach. Capacity, 10 ounces. Age of child, eleven months., 70 24. Infant's stomach. Capacity of measurement, 14 ounces 70 25. Colostrum corpuscles in a drop of milk 75 26. Heeren's pioscop, for optical milk test 79 27. Specimen of breast-milk from a young mother, 17 years old 81 28. Specimen of breast-milk, illustrating very high fat, causing gastric disturb- ance 81 29. Showing a drop of milk under the microscope 90 30. Drop of breast-milk from a very anaemic woman 90 31. Holt's milk test set, for testing human milk 91 32. Nipple-shield for relief of tender nipples 93 33, 34. Breast-pump 93, 94 35. Breast-milk taken from a wet-nurse during menstruation 102 36. Pear-shaped breasts, best adapted for nursing 106 37. The Chatillon scale 108 38. Chart showing gain in weight of baby Robert M. F 110 39. Chart showing gain in weight of baby J. S Ill 40. Chart showing gain in weight of baby fed on Eskay's food after third week. Ill (xiii) xiv LIST OF ILLUSTRATIONS. FIGURE PAGE 41. Chart shoAving gain in weight of baby A 112 42. Chart showing gain in weight of baby D. S 112 43. Centrifugal testing machine, for handpower 133 44. Graduated cream gauge 134 45. Marchand's tube 134 46. Feser's lactoseope 134 47. Cows' milk, showing fat-globules 135 48. Chapin cream dipper ■ 147 49. Author's choice of feeding-bottle 151 50. Bottle warmer 151 51. Bottle-brush 152 52. Anticolic nipple 152 53. Nipple-sterilizer 153 54. Enterprise juice extractor 200 55. Case of sprue (thrush) due to' faulty hygiene of the mouth 207 56. Case of stomatitis gangrenosa (noma) following scarlet fever 212 57. Hinged bucket 218 58. Infantile duodenal bucket Avith syringe attached, to aspirate bile 225 59. Drawing from a case of acute dilatation of the stomach 230 60. Translumination of the stomach with the aid of a gastrodiaphane, in a case of gastroptosis. ( Colored. ) 232 61. a, Normal position of stomach. 6, Position of stomach in a case of gas- troptosis •• • 233 62. Bacterium coli commune 243 63. Bacterium lactis aerogenes 244 64. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1898, 1899. . . 247 65. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1900, 1901 . . . 248 66. Chart of death-rate from diarrhea in Manhattan and Bronx, 1902, 1903 249 67. Insolation (heat stroke) 250 68. Bacillary diphtheria of the colon or diphtheritic colitis. (Colored.) 252 69. Croupous enteritis, diphtheritic colitis 253 70. A case of acute milk poisoning 257 71. Exact size of catheter used for irrigating a very young infant . 262 72 to 77. Abnormalities of the sigmoid flexure 267 78. Rubber bulb syringe 209 79. Irrigator, Avith tube attached and hard-rubber points 270 80. Soft- rubber rectal tube for Irrigating the colon 271 81. Mechanism of intussusception 286 82. Umbilical hernia 288 83. Umbilical hernia truss 289 84. Case of hydrencephaloid (spurious hydrocephalus) 308 85. Same child, two years later 308 86. Rickets, longitudinal section tlirough ossification junction of upper diaphy- seal end of femur 309 87. A case of spurious hydrocephalus, illustrating marked frontal and parietal protuberances 310 88. Rachitic ribs 312 89 to 92. Illustrating rachitic ciosions of tlie pcnnaniMit teeth 313 93. Five-week-old fracture of the humerus in a rachitic child l^^ years old .... 314 94. A severe type of rickets, Avith enlargement of both condyles of the femur. . ; 314 95. Case of rickets, showing enlarged spleen; also pendulous belly 315 LIST OF ILLUSTRATIONS. XV FIGURE PAGE 96. Rickets, showing beaded ribs and an onlaif^cd, pciiiliiloiis belly 317 97. Rickets, showing beaded ribs .318 98. Rachitic kyphosis (spine) . Front view 310 99. Racliitic kyphosis (spine). Back view, same child 319 100. Decomposition 322 101. Infantile atrophy 323 102. Apex beat in a very young infant 326 103. Apex beat in a child about 6 years old 326 104. Apex beat in child about 12 years old 326 105. Irregular pulse, low tension, from a case of mitral regurgitation 327 106. Natural size of Rowles stethoscope for examining children 328 107. Convenient stethoscope for children 328 108. Case of pulmonary stenosis — congenital — blue baby 333 109. Child with persistence of the ductus arteriosus Botalli 33.5 110. Case of tubercular peritonitis complicated by tul)frcular empyema 357 111. Gonoeoecus. (Colored.) 307 112. Nephritis complicating diphtheria 372 113. Case of pyelonephritis 377 114. Exstrophy of the bladder, and prolapse of anus 379 115. Atomizer 392 116. Lefferts's posterior and anterior nasal syringe 393 117. Lenox nasal douche 394 118. Graduated douche, suitable for older children 394 119. Influenza bacilli. ( Colored. ) : 396 120. Case of influenza pneumonia in a child eight months old 397 121. Case of influenza pneumonia in a child two years old 399 122. Angina tonsillaris (Colored. ) 403 123. Vincent's bacillus found in ulcerative angina 406 124. Throat spray 407 125. Throat ice-bag . 407 126. The Baginslcy tonsillotome ■ 409 127. The Mackensie tonsillotome 409 128. Typical adenoid face in a cretin 412 129. Digital method of exploring the rhino-pharynx for adenoids 413 130. Temperature chart from a case of retropharyngeal abscess 417 131. Oil atomizer 418 132. Steam atomizer 419 133. Croup kettle 421 134. Diplococeus pneumoniae ( pneumococcus ) . (Colored.) 430 135. Purulent ( svippurative ) bronchitis, peribronchitis, and peribronchial l)nin- cho-pneumonia in a cluld fifteen months old 431 136. Diphtheria (septic) bronch'o-pneumonia. Louis B., age three years 432 137. Diagram for pneumonia jacket opened at side 434 138. Diagram for pneiunonia .jacket opened at front 434 139. Fever curve in a case of dry pleurisy 436 140. Fever curve in a case of pleurisy, with effusion 438 141. Diagrammatic illustration of heart ajul lungs, left-sided pleuritic efl'usion . . 439 142. Illustrating a severe localized riglit-sided empyema 441 143. James's apparatus for expanding the lungs in empyema 443 144. Temperature chart, Case II, broncho-pneumonia 453 xvi LIST OF ILLUSTRATIONS. FIGURE PAGE 145. Focal metastatic hsematogenous streptococcus — pneumonia following angina. (Colored.) 461 146. Croupous pneumonia. (Colored.) 461 147. Case of influenza and pneumonia 463 148. Lobar pneumonia of a severe type 467 149. Case of cerebral pneumonia 468 150. Cerebral pneumonia, with high temperature and marked decrease in tem- perature after cold baths 469 151. Fever curve during the early period of clironic pulmonary tuberculosis .... 479 152. Temperature curve during the fifth month .'.... 479 153. Chronic nodular tuberculous broncho-pneumonia 480 154. Tubercle bacilli and micrococcus tetragenus (sputum). (Colored.) 487 155. Tuberculosis — horizontal section through lower lobe of right lung of two- year-old child 489 156. Acute pulmonary miliary tuberculosis (cut surface of the lung) 490 157. Diphtheria or Klebs-Loeffler bacilli ; smear preparation from tonsillar de- posit. ( Colored. ) 505 158. True and false diphtheria ■ . 506 159. Section from an inflamed imila covered with a stratifled fibrinous mem- brane, from a case of diphtheritic croup of the pharyngeal organs .... 509 160. Septic type of diphtheria, comjDlicated by myocarditis 513 161. Case of nasal diphtheria 514 162. Broncho-pneumonia complicating diphtheria 515 163. Pneumonia complicating diphtheria 521 164. Temperature chart from, a case of diphtheria complicated by broncho-pneu- monia (step-ladder type of fever) 524 165. Temperature chart from a case of diphtheria complicated by lobar pneu- monia 525 166. Temperature chart from a case of diphtheria complicated by otitis and meningitis 526 167. Temperature chart from a case of diphtheria, showing the specific eff"ect of antitoxin on the temperature 535 168. Method of transfixing and raising the vein 536 169. Introducer Avith tube attached 545 170. Introducer with tube and detached obturator 545 171. Introducer holding foreign-body tube 545 172. Extubator 546 173. Built-up tubes for granulation tissue 546 174. The mummy bandage, showing child in proper position for the dorsal method of intubation 547 175 Intubation. Left index finger raising the epiglottis 548 176. Tube, passing the epiglottis, entering the larynx 549 177. Tube, resting on vocal cords, in the larynx 550 178. Extubation. The left index finger finding the tube 551 179. Cliart showing laryngeal diphtheria complicated by broncho-pneumonia . . . 552 180. Gavage — method used in forced feeding «,t Willard Parker Hospital 555 181. Casselberry method of feeding 556 182. Temperature chart from a case of diphtheria: croup, intubation 557 183. Laryngeal diphtheria 564 184. Diphtheria — ^^laryngeal stenosis requiring intubation 571 J85, Temperature chart from a case of laryngeal diphtheria 572 LIST OF ILLUSTRATIONS. XvU FIGUBE p^Qj, 186. Silver trachea cannula used in traciieotxjmy 575 187. Hard-rubber tracliea cannula 575 188. Temperature chart, ease of rubella 580 189. A case of malignant measles complicated by diphtheria and ending with empyema 59 1 190. 191. Temperature charts, cases of measles/ complicated by broncho-pneu- "lonia 592^ 593 192. "Inclusion bodies," case of scarlet fever qqi 193. Septic scarlet fever with myocarditis, suppurative arthritis, double purulent otitis, general pyaemia 005 194. Unusually severe desquamation G07 195. Chart showing temperature and complications in a case of scarlet fever . . 609 196. Septic nephritis (515 197. Drop of urine from a case of post-scarlatinal nephritis 616 198. Coffey's glass apparatus for hypodermic saline injections 621 199. Temperature chart, scarlet fever treated with antistreptococcus serum .... 625 200. Method of nasal siyringing employed in the scarlet fever ward of the River- side Hospital 626 201. Pustules surrounded by inflammatory areola 633 202. Temperature curve in varicella 635 203. Erysipelas following varicella 636 204. Fatal smallpox in an unvaccinated infant 638 205. Temperature curve in variola _ 640 206. Smallpox in a child that was vaccinated during the incubation period .... 641 207. Mild, discrete smallpox in an unvaccinated girl 643 208. Typlioid infantum in a two-year-old boy 647 209. Stages in Widal reaction 650 210. Typhoid fever. Severe hsemorrhages 652 211. Ectogenous streptococcus infection. (Colored.) 658 212. Fever curve in facial eiysipelas • 659 213. Malaria plasmodia, tertian type. (Colored.) 663 214. Malaria plasmodia, tropical form. (Colored.) 663 215. Tertian fever (intermittent) 664 216. Quartan fever (double tertian) 665 217. ^stivo-autumnal fever (mild type) 666 218. Spirochseta pallida. Macerated skin of f(»tus 674 219. Syphilis. Child 14 years old 677 220 to 223. Syphilitic teeth 679 224. Congenital syphilis before injection of salvarsan 680 225. Appearance of lesions one week after injection of salvarsan 681 226. Blood from a case of chlorosis 697 227. Malignant purpura, complicating nasal diphtheria 706 228 Case of cervical adenitis in which a positive von Pirquet reaction appeared. 715 229 to 234. Sporadic cretinism 721, 723 235 to 242. A case of cretinism 725, 726, 727, 728 243. Sagittal section of normal head of seven and one-half months' foetus 734 244. Normar head as seen from above 734 245. Sagittal section of normal head 734 246. Sagittal section of head inmiedjately after normal, easy labor 734 247. 248. Sagittal section of head immediately after labor 735 249. Sagittal section of head of infant six days old 735 xviii LIST OF ILLtJSTRATIOKS. 250. Tetany 756 251. Case of spina bifida 766 252. Micro-organism causing epidemic poliomyelitis 708 253. Poliomyelitis 769 254. Infantile paralysis 771 255. Infantile paralysis 771 256. Infantile paralysis 773 257. 258. Case of chronic internal liydrocephalusi 775 259. Hydroeeplialic calvarium (or sknll-cap), widely gaping fontanels and sutures 777 260. Case of eneephalocele 778 261. Tuberculous spinal meningitis 780 262. Case of tuberculous meningitis, well marked, ending fatally 782 263. Anatomical illustration, showing the place best adapted for lumbar pimc: ture 789 264. Lumbar puncture needle 789 265. Lumbar puncture made between fourth and fifth lumbar vertebrae 790 266. Infantile cerebral paralysis 797 267. Pseudohypertrophic paralysis 801 268. Facial paralysis following mastoid operation 802 269 to 271. A case of pseudohypertrophic paralysis 803 272. Congenital idiocy 807 273 to 276. Imbecile (Louie W.) 808, 809 277. Complication of scarlet fever seen in my sexvice at Riverside Hospital .... 813 278. Ear syringe 814 279. A common type of acute mastoid inflammation following influenza 817 280. Trachoma, showing round, opaque bodies in upper and lower lids 824 281. Method of everting eyelid 825 282. Case of gangrene following lobar pneumonia 840 283. Spindle-cell sarcoma • 843 284. Anterior view of the tumor 844 285. Enchondromata involving the thumb and index finger 846 286. Pott's disease ". 848 287. Pott's disease, case of Harry F , 853 .288, 289. Schoolgirl, showing lateral curvature of spine, due to faulty position . . 855 290. Side flexion 859 291. Position maintained while ten or twenty deep breaths are drawn . 859 292. Sitting-hanging with rod 860 293. Resistance, especially adapted for young children 860 294. 295. Tuberculous coxitis 862 296. Congenital hip dislocation 863 297. Tubercular elbow- joint 866 298. Urino-pyloiometer, for estimating the specific gravity of small volumes of urine 880 299. The horismascope or albumoscopQ 882 300. Gas and ether inhaler 890 LIST OF PLATES. PLATE PAGE I. — Severe case of scarlet fever, showing eruption at its height. .Frontispiece II.— Hess Incubator 28 III. — The Byrd-Dew method of artificial respiration 46 IV. — A drop of normal breast-milk from primipara SO V. — Microscopic appearance of raw sitarch-granules 144 VI. — Microscopic apiiearance of starch-granules, showing the cfl'cc-t of heat 144 VII. — Geographical tongue, or epithelial desquamation 214 VIII. — Intussusception. (Courtesy of Dr. Hen) 286 IX. — Intussusception. (Coiirtesy of Dr. Reu) 286 X. — Cestodes (tape- worms) 288 XI. — Infantile scurvy .302 XII. — Femur divided by anteroposterior section in case of infantile scurvy. .302 XIII. — Subperiosteal haemorrhages in case of infantile scuryj^ 304 XIV. — Flaring, cup-shaped, irregular termination of diaphyses in rickets. Condition accounts for enlargement of wrists in rickets 308 XV. — Flaring, cup-shaped, irregular termination of diaphyses in rickets. Condition accounts for enlargement of ankles in rickets 308 XVI. — Chronic enlarged tonsils. Granular pharyngitis 412 XVII.- — Disseminated pulmonary tuberculosis, with collapsed right lung and natural pneumothorax 490 XVIII. — Papulonecrotic tuberculides 496 XIX. — Cutaneous reaction with concentrated and diluted tubercailin 498 XX. — Severe cutaneous reaction. Scrofulous reaction 498 XXI. — A, Common type of diphtheria. B, Follicular type of diphtheria. C, Hsemorrhagic type of diphtheria. D, Septic type of diphtheria. 514 XXII. — Morbilliform antitoxin rash 516 XXIII.— Schick reaction 520 XXIV.— Schick reaction 520 XXV.— Intubation 548 XXVI.— Extubation '. 550 XXVII. — Earliest symptoms of measles 584 XXVIII. — Forms of tongue in scarlet fever 604 XXIX. — Furfuraceous, circinate, and flaky desquamations 606 XXX. — Confluent type of smallpox 644 XXXI. — lodophilia. Pus reaction of blood 686 XXXII. — A, Progressive pernicious an?emia. B, Lienal (splenic) an«mia. C, Lienal (splenic) leukemia. 7>, Acute leukivniia 692 XXXIII. — Henoch's purpura 'i^^ XXXIV.— Front view of the foetal skull 736 XXXV.— Top view of the foetal skull 736 XXXVL— Posterior view of the foetal skull 736 XXXVIL— Disseminated pulmonary tuberculosis in two-year-old child having tubercular meningitis i^*^ (xix) XX LIST OF PLATES. PLATE PAGE XXXVIII. — 1, Meningococci in pus cells 784 XXXIX. — Cerebrospinal meningitis 786 XL. — Cerebrospinal meningitis due to the influenza bacillus ■ 788 XLI. — Intracranial injection in meningitis 792 XLII.— Normal mucous membrane of the middle ear in the new-born. In- flammation of the mucous naembrane of the- middle ear. Sec- tion of the vessel of the mucous membrane containing strepto- coccus pyogenes 812 XLIII. — ^X-ray of congenital dislocation of hip 858 PART I. THE DEVELOPMENT AND HYGIENE OF THE INFANT. DIAGNOSTIC SUGGESTIONS. CHAPTER I. INFANCY AND CHILDHOOD. The New-born Infant. There are several anatomical and physiological changes which occur when an infant passes from a passive intrauterine to an active extrauterine existence. The lungs have had no intrauterine function. They become active as soon as the infant makes its first inspiration. The stomach and bowels become active the moment the first mouthful of food is swallowed. The blood-vessels of the umbilical cord, which have nourished the child and connected it with the circulatory system of its mother, rapidly atrophy as soon as breathing is established. The following are the most important changes that take place during the first month of an infant's life : — 1. The meconium is expelled. 2. The umbilical cord separates. 3. The navel becomes cicatrized. 4. The epidermis cracks and falls off. 5. The hair is renewed. 6. The uml)ilical vessels are obliterated, and the foramen ovale is closed. Infancy. — The term infancy is best applied to that period from the end of the first month until all of the milk-teeth have appeared, which is about the end of the second year of life. There are certain anatomical peculiarities Avhieh may l)e important to mention, namely : — 1. The thymus gland. 2. The large size of the liver. 3. The existence of an anterior and posterior fontanel. Childhood. — The term childhood is applied to that period from tlie end of the second year to about the sixteenth year. Childhood ends when puberty begins. Then follows tlie stage of adoles- cence. (1) CHAPTER II. THE DEVELOPMENT OF THE VARIOUS SENSES. Mental Faculties.^ The following is the order in which the various senses appear devel- oped: taste, sight, touch. Heflex Actions. — Yawning may begin at the end of the first week of life. (^ Sighing^ commences in the twenty-eighth week. Urine is passed and attention called to it by the infant between the thirty-sixth and fortieth weeks. From this time on it is advisable to try to train the child to be clean and use a chair. Suckling or Nursing. — This seems to be congenitally acquired. Be- tween the eighth and tenth months an infant should know, enough to prop- erly guide a nursing bottle to its mouth. It should also know enough to properly inspect its various toys at this age. Supporting the Head. — The infant should support its head for a few moments in the fourteenth week, and should be able to properly support the head about the sixteenth week. Sitting usually commences between the seventeenth and twenty-sixth weeks. The child should be able to properly support the body between the thirty-sixth and fortieth weeks. About the forty-second week the child should be strong enough to support its back thoroughly. Commencing with the forty-fifth week the sitting position should be permanently established. When children can sit up and play they should be placed on the floor, having a clean rug under them. Active movements can be suggested by rolling a small ball or giving the child some toy to play with. The tendency to put everything into the mouth must be considered. Hence, large toys, such as hollow rubber balls, are best. Playing with beans, peas, and bullets has frequently given many a physician an opportunity to try his skill in removing them from such places as the middle ear, the nostril, and most frequently the stomach.- Stamping with the feet in the forty- fourth week. The first attempts at walking appear about the forty-first week. WaU-- ing unaided is rare Ijefore the end of the first year. Two-fifths of all children ^ The brain, fontanel, and reflexes of the body ai'e described in detail in Part IX, "Diseases of the Brain and Nervous System." (3) VERY LATE SPEAKING. ^ 3 Icain to walk between tne I'ourteeiitli and lil'teeiitli inoiitlis. 'J'lius eliildron must ]J<)t be exjtected to walk properly until ihe}' are one and a lialf years old. Children having sufl'ered with disordered stoniach and bowels, whether from faulty fee(lin ^ It 75 IS ~IS -is it 23 23 |27 M „ 33 3S TJ !» ^ ?3 ^ i *:t — — ~ \ /f" i/j I '4 y fr % IB 7. % ). ■/2 ). '/4 : ■j 7 IB I ; 1 % \ / ^A : / '/+ r > > 4 IB /. : : / % : /- y % '•/ A ,f IB fv s .V /. TT . % '^ Vi '4 // IB -1 • Fig. 11. — Birth: | Placed in Incubator; | Removed from Incubator. five pounds. The infant could not retain the diluted human milk, there Avas con- siderable projectile vomiting. Condensed milk was then given. Condensed milk V2 drachm to two ounces of sterile water. One-half ounce was given at each feed- ing. This food was retained but the infant emaciated and its lowest weight was four pounds. Gavage was resorted to at every other feeding. The vomiting became less and the weight increased, the infant gaining slowly. The extremities were cold. The infant was cyanosed and was placed in an incubator. It then weighed four pounds four ounces. As the weight remained stationary for one week, the condensed milk feeding was discontinvied and two drachms of the following formula were given: Cows' milk, 30.0; barley water, 50.0; peptogenic milk ])Owder, V3 measure. The infant gained ra])idly, vomited less, and slept longer. Whenever possible we procured woman's milk and substituted it for the cows' milk feeding. The dnfant remained in the incubator twenty-seven days, and Avas removed Aveighing six pounds seven ounces. '11 IK FEEDIN(i^ OF I'REMATURE INFANTS. 33 S The HlooJ. — From incooiiiiiin ;il l)irth, the stool {gradually become a grass-green, jelly-like mass; Inter it was a yellowish-green, saponified stool. The first three weeks the infant was constipated. This constipation later improved so that the stool was softer, pasty in consistency, and yellowish or yellowish-green in color. The infant grew and developed and was discliarged in June, 1009, weighing eleven pounds. Serum Injections. — The subcutaneous injection of sterile horse serum was com- menced with the idea of promoting nutrition. About 15 cubic centimeters were injected into the loose cellular tissue of the abdomen, and, when it was found that it Avas completely absorbed, a daily injection of 15 cubic centimeters was ordered. Later 30 cubic centimeters Avere injected and absorb, d. Xo febrile reaction fol- lowed such injection. Although many dozens of these injections were given, with the usual aseptic precautions, not once did an abscess or other sign of infection occur. The gradual daily increase in weight was attributed in some measure to this mode of treatment. Skimmed milk has given me excellent results in a series of premature infants. Whenever possible the mouth feeding was supplemented by hypo- dermoclysis consisting of 2 ounces of normal saline solution, temperature 103° F., injected twice a day into the loose cellular tissue of the abdomen. A close study of the details required in the successful rearing of undersized infants shows that the following points are helpful : — ■ 1. Vomiting, if present after feeding, means longer interval between meals. 3. An undeveloped and weak infant taking hut several drachms from a medicine dropper will be better fed by gavage. Most of my success has been due to gavage at regular intervals night and day. 3. The temperature of the infant is usually subnormal. In addition to placing the infant in an incubator, I have its body well oiled, especially the feet, and the infant wrapped in cotton. The heat of the incubator produces dryness of the mouth and lips, therefore water is given frequently by spoon or medicine dropper. 4. To aid metabolism and to assist the bowels, an injection of a table- spoonful of warm sweet oil into the rectum helps to move the bowels. The weight should be taken daily, and it is important to increase the percentage composition of the food until the infant gains in weight. 5. The great danger of exposure prohibits the daily bath, hence the infant should be cleansed by inunctions with warm oil. The Incuhator. — The strict supervision of an incubator demands two trained nurses, The heat must be regulated. The thermometer on the inside of the incul)ator must frequently be observed and the moisture properly regulated, so that the air in the incul)ator is not too dry. As a rule, an incubator infant, if otherwise healthy, shows restlessness when its feeding time arrives. The infant is taken from the incubator, the doors of the incubator are closed to retain the heat, the infant is rapidly fed by gavage or the feeder, and returned to the incubator. 3 CHAPTEE II. PROPHYLAXIS AND TREATMENT OF THE EYES IN THE NEW-BORN. The vaginal discharge of a pregnant woman contains pathogenic bac- teria. This frequently gives rise to an infectious catarrh in the new-born. It is therefore important to treat the eye of the new-born baby with extreme care to prevent an infection which can produce serious results. Teeatment of the Eyes in the JSTew-borkt. Ordinarily the eyes should be washed with a pledget of sterilized cotton dipped in plain sterile water or a 2 per cent, boric acid solution. The mouth and nose should be similarly treated. All cotton used for the hygiene of the mouth, nose, and eyes should be burned immediately after use. Crede advises the use of a 1 per cent, solution of nitrate of silver. One drop (no more than one drop) is allowed to drop from a solid glass rod or a medicine dropper on the center of the cornea. Its object is to prevent the infant from acquiring ophthalmia neonatorum. The prophylaxis of blindness is worth stvidying. The New York Association for the Blind reports many cases "of needlessly blind victims of ophthalmia neonatorum." The official census of the blind for the State of New York for 190G gives a total of 6200, out of which number 1984 were preventable blindness, most of them caused by ophthalmia neonatorum. Garrigues^ states that in lying-in asjdums before this treatment Avas adopted, purulent ophthalmia was very prevalent. Statistics show that one-half to two-thirds of those affected with blindness lost their sight from this cause. When the frequency of the gonococcus in the vaginal secretions of women delivered in lying-in asylums is considered, then the wisdom of prophylaxis cannot be questioned. Of late protargol (10 per cent, solution) has been subs^tituted for the nitrate of silver solution. It is just as effective and less irritating. Solution argyrol (20 per cent.) is very useful in the catarrhal affec- tions of infants and children. I have seen very good results during my service at the Willard Parker Plospital with the same.- 1 Henry J. Garrigues: "Textbook of Obstetrics," 1902. ^ See also Part X, "Diseases of the Eye." (34) CHAPTER III. DISEASES AND MALFORMATIONS OF THE UMBILICUS. Granuloma. A MASS of fungus or exuberant granulations is frequently found in the umbilicus. Sometimes the granuloma resembles a large red bead. It is usually seen after the cord has separated. A discharge usually oozes. These granulations bleed very easily. Treatment. — The application of a solid stick of nitrate of silver to thoroughly destroy the granulations is usually all that is required. If these granulations persist then the same can be removed with the aid of a sharp curette by simple scraping, after which a dusting powder like europhen should be used. Diphtheritic Omphalitis. The new-bom baby is occasionally infected with diphtheria. If there is an omphalitis the Klebs-Loeffler infection can easily be transmitted. The following case was seen by me in consultation : — A child 4 years old suffered with diphtheria of the upper air passages, -which finally spread to the larynx, necessitating intubation. This family lived in a crowded apartment. The mother gave birth to an infant five days later, and was herself infected with diphtheria of the vagina and vulva. Her new-boi'n baby was about six days old when I first saw it. The umbilical cord had just sloughed away. The region of the umbilicus was highly inflamed and covered with thick pseudo-membranes. The child died on the eleventh day, of septicaemia. A culture taken showed Klebs-Loeffler bacilli. The physician that attended this family told me that the nurse in charge of the older child with laryngeal diphtheria also nursed the mother and the new-born baby. He believed that the infection was undoubtedly carried by the nurse. Treatment. — Saturate a piece of sterile gauze with antitoxin and apply to the umbilicus. Eemoisten every hour, applying fresh gauze three times a day. ' Give an intramuscular injection of 1000 antitoxin units. Give ^o grain calomel twice a day for three days. The Dangers Incident to Carelessness in Handling the Navel. If through some accident the ligatures around the umbilical cord should slip, and blood oozes from the wound, fatal hgemorrhage can result. The attention of the physician should at once be directed to this condition. This can become a very serious matter if neglected ; hence it is of the utmost importance to remedy it at once. The neglect of such things, besides the (35) 36 DISEASES AND MALFORMATIONS OF THE UMBILICUS. improper bandaging or uncleanliness in this region, is liable to cause not only convulsions, but blood poisoning and death. Fig. 12. — Case of Omphalocele admitted to the Babies' Wards of the Sydenham Hospital. A semi-globular tumor 4 inches in diameter, and 2V2 inches above level of the body. The stump of the umbilical cord is seen on the left side of the tumor. Sterile gauze dressings were applied. After several weeks the mass gradually sloughed off and the wound closed. ( Original. ) Tig. 13; — Appearance of abdomen four weeks after treatment. Case was discharged cured when six weeks old. (Original.) Septic Omphalitis. An infant was seen by me, through the courtesy of Dr. S. Straus, in this city during the summer of 1902. History, as follows : — • It was the first child born; no previous miscarriage; family history excellent; no history of syphilis; labor was easy, and baby was born in natural manner. The mother was in excellent health; had milk in both breasts; normal temperature. Asepsis was thoroughly carried out. The infant had a temperature of 103° F., in the rectum, slight gastroenteric complication, greenish, colicky stools; the umbilicus was inflamed and excoriated; slight evidence of pus. Diagnosis. — Septic omphalitis due, probably, to infection by the nurse with un- clean hands while dressing the umbilicus. Treatment. — Strict asepsis to be followed. The umbilicus to be washed with CONGENITAL OBLITERATION 01'' THE BILE DUCTS. 37 1 to 2000 bichloride of mercury. Sterile gauze and aristol or some drying powder applied. The stomach and bowels were cleansed with calomel, and the infant fed every two hours at its mother's breast. The child made an excellent recovery in about four or five days. Meckel's Diverticulum. A condition wliicli may at first simulate umbilical polypus, and for which umbilical ])olypus may be a symptom, is the persistence of a Meckel diverticulum. This consists of the persistence of a piece of intestine, usually patent, connecting the small intestine with the umbilicus. It rep- resents a vitelline duct that failed to atrophy when the placental circulation became established, and betrays its presence by an escape of fasces from the umbilicus. It is a rare malformation (Eotch). r^ Fig. 14. — Illustrating Effects of the Persistence of the Omphalomesenteric Duct and Formation of the So-called Diverticulum Tumor (Riesman). 1. The omphalomesenteric duct shown as an opening' leading: from the umbilicus to the ilium. 2. Showing' a small portion of the proximal intestinal wall. This may happen in a constipated child, while straininsr at stool. The same condition may occur during a par- oxysm of whooping-cough, 3. The tumor is much larger, frequently sausage-shaped. It is irreducible. CONGETNITAL OBLITERATION OF THE BiLE-DUCTS. This condition has been carefully studied by John Thomson, of Edin- burgh. He has tabulated his studies in his book on "Congenital Oblitera- tion of the Bile-ducts," 1892. Etiology. — There can be no doubt that various malformations of the liver and bile-ducts do occur which are certainly of this nature. For example, congenital a-bsence of the gall-bladder has been frequently de- scribed, and some of the cases were due to arrest of development, although many were probably of inflammatory origin. Wenzel Gruber has published a case in which a forked cystic duct was fouiid, and Konitzky has described another in which the common duct had an unusualty long and curved! course, and opened into the middle of the horizontal portion of the duo- denum, its lumen being narrow^ed. 0. Witzel also has published notes of an infant boiTi with a large number of congenital abnormalities, in whom, in addition to hemicephalus, situs viscenim inversus, six fingers on each hand, etc., there was a cystic condition of the liver and complete imper- meability of both the cystic and common ducts. Other developmental defects have been obsei-ved, namely, in Heschl's absence of the bile-ducts in 38 DISEASES AND MALFORIHATIONS OF THE UMBILICUS. the liver-tissue, and in Professor Simpson's want of the spigelian and quad- rate lobes. The frequency with which this exceedingly rare condition affects sev- eral members of the same family is very strongly in favor of this view, and, indeed, it seems difficult to explain it otherwise. It has been suggested that this reappearance of the disease in the same family might be explained by supposing a common syphilitic taint. This suggestion, however, cannot be accepted, for we never find a tendency for an extremely rare manifestation of syphilis to recur four or five times in a family without any of the com- mon s}Tiiptoms of that disease being present at the same time. Pathology. — ^The liver is usually found much enlarged, of a very tough consistency — due to biliary cirrhosis — and of a dark green color, owing to tlie presence of numerous masses of inspissated bile in the small bile-ducts. In the great majority of cases there is complete obliteration of some part or parts of the hepatic, common or cystic ducts, or of the gall-bladder, while with very few exceptions, implication of the blood-vessels or other tubes in the neighborhood is conspicuous by its absence. Pathology of the Lesion of the Ducts. — The lesion has been ascribed to three different morbid processes, either acting separately or in combina- tion, namely: — • 1. Peritonitis and its results ^ acting on the ducts from outside, and either compressing them or being a source of inflammatory action, which spreads afterward to their walls. 2. An inflammatory or other lesion of the ducts themselves. 3. An arrest or defect of development. And further, various predisposing causes have been described as accounting for these morbid processes, namely : — 1. Congenital syphilis. 2. Digestive distu7'hance on the part of the parents. 3. Injuries or exposure to cold, either of the mother or child. 4. Erysipelas of the child. Symptoms. — Such children are jaundiced at birth or they become so within the first week or two of life; otherwise they are healthy and well- nourished. In some cases there is meconium followed by colorless motions ; in others the faeces are devoid of color from the very first. The urine is deeply bile-stained. The jaundice is of a dark greenish tinge, and lasts till death, and the motions remain colorless. A certain proportion of the children die from umbilical hjemorrhage within the first fortnight, and, of those who survive this period, a large number suffer from spontaneous haem- orrhage from other situations. The liver steadily enlarges, and the spleen also. After living some months the children become more or less emaciated. Spasms often supervene, and death ensues in the end m a state of exh^stioxj. from some trifling intercurrent disease. CHAPTER IV. H.EMORRHAGIC DISJOASES OF TllK NEW-BORN. Spontani:ous ILemoium i age. The occurrence of spontaneous luumorrliages is one of the most char- acteristic clinical features in these cases. In the cases collected by Thomson, in 21 out of the 50 — that is, in almost half of the cases which lived more than a few da3's — the fact of hii'morrhages having occurred from some part of the body is noted, and in all probability it may have occurred in some of the others also, although not mentioned, as the records of many of them are so meager. The situations of the haemorrhages mentioned in Thomson's collection are as follows : — Subcutaneous in 7 of the cases. Subconjunctival in 1 of the cases. Umbilical in 6 of the cases. From nose in 2 of the cases. Vomited in 4 of the cases. From bowel in 8 of the cases. From mouth in 1 of the cases. From lung in 1 of the cases. Into gall-bladder in 1 of the cases. From leech-bite (excessive) .in 1 of the cases. A tendency to bleed is found in many children. In the preceding chapter I have described haemorrhage as a symptom of congenital oblitera- tion of the bile-ducts.i I have also described a very serious haemorrhage in a case of congenital syphilis (see chapter. on ''Syphili,s") which ended fatally. Direct infection through the umbilical vessels is a frequent cause of pyaemia, and this same can result in haemorrhage. Etiology. — Eitter- studied 190 cases. Of these, 2-i were associated with sepsis. Kilham and Mercelis^ describe haemorrhages in 10 cases out of 54. It seemed that these M^ere all due to one and the same pyogenic infection. Gaertner* describes a short bacillus which he isolated from two -cases resembling the colon bacillus. When the same was injected into the perito- neum of animals, a disease was produced accompanied by htemorrhage ^ Read article on "Haemorrhages in Congenital Obliteration of the Bile-duct," page 35. "Oest. Jahrbuch fiir Pediatrik, 1871, p. 127. 'Archives of Pediatrics, March, 1899. ? Archly fiir Kinderheilkunde, 1895. (39) 40 HEMORRHAGIC DISEASES OF THE NEW-BORN. similar to that seen in the new-bom. Holt describes a case in which cultures were taken by Dr. J. J. Mapes from which a bacillus resembling that described by Gaertner was isolated. The absence of a sufficient quan- tity of calcium in the blood was supposed to be the prime cause of haemor- rhage. This has been disproven by the recent work of Addis. ^ Sahli and more recently Morawitz and Lessen have shown that the disease hemo- philia may be due to deficiency of thrombokinase. Pathology. — Small or large extravasations of blood may be found upon the various internal organs affected. The brain, the thymus gland, the stomach, the bowels, the pericardium, the pleura, and peritoneum may have ecchymoses upon their surfaces. A frequent source of haemorrhage is the presence of ulcers. Gastric and intestinal ulcers are by no means rare. Symptoms. — The first symptom noticed is the presence of blood. This may be present in the vomit, in the stool, or in the urine. There may be an oozing beneath the skin or from the umbilicus. The bleeding does not amount to a very large quantity. The infant is usually very anaemic. The pulse is small and feeble. The body is emaciated. The temperature fluc- tuates ; as a rule, it is subnormal, although it may be very high. The course of the disease is short ; the bleeding usually ceases in a few days. Umbilical Hemorrhage. Improper tying of the ligature around the umbilical cord or trau- matism frequently causes a slight oozing. These oozings are very easily controlled by the application of a proper-fitting ligature. When, however, a spontaneous haemorrhage occurs it may be impossible to arrest the same with ordinary means. In these cases the haemorrhage occurs without pre- vious warning. As a rule, the umbilicus has been perfectly normal for a few days prior to this haemorrhage. Some authors state that it may be fatal in less than twenty-four hours. Hemoglobinuria Neonatorum (Winckel's Disease). Considerable has been written upon this obscure condition, which is very rarely met with in the new-born baby. As a rule, this condition is seen as an epidemic in a maternity hospital. Winckel reports 19 deaths out of 23 cases. Pathology. — Haemorrhages are found in various organs. The lungs are black. The bladder, the spinal canal, the liver, and the spleen all show darkened secretions. The kidneys are dark colored. All observers state that the umbilical vessels are not involved. Symptoms. — The skin of the body has a peculiar icteric or bronzed appearance. The palms of the hands and soles of the feet have a bluish * Quarterly Jour, of Medicine, Jan., 1909. GASTROINTESTINAL HEMORRHAGE. 41 or purplish color. The conjunctiva has an icteric appearance. The stool is blackish or greenish. The urine is dark and contains blood ; it is thick and sometimes resembles syrup. There is no fever. The pulse is very rapid. Convulsions and squinting are usually seen. There is a rapid diminution in the blood cells, from 5,700,000 one day to 3,400,000 on the third day. These cases end fatally, as a rule. Acute Fatty Degeneration of the Nevt-born (Buhl's Disease). When an infant is born in an asphyxiated condition and there is asso- ciated umbilical haemorrhage, then an infection of pathogenic bacteria may take place. In some respects this disease resembles Winckel's disease. In both w^e have haemorrhages as well as fatty degeneration of the internal organs. The symptoms are a bleeding from the stomach and bowels, asso- ciated with jaundice. In Buhl's disease we have bleeding from the um- bilicus. Gastro-intestinal Hemorrhage (Melena). Dark-colored, tarry stools are the usual symptoms of melaena. The black stool may also contain clots of blood. A crucial test for the presence of blood in examining the faeces for the presence of blood-corpuscles is the microscope. Normally, meconium does not contain blood. Another symp- tom is the vomiting of dark-brown liquids; occasionally bright-red blood may be present. Haemorrhages of the mouth and nose are generally due to syphilis, although ulcerative conditions may cause local haemorrhage. When pem- phigus or furunculosis is present, haemorrhages frequently occur. Haemor- rhage from the female genital organs may occur as well as from any other part of the body. They are usually associated with catarrhal inflammation of those parts. Diagnosis. — This is usually very easy, especially if the bleeding is superficial. The diagnosis is difficult when an obscure place like the intes- tine is the source of the haemorrhage. The microscope will usually aid in establishing a diagnosis of blood in the excreta. When the bleeding is confined to the mouth and nose, syphilis should be suspected. Prognosis. — A careful prognosis should always be given, although the disease is not necessarily fatal. Townsend studied 709 cases and recorded a mortality of 79 per cent. A male infant, six days old, was seen by me through the courtesy of Dr. A. Goldwater. The child had vomited several times. The vomit contained blood of a bright-scarlet color. The stool had been yellowish, but now is black and tarry. There was a slight oozing of blood from the umbilicus. When I applied some absorbent cotton to the umbilical stump, bright-scarlet blood was seen. The infant was well nourished and was nursed by its mother. The diagnosis of melaena l^eQnatorum was made by the attending physician and I agreed in the diagnosis. 42 HEMORRHAGIC DISEASES OF THE NEW-BORN. The treatment consisted in the application of a solid stick of nitrate of silver to the umbilicus, and strict aseptic dressing. The haemorrhages were probably due to pyogenic infection. Treatment. — Umbilical hsemorrhage can best be controlled, as above cited, by the application of a solid stick of nitrate of silver followed by a dusting powder, such as: — T^ Aristol, Alum usta , aa 3ij, or 8.0 Sig. : Dust over umbilicus. Thromboplastin has been recently used by me to control intestinal hemorrhage. Twenty cubic centimeters of this liquid should be diluted with 8 ounces of water. Excellent results were* obtained in a child seven years old who received, by mouth, a tablespoonful of this dihition, every half -hour. Twelve doses in all were given. This preparations can be pro- cured from the Eesearch Laboratory of the New York City Health Department. For the control of intestinal hsemorrhage astringent injections are not to be relied upon. The suprarenal extract is a very good haemostatic. I have frequently used very small doses of hydrastine hydrochlorate, ^/go to ^/loo grain, three times a day, or % to % grain suprarenal extract, repeated every hour. The injection of 15 cubic centimeters to- 30 cubic centimeters of sterile horse serum is an excellent hsemostatic. In the case of a ''bleeder" recently seen by me in the Babies' Wards of the Sydenham Hospital, one injection of horse serum controlled the haemorrhage, due to a paracentesis, after all local means failed. If bleeding continues in spite of the injection of horse serum, an injec- tion of 15 to 30 cubic centimeters of human blood serum may be tried. If the latter fails we should resort to transfusion. Transfusion has been recommended by Lambert in hsemorrhage of the new-born. CHAPTER V. INJURIES OF THE NEW-BORN. Fracturks. Traumatism during labor is the cause of most fractures in the new- born baby. A predisposition may exist, due to defective ossification. When the skeleton is no£ properly developed, then a separation of the epiphyses of the long bones rather than an actual solution of continuity of the diapheses occurs (Ballantyne). This author also doubts the osteomalacic nature of fractures. Ante- natal fragility seems to exist by direct heredity. Griffith reports seventeen fractures occurring in one case^ during the first two years of an infant's life. Thus we can see that there must be some other factor at work per- mitting recurring fractures, rather than invariably traumatism. It is true that syphilis has frequently been given as a possible cause for a weak-boned skeleton. Bfittle bones have been attributed to rickets. Prenatal disease on the part of the infant or its mother is frequently the cause of fracture. Linck- describes a case of an infant that was born in little more than one pain. In this case there was found over thirty fractures in the limbs and ribs. Most of the fractures seen are of the "green-stick" variety. The prog- nosis in these cases is usually good, unless some complication appears. The following case was seen by me in consultation with Dr, A, S. Bienenstock, of New York: — An infant two days old had a fracture of the humerus. Tlie seat of the fracture was in the center of the bone, and not near the epiphysis. Mother's History. — The mother of the infant suffered with diabetes for the previous eight years, having between 4 and 4.5 per cent, of sugar. During the latter months of pregnancy she was in a subnormal condition. The labor was dry, and quite some skill was required to deliver the infant. The mother had no breast-milk, so artificial, feeding was resorted to. As this was in midsummer the infant soon became dj'speptic and later developed entero-colitis. At the seat of the fracture callus could be felt several days after I first saw this infant. Death resulted from summer complaint. Obstetrical Paralysis (Erb's Paralysis or Birth Palsy). This condition may be seen soon after birth, or it may not be noticed for several days after that event. It is a peripheral paralysis and usually ^American Journal of the Medical Sciences, Chap. CXIII, p. 426, 1897. *Arch. of Gynaek., x.\x, 264, 1887. (43) 44 INJURIES OF THE NEW-BORN. involves the deltoid, biceps, brachialis anticus, supraspinatus, infraspinatus, and supinator longus muscles. It may also involve the extensor muscles of the wrist. Symptoms. — The arm hangs limp at the side of the body. The position is governed by gravitation. The forearm is extended and pronated, and the wrist and fingers flexed. Movement does not cause pain. The reaction of degeneration can be demonstrated when the paralyzed muscles are exam- ined with the electric current. Such examinations are very difficult in in- fants having a thick layer of fat. At times very powerful currents are necessary, thus provoking pain. In making an electrical test, the normal arm should always be compared with the affected arm. Erb demonstrated the fact that "it is possible by a careful examina- tion to find a spot two centimeters above the clavicle, back of the outer edge of the sternomastoid muscle, corresponding to the point of emergence of the sixth cervical nerve between the scaleni, at which point irritation by the faradic current will produce a contraction in the deltoid, biceps, brachialis anticus, and supinator longus muscles; and if the irritation be increased, the extensors of the wrist will also contract. Pressure upon this particular region is often made during delivery, either by the clavicle, or by forceps, or by the fingers of the obstetrician. This is more common when there is a breech presentation and the after-coming head is extracted in the common method. The index and middle fingers of the left hand being open like a fork over the shoulders of the child, traction is commonly made upon the shoulders, and the pressure of the obstetrician's finger in the neck often produces injury of the plexus. In some cases injury of the plexus is produced by attempts to bring down the hand or arm in breech presentations, or to replace these when the head presents. Forceps appli- cations in an awkward position may also produce this injury." Progpiosis. — This depends on the time when the treatment is com- menced. As a rule paralysis of the upper-arm type remains three or four years. In a case of mine seen recently the paralysis remained until the child was 5 years old. When the faradic current is applied and the muscles respond, then the prognosis is good; if there is no response, a cautious prognosis should be given. Treatment. — The arm should be supported with a sling. Massage aided by a faradic current is sometimes beneficial. In severe cases it is better to use the galvanic current, using the mildest current that will produce con- traction of the muscles. If the child is old enough to be instructed, gym- nastics should be tried at home daily. Strychnine may be given three times a day. CHAPTER VI. ASPHYXIA NEONATORUM (APPARENT DEATH OF THE NEW-BORN). The center and regulator of tlie respiratory movements is located in the medulla oblongata From it ako is sent the motor impulse which gives rise to the fir. t act of respiration. The activity of this center is believed to be augmented b}' the condition of the venosity of the blood; therefore, all interruptions to placental re?pira- tion — for instance the premature detachment of that organ or the com- pression of the cord — and all obstacles to the introduction of air into the trachea, such as mucus or blood, will be attended with violent motor im- pulses: first, efforts to breathe, and later, convulsive movements producing death (Boisliniere). There are two forms of this condition usually observed : first, the apoplectic form called by older Avriters livida, and second, the antemic form called by older writers pallida. In the apoplectic form there is a bluish discoloration of the skin, a prominence and injection of the conjunctivae, and a swollen state of the face and lips. The cardiac pulsations are gener- ally strong, and the cord is distended with blood. In the anaemic form the child has a degfdly pallor; the lips and fingers are pale, the body limp, and muscles relaxed. .The heart's action is inaudible, presenting the condition known as asystole. Duvergie, in studying the asphyxia of adults, noted that when people were removed shortly after an embankment of earth had buried them, they presented a turgescence of the face, a violent hue of the skin, and frequent and regular pulsations of the heart. When they were found some time after an embankment of earth had buried them, they presented a deathly pallor of the skin, and the heart sounds were usually inaudible or very feeble. Thus it is apparent that the above conditions of asphyxia present, first, a mild; and then a severe type. Causes. The main causes of asphyxia are due to: — 1. Compression of the cord in a natural way. 2. Premature detachment of the placenta. 3. Forced rotation of the head in difficult forceps application or great contraction of the uterus in head-last cases, thus rendering the vessels of the uterus impermeable to blood and suspending the placental respiration. Another cause of asphyxia is shortness of the cord from its encircling the neck tightly after the head is born. The child's face in this condition be- (45) 46 DISEASES OF THE NEW-BORN. comes turgid and blue, and unless relieved the child will die. The promptest treatment consists in cutting the cord above the child's head and delivering the infant's body as quickly as possible. Boisliniere advises the above method even at the risk of fracturing a humerus. Sign for Distinguishing the Stillborn from the Dead. Bedford Blown says that, the best means for distinguishing the still- born from the dead is to be found in the temperature. If the temperature keeps near the normal, we must not cease our efforts at resuscitation, even if the complete suspension of cardia,c and respiratory action has lasted for twenty minutes or more ; but if the temperature of the child suddenly falls 10, 15, or 20 degrees below the normal, then the case is hopeless. Another sign is the, state of the pupil : in the dead the pupil is widely dilated, in the stillborn it is but little, if at all, relaxed (Therap. Gaz., Vol. XXXI, No. 6). The method consists in injecting into each arm 5 drops of whisky with 1 drop of tincture of belladonna. If the infant is only stillborn, the nervous and circulatory system respond quickly. If there is no response or only a very feeble one, warm sterilized water is injected under the skin (a drachm or two) and also about 2 drachms with a drop of aromatic spirits of ammonia, into the intestines. After this dry heat is applied. If these measures fail to produce a reaction, it is a fair test of the absence of vitality. Treatment. — If the child presents a livid condition and is apparently apoplectic with the cord pulsating strongly, then cut the cord as soon as possible and allow at least an ounce of blood to escape. Sometimes it is necessary to cut the cord in several places. If bleeding does not ensue rap- idly, then the cord should be severed and placed in warm water at a tem- perature of 105° to 110° F. This will usually stimulate the flow of blood. When the child is born in a pallid condition and feels cold, then the cord should not he cut until all pulsations therein have ceased. It is in this condition that it will be so important to rapidly cleanse the mouth, nose, and larynx of mucus and blood. Some authors advise mouth-to-mouth suc- tion or suction made through a soft-rubber catheter placed in the larynx, but these are usually preliminary means, and success will only follow me- thodical application of artificial respiration. Byrd's method is very simple. It can be conducted without rough handling, a matter of vital importance. The child's body rests on its back and is supported on the palm surfaces of the physician's hands. The physi- cian, by elevating and lowering his hands, can produce inspiration and expiration in a rapid and efficient manner. This method is well worth trying. An important point to remember is to pull the tongue forward; for this purpose an artery clamp will serve in an emergency, if the physician does not have Laborde's forceps for traction on the tongue. PLATE JII The Byid-Dew IMethod of Artificial Respiration. A. Extension. B. Semi- tlexion. C, Complete flexion. (C4randin & Jarman.) ASPHYXIA NEONATORUM. 47 Labor de advises rhythmical traciion upon the tongue- eight or ten times a minute. This is a valuable method and can be used while the child is immersed in hot water. Thus, the benefit of the stimulus on the tongue will be apparent while the hot bath is used. Hypodermics of strychnine, Vioo grain, combined with 5 or 10 minims of whisky, may be indicated. Flushing the colon with a pint or more of water, temperature 110° or 115° F., to which a half-drachm of alcohol has been added, may also aid in stimulating the circulatory and the respiratory tract. It is advisable to persevere for some time with the above method of resuscitation, even though we may be successful. It fre- quently happens that new-born infants will respond to active treatment and show signs of life, but we must continue for some time, or the respirations will cease and the infant may die. Fig. 15. — Ribemont's Tube for Inflating the Lungs. A valuable means of restoring suspended animation consists in im- mersing the new-born infant, first, into very warm water, and then into cold water. Alternate from hot to cold water every ten or fifteen seconds. Inflation of the Lungs. This method is sometimes useful when other means fail. Some authors advise the mouth-to-mouth method. This consists in filling the cheeks with fresh air and then blowing the same into the infant's mouth. It can also be done by introducing a catheter into the infant's larynx. While the mouth- to-mouth method is simpler, it is not always a sure way of inflating the lungs. Quite frequently the air will be blown from the mouth, through the pharynx, into the stomach. To avoid the latter, the head should be thrown backward, and compression made over the epigastrium. If the nose is closed, air is less likely to enter the stomach. M'outh-to-mouth insufflation of air is not devoid of danger. Reich reported a case of tuberculous meningitis due to attempts at reanimation by a tuberculous midwife. The Ribemont laryngeal tube is much safer. 48 DISEASES OF THE NEW-BORN. Eibemont's tube for inflating the lungs is inserted like an intubation tube. It serves two purposes : — 1. Forcing air into the lungs. 2. The aspiration of mucus from the trachea or bronchi. Great care should be used with any and all methods. No force is necessary. INFANT PULMOTOR Fig. 16. — Infant Pulmotor. Literature records many successful cases of resuscitation of the asphyxi- ated child with the aid of the Draeger pulmotor. ^ The infant pulmotor weighs twenty poimds and is carried in a box about 19 inches by 10 by 5. It contains a cylinder of oxygen. Each cylin- der contains oxygen sufficient for the continuous working of the apparatus for one hour (Fig. 16). Two flexible metal tubes connect the instrument with the mask: one H. D. Fry, Surgery, Grynecology, and Obstetrics, Oct., 1913. ASPHYXIA NEONATORUM. 49 forces the oxygen into the lungs under the required pressure ; the other is for suction, and removes the vitiated air from the organ. Technique. — The mouth, throtit, and upper air passages are freed of mucus by gauze wrapped round the finger and by holding the infant head downvi^ard. It is then placed in the dorsal position upon a table or hard surface, shoulders raised and head extended. If relaxed, the lower jaw must be held up and pushed forward. The tongue is pulled well out with a silk thread passed through the tip. This is preferable to the forceps or tenacu- lum, as it does not interfere with the close application of the mask. The mask is tightly applied to the face, covering the mouth and nose, and held firmly by an assistant or by a rubber band encircling the head. The trachea is pressed gently against the spine so as to close the oesophagus, and if this is not enough to prevent distention of the stomach a small gauze sponge, attached to a string, can be placed in the oesophagus below the larynx. Inspiratory and expiratory movements are induced by moving the lever alternately from side to side, filling the lungs and expanding the chest walls, holding the inflation for a few moments, and then deflating the lungs. If the infant should make any voluntary effort to breathe, the manipulation of the apparatus should be so timed as to inflate during the inspiratory efforts and deflate during the expiratory. Efforts to resuscitate the infant should not be abandoned as long as there is any heart action. CHAPTER VII. FCETAL ICHTHYOSIS. This condition is described by Ballantyne, Kyber, Wassmuth, and Carbone as a skin disease of the foetus most probably developed about the fourth month of intrauterine life. It consists of horny epidermic plates over the whole surface of the body, separated • from each other by fissures and furrows, associated with certain deformities of the mouth, nose, eyes, ears, and extremities, and leading to the death of the infant very soon after birth. It is a rare condition, as only 43 cases could be found in the whole literature up to the year 1895. For the following case I am indebted to Dr. A. S. Daniel :— Clinical History. — This case was first seen five hours after birth. The child had passed urine and meconium, cried continuously, sleep was impossible. The slightest jar of the crib or exposure to the air increased the crying. The respiration was irregular, the surface of the body cold. The child swallowed with difficulty and was fed with the aid of a medicine dropper. The child died suddenly twenty- four hours after birth. The temperature taken soon after birth was 103° F. Description of the Child. — There was no resemblance between the child and a human being or any living thing. The tongue was the only part of the body that seemed capable of motion. The body presents the appearance of having been in an integument much too small for the skeleton, and Nature in its growth had so stretched the skin that it has the appearance of being torn in some places. Where it is torn through, a piirple-covered slit appears; where torn partly through, a yellowish-colored fissure remains. There is no uniformity of arrangement of the fissures. Fewer are found on the back, and those on the extremities are more shallow. The color of the fissure, a purplish red, is in marked contrast to the color of the skin. In a few places bright blood is found, as if the break were of recent origin. The whole body is cold and rigid. The scalp is divided into fissures and numerous irregular conical projections, varying in size. A few thin hairs are found on the lateral surface of the scalp. The external ears are replaced by conical projections. The palpebral fissures are filled with purplish-red masses; deep down in the sockets, eyeballs can be distinguished. The nose is fiattened and is identified by the widely opened nostrils. The mouth is open, showing a non-hypertrophied tongue. The lips are of a purplish-red color. The mouth measures 5 centimeters in length. Circumference of head, 36.5 centimeters; glabella to occiput, 18.5 centimeters; ear to ear, 15.5 centimeters. The neclc is short. Anteriorly a fissure extends from the neck to the umbilicus, 2 centimeters in width. From this fissure, ridges of yellow skin and purple fissures extend toward the axillae; they are of irregular size and depth. The extremities are rigid and in the foetal position. The arms can be raised only at right angles with the body. They cannot be extended at the elbow. The (50) FCETAL ICHTHYOSIS. 51 hands are thickened and the fingers are rudimentary. Tlie legs are crossed. The motion at the hip and knee joint is very imperfect. The toes are rudimentary. The median raphe in the scrotum is faintly marked; testicles are not descended. The penis is Yj centimeter in length. The anus is open. The length of the fcetus is 42 centimeters, and its weiglit is 4 pounds 13 ounpes. In this case it was impossihle to find any clinical cause for the disease. Of the cause of foetal ichthyosis practically nothing is known. That it is not a fatal disease in utero is demonstrated hy the fact that only one case thus far has been stillborn. CHAPTEK VIII. INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. Icterus ISTeonatorum. This form of icterus is frequently designated as a physiological con- dition. It usually begins on the second or third day after birth, and may continue for a week or even a month. Henoch reports a case of icterus brought to his clinic which lasted five weeks and ended fatally. The ma- jority of text-books describe this condition as a mild disease and give a good prognosis. There are many theories as to the causes leading up to this condition. The hasmatogenic theory maintains that a disintegration of red corpuscles takes place. This liberates the hgemogiobin, giving rise to the yellowish pigmentation. Eacchi, of Naples, disproved the correctness of this theory by a series of blood-counts which he reported at the International Medical Congress held at Eome in 1895. "We can scarcely believe that the red corpuscles simply go to pieces in the blood, and that the products of such disintegration, floating freely about or temporarily lodged in the tissues, give rise to the yellow color. It is far more in accordance with the workings of the living organism to suppose that the disintegration takes place in some organ, e.g., liver or spleen, and if the products thereof are floating about, it is after passing such organ and on their way to final elimination." Infant F. J. was seen by me when three days old. Had greenish stools con- taining mucus, and appeared colicky and cried considerably. No vomiting. There was a universal yellowish pigment of the body; jaundice well marked; gums were yellowish; conjunctival mucous membrane showed yellowish pigmentation. The umbilicus was somewhat excoriated and moist from the presence of pus. The diagnosis made was septic omphalitis, resulting in hematogenic jaundice. Very small doses of calomel, 140 g'"^'"? several times a day, were ordered; also colon irrigations with chamomile tea. The infant was nursed by its mother. Aseptic treatment of the umbilicus with sterile gauze, cleansing with bichloride, and then dusting the parts with talcum salicylicuui quickly henled the inllammatory con- dition. The infant recovered in about one week, showing no sign of its previous jaundice. The following case is noteworthy owing to its rarity; — An infant was born of apparently healthy parents. Dr. Mehrenlander, the physician in attendance, stated that there was nothing, abnormal at the time of birth. The infant weighed about seven jjounds. It was the fourth child. Three children of this same family had previously died on the third day after birth. They (52) SCLEREMA NEONATORUM. 53 were to all appearances healthy, but were jaundiced. Nothing was noticeable with them, excepting the yellow pigmentation of the skin. The child died before I ar- rived at tlie bedside. It was three days old. The skin then presented a deep yellow- ish-green pigmentation, more marked on the abdomen. The conjunctival mucous membrane was deeply pigmented. There was no inflammatory condition noticeable in tlie region of tiie umbilicus. The cord was dressed witli aseptic gauze, and no infection was suspected from this channel. The attending physician suspected sypliilis in the father. There were no" other symptoms. Neither vomiting nor diarrhea. A stool passed before the infant died, which looked like meconium. An interesting jwint about the ease is that this was the fourth child in that family which died of icterus neonatorum a few days after birth. The child died witliout any apparent suffering, showing no symptoms of illness. The temperature when taken was normal. Zweifel describes a series of cases of icterus resulting from the effects of chloroform passing through the placenta. The writer has noted the asso- ciation of icterus neonatorum in a large number of children born after a severe labor, requiring prolonged chloroform narcosis. This may have been. accidental, yet it is ivorth noting. James D. Voorhees, in responding to my question concerning the asso- ciation of chloroform anaesthesia and icterus at the Sloane Maternity Hos- pital, states that "all women receive chloroform at said hospital, and about 33 per cent, of the infants born are jaundiced. All premature infants also are jaundiced." Sclerema Neonatorum. This disease is characterized by a hardening or thickening of the skin and the subcutaneous cellular tissue. The pathological lesions have been carefully studied by Xorthrup. His case was a foundling born amid insani- tary surroundings. When five days old the legs were swollen and the feet as hard as a board. The swelling spread upward, involving every part of the body. The temperature in the rectum was 35° C. (95° F.). The infant died on the ninth day. The body felt as though it were frozen. Osier also describes this condition in this country. Symptoms. — An oedema-like swelling, very cold to the touch, and very hard on palpation, involving circumscribed areas, appears soon after birth. I have seen sclerema spread from the shoulders to .the trunk and arms. The infant appears very sick. The temperature is subnormal, and recovery is rare. Was called to see an infant five days old. Found the trunk swollen, the hands and feet cold, and the temperature in rectum subnormal. The infant refused the breast and had no strengtli. Brandy and water were prescribed. ]\Iustard foot-bath ordered, and one pint of warm saline solution" injected into the colon. Tliere was no nausea or vomiting. No retention of urine. Sclerema neonatorum was diagnosed. The swelling spread, involving tlie legs and arms, until the whole body, including the 54 INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. face, was puffed and hard. The infant could no longer open its eyes and died on the ninth day in convulsions. Mastitis Neonatorum. The new-born infant frequently secretes a fluid in the mammae. Fe- males, both human and animal, occasionally secrete milk without having been previously pregnant. With regard to the milk secreted by infants, there is some doubt about its real nature. Kollicker does not view it as a true milk, but considers its appearance connected with the formation of the mammary glands. This secretion is also known as witch's milk. Sinety, on the other hand, upon anatomical grounds, considers it a true lacteal secretion. It probably is a sort of imperfect milk, loaded with leucocytes, and this is the more likely as Vollard^ notices that it frequently ends in abscess. Schlossberger gives an imperfect quantitative analysis of a sample of milk obtained by squeezing the breasts of a new-bom infant, a male. In the course of a few days about a drachm was obtained. The following was the result of the analysis : — Water 96.75 Fat 0.82 Ash 0.05 Casein, sugar, and extractives 2.83 Sugar-reaction strong The most complete analysis we possess of such milk is by von Gesner : — Milk-fat 1.456 Casein 0.557 Albumin 0.490 Milk-sugar 0.956 Ash 0.826 Water 95.705 Total solids 4.295 I was called to see a female infant six days old. The mother told me that the breasts were swollen and contained milk. The same could be expressed by gentle stroking of the mammse. The treatment consisted of the application of an ice-bag and inunctions of: — IJ, Ung. ext. belladonna 2 drachms Ung. hydrarg. cin 1 drachm Cold cream 1 ounce M. Apply on linen with tight compresses. After several days the breast dried and the swelling disappeared. Another infant, three weeks old, was seen by me recently, in consultation. The mother was delivered by a midwife, and her condition as well as that of the infant * "Traits des Maladies des Enfants Nouveau-nfis," third edition, 1837, p. 717. PERITONITIS IN THE NEW-BORN. 55 was apparently normal. The infant's breasts, when seven days old, appeared tender and swollen, and the mother was advised to poultice them with flaxseed. This she did, and in addition squeezed the secretion from the infant's breasts. Tliis trauma- tism caused irritation, inflammation, and finally the formation of an. abscess. An incision was made, the pus evacuated, and the wound healed. It is important to remember that the lacteal secretion in an infant's breast is a physiological condition, and if undisturbed will be absorbed gradually. Erysipelas in the New-born. When this disease occurs in the new-bom, and the mother has a septic peritonitis or other infectious disease, the infant should be immediately isolated from the mother. The symptoms are the same as those seen in erysipelas of older children, although vomiting and symptoms of general sepsis most often accompany this condition. The fontanel is depressed. Prognosis. — The prognosis is usually very grave, especially so if the infant must be removed from its mother's breast. Treatment. — The strictest antisepsis must be used. An infant should be placed under the care of a trained nurse, and all instructions in regard to the hygiene of the infant must be strictly carried out. The general plan of treatment is the same as that outlined in the chapter on "Erysipelas." Tuberculosis in the Nev^-born. The transmission of tuberculosis from the mother to the new-bom is extremely rare. Cases are on record in which the tubercle bacilli were transmitted from the mother to the infant. An occasional transmission of tuberculosis takes place through the placenta. The reason for the infre- quency of this occurrence is that the blood of a tuberculous patient rarely contains tubercle bacilli. Schmorl and Birch-Hirschfeld believe that ma- ternal tuberculosis can be transmitted, but not before the end of the fifth month of pregnancy, and that the placenta is always tuberculous when the foetus is infected. (For further details see chapter on "Tuberculosis.'^) Peritonitis in the New-born. Under "Septic Omphalitis" I have described a case of septic infec- tion seen in consultation practice. The case recovered. At times the in- flammatory condition will extend from the umbilicus to the peritoneum, and thus a septic peritonitis results. Bacteriology. — In such pyogenic infections the streptococcus can be found. The bacteria gain entrance directly through the umbilical vessels. Pathology. — The same lesions affecting the serous membrane, as the pleura and the pericardium, are found in the peritoneum. Adhesions fre- quently remain. 56 INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. The symptoms, prognosis, and treatment are described in the article on "Acute Peritonitis/' Part V. Pemphigus Neon-atorum.^ This condition is seen occasionally in the new-born infant. It consists of blebs, which contain yellow sermn. In size they vary from that of a pea to that of a small bean. When these rupture they are replaced by superficial ulcers covered with a thin, black crust. Sometimes a violet stain is left, which may last for some time. The duration of each bulla is about one week. The location of the eruption is on the palms of the hands and the soles of the feet. It is a streptococcus infection. The cases seen by me have in- variably occurred in poorly nourished children such as we find in athrepsia (marasmus). ' See article on "Chronic Pemphigus." CHAPTER IX. ABNORMALITIES AND CONGENITAL MALFORMATIONS. Angeioma. Circumscribed dilatations of the blood-vessels or capillaries are occa- sionally seen in the new-born baby. Spongy tumors consisting of tortuous blood-vessels of a bluish-red color are usually seen. These tumors are filled Fig. 17. — Infant ten months old. From my children's service at the German Poliklinik. The mass of bluish, tortuous vessels interfered with the eyesight. Bleeding was very easily provoked. Surgical treatment was the only means of eradicating this mass. (Original.) with blood and grow very rapidly. In a case seen by me (see Fig. 17) the mass was adherent to the forehead and completely obliterated the sight of the left eye. This condition is one that can easily be remedied by prompt surgical treatment. Some cases will, if neglected, ultimately result in sarcomatous degeneration. Treatment. — Injections into the mass of a 5 per cent, nitrate of silver solution, or destroying the mass with a galvanocauter}^, chromic acid, or (57) 58 ABNORMALITIES AND CONGENITAL MALFORMATIONS. nitric acid, are most generally used. A good plan is to apply first pure carbolic acid, after which the fuming nitric acid should be used. This latter method is painless and effective. Harelip. This congenital deformity is frequently seen in children. Sometimes it is simply "a slight indentation in the lip, or the fissure may extend to the,. nostril." The treatment is surgical. V Fig. 18. — Harelip Nipple.^ Cleft Palate. This abnormality is frequently seen in children. While the soft palate only may be affected, it not infrequently happens that the fissure extends through the hard palate, thus causing a wide gap in the roof of the mouth. Feeding Children with Cleft Palate. — An infant bom with cleft palate has a greater struggle for existence than a child born without this deformity. It is advisable to give the best possible food, and, therefore, breast-milk only should be used. The milk should be drawn from a woman's breast by means of a breast-pump, as described in the section on "Specimen of Breast- milk for Chemical Examination." An artificial nipple should be attached to the feeding-bottle, and to the former should be attached a flap of India rubber so made that it fits the roof of the mouth. The pressure of the nipple against the piece of rubber, when in position, converts it into an artificial palate-piece, and prevents the escape of the milk into the nose during the effort of swallowing. This shield is chosen to avoid permitting curdled milk to pass into the recesses of the turbinated bones and to cause aphthous patches. (See Fig. 18.) It is advisable to operate on an infant for this deformity between the third and sixth months of its life, if sufficient progress in its development will warrant it. When the above method of feeding is not satisfactory and the child shows evidences of starvation, then we must resort to gavage. (See article on '^Gavage.") Our aim should be to build up the infant from its birth, with breast- milk if obtainable. In one case known to me the breast-milk was pumped * This harelip nipple can be procured from the Miller Rubber Manufacturing Co., Akron, Ohio. CONGENITAL ADENOIDS. 59 off every four hours and tlie infant was nourislicd by gavago with this milk. When breast-milk is not obtainable, then properly modified milk should be used, to conform witb the age and requirements of the child. If the child does not assimihite its food properly, the operation should be postponed until tile child is built up and strong enough to stand the operation; hence the guide for estimating the time for the operation is dependent more on proper feeding than on any other factor. Hygienic measures are very important, as the irritation by food will frecjuently cause inflammation in the mouth. For details of the surgical treatment the reader is referred to the many good text-books on operative surgery. Tongue-tie (Adii/Esia Lingu.e). Tongue-tie consists of an abnormally short frsenum. In some instances it may interfere with nursing, and possibly with speaking. It is one of the most trivial disorders of infancy. Treatment. — Incise the frtenum near its attachment to the tongue with a pair of curved scissors. The incision may be enlarged with the aid of some dull instrument. Some authors advise using the finger-nail, which latter, however, is not aseptic. A tongue-tie should not be operated upon if an infection exists in the immediate surroundings. The after-treatment consists in using a bland mouth wash, such as a 1 per cent, listerine solution, or 1 per cent, alum solution, especially after feeding the child. Congenital Adenoids. We occasionally meet with infants in which this condition exists. This mechanical impediment prevents breathing through the nose. An infant, therefore, is at a great disadvantage, because it cannot breathe while nurs- ing. The following case will serve to illustrate this condition : — I was called to see an infant, Mary W., in consultation. The attending physi- cian gave me the following history: The infant is twenty days old and weighs 6 pounds and 14 ounces. At birth she weighed 7 pounds. She was nursed at the mother's breast for about one week. Tlie infant seemed to dislike the breast, as she would draw and immediately let go of the nipple. The mother believed the infant did not like the taste of her milk. A wet-nurse was procured, and the same trouble was encovmtered ;■ the infant would take one swallow and then let go of the nipple in order to get her breath. A nipple-shield was then used, but the same difficulty was encountered. The family believed that the infant did not like breast-milk, so she was given bottle feeding. She took the nipple of the bottle, drew quite well, and then let go, when it was necessary for respiration. I ordered spoon feeding, and this worked qjuite well. The breast-milk was pumped from the wet-nurse and fed by spoon. This method was successful. The child swallowed a spoonful of milk and then had a chance to breathe. An examination of the rhino-pharynx revealed adenoids. These were removed with the aid of a sharp spoon, and three days later normal conditions existed. 60 ABXOR]VIALITIES AND CONGENITAL MALFORMATIONS. The infant was again put to the breast when six weeks old and continued to nurse successfully for six months. She was then weaned, owing to the illness of the wet-nurse. Cows" milk was substituted. The child is today a perfectly healthy little girl. Peoteusion of the Eabs. Protrusion of the ears is frequently seen in children. The anxious mother will consult the phj-sician regarding the treatment. These cases are easily managed in very young infants. A fenestrated cap, closely fitting to the head so that the ears are well held back in their normal position, has served me very well. Young infants object to having their heads covered, but soon liecome accustomed to this cap, as it is only worn at night and removed in the morning. It is advisable to change the cap frequenth', as some children perspire from its use. It must be worn for months before any benefit is noted. In very severe cases in which the above treatment is not successful, it may be necessary to call in the surgeon. The operation is a simple one and the result is excellent. Abnoemalities of the Aie Passages. When there is deficient oxygenation of the lungs, collapse frequently occurs, and is called atelectasis pulmonum. This condition is due to the unaerated condition of the vesicles. The trouble is usually found in the nasophar}'nx in the form of adenoids, unless some rare malignant condition is present. Many pigeon-breasted children — with apparent rachitic manifestations of the thorax — owe this anatomical peculiarity more to improper oxj'gena- tion of the lungs than to improper feeding. In such children it is not rare to meet with congenital adenoids. (Eead article on "Congenital Ade- noids.") It is to be understood that changing the food or giving restorative treat- ment, such as iron or codliver-oil, cannot cure such a child until the cause is eradicated. Congenital Stenosis of the Larynx. In the chapter on "Inherited Syphilis" I describe a case of syphilitic stenosis of the larynx which necessitated a tracheotomy. Several years ago a child was brought 'to my clinic suffering with cyanosis and difficult breath- ing. Intubation was tried without affording any relief. As a last resort tracheotomy was performed, but this afforded no relief. A post-mortem examination showed that we were dealing with a diverticulum of the trachea. In addition thereto the larynx and trachea were lined with a series of syph- ilitic ulcerations. CEPHALHEMATOMA. 61 Prominent Sternum. This is frequently ealled pigeon-breast. It is usually seen in older C'liildron. It is occasionally seen as a result of Pott's disease, but more fre- quently it is associated with rickets. It has been described by me in the chapter on "Eachitis." Depressed Sternum. Congenital depression of the sternum is occasionally seen in very young infants. It is more frequently seen as a funnel-shaped depression, and is a symptom of structural weakness. It more often accompanies a general rachitic manifestation, to which I call attention in the chapter on "Kachitis." Hematoma of the Sterno-mastoid. During labor traumatic conditions frequently induce haemorrhages. These conditions are, therefore, seen in natural labor with very large chil- dren, or when forceps are used. Pressure is cited by most authors as one of the causes of this condition. Henoch believes that hsematoma of the sterno- mastoid is caused by twisting the head during labor. The swelling is due to an extravasation of blood and to inflammatory conditions of the muscle. It is rarely seen before the child is two or three weeks old. There is no treatment necessary. The blood is absorbed and the swelling gradually disappears. Cephalhematoma. A swelling is sometimes seen on the top of the head during the first few days of the infant's life. It is usually associated with the application of forceps or a similar injury during labor. This condition is rare in chil- dren. The statistics of the Sloane Maternity Hospital show that this con- dition was met with in 20 out of 1300 consecutive births, or 1.6 per cent. There may be several swellings. They are most frequently seen over the parietal or occipital bone. Symptoms. — A swelling that is very soft and fluctuating is noticed. This swelling gradually increases in size, and attains its maximum at the end of twelve or fourteen days. There is no pulsation palpable. The tem- perature is usually normal. Diagnosis. — This condition is frequently mistaken for encephalocele. The latter, however, is always seen in conjunction with the fontanel or along the line of the sutures. Pressure causes cerebral symptoms. This condition can be confounded with hydrocephalus. In the latter the symmetrical enlargement of the whole head is always a characteristic feature. 60 ABNORMALITIES AKD CONGENITAL MALFORMATIONS. Baby M., seven days old, was born with the aid of forceps, after a very diffi- cult and dry labor. When the infant was three days old a swelling was noticed on the scalp over the left parietal bone. This swelling gradually increased in size and felt soft, doughy, and fluctuating. An incision was made which liberated about four ounces of clear, fluid blood. Several days later this case was also seen by Dr. Willy Meyer, and as suppuration existed it was necessary to treat the wound on general surgical principles. The child recovered. Treatment. — The above case illustrates the mistake that can be made. A haematoma is a benign condition and disappears without treatment. Bandaging and compression are unnecessary, but injury to the part must be avoided. Caput Succedaneum (Spurious Cephalhematoma: Supplementary Head). This is a swelling of the scalp due to congestion, resulting in an ex- travasation of the blood and lymph into the subcutaneous tissue which is external to the pericranium. This swelling does not fluctuate. It is usually seen in that portion of the head which first presents itself at the vulva dur- ing labor. No treatment is required, as this condition usually becomes normal. Congenital Cyst of the Kidney. The literature records an occasional case of this condition. There are no symptoms which would be the means of determining this condition dur- ing life. The diagnosis is therefore made post-mortem. Fig. 19. — Congenital Cystic Kidney, half natural size. ( Langerhans. ) Congenital Sacral Tumor. J. B., male infant, eleven months old, was brought to my children's service at the German Poliklinik. He was breast-fed and appeared in good health. The mother noticed a large swelling over the sacral and lumbar regions. The infant did CONGENITAL MALFORMATIONS OF THE RECTUM. 63 not seem to be in paiu. The growth was non-inflammatory and did not interfere with the movements of the legs. The diagnosis of congenital lipmna was made and an operation advised. The case was sent by me to Dr. Geo. F. Shrady for operation at St. Francis Hospital. The tumor was removed. The ease recovered. Fig. 20. — Congenital Sacral Tumor. (Original.) Congenital Malformations of the Eectum. E. E. Kirby^ states that these occur under the following types : — 1. Congenital narrowing of the anus or rectum, without complete occlusion. The anal aperture is at times preternaturally small, either in consequence of a contraction of the lower end of the rectum, or from the fact that the skin may extend occasionally over the border of the anal mar- gin. The diagnosis is usually easy, for the contraction is near the anus and can be readily detected by the finger, or seen when due to a fold of skin extending across the anus. The treatment consists in dividing the ring or skin on the dorsum, and daily dilatation, either with the finger or soft-rubber bougie. 2. Closure of the anus by a membranous diaphragm (atresia of the anus) is the simplest of all fonus of congenital malformations, and is treated by a crucial incision through the membrane. 3. In imperforate rectum one may expect to find some of the most diffi- cult cases of malformation, although some are comparatively simple. In- stead of a normal anus the skin of the perineum extends across the anal region from side to side, and the rectum may terminate quite a distance from the normal site of the anus. The intervening space may be made up of connective tissue, while a circular elevation or depression marks the nor- mal site of the anus. Occasionally a distinct fibrous cord may be traced ^"Congenital Rectal Malformations." Archives of Pediatrics, August, 1897. 64 ABNORMALITIES AND CONGENITAL MALFORMATIONS. from the rectal pouch to the skin. If the rectal pouch be not at too great a distance from the skin^ a sense of fluctuation may be felt by firm pressure of one finger over the anus and the hand over the abdomen. 4. The system which separates the anal and rectal pouches in cases of imperforate rectum with a normal anus is generally within easy reach of the anus. It may be perforated and slow dribbling of meconium allowed. There may also be more than one septum. 5. The anus may be absent and the rectum open at any point in the perineum or sacral region. The lower portion of the rectum in these cases is usually of a fistulous character, lined by true mucous membrane, and the abnormal anus is always narrow and insufficient for its purpose. Occasion- ally the rectum terminates in two distiiict openings, at a greater or less distance from each other. 6. The anus may be absent and the rectum terminate in the bladder, urethra, or vagina. In females the vaginal opening is the most common ; in males the vesical. This condition is usually rapidly fatal unless relieved by prompt surgical interference. 7. The rectum or the large intestine may be entirely absent. Kirby lays down the following rules : — 1. An operation should always be performed, and performed without delay. 2. If there be any chance of establishing an opening at the normal site of the anus, the surgeon should at first direct his attention to this procedure. 3. The use of a trocar as an aid in finding the rectal pouch before or after incision through the perineum is not sanctioned by modern surgical authority. 4. The results of attempts to estal)lish an outlet for tlie imperforate rectum through the perineum are not favorable as regards the production of a useful anus. 5. In case of failure to establish a new anus in the anal region, colotomy should at once be performed. 6. In the formation of an artificial anus the left groin is the best site for the operation. 7. Attempts at establishing an anus in the anal region after a colotomy are attended with great danger, and are generally unsuccessful. PART III. NUTRITION. ■ CHAPTER I. THE INFANTILE STOMACH. The infantile stomach is vertical and cylindrical and the fundus but little developed. Thus, whenever there is a tendency to vomit, the anti- peristaltic motions do not press against the fundus, but directly upward. There is, therefore, rather an overflow than a vomiting of the gastric con- tents; this takes place so easily that the infants are not disturbed by it.^ Anatomy. — The muscular development is weakest at the fundus. Ac- cording to Fleischmann, the oblique and the longitudinal fibers described by Henle, which have their origin at the pyloric opening, "do not exist in the infant." The investigations of Leo and von Puteren show that, in spite of this lack of muscular development, the stomach of a nursing infant is emptied in one and a half or two hours. With food that is more difficult to digest, the gastric contents are propelled more slowly. The Mucous Membrane of the Stomach. — The mucous glands are far more numerous on the pars pjdorica than in adults, whereas they are far fewer in number at the cardia. The mucous membrane of the infant secretes gastric juice, which, in general, is similar in properties to that of the adults. The amount of secre- tion in the infant is far less than in the adult, while its chemical constitu- tion is the same, namely: pepsin, lab-ferment, and acids. The exact pro- portion of the ferment and pepsin has not yet been studied sufficiently to admit of any positive deductions being made. Physiology. — It is very important to know that the mucous membrane of the mouth is practically dry at birth; the secretion of saliva is very small, and, according to Korowin and Zweifel, increases toward the end of the second month. The fermentative (sugar-forming) property of saliva, which is trifling at the commencement, increases with the quantity of the saliva secreted. This is essentially true of other secretions; thus, the pancreatic juice does not have the same emulsifying properties in the infant as in adults. The nursing or sucking center is located, according to experiments made on animals by Basch, in the medulla oblongata on the inner side of the corpus restiforme. The sucking act is reflex; according to Auerbach, the muscles of the tongue participate most actively. * Jacobi, "Therapeutics of Infancy and Childhood," page 25. 5 (65) 66 KUTRITION. Acids in the Infant's Stomach. — The gastric contents in a nursling contain two acids : ( 1 ) In-drochloric acid ; ( 2 ) lactic acid. The relative acidity is smaller than in adults, the highest point being reached one and a half hours after nursing. According to von Puteren, the acidity is two and one-half to three times as small as in the stomach of adults. Accord- ing to Leo, the acidity of the gastric juice of nurslings 1% hours after drinking is only 0.13 per cent., whereas, in the adult, after the same time, the acidity is from 1.5 to 3.2 per cent. According to Wohlmann, free HCl can be found in healthy nurslings from II/4 'to 2 hours after taking food. The percentage of free HCl ranges from 0.83 to 1.8 per cent. Lactic Acid. — The quantity of lactic acid is, according to Heubner, between 0.1 and 0.4 per cent. Pepsin and Hydrochloric Acid. — There are two chief functions of the pepsin and hydrochloric acid which are the same in both infant and adult : First, the power of killing bacteria : a real bactericidal power. Second, as a solvent for albumin. Thus, it is apparent that pathogenic micro-organ- isms that might have entered the stomach can be destroyed, although we know the small quantity of acid is hardly able to cope with large quantities of food contaminated with bacteria. Unorganized Ferments. — The unorganized ferments seem to be nitrog- enous bodies; their exact composition is unknown, and it is doubtful if they have ever been obtained perfectly pure (Landois and Stirling). Action of the Saliva on Various Bacteria. — Triolo describes a series of interesting experiments with saliva. He first irrigated the mouth with bichloride or permanganate of potash solution, followed this by irrigation with sterilized water until the disinfecting substances were removed, and then inoculated the surface of various culture-media with the sputum. His results proved that saliva possesses a distinct bactericidal propert}^, for cultures of five-day-old bacteria were destroyed, as well as fresh bacteria eighteen hours old. This property, however, was lost when saliva was filtered. The saliva of the parotid and submaxillary glands, taken singly, were equally effica- cious as their combined secretion. He believes that the greatest bactericidal action is due to the secretion of the mucous glands in the mouth. The Influence of Gastric Juice on Pathogenic Germs. — Gastric juice is, according to the experiments of Drs. Kurlow and Wagner, an exceedingly strong germicidal agent, and when living bacilli get into the intestinal canal it is due to various conditions entirely independent of the gastric juice. When the latter is normal and in full activity, only the most prolific microbes — such as tubercle bacilli, the bacilli of anthrax, and perhaps the staphylococci — escape its destructive action ; nil others are destroyed in less than half an hour. Similar influences exist in the intestines, as proved by inoculation with the cholera bacilli. THE INFANTILE STOMACH. 67 Taule No. 8. — Shotriiit/ the Unorganized Ferments Present in the Body and Their Actions. Fluid or Tissues. Ferment. Actions. Saliva • • • Ptyalin Converts starch chiefly into mal- tose. 1. Pepsin . ,....•• Converts proteids into peptones in an acid medium, certain by- products being formed. Curdles casein of milk. Splits up milk sugar into lactic acid. Splits up fats into glycerine and fatty acids. Gastric juice . - 2. Milk-curdling 3. Lactic-acid ferment. . . . 4. Fat-splitting 1. Diastasic, or aniylopsin . . 2. Trypsin Converts starch chiefly into mal- tose. Changes proteid into peptones in an alkaline medium, certain by-products being formed. Emulsifies fat. Splits fat into glycerine and fatty acids. Curdles casein of milk. Pancreatic juice . 3. Emulsive (?) 4. Fat-splitting or steapsin . . 5. Milk-curdling 1. Diastasio Does not form maltose, but mal- Intestinal juice . 2. Proteolytic 3. Invertin tose is changed into glucose. Fibrin into peptune (?). Changes cane-sugar into grape- sugar. In small intestine (?). 4. Milk-curdling Blood Chyle .... Liver (?) . . . . Milk . ... Most tissues . . . Diastasic ferments .... Muscle Urine Pepsin and other ferments . Blood Fibrin-forming ferment . . Judging from the results of experiments made l)y Zagari, Straus, and Wurtz, who exjiosed various pathogenic organisms, among others that of tuberculosis, to the action of gastric juice, we must come to the conclusion that, so long as the gastric juice retains a sufficient degree of acidity, tuber- culosis of the alimentary canal will be unlikely to occur. Albumin and the Gastric Juice. — Another property of gastric juice in infants is the transformation of albumin in the following manner: (1) G8 NUTRITIOX. albiimose; (2) then peptone^ (3) and lastly syntonin. It is thus appar- ent that, although the infantile stomach plays a subordinate role as a nour- ishing organ, it cannot be denied that fluid sul^stances — like water, a solu- tion of salt, and solution of sugar — are absorbed, and in a less degree albu- min aleo. The relative size and capacity of the stomach prevent the func- tion from being as thoroughly developed as in the adult. Stomach Capacity. ' At birth the infant's stomach has a capacity of from 9 to 11 drachms, or 35 to 43 cubic centimeters. At the end of one month it is about 2 ounces, or 60 cubic centimeters. At the end of three months the gastric capacity is about four times the amount at birth. The very rapid increase from birth to this time soon ceases, and the stomach capacity grows in size, but at a much slower rate of development (Baginsky). The series of experiments at the Children's Hospital of St. Petersburg, made by Ssnitkin, showed that the weight, and not the age, determined the capacity of the stomach, and should be used as a guide for the quantity of infant-food required. If the normal (initial) weight of an infant is 3000 to 4000 grams, or about 6.6 to 8.8 pounds, then ^/^oq part, plus the daily increase in weight added, which normally amounts to from ^/g to 1 ounce, would give the amount of food required. Biedert also regards the body weight as an important factor in deter- mining the amount of milk to be given. Baginsky argues that, while this rule will hold good for a great many infants, he must insist upon relying upon the scales to show just how much nutriment has been digested, and thus a regular system of weighing, plus the inspection of the stools, will aid in establishing the quantity of food necessary. "There is no unanimity among experienced clinical observers upon the subject of infant-feeding." The majority of clinicians the world over order cows' milk in varying dilutions. Some use the cereals — ^like wheat, barley, rice, and farina — to dilute and subdivide the curd. Other clinical observers — Budin and Variot, French observers — advise giving infants, at birth, ivliole milh; that is, pure, undiluted coivs' mill'. The following illustrations will serve to show the difference in the capacity of infants' stomachs at various ages, tal:en by the author at the morgue of Bellevue Hospital. Fig. 21 —Infant's stomach. Actual Size. From a Case of Malnutrition. Capacity, About 2 Ounces. When Stomach was Filled it Held 4 Ounces Easily. (Author's Col- lection.) Fiff. 22.— Infant's Stomach. Actual Size. Died Suddenly from Convulsions. Age Seven Months. Cause of Death, Eclampsia. Capacily when Filled with Water, 8?^ Ounces. (Drawn from Specimen in Author's Collection ) (69) Fig. 23. — Infant's Stomach. Capacity, 10 Ounces. Age of Child, Eleven Months. Cause of Deaih, Enteritis. (Drawn from Specimen ia Author's Col- lection.) Fig. 24.— Capacity of Jleasuremcnt, 14 Ounces. Diseased Condition. Normal Capacity. Holding About 2 Ounces, or 50 Cubic Centimeters. (Author's Collection. ) (70) SIGNIFICANCE OF VOMITING. 71 Significance of Vomiting. The symptom of vomiting needs careful interpretation. Wlien tlie symptom occurs in gastric and intestinal conditions it is not difficult to make a diagnosis. It is important to note the frequency of vomiting : Does or does it not occur after every feeding ? Has the infant had a stool during the last twelve hours? Intestinal obstruction is usually accompanied by frequent vomiting and the absence of stool. Intestinal worms are frequently a cause of vomiting. Likewise, an early symptom of appendicitis is vomit- ing. Feeding high percentages of fat may provoke vomiting; likewise, ex- cessive quantities of sugar may produce vomiting as well as colic from flatulence. Pyloric spasm and pyloric stenosis are usually accompanied by vomiting. Vomiting is a reflex act. It can be produced directly by irritating the stomach, as, for example, when mustard is swallowed. It can also be produced by a great many vegetable products, as, for example, by ipecac root. Mineral poisons, such as sulphate of zinc or turpeth mineral, or sul- phate of copper, will produce violent emesis. Bacterial fermentation from stagnant food can also produce vomiting. These causes are, therefore, direct in their action and produce immediate results. It is a great mistake to look upon the stomach or the stomach contents as the etiological factor in vomiting, and as the only organ capable of producing emesis. The toxins in the blood of many acute infectious diseases produce vom- iting. One of the earliest symptoms of scarlet fever is vomiting. Several days before the eruption, of scarlet fever appears, vomiting of a most violent nature generally occurs. This is, no doubt, due to toxaemia. An irritation of the vagus or the pneumogastric nerves can result in vomiting. Any irritation brought about through the central nervous sys- tem will cause vomiting; thus it is that shock, fright, or disturbance of metabolism may produce vomiting of a most serious nature. Giddiness, caused by swinging or a rolling motion, as on a ship, may produce cerebral hypersemia, ending in vomiting. When a child falls on the back of its head and produces concussion of the brain, we have con- tinued vomiting as a first symptom. When vomiting persists in spite of gastric treatment, meningeal disease should be suspected. In meningitis, especially in hydrocephalus, vomiting is a frequent symptom. The writer does not presume that any physician will diagnose brain fever, scarlet fever, or gastric fever by the single symptom of vomiting. On the other hand, it is well to know that vomiting, with a suspicious rash and a sore throat, will strengthen the suspicion of an existing scarlet fever. A rule followed by the writer is to lay considerable stress on vom- iting. It means nothing if we are dealing with a spoiled stomach following a large dish of plum pudding. But woe to the physician who gives a good 73 NUTRITION. prognosis where vomiting is an early manifestation of intracranial disease that ends fatally. Stomach Washhstg. When vomiting persists^ especially in pyloric spasm, stomach washing (lavage) is indicated. One teaspoonful of bicarbonate of soda added to one pint of warm water can gradually be introduced by pouring through a fun- nel attached to a soft-rubber or flexible catheter. While many clinicians advise placing the child in an upright position during the lavage, I have found, especially in younger infants, that it is easier to fill the stomach and syphon off the gastric contents while the child is flat on its back. In the dorsal position the tube can be gently but quickly forced over the tongue, down the pharynx, through the oesophagus, into the stomach. In washing the stomach the funnel, holding three or four ounces, should be filled, and raised above the level of the stomach. After the fluid has entered the stomach, we can syphon off the contents by lowering the funnel below the level of the stomach. This process should be repeated several times or until the return flow from the stomach is clear. It is advisable to wash the stomach, preferably before food has been given. In obstinate vomiting lavage should be performed daily. No force should be used in pushing the tube into the stomach. The eyelet of the catheter should be carefully inspected to see that there are no sharp edges. An injury to the gastric mucosa by laceration with a sharp border of a stomach-tube will certainly result in an erosion. The Abdomen. The abdomen of a child is comparatively larger than that of the adult. Especial attention should be given to the condition of the abdomen; for instance, a retracted abdomen is usually seen in meningitis. (See chapter on "Meningitis.") A distended abdomen is frequently seen in rachitis (pot-belly). (See article on "Eachitis.") A very prominent abdomen is seen in chronic peritonitis, to which I direct attention in the special article dealing with that subject. The Intestines. Small Intestine. — At birth the length of the small intestine is nine and one-half feet. The length of the intestine may, however, vaiy with the size of the child. In the duodenum Brunner's glands are found. Below the duodenum Peyer's patches are found. The most important physiological function of the small intestine consists in aiding the assimilation of food THE INTESTINES. 73 by tlie action of the pancreatic juice and other secretions. The emulsifica- tion of the fat in the food takes place in the small intestine. Len^h of the Intestine. — The relative length of the intestine in nur- slings is greater than in adults, so that the intestines are six times as long as the body. Forster believes this is one reason why nurslings receive more nourishment from milk than do adults. The small intestine develops during the first two months of life more than the large intestine, and after the second month the reverse is true. The duodenum remains relatively the longer until the end of the fourth month. The transverse colon is the widest and most elastic portion of the large intestine. The continuation of the large intestine in infants, into the rectum, is indicated by a narrowing at this point. Large Intestine. — According to Treves, the large intestine measures : — At birth 1 foot 10 inches, or 55 centimeters At 12 months 2 feet 6 inches, or 76 centimeters At 6 years 3 feet, or 91.5 centimeters At 13 years ~ 3 feet 6 inches, or 107 centimeters Course of the Colon. — From the right iliac fossa up to the liver, then transversely across the abdomen to the spleen and then downward, ter- minating in the rectum. The colon forms at its first turn the hepatic flexure, at the spleen the splenic flexure, and finally the sigmoid flexure. The curve of the sigmoid flexure occurs in the left iliac fossa. Sigmoid Flexure. — The anatomical illustrations of the sigmoid flexure (see article on "Chronic Constipation") are important to remember in view of the mechanical cause of constipation so frequently seen in young children. The transverse colon, when distended with gas, is very easily mapped out by percussion. The Csecum. — Dwight found the ca3cum completely covered with peri- toneum in 33 out of 37 cases in 5^oung children. Treves states that in 100 cases observed by him he found the peritoneum infolding the ctecum in all of these cases on its posterior surface. The Cfficum occupies a higher position anatomically in a child than in adult life. Vermiform Appendix. — Behind the CEecum lies the vermiform appendix. It is important to remember that it lies in the line midway hetween the umhiliciis and the crest of the ilium. When the appendix is inflamed and swollen it can frequently be mapped out by rectoabdominal (bimanual) palpation. 74 NUTRITION. Formation of Gas in the Intestine. — When we consider tlie lesser development of the muscles of the intestine, we can readily understand that peristaltic movements are more irregular and less forcible, and that the muscles possess less tone; on this account there is a larger amount of gas contained in the intestine, which constantly distends it. Thus it is apparent why the abdomen always appears larger in the infant in propor- tion to the other parts of the body. Action of Intestinal Muscles. — The action of the intestinal muscles is chiefly to transport the food by a series of peristaltic movements. Parts of the intestine are active, while others remain passive. Heubner maintains that post-mortem examinations never show all parts of the intestine in the same condition, owing to the irregularity of the muscular movements. Development of Glandular System. — The development of the glandular system in infants is very poor, whereas the lymphoid tissues and follicles are comparatively well developed. Lieberkiihn^s glands are fewer in number than in adults, whereas the Brunner glands in the duodenum are numerous and well developed. The Secretory and Absorbing Power of the Epithelium and the Glands. — Heubner maintains that the secretion takes place from cells, located in the small intestine, which are scattered about and are few in number, whereas in the large intestine they are far more numerous. Absorption of Tat. — The absorption of fat takes place through the intestinal epithelium in the duodenum and jejunum; the glands also par- ticipate in this action. According to the histological investigations by Baginsky, the real absorbing system of the intestinal wall is found in the connective-tissue bodies of the mucous membrane of the infantile intestine, in which are located lymphatic vessels connected with the larger lymph- channels of the intestine. The physiological and chemical functions are much less developed in infants than in adults, because the intestinal glands are relatively less developed. breast-milk and wet-nursing. Colostrum. Colostrum is found in the breast of a woman several hours after giving birth to her infant. It resembles milk, but is a much thinner fluid. It is always the forerunner of a healthy normal secretion of breast-milk, which usually appears on the third day after the birth of the infant. Colostrum corpuscles have been described by Czerny as lymphoid cells, whose function is to absorb and reconstruct unused milk globules and to convey them from the milk-glands into the lymph-channels. These cor- puscles usually disappear in one week or ten days after birth. When colos- BREAST-MILK. 75 trum corpuscles are present after one month, then such milk will cause gastric disturbances. It is a wise plan to examine the milk microscopically whenever the slightest evidence of gastric or intestinal disturbance is noted. According to Baginsky, colostrum contains large quantities of serum- albumin, and is also very rich in fat and colostrum corpuscles, and contains a large quantity of salts. The last two ingredients are supposed to be the cause of the laxative action of the colostrum. When colostrum corpuscles persist in hreast-milk, in spite of the regu- lated diet and the hygienic condition of the mother, then breast-feeding must be discontinued. A very fretful and nervous mother will frequently have colostrum corpuscles in her milk. An instance of this kind was seen recently by me. Substitute feeding will frequently modify this condition COLOSTRUjM CORPUSCLES Fig. 25. — From a drop of milk on the third day after delivery. (Zeiss Ocular 4, dd Lens.) (Original.) unless there is a specific cause for the same. When a nursing mother is very weak and anaemic after her confinement, then iron is indicated. I saw a case in consultation recently in which the combined use of fresh air, cereals, and iron changed a thin milk containing colostrum corpuscles into a thick, creamy milk in less than one month. Continued menstruation or uterine disorder with disease in the endometrium may cause profound anaemia and thus render breast-milk very thin. Such milk is totally unfit for the proper nutrition of the infant. Bkeast-milk. According to Pfeiffer, human milk contains, several days after the birth of the infant, a large quantity of albumin, salt, and a small quantity of fat. He also found that the longer the period of nursing, the smaller the quantity of albumin, which, in the eleventh month, sinks quite low. There 76 NUTRITION. Tarle No. 9. Properties of Human Milk, Appearance. Bluish, semitransparent, no odor, sweetish. Specific Gravity. 1026 to 1036. Reaction. Amphoteric, relation of alkalinity and acidity as 3 to 1. On Boiling. Does not coagulate, and forms a very thin, hardly-per- ceptible skin. Coagulates. At ordinary temperature after several hours. Coagulates on addi- , . f T h f J Coagulates imperfectly in small isolated flakes, which do not precipitate as a uniform coaguluiii. ment. Fat. Yellowish white, resembling cow-butter. Specific gravity at 15° C, 0.966. Melts at 34° C. Varieties of Fat. Butyrin, palmitin, stearin, olein, myristin, caproin. Behavior of Various f Few volatile acids. More than half of the non- volatile Acids. I consist of oleic acid. Milk-plasma Casein. Difficult to precipitate with acids and salts. The pre- cipitate redissolves in excess of acids. During pepsin digestion there is no pseudonuclein produced. r Lactalbvunin and lactoglobin ; relation of casein to albu- Composition of Albu- j min, 0.5 to 1.2 or 1 to 2.4; of tlie 1.3 per cent. minoids. albumin, there are 64 parts of casein, and 37 parts I of globulin and albumin. Solids. Less solids than in cows' milk, especially CaO — PjOo Quantitative Analy- sis, according to Soxhlet. Water, 87.41; albuminoids, 2.29; fat, 3.78; milk-sugar, 6.21; solids, 0.31. Bacteria. Usually sterile, rarely staphylococcus albus and aureus. rKoi'KiniKs OK cows- .\III,K. 77 Appearance. Specific Gravity. Reaction. On Boiling. Table No. 10. Properties of Cows' Milk. ( Opaque white or whitibli yellow, in thin layers bluish c wliite, slijjht odor, faintly sweet. 1028 to 10.36. f Amphoteric; relation between alkalinity and acidity, 2 to 1 ; Soxhlet maintains that cows' milk contains three times the acidity of human milk. Does not coagulate and forms a skin containing casein and lime-salts. Coagulates. Coagulates on addi- tion of Lab-fer- ment. Fat. Varieties of Fat. Behavior of Various Acids. Coagulates very soon, owing to lactic-acid formation. (Coagulates to a solid mass at body-temperature, from which a yellowish fluid can be expressed. Yellowish-white mass. Sp. gr. at 1.5° C, 0.949 to 0.996. Palmitin, olein, stearin, myristin, caprilin, caprin, caproin, butyrin, laurin, lecithin, cholesterin, and yel- low coloring matter. Volatile fatty acids, about 70 per cent.; not volatile, 0.3 to 0.4 per cent, of oleic ; the remainder consists of palmitic and stearic chiefly. Milk-plasma Casein. | ^^^^ *° precipitate with acids and salts; excess of acid ( does not dissolve ; belongs to the nucleo-albumin group. Composition of Albu minoids. Solids. Quantitative Analy- sis, according to Soxhlet. Less lactalbumin and globin; the largest portion of the albuminoids is casein. Relation of casein to albumin. \ cllU I 0.3 to 3.0, or 1 to 10. Cows' milk contains more solids than human milk Water, 87.17; albuminoids, 3.55; fat, 3.69; milk-sugar. 4.88; solids, 0.71. Bacteria. Contains all milk bacteria, frequently also pathogenic bacteria, as typhoid, diphtheria, and tubercle ba- cilli, etc. 78 NUTRITION". is also a decrease in the quantity of salts, whereas the amount of sugar steadily increases. The fat varies constantly. According to Johannessen, the quantity of albumin in the first six months is 1.192 per cent. ; in the next six months 0.989 per cent., and at the end of the year 0.907 per cent. Breast-milk varies according to the length of time that it remains in the breast, and also the length of the nursing period; so it has been shown that the first milk taken at the beginning of the nursing act is the poorest in nutrient value, whereas the last milk is richest in fat. The longer the milk remains in the glands of the breast, the more will the solid substances of the same be absorbed, so that only a watery solution remains. If sucking is commenced, this stimulation soon changes the character of this watery milk, so that normal milk will soon be secreted. Forster studied the chem- ical constitution of the first, middle, and the last portions of milk from a nursing woman, with the following result. In one hundred parts he found : — • Tabi^ No. 11. Water Nitrogenous Substances Fat Sugar Ash First Portion of the Nursing Act. 90.24 1.13 ]-70 5.56 0.46 Second Portion Dur- ing Nur.sing. 89.68 0.94 2.77 5.70 0.32 Third Portion at the End of the Nursing Act. 87.50 0.71 4.51 5.10 0.28 The quantity examined was 37.3 grams. From a study of the foregoing tables we find a decrease of nitrogenous substances during the course of the nursing, a steady increase in the amount of fat, and an unvarying percentage of sugar. Thus, it is apparent that, in order to submit a specimen of hr east-milk to a chemical examination, it is necessary to stimulate the secretory fimctions of the mammary glands by putting the child to the breast at least two minutes ; thus an even milk can be procured. If this rule is overlooked, then we shall find proportions in the chemical components of milk which might otherwise be entirely dif- ferent. The most recent chemical analysis of breast-milk shows that in a hundred parts there are : — Solids 11.5 Liquids 88.5 Of the solid constituents there are: — Casein 1.2 to 1.03 Albumin 0.5 Fat 0.8 to 4.07 Milk-sugar 6.0 to 7.03 Ash 0.2 to 0.21 BREAST-MILK. 79 The above is the chemical examination of a good average breast-milk; I again call attention to the fact, however, that not only does the milk vary in different women, but it also varies in the same woman during one single nursing act. The albuminoids of milk consist of real casein, lactalbumin, globulin, and opalisin. This latter body has only recently been discovered by A. Wroblewski, and more recently by Schlossmann. Phosphorus exists in milk as nuclein-phosphorus, Wittmaack has demonstrated the fact that the phosphorus in woman's milk exists as an organic nitrogen compound in the casein. According to the examination of Stolasa, lecithin contains a larger quantity of phosphorus in woman's milk than in cows' milk. The specific gravity of breast-milk varies from 1026 to 1036. Fig. 26. — Heeren's Pioscop, for Optical Milk Test. The Mammary Glands. — The mammary glands of the same woman may yield somewhat different milk, as shown by Sourdat and later by Brunner. Also the different portions of milk from the same milking may have different compositions. The first portions are always poorer in fat (Parmentier, Peligot, and others). According to I'Heritier Vernois and Becquerel, the milk of blondes contains less casein than that of brunettes : a difference which Tolmatscheff could not substantiate. Women of weak constitutions yield a milk richer in solids, especially in casein, than women with strong constitutions. According to Vernois and Becquerel, the age of the woman has an effect on the composition of the milk, so that we find a greater quantity of protein and fat in women 15 to 20 years old and a smaller quantity of sugar. The smallest quantity of protein and the greatest quantity of sugar are found at 20 or from 25 to 30 years of age. The milk with the first-born is richer in water — with a proportionate diminution of the quantity of casein, sugar, and fat — ^than after several deliveries. The influence of menstruation seems to slightly diminish the milk sugar and to considerably increase the fat and casein. Pioscop. — One drop of milk can be examined in the pioscop and com- pared with the colors on the same. This is a rapid but rough method of estimating the richness of the milk. 80 NUTRITION. Table No. 12. — Comparative Analyses of Breast-milk. Human Milk, Normal Milks. Average Average Average Average 14 analyses from same woman Mean of 6, aged 23-33 years . Average From woman aged 18. .... . From woman aged 33 4 days after delivery 9 days after delivery 12 days after delivery Average of 84 samples Average of 107 samples Fat. Proteins. Suerar. Ash. 2.90 3.07 5.87 0.16 3.68 1.70 7.11 0.20 2.67 3.92 4.37 0.14 3.52 2.01 5.91 2.53 3.42 4.82 6.23 3.82 2.04 5.93 0.42 3.55 1.52 6.50 0.45 3.20 2.39 6.83 0.29 2.99 2.51 6.51 0.30 4.30 3.53 4.11 0.21 3.53 3.69 4.30 0.17 3.34 2.91 3.15 0.19 4.13 2.00 6.94 0.20 3.78 2.09 6.21 0.31 Authority. A. W. Blythe. Marehand. Vernois & Becquerel. Hammarsten. Simon. H. Gerber. Chevalier & Henry. J. Bell. J. Bell. Clemm. Clemm. Clemm. Leeds. Konig. Specimen of Breast-milk for Chemical Examination. — After the third, possibly the fourth, day the average healthy woman secretes milk that gradually becomes normal in quality and quantity, depending on her general condition. It is usual for an infant to lose some weight during its j&rst week of life, owing to various physiological changes, added to which is, no doubt, the deficiency in the quality and quantity of its food. It is a safe plan, and one that I have always urged, if at all possible, to send a specimen of breast-milk to a chemist and submit the same to a chemical analysis. In some women a specimen can be examined when the baby is one week old; in others it is better to wait until the end of two weeks. We then would have a proper working basis, and know just how much fat, carbohydrate (sugar), and albuminoids — including protein — we are feeding. Noting the weight of the child, its sleep, its digestion, color and frequency of its stools, we can easily see in one week how much the infant has gained in weight, and its general condition. To take a specimen, it is advisable to have all utensils absolutely clean ; hence the following plan would be suggested : Boil an ordinary one or two-ounce bottle in water, to which a pinch of baking soda has been added, for about one-half hour. Then place the bottle in plain water and boil again for a half-hour. Then turn the bottle upside down, and allow it to drain and dry. In this manner we can completely sterilize the inside of the bottle and avoid contamination. Withdraw a sample of breast-milk by means of a breast-pump. One which has served the author'very well is known as the Florence breast-pump, and has a glass mouth-piece. (See Fig. 33.) Another form is an English breast-pump, having a rubber bulb. Compressing this bulb, we can suck about an ounce or more in from five to ten minutes. This milk is to be poured into the bottle, and well corked, and set in a refrigerator, but PLATE IV A Drop of Normal Breast-milk from a Primipara. (Original.) BREAST-MILK. 81 not on the ice. Milk will keep for many hours in this way. My plan has been to inform the chemist the day previous to submitting the sample, so that it can be withdrawn from the breast early in the morning — at about 8 A.M. — and sent to the laboratory at once. The result of the analysis can be received on the evening of the same day or on the following day in all instances. A point worth noting is that the very first milk should not be used, but the infant should be allowed to suck at the breast for about two minutes before pumping the sample. After this the breast-pump should be applied for five minutes to procure the middle milk; then the infant can again be put to the breast to finish nursing. Fig. 27. — Specimen of Breast- milk from a Young Mother, 17 years old. Primipara. Baby four months old; thriving; gaining in weight; stools yellow; sleeps well. Chemical examination : Fat, 2.60; sugar, 6.50; proteins, 2.54. Milk looks creamy, and the mammae are well filled. (Original.) Fig. 28. — Specimen of Breast- milk, Illustrating Very High Fat, Causing Gastric Disturbance. Baby gaining; vomits frequently; stools yellowish; bluish-white milk; child sleeps well; excessive fats. Chem- ical analysis: Fat, 5.0; sugar, 6.50; proteins, 1.74; ash, 0.20. (Original.) Examination of Breast-milk. — A method which can be employed in general practice is recommended by Friedmann (Deut. med. Woch., Jan. 23, 1902). It is more easily done than a chemical analysis, and serves an equal purpose. It consists of determining by microscopical examination the number and character of the milk corpuscles. It is an advantage first to become familiar with the normal conditions by repeated examinations of the milk from healthy mothers, those whose children are well and show no sign of rickets or glandular enlargements. The milk corpuscles can be divided as to size into three groups, large, small, and intermediate, of which the latter are most numerous. The small ones are also found in almost equal numbers,, but the large ones are comparatively scarce, a mag- nification of 400 diameters showing only about 10-20 in the field. If these 82 NUTRITION. be more numerous the milk is found to be too fatty and more difficult to digest. A preponderance of the small corpuscles usually means a chronic dyspepsia for the nursing infant. An accurate count can be made with some form of blood-counting apparatus, but the latter is not essential. The proximity of the corpuscles to each other also serves as a guide to the grade of the milk, the more sparsely distributed the globules and the greater the number of the small ones, the poorer the quality of the milk. The method also serves to differentiate the character of the milk from the two breasts. In the selection of wet-nurses it is obviously useful. Reaction of Human Milk. — Bordet has called attention to the precipi- tation of the albuminoids in milk when it is added to the serum in animals which have been previously injected with milk from the same source. Schlossmann found, further, that the fluid from a hydrocele on a breast child was also able to precipitate the albuminoids in human, but not in cows' milk. According to Moro, if a few drops of human milk are added to a few cubic centimeters of fluid from a hydrocele, in a very few minutes the hydrocele fluid coagulates into a solid mass. This reaction does not occur with cows' or goats' milk. The hydrocele fluid evidently contains fibrinogen, and the milk, fibrin ferment. The combination of the two induces the coagulation. It occurs even with minute quantities of the milk; all the serum in contact with the milk coagulates around it. The same reaction occurs when human serum is added instead of the milk, but much less pro- nounced and much slower, and the same difference is observed when the human milk is boiled or long heated. Particles of coagulated ox blood also induced a slow and partial coagulation. It seems to be established that the mucous membrane of the stomach secretes an enzyme or fat-splitting ferment. Ibrahim discovered a lipolytic ferment in the stomach of a nursling. Diastatic Enzyme in Human Milk and in the Stools of Nurslings. — Dr. Ernest Moro reports from Escherich's clinic, in Graz, that : — First. — Human milk contains, normally, an intensive, saccharifying enzyme, which is not found in cows' milk. Second.- — This enzyme is found in the stool of breast-fed children and signifies a more pronounced diastatic action of the same. Third. — This diastatic enzyme is secreted by the glands of the intestine. Parts of the same can be found in the pancreatic juice of the new-born. Fourth. — The intestinal contents and faeces of nurslings contain at birth, as a rule, a diastatic enzyme, which increases in the first few weeks of life. Immunity Conferred by Breast-milk. — The nursing infant is usually exempt from infectious diseases, although we do find an occasional case of infection in a breast-fed infant. Such is the exception rather than the rule. Piead chapter on "Measles" for cases of immunity seen by me in the Riverside Hospital. ]5|{KAST -MILK. 83 There seems to be an ininmnity conveyed to the infant through its mother's milk. These substances which convey immunity have been studied by Brieger and Ehrlich. During epidemics nursing infants rarely succumb to infections. The following case will illustrate the manner in Avliich immunity can be "conveyed" through the milk: — A woman .suffering with diphtheria was four montlis pregnant at tlie time of infection. She was injected with 2000 units of antitoxin and recovered in about six days. Several months after the birth of lier child, an older child in the family was attacked with diphtheria, which required several injections of antitoxin, also intubation, to relieve a severe form of croup. Although the new-born infant was in the same room it did not show any signs of the disease. This was most likely due to the immunity conferred upon the child by its mother through her breast-milk. To Preserve Human Mlilk. — Human milk collected from various women may be preserved for many weeks if treated in the following manner: Test the milk with litmus paper to be sure that it is ampho- teric or alkaline. If it is not alkaline, add a few drops of bi-carbonate of soda solution. Then add 0.2 cubic centimeters of a concentrated 30 per cent, perhydrol solution. This quantity of perhydrol is sufficient for 400 cubic centimeters milk. The milk is then thoroughly shaken so that the perhydrol produces its chemical effect. On close inspection small bubbles can be seen in the milk. Lastly the milk is heated for ten minutes in a water bath to 120 degrees F. Milk so treated by Dr. Meierhoffer was tasted by me in the Children's Wards of Dr. Paul Moser, in Vienna, and seemed perfectly fresh although it was one month old. Table Xo. 13.; — Five Analyses of Human Breast-milk.^ Case Ko. 1. Per cent. Case No. 2. Per cent. Case No 3. Per cent. Case No. 4. Per cent. Case No. 5. Per cent. "Water 86.2 1.7 6.5 5.4 0.2 89.0 1.3 5.8 2.5 0.3 87.0 1.6 6.6 3.8 0.2 88.6 1.1 6.7 2.7 88 1 Proteins 1 1 Lactose 6 2 Fab 4 1 Salts Case I of Table 13 showed symptoms of gastric disturbance, chiefly vomiting, caused by "feeding high fat.'' The mother of the infant believed that by eating frequently and of very rich food, she would benefit her bab}', thus her millv showed 5.1: per cent, of fat. . By reducing her diet, excluding meat and too many eggs, discontinuing alcoholic and malted l)eveTages, her milk improved, the fat being decreased. Exercise, such as walking, was ordered for the mother. ticut. ^Analyses made by Lafayette B. :\rondol, Yale L'niversity, Xcw Haven, Connec- 84 NUTRITION. Table No. 14. — Table ShovAng Analyses of a Normal, a Poor, an Over-rich, and a Bad Human Breast-mAlk?- Normal Milk. Exercise and Good Food. Poor Milk. Poor Food. (Low Fat. High Protein.) Over-rich Milk. Rich Food. No Exercise. (Excess of Fat ) Bad Milk. Wet-nurse Menstruating. (Low Fat. Low Protein.) Fat 4.00 6.50 1.75 .19* 1.00 6.50 2.36 .24 6.59 6.69 1.16 .19 .65 Sugar 6.50 Protein 1.12 Mineral Matter . . . .11 Total Solids Water 12.44 87.56 10.10 89.90 14.63 85.37 8.38 91.62 Total 100.00 100.00 100.00 100.00 Specimens examined by Mr. Bailey, chemist of the Pediatrics Laboratory. Bkeast-feeding. Ihiring the first and second months feed every three hours, but never oftener. During the day awaken the child every three hours, to be nursed; but during the night let the child rest as long as it appears satisfied. This rule applies to healthy children only. In sickness special rules for feeding are required. If the child thrives and gains in weight, then it is advisable and in the interest of the mother and child to have an interval of from seven to eight hours at night; thus Bouchut advises the last feeding between 10 and 11 P.M., and the first feeding at 6 a.m. If the child is restless, then turn it from side to side ; thus, changing its position and giving it one or two tea- spoonfuls of boiled water will frequently satisfy it and prolong its sleep. Table No. 15. — Time for Feeding. From Birth to 3 Months Old. 3to 8 Months Old. 8 Months Until 1 Year Old. 6.00 A. M. 9.00 A. M. 12.00 Noon 3.00 P. M. 6.00 P. M. 9.00 P. M. 12.00 Midnight 6.00 P. M. 9.30 A. M. 1.00 P. M. 4.30 P. M. 8.00 P. M. 12.00 Midnight 6.00 A. M. 10.00 A. M. 2.00 P. M. 6.00 P. M. 10.00 P. M. ^ I am indebted to the chemist of the Walker-Gordon Laboratory for a series of chemical analyses herein reported. MATERNAL FEEDING. 85 The first three or four days require special feeding methods. On the day of the birth, the exhaustion of Jhe mother and presence of colostrum, besides the normal deficient quantity of food in the breast, demand large intervals of rest. Thus for the first three days (unless the milk-supply is profuse) putting the infant to the breast once in six hours is sufficient; if, however, the supply of milk is ample, then we can follow the table given above and nurse the infant every three hours. Maternal Feeding. The feeding of infants will always be a live question. It is simplifiea ^rhen maternal means are used. The plea, therefore, to resort to human milk i ceding means not only to obviate the difficulties of home modification of cows' milk and the dangers of contamination, but it also means that we give the infant the proper start in life. The foundation must be strong, and such foundation depends on the growth and development of the organs, due to proper metabolism of fat, carbohydrate, and especially of the protein. B'uman milk contains an assimilable form of iron besides a given quantity of salts to be utilized in the growth of bone and teeth ; it is thig lack of iron in cows' milk that renders it less nutritious. The virtues of human milk have been extolled from many infectious hospitals, where it is found that there is more vitality in an infant that nurses the human breast than in the infant reared by artificial means. The susceptibility to infections is far less in the infant nursed at the human breast than in the infant brought up by artificial means. What applies in infancy applies equally well in later life and there is no question in my mind that the breast-fed infant, being the stronger, will also be able to with- stand the infection of tuberculosis in later life. Our plea shonld, therefore, be primarily for the education of the mother, especially so for the mother who believes the modern fad of artificial feeding is equally as good as the natural method. * Human milk contains a diastasic ferment. Peroxydase is found in cows' milk. Many cases require but several months for a proper start in life. The most critical period of an infant's life is the first three months; hence it is imperative to start right. An infant is not born with a diseased stomach : it is born with a healthy stomach, with normal digestion, and with power to assimilate almost any kind of food. Any one who will study the digestive conditions of the first six or eight weeks of infantile life, will find that almost every type of food will be assimilated. If an excess of fat or protein, is ordered the same will not show marked systemic disturbance until after the first six or eight weeks of life. Feeding formula which would give rise to marked gastric disturbance during the third and fourth months are frequently well borne 86 NUTRITION. and apparently digested during the first month of life. This is because we are dealing with a healthy gastric ♦mucosa plus normal secretions, and because pathological conditions have not yet developed. This accounts for the tolerance of high fats and high protein in early infancy. Casein is a nucleoalbumin in a neutral combination with lime. Such casein will be precipitated on the addition of acid. It is not dissolved in milk, but exists therein in a colloid form. In addition to casein we have lactalbumin, which corresponds to serum-albumin. We also have lacto- globulin ; both are also present in colostrum. The albumin of milk if injected into a rabbit produces a serum which can give us the Bordet reaction. Alexins and antitoxins, in addition to sub- stances contained in the internal secretions, agglutinins, complements, are found in human milk and transferred thereto by the serum. According to Ehrlich, these substances give marked resistance and a distinct passive immunity to the infant. During the last few years a study of the physio- logical requirements of the infant has demonstrated the fact that our feeding rules and feeding intervals have been wrong, that the tendency to overfeed exists, and that the interval for proper assimilation between meals is too small ; hence we must change our methods to give the infantile stomach less work and at the same time sufficient food for its development. An infant should nurse at birth seven times in twenty-four hours, or once every three hours. At one month the interval of three hours should be increased to three and one-hal:£ hours ; thus, no more than five feedings by day and no feedings at night should be given. In special cases the infant may require feeding every two hours, but bear in mind that less frequent feedings stimulate a better flow of milk, give the infant a longer interval for digestion and thus an increased appetite. When scanty supply of human milk exists, then mixed feeding, alternate breast and bottle, may be given, but it is important to look upon the human milk as the most precious food, and every drop to be valued far more than the cows' milk that we use to supply the deficiency of the human breast. A close study of infantile stools during maternal feeding has shown that there are frequently tendencies to either constipation or the reverse, loose or green- ish stools. Neither of the above conditions should be regarded as serious factors and by no means should we look upon the human breast with dis- favor even though the stools do not correspond to that desired yellowish, pasty consistency. So many factors are at play, alkalinity of the intestine, or acidity of the intestine, likewise chemical alterations in the milk, and atmospheric or thermic influences inhibit the proper function of the glands so that the intestinal ferment may or may not perform its function. Such condiiions must be borne in mind before a final conclusion to discard a human breast of milk is reached. BREAST-FEEDING. 87 Another point, and one frequently submitted, is, shall a woman continue to nurse her infant if she menstruates ? to which one should reply that the condition of the infant is not afl'ected by the presence of the function of menstruation, and human milk may be utilized as if the same were absent. The bacterial content of the intestine of an infant nursed at the human breast has far less pathogenic bacteria than the infant fed on cows' milk. Suggestions for Breast-feeding. The mother or wet-nurse should always sit upright, be it at night or during the day, while nursing the infant. Danger of Suffocation. — A great many cases are on record where the mother or wet-nurse has fallen asleep while nursing and smothered the in- fant. For this reason it is important that the infant should sleep in its own crib or bed, and should never sleep with the mother or nurse. Shall an Infant Receive but One or Both Breasts for One Meal? — This depends on the infant's appetite. Some infants appear satisfied after nursing from one breast, and will let go of the nipple and fall asleep. Lightly tapping the cheeks of the infant will awaken it, or the withdrawal of the nipple from the infant's mouth will frequently arouse it to continue nursing. If, however, the infant will not renew its nursing, and still con- tinues to sleep, and if the infant has nursed steadily for ten minutes, then the sleep should not be disturbed. Length of Time for Nursing. — A good plan is to note the time when the nursing act commences and stops. No infant should nurse longer than twenty minutes, whereas frequently ten or fifteen minutes will suffice. If an infant nurses more than twenty minutes, say thirty or forty minutes, then we may be sure that the breast-milk is deficient in quantity and a specimen should at once be submitted for a proper chemical examination. Scanty Beeast-milk Eequieing Mixed Feeding. When there is a deficiency in the quantity of breast-milk, but the quality is good, then it is advisable to feed the infant alternately with breast-milk and bottle-milk. At the same time it is advisable to direct attention to the mother's general condition, and see if we cannot tone her up, and thus im- prove both quality and quantity of her milk. Frequently a subnormal or an ansmic condition requires iron. A day's outing to the country or seashore, with moderate exercise, will stimulate and increase the flow of milk. Every drop of breast-milk is so precious that no infant should be deprived of it, and wise is the physician who will insist upon giving all breast-milk. When there is deficient lactation, supply the deficiency by giving a properly diluted milk or cream mixture, adapted for the age and weight of the infant. 38 NUTRITION. To Increase the Quantity of Breast-milk. — Some of the galactagogues have given me satisfaction, in addition to a nutritious diet, such as meat, milk, and eggs. A preparation on the market known as Nutrolactis^ has proven a most valuable galactagogue. It is given in tablespoonful doses three times a day. This will not only stimulate the quantity, but also the quality, of the milk. Grandin and Jarman, in their text-book on "Obstet- rics," recommend the strong infusion of galega officinalis when the flow of milk is scant. This is to be ordered in tablespoonful doses three or four times a day. Malt tropon, one teaspoonful three times a day, after meals will stimulate the flow of milk. Somatose in Cases of Deficient Lactation. — "A primipara who secreted only a limited amount of colostrum, and kept that up so that the child was crying from hunger and had to be artificially fed, was put upon somatose, 4 teaspoonfuls a day, and in three days the patient secreted a sufficient quantity and quality of milk to satisfy the child, which increased one-fourth of a pound regularly each week. It seemed difficult to induce the mammary glands to perform their proper function; but when somatose was given there was a normal supply of milk, and the child was properly nourished without artificial feeding." Do Drugs Taken by a Nursing Woman Affect the Baby ? Physiological experiments have frequently demonstrated the fact that a great many drugs can be given to an infant through the milk ; thus, opium and morphine and narcotics in general do affect the infant, when taken by the mother, Baginsky calls attention to this fact in his text-book on "Dis- eases of Children": "Alcohol, when taken by the mother, is transmitted through the milk, but not in very large quantities. The following is a list of drugs which have been found in milk : The purgative principles of rhu- barb, senna, and castor-oil; the metals, antimony, arsenic, iodine, bismuth, lead, iron, mercury; the volatile oils, like copaiba, garlic, and turpentine; also salicylic acid, and the iodides and bromides." Do not give cocaine, chloral, atropine, or hyoscyamus. Care is to be used with the following: Digitalis, antipyrin, and ergot. An unpleasant flavor can be imparted to the breast-milk by the mother or wet-nurse eating onions, turnips, cauli- flower, or cabbage. Disturbances During Breast-feeding. Quite frequently we meet with gastro-intestinal disorders in infants that are wholly breast-fed. These disturbances are due to (a) insufficient exercise; (&) faulty diet; (c) extreme nervous irritability; (d) menstrua- tion while nursing; (e) physiological changes in the woman, causing an improper ratio of ingredients. Some of the causes just mentioned can easily be remedied. On the other hand, a very nervous woman, whose anxiety keeps her constantly fretting during the day and awake at night, will hardly be ^ Sold in all drug stores. BREAST-FEEDING. 89 adapted for breast-feeding, and the sooner the infant is removed from such a breast, the better for the infant. The following cases will illustrate the above conditions: — An infant was nursed by its mother. The mother was extremely nervous, fretful, did not sleep at night, and nursed her child too often. Tlie infant suffered with colic, had greenish, cheesy stools, and did not gain in weight. Had indigestion and all evidence of intestinal colic. The case was seen by me through the courtesy of Dr. A. A. Richardson, of New York City. The physi- cian assured me that the mother would not leave her home, and that she had had no outdoor exercise, no fresh air, and nothing but the constant worry of a sick, crying baby which she nursed as best she could. A chemical examination of the breast- milk showed the following: — Fat 1.20 Sugar 6.50 Protein 1.70 Ash 0.18 Total solids 9.58 Under the influence of exercise and careful diet the fat was increased. In this case we alternated breast and bottle feeding, and gave the child mixed feeding. A formula of 2 per cent, fat, 5 per cent, sugar, and 0.75 per cent, protein was pre- scribed at the Walker-Gordon Laboratory. An infant one month old was seen by me in the family of Dr. J. Grosner, of this city. The infant had been vomiting, had had colic, and was very restless. The mother was very nervous, but had an abundance of milk. From the history I learned that the child had had an explosive vomit, the food coming.out, besides large quantities of gas. There were five to seven stools in twenty-four hours. The bowels moved at each nursing. The chemical examination of the breast-milk showed: — Fat 4.00 Sugar 6.50 Protein 3.05 Ash 0.30 Total solids .' 13.85 From this examination it can be seen that for a baby six months old there was an excess of fat and also a very high percentage of protein. An infant one to two months old requires 2 per cent, of fat. ISTote also a normal infant receives between 1 and l^/^ per cent, of protein, while this child received more than 3 per cent, of protein. There being a profuse secretion of milk, the child received far more than it could digest in both quality and quantity. The feeding interval was lengthened, and the time of nursing was reduced to five minutes, whereas until the appearance of vomiting the child nursed twenty minutes. An ounce of sterilized water was ordered immediately after each nursing, hoping to thus dilute the milk. This method proved successful. 90 NUTRITION. A Case of Prolonged Lactation, Showing Deficiency of Nutriment. — ^A cMld. about 1 year old, was brought to me with the following history: It has no teeth. Can neither stand nor walk. It is colicky. Does not sleep well. Does not gain Fig. 29. — Showing a Drop of Milk under the Microscope. Note the poor character of this emulsion, the uneven fat-globules, and their irregular size and distribution. The infant nursed with the above milk was rachitic and colicky. Although 15 months old, no tooth had appeared. The mother of the infant states that she menstruated every twenty-one or twenty-two days since her infant was born — during this present nursing period. (Original.) Fig. 30. — This Drop of Breast-milk is from a very Anemic Woman. The child was extremely emaciated, had greenish stools and colic, and was always crying. Note the uneven character of above emulsion, when com- pared with Plate VII. The infant was poorly nourished; had rickets and marked cranio-tabes. Mixed feeding was resorted to, with decided improve- ment. (Original.) weight. The child was nursed every three or four hours. The mother was very nervous, and menstruated almost every month during lactation. The chemical anal- ysis of the milk gave: — Fat 1.22 Sugar 7.07 Protein 0.98 J BREAST-FEEDING. 91 It was very evident tliat this baby was receiving poor milk, very low fat, and deficient protein. The infant was weaned, artificial feeding was prescribed, and the infant immediately showed a gain in weight. The symptoms of colic disappeared. Illustration, of Prolonged Lactation Without Apparent Harmful Effects. — An infant fifteen months old was brought to me for the relief of constipation. It had ten teeth, was able to stand and walk, and was beginning to talk. The infant was still breast-fed. The analysis of the milk gave the following: — Fat 2.86 Sugar 6.78 Protein 1.76 Fig. 31.— Holt's Milk Test Set, for Testing Human Milk. The infant's weight in this case was normal, and I must regard this prolonged lactation, showing such good results, as an exception rather than a rule. Additional Foods During the Nursing Period, Between the sixth and eighth months, if the infant is thriving and gaining in weight, cereal feedings should be added. A small saucer of farina, or cream of wheat steamed with water, for two hours, and served with skimmed milk and a small quantity of sugar, should be given before the 10 A.M. feeding. This cereal feeding may be given daily if there are no symptoms of starch indigestion, such as flatulence, colic, or distended abdomen, noted. At twelve months the yolk of a raw egg may be added to the cereal. Additional foods which may be given to an infant after the teeth erupt, or between the seventh and twelfth months, are: Two ounces of expressed beef juice over a small saucer of steamed rice; a piece of rusk or 93 NUTRITION. biscuit after the bottle. A coddled egg at noon may be tried when the infant is one year old, and if it agrees, it may be ordered every other day. The Management oe the Nipples Before the Baby is Born. It is very important during the last few months of pregnancy to devote considerable time and attention to the condition of the nipples. If these be found long and round, well projecting, then it is advisable to try to harden them, because the irritation from the child will cause considerable, trouble unless we seek to prevent this. Oni, in treating the question of sore nipples, said at the Medical Society,^ that one out of every two nursing women was affected with lesions of the nipples. The determining cause of the fissures was macera- tion of the epiderm under the double influence of the saliva of the infant and the milk which flowed during the intervals. The epiderm exfoliated and the derm exposed became excoriated; the lesion thus produced became infected, and, instead of healing, progressed in extent. The predisposing causes were short and inextensive nipples and want of cleanliness. The primiparjE were affected with fissured nipples to the extent of 59 per cent. The prophylactic treatment consisted in astringent lotions during pregnancy, while after delivery the nipple should be washed with boric acid lotion before and after suction, the application of an antiseptic dressing during the intervals of nursing. The curative treatment, to be radical, consisted in the suspension of nursing, which, although excellent for the mother, would be deplorable for the child. The list of agents employed against the fissure was very lengthy, indicating their uselessness. In summer cold water will be found more agreeable, with a small quan- tity of alcohol. If the nipples are very small and flat, and do not protrude properl}'-, then suction by means of a breast-pump, applied directly over the breast, will draw them out. In some instances an ordinary clay pipe which has a smooth bowl, the bowl to be laid over the nipple and the stem to be sucked or drawn, is satisfactory. This is to be repeated every few days. A few minutes of drawing out will suffice until the nipples are sufficiently prominent. Biedert^ gives the following prescription for hardening the nipples : — Tannic acid 1 teaspoonful Red wine 8 ounces If red wine is not handy, then substitute brandy in its stead. This is to be applied after thorough washing with soap and water, and removing crusts, if they are present. Tender Nipples. — If, while nursing, the nipples crack and blood oozes from them, or if, from irritation of the child's gums biting them, the nipple ^ Paris Cor. Med. Press and Circular. * "Kinderernaehrung," fourth edition, 1900, page 110. BREAST-FEEDING. 93 is sore, then it is a good plan to allow the child to nurse through a nipple- shield. (See Fig. 32.) Fig. 32. — ^Nipple-shield for Relief of Tender Nipples, Nipple-shields can be used during the nursing act, and immediately thereafter the following salve can be smeared on the nipples : — IJ Zinc oxide 1 drachm Vaseline 1 ounce TREATMENT OF TENDER NIPPLeS (GARRIGUES). IJ Orthoform 1 drachm Lanoline 1 ounce M. Sig.: Apply. Fig. 33. — Breast-pump. Breast-pump. The breast-pump (Figs. 33 and 34) is a valuable addition to the nur- sery. It should be kept scrupulously clean by immersing it in boiling water containing a pinch of table-salt. In drawing a specimen of breast-milk for a chemical examination the breast-pump is very useful. If an infant is ill 94 NUTRITION. and refuses the breast — as^ for example^ if it has rhinitis or cold in the head, nasal obstruction, preventing it from breathing while the nipple is in its mouth — it generally will take the breast and immediately let go of it again. If the breast-pump is properly applied, and the required quantity of milk drawn off, the infant can be fed slowly with a spoon. In a serious condition — as, for example, in a severe case of pneumonia with loss of appetite — the life of the child may depend on forced feeding. This is described in the section on "Gravage." It is very important to have the cup or any other receptacle into which we draw the breast-milk properly sterilized; otherwise the breast-milk will be infected in the same manner as is described in detail in the chapters on "Cows' Milk" and "Bottle-feeding." Fig. 34. — Breast-pump. Massage oe the Bkeast Dueing Lactation. Caking. — ^The "caking," or hardening, of the breast is not due to cur- dling of the milk. This never takes place within the milk-tubes. ISTeither is it due to the presence of milk, for as a rule no milk is formed until nursing begins, or if any, but a very small amount. The hardening of the gland is due to the congestion of the blood and lymph, and therefore massage should be directed to the removal of these, and likewise should be centrifugal in direction, and not aim to the removal of the milk by centrip- etal stroking. The blood-supply of the gland is mainly derived from the subclavian and axillary arteries ; the venous outflow and the lymph discharge are by corresponding channels, and this is the anatomical basis for action. The massage should begin gently below the clavicle and in the axilla, and gradually encroach more and more on the mammary region. By this method a hard and painful breast is rendered lax and comfortable without the dis- charge of any milk. The writer does not recommend this treatment where there is infection or true inflammation, as in mastitis; in such conditions rest is indicated, and nothing should be done which will tend to spread the infection.^ Tpie Diet of a Nursing Moti-ier. Immediately after the birth of the child the exhausted condition of a woman following labor will certainly call for rest ; hence sleep is imperative, after which some form of stimulation is required. This can best be accom- ^See an elaborate paper on this subject by Bacon in American Journal of Obstetrics. JJIKT OK A NrRSIX(; .Mo'lllKll. !).-) plished by giving at intervals of several hours good, wholesome food, as chicken broth or beef broth, weak tea, or strained gruel. It is unnecessary to state that each woman's case and her former habits must be taken into consideration in prescribing a diet. If labor has been normal, then the nour- ishment will stimulate the milk. If warm liquids are not well l)orne, then cold di'inks like buttermilk, koumyss, zoolak, or iced tea should be em- ployed. Iced chanii)agne will frequently do more good to allay gastric irrita- bility than all medication. Raw milk in combination with seltzer or lime- water is indicated. In some instances ice-cream will aid nutrition and alle- viate gastric irritation. If the pelvic condition is normal, then it is wise not to give solid food for the first three days, but, rather, stimulate the milk- glands by giving meat broths, farinaceous gruels, and l)y all means milk. Zwieback soaked in milk or in tea is highly nutritious and easily digested. Other nutritious foods are calfsfoot jelly and chicken jelly. After the third day, if the pelvic organs are normal, it is wise to con- sider the action of the bowels. If the l)owels have not moved by this time, then buttermilk added to the diet or stewed prunes or peaches, baked apples, or grapes will aid in establishing a movement of the bowels. If the milk is scanty and the bowels have not moved, then the best remedy is a large tablespoonful of palatable castor-oil, modified to suit the taste by the addition either of lemon juice or orange juice, or by adding several drops of the ordinary spirits of peppermint. After the bowels have been evacuated and the general condition warrants it, then a diet consisting of the following is indicated : — BREAKFAST, 7 TO 8 A.M. Hominy and Milk. Grapes. Farina and Milk. Soft-boiled Eggs. Eice and Milk. Poached Eggs. Oatmeal and Milk. Eggs on Toast. Germea and Milk. Coffee and Milk. Cream of Wheat and Milk. Tea and Milk. Some Stewed Prunes, Figs, or Cocoa and j\Iilk. Peaches. Toast and Butter. Stewed Apples. Stale Bread (2 days old), with Oranges. Butter. I do not advise meat or fish in the morning, unless the nursing mother has always been accustomed to this fonu of diet. LUNCH, 12 TO 1 P.M. Some soup made from meat, either veal, beef, mutton, lamb, or chicken, i-ontaining also some rice, barley, farina, sago, or hominy; it should not be highly seasoned, and should not be strained. 96 NUTRITION. Fish, boiled or fried, and all shell-fish, particularly oysters, are very nutritious during the nursing period. If the appetite warrants it, then a piece of steak or chop, roast beef, chicken (white meat only), or raw chopped meat, with bread and butter, is very nutritious. EVENING, 6 TO 7 P.M. A Bowl of Oatmeal Gruel. Junket. Stewed Oysters. ^ Cup of Tea. A Drink of Milk. Eggs, if desired. Farina Pudding. Meat, if in the habit of eating Eice Pudding. it in the evening. Cornstarch Pudding. For Thirst. — Cool, filtered water, or the alkaline waters, like Seltzer and Apollinaris. If the milh is scanty, the flow can he stimulated hy drinhing a cup of hot broth, made from beef, chicTcen or veal, lamb or mutton, several minutes before putting the child to the breast. Alcoholic DrinTcs. — If the woman is in the habit of drinking wine or beer, then it is unwise to discontinue the use of alcoholics in moderate quantities while she is nursing. I have seen a great many women whose flow of milk was scant who immediately secreted an abundance of milk after partaking of a glass of beer, or ale, or porter with their meals for sev- eral days. Beer has a decided laxative effect, and this in itself is rather an advantage for those nursing mothers having a tendency to constipation. So my rule, therefore, would be to insist on abstinence from wine and beer unless the patient has been in the habit of taking it formerly. FOODS TO BE AVOIDED BY A NURSING WOMAN. Onions. Ethereal Oils. Garlic. Butter and Fat moderately. Cabbage. Candies and too much Sweets. Powerful Salts (Rochelle, Glau- Large quantities of Potatoes, her, Epsom). Inability of Mothers to Nurse their Children. It is surprising to note the gradual disappearance of the healthy, robust American mother who can perform the duty of nursing her infant. The following tal)le will give a fair illustration of the conditions as they exist in New York City to-day : — WET-NURSE. 97 Table No. 16. — A study of 1000 Mothers and their ability to nurse. Mothers. Condition of Mother. Able to Nurse 9 Months to 1 Year. Able to Nurse 4 Days to 2 Mouths. Primiparas. Multiparas. 500^ Living in Tene- ment Houses. Very Poor. 450^ 50 210 290 500 Living in Healthful Portions of the City. Prosperous. 84 150 305 195 According to the above statistics, 90 per cent, of the poor mothers are able to nurse their children, while only 17 per cent, of the rich mothers are able to perform the same duty. Wet-nurse. Two important points are necessary: First, the presence of suitable milk ; second, the absence of a constitutional taint^ or acute severe illness. What to Examine. — First, the breasts for the quantity of milk present. The breast should be gently but firmly held at some distance from the nipple; thus we can learn by palpation regarding the parenchyma of the glands. Also the quantity of milk, which, if expressed continuously about twenty to thirty seconds, should flow in several streams. Stagnant milk always shows sensitiveness on pressure. The statement of a wet-nurse tliat her "milk is deficient in quantity" can be determined by subjecting her to careful observation for several hours. After this time the milk in the breasts should be expressed and the quantity determined. The ease with which milk can be expressed by palpation is an impor- tant factor to note. If the milk flows with great difficulty, and requires considerable massage or pumping, then such a nurse is totally unfit to nurse atrophic, marasmic, or prematurely born babies. Weak or marasmic children require a wet-nurse having a plentiful supply of milk, so that the slightest effort while nursing will result in a liberal flow of milk. ^ Thirty-five, or 7 per cent., of these mothers suffered from puerperal disease, such as septicaemia, mastitis, and kindred affections; hence, they were ordered by their physicians not to nurse. * Three hundred and twenty-four infants were put on artificial feeding. This feeding consisted of feeding at the laboratory and home modifications. One himdred and fifty-four of these infants were supplied with wet-nurses, owing to loss of weight, dyspeptic conditions, or marasmus during the bottle-feeding. 'The blood of every wet-nurse should be examined for a Wassermann reaction. The danger of transmitting syphilis demands this precaution. 7 98 NUTRITION. ISTote if the expressing of milk causes pain; in the normal breast it should be painless. It is not always the quality of the milk, but frequently the quantity, that is the cause of poor assimilation of a wet-nurse's milk. In such in- stances a chemical examination of the milk is imperative; by this we can learn exactly how much we feed an infant in percentages. If necessary, we can modify the milk (by proper wet-nurse diet) until the required per- centages are attained. The Child of a Wet-nurse. — Certain allowances must always be made for babies presented by wet-nurses — for instance, if the hygienic surround- ings of a wet-nurse are very poor, and in addition thereto her food supply is meager, then a general angemic appearance must be expected. On the other hand, 'a healthy, robust-looking baby must not be regarded as the criterion by which we should judge the wet-nurse. The tricks of wet-nurses are manifold. Frequently they will procure a healthy-looking infant and pass it off as their own, in order that they may procure a position. Another point is that they will frequently resort to stuffing their babies by feeding a bottle in addition to their breast-milk. Thus we must judge for ourselves the quality of the wet-nurse physically, and, most important of all, by the quality and quantity of her breast-milk. Health of the Wet-nurse. — It must be borne in mind that the secretion of milk does not so much depend on her constitution as it does depend on her nervous system. Great importance must therefore be placed on the uselessness of hysterical or neurasthenic women for wet-nursing. The phlegmatic temperament — the broad-shouldered, easy-going woman — pleasant and gentle-mannered, is the one most useful and best adapted for wet-nursing. Wet-rmrses with Goiter. — Bezy, of Toulouse, considers the question: Should women affected with goiter be accepted as wet-nurses ? He does not think so because there is a certainty of danger for the infant, but because it is more prudent to exclude such women from nursing. In 1897 he saw a fatal case of tetany in an infant aged six months in wliich no cause could be found for the disease except the fact that the mother who nursed this baby had exophthalmic goiter. A few months later he saw another case of the same kind, and in 1898 he saw a case of tetany in an infant aged three months, who died after an illness of about forty days and whose nurse had simple goiter. The author thinks that tetany in infants may be of thyroid origin, and that the thyroid affections of the nurse are transmitted to the nurslings. • He does not pretend to establish an invariable law, but simply wishes to call attention to the possibility of such transmission and to suggest further investigations on the subject. We should reject a wet-nurse as unfit for nursing if she has : — WET-NURSE. 99 1. Enlarged cervical glands. 2. A goiter. 3. Diseased lungs, no matter how trivial. 4. Evidences of syphilis, such as a positive Wassermann reaction, or condylomata. 5. Condylomata on her genitals. 6. Mastitis. 7. Carious teeth. Eecurring menstruation is no contraindication for a wet-nurse. Some women are perfectly healthy and will menstruate regularly during their period of wet-nursing, without harm to the infant. Erosions or fissures on the nipple should not be looked upon as contra- indications for wet-nursing. Infants will thrive, although changed from one wet-nurse to another. Breast-milk is not uniform in its consistency. We know that its ingredients not only change' from day to day, but that the milk varies several times a day. In spite of this fact children thrive, as was demonstrated by Schlechter, who used 400 children in the Vienna Foundling Asylum. Among these an epidemic of gonorrhoeal ophthalmia developed, requiring isolation. Thus, several nurses were ordered to be isolated with these infected children, and it was noted that these children developed Just as well in spite of the change from their previous breast-milk. The mortality in this same institution resulting from feeding with sterilized milk has been entirely done away with since the introduction of wet-nursing. Finally, it is important to note that it is the quality of milk, rather than the quantity, which determines the value of breast-milk. When children are strong and well-built, and have a ravenous appetite, they require a slow-flowing hr east-milk, as a rapid flow of breast-milk, aided by a hearty appetite, will tend to overload the stomach, and is one of the reasons for dyspepsia in young children. It is a good point to try to secure a wet-nurse suckling a child about as old as the one we wish her to nurse, although it is quite common to find nurses who have older children than the one they wish to nurse, and to find the latter doing well. The proof of the usefulness of the wet-nurse is the condition of the baby after some time. If the child thrives it will increase in weight. Hence scales must be frequently used. The milk should be examined by a chemist to determine the percentage of ingredients. Especial note should be made of the percentage of fat and proteids. If a very quick examination is required, then a microscopical examina- tion of one drop of middle-milk will show the character of the fat globules. The rough method of examination is useful when the life of the infant is at stake and it is necessary to determine quickly whether or not a given wet-nurse is suitable for an infant. If a baby suddenly appears colicky or 100 NUTRITION. does not gain in weight while wet-nursing, then a chemical examination of the breast-milk is imperative. We can frequently find an excess of fat or, more often, an excess of proteids as the cause of colic. Von Bunge presents the results of an investigation in which he shows that the increasing inability of mothers to nurse their infants is a matter of inheritance. He obtained information relative to 665 cases with the following result : The daughter was able to nurse her offspring in 182 cases. The mother was able in 99.2 per cent., and unable in only 0.8 per cent. The mother was able in 237 cases. The daughter was able in 53.2 per cent., and unable in 46.8 per cent. The daughter was unable to nurse her off- spring in 483 cases. The mother was able in 43.2 per cent., and unable in 56.8 per cent. The mother was unable in 147 cases. The daughter was unable in 99.3 per cent., and able in 0.7 per cent. He concluded from the foregoing figures that inability to nurse is largely a matter of inheritance. Further inquiries also led him to believe that tuberculosis and nervous diseases were to a considerable extent asso- ciated with inability to nurse one's offspring. But much more prominent appears to be the relation of intemperance. Where the mother and daughter were both able to nurse he found that the fathers were usually at least mod- erate in the use of alcohol, and only in 4.5 per cent, were they hard drinkers. On the other hand, when the mother was able to nurse, but the daughter was unable, it was found that the father was often intemperate, and in 46.8 per cent, was an actual drunkard. In this inquiry the author considered those only as able to nurse who could nurse all their children for a period of nine months. All others as unable. The control of wet-nurses was very adequately discussed^ as a public prophylaxis. Many believed it was a matter that could be brought under the control of the law. Dr. Petrini, of Galatz, professor at the University of Bucharest, pre- pared an elaborate report in which the prevalence of infection of sylDhilis by means of wet-nurses was demonstrated. He showed that its frequency varied widely in different countries, and hence an English view, for instance, of its comparative importance, drawn from the rarity of the infection in that country, was not a criterion for the whole, since it had been shown for Oriental lands, and even for Paris, that it was an important element. He proposes a special medical service, working in co-operation with municipal authorities and having for its head a competent syphilographer. All children being nursed by wet-nurses should be inspected regularly by representatives of this bureau, and all wet-nurses should receive authoriza- tion for their calling by the same bureau after rigorous medical examina- tion. Special provision should be made for syphilitic children. * Second International Conference for the Prevention of Syphilis and Venereal Diseases, held at Brussels, Belgium, Septemher I to 6, 1902. WET-NURSES' MILK. JQI Clinical Iblustrations of the Variations in Wet-nurses' Milk. The following case will illustrate the peculiarity of breast-milk in a wet-nurse : — Case I. — First examination of breast-milk showed: — Fat 2.50 Milk-sugar 6.50 Protein 1.93 Mineral matter 0.21 Total solids 11.14 Water 88.86 When the wet-nurse was first employed, the infant gained more than eight ounces each week. Had yellowish stools, one or two each day. Slept well after nursing and appeared satisfied. Cried only at feeding time. No evidence of colic. A second examination of the breast-milk was made to compare the character of the milk with that of the first specimen: — Fat 2.10 Milk-sugar 6.50 Protein 1.41 Mineral matter 0.15 Total solids 10.16 Water 89.84 Two months later, same wet-nurse. Child's weight stationary. Green, curded stools; cries and has colicky pains. Restless at night. Wet-nurse is menstruating. Chemical analysis of milk shows: — Fat 0.65 Milk-sugar 6.50 Protein 1.12 Mineral matter 0.11 Total solids 8.38 Water 91.62 With the aid of cereals and malt, also a change from the city to the seashore, the milk improved. The infant was more satisfied. The stools again assumed a yellowish color. One month after this building-up treatment, an analysis of the breast-milk showed: — Fat 3.50 Milk-sugar 6.50 Protein 1.90 Mineral matter 0.19 Total solids 12.09 Water 87.91 102 NUTRITION. When the infant was eight months old the secretion of milk was scanty, so that the breast was alternated with bottle-feeding. The general condition improved. The child was again satisfied. A chemical examination of the breast-milk showed: — Fat 3.00 Milk-sugar 6.50 Protein 1.08 Mineral matter 19 Total solids 10.77 Water 89.23 As the proteins were found to be very low, I ordered the white of a raw egg, soup, and expressed beef juice. When the child was nine months old it was neces- sary to wean it, as the wet-nurse had very little milk. In this ease the stationary weight, the colicky condition, and the char- acter of the stools were important guides, and fully agreed with the analyses of the specimens given. Case II. — Colic. — ^An infant five months old suffered with severe colic. It cried continuously, especially after nursing. Relief was afforded when castor-oil was given or when warm colon fiushing was resorted to. Diluting the breast-milk by giving an ounce or two of barley or rice water immediately after each nursing seemed to modify, but not altogether relieve, this condition. The chemical examination of the milk gave: — Fat 6.59 Sugar 6.69 Protein 1.16 Ash , 19 Total solids 14.63 Water 85.37 The excessive amount of the fat was evidently the cause of the trouble. The quantity of meat was reduced. Exercise was ordered and beer forbidden. In a few weeks the percentage of fat in the milk was greatly reduced, and the infant far more comfortable. " o' Ooo % O „ oo o °. O^ O a, Case III. — Fig. 35. — Specimen of Breast-milk Taken from a Wet-nurse during Menstruation, Illustrating the Poor Character of the Emulsion. (Original.) DIET OF A WET-NURSE. 103 The infant was very restless, and had colicky attacks. Note the small, un- evenly divided fat globules — irregular form of the larger globules. It appears to be a very watery emulsion. Chemical examination of the specimen showed: Fat, 1.60; sugar, 6.50; protein, 2.43. The baby did not gain during the whole week. Case IV. — Good Milk in a 'Wet-nurse. — In this case we have a child that was gaining in weight. Appeared satisfied after nursing, but had a tendency toward con- stipation. A chemical analysis of the milk gave: — • * Fat 4.20 Sugar *. 6.50 Protein 2.80 Ash 28 Total solids 13.78 Water 86.22 Diet of a Wet-nuese. The diet given for a nursing mother can also be used as a guide in choosing the diet for a wet-nurse. The greatest care, however, must be bestowed on the manner of living. Manner of Living. — A wet-nurse that was a former servant, or worked out of doors, and is suddenly taken into this new mode of life and given charge of a baby, must have proper exercise. Otherwise she will very soon secrete milk which will be totally unfit for an infant, and as a result the child will probably have severe colic and irregular, cheesy stools ; will vomit excessively, and will not gain sufficiently in weight. It is therefore impor- tant to try to adapt a wet-nurse to the same condition as existed prior to her pregnancy; so that both her manner of living and, chiefly, her diet shall not be different. That alcohol may be eliminated from milk is shown by a case reported by Val- lani. A nursing infant was seized with convulsions with great regularity on Mon- day and Thursday, but was quite well on other days. Investigation showed that the wet-nurse on Sundays and W^nesdays (her days out) was in the habit of drink- ing freely of alcohol. The curtailment of these privileges resulted in the disappear- ance of the convulsions. Proper Rest. — To be equal to her task a nurse must be given plenty of sleep, if it is at all possible. Adriance, in the Archives of Pediatrics, says: 1. Excessive fats or proteins may cause gastro-intestinal symptoms in the nursing infant. 2. Excessive fats may be reduced by diminishing the nitrogenous ele- ments in the mother's diet. 3. Excessive protein may be reduced by the proper amount of exercise. 4. An excess of protein is especially apt to cause gastro-intestinal symp- toms during the colostrum period. 104 NUTRITION. 5. The protein, being higher during the colostrum period of prema- ture confinement, presents dangers to the untimely bom infant. 6. Deterioration in human milk is marked by a reduction in the pro- tein and total solids, or in the protein alone. 7. This deterioration takes place normally during -the later months of lactation, and unless proper additions are made to the infant's diet, is accompanied by a loss of weight or a gain below the normal standard. 8. When this deterioration occurs earlier, it may be the forerunner of the cessation of lactation, or well-directed treatment may improve the condi- tion of the milk. Methods of Chaistgikg the Ingredients in Woman's Milk. Eotch gives a condensed table for these changes as follows : — To Increase the Total Quantity. — Increase the liquids in the mother's diet, especially milk (malt-extracts may be helpful), and encourage her to believe that she will be able to nurse her infant. To Decrease the Total Quantity. — Decrease the liquids in the mother's diet. To Increase the Total Solids. — Shorten the nursing intervals, decrease the exercise, decrease the proportion of liquids, and increase the proportion of solids in the mother's diet. To Decrease the Total Solids. — Prolong the nursing intervals, increase the exercise, and increase the proportion of liquids in the mother's diet. To Increase the Fat. — Increase the proportion of meat in the diet. To Decrease the Fat. — Decrease the proportion of meat in the diet. To Increase the Protein. — Increase the exercise up to the limit of fatigue for the individual. It is wise in all cases of disturbed lactation^ whether in maternal or wet-nursing, to make efforts in accordance with these rules to produce a milk that is suitable for an infant who is not thriving, before changing to any other method of feeding. Wet-nursing. It is an established fact that the best possible food for an infant is breast-milk. Where the mother of an infant is prevented from nursing her child, the next thing to be considered is wet-nursing. That nursing a child is an advantage to the mother is a well-known fact, inasmuch as it influences the contraction of the uterus and stimulates the circulation. Contrary to the belief that nursing a, child is detrimental and contraindi- cated in women whose lungs are weak and who have a tendency to tuber- culosis, it does them no harm, and, indeed, seems to do them good. This statement is borne out by the experience of Dr. Heinrich Munk, of KarFs- bad, Austria, a specialist in the diseases of women. WET-NURSING. 105 In Austria the state supports public institutions for lying-in women. Tliey are kept there and confined gratis, and remain about fourteen days. They are admitted into these hospitals in the last months of pregnancy. Vienna usually has about 300 women on hand. Prague constantly has 100 women in this condition, who are utilized for the purpose of instruction to physicians and midwives. In Prague there are about 3000 women confined annually, and these women are put into the foundling asylum. There they remain until they procure a place as a wet-nurse or as long as their services are needed in the asylum. When wet-nurses are taken from the foundling asylum, it is a frequent occurrence to have those remaining therein nurse at least two chil- dren, and frequently three, at one time. In this manner they dispense grad- ually with these wet-nurses without hurting the remaining children. Many- children die, some of them intrapartum in operative confinements, and the women (mothers of such children) are then utilized for wet-nursing. It is a rule to keep the children in the asylum until they have attained a little over 4 kilograms (about 9 pounds), and they are then put out for further feeding (artificial feeding), for which the city pays about 13 florins ($5.00) a month. The children remain usually until they are 6 years old, and are then given back to their own mothers. Many of these children die; others are adopted by those who have reared them, but the greater portion are taken back to their own mothers. In Vienna there are about 10,000 con- finements annually in the public institution. There are a great many cities in Austria — like Innsbruck-Olmutz, Brunn, Linz, and Klagenfurt — where there are at least 200 confinements annually. In Vienna a wet-nurse receives 30 florins per month, for which she is sent (railroad expenses paid) to whoever requires her services. She is taken on trial for fourteen days to see if she is adapted for her place. A wet-nurse can be procured by sending a telegram and a money order any day during the year. The customary wages are from 12 florins upward per month. Each wet-nurse is carefully exam- ined by the professor before she is sent away. A great many families do not care to take a wet-nurse from an asylum, as they are usually women of the lowest walks of life, and they prefer, therefore, to take a woman who has been married. For this purpose agencies, duly licensed, exist. These will supply wet-nurses, and usually take orders in advance ; thus a wet- nurse may be reserved. Such wet-nurses cost much more, and those from one special region — Iglau, in Mahren — receive from 20 to 50 florins monthly. The Empress took a wet-nurse from Iglau (a married woman), and the Princess of Bulgaria took a wet-nurse from Iglau for her last child. Not only Iglau, but the whole region, is renowned for its excellent quality of wet-nurses. The Bohemian and Mahren nurses have very good mammae. They seem to love the children entrusted to them. In America the wet- nurses are uneducated servants. 106 NUTRITION. While it is a rule that a wet-nurse should be taken for an infant of the same age as that of her own, frequently wet-nursing of an infant at birth by a wet-nurse whose baby is three months old has not been followed by any bad results. In New York we are at a decided disadvantage regarding wet-nurses. As no licensed agents exist, a few people procure wet-nurses from superin- tendents and house physicians of hospitals where obstetrical work is done. The importance of properly supervising wet-nurses in the light of the danger of transmitting syphilis needs no further comment. The Health Department in every city should grant the use of their laboratories for a Fig. 36. — Pear-shaped Breasts, Best Adapted for Nursing. (Original.) careful blood examination of each and every wet-nurse. It is as important to prevent the transmission of syphilis to a child as it is to give an im- munizing dose of antitoxin to prevent diphtheria. Being positive that the blood of the wet-nurse is not diseased, our next examination should be of the milk. A wet-nurse whose milk contains colostrum corpuscles should be rejected until the colostrum corpuscles have disappeared. The chemical examination of the milk should be made to ascertain the percentage of fat. Milk that contains more than 2 per cent, of fat should not be used. If the wet-nurse selected has an exceptionally large quantity of milk and is otherwise healthy, then the milk, if it contains too much fat, may be pumped off with a breast-pump and diluted with water, and so fed from a nursing bottle. It is a pity that we have no municipal control for what the writer considers one of the most valuable adjuncts to our infant-feeding, and in WEANING AND FEEDING FROM ONE YEAR TO FIFTEEN MONTHS. 107 the same manner such control would regulate the supply to such unlimited number that modern arrogance on the part of the wet-nurse would probably disappear. The prices paid in New York are from $4.0 to $50 per month and board, and this price prohibits many an infant from securing the benefits of Nature's food. Let us hope for municipal regulation. Weaning and Feeding from One Year to Fifteen Months. When the teeth appear, weaning must be considered. If the nursing mother becomes pregnant weaning is imperative. The condition of the infant, its sleep, its stool and its weight are fac- tors that should influence the decision to" wean. In some infants gradual weaning may be attempted, but in most infants successful weaning can best be accomplished by the absolute cessation of the breast. If the infant has not gained in weight, puts its fingers into its mouth, cries or whines after the breast feeding, and if the stools are thin and watery, then weaning is imperative. Such an infant will gain in weight and be better satisfied when given the following formula : — Whole milk 6 ounces Sterile water 2 ounces Malt sugar 1 teaspoonful Heat until the steam rises. Feed the above quantity every four hours. An. infant nine months old may have a saucer of well-steamed (two hours) farina, hominy or Pettijohn, one-half hour before the second feeding each morning. The juice of one-half pound of broiled steak can be secured with a meat press and fed every other day at noon. A saucer of rice steamed in equal parts of milk and water, or half a cup of junket, may be fed before the 6 p.m. bottle. When constipation exists the juice of an orange or the pulp of stewed prunes pressed through a strainer may be given one hour before a milk feeding. Crackers, zwieback, and biscuits may be given, but all floury foods tend to constipate. In the bottle 8 ounces of whole milk steamed about five minutes may be given. The addition of one teaspoonful of Loefflund's malt soup to each bottle will offset constipation. If a tendency to loose bowels exists, the cream should be skimmed from the milk, and this fat-free milk boiled. The addition of limewater is indicated where looseness exists. 6.00 A. M Breast 9.30 A. M Cereal 10.00 A. M Bottle 2.00 P. M Breast 5.30 P. M Cereal or junket 6.00 P. M Bottle 10.00 P. M. . . . ; Breast 108 NUTRITION. Weight and Development. When a child develops normally, it gains in weight. Breast-fed infants, as a rule, gain more than bottle-fed infants. The progress of an infant can be watched by a comparison with its weight. The moment a child's weight is stationary, the reason for the same should be ascertained. Fig. 37. — The Chatillon Scale is a very convenient basket scale. It is very- useful in the nursery. If the baby is breast-fed the milk of the nursing mother should be sent to a chemist for examination. (The details have already been described in the article on "Breast-milk.") Disturbances of the mother interfering with proper lactation are at once evident in her milk. Such disturbances are: (a) menstruation; (&) general anaemia; (c) tuberculosis, and (d) pregnancy will frequently alter the percentage of the ingredients of milk so that a child will not receive sufficient nutrition. The first evidence of such malnutrition will be seen on the scales. The child will not gain in weight, and frequently it will lose weight. WEIGHT IN BREAST-FEEDING. 109 How Much Should an Infant Weigh? — The average weight at birth is 7 pounds. Some children weigh considerably more and some less. A child should double its weigbt at the end of five months, and treble its weight at the end of the first year. It must not be supposed that because a child weighs less than this amount it may not be healthy. All fac- tors should be taken into consideration and a child should be carefully examined to determine whether or no it is normal. Very many babies are up to the normal in weight, and still show marked rachitis. The very fat and flabby baby — usually supposed to be extremely healthy by the laity — is the one in whom physicians most frequently meet with constitutional disorders. Thus, too much stress should not be put on the scales, for we know that they have their limitations. In the beginning, or during the first and second months, a normal infant gains about 6 to 8 ounces a week. Dur- ing the third month a child gains from 4 to 6 ounces per week, and after the third month from 3 to 4 ounces per week. Weighing Immediately After Nursing to Determine the Quantity of Milk an Infant has Taken. — When scanty milk supply is suspected in either the nursing mother or in a wet-nurse, then we can, in some instances, resort to weighing immediately after the baby has nursed. It is understood that the child must be weighed both immediately before nursing and then imme- diately after nursing. The difl^erence in weight is the amount of milk ^.wallowed. While this may serve in some cases, the author has not found it very practical, and cannot recommend it, excepting in rare instances. It is well known that an infant whose stomach is filled requires rest after nursing, and the less it is handled the less is the chance for expelling its food. Thus, my advice is not to handle or fumble with a child after nursing, but rather aid Nature in resting an infant than provoke vomiting by unnecessary handling. Table No. 17. Tahle Showing the Gain of a Healthy Infant Fed at the Breast. Normal weight at birth, 7 Gain at the end of the first ib. week, none. Weight when 2 weeks old, 7 Gain at the end of 2 weeks, 6 lb. 6 oz. oz. Weight when 3 weeks old, 7 Gain at the end of 3 weeks, 8 lb. 14 oz. oz. Weight when 4 weeks old, 8 Gain at the end of 4 weeks, 8 lb. 6 oz. oz. 110 NUTRITION. The following cases will serve to illustrate the weight of infants with various methods of feeding — {a) breast-feeding, (&) home modification, (c) laboratory feeding : — fi&£- IN V/EEKS Fig. 38. (Original.) Baby Robert M. F, Normal at birth. Was wet-nursed. Gain, first month, 2% pounds; second month, li%6 pounds; third month, 1% pounds; fourth month, 1^^ pounds. Stools were normal. Had gastric disturbances and symptoms of colic while the wet-nurse menstruated. When the child was about seven months old the chemical analysis of the breast-milk showed a deficiency of fat and quite a high percentage of proteins. The milk supply gradually gave out and it was necessary to wean the child. WEIGHT IN ARTIFICIAL FEEDING. Ill ^c^tm\»<2.eXv^ i3iff- f-f/i n /SJ9ZO TFTrfrTTTTrFrNv ::^^ Fig. 39. (Original.) Baby J. S. Born prematurely. Weighed 5 pounds 14 ounces at birth. Was bottle-fed. Vomited; had dyspeptic symptoms, such as cheesy stools, restlessness at night, crying continually, and excoriated anus. When one month old the weight, including shirt and diaper, was 6 pounds. A wet-nurse was procured. The child gained 1 pound during the iirst week, and an average of 10 ounces a week thereafter. Dyspeptic symptoms disappeared; stools became normal. The child was not seen for six months, and is a perfectly healthy baby today. •^:> ^i- % \ ^z ;::' :^: 10 ^ uJA Fig. 40. (Original.) From baby fed on Eskay's food since end of third week. General condition satisfactory, although somewhat constipated. 112 NUTRITION. QcO>'lVXN.mt&\5.S Fig. 41. (Original.) Baby A. Case of chronic dyspepsia. Child four months old. Weighed 8 pounds 15 ounces. Gained 13 ounces the first week of treatment; 6 ounces the second week; 7, 12, 9 ounces respectively during each of the succeeding weeks. J* 3r> BIrIk • « 1 i> c ? ^^ w flt n 34 M 1»1W 31 IS It H a» «r l« H 4» a » 41 a« ^ " -rr ■■ "* ■■ -M "r '" " • r^ - - H — /. - :i -- r^ ;^ \ ... ._ :■; !* ^- ■ ^ 1 K A /• ^ **. /^ ' ■ y\^* / / / 1 ■J 1 f ' , ' t 1 y. f« ■ ■ ' ■ 1 ■ [ '■ / ii- I |- / V ■ '■ / K , . ^ _ ^ ^ ^ L- - . ^ M . « . ^ «• M ^ wm __ _ ^ ^ Fig. 42. (Original.) Baby D. S. Weighed 5 pounds at birth. Was fed at Walker-Gordon Labora- tory since six weeks old. Lost weight during an attack of measles when twenty-six WEIGHT IN PERCENTAGE FEEDING. 113 weeks old. Did not gain one ounce from the thirty-eighth to the forty-second week, although received a formula of: — Fat 4.00 Sugar 6.50 Protein 2.50 Six feedings, of seven ounces each. I ordered tlie following home modification : — ■ Raw milk 6 ounces Barley water 2 ounces Mellin's food 2 teaspoonfuls Feed every three hours. In addition thereto I ordered one ounce of steak juice or one ounce of orange juice, daily, one hour before feeding. I also gave the white of one raw egg with the evening feeding. The food agreed very well and child gained in weight as I gradually added more milk and reduced the quantity of barley water. A growing child needs far more food than its weight alone would indicate, for its income must exceed its expenditure so that it may grow. An infant for the first seven months or first one-half year of life should have nothing but milk. Up to this age vegetable food is unsuited to it; it is purely a carnivorous animal. The diet of the infant is nearly twice as rich in proteins, half as rich again in fats, and a little more than half as rich in carbohydrates as that of the adult. It is, therefore, in a physiologic sense a luxurious diet. The strain of growth falls heavier upon the more precious proteins than upon the more cheap and common carbohydrates.^ When children do not gain in weight, the quantity of sugar should be increased. This should be done continuously and with due consideration for the other ingredients. The constructive ingredient in an infant's food is the proteins. We must, therefore, consider this element when an infant's weight is stationary. Individual conditions must be considered, and chronic disorders elim- inated, e.g., dyspeptic conditions or tuberculosis, before arriving at a diag- nosis of what really causes an infant's loss in weight. "Stewart's Physiology," p. 412, 1S97. CHAPTBE II. COWS' MILK. Hammersten^ gives the following analysis of cows' milk in a thou- sand parts as follows: — Water 874.2 Solids 125.8 Fat 36.5 Sugar 48.1 Salt 7.1 Protein (casein, 28.8; albumin, 5.3) 34.1 A. Baginsky^ gives the following analysis of cows' milk, made at the Kaiser and Kaiserin Friedrich Hospital, Berlin: — Water 87.60 Solids - 12.38 In one hundred parts. The solids consist of : — Casein and albumin 3.65 Butter 3.11 Milk-sugar , 4.54 Inorganic salts 1-08 Besides large amounts of potassium and potassiimi salts and small quantities of iron. Composition, Variation, and Production. — Milk of all animals, roughly speaking, is composed of the same ingredients, but an analysis of milk is apt to be very misleading, as it does not show the physical condition of the milk, which is the important thing to know, from the physician's standpoint. The general ingredients of milk are fat, sugar, albumin, casein, salts, and water. These ingredients vary in quantity from day to day, and from milking to milking. An average analysis of a woman's milk does not show what an infant is getting, by any means, for the composition of the milk depends upon the food, the health of the mother, and the frequency of nursing. The Breed of a Cow, — Some l)reeds yield quantity; others quality. Holsteins produce the most milk; Alderneys and Jerseys yield the most fat; Shorthorns give the most casein and sugar. The average capacity of a cow's udder is about 5 pints, and the annual yield of milk is about 600 gallons. ^ "Physiological Chemistry." ""Diseases of Children," 1899, page 32. (114) COWS' MILK. 115 Time and Stage of Milking. — Cows are usually milked twice a day, the morning milk usually being larger in quantity and poorer in quality. The milk which is first drawn is known as the fore-milk, and contains very much less fat than that last drawn, known as the strippings. This is due to a partial creaming taking place in the udders. Dishonest dealers have often taken advantage of this fact in adulteration cases to have the cows partially milked in the presence of ignorant witnesses, the resulting milk consisting largely of the fore-milk. Age of Cows. — Young cows give less milk, while cows from four to seven years old give the richest milk, and less milk is given with the first calf. They give the largest yield, according to Fleishmann, after the fifth until the seventh calf; after the fourteenth calf they yield, as a rule, no more milk. The poorest milk is yielded during the spring and early sum- mer; the richest during the autumn and early winter. If cows are worried or driven about, the quality and quantity of the milk are reduced. If they "are kept warm and well fed, both quantity and quality are naturally in- creased. According to Rotch, the Durham, or Shorthorn, represents the best type of cow for this purpose. She has great constitutional vigor, great capacity for food, a perfect digestion, and, most important of all, a quiet tempera- ment. The analysis of her milk is as follows : — Per cent. Fat 4.04 Sugar 4.34 Proteins 4.17 Mineral matter 0.73 Total solids 13.28 Water 86.72 100.00 The Devon is another breed of cow having the same characteristics as the Durham. They are gentle and vigorous, and yield a large quantity of rich milk, the analysis of which is as follows :— Per cent. Fat 4.09 Sugar 4.32 Proteins 4.04 Mineral matter 0.76 Total solids 13.21 Water 86.79 100.00 116 NUTRITION. The Ayrshire, another type, while representing strength, is somewhat nervous, and while not as hardy as the Durham, they are '.free from disease and yield a large quantity of n>ilk, the analysis of which' is as follows:— ' ' . ■ ' Per cent. Fat ;... ....;.C;. ■.;.;. ...-..:. :..:.. 3.89 Sugar : ;....... ■.:■ ..4.41 Proteins , 4.01 Mineral matter 0.73 Total solids r: ......:..:... . 13.04 Water •'..'': ; 86.96 100.00 The Holstein-Friesian, commonly called Hohtein, represents the most perfect type of cow. She yields a large quantity of milk, though light in its total solids. The following is the analysis:^ Per eentr ' Fat 2.88 , r Sugar 4.33 Proteins 3.99 Mineral matter '. 0.74 Total solids ...;....: ;......:.... i,.. 11.94 , u Water 88.06 100.00 Some of the marks which distinguish the breeds of cows best adapted for infant feeding are : — 1. Constitutional vigor. 2. Adaptability to acclimatization. 3. Notable ability to raise their young. 4. Freedom from intense inbreeding. 5. A distinctly emulsified fat in the milk. 6. A preponderance in the fats of the fixed glycerides over the vola- tile glycerides. . The volatile glycerides do not exist in the mammae, but are formed in the milk soon after milking. In some breeds, as in those of the ChanneL Islands, this change occurs more quickly than in others. Such breeds, as the Jersey, Guernsey, and any others in which intense inbreeding has been car- ried on, and in which acclimatization has not been perfected, should not be used for infants and young children. These breeds, of course, do not represent all of those available for substitute feerling, for we may mention many others equally good each in its country. For example, the Kerry, of Ireland ; the Red Polled, of England ; the Dutch Belted, and the Flem- ish; also, the Flamande and the Cotentine, of France; the Norman breed, COWS' MILK. 117 of N'ormandy; besides the Sirinentbal, sometimes called Bernese, of Switz'^r- land; together with the Chianina, of Italy, and tiie Allgauer, of Germany. The native cow of this country, the "Red Cow," througli many generations of. neglec^ and exposure in winter, lias undoubtedly acquired an impaired digegJ;;Qi3j, ajid.dpes not respond readily to appropriate changes of food. . Care of the Cow.- — Knowing„.th]e cqw-to. be a sensitive animal, she should be carefully guarded from useless excitement. She should be care- fully groomed by cleaning and washing, arnl the parts should be thoroughly dried. The barn should have plenty of fresh air, and the sunlight should be admitted. There should be plenty of room for exercise. In the stalls the cow should have perfect freedom for her head and limbs. The food a cow receives should be wholesome and varied. She should never be fed with the by-products of brewery or glucose factories. The food best adapted for the cow is hay, wheat, bran, ground oats, and commeal. In winter sugar beets and carrots may be added. Much care is needed to graduate the change from green foods to dry, as disturbance of the equilibrium of the mammary gland is followed by injuripus effects to the consumer. "VVe should strive to give a cow green clover, green corn, green oats, and meadow grass. Poi- sonous weeds must be guarded against. Not infrequently we read of gastro- enteric conditions in children, which are traceable to poisonous weeds. Pure water in large quantities must always he 0.i hand. A cow is best adapted for the production of milk between her third and ninth years. The milk of a cow is not adapted for infant feeding until it is free from colostrum corpuscles. It should not be used in the advanced stage of pregnancy. Tuherculin Test. — Every dairy now resorts to prophylactic measures; hence, none, should be employed that has not been subjected to the tuber- culin test. Besides, this, each cow should be examined by a skilled veteri- narian regarding her physical condition. ,, Care ^pf the il/iVL-r— The .vital point consists in excluding germs and barn filtlj. The Mil,k CommissiQn of New York has tentatively fixed upon a maximufli of 30.,.00p ger^ms pf^iall, kinds per cubic centimeter of milk. A -.cubic centimeter is.about Qne:half a. teaspoonful, and a quart of milk con- tains about 900 cubic centimeters, so the total number of germs in a quart must be less than 27,000,000. . , ... , . _ ,, ;:,This standard must. not be exceeded in order to obtain the endorsement of; tlie Commission, and must be attained solely by measures directed toward sc;;upulous cleanliness, proper cooling, and prompt delivery. Furthermore, the milk certified by the Commission must contain not less than 4 per cent, of butter fat, on the average, and have all other characteristics of pure, wholesome milk. ,/,,In order that .dealers who incur the expense and take the precautions necessary, , to., tij^riiiish a truly pleanajXjtl T^ho^ssome milk may have some suit- able means of bringing these facts before the public, the Commission offers 218 NUTRITION. them the right to use caps on their milk jars stamped with the words: "Certified hy the Commission of the Medical Society of the County of New York:' Eowland G. Freeman, answering an inquiry of mine concerning the pos- sibility of procuring milk free from germs in the dairy, says : "By means of special methods it has been found possible in some cases to obtain milk with only 10 bacteria per cubic centimeter. These methods are, however, ncft- 'practicable for a large commercial supply. When the conditions at the dairy are known to be good a bacterial content averaging less than 5000 per cubic centimeter has seemed to me satisfactory^ while a bacterial content averaging less than 10,000 is fairly good." Thus it appears, that with excellent care, as described in the handling of milk, with modern hygiene, practically sterile milk can be procured for infant feeding. Cektified Milk in New Yoek. The dairy rules of the United States Department of Agriculture de- scribe in detail the caring and feeding of cattle. It was decided that the acidity of milk should not be higher than 0.2 per cent., and that the num- ber of bacteria should not be more than 30,000 per cubic centimeter. The Rockefeller Institute for Medical Research inaugurated a periodical inspection of the dairies and milk of the dealers who were willing to co- operate to secure a clean, fresh milk. It was observed that the milk from a cow milked in a dirty barn showed 120,000 bacteria to the cubic centimeter, while another cow of the same herd milked in a pasture gave milk with only 26,000. A cow standing near a pile of dry feed had 1,000,000 bacteria per cubic centimeter, while the milk of other cows had a low bacterial count. Dirty cows gave a much higher count of bacteria than clean ones. Clean cows in a herd gave a count of 2000 as against 90;000 in the milk of the dirty cows. The milker was frequently found to be dirty, and the milk from some milkers always gave a high bacterial count. With the utensils it was sometimes difficult to find which factor was at fault. The ordinary strainer was, however, a prolific source of bacteria. With a sterile pail and a sterilized cotton or cheese-cloth strainer the bacteria would fall in numbers. Aeration by requiring more complicated apparatus increased the danger of contamination. This was particularly so if aeration was carried out in a dirty barn or without regard to strict cleanliness. The process of rapid cooling is one of the most important factors in the production of uncontaminated milk. The cooling of milk in springs is seldom sufficient, as the temperature of water in summer was found to vary from 45° F. to 70° F., whereas the milk should be brought below 45° F. THE ADULTERATION OF MILK. 119 to insure few bacteria. Ice is absolutely necessary to the farmer who handles milk. W. H. Park {Yale Medical Journal) says, as to the number of bacteria in the city milk : "From an examination of nearly 1000 speci- mens there is no question about the enormous number of bacteria present in the city milk. Now as to the harmfulness of this milk: The group of chil- dren under 1 year, on heated milk, received from decent farms, running before heating from 1,000,000 to 5,000,000 bacteria per cubic centimeter, did not, so far as we could see, suffer any serious harm from the bacterial products in the milk. During the summer these children had, off and on, intestinal disorders, but not much more than those in the same section of the city receiving milk from the very best possible dairies around Few York. The children on pasteurized milk showed some very interesting results. "There were very few bacteria in this milk when first received — any- where from 10,000 to 20,000; but on the second day they had so increased as to be from 10,000,000 to 30,000,000. In some cases where the second day milk was given there was immediate vomiting, followed by diarrhoea. "In the asylums, where the children were from 3 to 13 years of age, we found no trouble from the milk during the summer months, although in some cases it ran as high as 100,000,000 bacteria per cubic centimeter. "The reasons for the enormous development of bacteria in the milk were insufficient cleanliness in getting the milk and very faulty cooling arrange- ments. The farmers mostly put their milk in springs; as the summer advances the water gets higher in temperature until it reaches about 60° F. Some farmers hardly cool their milk at all. "The author has seen milk shipped in cans standing in a car where the temperature was 90° F., and left there without any ice for seven hours. The City Health Board has passed a rule that all milk shall be at a temperature of 50° F., or under, when it reaches New York City." The Adulteration of Milk. Formaldehyde in Milk. — ^The adulteration of milk by the use of for- maldehyde is becoming more common than is generally suspected. For a time its use was a "trade secret," but it has been so thoroughly advertised that every obscure individual who has a milk route is now familiar with the preservative qualities of formaldehyde. In our large cities the health officers are J on the watch, and hence in these its use is being curtailed, but in the smaller towns and villages the people have not this protection. It would be well, therefore, for physicians to guard against this and keep it in mind when mysterious illness develops in milk-users. They should also be pre- pared to make an analysis of milk at any time as to its freedom from the drug. This is a simple procedure, and yet one that requires considerable 130 NUTRITION. technical- skill in the use of some of the tests. The Lancet-GUmc gives the various methods for testing formaldehyde as laid down hy Herman Harms, some of which are quite simple : — Rimini Test. — (A) : Phenyl-hydrazine muriate, 0.5 gram; distilled water, 100 cubic centimeters; dissolve. (B) : Sodium nitroprusside, 0.5 gram; distilled water, 30 cubic centimeters; dissolve. (C) Soda, TJ. S. P., 15 grams; distilled water, 60 cubic centimeters; dissolve. To 15 cubic centimeters of the suspected milk in a test-tube add 10 drops of A, mix and add 3 drops of B; mix; and let 5 drops of C run in slowly on the side of the test-tube. In the presence of formaldehyde a blue color is instantly produced, changing, on standing, to red. On adding to the mixture of milk and solution A, 2 drops of ferric chloride solution, and then about 2 cubic centimeters of concentrated hydrochloric acid, a red color is pro- duced, which later changes to orange-yellow. In sour milk the above-men- tioned blue is supplanted by green. The Eimini test is easily applied, and readily detects formaldehyde when present to the extent even of 1 part in 25,000 or 30,000. . ■ Phloroglucin Test. — Dissolve 1 gram of phloroglucin in 100 cubic centimeters of distilled water. Put 10 cubic centimeters of the suspected milk in a test-tube and add 5 cubic centimeters of the phloroglucin solu- tion; shake and add 1 cubic centimeter of solution of potassa (U. S. P.). If formaldehyde is present, a red color is developed at once, fading usu- ally within five or ten minutes ;. hence the color must be observed at once. One part in 20,000 gives a decided reaction. Hehner's Test. — ^To 15 cubic centimeters of concentrated sulphuric acid in a test-tube add 1 or 2 drops of ferric chloride test solution (U. S. P.) and mix. Then pour upon this, in such manner as not to mix the layers, the suspected milk. A violet color indicates the presence of formaldehyde. In the case of cream dilute the cream with an equal volume of water, and then apply the test as above described. The violet color is sometimes pro- duced at once, but oftener not for five or ten minutes, and sometimes not for an hour or so, depending on the amount of formaldehyde present. By this test 1 part in 10,000 or 15,000 is readily detected. ;- , Liehermann Phenol Test. — In the presence of small traces of for- maldehyde, distill off from the milk a few cubic centimeters, and add to this 1 drop of very dilute aqueous phenol solution. Then pour this mix- ture slowly upon concentrated sulphuric acid in a test-tube solution so as to form a layer. A bright crimson color appears at the zone of contact. This is easily seen in as little as 1 part in 200,000, and in greater propor- tion in 1 to 100,000. There is a milky zone above the red color, and, if more concentrated, there will be a whitish or pinkish precipitate. Some- times the zone will appear in about one hour, one-tenth of an inch below the line of contact. MILK PRESERVATIVES. 121 sis Sail. d Sour and curdled 0.43 -1^ a> a> r-< ^d ©1 in d d 02 to d After 8 Days. Lactic Acid, Per Cent. 00 CO d 1- 1 = ^ i-H ^d ^d d OJ 4) pi 1- 02 ® -4J 0) O' I— 1 ex n S . □ (O *a at tea CO O t) 02 OJ CO Ol 02 02 O) Ol 02 Ol c 3 Eh -♦J Ol 1 w : a mo o m OJ 02 4) CO Ol B H ID Ol 02 Ol aj 02 '5b t- . tig a •-3 . §1 4d 03 < -k3 Ol 0) OJ CI 02 0) 02 -4J Ol Ol aj t/3 Ol be a S . a to So. a c a II CO 0) CQ ■Ol 02 02 1 02 1 OQ !| ©a 1" go o CI 0) 00 (M I— 1 o d s eg o d -(J 1=1 Ol us q d C 0) &I l« d Cj 0) eo f— 1 c (D ^^ d B aj d S u 1 ■ ^ t:; f^ d a) to t3 a> 1 a> £ pi ' Ol a> a> Ol 3 '3 "C §^ •^ TO — ' ■2-^:2 r2 *3 C!i 02 Cj 02 r2 '3 « "i c (V pq 122 NUTRITION. HydrocTiloric Test. — Fifteen or 20 cubic centimeters of suspected milk, together with 2 or 3 cubic centimeters of strong hydrochloric acid, are boiled for a few minutes in a test-tube. A red coloration indicates for- maldehyde. Other tests are known, but they are more complicated and require apparatus or reagents not kept by the average pharmacist. The above tests are all simple in their application and afford a ready means of detecting formaldehyde in milk and cream. The Eimini test is highly recommendable. The reaction in sweet milk appears rapidly and" with certainty. Hehner's test, as well as the phloro- glucin and phenol tests, are very reliable and are all extremely sensitive. The hydrochloric acid test is very simple, but is not to be depended on; it may show formaldehyde in most instances; however, cases have come under our observation when it has utterly failed to show the reaction, probably because of the milk having undergone some unknown changes. The Lie- bermann test is simple, delicate, and shows formaldehyde very readily. As corroborative evidence, it is well, after the tests are finished, to let the suspected milk or cream stand in a warm place for twenty-four hours, A pure sample will invariably turn sour and separate. A sample which has been "doctored" with formaldehyde, however, will show, at the end of twenty-four hours, but a very slight separation, if indeed any at all, and will have but a slight odor. It is desirable that all test solutions be freshly prepared, especially the nitroprusside of sodium solution in the Eimini test, and that the suspected sample be as fresh as possible. Sour samples are difficult to test, and may yield variable results, because in these formaldehyde has been oxidized, and is no longer present as formaldehyde. In carrying out the tests for for- maldehyde it is advisable to work the suspected sample and the one known to be pure side by side. Finally, do not expose your tests or have your milk placed where a bottle of formaldehyde is being opened, for the vapor is very penetrating, and you thus may be easily led to misleading results. When formaldehyde has been found to be present by at least three of the afore- mentioned tests, it may be considered that its presence has been shown. ' Tuberculous Infection Through Milk. The question of tuberculous infection by ingestion of milk is answered in the negative by N. Aspe (Rev. d. Med. y Cir. Prac, Nov. 21, 1901). If the tubercle bacillus reaches the cow's udder, it must necessarily be carried thither by the blood. The bacillus has yet to be found in the blood; but, supposing its presence there, we are taught to believe that every gland in the body, by its selective power, takes from the blood only those elements which are necessary to the elaboration of its peculiar products. This would seem to dispose of the possibility of infection of the milk before it leaves TUBERCLE BACILLI IX MILK. 123 the cow's body, unless the elective faculty, attributed to other glands, be denied to the mammary. Granting this possibility, if we recall that in the production of experimental infections by subcutaneous inoculation the first organs to be affected are the lymphatics, it is natural to suppose that the first and invariable effect of the ingestion of tuberculous milk would be the development of tabes mesentcrica, yet primary tabes is comparatively rare. The author of this paper further raises the question of identity between the- human and bovine tubercle bacillus, and quotes experiments in inoculation of cows with cultures from human tuberculous products with negative results in the nineteen animals experimented upon, whereas animals injected with the bovine form quickly succumbed, and autopsy showed tuberculous lesions. The Influence cf High Temperature on Tubercle Bacilli in Milk. — Barthel and Stenstrom {CcntialhJt. f. Baht., October 8, 1901), in reviewing recorded experiments on the sterilization of tuberculous milk, remark on the very variable results obtained by different observers. Bang has stated that heating tuberculous milk to 80° C. is not sufficient to kill the bacilli, but that a temperature of 85° C. is sufficient for the purpose. Forster has found 70° C. for five to ten minutes capable of killing the organisms; de Man, 70° C. for ten minutes, and 80° C. for five minutes. Galtier has shown that milk submitted to 70°, 75°, 80°, and 85° C. for six minutes is still capable of conveying infection, and others have had similar results. Barthel and Stens- trom have conducted experiments which go to shoiv tliat the chemical reac- tion of the milTc has much to do with the facility with irhich it is sterilized. The material was obtained from a cow with an udder in an advanced state of tuberculosis. Guinea-pigs were used to test the results, and the effect of 65°, 70°, 75°, and 80° C. was studied. The results were positive in all cases; that is to say, a temperature of 80° C. for ten minutes, a temperature of 75° C. for fifteen minutes, 70° C. for fifteen minutes, and 65° C. for twenty minutes were all incapable of sterilizing the milk. These results the authors interpret as follows : Storch has shown that the chemical changes in milk are the more marked the more advanced the disease of the udder, and that the reaction becomes more and more markedly alkaline. On the other hand, it has long been known that it is more difficult to sterilize an alkaline than a neutral, and a neutral than an acid fluid. The specimen with which they worked was strongly alkaline, and to this they ascribe the difficulties in its sterilization. Variations in chemical reaction explain, in their opinion, the variations in the results obtained by other investigators. The Tuberculin Test of Pure-bred Cattle.— Mr. D. E. Salmon, D. Y. M., Chief of the Bureau of Animal Industry of the United States Department of Agriculture, has recently issued a pamphlet in which he demonstrates the necessity of guarding against the importation of disease by means of cattle, and upholds the present regulations to prevent such occurrences as proper and consistent. The chief danger to cattle arises from the prevalence of 124: NUTRITION. tuberculosis, which disease affects herds more widely and more disastrously than any other. Even if the point urged by Professor Koch at the British Congress on Tuberculosis be granted, and it is allowed that the spread of tuberculosis by milk and meat is to be feared but to a slight extent, the fact must still be borne in mind that tuberculosis, in itself, is a decimating factor among cattle of immense importance. Mr. Salmon shows that the United States has a very large export trade in cattle, and one that is continually increasing. He further points out that rigid restrictions are in force in many countries in the world to prevent tuberculous beasts from gaining an entrance into those territories; conse- quently, if we wish our cattle to enter those markets, they must not only be free from tuberculosis when they leave the farm, but also when they arrive in a foreign country. To effect this object, every effort must be put forth to keep out tuberculous cattle from this country, for a. few thus diseased will quickly spread contagion. The argument is therefore advanced that the tuberculin test as now adopted must be strictly enforced to guard against such a result. The con- tention is likewise made that the pure-bred cattle mainly imported from Great Britain are the chief menace in this respect, and that, if the tuber- culin test were not strictly adhered to, the blue-blooded immigrants from the United Kingdom would disseminate the germs of tuberculosis among cattle from one end of the country to the other. Tubercle Bacilli Disseminated by Cows in Coughing, as a Possible Source of Contagion. — The general belief at the present time that the means by which tuberculosis is chiefly disseminated, by the inhalation of dried tuberculosis sputum which becomes pulverized and is carried about by cur- rents of air, or put into motion in other ways, has been strongly substan- tiated by numerous experiments. Fliigge, however, is not in accord with these views, and is of the opinion that the spread of tuberculosis -is due mainly to the inhalation of minute particles of sputum which the act of coughing thus ejects. He further holds that these particles float in the air for a considerable period of time, and may be blown hither and thither by very slight currents. Klebs, in this country, has demonstrated the fact that, during the act of coughing, minute particles of sputum, often' con- taining tubercle bacilli, are thrown out. At his instance, too, Curry, of Boston (Boston Medical and Surgical Journal, October^ 1898,' vol. cxxxix, No. 15), carried out a series of elaborate experiments with the object of thoroughly investigating the matter. Dr. Curry concluded from his experiments that, although there is a possible, and even a probable, danger from this source, Pliigge has greatly exaggerated this danger. Dr. Mazyck, lecturer and demonstrator of bac- teriology, Veterinary Department, University of Pennsylvania, has been led TUBERCULorS INFECTION THROUGH MILK. 125 to luideitako oxperiinenls to ?ee if it were not possible tliat cows in the act of coughing would likewise expel small particles of tuberculous material rich in tubercle bacilli. The results of these studies were made the subject of a paper by Dr. ^Maz^ck, which was read before the Pathological Society of Philadelphia on November 8, 1900. The belief is common that cows when coughing swallow all their sputum, and do not project it to any extent. Dr. Mazyck, by ingenious methods devised by himself, has disproved this theory, and has practically demonstrated that, in the act of coughing, cows, as well as men, atomize, ?o to speak, their sputum, and project it into the air in minute particles, which may float for some time. Inoculation of guinea- pigs with this secretion gave a considerable proportion of positive results. Dr. Mazyck came to the conclusion that the danger of infection by means of this atomized sputum, as far as mankind goes, is confined practically to those in constant contact with the animals, but for other animals in the same stable the infected animals must be considered a source of danger. The moral to be derived from the outcome of Dr. Mazyck's experiments would seem to be that when tuberculosis is diagnosed in a cow she should be isolated as far as is possible; at any rate, she should not be confined in a shed with healthy animals. Sterilization and Pasteurization vs. Tubercle-free Herds, etc.^ — The comparative dependence upon sterilization or pasteurization and the insur- ance of absolute absence of tubercle in herds supplying milk are discussed by Hope, who thinks that, while raw milk is especially liable to contamina- tion, sterilization, valuable as it is, is, after all, only an expedient, and must not be put in such prominence that the importance of the other safeguards of absolute cleanliness of source and handling are neglected. Beyond any question, he says, the ultimate advantage lies in obtaining the milk from herds free from tuberculosis. A comparison is made with having water from a contaminated source and making it pure later by chemical processes or boiling it, and obtaining it in the first place from an uncontaminated source. He thinks it is quite possible to insure that the milk supply shall come from cows free from tuberculosis. The State Veterinarian of Pennsylvania, Dr. Pearson, thinks that not over 2 per cent, of the cattle of that State are tuberculous, and probably if a general test of all the cattle of the other States mentioned were made we should find a very much smaller proportion tuberculous than is indicated l)y this tabular statement. The explanation of the high percentages that have been given is found in the fact that it has been, for the most part, suspected herds which have been tested. Admitting that the greater part of these percentages are too high, Ave still have revealed a condition which is worthv of our serious consideration. 'E. W. Hope (The Lancet). 126 isrUTRITION. The classes of animals most affected are breeding animals and dairy- stock. The beef cattle coming to our markets are still singularly free from tuberculosis. Of 4,841,166 cattle slaughtered in the year 1900 under Fed- eral inspection, but 5279, or 0.11 per cent., were sufficiently affected to cause the condemnation of any part of the carcass. Of 23,336,884 hogs similarly inspected, 5440 were sufficiently affected to cause condemnation of some part of the carcass. This is equal to 0.023 per cent., or slightly more than one- fifth the proportion found in beef cattle. It is scarcely necessary to add that there are certain lots of cattle and hogs encountered which are affected in much greater proportion than the general average Just given. From a recent view by Drs. Eussell and Hastings, of the Wisconsin Agricultural Experiment Station,^ of the tests of cattle for tuherculoms made in the United States, the following summary is presented : — ■ Table No. 19. Vermont Massachusetts Massachusetts, entire herds Connecticut New York, 1894 New York, 1897-98 Pennsylvania New Jersey Illinois, 1897-98 Illinois, 1899 Michigan Minnesota Iowa Wisconsin — Experiment Station tests: Suspected herds Non-suspected herds State Veterinarian's tests: Suspected herds Tests of local veterinarians under State Veterinarian on cattle in- tended for shipment to States requiring tuberculin certificate . Number Tested. 60,000 24,685 4,093 6,300 947 1,200 34,000 22,500 929 3,655 3,430 873 323 935 588 3,421 Number Tuberculosis. 2,390 12,443 1,080 66 163 4,800 560 122 115 84 191 76 Per cent. Tuberculosis. 3.9 50.0 26.4 14.2 6.9 18.4 14.1 21.4 12.0 15.32 13.0 11.1 13.8 35.6 9.0 32.5 2.2 The following suggestions, adapted from the fifty dairy rules of the United States Department of Agriculture, are recommended for strict adop- tion in our dairies : — The Stable. — Keep dairy cattle in a room or building by themselves. It is preferable, when possible, to have no cellar below and no storage loft above. The stables should be well ventilated, lighted, and drained; should have tight floors and walls and plainly constructed. Store the manure under cover outside the cow stable, and remove it to a distance as often as prac- ^ Bulletin No. 84, Wisconsin Agricultural Experiment Station, March, 1901. CARE OF THE MILK. 127 ticable. Whitewash tlie stables once or twice a year; use land plaster ill the manure gutters daily. Clean and thoroughly air the stable before milk- ing; in hot weather sprinkle the floor. The Cows. — Have the herd examined at least twice a year by a skilled veterinarian. Promptly remove from the herd any animal suspected of being in bad health and reject her milk. Xever add an animal to the herd until certain it is free from disease, especially tuberculosis. Do not allow the cows to he excited by hard driving, abuse, loud talking, or any unneces- sary disturl)ance. Feed liberally, and use only fresh, i)alatable food stuffs. Provide water in abundance, easy of access, and always pure. Do not allow any strongly flavored food, like garlic, cabbage, turnips, to be eaten except immediately after milking. Clean the entire body of the cow daily. If the hair in the region of the udder is not easily kept clean, it should be clipped. If the sides of the cow are plastered with dirt or manure, as is often the case, a certain amount is sure to fall into the pail of milk. This is where the trouble really begins, for this dirt and manure abound in bacteria which cause decomposition in milk, and thereby induce bowel disturbances. The Milk. — The milker should be clean in all respects. He should wash and dry his hands and clean his nails just before milking. After the hands have been washed, a little vaseline may be used on them, thereby preventing scales from the teat or fingers getting into the milk. The milker should wear clean, dry garments, used only when milking, and kept in a clean place at other times. Brush the udder and surrounding parts just before milking, and wipe them with a clean, damp cloth or sponge. Commence milking at the same hour every morning and evening, and milk quietly and thoroughly. Throw away (but not on the floor — ^better in the gutter) the first few streams from each teat. This first milk is watery and of little value, and during the intervals between milking, the bacteria from the air get into the cow's teats and grow with great rapidity. These bacteria cause early souring of the milk. If in any milking a part of the milk is bloody or stringy or im- natural in appearance, the whole mass should be rejected. Milk with dry hands, or oiled as above ; never allow the hands to come in contact Avith the milk. If any accident occurs by which the pail, full or partly full, of milk becomes dirty, do not try to remove this by straining, but reject all this milk and rinse the pail. Care of the Milk. — ^Eemove the milk of every cow from the dairy at once to a clean, dry room, where the air is pure and sweet. Do not allow cans to remain in stables while they are being filled. Strain the milk through a metal gauze and a flannel cloth, or layer of cotton, as soon as it is drawn. Aerate and cool the milk as soon as strained. The rapid aeration and cooling of milk are matters of great importance. Combined aerators and coolers, suitable for use with well water or ice water, can be had at any dairy supply house at a small cost. By using one of these, the cow odor, the animal heat, 128 NUTRITION. and much of the dirt can be removed from milk in a few minutes. The milk should be cooled to 45° F., if for shipment, or to 60° ¥., if for home use or delivery to a factory. Never mix fresh, warm milk with that which has been cooled. Do not allow the milk to freeze. When cans are hauled a dis- tance they should be full and carried in a spring wagon. In hot weather cover the cans, when moved in a wagon, with a clean, wet blanket or canvas. If milk is stored, it should be held in tanks of fresh, cold water, renewed daily, in a clean, cold, dry room. Clean all dairy utensils by first thoroughly rinsing them in warm water; then clean inside and out with a brush and hot water into which a cleansing material is dissolved ; then rinse, and lastly sterilize by boiling water or steam. Use pure water only. After cleaning, keep the utensils inverted in pure air and sun if possible, until wanted for use. Old cans, in which parts of the tin are worn off, or where there are seams and cracks, are impossible to keep clean, and should not be employed. Small Animals. — -Cats and dogs must not be in the stables during the time of milking. The reason for this is that cats are peculiarly liable to transmit diphtheria; both cats and dogs have disgusting skin diseases which may be transmitted to children, and both animals also are apt to nose around and dirty the utensils. if precautions like the above are strictly carried out, the milk will be clean and remain fresh for a considerable length of time. The fresher the milk is, the better it will be for family use. The test for uncleanliness con- sists in an increase in the proportion of lactic add generated in the milk, and in a large increase in the number of bacteria per cubic centimeter. The New York Senate passed a bill recently, forbidding sale of milk containing formaldehyde or salicylic acid, owing to their injurious effects on infants. Eaw Milk. Monrad {Jahrbuch f. KinderheilTcunde, No. 55, p. 61) describes a series of children fed with raw milk. These infants could not digest ster- ilized or boiled milk. Their condition improved when raw milk was sub- stituted. It was interesting to note that during the course of Monrad's investigations an infant received sterilized milk by mistake, and its former dyspeptic symptoms reappeared. Jensen found that new-born calves assimilated raw milk, but when boiled milk was given, they were subject to coli-enteritis. Such calves that recovered were atrophic. Milk, when subjected to prolonged sterilization, such as tyndalizing the milk, undergoes certain chemical changes. These are: — 1. Nuclein and lecithin are rendered insoluble. 2. Milk-sugar is completely changed. 3. The coagulability of the casein is impaired. 4. The fat globules are separated and rise to the surface of the milk. RAW MILK. 129 5. By tlie influence oC tlie clilorides oa tlie casein ])0|)t(nies are foi-nied in the milk. G. The milk is rendered unpalatable by this superheating. 7. The albumin is rendered much le?s assimilable by prolonged heating. The increased number of cases of rickets and Barlow's disease since the advent of sterilization does not speak well for this process. Certain factors should be noted : — 1. That stei'ilization is intended to kill pathogenic l)acteria in the milk. 2. That not only are ])athogenic bacteria destroyed, but also sapro- pliytes, which certainly have ?ome bearing on the digestive functions of an infant. We know that the proteolytic bacteria are in the milk for certain reasons : — 1. To coagulate the casein. 2. To peptonize this coagulated casein. It is possible that by sterilizing milk and destroying these bacteria, Ave rob the milk of microbes necessary to perform certain aids in the digestive process. Such assistance in the digestion of milk may not be necessary in the rol)ust and normal infant, but it is quite different when we are dealing with dyspeptic or atrophic infants. When infants ilirive on sterilized mill-, then it is a good plan to con- tinue the mme; but if dyspeptic symptoms — vomiting and undigested, cheesy stools with colicky symptoms — show themselves, then such food should be discontinued. Such cases demand a radical change of diet, and it is here that an easily assimilated form of food is indicated. Such food is raw milk. Scorbutic cases in which we continue giving sterilized milk will not be modified whether we add HCl, pepsin, or alkalies. The character of the food is at fault and a radical change must be made. For the treatment of atropliy nothing will supersede raw milk. Certain precautions must' be taken in securing raw milk for infant feeding. The ideal cows' milk is clean, raw milk. By this is meant milk free from all possible contamination. Such milk should be obtained from a stable having all modern hygienic surroundings. If greater attention were l)estowed on the condition of the cow, the cow's udder, the stable, the l)ucket, the hands of the milker, then less sterilization and pasteurization would be necessary. Let it be distinctly understood that certain chemical changes are brought about in milk when it is steamed, he it in the process of sterilization «r pasteurization. Neither sterilization nor pasteur- ization adds to the digestibility of milk. Indeed, chemical experience has demonstrated the fact that raw milk, sold in some places as certified milk, in the Walker-Gordon milk laboratories as guaranteed milk, is more easily 130 NUTRITION. assimilated. It is jDroven by the condition of the stools as well as the gas- tric digestion. Nature has given us a good example of how milk should be fed to an infant. Breast-milk is certainly raiv milk, and is served to the infant at the temperature of the body. N"ot only does boiling and steaming of milk produce chemical changes in the albuminoids, but it renders the process of digestion much more difficult, and thus it is that most infants taking boiled milk suffer with constipation. This is not so, however, in the case of infants fed on raAv milk. When sterilized and pasteurized milks are found to disagree with chil- dren, raw milk may sometimes be easily assimilated. Thus it will be found that, while boiled milk, or sterilized or pasteurized milk, given either whole or with its proper dilution to suit the various ages, will provoke constipa- tion, by substituting raw milk for heated milk the same will be more easily assimilated. The author has frequently noted decided antiscorbutic prop- erties in fresh raw milk. In children with pronounced rickets, and even scurv}^, the withdrawal of sterilized or other milk and the substituting of fresh raw milk will work surjjrising changes. Biedert^ states that he has followed Escherich and Epstein, who rec- ommend giving full milk to children at birth. In France, Budin and H. de Eothschild, and more recently E. Schlesinger, in German}^, have given undiluted milk to both sick and well children as a substitute for breast- milk. Biedert claims to have seen good results in some instances, but cannot recommend whole milk, as a rule, for feeding children. Marfan, another advocate of pure-milk feeding, believes that milk should be diluted until the fourth or fifth month, but later he advises pure-milk feeding. Schlesinger, of Breslau, while giving pure milk, gives a longer interval between the meals. That the greatest possible success is not achieved by this method in France can be judged by the statement of Marfan while discussing the subject of athrepsia. He says: ''N'a jamais vu VatUrepsie confirmee se terminer favorahlement/' Thus it seems that even we have much better results than the French, for there are certainly a great many children who can and will digest a diluted milk, and thin milk-and- . cream mixtures, as shown by their stool, their sleep, and their increase in weight. These same children with enfeebled digestive functions will in- variably show gastric disturbances — such as vomiting, colic, constipation, or diarrhffia, restlessness, sleeplessness — and will cry continually Mdien given whole milk. So that tvhole-milk feeding is not assimilated during the early months of a child's life; besides they do not increase in weight. This method of feeding has been tried over and over again^ and we are compelled to discontinue the heavier food, consisting of whole milk, and substitute a light food, consisting of dihitod milk. * Fourth Edition of Kindcrorniilirung, 1000, page 184. RAW MILK. 1;}1 Fresh Raw Milk. — Just as the medical profession, and to some extent the laity, liave boconie hiipresscd with the idea that milk should be boiled before being used, to iii-sui-e the destruction of the microbes which it contains, Dr. Freudenrich comes fonvard with a series of experiments, by which he claims to ])rove tliat raw milk possesses remarkable germicidal proper- ties. According to liis experiments, the bacillus of cholera, when put ■into fresh cows' milk, dies in one hour, the bacillus of typhoid fever suc- cumbs at the end of twenty-four hours, while other germs die at the end of varying periods. Milk which has been exposed to a temperature of 131° F. loses its germicidal properties. Milk which is four or five days old is also devoid of microbe-killing power. ^ Undiluted Milk as a Food for Infants. — Xotwithstanding tireless re- search and wonderful ingenuity, a perfect substitute to replace mother's milk as an article of food for the nourishment of infants 3-et remains to be discovered. This is greatly to be regretted, as the occasions are not rare on wdiich mother's milk is not available, or it is desirable or even necessary to have recourse to such a substitute. The fact is that there is yet not a little to learn concerning the assimilative processes in children, and knowl- edge, particularly of a practical character, concerning food is not so exten- sive or so precise as it might be. As K. Oppenheimer points out in a recent communication, an article of food for the infant to serve as a perfect sub- stitute for mother's milk should be as useful as the latter in the nourish- ment both of healthy children and of those suffering from gastro-intestinal catarrh. These requirements, however, are not met by any of the large number of artificial foods that have been devised. For the purpose of estab- lishing the usefulness of undiluted cows' milk as judged by this standard, Oppenheimer made comparative observations in normal healthy children, in infants suffering from gastro-intestinal derangement, and in atrophic children. In almost all of the 11 cases of the first group the body weight exhibited a steady and uniform increase, while of 36 cases of the second group only 6 failed to do well, and of 12 cases exhibiting marked atrophy 8 failed to do well. All of the foregoing cases were under observation for periods of more than four weeks. Of 33 additional cases under observation for a shorter period than four weeks, 20 thrived and 13 did not. The Dangers. — ^We naturally regard the dangers of having tubercle bacilli in the milk as one of the prime reasons for sterilizing the same. \Ye should never employ the milk from one cow, but always from a mixed herd. The danger of transmitting tuberculosis is certainly very rare. Au- thentic cases have been reported from time to time in medical literature 'Bacteriological World. December, 1891; Journal of the American Medical Association, February 27, 1892. 132 NUTKITION. in which a supposed infection could be attributed to milk. E. Koch disputes the possibility of transmitting bovine tuberculosis to man. In a herd of cows which has undergone the proper veterinary inspection, the danger of overseeing tuberculosis of the udder is reduced to a minimum. Fat. While it is true that a new-born infant with a healthy stomach can tolerate a higher fat percentage than an infant with a weak stomachy great care must be ezercised to avoid overtaxing the digestive functions, so that a stomach breakdown does not result. Fat Metabolism. — ^The proper amount of fat that an infant can digest at birth is between 1 and 2 per cent. After several weeks 2 per cent, will be digested. Nutritional disturbances such as regurgitation and vomiting of sour-smelling liquids will follow the feeding of more fat than the stom- ach can tolerate. Some infants will thrive on 2% per cent, of fat, while others demand 3 to 3% per cent, of fat when six months old. The stool of excessive fat-fed infants will contain round or lentil-shaped particles of fat. Clinical experience has demonstrated that vomiting, colic, and restless- ness results more often from excess of fat than from any other ingredient in the food. Eesearch has demonstrated conclusively that fat favors nitrogen excre- tion. The higher the fat, the less nitrogen will be retained. High fats usu- ally lead to the development of soap stools. Of the total fat ingested it is estimated that 87 to 98 per cent, will be absorbed. When we have a disturbance of fat metabolism there results a relative acidosis. Usuki believes that the soap stool is caused by a disturbance of fat metabolism due to excessive fat absorption rather than to poor fat ab- sorption. Bahrdt's^ conclusions are just the reverse. He regards the soap stool due to a smaller absorption of fatty acids, resulting from an increased peristalsis of the small intestine, which, with an increased excretion of alkali, results in the formation of the saponified stool. The urine of an excessive fat-fed infant contains an excess of ammonia. The- condition called "acidosis" results. High fat feeding results in an excess of volatile acids in the stomach and intestines. If the text-books of ten and twenty years ago are consulted the reader will find that the high fats were generally advocated. Whole milk and cream or top milk were strongly recommended for general feeding methods. That this was a fal- lacy has now been demonstrated. Finkelstein believes that when the fat content of the food is high, the disturbance caused thereby lessens the tolerance for sugar. Fat disturbances can be made out independent of whether the sugar content is high or low. ^Bahrdt, Jahrb. f. Kinderh., 1910, 249. FAT. 133 Digestion of Fat. — The digestion of fat begins in the stomach and is continued in the intestine. This synthesis of the fatty acids in the fat is a function of the intestinal epithelium associated with the secretion of the pancreas and other intestinal glands. Regarding the absorption of fat, we must not suppose that all fat found in the faeces is unabsorbed fat from the food. Normally the stool contains from 1 to 10 per cent, of fat, besides free fatty acids and their combinations with saponified fats. Fat is not the most important item of nutrition, because fat may be replaced by a certain quantity of carbohydrate. Whether an infant could live entirely without fat and receive in its stead a given quantity of carbohydrate has never been proven. Theoretically it is possible. - Bab cock's Milh Test. — In this country the so-called Babcock milk test, invented by Dr. 'S. M. Babcock, has been adopted in preference to other practical milk tests, in creameries and cheese factories as well as in milk Fig. 43. — Centrifugal Testing Machine, for Handpower. laboratories. The cause of the general adoption of this test is doubtless to be found in its simplicity, cheapness, and ease of manipulation. Briefly stated, the test is operated as follows: 17.6 cubic centimeters of milk are measured into a special milk-test bottle, an equal quantity of commercial H2SO4 (specific gravity, about 1.83) is added, and after mixing the two liquids the test bottle is placed in a centrifugal machine and whirled for four minutes; hot water is then added to the bottle to bring the fat into the graduated narrow neck of the bottle, and after a second whirling of one minute the per cent, of fat in the milk is read off from the scale of the test bottle. A determination of fat in milk by this method takes less than fifteen minutes, and when care is taken in sampling the milk the reading of the result is accurate to within one-tenth of 1 per cent. Babcock testei*s are now placed on the market by many manufacturers of dairy supplies and at a remarkably low price, thanks to shai'p competition among the manufac- turers. The testers are either hand or power (steam or motor) machines and built to hold from two to thirty or more test bottles at a time. The number of revolutions at which they must be run ranges from 800 to 1200 per minute, according to the diameter of the testers. 134 NUTRITION. The Determination of Fat. — The simplest method is by the cream gauge (Fig. 44). Although its results are only approximate, they are in most cases sufficiently accurate for clinical purposes. The tube is filled to the zero mark with freshly drawn milk, which stands at a room temperature for twenty-four hours, when the percentage of cream is read off. The ratio of cream to fat is approximately 5 to 3 ; thus, 5 per cent, cream represents 3 per cent, fat, etc. Another rapid method is by Marchand's tube. Marchand's Test. — First put into the tube five cubic centimeters of milk, up to the line M; then four or five drops of liquor sodge; shake; add n CO CMj t m Fig. 44.— Graduated Oream Gauge. 10 stimulate the thymus and the parathyroids seems plausible, and when they are absent from the food there results either rickets or tetany. Vitamines are found in the Ijrain of the ox, also in lecithin and in testiculin as sold in commerce. Cereals such as oats, wheat, barley, and various kinds of beans contain vitamine, so also fresh vegetables. ^Die Vitamine, by Casimir Funk, Wiesbaden, 1914. PLATE V Microscopic Appearance of Raw Starch-granules. PLATK Xl Microscopic Appearance ot Starcli iiianules, showing the effect of Heat. STARCH. 145 Vitamines are best administered in the form of yeast with yolk of egg. Funk lias found that beriberi is not due to an infection or intoxication, but is caused by a deficiency of this vitamine. The absence of vitamine is noticeable in polished rice, white bread and starch. If to this food we add yeast or beans, then we add vitamines which are required for tlie development of the organism. Vitamines in milk are sometimes dependent on the nutrition of the cows; thus we find that milk of cows lacking fresh fodder, as for example in winter, will produce less vitamines. It is, therefore, quite plausible that the use of such milk may be a factor in the causation of rickets. Funk states that the vitamines are practically destroyed by moderate heating of milk, and are completely destroyed by the sterilization of milk. We can, however, add vitamines to sterilized milk and tlius render it nutritious and also anti- scorbutic. Antiscorbutic Diet. — Fresh green vegetables like lettuce, cauliflower, onions, potatoes, apples, oranges, lemons, raw milk, yolk of egg, meat, wheat, oats, and barley. Juicy fruits and vegetables lose their vitamines (scurvy vitamine) en- tirely on drying or heating to 212° F. for one hour. The action of the vitamines resembles that of hormones and the secretions of the ductless glands. Albuminous substances vary in their nutritive value depending on the presence or absence of amino-acids. In like manner there are certain foods the value of which is dependent on their vitamine content. Chemical examination shows that vitamines occur in maize in very similar fashion to rice in the peripheral layers. Enzymes (Effront and Prescott). The enzymes, soluble ferments, zymases, or diastases, are active organic substances secreted by cells, and have the property, under certain conditions, of facilitating chemical reactions between certain bodies, without entering into the composition of the definite products which result. These substances play a very important part in the phenomena of assimilation and of dissimi- lation of foods. In fact, most of the foods which occur in Nature at the disposition of men, lower animals, or plants are not directly assimilable; they require the intervention of a diastase in order to be transformed into substances assimilable and suitable for the formation of new tissues. Starch. Amylaceous dilutions of milk have been in use very many years. They increase the carbohydrate ; besides aid mechanically in breaking up the curd into fine particles, thus rendering it more digestible. The saliva of the newly born infant can dextrinize starch. Starch is not assimilated as such, 10 146 NUTRITION. but is transformed into maltose and glucose. These latter are suitable for the construction of tissues. Cereals. — In the feeding of infants we should give sugar to supply the carbohydrate element in preference to starchy foods. Cereals should not be ordered until the infant is six months old or until the teeth begin to appear. Experience has shown fair quantities of starch can be digested as early as the third month. My method has been to use cereal dilutions such as barley water or rice water to dilute cows' milk after the third month. When the infant is 6 months old it is safe to feed a small saucer of well-steamed cereal, but care must be used to avoid starch indigestion, which condition is brought about by improper cooking of cereals and by overfeeding or feeding excessive quantities of carbohydraies. Ckeam, When food contains too little fat, or its equivalent (cream), we have fat-starvation, which is soon manifested by symptoms of rickets. One of the earliest symptoms of rickets is constipation, showing deficient muscular tone : a distinct atony of the bowel. This can be remedied by the addition of fat or cream to the food. Some children are benefited by giving them codliver-oil, butter, or olive-oil ; thus, it is plain that each one desires to remedy the deficiency of fat in his own manner. In buying cream from small milk-stores one can make a rough guess at the proportion of fat in cream by its thickness. A 50-per-cent. cream at the ordinary temperature of the room runs from a jug slowly and in a thick stream, almost like thick mucilage, whereas a 16 per cent, cream runs alm.ost as freely as milk. This is, however, a crude way of estimating the difference between poor and rich cream. It is a very important point to know exactly what percentage of cream we are using, for such mixtures like Biedert's, in which 1 ounce of cream is mixed with 3 ounces of water, may agree very well when we use a 16 or 20 per cent, cream, but might be disastrous if we use a cream containing 40 per cent, of fat. Such infants would not tolerate this rich cream, and might have troublesome vomiting. Cream for Home Modification. — Ordinary Cream.- This is made by setting milk at night and skimming it in the morning; it is called gravity, or skimmed, cream, and contains 16 per cent, of fat. Twelve Per Cent. Cream. — Obtained in the city by using equal parts of ordinary (20 per cent.) centrifugal cream and plain milk. In the country we must use 2 parts of ordinary skimmed, or gravity, cream (16 per cent.) with 1 part of plain milk, or by taking the top layer of milk, after it has stood five or six hours, by means of siphoning. Eight per cent, cream is obtained in the city by diluting 1 part of cen- trifugal (20 per cent.) cream with 3 parts of plain milk; in the country. CREAM. 147 by using 1 part of gravity cream and 2 parts of plain milk, or by using the top layer of milk that has been standing five or six hours, siphoning it off. How to Procure Cream. — Set aside the ordinary quart bottle of milk on the ice for several hours (from six to eight hours) to allow the cream to rise. After the cream has risen draw the milk from the bottom of the bottle ; this can be accomplished by means of a siphon. To make the siphon, get a piece of glass tubing 21 inches in length and a quarter of an inch in caliber. This can be procured in any drug store. German glass is less liable to crack than American glass. If the glass tubing is longer than 21 inches make a small scratch in it, after measuring off 21 inches, with a three-cornered file, then grasp the glass tubing between the fingers and opposing thumbs of both hands, having the thumb-nails touch- ■^ Fig. 48. — Chapin Cream Dipper. ing each other on the side of the glass just opposite to the scratch. On attempting to bend the glass tube it will break smoothly across, and if there are any sharp edges they can be smoothed by rubbing down with the file. To bend the glass tube to the V shape, hold it in the flame of an ordi- nary gas jet or alcohol lamp for a few moments, twirling the glass rod until it softens sufficiently to allow it to be bent to the required angle. The tube should be warmed gradually at first, and then put right into the flame. It is better in bending the glass to make one arm of the siphon a few inches longer than the other. In using the siphon hold it with the angle down, fill it with water, and close the long arm with the tip of the finger; then, keeping the finger applied to the long end, turn the siphon with the angle up, and introduce the short arm into the bottle of milk, letting it rest upon the bottom. On removing the finger, the milk will flow through the tube, and continue to 148 NUTRITION. do so until the bottle is empty. It is, therefore, necessary to watch the layer of cream, so that the siphon can be lifted out of the bottle just before the cream reaches it. There will thus remain in the milk-bottle all of the cream and a small portion of the milk, the latter depending upon the ex- pertness of the person using the siphon. A simpler method of obtaining the cream is by the use of a cream dipper (see Fig. 48). This can be purchased at any large drug-store. The illustration explains itself. To Pasteurize the Cream. — Take a clear glass bottle having a neck not very wide; fit into the same a perforated cork with a chemical thermom- eter registering up to 213° F. The bulb of the thermometer should come within half an inch of the bottom of the bottle. The cream is put into the bottle, and the cork carrying the thermometer is inserted; the bottle is then placed in a pot containing a couple of inches of warm water and allowed to heat on the stove. The thermometer should be watched until it reaches 140°, taking care that it does not go above 140°. When the ther- mometer has reached this point, set the pot back on the stove, where it will cool off, and allow it to remain there for twenty minutes. At the end of this time substitute a plug of absorbent cotton for the cork containing the thermometer. Great care must be taken to keep the absorbent cotton dry. Cream thus prepared is pasteurized, and will keep sweet and fresh for twenty-four hours without being kept on ice, and all that is necessary in removing a portion from the bottle is to be sure that the cotton plug does not become moist, or, if it should, to replace it with a dry piece at once. To Clean the Glass Siphon. — It is advised to fill it with water imme- diately after using it, and the ordinary tube-brush having eighteen inches of wire added to it will permit thorough cleansing. IvTothing, how- ever, will be found as good as thorough boiling in plain water to which a pinch of soda has been added. Modification of Milk. — It has been shown previously that the percent- ages of fat in woman's and in cows' milk are about the same, that the quantity of sugar is rather lower in cows' milk, and that the quantity of casein and albumin is greater in cows' milk, as is also the ash. Experience has shown that cows' milk must be diluted before it can safely be fed to infants. Simply diluting the milk reduces the percentages of fat and sugar too much ; so that the practice of adding cream and sugar has arisen, but the processes that have been advocated for obtaining the desired additional quantities of fat and sugar have been too complicated for general use. The top 9 ounces of a quart of milk on which the cream has risen will be about three times as rich in fat as the whole milk, the top 15 or 16 ounces will be about twice as rich as the whole milk, while the other ingredients remain about the same as in whole milk. For babies under three months of age the top 9 ounces of a quart of CREAM. 149 milk on which the cream has risen should be diluted from three to ten times and 1 part of sugar added to 25 parts of food. For babies under three months of age the top 9 ounces of a quart of milk on which the cream has risen should be diluted two or three times and 1 part of sugar added to 25 or 30 parts of food. For babies six to nine months old the top 20 ounces of a quart of milk on which the cream has risen should be diluted one-half to one time and 1 part of sugar added to 50 parts of food. An even tablespoonful of granulated sugar equals half an ounce. By following this method the infant commences on weak mixtures that show about the same composition and variations as woman's milk and gradually takes food richer in casein until plain milk is reached. The diluents used are water, gruels, or dextrinized gruels, which are simply ordinary gruels the starch of which has been converted into soluble forms, leaving the cellulose and proteins of the cereal in a finely divided state. The effect of the different diluents will be mentioned farther on. The indiscriminate feeding of cream, to strengthen the bab)^, cannot be too strongly condemned. Many a dyspeptic owes his trouble to over- feeding by a too good mother or nurse. When cream is added, and the pro- portion of fat or protein is too large, vomiting will result. Stuffing delicate children with cream, regardless of their digestive power, cannot be too strongly condemned. When improper food is given, and the infant's stom- ach is overtaxed, the excess of food irritates and may cause vomiting. If, however, the food remains, then the gastric mucosa is inflamed by bacteria] fermentation of stagnant food. This may result in diarrhoea or in fermen- tative gastritis, and cause chronic enlargement of the stomach. CHAPTER III. • HOME MODIFICATION OF MILK. Bottle-feeding or Hand-feeding. The following utensils are required for the home modification of milk : — Two-quart pitcher, "] Funnel, V glass or porcelain. One large spoon, J One dozen 4-ounce bottles (later substitute 8-ounce bottles) . One dozen anticolic nipples. One box non-absorbent cotton. One saucepan (for heating milk). One high saucepan (for warming bottle before feeding). FJieding-bottles. A proper feeding-bottle is one that has no corners or angles on the inner surface. The bottom should be rounded, so that every part of the same can be properly cleaned. Bottles that have corners and grooves will harbor bacteria. My preference has always been for two kinds of bottles: 1. Those holding 4 ounces and graduated on one side in both ounces and tablespoons ; this saves much time and trouble. 2. Bottles holding 8 ounces and divided off into 16 tablespoonfuls or 8 equal ounces. Exactness of Ounces. — It may not be out of place to ask each physician to insist on having the graduated ounces on an infant's feeding-bottle meas- ured with an accurate graduate, obtainable at every drug store. In many instances the author noted feeding-bottles wherein the ounces indicated were very unequal, and one particular bottle, graduated to 8 ounces, held 12 ounces. Long Rubber Tubes. — Most prominent podiatrists agree that the long rubber tubes are a convenient place for harboring micro-organisms, and they have been universally condemned. Care of the Bottle. — Every bottle should be thoroughly cleaned with a brush and a solution of baking soda and water, a teaspoon of soda to a pint of water. The bottles must then be thoroughly rinsed with clear water. If milk has fermented or if some residue adheres to the bottle and the same cannot be properly cleaned, then boiling the bottles will be necessary. In general and for daily use the bottle need not be boiled every day. (150) FEEDING-BOTTLES. 151 Proper Time for Gleaning Bottles. — The best time to clean a bottle is immediately after the baby has been fed; this prevents the food souring in the bottle, and it is very easily cleaned. The bottle brush has a long handle and bristles for cleansing the bottles. This brush should be used before the bottles are put into the soda solution. It is understood that the brtish can itself harbor bacteria and particles of milk removed while cleansing. It is therefore understood that the brush must be thoroughly boiled in a soda solution after each use. Choice of a nipple is another important matter. My preference has always been for a black-rubber nipple, and it is a very wise point to use a nipple no longer than one week ; in other words, old, worn nipples are useless for the proper management of infant-feeding. Black rubber is softer than Fig. 49 Fig. 50 Fig. 49. — Author's Choice of Feeding-bottle. Fig. 50. — Bottle Warmer. A convenient bottle warmer, adapted for keeping the night feeding warm, is here illustrated. It is made by the Arnold Sterilizer Co. It is also useful when traveling. white rubber ; most white rubber is supposed to contain lead ; hence , a decided reason for not using it. Nipples Recommended. — One of the best nipples made is the so-called anticolic nipple. This nipple has a ball-shaped top, which enables a baby to take a firm hold; it has three small holes, which give an easy flow of milk, and regulate a slow meal. Nipples having very large openings, which will permit a baby to finish a 6- or 8- ounce bottle of food in five or six min- utes, are useless, and this gulping of food is really the cause, or one of the causes, of infantile colic. I have used another nipple, but it is much harder to clean, and unless all precautions for sterilization are carefully noted it should not be used; yet, in the hands of the intelligent or where we have a trained nurse, it ct^n 152 NUTRITION. be safely recommended. It is called the "Mizpah." This nipple has also a very small puncture, so that the baby gets the food slowly. The "swan-bill'^ nipple and the long French, nipple I also like. I have noted just as good results as with the above-mentioned kinds. Ventilated Nipple. — A nipple very highly spoken of is the ventilated nipple made by Ware, of Philadelphia, which has a small opening or valve on the side, and, as the milk is drawn in from' the bottle, it permits air to ^\l 'Ail i\A Fig. 51.— Bottle-brush. enter, thus preventing a vacuum from being formed. It is also supposed to be non-collapsible, and is highly recommended by those who have used it. The only objection — already offered— is that all nipples must not only be practical for use, but must be capable of thorough sterilization. Cleaning the Nipples. — The prevention of stomatitis and mouth affec- tions depends upon proper hygiene of the nipple. It does not require much time or trouble to remove the nipple from a bottle and throw it into hoiling water immediately after using, wrap in sterile cheesecloth, and keep in a covered jar. A nipple thus treated is properly sterile. Fig. 52. — Anticolic Nipple. The nipple sterilizer (see Fig. 53) is a very convenient little arrange- ment made by Ware, of Philadelphia. It serves the purpose admirably for the sterilization of nipples. Sterilization of Milk. When Soxhlet first announced the method of sterilization, he awoke the profession to the realization of the dangers lurking in crude cows' milk STERILIZATION OF MILK. I53 His aim was to destroy pathogenic bacteria, and give the infant a milk which did not contain living bacteria. In order to sterilize milk, according to Soxhlet, we must heat milk to a temperature of 212° F. and continue this steaming for thirty minutes. We know that heating milk produces many changes, some of which are not thoroughly understood. Other changes have been positively proven. Changes in Milk Caused by Sterilization. — In some experiments made by Dr. E. M. Hiesland and published by Dr. B. C. Hirst/ it was found that by sterilization : — • 1. The albumin is coagulated. 2. Casein is less readily precipitated by rennet than in normal milk. 3. Fat is freed to a slight extent; fat not freed has a lessened tend- ency to coalesce. Fig. 53; — Nipple Sterilizer. 4. Sugar undergoes some change, as shown by its lessened dextrorota- tory power. The considerations suggested by the foregoing facts are: — 1. The coagulation of milk-albumin by sterilization may render the milk more difficult of digestion. 2. Sterilization interferes with the coagulability of milk by rennet, and presumably, therefore, with its digestibility by the gastric juice. 3. Free fat, as found in sterilized milk, is probably not readily assimi- lated in infant food. The fat not free, being inclosed in a less easily destructible envelope, is probably slow of digestion.^ On the question of sterilized milk the weight of evidence seems to show that the process, while preventing undue fermentation, so changes certain of the natural ferments and some of the fats that the milk is less easily digested and less nutritious.^ The sterilization of milk is advocated chiefly to destroy pathogenic bacteria. The profession has been educated to the belief that we must kill all livins; micro-organisms in food. ^Medical News, January 31, 1891. 'Medical Record, February 28, 1891. 'North American Practitioner, June, 1892, from the "Year-book of Treatment" (Lea Brothers & Co.). 154 NUTRITION. When the method was first advocated, the profession adopted it in all parts of the world; so that thousands of babies have been brought up on sterilized milk. Within the last few jea.rs sentiment has changed. Sterili- zation accomplishes the destruction of pathogenic bacteria, but it also pos- sesses certain disadvantages. The spores of pathogenic bacteria cannot be destroyed by the ordinary process of sterilization. To properly sterilize milk it is necessary to subject it to the process of tyndallization. This will render milk germ-free. This latter process con- sists of subjecting the milk to the process of sterilization for at least twenty to thirty minutes on three successive days. For practical purposes it is useless. The chemical changes produced in milk by the process of sterilization are as follows: The lactalbumin coagulates at a temperature of 160° F. (70° C). Thus the temperature being 212° F. renders this ingredient decidedly different from what it appears in its raw state; the casein is rendered less coagulable by rennet and appears to be acted upon more slowly both by pepsin and trypsin; the organic phosphorus is changed into an organic phosphate; citric acid is partially precipitated as calcium citrate, and some lime salts, which are usually soluble, are converted into insoluble compounds. Certain changes also occur in the fat. Moreover, certain natural fer- ments in fresh milk, believed to be of value in digestion, are destroyed by heat. Many of these changes are but imperfectly understood, and some of them are doubtless without any injurious effect upon nutrition. There is, however, one important clinical reason for believing that the nutritive properties of milk are impaired by heating to 212° F., viz., the occurrence of scurvy in infants who are fed upon such milk for a long time (Holt). We know that a great many children fed on sterilized milk develop scurvy. The same is true of children fed on boiled milk. The reason is, Eundlett so ably says: "Changes take place not in the albumin, fat, nor sugar, but in the albuminate of iron, phosphorus, and possibly in the fluorine vital changes take place. These albuminoids are certainly in the milk, de- rived as it is from tissues that contain them, and are present in a vitalized form as proteins." On boiling, the change taking place is simply due to the coagulation of the globulin, or protein molecule, which splits away from the inorganic molecule, and thus renders it, as to the iron and fluorine, unabsorbable and, as to the phopphatic molecule, unassimilable. This is the change that is so vital, and this only takes place when milk is boiled. It is evident that children require phosphatic and ferric proteins in a living form, which are only contained in raw milk. Cheadle says that phosphate of lime is necessary to every tissue; no STERILIZED MILK. 155 cell growth can go on without earthy phosphates; even the lowest form of life — such as fungi and bacteria — cannot grow if deprived of them. These salts of lime and magnesia are especially called for in the development of the bony structures. Avoidance of Scurvy. — Since clinical experience has demonstrated that the prolonged use of sterilized milk and boiled milk will produce scurvy, and that improvement is immediately noted when raw milk is given, or raw muscle juice (beef-juice) or raw white of egg, added to fresh fruit juices, does it not seem more plausible to commence feeding at once with raw milk rather than after scurvy or rickets is developed? There is a certain deadness, or, to put it differently, absence of fresh- ness, that is lacking in milk that has been boiled or sterilized, just as it is the absence of fresh meats and green vegetables which is known to cause scurvy in the adult. In my own practice I have so frequently been disappointed in the use of sterilized milk that within the last few years I have entirely discarded its use. The Disadvantages of Sterilized Milk From a Clinical Standpoint. — The first effect of using sterilized milk is that the child will be con- stipated. It is for this reason decidedly objectionable. It is wise to re- member that one of the earliest symptoms of rickets is constipation. We have known that the prolonged use of sterilized milk results in rickets. The symptom of constipation should therefore be looked upon not as a temporary, but as a permanent, damage to the body. Therefore, it should not be neglected. Appropriate dietetic treatment can easily modify con- stipation. Clinicians all agree that the prolonged use of sterilized milk cannot be advocated. There may be individual children who thrive on prolonged use of sterilized milk, and I dare say on any form of feeding. We are dealing, however, with average children, and these all show a cer- tain train of symptoms. Constipation of the most stubborn kind will be encountered in all children fed on sterilized milk. This condition exists regardless of the season of the year. Children do not thrive as well on sterilized milk as they do on milk subjected to a much lower degree of temperature. Sterilized milk is rendered less digestible than it is in its raw state. Freeman^ says that the modifications produced in milk heated to 212° F. consist in the starch-liquefying ferment being destroyed, the casein being rendered less coagulable and therefore being acted upon slowly and imperfectly by pepsin and pancreatine, and the milk-sugar being destroyed. Fayel,^ discussing boiled milk, says that it is more indigestible and in no respect safer than unboiled milk. The temperature at which it boils ^ Paper read at Academy of Medicine, New York, May 11, 1893. =* Medical Age, September 25, 1893. 156 NUTRITION. is insufficient to destroy microbes, and the milk is therefore not ster- ilized. Its density is increased by the boiling, above that suitable for infant digestion. Milk consists of a multitude of cells suspended in serum. The cells are fat cells, which form the cream. The remaining cells are nucleated and of the nature of white corpuscles. The serum consists of water in which is dissolved milk-sugar and serum albumin, with various salts and, chief of all, casein. The cells, with the exception of fat corpuscles, are all living cells, and they retain their vitality for a considerable time after the milk is drawn from the mammary glands.^ There is reason for supposing that when fresh milk is ingested the living cells are at once absorbed without any process of digestion, and enter the blood-stream and are utilized in building up the tissues. The casein of the milk is digested in the usual way as other albuminoids by the gastric juice, and absorbed as peptone. There is also absorption of serum albumin by osmosis. The chemical result of boiling milk is to hill all the living cells and to coagulate all the albuminoid constituents. Milk after boiling is thicker than it was before. The physiological results are that all the constituents of the milk must be digested before it can be absorbed into the system; therefore, there is distinct loss of utility in the milk, because the living cells of fresh milk do not enter into the circulation direct as living protoplasm and build up the tissues direct, as they would do in fresh, unboiled milk. In practice it will have been noticed by most medical practitioners that there is a very distinctly appreciable lowered vitality in infants which are fed on boiled milk. The process of absorption is more delayed and the quantity of milk required is distinctly larger for the same amount of growth and nourish- ment of the child than is the case when fresh milk is used. Vaughan does not believe that railk is benefited by either sterilization or pasteurization, but such procedure is necessary when market milh is used, because the latter is seldom or never obtained under aseptic precautions. Some people have an idea that it matters not how flUhy a cow's milh is, or how many germs it may contain, if it be pasteurized or sterilized it then becomes a fit food for children. This is not true, because, in the first place, even prolonged boiling does not kill the spores of all bacteria, and, in the second place, the chemical poisons produced by certain germs are not altered by the temperature of boiling milk. After milk has been either sterilized or pasteurized it should be kept at a low temperature before being fed to the child. This should be regarded as a necessary procedure in the preparation of infant food. The fact that milk in which the colon germ has already grown abundantly cannot, by any process of sterilization or pasteurization, be rendered fit food for chil- J. L. Kerr, British Medical Journal, December, 1895. PASTEURIZED MILK. 157 dren should be emphasized. The toxin of the colon hadllus may he heated to 180° C. {356° F.) for half an hour without having its poisonous prop- erties diminished. If clean milk he ohtained and heated at 1^0° F. to 150° F. for ten to fifteen minutes and then kept at a low temperature until fed to the child, it furnishes the hest food tvhich it is possible for u.s to ohtain under ordiua/ry circumstances. Pasteurization. Pleating milk to 75° C, as is done by many of the methods, does not sterilize, for the spores of the bacillus subtilis can withstand this temperature for several days. The spores will resist the temperature of 100° C. (212° F.) for six hours. Upon heating to 110° to 120° C. (230° to 248° F.) the milk will be thoroughly sterilized, but such heating causes a browning of the milk, and the cream-cells are apt to be broken and the fat or butter will rise to the surface. Pasteurization with a temperature between 60° and 80° C. (140° to 176° F.) destroys tubercle bacilli and, according to Van Geuns, destroys also the typhoid bacillus, the cholera bacillus, and the pneumococcus of Friedlander, and also most of the ordinary milk germs, and does not injure the milk, C. H. Stewart gives the following interesting result of the heating of milk at various temperatures, and its result on the albumin : — Table No. 21. Time of Heatingr. Soluble Albumin in Fresh Milk. Soluble Albumin in Heated Milk. 10 minutes at 60° C. ( 140° F.) 30 minutes at 60° C. ( 140° F. ) Per Cent. 0.423 0.435 0.395 0.395 0.422 0.421 0.380 0.380 0.375 0.375 Per Cent. 0.418 0.427 10 minutes at 65° C. ( 149° F.) 30 minutes at 65° C. ( 149° F.) . . .• 10 minutes at 70° C. (158° F.) 30 minutes at 70° C. (158° F.) 10 minutes at 75° C. (167° F.) 30 minutes at 75° C. (167° F.) 10 minutes at 80° C. ( 176° F. ) 30 minutes at 80° C. (176° F.) 0.362 0.333 0.269 0.253 0.070 0.050 none noue We can see that heating milk at 140° F. for ten minutes or for thirty minutes still leaves about the same proportion of soluble albumin as we find in fresh milk. When milk is heated only ten minutes at 176° F. no soluhle albumin remains, while in fresh milk about 0.375 is found. There is a slight taste or flavor which is noticeable when milk is heated to 158° F. for fifteen minutes. For practical purposes, however, milk heated to 1^0° F. serves very well and has no taste at all. Pasteuriza- 158 NUTRITION. tion of milk has been received by the jDrofession with the same enthusiasm as was sterilized milk when it was first announced. The mistakes that have been made by forcing infants to swallow milk sterilized at a temperature of 212° F. for tliirty minutes are evident in so far as such children can show a devitalized condition into womanhood and manhood. Constipation and rickets are recognized as associate factors during sterilized milk feed- ing. The profession at large is rapidly departing from this improper and dangerous method of treating raw milk. What has been said of sterilized milk applies in a lesser degree to pasteurized milk. I have frequently found cases of infants fed on pasteurized milk that showed the same symptoms, though in a milder degree, than what we know to be true of sterilized milk feeding. When my advice is sought regarding the utility of pasteurizing milk, I always say: You should pasteurize your milk at a temperature of 140° to 150° F., for ten minutes, if you do not know the source of your milk supply. In New York certified milk or guaranteed milk is procured, and it is un- necessary to change the chemical character of the milk by prolonged heating. With certified milk it is simply necessary to use sterile utensils and warm the food to a little higher than feeding temperature. General Eules of Bottle-feeding foe Normal Infants. No set rule can be given for all infants. Each infant's desires must be studied. The stomach capacity of one infant may be 6 ounces at the age of two months, while another equally healthy infant will be satisfied with 4 ounces at one feeding. In the home modification of milk our aim should be to give a simple formula, and one that can be easily understood by the mother or nurse. These formulae, with specific directions added, should be written out by the physician, and the following conditions noted: The weight of an infant to be taken when a new formula is given; the character, color, and frequency- of the stool to be noted; constipation or diarrhoea supervised; sleep and general comfort inquired into. Does the infant appear satisfied after its feeding, or does it put its fingers into its mouth and whine after each feeding ; does it draw up its legs, is it flatulent ; is there vomiting after each feeding, and is there frequent eructation? Summary. — If the food agrees the infant should be comfortable, have one or more natural stools in twenty-four hours, sleep at least four hours at one time, and gain in weight from 4 to 8 ounces during the week. Caloric Method of Feeding. A calorie is the amount of heat necessary to raise the temperature of 1 kilo. 1° C. The determination of the heat energy expressed by a given CALORIC FEEDING. 159 number of calories can be applied in estimating the food requirement of infants : — 1 gram or c.c. of fat equals 9 calories 1 gram or c.c. of sugar equals 4 calories 1 gram or c.c. of protein equals 4 calories The most prominent podiatrists in Europe calculate their food values in calories. My experience with this method of feeding has been very satisfactory. When the metric system of grams and kilograms is used the method is extremely simple. The requirement for the first three months is 100 calories for each kilo, of weight, for the second quarter year about 90 calories; therefore, an infant weighing 5 kilos, requires 500 calories in twenty-four hours. Later on, the requirement is 80 calories, and some infants at the end of six months do not require more than 70 calories per kilo. Emaciated and premature infants require 120 or more calories for each kilo. The simplest method of calculating the given number of calories in a pint or quart of food is as follows : — The caloric value of 1 ounce of 4 per cent, milk is 20; 16 times 20 calories equals 320 calories to 1 pint, or 32 times 20 calories equals 640 calories to 1 quart. 20 ounces of 4 per cent, milk 20 x 20 400 calories 12 ounces barley water 12 x 12 24 calories 1 ounce malt-soup extract 80 calories 504 calories Table No. 22. — Foods and Caloric Value of Each. Food, 1 Ounce. Cream ( 16 per cent.) Milk (4 per cent, cream) Milk (2 per cent, cream) Milk (1 per cent, cream) Milk, fat-free Whey Condensed milk Buttermilk Albumin milk Malt-soup extract Malt-soup (formula as given) Milk-sugar (by volume) Milk-sugar (by weight) Cane-sugar (by weight) Malt-sugar'' (by weight) Barley flour (by weight) Eice flour (by weight) Wheat flour (by weight) Approximate Caloric Value. 54 20 15 12.5 10 6 1.32 10 13 80 22 72 117 117 110 102.5 102.5 102 ^ Dextrimaltose, Mead, Johnson & Co. 160 NUTRITION. To make malt soup : — Cold water 666 parts Milk (4 per cent, fat) 333 parts White flour 50 parts Malt extract (Loefflund's) 100 parts Mix flour and water and bring to boiJ. Add malt extract, stirring constantly, and bring to boil. Lastly add the milk, stirring constantly. Bring to boil three times, in the mean time cooling it off quickly by standing it in cold water. Eight level teaspoonfuls of starches or sugars are approximately 1 ounce in weight. The formulge on following page are based on the studied requirements of an infant of normal bodyweight, which is approximately 45.5 calories for each pound weight; hence an infant weighing 7 pounds requires 318 calories in twenty-four hours. This method is useful in controlling the feeding of infants who are not gaining in weight. We can increase the calories up to the required, physiological standpoint, so that this method is in some respects similar to the percentage method advocated by Eotch and others. Formula No. 1 (for an infant from birth to three weeks old, weighing about 7 pounds, requirement 318 calories) : — IJ Wliole milk 13 ounces Hot water 12 ounces Dextrimaltose 4 drachms Mix thoroughly and heat in a saucepan until steam rises. Continue steaming at same temperature, five minutes. Divide into ten bottles of 2% ounces each. Feed every two hours. Insert large stoppers of non-absorbent cotton in the necks of the bottles. Place in a refrigerator, but not on ice. Warm before feeding by placing bottle into a deep saucepan of hot water until the food reaches body temperature. Formula No. 2 (for an infant from three weeks to six weeks old, weigh- ing about 8 pounds, requirement 364 calories) : — I^ Whole milk 14 ounces Hot water 10 ounces Dextrimaltose 6 drachms Divide into eight feedings of 3 ounces each. Feed every three hours. Formula No. 3 (for an infant from six weeks to two months old, weighing about 10 pounds, requirement 455 calories) : — ij Whole milk 17 ounces Hot water 15 ounces Dextrimaltose 1 ounce Divide into eight feedings of 4 ounces each. Feed every three hours. Formula No. 4 (for an infant from two to four months old, weighing about 11 pounds, requirement 500 calories) : — CALORIC FEEDING. ICl ■Ha- eing that an emulsion which is digestible and supposed to be rich in albumin is doul)tless better than pure water or a thin starch paste. In order to add food salts, which are not supplied by this means, he extracted them from leaf vegetables, which are rich in food salts, and added some sugar syrup. In this manner he claims to have made a preparation which he states is chemically equal to human milk, and full of nutritive value. His CONDENSED MILK— CONDENSED CREAM. 17 9 idea is that the interposition .of plant-albumin (conglutin) particles, which coagulate with difficulty between the coagulating casein masses, would in- crease their digestibility by breaking them up, and that the digestion of the plant-albumin and oil, as well as of the sugar and food salts, would present no difficulty. Stutzer, of the University of Bonn, reports thus: The vegetable milk is distinguished from children's food by the absence of starchy substances. In common with Biedert's cream mixture, the vegetable milk contains con- siderable quantities of fat in an emulsified condition. It differs from the cream mixture in the way it is prepared, and in its other qualities. Chemical Analysis. Fat 34.72 per cent. Plant-casein and similar nitrogenous constituents.. 12.00 per cent. Sugar and plant-de.xtrin 31.02 per cent. Salts 1.64 per cent. Water 20.62 per cent. My own personal experience has been rather favorable with the use of the vegetable milk, inasmuch as an emulsion of almonds and nuts was used to dilute the curd of cows' milk. Thus, equal parts of vegetable milk with cows' milk were taken by an infant for several months, and it was very well assimilated. Not only did the child gain in weight, but the bowels were in a fair condition, and the infant remained strong. Condensed Milk or Condensed Cream. Hundreds of infants are fed with condensed milk. This has its reasons : — 1. The readiness with which condensed milk is obtained. 2. The great cheapness of this article. 3. The ease with which the feeding mixture can be prepared. Jacobi says that some manufacturers use pure cows' milk; others find it in accordance with the health of their bank accounts to use skimmed milk. Quantity of Sugar in Condensed Milk. — Milk sold in our city for im- mediate use contains about 12 to 15 per cent, of sugar. Milk to be kept for an indefinite time contains as much as 50 per cent, of sugar. These varia- tions show how serious it is to use the same quantity of condensed milk all the time and from different sources with such an enormous variation in the quantity of sugar, Kehrer — quoted by Jacobi — states, regarding it, that it increases the formation of lactic acid. Fleischman states that it gives rise to thrush and diarrhoea; Daly, that it fattens them ( ?), but gives rise to rachitis. The worst specimens of rachitis and spinal rickets seen in my clinic are in condensed-milk babies. Our medical literature reports many cases 180 NUTRITION. of apparent health in infants fed on condensed milk. It has led Des- sau, with a large experience with infants, to mention such a method, al- though he advocates cows' milk, properly modified, for continued use.^ In traveling, when good fresh cows' milk cannot be obtained, then I permit the use of condensed milk, but for a few days or for a week only, as on the ocean steamer, where cows' milk cannot be had. My experience among thousands of children seen in my Children's Service at the German Poliklinik and also at the service at the West-Side Gennan Dispensary during these last fifteen years has been that children so fed have rickets; that they are predisposed to the infectious disorders; that they have less resistance and far less vitality, especially in combating such diseases as pneumonia or diphtheria; that they have tendencies to hernias and deformities, owing to the softer condition of their muscles and bones; that they invariably suffer with constipation, alternating with diar- rhoea; that their dentition is delayed, compared with other methods of hand feeding. Thus summing it up, I cannot approve of this method at all. Condensed cream will be lauded by the mother whose baby is well, and again the same food will be condemned by the mother of an infant whose rickety head, bones, and muscles are founded on an impoverished diet of condensed milk. We can account for the rickety child, but we cannot account for the healthy one on the same food. The directions on the tin of the Anglo-Swiss Condensed Milk Com- pany's Milkmaid Brand of condensed milk are, for new-born infants, add 14 parts of water; as the child grows older, gradually use less water, but never less than 7 parts. On studying the clinical relationship of the component parts of con- densed milk, it is very apparent that, diluting the Eagle brand of condensed milk with 14 parts of water, we have but 0.7 per cent, of protein, 0.6 per cent, of fat, and 3.5 of sugar. The deficient bone-building and muscle- forming ingredients account for the rachitis which invariably results. ^ See my paper on infant- feeding ( read before the Society for Medical Progress, April 11, 1896), published in extenso in Pediatrics for July 15, 1896. CHAPTER VI. PROPRIETARY INFANT FOODS. Patent Foods. Theke are a great many infant foods in use at the present time. No one will question the large amount of foods sold. This is due to several reasons: First, because the laity have been educated to use them, when cows' milk or even when breast-milk, in rare instances, disagrees; second, physicians of large experience advocate the use of a great many patent foods. When disturbances in the stomach or intestines interfere with the proper digestion and assimilation of the proteins, then frequently the modification of the milk, by the addition of these foods, yields good results. In some instances where there is no appetite we frequently can stimulate an appetite by advocating the temporary use of these foods. In the large cities, where breast-milk is unobtainable for infants, these foods are frequently given. During the course of summer complaint, typhoid fever, or acute infec- tious diseases, I have frequently advised the use of diluted milk with several teaspoonfuls of a nutritious food, rich in barley malt. The objectionable features of patent foods consist in the ease with which they are procured, and the careless manner in which they are given. Thus, a large portion of the laity will follow the directions on the label of the box of patent food to the detriment of the child. Many a case of rickets or scurvy can be traced to ignorance in giving patent foods. We know, however, that there are some virtues in these patent foods, and to attribute all cases of rickets or scurvy to this one cause is wrong. Investigations made by the American Pediatric Society showed that a large number of children fed on sterilized milk suf- fered with scurvy. A great many facts must therefore be considered before condemning or praismg one or all of the foods. Every physician knows that raw milk or milk warmed to blood heat possesses anti-scorbutic properties. When a given commercial food is added to raw milk, thoroughly mixed, and heated to blood heat or to a pasteurizing temperature, we still retain the virtues of the milk and increase its nutritive value with the aid of the foods selected. Roughly speaking, there are two kinds of infant foods on the market : (a) Infant foods to be used as adjuncts to fresh cows' milk. (&) Infant foods in which desiccated cows' milk is a constituent. ^ These foods are commonly known as dried-milk foods, although in this class of foods milk solids constitute but from one-eighth to one-fourth the (181) . 183 • NUTRITION. substance of the foods, the balance consisting of matter derived from cereals. In some of these foods the starch of the cereals is untransformed, and they may be termed farinaceous dried-milk foods. In others the starch of the cereals has been transformed into dextrin and maltose, and they may be termed dried malted milk foods. The group of infant foods used as adjuncts to cows' milk are either farinaceous foods, made from cereals and consisting largely of unconverted starch, or malted foods, also made from cereals, but having the starch transformed into soluble maltose and dextrin. As fresh cows' milk is, with- out doubt, the best generally available material for the artificial feeding of infants, the foods of the latter class, used for the modification of fresh cows' milk, are more in accord with physiological principles than are the dried-milk foods. Of the large number of infant foods that have been put on the market, it is my purpose to describe a few commonly known foods. In order to judge fairly of the nutritive value of an infant food and its resemblance to woman's milk, it is necessary to know its composition after its preparation for the nursing-bottle according to the directions of its manufacturer, and the analyses that accompany the following descriptions are of the foods prepared for use for infants six months of age as per directions on the packages. List of Infant Foods. The following list of infant foods is quite complete, although there are but four or five foods that are used in any quantity, the balance having a small demand : — Blair's Wheat Food (cereal food; baked wheat). Hubbel's Wheat (cereal food ; baked wheat) . Wampole's Milk Food (composed of predigested cereals, beef, and milk) . Wyeth's Prepared Food (composed of malt milk and cereals). Just's Food (partially predigested cereals. To be used with milk). Malted Milk (malted and containing dried milk). Horlick's Food (predigested, to be added to milk), Mellin's Food (predigested, to be added to milk). Imperial Granum (baked wheat) . ISTestle's Food (composed of cereals partially predigested and dried milk) . Jjacto-Preparata (dried milk). Lactated Food (farinaceous with milk-sugar). Mammala (dried milk food). Eidge's Food (farinaceous). NESTLE'S FOOD. 183 Peptogenic Milk Powder (to modify milk) . Pegnin (also used to modify the casein of cows' milk). Zimmerman Barley Oat Food (cereal). Nutrico Food ( cereal ) . Lange's Tissue Food (a condensed milk). Hayes's Oat Food (cereal). Allenbury's Milk Food, No. 1 (predigested; prepared with water, con- tains dried milk) . Allenbury's Milk Food, No. 2 (predigested; prepared with water, con- tains dried milk), Allenbury's Malted Food, No. 3 (partially predigested; prepared with milk). Benger's Imported (cereal and not predigested). Neave's Food, Imported (farinaceous). Eskay's Albuminized Food. 'Cereal Milk. Carnrick's Soluble Food. Diastased Farina. Coombs's Malted Food. Eobinson's Groats. Eobinson's Patent Barley. Chapman's Whole Flour. Scott's Oat Flour. Milkine. The published analyses of woman's milk show the great variability of its composition, especially as regards the percentage of proteins and fats. The analysis of woman's milk used in the following tables is by Dr. Luff, adopted as the standard by Cheadle. It agrees closely with Leed's analysis, excepting as to the fat, which is given by Luff as 2.41 per cent, and by Leeds as 4.13 per cent.; the latter amount seems too large, as it exceeds considerably the published averages of a number of observers. Nestle's Food. Nestle's food is a farinaceous dried-milk food. According to the manufacturers, it is made of pure cows' milk, ground wheaten biscuit, barley malt, and cane-sugar. It is a form of modified milk. No cows' milk is to be added to Nestle's food — nothing but water. Upon examination, maltose, dextrin, and cane-sugar will be found to be its principal ingredients, amounting to about 52 per cent, of the whole. The amount of lactose (6.57 per cent.) represents only that contained in the milk used in. manufacture. For 3d Mo, 6th Mo. 9th Mo. 0.96% 1.18% 1.30% 2.03 2.50 2.73 1.76 2.16 2.36 3.22 3.96 4.33 2.24 2.77 3.03 0.74 0.90 1.00 1.42 1.75 1.91 0.19 0.24 0.26 87.44 84.54 83.08 100.00 100.00 100.00 Reaction alkaline. 184 NUTRITION. The directions for preparing Nestle's food for the nursing bottle, for infants six months of age, are as follows : — Place. the required amount of food in the saucepan and add a sufficient amount of cold water to make a smooth, creamy mixture, then add the rest of the water, and boil for two minutes. Tabi,e No. 29. — Composition of 'NestWs Food, When Prepared for Different Ages. Analysis by Composition when Prepared Dr. Boyce W. Knight. According to Label Directions. Milk sugar . , 7.40% Maltose 15.60 Dextrin 13.51 Cane sugar 24.77 Starch 17.31 Fat 5.63 Proteins 10.92 Mineral matter 1.49 Water 3.37 100.00 The total carbohydrate content of this mixture (12.57 per cent.) is considerably higher than the carbohydrate content of milk sugar (6.39 per cent.) of woman's milk. This, however, may be accounted for by the fact that the fat content (0.90 per cent.) is equally lower than the fat content of woman's milk (2.41 per cent.). It is claimed by the manufacturers that the value of the milk used in Nestle's food is not destroyed, as the condensing is done in vacuum, at a temperature not exceeding 130° F. When cows' milk disagrees and gastric symptoms such as fever, vomit- ing, and intestinal catarrh appear, the substitution of Nestle's food for several days will frequently relieve this condition. Horlick's Malted Milk. This is a dried milk food, said to be composed of pure, rich cows' milk combined with the extract of malted grains, and not to require the addition of milk, nor any cooking. The manufacturers claim that by their methods and apparatus the proteins are rendered very digestible and do not form large, irritating curds in the stomach. The directions for preparing the food for an infant six months old are to dissolve 3 to 4 heaping teaspoonfuls in 4% to 6 ounces of water. CEREAL MILK. 185 Table No. 30. Eorliclc's Malted Milk. Woman's Millc. Water 86.29 88.51 Salts 0.55 0.34 Proteins 2.31 2,35 Fat 1.24 2.4] Carbohydrates 9.61 6.39 This product is very neatly soluble in water, as its principal con- stituents are the soluble carbohydrates — maltose, dextrine, and milk sugar. The drying process is said to be conducted very carefully in a vacuum, and hence the solubility and digestibility of the product, it is claimed, are not lessened. The proteins are about the same as in woman's milk, but the fat is about three-fifths and the carbohydrates are about five-thirds as much as in. woman's milk. When cows' milk causes continued constipation, the substitution of a bottle containing hot water 8 ounces, in which 4 teaspoonfuls of malted milk are dissolved, is indicated. It acts as a corrective, as the maltose has a laxative effect. Horlick's Food. Horlick's food is prepared from barley, malt, and wheat flour, and is designed to be used in connection with cows' milk, as a modifier. It is free from starch or cane sugar, and is completely soluble. When prepared with milk, as directed, it brings the carbohydrates in the form of maltose and dextrine to the proper standard, and at the same time acts upon the milk so that it is easily digested. In some cases food prepared as above has a tendency to constipate. In Buch cases the substitution of malted milk for the first morning bottle will modify such constipation. This method of modifying milk has been followed for years, by many of the medical profession, as a substitute for mother's milk or as an alter- nate with Horlick's malted milk. This food is also indicated as a diet for dyspeptics, fever patients, and convalescents, as it is easily digested, palatable, and free from some of the objectionable features that pertain to the use of milk alone, as a diet. Cereal Milk. Cereal milk is a malted dried-milk food. It is stated by its makers to De a complete food, cooked and ready for use with the simple addition of 186 NUTRITION. water, and to be made from, the purest Vermont dairy milk, the finest wheat gluten flour, the best barley malt, and milk-sugar. Cereal milk in general appearance very much resembles the other malted dried milk foods, but it contains a much greater percentage of milk- sugar, showing that this substance is used in its manufacture, as claimed. The directions for preparing it for use are to mix 1 teaspoonful of cereal milk in a teacupful of hot water for infants under three months of age or for a very delicate child. Preparation for a child six months old : — "To make 6 ounces Prepared Food, use 3% rounding teaspoonfuls Cereal Milk Powder," as directed. Composition when prepared : — Table* No. 31. Cereal Milk. Woman's Milk. Water 90.98 86.73 Total solids 9.02 13.26 Fats 0.38 4.13 . Proteins ^ 1.09 2.00 Inorganic salts 0.21 0.20 Carbohydrates 7.34 6.93 The reaction to litmus was neutral, or faintly acid. The food contains starch. No white of egg or cream was added, since neither is definitely pre- scribed. This fact may be taken into consideration when comparing the analysis with that of the other foods. The total of soluble carbohydrates as above is practically the same as in woman's milk; the amount of proteins is less than one-half the amount in woman's milk, and about one-half is insoluble in water. The amount of fat is one-eleventh the amount in woman's milk. The small amount of fat indicates that the cereal extractives and milk-sugar make up the bulk of the solids of this food, and that a dilution of 1 part of good cows' milk with 11 parts of water would be the counterpart of the above mixture as to the amount of milk therein. Wampole's Milk Food, Wampole's milk food is a malted dried milk food. Its makers state that it is made from malted cereals, beef, and milk, and when mixed with warm water it is immediately ready for use; no other preparation necessary. This dried milk food is very nearly soluble in water, owing to the solu- ble carbohydrates being so large a constituent. A little less than one-half of the proteins is insoluble in water. A small amount of beef extract has been combined with the cereal extractives and dried milk. IMPERIAL GRANUM. 187 To prepare it for an infant 6 months to 1 year of age, the directions are to dissolve 4 to 6 teaspoonfuls of the food in 6 ounces of hot water. Com- position when prepared by dissolving 6 teaspoonfuls in G ounces of water : — Table No. 32. Wampole's Milk-food. Woman's Milk. Water 88.59 88.51 Salts 0.46 0.34 Proteins 1.58 2.35 Fat 0.73 2.41 Maltose, dextrin, etc 7.65 Milk-sugar 0.99 6.39 Reaction alkaline. Reaction alkaline. Compared with woman's milk, it is seen that the carbohydrates are considerably in excess, and the proteins and fat are deficient, the fat espe- cially, it being less than one-third the amount in woman's milk. One part of good cows' milk diluted with about 3i/2 parts of water would be analogous to the dilution of milk in Wampole's milk food pre- pared as above. Imperial Granum, Imperial granum is a farinaceous food to be used as an adjunct to cows' milk. Its makers state that it is a solid extract derived from very superior growths of wheat, nothing more. It appears to be made as claimed from wheaten flour and to be mainly composed of torrefied starch. For an infant six months of age it is to be prepared by cooking 3I/2 teaspoonfuls of food in 21 ounces of water and 20 ounces of milk. Composition when prepared as above : — Table No. 33. Imperial G-ranum.^ Woman's Milk. Water 9L53 88.51 Salts 0.34 0.34 Proteins 2.15 2.35 Fat 1.54 2.41 ■ Starch 1.22 Maltose, dextrin, etc •. 0.58 Milk-sugar 2.71 6.39 Reaction alkaline. Reaction alkaline. The total of solids contained is one-quarter less than in woman's milk; the carbohydrates are nearly one-third less than the amount in woman's milk, and it should be observed that 1.22 per cent., or about one-fourth of them, consist of starch; there is only a slight deficiency in the amount of ^According to Chittenden. 188 NUTRITION. proteins, but a considerable deficiency in the amount of fat. By using more milk or milk and cream and less water than above employed the percentages of fat, proteins, and soluble carbohydrates would be increased. Its very large proportion of starch forms the principal objection to this food. The presence of unconverted starch causes the thick condition of the mixture. Eskay's Albumenized Food.^ This food is to be prepared with cows' milk. Its makers state, in rec- ommending their product, that it contains the more easily digested cereals, combined with egg albumin. Eskay's albumenized food consists largely (about 88 per cent.) of car- bohydrates; the soluble carbohydrates, mostly milk-sugar, are about 50 per cent., and the insoluble carbohydrates, mostly starch, are a little less than 40 per cent. On account of this proportion of starchy matter in the dry food, it may be termed farinaceous. The makers, however, claim that in the process of manufacture the starch granules are almost entirely disin- tegrated, and when the food is prepared with milk according to directions the percentage is said to be not over 11/2 to 2 per cent. An analysis of the dry food shows that it contains about 9 per cent, of proteid matter, but when prepared according to the six months' formula it analyzes about 2.55 per cent. The fats as well as the proteins are almost entirely vegetable, with a small percentage of each derived from 'eggs. Excepting the egg, fat, and albumin, the preparation is produced from wheat, oats, and barley, and, while no proteolytic ferments are used in its manufacture, the insoluble carbo- hydrates are' nevertheless partially converted into dextrin by a special process of heating, which ruptures the starch granules and converts a small amount of the starch. The egg albumin is said to be first combined with sugar of milk in such a thorough manner that the particles are finely subdivided, and no firm, hard coagulum can therefore take place in the stomach. The particles retain their identity, and do not coalesce; so that in the finished prepara- tion the egg albumin is suspended throughout the whole mixture in very fine particles, which are easily digested, because the gastric juice acts by contact, and, the smaller the particles, the greater the effect of the gastric juice. No claims are made by the manufacturers for its solubility, but for its ease of digestion and its nutritive value. ^ The chemical analyses of Eskay's food, Mellin's food, cereal milk, and malted milk here given were specially made for me by Professor Lafayette B. Mendel, at the Sheffield Laboratory of Physiological Chemistry, Yale University. MELLIN'S FOOD. 189 Tlie directions for preparing it for an infant six months of age are to take : — Eskay's food 5 tablespoonfuls Hot water 1 pint Rich cows' milk 2 pints As directed. Composition when prepared as above : — Table No. 34. Eslcay's Food. Woman's Milk. Water 84.46 86.73 Total solids 15.54 13.20 Fats 3.07 4.13 Proteins 2.78 2.00 Inorganic salts 0.58 0.20 Carbohydrates 9.11 6.93 The reaction to litmus was amphoteric. The food contains a noticeable quantity of starch, which is in the form of a thin paste, in which all the grains are ruptured by the process of prepa- ration. The boiling was carried on for fifteen minutes in the sample an- alyzed. Kich milk (4.85 per cent, of fat) was used as specifically directed. Mellin's Food. Mellin's food is a malted cereal. This food is stated by its makers to be a soluble dry extract from wheat and malt, for the modification of fresh cows' milk. Analysis. Fat .16 Proteins - 10.35 Maltose 58.88 Dextrins 20.69 Soluble carbohydrates 79.57 Salts 4.30 Water 5.62 100.00 The salts, 4.30 parts, consist of: — Bicarbonate potassium 2.536 Phosphate potassium 897 Phosphate calcium 037 Phosphate magnesium 213 Phosphate iron 016 Chloride sodium 097 Sulphate sodium 131 Sulphate potassium 383 4.310 190 NUTRITION. The carbohydrates therein are in the form of dextrin and maltose, and constitute about 80 per cent, of the food; the proteins amount to about 10 per cent, and are derived from the cereals. Mellin's food is almost com- pletely soluble in water. It is especially noticeable that this food does not contain any starch. Whole Milk Formula for Normal Infant, Six Months Old or Over. Mellin's food 3 % level tablespoon! uls Milk 12 ounces Water 4 ounces Analysis of Above Mixture: Fat 2.67 ^ , . r milk 2.52 Proteins-^ , .„ „ „, (cereal 49 3.01 Carbohydrates (no starch) 7.12 Salts .71 Water 86.49 100.00 Calories per fluidounce 21 The reaction to litmus was amphoteric. The food gave no reaction for starch. Milk having 4.25 per cent, of fat was used in this preparation. In total solids this food differs but slightly from woman's milk, and in the various constituents its similitude to woman's milk is remarkably close. Of the carbohydrates the maltose and dextrin are a little less in amount than the milk sugar, and the total carbohydrates (7.12 per cent.) are greater than the amount in woman's milk. One level tablespoonful of Mellin's food added to a 16-ounce mixture increases the percentage of Proteins 0.14 per cent. Carbohydrates 1.10 per cent. Salts 0.06 per cent. Mammala. Mammala is claimed to be a milk from which a part of the cream has been removed, an additional proportion of milk sugar added, and then dried by the Hatmaker process, at a temperature of 280° F. It is a white powder to be dissolved in hot water with no addition of sugar or lime water. It is a simple formula and one adapted for substitute feeding. The absence of a live factor such as an enzyme would contraindicate the use of such food for a prolonged period. We must always bear in mind the possibility of the development of scurvy where an absence of fresh milk exists. BENGER'S FOOD. 191 Just's Food. Maltose, free 12.6 parts Maltose, combined with dextrin as maltodextrin 15.5 parts Dextrin, with trace soluble starch 61.3 parts Albuminoids 1.1 parts Fat 0.1 part Ash 0.9 part Water 5.3 parts Cellulose 0.2 part Indeterminable (insoluble) 3.0 parts 100.0 parts This sample was neutral in reaction; the sample was analyzed June 14, 1895; was slightly acid, which suggests that the process of manufac- ture has been changed a little. The food has no diastasic action. The small amount of albuminoids, light color of the food, and the low degree of conversion, particularly of the last sample analyzed, indicate very conclusively that no considerable quantity of malt or any entire cereal is used in its manufacture. It is not hygroscopic — it can be exposed to air for quite a long time without becoming sticky. Upon examination, the above analysis indicates a close relation of Just's Food to commercial glucose, although it contains no dextrose. A product similar to Just's might be obtained from the glucose process if the process were stopped early in the conversion before the starch was converted to glucose; that is, when the conversion of the starch has pro- gressed only as far as dextrin and maltose; or it might be possible, during the process of making glucose, to draw off a portion in the earlier stages of the process, and neutralize and clarify, and obtain a product similar to Just's food. In order to get such a percentage, as is given in the analysis of dextrin and maltose, from a starch material by the action of malt diastase, it would be necessary to use so much malt that the amount of albuminoids contained would be much larger than is shown by the analysis, and the product would have a decided malt flavor and quite a marked color, and these Just's food has not. Benger's Food. Benger's food contains ferments which convert the proteins and starch during the preparation. It consists of cooked wheaten meal, to which is added the natural digestive ferment of the pancreas. * Analysis by Chambers Watson. Water 11.2 Protein 10.4 Fat 1.1 C Soluble 0.9 Carbohydrates j Starch 66.3 ( Ash 9.9 192 NUTRITION. The preparation recommended is as follows : — Mix 2 tablespoonfuls (about an ounce) of food and 4 tablespoonfuls of cold milk, then add 8 ounces of boiling milk and water ; set aside in a warm place for fifteen minutes, then bring to the boil. When mixed with warm milk as recommended, the carbohydrates are nearly all converted into soluble dextrin and sugar, and the proteins are also partially peptonized. This form of food is adapted for marasmic and atrophic infants where a predigested food is indicated temporarily. Peptooenic Milk Powder. This product is stated by its makers to be an article containing milk sugar and a digestive ferment capable of acting on casein, offered for the preparation of an artificial infant food. McGill states: "It is not, in the strict sense, a food. Its professed object is so to change the composition of cows' milk as to render this comparable to human milk. This it seeks to do by introducing milk sugar and small quantities of albuminoids." Ac- cording to McGill's analysis, it is composed almost entirely of milk sugar (96.6 per cent.). The following analysis is by Leeds, and is taken from a circular of the makers. Composition of "humanized milk'' prepared as directed, using 4 meas- ures of peptogenic milk powder with % pint of milk, I/2 pint of water, and 4 tablespoonfuls of cream : — Table No. 35. Humanized Milh. Woman^s Milk. Water 86.20 88.51 Ash 0.30 0.34 Proteins . . 2.00 2.35 Fat 4.50 2.41 Milk-sugar 7.00 6.39 Reaction alkaline. Reaction alkaline. Chittenden's analysis of this "humanized milk" is almost identical with the above. The proteins of the cows' milk undergo a change in the peptonizing process, being converted chiefly into partial peptones, and in this form they cannot be said to resemble the proteins of woman's milk, which have not been acted upon by a proteolytic ferment. The prolonged use of peptogenic powder may do harm. It should be used as a corrective for several weeks and gradually be replaced by a higher protein content. Excessive carbohydrate feeding will do harm; this caution applies as well to peptogenic powder. PEPTOGENIC MILK POWDER. 193 Table No. 36. — Summary Chiving Comparison of the Foods Analyzed by Professor Mendel. Cereal Milk. Malted Milk. Mellin'B Milk. Eskay's Milk. Human Milk. Water Total solids 90.98 9.02 90.74 9.26 85.37 14.63 84.86 15.54 86.73 13.26 Fats Proteins Inorganic salts.. Carbohydrates . 0.38 1.09 0.21 7.34 0.63 1.65 0.36 6.62 3.16 3.03 0.70 7.74 3.07 2.78 0.58 9.11 4.13 2.00 0.20 6.93 Reaction to litmus neutral alkaline amphoteric amphoteric (The figures indicate percentages by weight.) The figures quoted for human milk are well-known averages; it would be more accurate to give figures indicating the healthy variations. CHAPTEE YII. COXCEXTPvATED PREPAEATIOXS OF ALBUMIN. Amoxg the concentrated preparations of allnimin on the market are: — SO^IATOSE. Somatose, meat albumin, isolated artificially^ by chemical process. A remed}- which has more the character of a ^Dharmaceutical ]3reparation of a stimnlant tonic, ratlier than of a food. This is evident also in its cost. It is used extensiveh' and with good results. It is advisable to be cautious with the same owing to the diarrhceal tendency. It should, therefore, not be given to very young infants. Chemical analysis : — Water 11.41 parts Digestible albumin 41.21 parts Peptone 27.12 parts Otlier nitrogenous substances estimated by difference and assumed to consist of meat basis and ex- tractiA'es 14.51 parts Ash 5.75 parts 100.00 parts Somatose is stated to be prepared from meat. It is a light-}' ellow pow- der, odorless, nearly tasteless, and readily and completely soluble in water. The solution has a slightly alkaline reaction. The substance is a predigested, nitrogenous food. It is probably made from animal substances, but we are unable to state from what materials or by what process the article is manufactured. Its contents of phosphoric acid and potassium are very much less than should be the case if it were prepared from muscular tissue, or meat in the usual sense of the term. EUCASIX. Eucasin is an ammoniated salt of casein. A soluble preparation of casein, obtained by chemical process. It contains phosphorus, 0.8 and 13.1 per cent, of nitrogen. It is well tolerated by older children, but does not prove very satisfactory in very young infants. Ntttrol. Nutrol is the sodium compound of casein; also soluble. (194) AIJU'.MIN'orS FOODS. 195 TRoroisr. Tropon is a mixture of animal and vegetable albumin. Obtained chiefly from but'kwlieat flour by dipsolvinp: with dilute caustic soda, precipitating with acid, and purifying witli liydrogvii ])eroxide. It was introduced by Tinkler {Berlin, kiln. ^Yo(■h(^n., 1897, Nos. 30, 33). Also sano-tropon, which is real]\- n luixture of dextrinized barley flour with tropon. Sana- togen is verv similar to tlu' latter preparation, and consists of casein with glycero-phosphate of sodium, and 13 per cent, nitrogen. Plasmon". Plasmon is a preparation of casein, partly soluble. Obtained by chem- ical process, the use of carbonic acid and Incarbonate of soda. It is adapted for the strengthening of ordinary In'oths, but it must be distinctly remem- bered that all of these preparations are merely suggestions as "substitutes," and should never be thought of as suitable for constant feeding. SOSON. Soson is a new albuminous product resembling plasmon and tropon in nutritive qualities. Other foods are Sanose-Albiimose {Scliering) ; also Sanatogen., Eu- lactol, Protogen (Blum), and the Somatose Cream Mixture of the Elher- feld Farhenwerhe. All of the above preparations have been used by the author in doses of % teaspoonful added to either barley soup, chicken broth, farina, or rice gruel. When typhoid fever and such disorders tax the ability of the attend- ing physician, owing to the rejection of food, then, and then only, should milk or its dilution be laid aside and the above foods given a trial. Valu- able service has been frequently given by such standard preparations as panopepton, liquid peptonoids, and jMosquera's beef jelly where the gastric irritability prevents the regular administration of milk. Mosqueea's Beef Meal. This is a partially digested beef preparation, containing in addition to the proteins 13.06 per cent, of fat. The analysis is : — Water 6.68 Salts and inorganic substances 4:.20 Fats , 13.01) Insoluble proteins 47.01 Albumose 29.43 196 NUTRITION. Taking the insoluble proteins, albumope and fats, together, 100 grams are equal to 435 calories, while the albumose alone represents 122 calories. MosQUERA^s Beef Jelly. This beef jelly contains 12.66 per cent, of albumose and 14.35 per cent, meat extractives. It represents therefore the stimulant as well as the nu- trient qualities of beef. A two-ounce jar is equal to 34 calories from the albumose, and if we were to take the meat extractives at the same ratio the total number of calories would be 94. Panopeptojst. Panopepton represents the products of the peptic digestion of fresh, lean beef, and of the proteolytic and amylolytic digestion of whole wheat; proteins in the form of albumose and peptone, carbohydrates as achroo- dextrins and maltose, and the natively associated soluble, savory, and stimulant mineral constituents. These soluble food constituents are ster- ilized, concentrated, and, after being duly proportioned, are redissolved in sherry wine. Panopepton contains 20 per cent, of solids as follows :- — Soluble proteins 6 per cent. Carbohydrates 13 per cent. Ash 1 per cent. It will be noted that the ratio of proteids and carbohydrates is as 1 to 2.16, which is best calculated for a proper nutritive balance. Harrington-'s analysis shows that it yields 17.99 per cent, of solid matter (including 0.97 per cent, of mineral matter) and 18.95 per cent, by volume of alcohol. This is undoubtedly one of the best predigested foods of the class that contains both proteins and carbohydrates in their most available forms, and, from the data supplied by its manufacturers, it is evident that it is designed upon scientific principles to represent the varied constituents of a mixed diet, and that its preparation is carried out in a most perfect manner in all respects. The wine serves both as a stimulant and preservative, and the product has an agreeable taste and flavor. One hundred grams (about 3V3 ounces) equal 77.5 calories. It must not be taken for granted that because one chemist finds a very high percentage of alcohol in a standard preparation the same amount will be found by other chemists; for instance, the preparation of "liquid peptonoids," made by the Arlington Chemical Co., was sent to Dr. Ernst J. Lederle. This chemist found 17.59 per cent, alcohol by volume. ALBUMINOUS FOODS. 197 Table No. 37.- — Chemical Analyses hy Dr. Ernst J. Lederle and J. A. Deghuee, Ph.D. An interesting comparison as to the alcohol content can be made by studying the analyses of the six nutritive tonics submitted for examination; they are: — Nutritive Liquid Peptone 23.49 per cent, alcohol by volume (Parke, Davis & Co.) Liquid Peptonoids 17.59 per cent, alcohol by volume (Arlington Clicmical Co.) Mulford's Pre-Digested Beef. . . . 19.39 per cent, alcohol by volume (H. K. Mulford & Co.) Tonic Beef 17.04 per cent, alcohol by volume (Sharp & Dohme) Trophonine 18.98 per cent, alcohol by volume (Reed & Carnrick) Panopepton 20.05 per cent, alcohol by volume (Fairchild Bros. & Foster) CHAPTER VIII. ADDITIONAL NUTRIENTS AND STIMULANTS. Meigs's Food. Meig^s food consists of milk, cream, sugar, gelatine, and arrowroot, and is prepared as follows : Of Eussian gelatine or isinglass, 20 grains, or a piece about two inches square, is soaked for a few minutes in cold water, and then boiled in half a pint of water for fifteen minutes, or until com- pletely dissolved. One teaspoonful of arrowroot is mixed to a paste with cold water, and then added to water to make half a pint. This is now added to the gelatine solution, as is also, with constant stirring, the desired quan- tity of milk; just before removing from the fire the cream is added. The amount of milk and cream used should vary with the age of the infant. For an infant under one month, 4 ounces of milk and 1% ounces of cream are to be used; for those older the milk is gradually increased to 16 ounces and the cream to 3 ounces.^ ZOOLAK. The subjoined analysis of Dr-. Dadirrian's zoolak was made by Edgar E. Wright, of Brooklyn, N. Y. In every 100 parts of zoolak there are : — Water ' 87.69 Protein substances '3.98 Fat 4.91 Milk sugar , 2.03 Alcohol 0.07 Ash or mineral salts 0.78 Lactic acid 0.50 Carbon dioxide 0.04 This analysis shows that in the production of zoolak but little change is wrought in the percentage composition of the original cows' milk, save what would naturally he prodiiced by the fermenting and peptonizing actions of the kefir ferment. These fermentative changes — primary and secondary — consist in: — 1. The transmutation of a portion of the natural milk sugar into alcohol, lactic acid, and carbon dioxide. 2. The transmutation of a certain percentage of the protein sub- stances into proteoses, and finally, perhaps, into time diffusible peptones. ^ Meigs and Pepper: "Diseases of Children," 1887. (198) LECITHIN. 199 This latter action, however, does not change the percentage presence of the protein bodies, as related to the total quantity of milk, but simply changes their chemical form. Owing to the instability of the Bulgarian bacillus in diy or tablet form, it is advisable to procure a fresh culture in liquid form, which can be used as an antifermentative in gastrointestinal colic, and especially in con- stipation. The iSTuTKiTivE Vali'e of Ecgs. It is commonly asserted tliat an eg'^ contains as much food value as a half-pound of meat. This is not true. While there is an approximate equivalent between the albuminoids contained in both, the egg contains no carbohydrates. Very young infants do not digest eggs, and frequently gas- tric disturbances result from their use. This does not necessarily imply that the white of egg in its raw state should never be used as an adjunct to other forms of feeding, or as a temporary food when milk disagrees or when diarrhoeal conditions, such as fermentative and catarrhal intestinal dis- eases, prohibit the use of milk. Lecithin". Lecithin is a crystal] izable fat of a peculiar nature containing nitrogen and phosphorus. It is unstable. When chemically treated by neurin and glycerine phosjohoric acid can be isolated. Lecithin has also been found in the yolk of egg, in the egg of fish, etc. Hoppe-Seyler isolated this sub- stance in 1870 from its constant association with phosphorized albumins, nucleo-albumin, and nucleo-protein. Lecithin is also found in the brain matter. Free lecithin has l)een used clinically and physiologically by Danilewski in 1895. According to this physiologist, animals fed with lecithin grew more rapidly than those not fed on this substance. It is a reconstructive and is indicated in the treatment of all disorders of nutrition. My experi- ence with lecithin has been limited to racliitis, tuberculosis, and cases in which atrophy due to malnutrition is found, such as result from pertussis. I am also using it in cases of sporadic cretinism. A preparation of lecithin containing one grain of pure lecithin to the drachm is made by Eairchild Bros. & Foster, of New York City. A tea- spoonful of this solution given three times a day before meals has given me very good results. Lecithin of the Egg. — According to Coloumbe, lecithin exists in all the tissues, esijeeially in those endowed with great vitality. From a thera- peutic point of view it is not toxic, and it is assimilated as a whole in ordinarv doses. Its action consists in increasino- the number of red cor- 200 NUTRITION. puscles; in increasing, in certain cases at least, hsemoglobin ; in increasing urea and diminishing uric acid, and in stimulating the appetite. Its em- ployment is indicated in anasmia, in all troubles of nutrition, in wasting dis- eases, and in neurasthenia. It may be administered hypodermically or by the mouth. Steak Juice or Meat Juice. The juice of broiled steak possesses anti-scorbutic properties. I have referred to this in the chapter on scurvy. When dentition is delayed or when the bony structure is weak, as in rickets, steak juice should be freely given. It is best prepared, fresh each day. For this purpose a meat press Fig. 54. or lemon-squeezer is convenient. From a pound of lean steak, slightly broiled, about three ounces of juice can be obtained. This may be slightly salted and given cold or warm, but not sufficiently heated to coagulate the albumin. If the taste is objectionable, it may be given in milk; two to three teaspoonfuls added to eight ounces of milk will not be noticed. The milk should not be warmed above 100° F'. before the addition of the steak juice. For older children we can add the steak juice to mashed potato, spinach, or rice. Bread or toast saturated with steak juice is liked by many children. When fresh steak juice cannot be obtained, then Valentine's meat juice can be tried. For the treatment of scurvy fresh meat juice must be used. Chocolate and Cocoa. The addition of cOcoa to milk is a valuable adjuvant. The flavor of cocoa will frequently render the milk more palatable. Where fat is needed, ICE-CREAM AND WATER-ICES. 201 especially in the ana3mic, rachitic, and marasmic child, cocoa is indicated. High fats are demanded, for example, during cough, or during con- valescence following influenza, bronchitis, or pulmonary lesions. It is of especial value in tuberculosis. While cocoa is looked upon with disfavor in the treatment of intestinal disorders, it will be found of advantage in con- stipation for two reasons: first, because of the high fat content; second, because of the mechanical stimulus which cocoa exerts in exciting peristaltic waves. It is also indicated as a restorative following the acute infectious diseases and where considerable emaciation exists. Cocoa is made from bitter chocolate by expressing part of the cocoa butter and grinding the partially defatted material to a fine powder. The amount .of cocoa butter remaining varies from 20 to 30 per cent. Cocoa for drinking purposes has about 25 per cent, cocoa butter. Cocoa of this com- position has a calorific value of about 1769 calories per pound, and contains approximately 19 per cent, protein. A teaspoonful of cocoa powder, required to make a cup of the beverage, would therefore have a fuel value of about 20 calories. Added to the caloric value of a cup of 4 per cent, milk, which is 120 calories, we have the caloric value of a cup of cocoa, which is 140 calories. Analysis of Hekshey^ Cocoa Powder. Fat 24.12 per cent. Moisture 3.57 per cent. Crude fiber 4.48 per cent. Total ash 5.17 per cent. Water-soluble asli 2.06 per cent. Water-insoluble ash 3.11 per cent. Alkalinity (soluble of ash) 1.85 c.c. N/10 acid per gi-amme sample, (insoluble) .... 4.51 c.c. N/10 acid per gramme sample. Bitter chocolate is the product obtained by grinding cocoa nibs (roasted cocoa beans) . Such bitter chocolate contains about 52 per cent, of cocoa butter. Sweet chocolate is the same as bitter chocolate with the addition of about 50 per cent, of sugar, depending on the formula. Its caloric value is about 2620 calories per pound. Ice-cream and Water-ices. Ice-cream and water-ices are very grateful to a feverish child. When milk and cream are refused they will be gTeedily taken. These prepara- tions will alleviate the pain on swallowing in the case of diphtheria. They contain considerable nourishment, but must be given in moderation. Nau- sea and vomiting may frequently be controlled by them. * This cocoa is manufactured by Hershey, of Pennsylvania. 202 NUTRITION. The Use of Coppee in Children.^ Contraindications. — When giving coffee to children we must hear in mind that : — First. — Coffee is in no sense a food, because it can neither build up the tissues nor provide them with potential energy. Second. — Coffee perhaps acts the part of a lubricant to the machinery of the body, and exerts its stimulating influence by toning up and dimin- ishing nervous fatigue in adults, and is not called for in children. Third. — Coffee produces a disturbance of digestion due to a direct interference with the chemical part of the process, but in part also indi- rectly brought about by the nervous system; it also produces a dyspepsia which is of the atonic type, and a slow digestion, accompanied by flatu- lence, with a disturbance of the heart's action, so that it is decidedly con- traindicated from a feeding standpoint. Coffee is a cardiac stimulant, quickening the heart's action in small doses, and depressing it in large quantities. It certainly disturbs the cardiac rhythm when taken in excessive doses by children. Such symptoms as muscular tremor, nervous anxiety, and dread of impending danger, as well as palpitation; cardiac intermissions, and an uncomfortable feeling referred to the cardiac region can be traced to coffee, according to Yeo; it is a diuretic, and increases the excretion of urea; it produces insomnia, nervousness, and fear; also, choreiform move- ments. Caffeine has been known to produce paralysis in the lower animals, and might produce a similar effect if taken in large quantities by children. It retards digestion ; hence it is contraindicated in children. Owing to the great tendency to produce insomnia coffee should not be administered in the evening unless the heart's action demands it. Indications. — As a cardiac stimulant, or whenever caffeine is indicated, hot coffee should be given in sm.all doses, one or several teaspoonfuls, re- peated every fifteen minutes, until its physiological effect is manifested. This can only be noted by studying the pulse. Great care should be exer- cised in administering large quantities of coffee to children, or very strong coffee, as in either instance it will produce a marked cardiac depression, and also a disturbance of the cardiac rhythm. In the convalescence of typhoid fever or pneumonia in children, there is no better stimulant than coffee administered in small doses to which large quantities of milk or cream are added. This is an especially valuable drug in the great cardiac depression so frequently noted in the convales- ^ Paper read by me before New York County Medical Association, December 17, 1900, "Acute and Chronic Coflfee Poisoning." See Transactions. ALCOHOL. 203 cence of diphtheria. (See chapter on "Diphtheria.") The coffee usually used consists of the following strength : — Coffee 2 ounces Water 1 pint When an infusion of the ahove strength is made, Hutchison found that each teacupful of coffee contained : — Caffeine L7 grains ; and also Tannic acid 3.24 grains The latter in the form of gallo-tannic acid; so that judging from this analysis, coffee should be made much weaker (one ounce to a pint of water), and should be administered in teaspoonful doses. For fuller details on "Physiological Effect of Coffee," read paper and discussion at the Kew York County Medical Association, 1900, by Leszyn- sky, Fischer, and others. The Use of Alcohol in Children. Alcohol in the form of wine or beer or whisky, in any and every form, is not only detrimental to the infantile organism, but will leave permanent injury if its use is prolonged. There is a decided difference between the continual use of alcohol as a food and its use' when indicated as a medicine. Physicians know that whisky or wine, given to stimulate the weakened heart in the course of a septic pneumonia or diphtheria, is not only necessary, but frequently the only means of prolonging life. If a child has been given alcoholic drinks daily as an adjuvant to other articles of food, when it is required to stimulate the heart we must resort to enormous doses to procure an effect. Alcohol should be regarded as a poison ; therefore, as an irritant to the kidneys. The growing child does not assimilate alcohol. It interferes with the metabolism of fat and protein, and its use therefore should be limited to stimulating the heart when weakness exists during a septic process. In a large children's clinic with which I have been associated it was very interesting to study the amount of alcohol given to young children, and I was surprised to find that more than 50 per cent, of all children from six months old and upward regularly received their sip of beer or drop of whisky "to strengthen their hearts." The author has frequently attended alcoholic dyspepsia due to prolonged use of beer and wine. This is most common among the tenement population, where the baby forms part of the family at the table, and necessarily partakes of almost everything eatable and drinkable along with its parents. In the routine examination it is the duty of every physician to inquire into the habit of giving alcohol to children. 304 NUTRITION. The Use oe Tea in Childkeit. In my chapter on the use of coffee, I have already mentioned the deleterious effect of coffee on the growing infant or child; what has been said there regarding coffee applies equally strong to the use of tea. The nervous system when overstimulated in an infant is far more sensitive than the adult. The author has frequently noted that children suffered with sleeplessness and were very irritable, simply through the prolonged use of such stimulants as tea and coffee. A noteworthy point is that the appetite disappears when tea and coffee are given, and reappears when their use is interdicted. It must not be supposed that tea is a poison, and there are times when physicians will find it necessary to use small quantities of tea to stimulate the body, as, for example, in that form of exhaustion following a protracted diarrhoea, as is usually the case in summer complaint, so-called cholera infantum. PAET IV. DISEASES OF THE MOUTH, (ESOPHAGUS, STOMACH, INTESTINES, AND RECTUM, AND DISEASES ASSOCIATED WITH IMPROPER NUTRITION CHAPTEIi I. DISEASES OF THE MOUTH. Stomatitis. An infection existing on the tonsils or in the pharynx can spread to the month. Pood, especially milk, is sometimes the means of directly con- veying poison ; this is especially true when milk contains pathogenic bac- teria. As I have frequently stated that syphilis and rickets undermine the system, so also we find these conditions frequently as predisposing causes. The mouth is particularly liable to local infection. The slightest trauma- tism by diseased teeth, especially in acute cases, can produce local irritation. Non-pathogenic bacteria are always present in the buccal cavity under nor- mal conditions. "The glands of the mouth being excretory frequently produce inflam- matory conditions by virtue of systemic poison excreted by them which may produce local lesions." One of the best writers on this subject is Forchheimer, whose classification I have adopted : I. Stomatitis Catar- rhalis. II, Stomatitis Aphthosa. III. Stomatitis Mycosa. IV. Stomatitis Ulcerosa. V. Stomatitis Gangrenosa. • VI. Stomatitis Crouposa; Stoma- titis Diphtheritica. VII. Stomatitis Syphilitica. Stomatitis Catarrhalis. Simple stomatitis may be confined to a local area or it may be general. When the mucous membrane is irritated by severe rubbing, as during mouth cleaning, this condition frequently follows. Dentition does not produce stomatitis. This catarrhal form is usually one of the earliest manifesta- tions of acute infectious diseases. Great stress is laid on this condition as a diagnostic point in measles prior to or associated with tlie enautheni on the buccal mucous membrane. When a small area is affected, a local cause, such as a diseased or sharp tooth, or some mechanical cause, must be looked for. (205) 206 DISEASES OF THE MOUTH. Symptoms. — The usual symptoms of pain, hypersemia, and swelling are noted. The lining of the mouth is puffed and hypersemic. The mucous membrane is covered with small, round prominences due to the swelling of the muciparous follicles. When the ducts of the latter become closed the glands dilate and there are produced cysts, the contents of which are clear, viscid mucus. We also find slight epithelial abrasions, sometimes leading to the production of a deeper process; at all events important in that they may become the seat of infection. The lymphatics are usually involved, and they serve as a guide to the intensity of the inflammation. Cases are on record where the temperature reached 104:° P. in the rectum, but these are rarities. The prognosis is invariably good. Unless some chronic disease is the seat of this trouble there are rarely any disagreeable after-effects. Treatment. — The treatment consists in cleanliness. Eemove the cause if possible. Eemove mechanical irritants, such as diseased or sharp-pointed teeth. Boric acid, 1 per cent, solution, or sulphocarbolate of zinc or sulpho- carbolate of soda, 1 grain to the ounce, are valuable local astringents. At times nitrate of silver (2 grains to the ounce) will act well when applied locally. Forchheimer recommends the application of silver nitrate when there is loss of epithelium. Cysts should be opened and their walls cau- terized when necessary. My best results are obtained by the use of argyrol, 5 to 10 per cent, solution. Stomatitis Appithosa. This condition is not follicular and has nothing to do with the mucip- arous follicles, as it is found in places where there are none. It consists in a hypersemia of the mucous membrane of the mouth associated with superficial ulcers. Causes. — There seems to be a decided reason for believing that this disease is of microbic origin. Aphthous ulcerations have been seen in children partaking of milk from cows that suffered with foot and mouth disease. Demme^ reports a case of twins fed on goat's milk, the goat having foot and mouth disease. The milk was fed fresh and raw. One of the twins, the boy, had a severe aphthous condition of the entire mouth and throat, and died after seven days of illness. The other, a girl, was also sick with aphthous sore mouth, but recovered after five days' illness. Eobinson^ reports a severe epidemic of aphthge acquired from foot and mouth disease in Devonshire. Two hundred and five persons were affected in one week. Two children died, the aphthous condition having extended to the respiratory tract. ^Vienna Medical Journal, vol. vi, 1883. ^London Practitioner for 1884. STOMATIIIS AI'iri'lloSA. 207 Boas, of Berlin, lias also reported cases of foot and mouth disease and their results. Bolm states that the disease is most common between the tenth and'tliirteeiiili iiioutlis of life. Therefore, teething has something to do with the eruption. iSiegel studied an epidemic of foot and mouth dis- ease, resulting in aphthous stomatitis in children. An ovoid bacillus 0.5 /a long was found in all cases. AVe can assume that foot and mouth disease in cattle is tlie etiological factor of stomatitis aphtliosa in the human being. Symptoms. — White or yellowisli-wliite epitlielial spots are seen singly or in groups, surrounded by an areola and developing anywhere in tlie mouth. In many cases the}^ extend into the pharynx, and Forch- heimer believes into the larynx. This dis- ease is frequently as- sociated with acute gastric catarrh, consti- pation, and with gen- eral toxEEmic condi- tions. The eruption may be preceded by pain in the throat, fever, enlargement of the lymphatics, and a general train of nerv- ous symptoms so com- mon in children. The diagnosis, therefore, will be ditfi- cult until the erup- tion appears. Tiie spots frequently are absorbed. Successive crops may come and go. Treatment. — The treatment consists in giving laxatives such as rhu- barb and magnesia, or inf. senna comp. The diet must be regulated. If the child has been given solids they should be excluded. The discontin- uance of milk is frequently beneficial. Localhj, a weak solution of listcrine as an antiseptic can be used. If the child is old enough it should rinse its mouth and gargle its throat with the same. Nitrate of silver, 10 grains to the ounce, or in some instances tincture of chloride of iron, has served me very well. The glycerite of car- bolic acid ajjplied with absorbent cotton is frequently efficacious. Fig. 55.— A Case of Sprae (Thnish) due to Faulty Hygiene of the Mouth. Note Threads (Mycelium) and Small Oval Bodies (Spores). (After Jagic, Klinische Mi- kroskopie.) 208 DISEASES OF THE MOUTH. Bednae's Aphtha. The small, yellowish-white, -ulcerative patches which appear on one or both sides of the hard palate in the new-born are known as Bednar's aphthae. They may be mistaken for the nlcers produced by the breaking down of milia or retention cysts, or for that condition described by Epstein in which there are congenital defects in the mucous membrane filled up with epithelial detritus (Forchheimer). They are usually the result of violence in cleaning the mouth. Fi'equently an improperly shaped nipple will cause this condition by pressing on the palate. Dr. A. Jacobi, in the Archives of Pediatrics, says : — "Do not be so fearfully clean. Perhaps it is best to leave the infant's mouth alone with the exception of the first washing with sterilized water immediately after birth. Otherwise the mouth should be cleaned by the baby's feeding and by the practice I have recommended these dozen of years — viz. : to give a teaspoonful or two of water after every feeding. That will wash down all remnants of food that might get decomposed in the mouth. These 'aphtha' will get well when left alone; but as long as there is a sore surface there is a possibility of microbic invasion; for that reason alone they should be treated." The affected area should be gently wiped with cotton wound around the finger, and dipped into a saturated solution of boric acid. Stomatitis Mycosa, oe Paeasitic Stomatitis. This disease is commonly known as thrush, sprue, soor, or muguet. It occurs in' the mouth in the form of yellowish- white spots and is due to a microbe. A fungus was first discovered by Berg, of Stockholm, and called o'idium albicans by Bobbin. Forchheimer states that the fungus is found in two forms, the yeast form and the globulofilimentous form (frequently called mycelium). "There is no ascospore, therefore. Eoux and Linoissier state that the fungus is not a saccharomyces. The chlamydospore has, however, not been satisfactorily worked out." Propagation goes on in three ways : by filaments produced from conidia, by isolated conidia, and by spores. Symptoms. — Local symptoms vary with the severity of this condition. At times no symptoms precede the appearance of these small spots. The spots are grayish white or creamy in color. They may be elevated above the surface of the mucous membrane. They are not confined to the gums, but appear frequently on the lips, tonsils, pharynx, and cheeks. There is a fetid breath due to the inflamed gums. Children that are old enough to complain do not describe any subjective symptoms. The lymphatic glands are always enlarged and do not suppurate. When suppuration takes place it will follow after the disease in the mouth has disappeared. CROLTOrS STOMA Til' IS. 209 Treatment. — rro'phylactic ireaiuicnt of the mouth, consisting in the usual liygic'iiic measures, can ])revent this condition. Aseptic details must he rigidly enforced in the nursing l)ottles and nipples when tins disease is present. Treatment consists in the ajjplication of a 1 per cent. l)oric acid solu- tion as a mouth cleanser, followed by the local application of a '^ per cent, chlorate of potassium solution. Where a specific cause exists, such as carious teeth or dead bone, the same should be removed before attempting to cure this condition. CROurous Stomatitis, or Diphtheritic Sto^matitts. This rare condition is occasionally met with in children. The prog- nosis and treatment should be considered just the same as though we were dealing with diphtheria in the throat. The following interesting case was sent to my clinic at the New York Post-Clraduate Medical School in 189-i:— The child was seven months old, female, breast-fed, had always been in good health. No family history of tuberculosis, lues, rheumatism, or epilepsy. The child was vaccinated when about six months old, had had no previous illness excepting slight irritability about the time of the eruption of the first tooth. It has two teeth, incisors, lower jaw. General aj^pearance not anaemic or rachitic, has well- nourished muscles and a fair amount of fat. Skin has a healthy appearance. Four other children in same family; three apparently healthy; the fourth is convalescing from an attack of "sore mouth." The infant has been gaining weight regularly since birth. It now weighs 15 pounds and 8 ounces. An examination of the infant showed: Two large patches — one on the tip of the tongvie; the other on the soft palate — which were irregular in outline, yellowish- green in appearance. Temperature in the rectum 1001-^° F., at 11 a.m.; pulse, 142; respiration, 39. Cervical glands considerably enlarged on both sides. No history of existing infectious disease in the same locality. The diagnosis of stomatitis ulcerosa was made and a question mark (?) entered after the same. Diphtheria was suspected. The mother was cautioned in regard to the other children, and the case carefully watched. I again saw the case two days later and found the child in a worse condition. The temperature in the rectum at 4 p.it. was 102if,° F. ; pulse, 160; small, feeble, but quite regular. The examination of the mouth showed an extension of the inflammatory condition of the patches, now involving the uvula and left tonsil. The pharynx showed an abnormal redness, but no membrane was visible. The mother's breast was painful on pal])ntion. Tlio glands were distended with milk, and the axillary glands enlarged and tender on palpation. The motlier complained of aching in her limbs — a '"tired feeling," as she called it — and had chills, alternating with fever. Her temperature was 90ff,° F. in the mouth. There were membranous patches around one of her nipjiles. This resembled a cracked nipple. While examining the infant's mouth I saw what appeared to be membrane. A similar condition was found around the nipple. T inoculated two agar-agar tubes and placed them in the thermostiit. After twelve hours, small colonies of both streptococci and bacilli could be seen. On staining with Loelfler's 14 210 DISEASES OF THE MOUTH. alkaline methylene blue, showed distinct semblance to Klebs-LoeflBler bacilli. A culture was made from the patch in the mouth, from the uvula, and also from the pharynx. The tube inoculated with the uvula patch and the one from the tongue contained, in almost pure culture, the characteristic Kleb.s-Loeffler bacilli. The usual method of treatment and active stimulation was given. Concentrated liquid diet (rectal feeding) was given when the infant refused the breast. An important question suggested itself: Shall we wean the infant? or, mother and infant having the same disease, could the infant be nursed on the healthy breast? It will be remembered that only one nipple was diseased. I resolved to give the infant the milk of the healthy breast and to guard against another sore nipple by nursing through a glass nipple shield. The milk in the diseased, or left, breast was drawn out with a breast-pump and thrown away. Three weeks after the apparent cure of the mother's breast and also after the last visible membrane from the infant's throat disappeared, the mother complained that she slept with one eye open. On examination, I found a distinct facial paralysis on the right side. The diagnosis was strengthened by the sequel in the case. To sum up: I believe the infant, while having diphtheria, infected its mother through the fissure of the breast during the act of nursing. Considering the physiology of nursing, we know the role played by the tongue, and, as the disease was first mani- fested thereon, it can be readily seen how this might have been inoculated from tongue to the breast through its cracked nipple. Syphilitic Stomatitis. Primary infection in syphilis is by no means rare. It usually occurs by transmission from a wet-nurse suffering with syphilis. A case of this kind was seen by me in an infant nine months old. This infant was accidentally infected by a woman who nursed it during the mother's illness. She had erosions (cracked nipples) and did not know that she suffered with syphilis. Her own child died of distinct syphilis, having had pemphigus and the general cachexia so common in luetic conditions. This case was given small doses of calomel, and given a bichloride bath (see chapter on "Syphilis") and showed signs of improvement almost immediately. In the mouth of this child the ordinary mucous patches were found. Treatment is that of syphilis. (See chapter on "Syphilis.") Noma (Stomatitis Gangrenosa; Cancrum Oris^). This disease is frequently called noma, and sometimes cancrum oris. It is characterized by a gangrenous destructive process located on the cheek. Although the left cheek is the favorite site of the disease, it can frequently be found on both cheeks. The writer has met with children suffering from this disease on the right cheek. Girls are more liable to noma than boys. It is usually secondary to some contagious disease, and has been known to follow typhoid fever, smallpox, scarlet fever, measles, pertussis, and allied infectious disorders. We must, therefore, assume that the infectious diseases are predisposing factors in the development of this disease. "■ Extracted from the American Journal of the Medical Sciences, April, 1902. NOMA. 211 The process usually commences on the gums or the inner portion of the cheek, and spreads very rapidly to the adjacent tissues. Thus it is that it will destroy the inner portion of the cheek and spread to the outside, causing similar destruction to the healthy tissues. Bacteriolo^. — Perthes^ in 1899 found that noma is due to a fungus-like growth belonging to the streptothrix group. At the border line between the gangrenous ulcer and nomial tissue he found a thick, branching network of fine, fusiform threads — mycelium. From this mycelium single, fine rods and spirilla extend into the normal tissue, suiTound the cells, and cause their death. Krahn believes that the growth described by Perthes consists of two organisms — the spirillum sputigenum and spirochete dentium. The major- ity of observers agree with Perthes and Seiffert. The same bacteriological picture was described in noma of other parts of the body by Matzenauer. Perthes prepared his specimens for examination by treating the teased tissue or section from the edge of the ulcer — removed post mortem — with dilute carbol-fuchsin for twenty-four hours and then briefly washing with alcohol. Weaver and Tunnicliff- demonstrated that this streptothrix is decolorized by Gram's method. They obtained the best staining reactions by dropping a 10 per cent, saturated solution of alcoholic gentian violet in 5 per cent, phenol on the section (that had been embedded in paraffin, treated with xylol, fol- lowed by absolute alcohol) for five minutes, clearing with aniline oil, wash- ing with xylol, and mounting in balsam. K complete bibliography of noma is given by Weaver and Tunnicliff.^ Symptoms. — The cheek will appear swollen, hard, and oedematous to the touch, the oedema causing such .swelling that frequently the eye of the affected side cannot be opened. There is a decided fetor to the breath, which is often the first symptom noticed. The disease spreads very rapidly from tlie gums to the cheek. Frequently the teeth will loosen and fall out. The latter is frequently caused by the previous administration of mercury. Thus it is that great care should be used in giving mercurj' to children. That it is not an inflammatoi'y disease can be seen by the fact that the temperature is rarely or never above normal. The swelling can best be felt by opening the mouth and grasping the cheek between the thumb and forefinger. The skin over the induration is frequently mottled with purple spots resembling ecchymoses. The appetite is diminished, partly due to the fear of pain caused by chewing. Some authorities state that children so affected have diarrhoea. Forch- heimer believes that ha?morrhages rarely occur, owing to the blood-yessels being filled with thrombi. ^Arcli. fiir klin. Chir., 1899, lix. * Journal of Infectious Diseases, 1907. 'Journal of Infectious Diseases, Jan., 1907. 213 DISEASES OF THE MOUTH. When this gangrenous mass discharges we will find a dirty, fetid saliva, with threads of broken-down tissue. The cervical glands in the immediate vicinity are always found enlarged. In severe cases it is not rare to have the parts ulcerate and even perforate the cheek after several days. When the disease extends inward, not only does periostitis occur, but necrosis of the jaw-bone has been noted. When the disease is as malignant as has just been described, then subnormal temperature, possibly delirium, may complicate the condition. The disease may extend to the lungs, caus- Fig. 56. — Case of Stomatitis Gangrenosa (Noma) Following Scarlet Fever. The picture shows the unilateral gangrenous condition involving the right cheek and the lips. Case recovered. Clinical history given in the text. (Original.) ing a gangrenous infiltration. When the gangrene affects the genitals in girls, then a serious prognosis must be given. The following cases will illustrate the condition described : — Elsie G., aged 7 years, was seen by me in January, 1900. The child had com- plained of severe headache for three or four days, and was very feverish. Her mother became alarmed because of persistent vomiting. She stated that the child vomited at least six times in twenty-four hours. She complained of feeling fatigued and had pains in her arms and legs. The child was nursed for ten months, and was a strong baby up to this time; dentition commenced at the seventh month; the child's muscles and bones were well developed; there were no evidences of rickets; the first two years were passed NOMA. 313 without any sickness except an occasional attack of constipation. The child walked at the end of the first year and commenced talking at its fourteenth month. Twenty teeth — "milk teeth" — appeared at the end of two years. The child had measles in its third year, which left a bronchitis; the mother states that this same cough recurs every winter. The child had had whooping-cough, lasting four months, which was so violent that it had epistaxis almost every day for one month. This whooping- cough was so severe that, in addition to the nose-bleed, the child vomited almost continuously. From loss of sleep, in addition to the above-named symptoms, the child commenced to emaciate. This was at the end of her fifth year. Wlien the child was undressed an eruption was found all over the body, which was that of typical scarlet fever. The throat was filled with evidences of pseudo- membranous patches, which were distinctly scarlatinal in character. The tempera- ture was 103.4° F., taken in the rectum; pulse, 128; respiration, 22. The child was put to bed and an expectant plan of treatment ordered, in addition to a very light liquid diet consisting of soup, milk, buttermilk, broth. Nothing else was allowed; no solids were given. For the thirst I ordered orange juice and apple sauce. Small doses (wine-glasses) of citrate of magnesia were given for their laxa- tive and diuretic effects. The heart sounds were very feeble, and a loud, blowing, hsemic murmur, which was attributed to the anaemic condition, was audible. Iron was given in the form of the syrup of iodide of iron; hypophosphites were also administered as restoratives. Convalescence lasted in all until April, a period of almost three months from the time of the child's first illness. About this time she complained of pain in the gums and on the cheek while chewing. Later, the foul breath attracted attention. At first this condition was attributed to the teeth, but a dentist who saw the child found the teeth and gums healthy. The ulceration, which had now become quite marked, from the size of a silver dollar, spread with remarkable rapidity. Its color was that of a dirty, blackish gray, and had purpuric spots scattered around the edges of this ulceration, resembling subcutaneous haemorrhages. On examining it considerable fluid, which was very foul smelling, exuded on pressure. Antiseptic lotion, consisting of 50 per cent, peroxide of hydrogen diluted with water, was ordered as a mouth wash. The child was told to rinse the mouth every half-hour, especially after eating. The gangrene extended to the outside of the cheek, involving, as can be seen by the illustration, almost the whole cheek. The streptothrix is usually present in the pregangrenous stage and it is here in this stage that the best therapeutic results are attained. As a rule, the disease appears in epidemic form. In diphtheria, scarlet fever, and espe- cially measles oral hygiene must be instituted to prevent stomatitis, and especially ulcerative stomatitis. The latter is frequently a soil for the de- velopment of noma and hence every case of stomatitis should receive active treatment to prevent gangrene. The following case was seen by me at the Willard Parker Hospital dur- ing my service in April, 1913 : — Child C, 3 years old, was admitted with a moderately severe type of scarlet fever. Later a complication of noma developed, and this was the reason for the injection of 0.2 neosalvarsan. Within three days after the injection a slight im- provement was noted, which continued steadily until the case recovered, in all ten days from day of first injection. The noma involved the pharynx, tonsils, and soft palate. 214 DISEASES OF THE MOUTH. When fetor of the breath exists, a strong solution of permanganate of potassiiun as a gargle or spray every two hours will deodorize. Internally tincture of iron as a restorative. The insufSation of a small quantity of neosalvarsan used locally once a day is advised. If fever exists, and toxaemia complicates, an intravenous injection of 0.2 neosalvarsan dissolved in 40 c.c. of sterile water and injected into the jugular vein has shown marked improvement in a number of my cases. Epithelial Desquaiiation (Geographical Tongue). A very common condition consists of epithelial desquamation of the tongue, giving rise to irregular, round or crescent-shaped patches. The borders of these patches are surrounded by a thickish, grajash margin. The center has a glazed appearance. From the irregular outline resembling a map the name of geographical tongue originates. There are usually two or more of these red patches seen at one time. They last weeks and months. I have met these cases among the poorest hygienic surroundings and have seen the same condition among the wealthy. Malnutrition seems to be associated in all my cases, I have frequently seen eases of this kind among the children suffering with diphtheria at the WillaTd Parker Hospital, especially during convalescence. The following case illustrates this' condition : — Minnie H. Fourteen months old. Has been in delicate health since birth. Although breast-fed, has always been constipated and suffered with gastritis, and vomiting occasionally. She is very anaemic. Can neither stand, walk, nor talk. Dentition has been delayed; there is no sign of teeth.- The tongue shows four large, irregular shaped patches and tsvo smaller ones in the center. They appear as though a coated tongue had irregular patches of red, and shining flesh interspersed. Diagnosis, rickets and geographical tongue. Treatment. — Increase the proteins and fats to stimulate nutrition. Cleanse the tongue with boric or tannic acid solution. Most authors advise no treatment. Congenital HypeflTrophy of the Tongue. A thickened, swollen tongue is always seen in sporadic cretinism. (See chapter on ^'Cretinism .'^) The specific thyroid treatment will usually modify this enlargement. When diseased lymphatics exist we may have a lymphangioma. Such conditions are rare, and if present require surgical treatment. Bifid Tongue. Brothers reported a case of this kind to the New York Pathological Society. The child was one month old, had a cleft tongue and a fissure of the soft palate. PLATE VII Greographical Tongue, or Epithelial Desquamation. (Original.) ALVEOLAR ABSCESS. 215 Bifid Uvula. This condition is occasionally seen. I have seen bifid uvula several times without cleft palate. Some authors report the co-existence of bifid uvula with cleft palate. It requires no treatment. Glossitis. An inflammation of the tongue is very rare in children. Some authors state that it is due to traumatism, such as biting the tongue in an epileptic fit, or a ragged, sharp tooth may infect the tongue and cause inflammation. Any irritation, such as caustic acids or alkalies, may cause inflammation. The following case occurred in my private practice : — A child 1 year old was bottle-fed, and suffered witli severe constipation. He was backward in development, had no teeth, could neither walk nor talk. Several adults in the family had influenza and the child was exposed and infected. The fever reached 104° F. There was anorexia, cough, and running of the nose. The tongue was thickened and inflamed and protruded from the mouth. He refused to take any food and seemed relieved when a piece of ice was placed on the tongue. Ice cream was ordered to nourish and cool at the same time. Rectal suppositories containing aconite, 1 minim, and sodium salicylate, 3 grains, were ordered every two hours. Under this treatment, aided by ice applied on the tongue and an ice collar on the neck, the swelling of the tongue disappeared in about four days. Eanula. A swelling in the floor of the mouth, located on either side of the fraenum, is frequently met with in children. It is a cyst varying in size, and is due to an occlusion of the duct leading into the mouth from the sublingual gland. Character. — It may be simple or multilocular. It may be of such pro- portions as to interfere with proper nutrition. Symptoms. — ^The symptoms are those of a mechanical obstruction of a non- inflammatory character. It is painless, soft, fluctuating, and con- tains mucus. The color of the growth is the same as that of the adjacent parts. Treatment. — An incision should be made to evacuate the contents of the sac. The interior of the sac should be cauterized with iodine or nitrate of silver. In some instances the Paquelin cautery may be required. Alveolar Abscess. When there is defective hygiene in the mouth and the teeth are not properly cleaned, caries of the teeth results. The carious condition fre- quently sets up an inflammation, and pyogenic bacteria, gaining entrance, cause abscess formation at the root of the tooth. 216 DISEASES OF THE MOUTH. Symptoms. — The symptoms are pain, swelling, fever, interference with feeding, foul breath, and general constitutional disturbances. The diag- nosis can be made by the presence of fluctuation in the mouth, by the swollen face, mouth, and jaw. Treatment. — Locally, warm (dry) chamomile bag or warm (moist) flaxseed poultices will have a soothing effect, used externally over the swell- ing. Einsing the mouth with warm chamomile tea to which a few drops of listerine have been added is grateful. Painting the gums with equal parts of tincture of iodine and tincture of opium every hour will relieve pain. If fluctuation is detected an incision should be made into the gums on the inner surface, and the pus evacuated. If this condition is neglected the periosteum of the jaw may be involved and the pus will burrow and evacuate itself spontaneously, leaving a disagreeable fistula. Cases have been reported where neglect of this condition has resulted in necrosis of the jaw. Angina Ludovici. Angina Ludovici is an inflammation of the cellular tissue of the floor of the mouth and neck. It is probably a form of actinomycosis. The swelling is most marked below the jaw of one side. The symptoms are very intense and both local and general. There are general septic symptoms from the outset. With the swelling there are oedema and board-like indura- tion. Eedness and the rapid formation of an abscess occur rarely. The throat is not affected. Death takes place from reflex suffocation or in coma. CHAPTER II. DISEASES OF THE (ESOPHAGUS. Acute G^Isophagitis. An mflammation may extend from the pharynx into the oesophagus. When such conditions arise the symptoms of pain on swallowing are asso- ciated with fever. The treatment consists in giving bland food, milk, seltzer, and alkaline waters or water containing bicarbonate of soda. Croupous or Diphtheritic (Esophagitis. Diphtheria can invade the oesophagus as well as it can spread to the larynx. Some authors describe croupous inflammatory patches in the oesophagus. I have seen diphtheria of the oesophagus and also a diph- theritic patch post-mortem in the stomach of this same case. Such a con- dition is invariably serious and recovery is rare. The treatment of diph- theria affecting the msophagtis is the same as that described in the chapter on "Diphtheria." When dysphagia occurs and there is an interference with deglutition, rectal feeding may be demanded to save life. If severe pain exists morphine or codeine in suitable doses. Nau- sea and vomiting can best be controlled by giving large doses of chloral. If an oesophageal stricture remains, then surgical treatment will be required, for which the reader is referred to modern text-books on surgery. Eetro-gesophageal Abscess. This condition may follow measles, scarlet fever, or diphtheria ; in fact, it may be associated with any infectious disease. As a rule, this disease con- sists of a breaking down of the lymph glands ending in suppuration. In a case seen by me the streptococcus was found. This condition is also frequently associated with tubercular conditions. The following case will illustrate the type most frequently met with : — I was called in consultation with Dr. S. Brothers to see a child 3 years old with the following history: — There was fever, an irritant cough, stertorous breathing, and evidence of obstruction pointing to the larynx. The neck was swollen and the glands enlarged. The temperature was 102° F. ; pulse, 130; respiration, 36. At first the case resem- bled one of laryngeal stenosis as is usTially found in diphtheria. The dyspnoea was so marked that intubation was suggested. The symptoms of dyspnoea continued, (217) 218 DISEASES OF THE (ESOPHAGUS, and. an incision was made into the posterior pharyngeal wall. The abscess cavity extended into the oesophagus. Caries of the dorsal vertebrae was associated with this condition. The child died from inanition. The tubercular process was evidently responsible for the abscess, which consisted of pus and large curded masses. The diagnosis was made after a careful study of the case. It is not an easy matter to diagnose this condition, as it is absolutely impossible, in some cases, to reach the abscess cavity by a digital examination of the pharynx. In the case above reported the dyspnoea was very alarming. The litera- ture records cases of spontaneous evacuation of the abscess into the oesoph- agus resulting in recovery, but usually these cases end fatally. The treat- ment is surgical, and tuberculosis, if present, requires the usual form of treatment. (See chapter on "Tuberculosis.") Fig. 57. — Hinged Bucket. Foreign Bodies in the CEsophagus. I have frequently been consulted regarding the removal of buttons, coins, etc., which were swallowed. The habit of children to put everything into the mouth should be remembered when buying toys. The best method of extracting foreign bodies in the oesophagus is by means of the hinged bucket ; also known as the "coin catcher." CHAPTER III. DISEASES OF THE STOMACH. Acute Gastric Catarrh (Dyspepsia; Gastritis). One of the most frequent diseases met with in infants or young chil- dren is dyspepsia. This is due to improper feeding of both quality and quantity of the food. Nursing children are very often seen suffering with this disease, especially among the tenement population. That poor hygiene has some bearing on the development of this disease is certain. The largest number of cases are seen with bottle-fed babies. Errors in- feeding, particularly over-feeding, and giving the infant the bottle whenever it cries, must be looked upon as a means of aggravating and exciting gastritis, if not being the real cause of the dyspepsia. Pathology. — The mucous membrane of the stomach is always swollen and thickened. Occasionally erosions and hgemorrhages are found. The tissue beneath the mucous membrane, the submucosa, will be found oedema- tous. The interstitial tissue is infiltrated with leucocytes, and the differen- tiation between the parietal and principal cells cannot be clearly outlined. All the cells appear cloudy and granular and partially separated from the membrana propria of the gland. There is an abundance of the mucous cells in the pyloric region, and this increase extends deeply into the ducts of the glands. In older children the origin of the trouble can easily be traced. Over- eating, especially cakes and pies and puddings; too rapid chewing and swallowing of unmasticated pieces will aggravate an attack of this kind. Gastritis is seen more often in older children who are permitted to drink wine or beer at the table with their parents. Children are permitted a drop of whisky or wine or beer, as their parents say, "to strengthen them." Candies and ice creams frequently cause acute gastritis, in children. Symptoms. — A young infant will suddenly refuse to take its bottle and will appear very peevish and thirsty, flex its legs on its abdomen, will seem dissatisfied, and refuse to play. Vomiting is a frequent symptom. The infant will cry and put its fingers into its mouth. The temperature on the first day ranges between 102° and 103° F., though it may reach as high as 105° F. in the rectum. The pulse ranges between 140 and 160. The res- piration is sometimes accelerated. The tongue is usually coated with a white or a grayish-white fur, and there is a foetid odor to the breath. Diar- rhoea may be present, although constipation is more frequently met with. When children are extremely antemic, or if from previous malnutrition they are rachitic, the disease will commence with convulsions. Convulsions (319) 220 DISEASES OF THE STOMACH. must not be looked iiiDon as very serious unless they recur several times during the first day of the attack. A diagnosis of meningitis will frequently be made in the commence- ment of an acute catarrhal gastritis, unless we study the pulse-rate. In meningitis the pulse-rate is usually slow ; in gastritis it is greatly accelerated. Pressure on the epigastrium Avill show marked tenderness. The stomach is usually distended and tympanitic on percussion. If a child is old enough to complain, there are usually subjective symp- toms such as headache, frontal in character, and pains in the arms and legs will be described. Jaundice will usually be found in older children in the course of the disease, and denotes an extension of the catarrhal inflam- mation from the stomach into the duodenum; thus gastro-duodenitis may 'be diagnosed when jaundice is established. Prognosis and Course. — The prognosis of an acute catarrhal gastritis depends on the time of the year and the condition of the child at the time of the attack. If a bottle-fed infant is attacked with gastritis in midsum- mer, and it cannot be removed from the sultry city, then the prognosis is grave. If, however, breast-milk can be given judiciously and the feeding interval conform with the requirements of the weak digestive apparatus, then we may reasonably hope for a favorable termination. If complications occur, chief among which may be typhoid fever, or an extension of the disease from the stomach into the bowel, then the outlook will not be good, unless we can remove the patient to the mountains or seashore. Nephritis frequently complicates gastritis, and when such complica- tions exist the prognosis is bad. Infectious diseases complicating gastritis will render the prognosis unfavorable. The important point to note is, how much food is being assimilated. If the infant digests a proper quantity of food the prognosis is good; if, however, vomiting continues and we cannot feed the child per mouth or per rectum, then the prognosis is very grave. We must aim to prevent starvation if the child's life is to be saved. Treatment. — The first thing to do is to cleanse the stomach. This can be accomplished by giving a dose of castor-oil, syrup of rhubarb, or calomel. If the child is old enough some citrate of magnesia in wineglassful doses, repeated every two or three hours, will correct fermentation. When rapid cleansing of the stomach is demanded, owing to toxic symptoms from ptomaine poisoning or from other poisons, an emetic should be given. A dose of 1 grain of sulphate of copper in a teaspoonful of water, repeated every half-hour until vomiting is produced, will materially aid in cleansing the stomach. Syrup of ipecac, in teaspoonful doses, may also be given in some instances, although the writer does not advocate the use of syrups in acute fermentative diseases of the stomach or bowels. In other cases wash- ing the stomach with a soft catheter, as mentioned in the treatment A.CUTE GASTRIC CATARRH. 221 of summer complaint, will prove very valual)le. Several pints of table salt solution or of noniuil salt solution^ can be used to tboroughly cleanse the stomach until the water is syphoned oft' quite clear. In washing the stomach wjth the aid of a sol't-rul)l)cr catheter there is usually (piite some irritation produced in the pharynx and oesophagus, and thus vomiting will usually aid in the lavage in clearing the stomach of its contents. When such treat- ment has been instituted it is advisable to allow tlie stomach to rest at least six or seven hours, and meanwhile give sterile water — "ordinary jjoiled water" — ad Uhituni. When the bowels have been properly cleansed and the stomach has been washed by lavage, or treated wdtli one of the above-mentioned laxa- tives, then the after-treatment will consist in preventing further fermen- tation, and also in toning up the patient's condition. Medicinal Treatment. — Experiments have shown that when the gastric contents have been syphoned off or examined immediately after an emetic has been given, in an acute gastritis, there is a deficiency of hydro- chloric acid. This is an indication then as to what is required. Diluted hydrochloric acid given in doses of from 2 to 5 drops has served the writer very well wdien given every three or four hours. IJ Acid hydrochloric dilut 1 drachm Essence pepsin ( Faircliild) 2 ounces M. D. S. Teaspoonful repeated every two or three hours. Beta-naphthol bismuth in doses of 1 to 5 grains, every two hours, has served me very well. Calcined magnesia^ is also very valuable. The fol- lowing prescription has been used with very good results in dyspeptic con- ditions attended with constipation : — . IJ Magnesia usta 1 drachm Pulv. rhei 1 draclim Saccharum' 2 grains M. and divide into 12 powders. One powder to be given in a teaspoonful of sterile water every two or three hours. Powdered charcoal added to the above prescription in doses of 1 grain three times a day is frequently useful. Salol in doses of 1 grain every two or three hours, and resorcin in doses of ^/m grain or i/4 gi'ain, for a child 1 year old, repeated three times a day, will do good in some instances. A very good liquid preparation sold- in drug stores is milk of magnesia (Phillip's). It is an excellent antacid and corrective when flatulence exists. ^Formula? for saline solutions will be found in the chapter on "Scarlet Fever." - Magnesia in powdered form I frequently use is known as Husband's Magnesia in drug stores. 223 DISEASES OF THE STOMACH. "When severe thirst exists boiled water ma}' be given. This water may be acidulated with a few drojos of diluted i^hosphoric acid, and will be found not onh' very grateful and cooling, but very serviceable if the child has a tendency to diarrhoea in midsummer. Dietetic Treatment. — The most important point to remember is the feeding. If we are dealing with the nursling, then breast-milk should be withheld for about one-half day. When the breast is given again, the infant should not be permitted to nurse more than two or three minutes, and immediately after taking the breast the infant should receive 3 or 4 ounces of sweetened rice water. In this manner we will give the infant diluted milk. This breast and rice-water feeding should be repeated in four hours, no sooner, no matter what the age of the infant. "What might appear very radical is simply advised, to prevent the stom- ach from performing its usual amount of work until the gastric function is reestablished. If, however, the child's appetite warrants it^ then one or two days should elapse before giving it its former regular quantity of nurs- ing. The guide to the return of the normal quantity of nursing will be the disappearance of the fever and of the accelerated pulse-rate. The child's craving for the breast can be noted chiefly by constant crying when the breast is removed, and the ravenous manner in which it nurses. In bottle-fed babies it is advisable to give the child one-half of the former quantity of milk or cream which it received at the time of its illness,, and if it is found that the sugar contained in the food aggravates this con- dition, a small quantity of saccharine may be used to sweeten the milk, and the sugar discontinued. Some children show distinct fermentative changes after the use of too much sugar. In such cases the use of saccharine or one- half teaspoonful of glycerine to each bottle of milk is sometimes beneficial as a temporary substitute. Glycerine is al:)Solutely harmless and may be given for months with impunity. My rule is to insist on the use of sugar if at all possible. Lime water in doses of a teaspoonful or a tablespoonful may be added to the milk. Five grains of bicarbonate of soda may be added to the milk or given Ijefore each feeding. If vomiting follows the milk-feeding, whey should be substituted. Attention must be paid to the quality of milk given to infants. There are many dairies in Xcav York City which furnish an excellent quality of milk, owing to the great care liestowed upon the milk supply by the Health Department, and also by the Milk Commission. If milk seems to aggravate an attack of dyspepsia, then zoolak or kumyss or other fermented milk may be tried. Buttermilk is very nour- ishing and very useful in dyspepsia. Junket may also be tried; so also can whey be given several times a day. Soups and broths, calf's foot and chicken- jellies are all nourishing. Steak juice and unfermented grape juice will ACUTE GASTRIC CATARRH. 223 be serviceable. Boiled fruits, such as apples and peaches, if the child is old eriour — ---i - ::::: j::. fMfHilllliillJIIIIMHMffMfiiLt^^fl i -A & D. aJ o o ^ O o ? o o - t. L, S ^ '^ »- M rt ^ 250 DISEASES OF THE INTESTINES. Prognosis. — The prognosis depends upon the vitality at the time of simstroke. We must differentiate this condition from meningitis. The suddenness of the attack following exposure to the sun will usually aid in making a diagnosis. The majority of cases seen by me recovered. Occa- sionally a fatal case was encountered, especially in bottle-fed infants. Fig. 67. — Insolation (Heat-stroke). Type of midsummer cases in New York City. (Original.) This infant (Fig. 67), brought to my clinic July, 1909, weighed 5 pounds 6 ounces. He was a bottle-fed infant, reared on condensed milk. He was nine weeks old. Vomited after each feeding, had greenish, mucous, sour-smelling stools, every half-hour and oftener. There was eczema between the thighs from excoriation and acid stools. The child weighed 6^/^ pounds at birth, and was a full-term baby. The child was pulseless. The extremities were cold and covered with a clammy perspiration. The temperature was subnormal — 97° F. The fontanel was de- pressed. The heart sounds were barely audible. The mouth, tongue, and lips were very dry; food and water were refused. Spirits of camphor, 5 drops, was injected hypodermically ; a mustard foot-bath was ordered. The child died fifteen minutes later. DYSENTERY. 251 Diagnosis. — Cholera infantum, marasmus, due to malassirailation of food; im- proper food to commence with. Extreme heat caused heart-failure and general pros- tration. Treatment. — A tub-bath, temperature 90° F., gradually decreased to 70° F., duration five minutes, is advisable. An ice-bag should be applied to the head. If consciousness has been restored, the child should be al- lowed to rest; if not, then we can restore the circulation to relieve cerebral hypergemia by giving a mustard foot-bath for several minutes until the skin is reddened. The rectum and colon should be flushed with a hot saline solution at a temperature of 110° F. ; thi's will stimulate diuresis besides cleansing the bowel. One-drop doses of aromatic spirits of ammonia with water may be given every fifteen minutes. If the child can swallow then : — IJ Bromide of sodium 10 grains Chloral hydrate 3 grains should be given to a child 5 years old. This can be repeated every hour until a sedative effect is produced. In some cases (comatose) it may be advisable to inject per rectum : — IJ Bromide of sodium 15 grains Starch water 1 ounce Cold water should be given by mouth, with several drops of diluted hydrochloric acid. Peptonized milk, thin soups, and broths may be given every few hours. Liquid peptonoids can be tried if food is rejected. Dysentery (Ileo-colitis). The lower portion of the intestine is frequently the seat of an infection by pathogenic bacteria. Pathology. — As this condition frequently follows severe milk infection, the pathogenic lesions are necessarily the same, although in a more ag- gravated form. In addition to the hypersemia of the mucous membrane there may be a small haemorrhage in the mucosa or submucosa. The mucous membrane is very deeply pigmented, frequently being of a purplish line. The solitary lymph follicles along the colon are swollen. The discharge of mucus is tinged with blood, and not infrequently the amoeba coli described by Lbsch, or known as the amoeba dysenteries, described by Councilman and Lafleur, can be found. "It is a unicellular, protoplasmic, motile organism from 10 to 20 micro-millimeters in diameter, and consists of a clear outer zone (ectosarc) and a granular inner zone (endosarc), containing a nucleus and one or more vacuoles." Multiple abscesses are frequently found. "The ulcer first begins as a small papule, the upper part of which sloughs off, leaving a grayish-yellow ulcerating surface." 252 DISEASES OF THE INTESTINES. Diphtheritic dysentery, sometimes known as the croupous variety, is a catarrhal form of this same condition previously described, in which the infection can be traced to an invasion of the Klebs-Loeffler bacillus. The ulcerations are covered with a pseudo-membrane, and the pathogenic con- ditions are as previously described. Bacteriology.^ — There are two groups of bacilli which are responsible for the development of various types of epidemic dysentery: — • 1. The true Shiga group. 2. Group of mannite fermenters. The latter group is divided into two types : — f'\::r- .. '\^^; r-'Si- ^>^, Wl. •^ Fig. 68. — Bacillary Diphtheria of the Colon or Diphtheritic Colitis, a. Necrotic tissue containing bacilli. 6, Gland with necrotic epithelium, d, Connective tissue, e, Degenerated and exfoliated epithelial cells, f, Bacilli in the lumen of the gland, g, Bacillary deposit beneath the epithelium. 7i, Nests of bacilli in the connective tissue. X300. (Ziegler.) (a) Fermenting mannite alone in peptone solution. (h) Fermenting maltose and saccharose. Symptoms.— The attack is usually ushered in with diarrhoea. There is also considerable straining with each stool. At first the stools contain particles of faeces, and as the disease progresses they become more liquid and contain mucus and blood. Some authors describe the stool as con- taining shreds that resemble the washings of raw meat. The face shows a very anxious expression. There is extreme pallor. The child appears prostrated. The pulse is accelerated and very feeble. The abdomen is distended, especially over the colon. Vomiting is a rare symptom. Unless treatment is rapidly instituted the child will fail in strength and may die. ^ The Journal of Medical Research, a^oI. xi, No. 2, May, 1904. DYSENTERY. 253 Such children usually sleep with the eyes hall: open and show evidences of collapse. The rectum may protrude, especially when there is a distinct relaxation of these parts. Cold, clammy perspiration is usually found, especially on the head. The extremities are cold. Convulsions appear in the severer forms of dysentery. In the diphtheritic variety the temperature and pulse resemble a case of true diphtheria. The stool, in addition to mucus and blood, may have particles of pseudo-membrane. Toxemia can usually be seen by its effect on the heart and pulse. The urine may contain albumin. Where the toxasmia progresses, convulsions may set in and death result from cardiac paralysis. Fig. 69. ■^Croupous Enteritis, Diphtheritic Colitis, two-tliirds natural size. (Langerhans.) Diagnosis. — The bloody mucus and watery stools seen in this con- dition, associated with tenesmus, will usually aid in eliminating acute milk infection. In gastro-enteritis and entero-colitis there is usually a greenish, spinach-like stool, or a brown, muddy stool having a very foetid odor. The stools in dysentery are smaller in quantity. Both the diph- theritic and the amoebic forms of dysentery are rare in children. Prognosis.i — If this disease is epidemic, or if it occurs in children having bad sanitary surroundings, then the prognosis is bad. The dura- tion of an acute attack is usually about five or six days. The prognosis is good when the diarrhoea and blood gradually disappear. The main point to remember is that the heart must be sustained by proper nutrition, and we should try to coimteract the toxaemia by proper stimulation. 254 DISEASES OF THE INTESTINES. Treatment. — ^The same hygienic measures described in the chapter on "Food Intoxication" apply equally as well here. Impress the mother or nurse that unless she carries out the directions minutely, the child has little chance of recovery. Dietetic Treatment. — The dietetic management will consist in leaving out milk. Whey, barley water, rice water, or toast water may be given. Mutton broth thickened with rice may be given to an older child. Whisky and water should be given from the beginning. It is not too much to give 2 to 4 ounces of whisky per day. The physician should order the amount of whisky by telling the mother or nurse to give % drachm or more well diluted with barley or rice water, every half -hour. Coffee is a valuable cardiac stimulant. Champagne may also be given. Local Treatment. — ^The physician will be most successful who places his patient in bed, regulates the diet, cleanses the intestinal tract, and relieves the tenesmus by local treatment. The heart should be supported. The strength must be sustained with nutrition and the flushing of the bowel should be performed as soon as possible after a stool is evacuated. Warm chamomile tea should be used to cleanse the colon and rectum. This should be injected at a temperature of 100° to 105° FL, with the aid of a small rubber catheter. This can be followed by an injection of 1 ounce of sterile water containing 2 grains of nitrate of silver. Very bland injections, such as I^ Raw starch 1 teaspoonful Chamomile tea 1 quart Laudanum 10 drops injected at a temperature of 100° F., will soothe the rectum and frequently relieve tenesmus, I have successfully treated dysentery cases with the following : — IJ Argentum nitrate 6 grains Cocoa butter q. s. M. Form into twelve suppositories. IJ Oleoresin terebinthinae 12 grains Extract of belladonna 6 grains Extract of opii aquosa 1 grain Cocoa butter q. s. M. Form into twelve suppositories. Sig. : Insert alternately q. 3 liours.^ Sulpho-carbolate of soda, in doses of 5 to 10 grains, can be used several times a day. Bismuth combined with Dovei*'s powder is frequently valuable. An ice-bag placed on the abdomen in the region of the colon will sometimes do good. Very cool injections of table salt and water are some- times of value when hot injections are not well borne. ^ As the nitrate of silver would oxidize the organic matter contained in the second formula, the suppositories must be given at intervals of three hours. PELLAGRA. 255 Pellagra. 'The etiology of pcllagTa is still obscure. Jos. Goldberger/ in an extensive study of this subject for our government, found that, first, this disease is essentially rural; second, associated with poverty. While posi- tive data are not available as to the real etiological factor, be it insect transmission or diet, the impression prevails that canned goods, vegetables, and cereals, especially corn products, should be laid aside, and fresh milk, fresh eggs, and fresh meats used instead. In a study of an orphanage at Jack- son, Miss., of 211 orphans, 68, or 32 per cent., had pellagra. Practically all of the cases were children between the ages of 6 and 12 years. In a group of 25 children examined, under 6 years of age, there were 2 cases. In a group of 66 cases over 12 years of age, there was 1 case. The exempt group were found to subsist on a better diet than the affected group. In the diet of those developing pellagra, a small amount of meat and other animal protein food was found. A large part of the ration consisted of corn, sirup, and legumes. The inference may therefore be safely drawn, that pellagra is not an infection, but that it is a disease essentially of dietary origin. It may be caused, for example, by the ab- sence from the diet of essential vitamines. Meyer and Voegtlin believe that the presence, in the vegetable food component, of excessive amounts of soluble aluminum salts is the responsible poison causing this disease. Symptoms. — ^The skin manifestations may either be a slight roughening or thickening of the affected skin, so that an urticarial or erythematous flush resembling erysipelas may be found. Other types are either oedema- tous or have an extensive desquamative dermatitis. In fatal cases marked sloughing of the skin is noted. Glossitis and stomatitis are common symp- toms. The bowel disturbance is usually diarrhoeal in character. Now and then a case will appear in which constipation exists. Lorenz- has made a study of the cerebrospinal fluid in pellagra. He finds that: 1. A lymphocytosis of the cerebrospinal fluid does not occur in uncom- plicated pellagra. 2. Globulin excess of the spinal fluid is only occasionally observed. 3. Lange's colloidal gold chloride test is uniformly negative in pellagra. 4. The Wassermann is negative with a few exceptions. In this in- vestigation the exceptions were moribund cases which gave weakly positive reactions with blood-serum. 5. The spinal-fluid findings would seem inconsistent with a concep- tion that pellagra is an infectious disease of the central nervous system. ^The Treatment of Pellagra. Reprint No. 21S from the Public Health Reports, September 11, 1914. "Lorenz, W. F., special expert, United States Public Health Service, and director Wisconsin Psychiatric Institute. 256 DISEASES OF THE INTESTINES. It is very evident from Lorenz's examination that we are dealing witli some local disturbing, agent in which the gastro-intestinal canal is the part affected. When one considers that the bulk of cases appear in those districts in which the food is largely made up of preserved, canned, and desiccated or packed meats, then the diet must be looked upon as probably responsible for the sj^mptoms noted. Treatment. — Treatment consists in reducing the food that probably causes the disease, and adding fresh meat, milk, eggs, vegetables, and legumes to the diet. The diet advised in the treatment of scurvy is similar to that advised in the treatment of this condition. Arsenic, atoxyl and salvarsan have been recommended, but one and all found wanting. Small doses of quinine, iron and strychnine, codliver oil, olive oil, fresh butter and fresh cream will aid in restoring normal conditions. To relieve the diarrhoea a dose of castor oil followed by 5- to 10- grain doses of bismuth or tannigen should be given. Pood Intoxication (Toxicosis; Cholera Infantum; Acute Milk Infection) . For ma:ny years we have been taught that the ingestion of bacteria in milk causes diarrhoeal diseases. Some authors have found one or more million bacteria in 1 cubic centimeter of ordinary milk; other specimens have contained only 50 thousand bacteria in 1 cubic centimeter. In count- ing these bacteria, the harmless and harmful varieties are not separately considered. In other words, bacteriologists merely consider germs. There are many forms of bacteria which normally inhabit the intestine. That these innocent bacteria assume a virulent form under certain irritated con- ditions has been suspected. The bacillus of Shiga has been found in many cases of intestinal catarrh with diarrhoea and symptoms of intoxi- cation. There are equally as many cases of the same type in which no Shiga bacillus can be found. One must assume, therefore, that there are other factors equally as important as bacteria causing this condition. It has been possible to reduce one or more million bacteria in each cubic centimeter of raw milk to 50 thousand bacteria per cubic centimeter, by subjecting the milk to steaming at a temperature of 140° F. for ten minutes. We know that the toxins generated by some bacteria are more deadly in their action than the bacteria themselves. Such toxins can with- stand a temperature of 300° F. without destruction. To Finkelstein belongs the credit of having shown that bacteria do not enter into the causation of this disease, but that the faulty assimilation of fat and sugar is responsible for this condition. Finkelstein proves this by relieving the symptoms when fat and sugar are withdrawn from the food, and when the protein element is increased. This he does regardless of the presence or absence of bacteria. INTOXICATION. 257 In bottle-fed children, especially among the poorer classes, acute milk poisoning is frequently seen during the summer months. This is due mainly to the chemical or toxic product developed in the milk. The heat of the summer rapidly decomposes milk, and large quantities of bacteria multiply and generate their toxic products. When such milk is fed to infants they show the effect of the toxin very rapidly. Park found that when milk was first received from the farms it contained from 10,000 to 20,000 bacteria in each cubic centimeter. On the second clay the bacteria had so increased that there were between 10,000,000 and 30,000,000 per cubic centimeter. Summer diseases, particularly entero-colitis and cholera infantum, will Fig. 70. — A Case of Acute Milk Poisoning Having Vomiting, Diarrhoea, Mucous and Bloody Stools, General Emaciation, Acute Cholera Infantum, and Dysentery. (Original.) appear just as readily in breast-fed children who are improperly managed as in bottle-fed children. Pathology. — There is extreme emaciation of the entire body affecting muscles and fat. The fontanel is depressed. The eyes are sunken. The elasticity of the skin ie gradually lost; the skin hangs in loose folds. The body resembles an advanced form of tuberculosis. Minute haemorrhages are found associated with intense congestion in the stomach and intestines. The evidence of catarrh is everywhere seen. There is an excessive secretion of mucus in the larger intestine ; in the colon ulcers will be found. Ashby and Wright describe a general distention of the net-work of the capillaries situated in the mucous membrane of the intestine. The same condition is found in the submucosa, in the villi, and between the tubules and crypts of Lieberkiihn. '"The central portions of the solitary glands are softened, or, the softened portions having been discharged, the remains of the glands appear as sharply cut ulcers, although the sinuses of the brain 17 258 DISEASES OF THE INTESTINES. are found distended with blood. Occasionally cerebral anaemia may exist." Meningitis is rare. Bacteriology. — The enormous material at our command in this country gave the Rockefeller Institute an advantage in studying the pathogenic bacteria in this disease. It was found that the bacillus dysenterise (Flexner) is present in very many cases. Other investigators along the same liues have found the bacillus pyocyaneus (Cooper) a probable causative factor in this disease. On the other hand, Finkelstein, Escherich, and Moro believe that the bacillus acidophilus is the causative agent. Other investigators believe the bacillus coli communis or the streptococcus to be the causative agent. Finkelstein and Meyer have shown that milk sugar in food can alone produce intoxication. When a high fat content is present, this naturally aids in the intoxication caused by the sugar. It is impossible to believe that bacteria per se are not at the root of the disease, and yet convincing argument is ofEered by the German investigators to prove their claim: that the disease is one in which there is a dietetic error resulting in, first, a local ; and later, a general systemic disturbance. Causes. — The etiological factors can be briefly outlined as follows :— 1. Food, improper quantity and quality of the same, be it breast-milk or hand-feeding. 2. The most frequent cause is certainly improper bottle-feeding, wherein food unsuited to the infant's digestive abilities is continued, in spite of Nature's efforts to warn us, as frequently manifested by either vomiting or diarrhoea, or both. 3. Milk from mothers suffering with tuberculosis or syphilis. Preg- nant, menstruating, and all anaemic women secrete such poor milk that gastro-enteric derangements are exceedingly common. 4. The influence of the weather on digestion, especially the extreme heat of summer. Harry G., ten months old, bottle-fed, was brought to me with a history of vomiting, high fever, and diarrhoea. The temperature was 104° F. The stool was green and contained mucus and curds, and had a very foetid odor. The stools were as frequent as twenty in twenty-four hours. There was a great deal of flatulence, the abdomen was distended, and there was constant tenesmus. The mouth was dry, the tongue had a whitish fur coating, and in the mouth small patches of stomatitis could be seen. Tlie tongue protruded constantly and when liquids were given they were taken ravenously. The mother stated that ordinary grocer's milk had been used, and that she believed the milk had turned sour "after a thunder storm." The diagnosis of acute milk infection was made. The stomach was washed by the use of 1 quart of saline solution. Two drachms of castor oil was ordered, and one hour later the rectum and colon were flushed with 1 quart of chamomile tea. All milk was stopped. No food was given for six hours. A bland diet of sweetened rice water and whey was then given in quantities of 4 ounces every two hours. As a stimulant, 15 drops of whisky was given with i/ioo grain of strychnine every three hours. The child improved, and three days later 1 ounce of milk, with 7 ounces of rice water, was given every three hours. The milk was gradually increased every other day, and the rice water decreased. The child recovered. INTOXICATION. 259 Symptoms. — The two cardinal symptoms are (a) vomiting, (b) diar- rhoea. In some instances the first evidence of this infection will be fever. The temperature may be as high as 103° to 105° F. There will be intense thirst. There is no appetite. The infant will refuse its bottle, and if forced to take it will immediately throw it off. Bile, mucus, and sour- smelling curd form the bulk of the vomit. The abdomen is usually dis- tended. There is a great deal of flatulence. The stool is watery and green- ish in color, with a very foul odor. When the diarrhoea continues for several days, the temperature may become subnormal and the infant's fore- head may be covered with a cold, clammy perspiration. The extremities are usually cold. The child will sink very rapidly, owing to the amount of exhaustion. The body is constantly drained by the diarrhoea. Unless the clinical picture is recognized and proper treatment instituted, the infant may sink into a coma and have convulsions, followed by death. The following case illustrates acute milk poisoning in an infant less than 1 year old. The infant was bottle-fed and received the food daily, modified, from a milk laboratory. This food seemed to agree until the time of the present illness. The child was under the treatment of Dr. John Logan and Dr. J. Martinson, both of New York. The case was seen by me in consultation after several days' illness. The infant was vomiting and had greenish, mucous stools. There was severe tenesmus. The infant showed severe prostration and was apparently comatose. The fontanel was sunken. The pulse was very feeble. The circulation was poor and the extremi- ties cold. As no food was retained, in addition to the amount of toxin in the circulation, the heart's action became weaker and weaker. It was very difficult to rouse this child. In spite of high saline colon injections, the child died of exhaustion associated with general toxaemia. Diagnosis. — The diagnosis of this condition is extremely easy. It is usually aided by the clinical history. The disease usually occurs in sum- mer, although milk poisoning can take place during any time of the year. Differential Diagnosis. — Sunstroke may sometimes be confounded with cholera infantum, but the continued diarrhoea in cholera infantum, and its history, should aid in eliminating this condition as a factor. Asiatic cholera shows symptoms similar to cholera infantum. The presence of the comma bacillus in the stools will establish the presence of Asiatic cholera. An important point to remember is that very many diseases have symptoms resembling cholera infantum and must be carefully differen- tiated; for example, typhoid fever occurring in midsummer may simulate this disease and give rise to symptoms which greatly resemble cholera in- fantum. We occasionally see children having diarrhoea, vomiting, and fever in whom on palpation a tenderness in the ileo-csecal region can be palpated. Such cases may have appendicitis and still show all the symp- toms of cholera infantum. The blood examination will aid in establishing the diagnosis of ap- pendicitis. In the latter condition we have a marked leucocytosis and a high polynuclear percentage. 260 DISEASES OP THE INTESTINES. The prognosis depends on the infant, its surroundings and the amount of infection, and the length of illness. An infant having good vitality and being given a careful diet and stimulation with proper hygienic treatment certaialy has more chance than one left in the city amid poor surround- ings with faulty hygiene. Hygienic Treatment. — Before feeding is considered we must put the infant into the best possible surroundings, a clean room, clean linen, a clean bed ; in fact, all sanitary conditions must be perfect. If possible the infant should be placed on the roof of a house in the city, or out-of-doors in the country, both day and night. To place a case out-of-doors during the day is not sufficient. // sea air is obtainable, it is best to remove the child to the seashore, or at least insist on daily excursions. Cold bathing, or bathing in cold or lukewarm water, to which some sea salt has been added, has proven beneficial. Dietetic Treatment. — ^After the hygienic conditions are satisfactory, at- tention should be directed to the food. Knowing that this disease is caused by faulty feeding, the most important and therapeutic indication is the feeding. Liberal quantities of water sweetened with % grain of saccharine to the pint should be given. Skimmed milk, or diluted skimmed milk, or junket made with skimmed milk is the best food for this condition. Butter- milk made from the lactic acid bacillus and skimmed milk should form the bulk of the diet. Rice or barley water sweetened with saccharine may be useful in controlling the diarrhoea. The intervals of feeding should be from three to four hours. The quantity should be reduced. If the infant had been getting 6- or 8- ounce feedings, the quantity should be reduced to 4 or 6 ounces at one feeding. Lime water may be given liberally, several teaspoonfuls in one hour. Weak, cold tea may be given ad libitum. If the infant is breast-fed discontinue the breast at least twenty-four hours. If the acute symptoms of vomiting and diarrhoea have been stopped by appropriate treatment, then the breast may be permitted once every six or eight hours, the alternate feeding to consist of rice or barley water sweetened with saccharine. In other words, we must return gradually to milk feeding. If acute symptoms return when the breast-milk is given, then it is a question as to whether or no the breast should be entirely withheld. Antipyretic Measures. — Cold applications to the head and an ice-bag over the fontanel, cold towels changed every fifteen or thirty minutes over the abdomen, will tone up the nervous system in addition to reducing the temperature. I am a decided opponent to antipyretic drugs, and never use antipyrin or phenacetine, but invariably resort to hydropathic measures for the reduction of the temperature. Sponging of the body with alcohol and water is very grateful and refreshing, besides a good antipyretic measure. If cyanosis and cold extremities exist, then it is wise to resort to hot mustard baths to stimulate the circulation. INTOXICATION. 261 Drug Treatment. — The tendency to constipation following a dose of castor-oil makes it a valuable remedy in all forms of diarrhoea. Bismuth is the sovereign remedy; I have used the subcarbonate, subnitrate, salicylate, and betanaphthol bismuth, and find the latter an extremely valuable prepara- tion. In doses of 2 to 5 grains every few hours, mixed with a little boiled water, it not only agrees very well with children, but seems to exert a heal- ing effect in that form of bacillary diarrhoea which is met with in the acute catarrhal gastro-enteritis. Salol in doses of 1, 2, and 3 grains, for each year respectively, is an- other valuable remedy; so also is resorcin, in doses of 1/4 to 1 grain for a child 1 year old, three or four times a day. It is advisable not to add sugar for sweetening, but only glycerine, the latter, however, in very small quantities, as it has a tendency to loosen the bowels. Tannalbin and tannigen in doses of from 1 to 10 grains seem to act well in some cases, poorly in others, but are well worth trying in those desperate cases in which we change the drugs, if they are ineffectual. Hypodermic Medication. — In forms of collapse, where constant diar- rhoea has drained the system, it is a good plan when the extremities are cold to give hypodermic injections of 10 to 20 drops of whisky. Sulphuric ether can also be administered hypodermically in the same dose as whisky. An intravenous injection of 1 pint of normal saline solution containing a drachm of adrenaline solution 1 : 2000 may be given. Another valuable stimulant is musk; 2 to 3 drops of tincture of musk administered hypo- dermically every hour will frequently rouse the circulation. When this form of treatment proves unsuccessful, and the condition of collapse continues, then a good plan is to resort to hypodernioclysis. This consists of introducing a long aspirating needle (previously sterilized by boiling) into the loose connective tissue of the abdomen, and allowing sev- eral ounces of the normal saline solution, containing about 7^/2 grains of table salt to a pint of water, temperature 100° F., to flow in subcuta- neously. It is remarkable to note how much liquid can be introduced in this manner, and some of the most desperate cases of collapse will respond very rapidly. I have seen children who previous to this injection were pulseless suddenly brighten up, and within a few minutes show a distinct radial pulse. Too much care cannot be bestowed on the sterilization of every part of the apparatus, and the absolute cleanliness of the water to be used for this purpose. Rectal and Colon Flusliing. — It is advisable to irrigate the colon and rectum by placing the child on its left side, introducing a flexible rubber tube anointed with carbolized vaseline. Having passed the external sphinc- ter, I invariably allow the water to flow into the rectum in order to balloon the same, and then continue to push the tube beyond the rectum into the colon. A little difficulty is sometimes encountered, owing to the spas- 263 DISEASES OF THE INTESTINES. modic contraction of the muscles, but if we wait a short time, using a little patience, the tube can easily be pushed into the colon. The method pur- sued is the same as described previously in irrigating the stomach, excepting that we do not seek to syphon ofE the contents of the bowels, but rather allow a pint or a quart of the. warm saline solution to flush the bowels, and in this manner wash. away as much of the offending debris as exists within the bowels. I have frequently used cold water, but I find much greater benefit from the use of a warm solution of the temperature of 105° F. Some of our cases require irrigation once in twenty-four hours for one week, and others again are so greatly improved after one rectal washing that it is not necessary to resort to it again. Fig. 71. — Exact Size of Catheter Used for Irrigating a Very Young Infant. Starch injections, made by adding 2 tablespoonfuls of the ordinary starch to a quart of warm water of a temperature of 105° F., may be gi^en. They are very advantageous, as the colon changes starch into dextrin, which is easily absorbed. Thus not only does the latter cleanse, but it is also nutritious. Large quantities of saline solution can be introduced into the circulation by means of colon washing, thus adding to the volume of the blood, I tlierefore lay great stress on this form of treatment, as one of the most valuable for this depleting condition. Thromboses can frequently be avoided by these injections. When severe tenesmus exists, painting of the lower end of the rectum with a 2 per cent, solution of cocaine is frequently very advantageous. Pro- lapse of the rectum and anus can frequently be prevented by applying a strip of zinc oxide plaster from one buttock tightly to the other, so that the buttocks will support the bowel and mechanically prevent its protrusion. SUMMEE DlAEKHffiA, In this condition we have a gastro-intestinal disorder due to the toxins generated from the bacteria in milk. This usually occurs during the sum- mer months, when there is great humidity in the air. The symptoms are not so severe as those seen in the acute form of milk infection. It is usually met with among the poorer classes, who buy a cheap milk which usually contains millions of bacteria. Victor Vaughn, of Ann Arbor, Mich., in. a letter to me, stated that although it is possible to destroy all bacteria by repeated and continued sterilization, he found it impossible to destroy the toxins generated in milk even though the temperature was raised to 300° F. Cause of Infant Mortality. — The weeds eaten by cows in their summer pastures are responsible for many cases of gastro-intestinal disease. Many bUMMEil DixViliUiCLlA. i>G3 of these weeds are poisonous and their juices pass into the milk. In support of this theory Hauser gives the statistics of mortality in a number of districts in his experience, classifying them by the soil and the weeds that grow by preference on certain soils. Bacteriology. — BacteriologicaP investigation of summer diarrhoea com- menced when Escherich, in 1886, published his work on the intestinal bacteria of infants and their relation to the physiology of digestion. Lesage, Hayem, and Baginsky contributed further researches, but the most important and exhaustive researches were made by Booker from 1886 to 1897. As the result of these he called attention to three principal forms of summer diarrhoea, based on a correspondence of their clinfcal, anatom- ical, and bacteriological features: (1) dyspeptic or non-inflammatory diar- rhoea, in which the obligatory milk-faeces bacteria are found, chiefly the bacillus coli communis, the bacillus lactis aerogenes appearing in smaller numbers; (2) streptococcus gastro-enteritis, in which there is a general infection and ulceration of the intestine, with streptococci as the pre- dominating forms, some bacilli being present as well; (3) bacillary gastro- enteritis characterized by a general toxic condition with less intestinal inflammation, and the presence in the stool of several varieties of bacilli, the proteus vulgaris being the most common. Escherich studied the streptococcus cases more closely (1897-1899) and found the cocci numerous and in almost pure culture in the stools in acute, severe cases, while it was possible to isolate them from the urine and the blood during life and from the viscera after death. Clinically, the symptoms vary much in the mild and the severe cases; the stools may be watery and contain much pus and blood. Staphylococci have also been found in diarrhoeal stools, but much less frequently than streptococci. Later Escherich described cases of dysentery due to a virulent colon bacillus. Valagussa found a bacillus belonging to the colon group and identical with that isolated by Colli and Fiocca from cases in Italy and Egypt. In 1898 Shiga, in Japan, described the bacillus dysenteriae, an organism more nearly related to the typhoid than to the colon group, and Flexner found the same bacillus in one form of acute dysentery studied in Manila. Both Celli and Escherich tried to identify the bacillus they described with that of Shiga. The bacillus pyocyaneus has also been found in the stools of cases of epidemic infantile dysentery. It is evident, then, that no specific bac- terium of gastro-enteritis has been found; there is one form in which the streptococcus is the predominating organism, and the bacillus dysenteriae may possibly be proved to be the cause of epidemic dysentery both in chil- dren and in adults. Pathology. — Inflammatory lesions and ulcerations can be seen in the colon. It is rare to find the duodenum and jejunum involved. The micro- "^An editorial in Archives of Pediatrics, August, 1901. 264 DISEASES OF THE INTESTINES. scopical findings of the stool sliow numerous bacteria, epithelial cells, de- tritus, and occasionally blood. Sometimes particles of food are also seen. Symptoms. — Vomiting and diarrhoea as in the acute form are the main sjmiptoms. If an infant has just recovered from an acute milk infection and is placed on milk feeding too soon, a relapse frequently occurs, which is a subacute infection. The stools are gTeenish and resemble those de- scribed in the acute form. There is a loss of appetite, a coated tongue, and the temperature ranges between 101° and 105° F. ; at times the tempera- ture may be normal or subnormal. The infant does not want to be dis- turbed, and is very irritable. The irritation and tenesmus accompanying this diarrhoea usually cause the rectum to prolapse, and from the constant discharges of the bowel the anus and buttocks are excoriated. An eczem- atous eruption frequently is seen between the thighs. Local infection of the skin and lymphatics, by the presence of the pyogenic bacteria, some- times causes furuncles. Biag^nosis. — This is usually made when the history and symptoms are carefully noted. It is much milder than cholera infantum. The tempera- ture is lower, the vomiting less, and the prostration not so marked. Jonah W., seven months old, twin baby, bottle-fed, had been constipated since birth. There was a slight cough. The child had beaded ribs, craniotabes, and bald- ness of the occiput. Since one month he had vomiting and diarrhoea. This had improved and disappeared entirely. The child was given milk, and ten days after the milk diet was commenced the symptoms of vomiting and diarrhoea again appeared, but in a milder form. Several furuncles were found on his scalp. Owing to the intolerance of milk, whey was given in the same quantity and frequency as the milk was formerly given. Rice water, barley Avater, and thickened pea soup wei'e allowed. Toast Avater was given for thirst. Cocoa was also given without milk. The cocoa was made with rice water, in the following proportions: — IJ Cocoa 1 drachm Rice water 8 ounces Saccharine % grain Scald about five minutes. A large dose of castor oil followed by a 2-grain dose of tannopine every two hours was given. A high saline injection, 1 quart, temperature 115° F., was ordered to cleanse the rectum and colon ; also for its stimulating effect. The diagnosis of subacute milk infection, congenital syphilis, and furunculosis was made. The case recovered. Prognosis and Complications. — This depends on the condition of the child. If there is a complication such as nephritis present, then the prog- nosis is worse than if uncomplicated. If an infant can be removed to the seashore from unsanitary surroundings and proper food given, the prog- nosis is good. Treatment. — ^Two points to be considered in this condition are : First, stop all milk for at least one week and give the stomach and bowels absolute SmiMER DIARRHCEA. 265 rest. Second, cleame the stomach and howels of all offending debris which may have caused this trouble. Such cases sliould be put on a light, nutri- tious diet. The golden rule is to give the stomach and bowels absolute rest in both quality and quantity of food. The feeding interval should be longer and the amount of food reduced. In substituting other forms of feeding, pro tempore, we invariably do so at the expense of body weight. It will always be noted that children deprived of milk will lose weight unless care is taken to substitute a proper nutritious food. The body will lose to such an extent that atrophy may frequently follow. Formula for Weak Infants in Substitute Feeding. — When vomiting and diar- rhoea persist give either: — Barley water 4 ounces Rice water 4 ounces Oatmeal water 4 ounces Or: — Whey 4 ounces Feed every two or three hours. Add % of yolk of egg to each feeding. If fermentation exists — colic, greenish stools, and eructations — use saccharine, % grain, instead of sugar for sweetening. The liquid culture of the Bulgarian bacillus generates lactic acid. This liquid culture has sensed me very well in acute enterocolitis, and especially to control fermentation and colic caused by intestinal toxic bacteria. The liquid culture in drachm doses, repeated every three or four hours, is non- toxic. Older children may also have junket, cream cheese, albumin-water and expressed beef-juice. Medicinal Treatment. — A dose of castor-oil should be given at the beginning of the treatment, first to cleanse the gastro-intestinal tract, and secondly, for its constipating after-effect. Rhubarb and soda mixture in doses of one-half teaspoonful is valuable after the castor-oil has been given. The treatment described in the article on "Intoxication" should be carried out as well in this condition. The successful outcome of the case depends on proper rest, careful stimulation, and a thorough cleansing, aided by a decided change of air, to the seashore or to the mountains. Milk should not be given until all conditions appear normal. Essence of caroid in teaspoonful doses, every three hours, is serviceable. Powdered caroid combined with charcoal, in doses of 3 grains each, repeated several times a day, is very valuable. Carbolic acid is extolled by some physicians with large experience in infantile diseases. S. Henry Dessau strongly advises a 1 per cent, solution of carbolic acid as an intestinal corrective when fermentation exists. He has not seen any toxic symptoms from its use. I can fully indorse his 3(36 DISEASES OF THE INTESTINES. statement and nsually advise watching the urine during the administration of carbolized water. A teaspoonful of a 1 per cent, solution, sweetened with saccharine, can be given three or more times a day. If no effect is noticed in twentj^-four hours, then 1% or 2 teaspoonfuls can be given at each dose. I have also used creosote water, 1 per cent, solution, in the same doses as carbolized water with excellent results.^ CoiSrSTIPATION AND ChRONIC CONSTIPATION. The bowels of an infant during the nursing period should have one or two evacuations daily. Some children will be quite normal with one evacuation daily. Older children who partake of solid food suffer more frequently with constipation. There are decided peculiarities noted in children with reference to the movements of the bowels. One child will enjoy good health, have a good appetite, and will gain in weight with three or four movements of the bowels daily. Another child in equally good health will have but one movement daily. These differences or peculiarities must be taken 'into consideration before definitely maintain- ing that our patient is really constipated. The colon ascendens being very short, the surplus of length, partic- ularly as the transverse colon also is not long, belongs to the descending colon, and especially to the sigmoid flexure. Drandt found it between 8 and 24 centimeters in length, avera,ging from 14 to 20 centimeters. Jacobi saw a case in which it was 30 centimeters long. As the pelvis is very narrow, the great length of the lower part of the large intestine is the cause of multiple flexures, instead of the single sig- moid flexure of the iadult. Thus it is that, now and then, two or even three flexures are found, and to such an extent that one of them may be found to extend as far as the right side of the pelvis. Cruveilhier and Sappey speak of this position of the loAver part of the intestine in the right side of the pelvis as an anomaly. Huguier finds it on the right side of the body in the majority of cases. Others only occasionally, although they admit the great length of the sigmoid flexure. In common with Huguier, who even proposes to operate for artificial anus in the right side, Jacobi found one of the flexures on the right side many times. The great length of the large intestine and the multiplicity of its flexures are of great functional importance. At all events, they retard the movement of the intestinal content, facilitate the absorption of fluids, and thus the fseces are rendered solid. When this length is developed to an unusual extent, constipation is the natural result. Records of post-mortem observations made by Dr. T. C. Martin^ prove ^ See chapter on "Decomposition" for general treatment of Summer Diarrhoea. ^ "A Study of the Dilficulties of Defecation in Infants," by Dr. T. C. Martin, read at the forty-eighth annual meeting of the American Medical Association, June 4, 1897. CONSTIPATION. 267 ¥i". 72. — Ascending Position. Fig. 73. — Ascending Position. Fig. 74. — Transverse Position. Fig. 75. — Transverse Position. / Fig. 70. — Descending Position. Fig. 77. — Descending Position. Il>ustrations of tlie various types of abnormality of the sigmoid flexure, whicli are the source of habitual constipation in infants. (After Marfan and Neter.) 268 DISEASES OF THE INTESTINES. that the muscular development of the adult rectum and lower sigmoid is plainly apparent, and that a deficient muscularity is observable in the in- fant specimens. In the infant gut the intrinsic power of peristalsis is not present in that degree necessary to it as a competent expulsory factor. The nieso-peritoneum of these parts in the adult is, relatively, very considerably shorter than that in the infant. The adult gut is slightly tortuous; that of the infant is much angulated. Mobility and angulation of the infant gut conspire to obstruct the passage of formed faeces. The rectal valve appears to bear the same proportion to the gut in both adult and infant, but when the difference in muscular development in the two is noticed the disproportionate great resistance of the valve in the infant rectum becomes an obvious fact. Causes. — This condition is most frequently met with in bottle-fed infants. It is sometimes caused by a deficiency in the amount of sugar, or a deficiency in the amount of fat in the infant's food. An insufficient quan- tity of water in the diet is sometimes responsible. In dyspeptic or rachitic infants the peptic and intestinal glands do not perform their normal functions; this absence of intestinal glandular secre- tions is one of the main factors in the causation of this condition. In- complete peristalsis, such as exists in the rachitic debility of the muscular layer, in the muscular debility dependent upon sedentary habits and peri- tonitis, intestinal atrophy, and hydrocephalus, results in constipation. Boil- ing or sterilizing the milk fed to infants renders it constipating. Symptoms.— Some children are in apparent health; others show con- stant crying, with the legs draAvn up; flatulence and a distended abdomen are the symptoms most frequently noted. A temperature of 102° to 104° may sometimes be caused by the stagnation of f^cal matter in the intestinal tract. Loss of appetite, restlessness at night, may frequently be noted in such infants. In older children anorexia, headache, and stomachache will be described. Eructations and flatulence usually accompany constipation. Diagnosis. — Before the diagnosis of constipation is made, we must be sure to exclude pyloric stenosis, intestinal obstruction, or incarcerated her- nia as a possible cause of this condition. In like manner cystic tumors in the intestine may give rise to sj^mptoms of constipation. We must also exclude the possibility of our dealing with a case of Hirschsprung's disease. The diagnosis should not be made without bimanual examination. In most of the cases the abdomen is inflated, though it be painless. The faeces come away in small, hard lumps or in large masses. The liver and spleen are displaced. The liver may be so turned that a part of its posterior surface comes forward. The abdominal veins are enlarged to such an extent that they form circles around the umbilicus, similar to what is seen in hepatic cirrhosis. These children lose their appetite, sometimes vomit, and the irritation produced by the hardened masses in the intestinal canal CONSTIPATION. 269 may be such as to finally result in diarrhoea, which, however, is not always sufficient to empty the tract. There is, besides, an apparent constipation, which should not be mis- taken for any of the above varieties. Now and then a ehil'd will appear to be constipated, have a movement every two or three days, and at the same time the amount of faeces discharged is very small. This apparent con- stipation is seen in very young infants rather than in those of more ad- vanced age. Such children are emaciated, sometimes atrophic. They ap- pear to be constipated because of lack of food, and not infrequently this apparent constipation is relieved by a sufficient amount of nourishment. Treatment.- — Our aim should be to modify the food, if the same is at fault. It must be remembered, however, that many factors may induce coprostasis ; for example, deficiency in the tone of the intestinal muscles and insufficient peristaltic waves result in the stagnation of the intestinal con- Fig. 78. — Rubber Bulb Syringe. tents. Deficient secretions of the intestinal glands favor constipation, so also a deficient secretion of bile. The indications for the treatment of a given case of constipation de- pend upon the cause which leads thereto. If an atony of the gastro-intes- tinal tract with deficient peristalsis exists, then stimulation by means of massage should be carried out. In addition thereto nux vomica in the form of tincture should be given in 1- or 2- drop doses three times a day. For the immediate relief of constipation in an infant a glycerine or gluten suppository should be used. If this is not effectual, an injection of % pint castile-soap water should be given. When constipation per- sists, it may be necessary to give a soap-water injection every evening for many weeks. There is no danger in this procedure even though it be con- tinued for several months. When hard, dry, scybalous masses are passed and the infant strains considerably, it is advisable to inject 2 ounces of lukewarm sweet oil. with a small syringe, before the infant retires. If the buttocks are supported for several minutes after such injection, we favor the retention of the oil. Such oil injections will soften the hardened masses and favor their expul- sion the following morning. If constipation cannot be relieved by the simple methods above pro- 270 DISEASES OF THE INTESTINES. posed, it may be necessary to use a catheter inserted between six and eight inches into the colon. If we inject . about 8 ounces of warm water and % teaspoonful of the inspissated ox-gall into the colon, we will have excellfent results. Owing- to the irritating nature of the ox-gall, its use should be restricted to fever, or when the child is very ill, and we aim at a rapid evacuation of the colon and rectum. Drug Treatment. — No one should expect to cure a constipation by the use of drugs alone. There are so many factors which must be considered that drugs form but one part of the treatment. ^^sH^ Fig. 79. — Irrigator, with Tube Attached and Hard-rubber Points. For older children, a teaspoonful of maltine with cascara sagrada taken in the morning, once only, is an excellent laxative. When a large quantity of starchy food is fed, resulting in an excess of acid, calcined magnesia should be given. In rachitic and general atonic conditions % to 1 tea- spoonful of olive-oil or codliver-oil may be ordered three times a day, or aromatic albolene, 1 teaspoonful in the morning as a laxative. Dietetic Treatment. — For a very young infant, % teaspoonful of malt extract, or 1 teaspoonful of Loefflund's malt soup, may be added to each feeding. In estimating the required dose of malt soup it is impor- tant to supervise daily the frequency and character of the movements. Individual peculiarities must be considered. One infant will have an ex- cellent result from 1 teaspoonful added to the morning feeding, whereas other infants will require the same dose added to every feeding. Milk of CONSTIPATION. 271 magnesia, 1 teaspoonful given in the morning, to bottle-fed infants, dur- ing the first half-year, is an excellent corrective. The method of heating the food, the source of the milk supply, and the quantity of water given the infant are all factors to be considered when dealing with an infant suf- fering from constipation. Instead of using plain water as a diluent of the food, use oatmeal water, if constipation persists. Sometimes diluting the milk with a 5 per cent, solution of sugar of milk will relieve this condition. For infants over 1 year a small saucer of oatmeal porridge containing a drachm of butter may be tried. A teaspoonful of sugar of milk may be added to one feeding. It must be remembered that bread, potato, macaroni, and most of the carbohydrate foods have a tendency to constipate. Prunes and senna leaves stewed to a jelly in sugar and water, apple sauce, oranges, grapes, and grape jelly all have a laxative tendency. When the casein of milk is altered by the Bulgarian bacillus into a casein lactate it has a laxative tendency. All Fig. so. — Soft-rubber Rectal Tube for Irrigating the Colon. fermented milks and buttermilks loosen the bowels. One or 2 oimces of fermented milks may be given ; large quantities produce colic. Exercise. — What massage is for a young infant, exercise is for an older child. Thus, it is apparent that atonic conditions can best be relieved by combating the dietetic and medicinal treatment with out-of-door exercise. Children should be permitted to romp about and walk and play out of doors, but not to a point approaching fatigue. Older children will find bicycle exercise or horseback riding decidedly beneficial. It is important, however, to regulate the amount of such exercise, and thus it is the physician's duty to tell the mother or nurse just how long a child should be permitted to exercise. It would seem that one-half hour twice a day is ample to arrive at beneficial results. Overindulgence in such sports will frequently result in rupture and produce heart strain. In cardiac lesions, in asthmatic condi- tions, if children suffer with whooping-cougii, and in tuberculous conditions, such exercises must not be allowed. Massage. — Continued kneading of the abdomen with the aid of vase- line or oil will be found serviceable, and, if properly done, will provoke an action of the bowel. Thus it is that rubbing the abdomen with castor-oil has frequently been recommended in the treatment of constipation; the 372 DISEASES OF THE INTESTINES. effect supposed to be due to the castor-oil is, in reality, due to the massage, and to nothing else. When vibratory massage is used, it should be con- tinued from five to ten minutes every day for . one month. This will cer- tainly aid and stimulate peristalsis, and ultimately tone the muscles and cure the constipation. The hands are gently placed on the right side of the abdomen at .about the ileo-csecal region. Gentle pressure should be made; otherwise, the abdominal muscles will be tense. Commence each stroke of the massage with gentle pressure and utilize each inspiration for firmer and firmer pressure. The same method of palpation which is employed for the diagnosis of a tumor in the deep tissues should be employed. After firm pressure has been made, we can then gradually massage by a rotary move- ment, first, the ascending colon, continue over the transverse colon, and finally over the descending colon and rectum. Hardened scybala can fre- quently be felt in the region of the caecum and can be propelled by this mechanical treatment through the various portions of the colon to the rectum. Massage from five to ten minutes morning and evening may be con- tinued several weeks. If improvement is noted, then less frequent treatment is required. To be successful, several months of treatment may be neces- sary in obstinate cases. We must persist in stimulating the peristaltic waves regularly and not be disappointed if immediate results are not secured. My plan has always been to inform the parents that I do not expect any success in a chronic constipation which has persisted for months or years, until six months or more have passed. Electricity. — This is very valuable to stimulate peristalsis. The faradic, galvanic, or static current can be used. For the general practi- tioner the use of the galvanic current, five to ten cells, is sufficient. The negative pole (cathode) should be applied in the rectum, and the positive pole, which produces peristaltic waves, should be applied over the ascend- ing, descending, and transverse colon. Local contractions result from the negative pole. A gentle faradic current applied over the spine and the abdomen will answer if used for several minutes in the absence of "the galvanic current. Galvanic electricity should be used every day: fre- quently months are required to insure a cure, in conjunction with the medicinal and dietetic treatment. Hirschsprung's Disease (Dilatation of the Colon; Megacolon). Dilatation of the colon and hypertrophy of the colon may be due to muscular weakness or a partial defect in the muscles of the lower portion of the large intestine. When such condition exists there is a stagnation of fascal matter, and we have the usual products of fermentation and decom- INTESTINAL COLIC. 273 position. The latter will give rise to considerable flatulence and by reason of the muscular weakness of the intestinal walls there results a dilatation which remains permanent. There are two prominent symptoms characteristic of this disease : first, obstinate constipation, in some cases extending over many days; second, extreme abdominal distention. Some of these cases by reason of the stagnation of fa-cal matter will show loss of appetite, marked irritability, and insomnia. The urine usually contains indican. The diagnosis depends on whether or not the condition can be traced back to early infancy. It is important to differentiate this disease from ovarian tumor, cirrhosis of the liver, or abdominal cysts. The diagnosis may be grave if colitis ends in an ulcerative process. The treatment consists in abdominal massage and mild, stimulating laxatives. It is important to correct the stagnation of fiecal matter by daily injections of soap water. Surgical aid, such as resection of the intes- tine, may be demanded in the severer forms of the disease. An artificial anus has been suggested; this must be considered, however, as a temporary benefit only. Intestinal Colic (Intestinal Neuralgia; Enteralgia). Intestinal colic consists of pain which is paroxysmal in character, located in the bowel, and without evidence of inflammation. Symptoms. — Colic is one of the most frequent causes of crying in children. They not only cry loudly, but will suddenly shriek, and when put to sleep will awaken with a sudden start, and cry loudly. The legs are usually flexed or they will move their legs back and forth, or up and down. They will seem to bend the body on itself. These attacks are usually asso- ciated with constipation; hence, it is a good plan, when the child is rest- less and utters a painful cry, to see if the bowels have moved. It is well known that this colic may be as well associated with diarrhcea. The origin of all colic is certainly the feeding. When dyspeptic conditions, arising from undigested particles of food in the bowel, exist, then fermentation, resulting in gas formation, is the result. Colic is frequently, but incorrectl)'', known by the terms of "meteoris- mus" or "tympanites," but in the latter conditions the abdomen is greatly distended, and there is a permanent enlargement of it. Borborygmus (rumbling sounds) can usually be made out, if the ear is applied to the abdomen. The vast majority of cases of colic have their seat in the intestine, and can be relieved very quickly. Causes. — ^^7"orms (ascarides) have been known to cause colic. When there is a general loss of tone on the part of the muscular layers in the walls of the intestine, colic will frequently result. Jacobi believes that colic can 18 274 DISEASES OF THE INTESTINES. be caused by chronic peritonitis resulting in adhesions or local changes in the walls of the intestine that will produce local contractions or dilatations. Excess of Sugar. — When colic is caused by an excess of sugar, there will be considerable eructations of gas, and, frequently, small quantities of food will be regurgitated. The stools, when an excess of sugar is given, are thin and greenish,- smell very acid, and usualljr produce a reddened excoriation of the buttocks around the anus. When children show a tendency to the development of gas and have constant recurring colic, my plan is to discontinue the use of sugar until such time as this fermentation is absent. To sweeten the food I use small saccharine tablets, 1 grain being ample to sweeten 1 pint of food. When there is a tendency to constipation, it is possible not only to sweeten the food, but also to modify this constipation by adding a teaspoonful of malt- extract to each bottle. One-half teaspoonful of calcined magnesia added to each bottle of food will also relieve constipation. Excess of Protein. — A careful observation of the stools would easily show whether the albuminoids are in excess, for they are usually present in the form of curds. This condition is usually associated with constipa- tion, and the indication would be to cut down the quantity of protein administered. Undigested curds due to excess of protein and excessive fats are a frequent cause of colic. Irregular feeding, too frequent or over-feeding, are the commoner causes. The majority of cases of colic are seen in bottle- fed babies. This is usually due to milk which is too acid or superheated milk, as in prolonged sterilization. In the latter manner of treating milk the casein is rendered very difficult to digest, and frequently results in intestinal fermentation, causing colic. Colic in Breast-fed Babies. — -If colostrum continues and the milk does not assume normal conditions, colic may result. Colic is frequently seen during menstruation of nursing women. Pregnancy occurring during lac- tation usually causes colic. Differential Diagnosis. — We must be extremely careful to exclude the pain of intussusception, the pain from gall-stones, the pain of appendicitis, or the pain of a strangulated hernia. The absence of fever, the disappear- ance of the symptoms by the regulation of the diet, the flushing of the colon to remove the offending cheesy debris, will materially aid in strength- ening the diagnosis. Sudden cry frequently denotes earache. In infants the ears should be examined in all febrile conditions. Infant J., eleven months old, bottle-fed, cried and suffered with pain from one to two hours after taking his feeding. The temperature was 101° F., rarely higher. The infant would scream for a few minutes at a time, then expel flatus per rectum, and be apparently relieved. He would be cheerful and play for a short time, when another paroxysm of pain would come on and start him screaming again, INTESTINAL COLIC. 215 until flatus was expelled. Relief was immediately given when the rectum and colon were flushed with warm water temperature 105° F. to which several ounces of glycerine had been added. Antifermentatives, such as rhubarb and soda mixture, or several grains of calcined magnesia, invariably relieved the child and prevented intestinal fermentation. The treatment of colic is simple when the cause is known. The quick- est method of relieving colic is to give an enema of soap and w^ater or of warm chamomile tea. Take an ounce of German chamomile flowers and steep them in a quart of boiling water from ten to fifteen minutes, then strain. With the aid of a rectal tube allow 1 or 2 pints of chamomile tea at a temperature of 100° to 110° F. (no hotter) to flow slowly into the rectum and the colon. When the colon is thoroughly flushed with this warm tea, and emptied of its faeces, it is usual for the attack of colic to cease. In addition to washing the colon, it is a good plan to apply a small bag of either chamomile flowers or slippery elm bark, or ground flaxseed meal. To do this, I make a bag of cheese-cloth capable of holding from 1 to 2 ounces, and then fill it with one of the above-mentioned ingre- dients; sew the bag shut when filled, and heat it before applying to the abdomen. Several of these bags can be made and kept in readiness, so that they can be applied quickly. It is a good plan to have one heating on the stove while another is on the abdomen. These little bags are very soothing. Massage. — During an attack of colic gentle massage with warm sweet- oil or melted vaseline or lard will be very comforting to the child. The distended abdomen should then be thoroughly massaged until the gas is expelled and the warm applications applied. Drug Treatment. — If the colic originated from a fermentative dys- pepsia, then treatment must be directed to the stomach. For this purpose antifermentatives, like the mistura rhei et sod^e, should be given in doses of i/o to 1 teaspoonful, diluted with water, every two or three hours until there is a thorough evacuation. Five to 10 grains of bismuth or i/2-grain doses of resorcin will also be found useful. Paregoric in doses of 10 to 15 drops should be administered to children of six months or older. It is under- stood that no physiciaji will forget the danger of giving repeated doses of paregoric or permitting the same to be administered by incompetent persons not aware of the dangers of the drug habit. The author has not only seen distinct opium poisoning follow the use of paregoric, but has also had occa- sion to see the distinct opium habit in very young children. This was reported by me in a paper read before the New York County Medical Society, January 22, 1894.^ For an infant during the first few months, it is hardly safe to give more than 5 drops of paregoric, repeated in an hour if there is no relief. Another drug that has served me very well is Hoff- mann's anodyne in doses of from 1 to 5 drbps, repeated in an hour if ^ Published in extcnso in the Medical Record of February 17, 1894. 276 DISEASES OF THE INTESTINES. necessary. For an infant up to two months, 1 drop per dose; from two to four months, 2 drops per dose ; four to six months, 3 drops ; six to nine months and until 1 year of age, 4 drops; children from 1 to 2 years, 5 drops. This is to be given in a teaspoonful of sterilized water. Another valuable drug, and one that is to be given cautiously, and in the same doses as Hoffmann's anodyne, is spirits of chloroform; never should more than from 1 to 4 drops be given to a child up to 1 year of age, and younger children less in proportion. I cannot favor the administration of nauseating or foul-smelling drugs, such as asafoetida. We must ti^ to cater to an infant's taste, especially so when in pain. An excellent preparation to relieve colic is calcined magnesia, or milk of magnesia, made by Phillips.^ It has served the writer very well, espe- cially in young infants, where acidity was prevalent. A half-teaspoon- ful several times a day was enough in some cases, while others required several teaspoonfuls during the day. It is valuable where constipation exists, and can be added to the bottle of food. Chronic Intestinal Indigestion (Duodenal Catarrh; Mucus Disease) . This condition is always associated with a chronic derangement of the stomach. It is usually a functional disturbance and is one of the most difficult conditions to treat ia children. Etiology.— This is usually obscure, although it follows exhaustive dis- eases such as typhoid, diphtheria, or other infectious diseases. The most frequent cause is improper food, unsuited for the age and development of the child. Symptoms. — As a rule, gastro-enteritis precedes this condition for months, in each and every case. The stool shows a tendency to looseness and mucus is found covering the fgeces. The mucus is seen in shreds and masses at times covering the fsecal matter. Such children are usually backward in development. They are very irritable, tire easily, and lose in weight. As a rule, the abdomen is distended. There is no fever. The appetite varies and is poor. The liver does not functionate properly, and in some cases very little bile is secreted, giving rise to clay-colored stools. The skin is dry. ^PMllips's Milk of Magnesia — Hydrated Oxide of Magnesium (MgHjOj). — A teaspoonful of Phillips's Milk of Magnesia is equivalent in acid-neutralizing power to 4 ounces of lime water, or 10 grains of sodium bicarbonate. It will neutralize nearly twice its volume of lemon juice. Each fluidounce represents 24 grains of magnesium hydrate. Dose: From a teaspoonful to a tablespoonful, according to age — increased or diminished at discretion. Dilute with equal quantity or more of water. . . CHRONIC INTESTINAL INDIGESTION. 377 Diagnosis. — The only condition which might resemble chronic intes- tinal indigestion is general tuberculosis. The absence of cough, the ab- sence of fever, and the absence of physical signs in the lungs should help to exclude tuberculosis. The diagnosis will be more readily made when previous gastric or gastro-intestinal derangements are taken into account. Prognosis. — This is usually good, even though the»e attacks may ex- tend over years. If, however, rapid emaciation and general weakening of the heart exists, the prognosis becomes grave. Treatment. — Dietetic Treatment: This is the most important part of the treatment and requires very careful consideration. • Excessive fats and sugars should be avoided. Light meals rather than heavy should be ordered. Give predigested food if required. Whey, skimmed milk, zoolak, thin cocoa, chicken broth, beef broth, clam broth, soft-boiled egg, fish, oysters, raw scraped steak, apple sauce, baked apple, to be varied with other well-stewed fruit, should be given. Avoid all fresh bread. Eusk (zwieback) may be given. Give all green vegetables in season. Avoid all heavy cakes, pies, and puddings. If this light diet is continued for several months great improvement will be noted. The ultimate care will depend on restricting the diet to nutritious and very easily digested food. Medicinal Treatment. — Give nux vomica, 1 to 3 drops, three times a day, before meals. Or : — Ijs Acid, hydroehlor. dilut 1 ounce Five minims three times a day, after meals. Pay careful attention to the bowels; give a laxative if necessary. If severe anaemia exists then give : — IJ Tr. ferri acet. seth 1 ounce Ten drops, three times a day. One hour after meals. This has been found to be the best form of iron in the management of this condition. A girl, 8 years old, was breast-fed in infancy and appeared apparently healthy. Her dentition, walking, and talking normally developed about the end of the first year. During the second year she suffered with measles. When 4 years old she had an attack of acute milk poisoning, resulting in gastro-enteritis. From this time on she has not been in good health. She complained of headaches, nausea, and anorexia. She has a foul breath, and is very anaemic. She does not seem to thrive. The slightest imprudence in eating causes gastric symptoms. Her abdomen is large and gas is frequently expelled per rectum. She is always languid. The temperature is normal, the pulse-rate feeble; it usually ranges between 90 and 100. She does not sleep well, talks in her sleep and tosses about. Under a rigid diet, excluding pure milk, and giving diluted milk, whey, thin soups, soft-boiled eggs, and fruit, improvement was noted. The interval of feeding was restricted to five hours, so that the child was fed three times a day. A daily movement of the bowels was insisted upon. One-half teaspoonful of phosphate of soda in a teacup of warm water was given when the child was constipated. Five drops of acid hydrochloric 378 DISEASES OF THE INTESTINES. dilute was given three times a day. The case improved and the child is in a good condition to-day. Appendicitis. Appendicitis is an inflammatory condition in and about the vermiform appendix. The size of the appendix varies in infancy. Eibbert gives 3.4 centimeters as the average length, whereas Tojts found the average length .to be 5 centimeters. A characteristic of the appendix in infancy is the general richness in follicles. Fgecal concretions are rarely found in the appendix of infants and young children; this may be due to the fluid diet. The appendix usually contained parasitic ovi and mucus, besides undigested particles of food. Position of Appendix in Infancy. — The appendix is situated higher than McBumey's point. ISTo definite rule applies to the position during infancy. It may be found pointing downward into the pelvis, or it may be directly on the cecum in the right iliac fossa, or it may point upward. Cumston reports a case in which the- tip reached the right lobe of the liver. The appendix has an anatomical similarity with the tonsils. Both are composed of lymphatic tissue, and are adjacent to cavities filled with bacteria. The appendix partakes of the infiammatory process of the struc- ture with which it is intimately associated. Bacteriology. — Macaigne and Cumston found that cultures of the bac- terium coli obtained from stools of patients suffering with appendicitis were far more virulent than similar cultures from healthy subjects. The strep- tococcus in milder cases produces a serious catarrhal process. The bacillus coli is the commonest organism found in appendicitis, although the strepto- coccus is frequently associated with it. Klecki^ found that pathogenic bacteria of a most virulent type can penetrate the peritoneal cavity. This penetration is either during perfora- tion or through the lymph spaces of the damaged intestinal walls. The bacteria penetrating into the mucosa and muscularis may produce rapid necrosis of the tissue elements, the occurrence of perforation depending upon the virulence of the organism present and to some extent the position of the appendix in which gangrene occurs. In infants and very young children inflammatory processes in the appendix tend to progress rapidly, that is to say, necrosis of the mucosa and muscularis occurs promptly, so that the bacteria reach the serosa quickly before protecting adhesions bave had time to be thrown off. For this reason it was found that in 50 per cent, of cases of appendicitis in infants and young children extensive peri- tonitis developed, this being based on the combined statistics of Schiile, Rotter, Lenander, and Sonnenburg. Death is frequently caused by the toxic forms of appendicitis. The ^Annales de I'Institut Pasteur, vol. lix, p. 710. APPENDICITIS. 279 absorption of the bacterial toxins causes the body to be overwhelmed with this poison. A thrombophlebitis of the vessels of the mucosa takes place; the bacteria become attached to the tlirombi, liquefy them, and thus enter into the general circulation, producing metastatic foci in distinct organs, such as the lung, kidney, and myocardium. Thick, inflammatory adhesions always denote a previous inflammatory process. In 1867 Willard Parker, in the Medical Becord, stated that necrosis with rapid perforation of the appendix was quite frequently found in children. Pathology. — Catarrhal Appendicitis: In this form the walls of the appendix are found thickened and hypera^mic. The lumen of the tube is filled with debris of inflammation. If this inflamed condition continues, the canal may become ol)literated. The catarrhal stage frequently ends in resolution. Ulcerative Appendicitis. — In this condition the process involves the muscular coat, because the mucous and submucous tissues have been de- stroyed. The ulcer frequently terminates in perforation. Gangrenous Appendicitis. — In this condition, also known as intestinal appendicitis, rapid necrosis of all the coats of the intestine takes place. If a fsecal concretion exists and the ulcer perforates, an infection of the peri- toneal cavity takes place from the virulent bacteria. This is usually due to a thrombosis of the artery of the appendix by direct extension of the in- flammatory process in the intestine. By this means the entire nutritive supply to the organ is shut off and a rapidly progressing partial or total necrosis results. Suppuration frequently follows the serous exudation, and a localized abscess is formed. The danger of such an abscess consists in the perforation taking place and the escape of the pus into the peritoneal cavity, setting up a diffuse peritonitis. Causes. — Injury to this region, exposure to extreme cold, and overin- dulgence in purgatives have been looked upon as causative factors. Whether, foreign Bodies, such as seeds or hair swallowed by mouth, will lodge in the appendix and cause this disease is doubted by many. Cases of helminthic appendicitis have been reported in which oxyurides were found in the tip of the appendix. Pf oundler and Schlossman report a case in which a larger number of ascarides were found. Symptoms and Diagnosis. — Muscular rigidity cannot be depended upon as a symptom in children. Every young child resists an attempt to examine the abdomen. Cutaneous h5'per8ssthesia is often significant of appendicular inflammation. A sharp pain is elicited when the skin is lightly touched. Palpation of the appendix is always somewhat problematical. We may be deceived by loops of the intestine in that region, or by the psoas muscle. If the appendix is very superficial, and if it is distended by an empyema, then only can a positive diagnosis be made. 280 DISEASES OF THE INTESTINES. Pain in the right iliac fossa is rarely a prominent sj^mptom in children. Some children complain of an acute pain, neuralgic in character, in the right thigh. An abscess may appear in the left iliac fossa or in both fossae at the same time; the so-called left-sided appendicitis is a left iliac abscess. Subjective symptoms in children must always be carefully interpreted ; fear will frequently prevent complaining when an operation or a hospital has been spoken of. Localized abscess is not as frequent as a general peritonitis, nor can we make out a tumor as promptly in children as in adults. Tense abdominal walls with distention more marked on the right side would lead us to suspect an inflammation in and around the appendix. The ceecal region can be easily palpated in a child. If it is impossible to properly examine the abdomen and rectum, then an anaesthetic should be given and a proper examination made. Eectal examination is advisable in every case where an appendicitis is suspected, and where vomiting and diarrhoea are marked. Palpable resist- ance may sometimes be made out in the right pelvis. If pus has formed, a tumor surrounding the rectum can be felt. The temperature may rise as high as 105° in some cases and remain as low as 101° in other cases. It is only at the beginning of an acute inflammatory appendicitis that we will have a rise in temperature. Septic cases will frequently show a normal temperature; therefore, the temperature must not be our guide as to the necessity for an operation. The pulse is a more positive guide as to the presence of an inflammatory process; it also offers a distinct indication for an operation. A septic appendix will show its presence by an increased pulse ; thus, the pulse rate in an acute attack may vary between 90 and 100, but if resistance is poor the pulse rate may rise to 110, 120, or 130 beats per minute, and the prognosis is correspondingly bad in such a case. Vomiting is an early symptom and one that occasions considerable dis- comfort. In mild forms of the disease vomiting generally subsides. When peritonitis complicates, vomiting usually recurs. Periodical attacks of vomiting, so-called cyclic vomiting, may be a symptom of chronic appendi- citis, with interval attacks. The Bowels. — It is difficult to say whetlier constipation or diarrhoea more often accompanies these attacks. I have seen cases in which diarrhoea continued throughout the whole attack, so that my suspicion concerning typhoid continued until the localized area of inflammation formed. Fre- quently the symptoms of typhoid are so well marked that it is well to bear in mind the possibility of this disease. In other cases constipation was noted during the whole course of the disease. The diagnosis is usually not very difficult. A sudden pain localized in the right iliac fossa, associated with gastric or intestinal symptoms and APPENDICITIS. 281 fever, should render the diagnosis easy. I rely upon the examination of the blood as an important guide in determining the presence of pus in the system. ■ We must not mistake appendicitis for an abscess in the right ovary. The same can be differentiated by a careful vaginal examination. In young girls, where this is very difficult, an examination can be made with greater ease in the rectum. By means of bimanual palpation we can usually dif- ferentiate the same. Acute intestinal obstruction occurs frequently in young children. When the obstruction is due to an intussusception, bloody dis- charges from the bowels are generally present. In intussusception the tumor is found either in the median line or in the left side, whereas in ap- pendicitis it occupies the right iliac fossa. When there is a strangulated gut due to a volvulus the pain is not localized. In this form of obstruction of the bowel there is usually stercoraceous vomiting. Hip-joint disease and tuberculosis might possibly be mistaken for ap- pendicitis. There are a great many cases in which a diagnosis will only be positive after the abdomen has been opened. An important aid in the diagnosis is the examination of the blood. A marked increase in the leucocytes occurs in appendicitis, and there is a marked decrease, leucopsenia, in typhoid fever. Differential Leucocyte Count. — When the polynuclear percentage is 70 to 80, and there is a marked leucocytosis, we should suspect pus. This blood examination must be used to support the other symptoms indicating an empyema, an appendicitis, or a mastoid — in fact, any suppurative condition. In studying the leucocytes by the daily blood examination there are certain positive indications. Steadily increasing leucocjttosis demands operation. Steadily decreasing leucocytosis is a favorable symptom, and contraindicates the necessity for an operation. Course and Prognosis. — The prognosis depends on the time when treat- ment is commenced. A mild case of appendicitis may resemble colic icitli a slight rise of temperature and pass off unnoticed. If these attacks recur our suspicion should be aroused and the appendix removed. It is a good plan for the physician to call the surgeon in consultation when symptoms point to appendicitis. Very young infants do not hear laparotomy well, owing to the shock caused thereby, but if the surgeon operates rapidly shock is greatly lessened. Cases of appendicitis frequently assume a chronic course. Attacks may recur at intervals of weeks or months. If the diag- nosis is positive, it is much wiser to operate during the intervals of health rather than run the risk of a fatal complication such as peritonitis. Treatment. — First and foremost, absolute rest in bed. Until the diag- nosis is positive, the diet should be restricted to strained soups, skimmed 282 DISEASES OF THE INTESTINES. milk, and weak tea for thirst. All starchy food should be excluded; hence neither bread, cereals, nor potatoes should be permitted. The choice be- tween hot-water bags and ice-bags depends on individual experience. An ice-bag is soothing to children. The application of several leeches in 'the early stage of the disease will sometimes prove beneficial. It is of impor- tance to see that the bowels have an evacuation once or twice in each twenty-four hours. While it is desirable to have an evacuation, no active catharsis should be prescribed. Do not stir up the abdomen with drugs, as it will positively do harm. To relieve the constipation, an enema of 1 pint of soap water and 1 ounce of glycerine will evacuate the stagnant faeces. This enema may be repeated daily until the acute attack has subsided. If vomit- ing persists cracked ice and champagne may be given. The value of opium is disputed by many. It certainly relieves pain, but prevents peristalsis. My choice has been codeine, ^/jo grain, increased to ^/g grain, repeated every hour, depending on the age of the child, until the pain was relieved. If the symptoms continue in spite of the above treatment, it is pos- sible that medical treatment is insufficient. No time should be lost, but prompt surgical relief should be given. The Time to Operate. — If a child has had a series of attacks of ap- pendicitis, then it is well to operate after a thorough convalescence. This operation is termed the "interval operation.'^ During the interval between the attacks the physical condition of the patient is usually better. Great stress should be laid on what I have previously mentioned regarding the blood examination with especial reference to the leucocyte count and the percentage of polynuclear neutrophiles. If we have a high polynucleosis with a corresponding leucocytosis, then an operation is indicated. There are a few guides which may be of assistance when the blood is examined from day to day. Daily variations in the leucocyte count in a suspicious appendicitis, are doubtful. If the leucoc5?tosis is stationary, then the abscess may be walled off. If the leucocytosis increases it means a spreading abscess. When the leucocytosis declines from day to day it means a favorable course and operation may be postponed. If a general peritonitis is present operative interference must not be delayed. It is in this class of cases that we find a general septic process and in which, in addition to the local manifestations, we have a general systemic infection. Pseudo-appendicitis. In atony of the bowel we frequently have impacted faeces. In such cases I have known constipation to cause colicky pains and sudden cramps, so that the children would cry out suddenly. Eelief was quickly afforded by a high soapsuds enema, which brought away the offending masses of hardened faeces. Fever is frequently an accompaniment of constipation. PSEUDO-APPENDICITIS. 383 It is tlierefore an important matter to exclude all otlier factors l)efore resorting to extreme measures and advising an appendectomy. The fol- lowing two cases were reported by me in Pediatrics, Vol. XllI, Xo. 1, 1902 :— Case I.^Maggie W., 10 years old, was perfectly liealthy until the time of her present illness. She was suddenly attacked with pain, which was localized in the right hypochondriac region; the pain was very acute and was increased on pressure; the abdomen was distended and quite tympanitic on percussion; there was a marked dullness in the ileocaecal region ; there was an intense vomiting, the vomit containin*^ particles of food along with mucus and bile and had a very offensive odor. Tha child vomited several times in one liour and seemed to vomit whenever the pain was most acute. The mother stated tliat the child had a regular movement of the bowels once in twenty-four hours, that she had had a movement tliat day and that her appetite liad been quite good. She was a very strong and well-nourished child with no evidence of organic disease; there was no hysterical element; the child complained of no other pain but that directed to this abdominal condition ; there was a history of improper diet but no history of traumatism; the heart-sounds were normal; no murmurs were audible, the lungs were normal on percussion and auscultation; the liver did not seem to be enlarged; the spleen was jjalpable but not enlarged; the temperature was 104° F., taken in the rectum; pulse, 110; respiration, 20. When first seen an ice-bag had been applied over the most tender spot in the abdomen. Codeine in Vcrgrain doses had been administered and a liquid diet pre- scribed. The child was first seen by me abo\it twenty hours after the commencement of her illness with the above-named conditions. As this case had been seen by another colleague I was requested to meet him in consultation. The diagnosis of perityphlitic abscess had been made and an operation advised. The diagnosis was not so positive owing to the history of overeating. The child partook of many kinds of cake and pastries while celebrating a birthday, and an overloaded stomach appeared most plausible. Hence an acute catarrhal gastritis was diagnosed. The pain and tenderness in the abdomen was ascribed to a colicky condition, resulting from fermentative processes in the stomach and extending into the intestine. The indication was to cleanse the stomach and bowels as rapidly as possible and thus remove the toxsemic condition which existed. Meanwhile an operation was not con- sidered until after the above measures were used. The urine was examined and sliowed a lai'ge excess of phosphates; no albumin, no sugar, no casts, no diazo-reaction ; hence we e.xcluded typhoid. There was a very strong indican reaction and this latter strengthened the diagnosis of fermentation due to intestinal putrefaction. The Treatment. — I suggested the use of a very high enema with a long tube reaching into the colon; the enema consisting of 1 pint of glycerine diluted with 2 pints of warm water; the temperature of the same was 102° F. The enema was very effectvial and brought away .a large amount of gas. The t?mperature which, as above stated, was 104° F., fell to 102° F. within one hour and gradually returned to normal in twelve hours, although no other antipyretic measure was used. Small doses of citrate of juagnesia were ordered, a tablespoonful hourly, to quench thirst and at the same time to have a slight laxative effect. A liquid diet was continued, and thirty-six hours after the above remedies were ordered the child was in a normal condition. Case II. — A female child, about 10 years old, was seen by me through the courtesy of Dr. L. Harris, with severe abdominal symptoms. The most prominent 284 DISEASES OF THE INTESTINES. symptom was an intense pain localized in the right hypochondriac region, more espe- cially in the ileocsecal region. There was a marked distention of the whole abdomen; there was constipation and vomiting; the temperature ranged between 102° and 103° F. ; the pulse, which was 110, rose to 120. The child complained of an intense headache; in the beginning she also had a chill. The history, as given to me by Dr. Harris, was that the child had fallen from a fence on which she was standing, in tlie yard, a distance of about three feet. He believed that she had injured herself. The doctor's diagnosis was peritonitis from traumatism. In this diagnosis I con- curred. There was no distinct localized area of pain, but rather a diffused area of pain extending over the whole of the abdomen, Avhich was intensified in the immediate locality of the injury. There Avere no chills; there were no rigors; the tempera- ture rose gradually; there was no evidence of suppuration and none suspected. The child Avas placed on a carefully restricted liquid diet, consisting of broth, soup, strained gruel, milk, egg albumin in various forms and in addition thereto opium in the form of deodorized tincture was given to alleviate pain. Attention was directed to the bowel and an enema, was given to flush the rectum and colon and relieve accumulated fseces. Another colleague saw the child and diagnosed appendicitis, and suggested immediate operative treatment. I Avas again requested by the attending physician, Dr. Harris, to meet Avith this other colleague, and as a result, Ave decided not to have operative interference until Ave Avere satisfied that we were dealing with a puru- lent case. Palliative measures were used, such as ice, locally. In addition thereto the most absolute rest Avas enjoined, and the child made a brilliant recovery without an operation. We Avere satisfied that Ave Avere dealing Avith a traumatic peritonitis in which the local area of pain Avas due to the traumatism. A careful review of tlie above two cases will show that when the diag- nosis of appendicitis is made b}^ a process of exclusion then greater care should be exercised before resorting to extreme measures. In the first case the high temperature and the suddenness of the attack certainly showed marked symptoms pointing toward appendicitis. The high temperature was due ' to the toxsemic condition resulting from impacted faeces. The pain was an enteralgia due to a distended gut filled with gas. Such colicky conditions are so frequent in young infants that we could operate very frequently if the diagnosis of appendicitis were made every time an infant screams Avith pain. The cases above reported are very interesting as shoAving that cases will frequently have symptoms resembling perityphlitis or perityphlitic abscess, so that a differential diagnosis will be very hard to make. Not infrequently cases of appendicitis will be over- looked, and when such is the case, if they are of the catarrhal type, no harm will ensue therefrom. On the other hand, I must not be understood as disparaging the idea that no case of appendicitis requires an ojDeration, but my object in calling attention to these two cases is to offer a plea that before a case of supposed appendicitis is subjected to an operation, that we should be sure that all other conditions, such as impacted faeces, as in my first case, and other allied conditions have been excluded in the diagnosis. INTrSSlS( 'lOI'TION. 2-> »2 Time V Cf6f 6. «? 6 Cf % ^^^ ^^ 9 ^ n-v - rx^- :l 105*^ : : ■ i : 1 1 : : : i i : r i ; \C\-^ \\\ iotT^ ^ '"?:= i- ■ i- •A- f[ K- --»-■- ^A '^ ■ A h ^ •■ , ^ ^ -^ • ii^UU^ 12 : V ^iA ri^ •\ iV ^ '■■ i K k, ^ ; ': f^ 'i^ 'i\:-' li/^i htilM & too: I ■: M ■: f:V \> ^i ':\ 1 ^ w \^i Vi^ ^; ; i^ >V • V m^itllL f fl9 - : ^ •: « : T l/iV •: ? •: T ; : ; { .• f" S8 = -^- T-- r ^^'r -:■ -i- ^-^ J -L :-- -i-j - 4-: -:•-! J. -L - +-I- j- -:- f- J- L L-L !. i-.i. .!. .L 97": 9(?: Qjsi ■ w i ; i •; : : i i ■ i i iii. Fig. 113. — Fever Curve m Pyelonephritis. (Original.) sition of urine in the bladder or pelvis of the kidney may produce suppura- tive changes in the kidne3^s. If the dilatation of the kidney is not compli- cated by suppurative pyelitis hydronephrosis results. If it is so compli- cated, loyonephrosis is jDroduced. Klebs and others believe that bacteria have migrated to the pelvis and calices of the kidney, there to produce their destructive changes, hence the names of parasitic nephritis and pyelo- nephritis as proposed by Klebs. Lindsay Steven in a thesis on the pathology of the suppurative inflam- mations of the kidney, published in the Glasgow Medical Journal, Septem- ber, 1884, corroborates Klebs's view and expresses a decided opinion that micro-organisms are at the root of the infection, and cause the formation of multiple renal abscesses consequent on diseases of the lower urinary passages. He, however, considers that there are two ways "whereby the par- ticular virus gains access to the kidney and sets up suppuration in many different points, namely: first, by means of the uriniferous tubules, and second, by means of the lymphatics of the ureter and kidney. 378 DISEASES OF THE KIDNEY AND BLADDER. Steven shows that the lymphatics, quite independently of any other ■channel, may form the pathway of the virus from the bladder to the kidney. He admits that the two ways may be more or less combined in many cases ; so that multiple miliar}^ abscesses may originate in the same kidney, partly by the invasion of inicrococci along the ureter and uriniferous tubules, and partly by their inroad along the lymphatic tracts of the kidney. Traube and others who do not think that the bacteria themselves excite the inflammation, consider that these organisms cause the decom- position of urea into carbonate of ammonia and that this in turn excites the inflammation of the mucous membrane of the kidney. Prognosis. — The prognosis is grave and depends on the toxin caused by the presence of the pus. The outcome of the case depends on the dis- appearance of the pus in the urine, which must be watched for at times. Treatment. — A child suffering with pyelitis should be put to bed in a cool room having plenty of fresh air and sunlight. Dietetic treatment such as milk with some alkaline water is useful. ISTo solid food should be permitted. Whey, soups, broths, and fruit juices may be given. Oranges and lemons, owing to their diuretic effect, are valuable. The internal use of Eoncegno water or Wildungen water is also recommended for its diuretic effect. Diuretin, in 2 to 10-grain doses three times a day, is sometimes useful. Urotropin is a very valuable drug and serves both as a diuretic and as an internal antiseptic. The Bladder. The bladder takes up almost all of the lower portion of the abdomen, as it is capable of marked distention when filled. To make proper physical examination the bladder should be emptied by catheter. Eotch refers to a distinguished laparotomist who did not empty the bladder of a child before operating for an appendicitis ; on opening the abdominal cavity he cut directly through the walls of the bladder. The urine flowing out reminded him of his failure to appreciate the fact that in early life the bladder is essentially an abdominal organ. Ectopia Yesicje Congenitalis (Extroversion of the Bladder: Exstrophy of the Bladder). This anatomical peculiarity is due to deficient closure of the neutral laminas causing this hiatus of the abdominal wall in some cases. "The lower part of the abdominal wall, from the umbilicus or its neighborhood downward, may fail to close, and, coupled with this, there may be deficiency of the anterior wall of the bladder." This constitutes extroversion, some- KCTOIMA VESIC-E CONGENITALIS. 379 times called exstrophy of the bladder. The ureters are plainly visible and the urine dribbles continuously. 'J'he child is constantly wet and excoriated from the moisture and its irritation. 'J'he urine is passed in distinct jets or streams, and is especially noticeable when the child cries or strains. The following case was presented by me to the children's clinic of the New York Post-Gradaate Medical School and Hospital.^ A female infant, 1 year old, was seen by me. She was breast-fed and well- nonrished. Soon after birth the mother noticed a constant dribljling of urine and attention Avas directed to a swelling situated in the region of the umbilicus. The Fig. 114.— Exstrophy of the Bladder, and Prolapse of Anus. (Original.) diagnosis of exstrophy of the bladder was made. A bland ointment was prescribed to relieve the excoriation from the constant dribbling of urine. As this case required a jilastic operation it was referred to Dr. Carl Beck, at the St. Mark's Hospital, for surgical treatment. 1 This case was also presented by me at the Scientific Society of German Phy- sicians held at the residence of Dr. A. Jacobi about ten years ago. 380 DISEASES OF THE KIDNEY AND BLADDER. A child in this condition should not be operated npon until 3 or 4 years of age. Indicandria. A trace of indican is found in the urine in health. A very strong indican reaction should always be regarded as abnormal and hence it is pathological. As indican is derived from indol it signifies a product of decomposition and denotes putrefaction of the proteins. It has also been found in empyema and in extensive suppurative processes where putrefac- tion abounds. Stagnant faeces, constipation, chronic intestinal indigestion, and some forms of putrefactive diarrhoea will give a strong indican reaction. Herter has reported the presence of indican in the virine in cases of epilepsy at the time of the seizures. In the early stages of typhoid fever, when the diagnosis is doubtful, the presence of a diazo reaction and the absence of indicanuria is a valuable aid in establishing the diagnosis. Eliminative treatment such as cleansing the gastro-intestinal tract, besides reducing the amount of meat and eggs, will relieve an excess of indican (see articles on "Intestinal Indigestion"). Acetonemia. This condition is caused by the faulty assimilation of food. It is usually found in children over 2 years of age, and occurs most frequently in children between the ages of 5 and 12 years. Symptoms. — Fever ranging between 102° and 105° is usually present. There is a correspondingly increased pulse rate. Some cases show nausea or singultus, anorexia, and intense thirst. Some complain of headache, and vomit. The characteristic sweet vinegar odor, "acetone breath," is present. The urine contains acetone and usually indican. The eyes appear sunken. The child presents a typhoidal appearance. Treatment. — The diet must be restricted for twenty-four or forty-eight hours to skimmed milk or weak tea, strained soups, and fruit juices. Large doses of soda bicarb, are indicated. In severe forms of acetonuria typhoidal symptoms may be present, and, if so, an intravenous injection of soda bicarb, is indicated. The prognosis, as a rule, depends on the restriction of the diet, and on the amount of soda bicarb, given to counteract the effect of this poison. The injection of a 10 per cent, soda bicarb, solution into the colon will also aid in modifying this condition. Acetonuria. — Diacetonuria. We are indebted to Baginsky for a careful study of this condition. He found that it was present in children during epileptic attacks. It is also PYURIA. 381 found during the height of fever. He does not believe that acetonuria bears any relation to the nervous symptoms which accompany fever. Diacetonuria is very common during high fever. It is more frequently present than acetonuria. Binet, quoted by Holt, found diacetic acid in G9 out of 150 examinations in febrile diseases, chiefly in scarlet fever, measles, and pneumonia. Pyuria. "When pus is found in the urine, it gives a reaction like albumin, namely, coagulates on boiling. Pus cells, however, can be seen only by placing a drop under the microscope, using low power. While pus usually indicates pyelitis or pyelonephritis, it may exude from the ureters, the bladder, the urethra, or the vagina. Tubercular or suppurative conditions affecting the spine associated with caries of the spinal vertebrge may drain into the urinary tract. It is impor- tant, therefore, to locate the cause before treatment is commenced. Pus from the bladder is always mixed with mucus. It may be acid or alkaline in reaction. The urine containing pus due to pyelitis has an acid reaction. If the child is old enough, a cystoscopic examination should l)e made. This will aid in excluding the bladder and the ureters as a possible source of the pus. Treatment. — ^Demulcent drinks, alkaline waters, such as the Wildungen water, have a mild, diuretic effect. Salol and urotropin are the best drugs in doses of 2 to 5 grains three times a day. Milk, cereals, and fruits should be ordered ; meat and eggs prohibited. Lordotic Albuminuria (Orthostatic Albuminuria). Heubner has directed attention to the presence of albumin in the urine when children are standing erect. The albumin disappears wlien the child assumes a horizontal position ; hence albumin will be present by day, and will disappear in the urine voided at night. Jehle, of Vienna, in his monograph published in 1909, has studied this question more closely, and finds a different cause for the presence of the albumin in the urine. Pie finds that when lordosis is present, and in con- sequence the lumbar vertebrae offend the kidneys by displacement or pres- sure, albumin will at once appear in the urine. That this is no theory he shows by producing an artificial lordosis. When in the dorsal position albumin will be found in the urine and disappear wlien such pressure is removed. This presence of albumin is found in normal kidneys in which no previous scarlatinal or other forms of nephritis have existed. It is, therefore, a mechanical type of albuminuria which can be made to appear during the lordosis and to disappear when the lordosis is corrected. 582 DISEASES OF THE KIDNEY AXD BLADDER. ILematuria (Bloody Urine). IlaMiiatuiia is known by the presence of red blood-cells in the -urine. It may be due to local irritation or to systemic disease. It is therefore fre- quently met with during the course of a severe attack of acute nephritis complicating scarlet fever. A case of this kind is reported in the chapter on "Scarlet Fever." I have frequently seen hgematuria during the course of the hemorrhagic form of diphtheria while on duty at the Willard Parker Hospital. I have also seen hasmaturia in scurvy. It is important to remember that irritation caused by. a calculus in the kidney, the ureter, or the bladder may give rise to bloody urine. Direct injury to the kidney or bladder, or a tumor in the' bladder, may cause bloody urine. Tlie ge?ieral causes frequently met with arc hsemorrhagic diseases of the new-born; the blood dyscrasias, such as scurvy, purpura, and hemo- philia; and infectious diseases, particularly malaria, typhoid, variola, scar- let fever, and influenza. In most of these cases the amount of blood passed is small. When it is large it may appear in the urine as clear blood or as clots, or it may impart simply a reddish or smoky color 'to the urine. The color, however, is not a reliable guide; the best of all is the microscopic examination. For a simple chemical test guaiacum may be used (Holt). It is a difficult matter to discover the source of blood in some cases, although large haemorrhage is more apt to result from the kidneys than from the bladder. To differentiate we must rely on the presence of casts from the renal tubules; thus we can satisfy ourselves of the renal origin of the hemorrhage. The prognosis depends on the amount of hemorrhage and the general condition of the child. It should always be regarded as a bad symptom,, although not necessarily fatal. Treatment. — The application of an ice-bag or dry cups over the region of the kidneys, rest in bed, Squibb's ergot, gallic acid, 3 to 10 grains, repeated every three or four hours, or the fluid extract of hydrastis cana- densis, in 3- to 10- drop doses, for a child 2 years old, repeated every three or four hours, will sometimes do good. The food is best given either cool or very cold. If the child is old enough, small pieces of cracked ice or ice cream may be given until the blood disappears. HEMOGLOBINURIA. Instead of blood cells in the urine this condition manifests itself by the presence of hlood pigment in the urine. Sometimes the urine is blackish. Albumin may frequently be found associated with hemoglobin. The pathology of this condition is at present unknown. It is very easy to- DIABETES INSIPIDUS. 383 recognize the pigment under the microscope. It can also be noted by Heller's test. The most positive method of diagnosis is the spectroscope. Not infrequently this condition is met with in the infectious diseases, which is evidently due to the effect of the toxins generated by the specific micro-organisms causing these diseases. When an irritant poison, such as carbolic acid, is swallowed, this condition is encountered and recognized, clinically, by the familiar term "smoky urine." Paroxysmal haemoglobinuria is occasionally met with in childhood. It is usually associated with syphilis. Other cases have been reported.^ Glycosuria. The appearance of sugar in the urine is not necessarily pathological. Grosz published a series of investigations dealing with this condition. He found that glycosuria occurs in nursing infants who have either functional or inflammatory disturbances of digestion. He did not see it in perfectly healthy nursing infants. The sugar found in the urine reacts to Fehling's test; it does not respond to the fermentation test. The polariscope shows that it has the power of dextro-rotation, so that the sugar present is pos- sibly milk sugar or one of its derivatives. Artificial glycosuria can be produced by administering a large quan- tity of milk sugar in the food; hence it may be presumed that the sugar excreted in the urine is simply the excess of what could not be absorbed in the system. Glj'cosuria was frequently noted by me in the urine of children fed exclusively on Nestle's food. When this form of feeding was discontinued, the glycosuria disappeared. These cases could therefore be classified under the head of dietetic glycosuria. Diabetes Insipidus (Polyuria). This is a very rare condition in children. Its etiology is obscure, although males are more frequently attacked than females. Little is known of its origin excepting that traumatism involving the brain has been known to be followed by diabetes insipidus. The pathology of this disease is unknown. It is supposed to be a neurosis, but whether the lesion is near the fourth ventricle, or whether its seat is in the renal nerves, has not yet been determined. Symptoms. — Excessive thirst and an excess of urine constitute the main symptoms. From five to ten pints or even more may be passed in twenty- four hours. The urine looks like water and has a specific gravity from 1001 to 1005. In some cases mosite (muscle sugar) has been found (Holt). Albumin and grape sugar are not found. Urea is excreted in large quan- * Archives of Pediatrics. 384 DISEASES OF THE KIDNEY AND BLADDER. titles, whereas uric acid is not. Eestlessness by day, headache, insomnia, and marked irritability are the chief symptoms. Unilateral flushes of the face and one ear and similar vasomotor disturbances are present. There is an absence of perspiration. The skin is dry. Development is retarded, -especially growth'. The appetite remains good. The temperature may'^be subnormal. Prognosis. — The disease has been known to last years. Some cases recover spontaneously. As a rule, it is wise to give a guarded prognosis. Cases of diabetes insipidus are very susceptible to other diseases and usually die from some complication. Treatment. — A very nutritious diet consisting of milk, meat, eggs, and fruit with some restriction as to the quantity of liquid should be made. Eestoratives such as Fowler's solution, iron, and codliver-oil will sometimes •do good. When marked nervous symptoms exist, then atropine, Dover's powder, belladonna and the bromides may be tried. Change of air such as an ocean voyage or mountain air may be of benefit. Diabetes Mellitds. The pathological studies of Weiehselbaum and Opie at the Rockefeller Institute have established the relationship which the pancreas and more especially the islands of Langerhans bear to this disease. The internal secretions, notably the adrenal system, play an important part in influencing the metabolism of fat, casein, and the carbohydrates. Congenital syphilis is sometimes responsible for diabetes. Predisposition must also be con- sidered when the tendency toward family diabetes is noted. Saundby, in a report of 2011 cases of diabetes in adults and children, found only 15 occurring in .children under 5 years of age, and 58 in children under 10 years. The extreme rarity of diabetes is recognized. Acidosis is generally considered to be a result of the diabetic condition. It is probable, however, that an acid condition may have much to do with the causation of diabetes. This condition has been termed "acidsemia" — hyperacidity or, rather, hypoalkalinity of the blood. It has no connection with the term "acidosis," this latter being considered as occurring only when oxybutyric acid or its congeners (acetone or diacetic acid) are present. Acidsemia is an extremely common, everyday occurrence and, unfortunately, it is all too often overlooked in routine work. A one-sided dietary in which meats, fish, fats, etc., predominate produces organic acids, whereas a dietary of cereals, milk, vegetables, and fruits tends to maintain the normal alka- line condition by reason of the food-salts they contain in their best and most assimilable form. According to the theory of Naunyn and his school, the diminution of the alkalinity of the blood and tissues is at the root of the essential nature COLICYSTITIS. 385 of the diabetic intoxication. This they regard as a true acid poisoning, the culminating point of which is eventually diabetic coma. The carbohydrates form about one-half the diet of a growing child. The adult diet contains about one-third carbohydrates. The liver, pan- creas, and intestinal glands of the child assimilate much more carbohydrate than those of the adult. Symptoms. — The most prominent symptoms noticeable are irritability and general indisposition, increased thirst with associated polyuria. Some- times the extreme thirst and polyuria are wanting. Fever seldom occurs. Tenderness is sometimes present over the region of the pancreas. The knee-jerks are sometimes entirely absent during the height of the disease*. When a tendency toward slow healing is noted in surgical conditions, then we should suspect glycosuria. Albumin when present is a serious factor. Wegeli found that in 13 cases ending fatally albumin was present. Acetone and diacetic acid are very frequently found in infantile glycosuria. The urine may vary between 1% and 10 pints in twenty-four hours. The specific gravity varies between 1.008 and 1.050. The quantity of sugar varies between 1 and 6 per cent., depending on the time of the day and the type of food ingested. Albumin when present is usually a serious complication. Prognosis. — The prognosis is always grave. When the urine contains diacetic and oxybutyric acids the condition is more serious than when the urine contains sugar alone. Eoughly stated, the duration of the disease may be about six months, although some children linger for years. Treatment. — The body demands carbohydrates; hence the treatment should aim to secure a tolerance for carbohydrate food. Milk, oatmeal oc- casionally, cabbage, lettuce, asparagus, vegetable soups of tomato or spinach, eggs, chicken, beef, and nuts, chiefly almonds, should form the bulk of the diet. Honey contains levulose and is sometimes well borne. A school child should be removed from school and sent to the country. The method of living should be entirely changed. When acidosis is present, 10 to 15 grains of bicarbonate of soda may be given three or four times a day. Atropine, Vooo to ^/n,o grain three times a da}^, and methyl bromide, Vi2o grain, should be tried. COLICTSTITIS. We are chiefly indebted to Escherich for calling our attention to this condition. Bacteriology and Pathology. — The bacterium coli commune gives rise to this condition. The bacteria can migrate through the female urethra and set up a cystitis. When the intestinal mucous membrane is not intact, 386 DISEASES OF THE KIDNEY AND BLADDER. as, for example, in catarrhal enteritis, these bacteria can enter the bladder by migrating through the intestinal mucous membrane. Symptoms. — There is fever and irritability of the bladder shown by tenesmus. The urine contains pus, sometimes traces of albumin, and has a very foul odor. As a rule, the urine is milky or cloudy, or it may be dark in color. In some cases there may be vomiting and headache associated with pains in the bladder and in the back. Prognosis. — The prognosis is good. Treatment. — Internally, 3 to 5 grains of urotropin, several times a day, or oleum gaultheria, 1 to 3 drops, three times a day, or salol, 3- to h- grain doses, three times a day, may be given. Locally. — The bladder should be washed with a double current catheter. A weak permanganate of potash solution should be used, 3 or 4 ounces being injected at one time; this should be continued until several pints have been used. In some cases irrigations of a bichloride of mercury solu- tion, 1 to 4000, repeated several times a day, may be useful. Ueethral Calculi (Vesical Calculi; Stone in the Bladdek). This condition is extremely rare in infancy. It is not so rare in chil- dren after the third year, owing to their solid diet. Stone in the bladder is usually composed of uric acid, and is often the result of uric acid in- farction in the kidney. In this condition calculi pass from the pelvis of the kidney through the ureters and, lodge in the bladder. Sjrmptoms. — While urinating there will be a sudden cessation of the flow of urine. Pain either in the penis or in the perineum is sometimes described. As has been described (in the articles on ''^Cystitis"), whenever severe tenesmus exists,' causing prolapse of the rectum without definite in- testinal trouble, we should suspect trouble in the bladder. Incontinence of urine is sometimes present. Diagnosis. — If the child is old enough a diagnosis can sometimes be made by inserting one finger into the rectum and pressing over the bladder in the abdomen (bimanual examinatioli) . Although this method of bi- manual palpation is frequently valuable, it sometimes gives negative re- sults. The surest method is to explore the bladder with a sound. In very sensitive children cocaine may be injected into the urethra before the sound is passed. In exceptional cases, only with the aid of an ansesthetic, can a positive diagnosis be made. Treatment. — Such cases should be treated by the surgeon, although an attempt at. crushing the stone might be made. The radical operation of suprapubic lithotomy may be necessary. Very large calculi have been seen by me in the Stephanie Children's Hospital, in Buda-Pest. Professor Bokai told me that from certain districts CHRONIC CYSTITIS. 387 in Hungary they receive many cases of large vesical and urethral calculi. It is therefore quite evident that the calculi are intimately associated with the geographical conditions favoring the same. Acute Cystitis. This condition is seldom seen in children. Etiology. — It is most usually due to the invasion of pathogenic bac- teria, such as the bacterium coli and the gonococcus. It is most frequently the result of an extension of an infection from the external genitals through the urethra into the bladder, so that blenor- rhoea in children may be an exciting cause of acute cystitis. It has also been known to arise from typhoid bacilli eliminated through the kidneys by the urine. Stone in the bladder and intestinal irritants, such as turpentine or copaiba, have been known to cause cystitis. Females are more prone to this affection than males. Symptoms. — ^Very frequent desire to urinate, accompanied by pain on urination, is the principal symptom. The urine has a reddish color, but later in the disease has a light color. Its specific gravity is high. The reaction of the urine is alkaline. On standing there is a thick sediment consisting of mucus, pus, and blood. Microscopically, there are pus cor- puscles, squamous epithelium, and blood-corpuscles. In females it is neces- sary to use a catheter in drawing off the urine to obtain a specimen for examination, as the epithelium of the bladder and the vagina are strikingly similar. Prognosis. — ^This is invariably good. Treatment. — Bladder washing with mild antiseptic solutions, such as a 1 per cent, boric acid or bichloride, 1 to 5000, or a weak permanganate of potash solution, is useful in some cases. Alkaline waters, such as the White Eock, Lithia, or Appollinaris, in large quantities should be given. Internally the diet should be regulated so that the child receives milk and Seltzer, thin soups and broths, fruit and fruit juices. Meat and all spices must be avoided. Only bland articles may be permitted. Drug Treatment. — ^Urotropin, in doses of 5 to 10 grains, several times a day, is very beneficial, or Dover's powder, 1 or 2 grains, several times a day, will do good. In very high fever an ice-bag can be applied over the bladder. I Chronic Cystitis. This condition is usually associated with a malignant growth in the bladder, such as a tumor, or frequently by stone in the bladder. It may also be due to a general tuberculosis with special local manifestations in 388 DISEASES OF THE KIDXEY AND BLADDER. the bladder. Tlie composition of calculus is mainly uric acid, with large quantities of phosphates from the alkaline urine. Symptoms. — From the constant dribbling of urine the child will have an offensive urine smell resembling ammonia about him. There is an irritation around the external genitals, due to excoriation from the moisture. If stone is the cause of this condition the urine will be interrupted while passing and the child will complain of pain. The pain is difficult to localize, although it is described as being at the end of the penis. Girls will localize the pain at the meatus. From severe tenesmus there may be prolapse of the rectum. The urine resembles the urine of an acute cystitis. Tubercle bacilli are found in bladder tuberculosis. Prognosis. — This depends upon the condition of the child and on the cause of this affection. A cautious prognosis is necessary in tuberculous affection, or if a tumor exists. Treatment. — If a stone is present the treatment is surgical. Urot- ropin and salol are very valuable, and I have seen permanent benefit from their use. IJ Sodium sulpho-carbolate 25 grains Sig. : Divide into 5 powders. One powder every three hours in an alkaline water is also beneficial in some cases. Bladder washing and the diet as described in the article on "Acute Cystitis" should be employed in chronic cases. When there is a general atony of the body, then this condition will fre- quently result in the weakening of the sphincter vesicse muscle or in the spasm of the detrusor urinse muscle. Other conditions causing enuresis are lithiasis vesicalis, and where stones are suspected the bladder must he very cautiously inspected. Children that convalesce from a severe form of disease, such as typhoid fever or any long-existing febrile disorders, will usually have enuresis as a result of a general breaking down of the body wherein the muscles lose their tone. Other conditions causing irritation may be enumerated as congenital phimosis or adhesions of the prepuce, strictures of the urethra; also irrita- tions from worms, such as ascarides, commonly kno^vn as pin-worms; fis- sures of the anus; frequently also in older children masturbation and vulvitis may be considered as possible causes of this condition. (Eead article on "Lithuria.'^) Calcareous deposits in the kidney or stone in the bladder, the over- loading of the urine with lithates or phosphates, have frequently caused abnormal irritations resulting in enuresis. ENURESIS. 389 Enuresis. An involuntary emptying of the bladder during the day is known as enuresis diuma. When this condition exists at night it is known as enu- resis nocturna. Causes. — (a) Organic; (&) functional. ^ Organic Causes. — Any inflammatory condition involving the urethra or bladder, or diseases of* the brain or spinal cord, frequently cause this condition. Thiemich^ considers this condition, when occurring in a child who has been clean for months or years, and who shows no sign of organic dis- ease of the urogenital or nervous system, as a sign of that general neurosis, hysteria. In children hysteria usually occurs in a monosymptomatic form. The children who suffer from enuresis at some period usually come of a neuropathic family, and later show some other symptoms of hysteria. Functional Causes: Adenoids. — It is not infrequent to find that ob- structions of the nose and in the nasopharyngeal spaces can cause enuresis. One of the most frequent causes met with is adenoids. It is a safe rule to examine the pharyngeal vault when enuresis exists. My experience has been that over 50 per cent, of the cases of enuresis seen in my clinic have adenoid vegetations. Tight Prepuce. — If other irritations, such as a tight prepuce, exist, then circumcision must be insisted upon. If irritation exists in the urine on account of an excess of lithates or phosphates, then internal treatment must be directed toward relieving this condition. (Eead article on "Lith- semia.") Prognosis. — The prognosis of this condition is usually good. In ob- stinate cases it may be valuable to insist on a change of air ; thus, removing the patient from the city to the country or to the seashore is of value in some severe cases. Treatment. — A very bland, non-irritating diet, consisting of cereals and milk, will be indicated. All spices, alcoholics, coffee, and tea must be prohibited. Do not permit liquids to be taken before retiring. It is also important to have the bladder emptied immediately before retiring. Drug Treatment. — One of the best drugs is strychnine in doses of ^/loo grain, three times a day, gradually increased. In addition thereto small doses, V^o grain, gradually increased, of the extract of belladonna. When a general atony exists, then nothing will be better than iron given in the form of elixir of quinine, iron, and strychnine. Massage and gentle friction of the whole body, cold sponging, especially of the spine, are valu- able adjuvants to the treatment of this condition. A cold douche di- ^Berl. klin. Woch., vol. xxxviii, No. 31. 390 DISEASES OF THE KIDNEY AND BLADDER. rected to the spine, especially to the lumbar region, will be found of great assistance. Fowler's solution and iron are very valuable in weak children. For incontinence of urine, internally may be given : — IJ Ext. rhus aromaticse, fl 10 minims Syrupi aromatici 20 minims Aq. destillatse q. s. ad 1 drachm Sig.: This amount to be given three times a day\ Or:— IJ Liq. atropinse sulphatis . . .• 1% drachms Liq. strychninge hydrochloratis 45 minims Syr. aurant q. s. ad 1 ounce Sig.: For a child 14 years old, 5 drops at night; increase gradually. Younger children in proportion. Tlie Use of Electricity. — Faradic electricity applied over the bladder, and also over the lumbar region of the spine for several minutes every day, and gradually decreased to every two or three days, is of value in some cases. According to Thiemich, excellent results are obtained by means of pain- ful faradization, not necessarily of the sphincter vesicae, but of the arms, back, or thighs. Care should be taken to prevent the impression that the treatment is a punishment, but instead it should be explained that the measure is certain of success, even though painful. More than one appli- cation is rarely required if care and tact be exercised. As in all forms of hysteria, isolation and removal from home are the most potent of all remedies. Mechanical Treatment. — The passage of cold sounds and the dilatation of the urethra by this means are sometimes very effectual. Elevating the foot of the bed is of value in some cases. The child should not be allowed to sleep on its back. To prevent this position it is advisable to tie a towel around the child's body so that the knot is in the center of the back. This will awaken the child if it turns on its back and will compel it to sleep on the side. PART VI. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTER I. DISEASES OF THE NOSE AND THROAT. Acute Nasal Catarrh (Rhinitis; Coryza). Infants sneeze normally during the first few days of life, the me- chanical irritation of dust in the air being the cause of the same. The great difference between the intrauterine temperature and the temperature of the air renders the new-bom baby sensitive and invites respiratory catarrh. Etiolo^. — ^The micrococcus catarrhalis is usually found to be the cause of this condition. Weakened and delicate infants are more susceptible to the development of nasal catarrh. For this reason iafants with hereditary disease, such as syphilis, have constant catarrh. The handkerchief containing dried secretions laden with bacteria fre- quently disseminates this disease. Children who are too warmly clad and muffled are rendered more sensitive ; they are susceptible and usually suffer with rhinitis. Recurring catarrh usually indicates the presence of adenoids. The vault of the pharynx should be explored with the finger for a positive diagnosis. *■ Diagnosis. — Acute nasal catarrh must not be confounded with syph- ilitic rhinitis. The history should be carefully noted. Rhinitis is one of the earliest symptoms of measles ; hence the buccal mucous membrane should always be examined for the presence of an enanthem. If the temperature is high — 102° to 103° P. — and there is an eruption, tlien the possibility of measles should not be overlooked. In all cases of measles the pharynx and tonsils should be carefully examined. Diphtheria of the pharynx frequently has an acute rhinitis associated with it. Per- tussis is very often preceded by rhinitis. Inflammation of the lachrymal duct is at times associated, causing acute con]uncti\dtis. Sometimes the inflammation will extend through the Eustachian tube and cause otitis. In older children deafness is frequently caused by closure of the Eu- stachian tubes. Treatment. — Hygienic Treatment: Put the child to bed if there is fever, but if the temperature is normal then keep the child indoors in a (391) 392 DISEASES OF THE NOSE AND THROAT. room with a temperature of 70° F. The body should be warmly clad after having been given a good tub bath, followed by friction with a coarse Turkish towel, Ehinitis tablets, containing the following ingredients, for the prophy- lactic and general treatment of catarrh of the nose and throat, have been used by me : — ■ IJ Soda salicylate 1 grain Tinct. aconite 1 minim Tinct. belladonna ^/m minim The above quantity is for one tablet. One tablet can be given with vi'ater every three or four hours to a child 2 years old; smaller children in proportion. Fiff. 115. — Atomizer. Medicinal Treatment. — The gastro-intestinal tract requires cleansing. A drachm of castor-oil at the commencement of treatment is beneficial. The best drugs are quinine and bfelladonna given internally. The quinine chocolates, 1 grain of quinine, can be given to a child 1 year old; to an infant six months old one-half the dose. Fluid extract of belladonna, ^/^g to % minim, three times a day. Salol tablets, containing 1 grain of salol, can be given with benefit every three or four hours. Local Treatment. — A solution of adrenalin chloride, 1 to 10,000, may be used to cleanse the nostrils in very 5^oung infants. In older children a solution of 1 to 4000 may be used for the same purpose. The discharge can also be removed by irrigating with a 1 per cent, boracic acid or borax solution or a 1 per cent, table salt solution, contain- ing some glycerine, with an atomizer (see Fig. 115) or with Lefferts's poste- rior and anterior nasal syringe, followed by an alboline spray. The fol- lowing prescription is useful for the nasal toilet: — IJ Table salt 1 drachm Borax 1 drachm Water 8 ounces ACUTE NASAL CATARRH. 393 Aspirin or novaspirin in 1- to 3- grain doses every three hours, depend- ing on the age of the child, is indicated. Locally, the inunction of the following ointment in the nostrils will lessen the thickened nasal secretion. R Pulv. camphor 5 grains Pulv. acid boric 10 grains Menthol 1 grain Vaseline 1 ounce Other valuable preparations for cleansing the naso-pharyngeal spaces are Dobell's solution, borolyptol, and glycothymoline. Dobell's Solution. I^ Sodium biborate 1 drachm Sodium bicarb 1 drachm Glyc. of carb. acid 2 drachms Water to make % pint Fig. 116. — Leflferts's Posterior and Anterior Nasal Syringe. Borolyptol contains 5 per cent, acetoboroglyceride ; 0.2 per cent, for- maldehyde, in combination with the active antiseptic constituents of pinus pumilio, eucalyptus, myrrh, storax, and benzoin. This is a very bland, mildly astringent solution adapted for the naso- pharynx. I frequently use this solution as a menstruum for carbolic acid or bichloride. All solutions used in the nose should be non-irritant ; hence caustics should be avoided. Setter's Solution. IJ Sod. bicarb 1 ounce Sod. biborate 1 ounce Sod. benzoat 20 grains Sol. salicylate 20 grains Eucalyptol 10 grains Thymol 10 grains Menthol 5 grains Oil of gaultheria 6 drops Glycerine 8^/4 ounces Alcohol 2 ounces Water 16 ounces Tablets sold in shops under the name of Seller's tablets can be dis- solved in 4 ounces of water. They are of the same strength as the solution here mentioned. 594 DISEASES OF THE NOSE AND THROAT. Cocaine and eucaine, which are so valuable in adults, should not be used in children. My preference is for novocain. In older children the inhalation of equal parts of tincture of iodine and aqua ammonia every half -hour will frequently abort the disease. Dietetic Treatment. — The nursing infant should be fed at regular intervals. If bottle-fed the same regularity should be observed. No stimu- lants should be given. It is unwise to give codliver-oil or other restoratives when radical treatment is called for. Naso-phaeynge^l Cataerh Fkequently Associated with GrASTRic Catarrh. The association of naso-pharyngeal catarrh with catarrh of the stomach may at first seem .peculiar. When, however, the anatomical relationship Fig. 117. — Lenox Nasal Douche. Fig. 118. — Graduated Douche Suit- able for Older Children. of the mucous membrane of the naso-pharynx with the oesophagus and stomach are considered, an extension of the disease can easily be understood. There are certain points which have a decided bearing on the etiology of gastric catarrh when caused by naso-pharyngeal disease. Such are: — 1. The fact that children rarely, infants never, expectorate. When they have post-nasal catarrh and there is an irritation from mucous or muco- purulent secretion infants invariably swallow the same. It is for this reason that the old-fashioned dose of ipecac or castor-oil was given, not to relieve the cough nor to hasten the expectoration, but rather to cleanse the stomach from non-expectorated secretion. 2. Loss of Appetite. — The loss of appetite, usually associated with se- vere naso-pharyngeal catarrh in which the stomach has been normal up to the beginning of the attack, is usually due to the swallowing of large quan- tities of this infectious secretion. INFLUENZA. 395 The benefit derived from curing a cold witli a dose of castor-oil simply means removing some of the swallowed muco-purulent secretion from the stomach which should have been expectorated. When catarrhal disease affecting the naso-pharyngcal space is muco- purulent and contiiiues for a long time in very young infants, we can easily see why the loss of appetite may be the means of causing deficient nutri- tion. Such cases may end fatally. The importance of attending to diseases in the naso-pharynx can be seen when it is considered that diphtheria can spread from the pharynx to the oesophagus, and also to the stomach. While it is true that diphtheritic gastritis is reported very rarely, it is well to bear such cases in mind, for they show the great danger to the stomach from an infectious catarrh located at the food entrance. There is usually a deficiency of hydrochloric acid secretion in all severe catarrhal diseases. This is most apparent in those febrile conditions which accom- pany diphtheria. It is for this reason that it is not very difficult for the stomach to be -the seat of an infection if diphtheritic membrane is swallowed. It is of the greatest importance to have every child's throat in a nor- mal condition. Adenoid vegetations and diseased tonsils favor the devel- opment of malignant disease. The vast majority of patients who are infected with diphtheria owe this infection to the diseased state of their throat, which favors the development of pathogenic bacteria. This can as easily be verified in children as in adults. It is rare to find a case of diph- theria in which a previous normal throat existed. Hence it would seem plausible to eradicate all trifling as well as serious nose and throat disease, and aim to secure a healthy state if ive are to ward off infections. Influenza (La Grippe). Commonly known as "grip" or "epidemic catarrhal fever.". This is an acute infectious disease with which catarrhal disturbances of the respiratory or gastro-intestinal organs are usually associated. There is also a profound nervous disturbance with marked perspiration and very high fever. The disease occurs epidemically, spreading from case to case with great rapidity, so that it was formerly attributed to meteorologic condi- tions. It is for this reason known and described by the Germans as a •'Blitzkatarrh." The disease occurs most frequently in cold and damp weather, and frequently attacks the same person several times. Bacteriology. — -The disease is caused by a very small bacillus, about 0.8 micro-millimeter long and 0.4 micro-millimeter broad. This bacillus was first discovered by Pfeiffer, in 1892. It stains very intensely at the ends and resembles a diplococcus. 396 DISEASES OF THE NOSE AND THROAT. In the mucous membrane of the nose, throat, and lungs we find the greatest number of bacilli; thus, it is reasonable to suppose that the in- fection takes place through the respiratory tract, and in this manner the germs gain an entrance into the body. The bacillus of PfeifEer only is present in influenza. The poison gen- erated by this germ resembles a group of bacterial proteins, described by Buchner. Such poisons occur within germs and are excreted, but only to a limited extent, in the media in which they groAv. Examples of these germs are the diphtheria and tetanus bacilli. Such toxins affect the cen- tral nervous system very powerfully. Thus we find severe nervous depres- sion in the course of an attack of influenza, just as we do in the course Fig. 119. — Influenza Bacilli. Sputum smear, stained with dilute ZieM's solution. Bacilli chiefly intracellular; most of them show thickened ends. X800. (Lenhartz-Brool<;s.) of a severe case of diphtheria. The influenza bacillus is frequently asso- ciated with other pyogenic bacteria. The tendency of mixed infection in the course of influenza is to generate pus. It is therefore a wise plan to examine the middle ear for possible suppurative conditions. Not infrequently tuberculosis is associated with or follows a severe attack of influenza. Symptoms. — When children are old enough to complain, then one of the most frequent subjective symptoms will be either a violent headache or pains in the muscles of the body. In young children and nurslings violent vomiting, associated with diarrhoea, may be the initial symptoms of the disease. While fever usually accompanies an attack of influenza, there are many cases in which a subnormal temperature is present. As has been previously stated, chills or rigors are seldom or never present. Convulsions in young children are frequently a forerunner of an attack INFLUENZA. 397 of influenza. The differential diag- nosis between an attack of measles and influenza is sometimes quite difficult. Both commence with sneezing, coughing, and catarrhal symptoms, with suffused eyes, and an eruption resembling measles may frequently be found in influenza. Diagnosis. — The diagnosis of this disease is sometimes very diffi- cult. If an epidemic exists, or if several members in a family are at- tacked with grip and the children suddenly exhibit symptoms of ma- laise or have a disordered stomach, and show high fever without any apparent reason, then influenza should be suspected. If catarrhal symptoms associated with influenza present themselves, then such symp- toms are of a more severe type than those usually seen in simple coryza. An eruption resembling scarlet fever, complicated by tonsillitis or pharyngeal symptoms, will baffle the diagnostic ability of the physician, but the presence of influenza in a house will aid in eliminating other diseases and assist in establishing the true diagnosis. Not infrequently a child will suddenly show high fever and diarrhoea, with severe nervous depression, intense thirst, and ty- phoid tongue, with hei'e and there small lenticular spots which may so resemble typhoid fever that only the course of the disease and constant watching will aid in making a cor- rect diagnosis. Where such sj^mp- toms exist we must resort to an examination of the urine, and it is here that the diazo reaction will render material assistance. In ad- Bdte. 1 / 1 ^ L5 U 1 .'J k 1 -/ 1 160 150 140 130 120 1 ^ MEMEMEiV IEM,E|(V!,EME \ ."C) 1 1 I 1 CiA." =. — —. — , 1 lU^.ot.. ' A / _ll_ irta° II 1 tt \ ± , IT 1 . ... u 102° \ M \\J^ t 1 _i t: i t t t ioi° ^ X 1 4--A -A h- A^ t V- t -t \ C -A t -iA t. X 4 X 1/ ioo° - ± 7 3 3 n T i\ / , r A\y , ^ t ftvf t t QQ° W A-. ^ 99 ij n ^ , 3 A CI 4 V T A Ofl° I -J »e t: T V t J t A A i- H Vl^ ~^ Q 4 b C SI 97° I tt ^ ^:>» **' I » r r it «;5 t-^ ^ Ji H n L ejO t -J JL AS ttt ^^ tT 1 ttit TT J-4 it 11 □ AO ^ n 4U 1 \ 1 II 4 tz It , IT 35 T i V I t T T tt ± t t I^ t E 30 It t\ - C\,c\^ v'S\\?.Qx?> - ^W ^A.PL\\^ °' « ' >^\\.\■\\\\?,■C\0..(^?^p\^t^ Vy C^\^c\\0-Y■^'^ P.^^^'\'\t^•n^ (\, ^ ^Ky(\\\\?,^ *?V\\(\\\5X \0|%- 190 'V ^ >\. ' DATES OF OBSERVATIONS *5 ' Rua. V9 (LO 1\ u v^ v\ (L5 %x M n i") 30 3\ r 1 3 ■^ 5 b 1 s 9 10 \\, SI Cent. ■fo*''- m.m m.m uH.m »»:pi« m:m AMiPM am:fm m-m A»i:pi« AWlPM am:pm am;pm ak:pm am:pm AMIPM am:pm m'.m ASiPH am:pw ai>:pm ah:pm •m:pm am:pm am:pm am:pm e Z 39'" 3S-- 37"- ■m'-l '■ \ 106* -2 ■ (XKX i-yt XX X; X- 101 ■! • :■ -103 ■! • I; \\ N .7 yi i 5: i V \: :/ sj A \A '■■/ f\ \ '■ ■j \ '■ :/ \\ V V S/ i A M V-' A A A ioo'-3 • V V \ /■ \^ nown de- 434 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. pressing effect upon the heart. The author has never used them without seeing an ill effect. When they are used they should be combined with camphor or musk to counteract this well-known depression. The safest antipyretic measure in pulmonic affections is undoubtedly hydrotherapy. A cold compress applied over the thorax and repeated once every half -hour, not only acts as an antipyretic, but will stimulate the respiratory muscles and provoke deep inspirations. This will distend the smaller portions of the alveoli and will prevent atalectasis pulmonum. If there is very great Fig. 137. — Diagram lor Pneumonia Jacket Opened at Side. Fig. 138. — Diagram for Pneumonia Jacket Opene^ in Front. (Original.) dyspnoea owing to the presence of viscid secretions, then an emetic is indi- cated. One of our best emetics is sulphate of copper in 1-grain doses, re- peated in an hour if necessary. Another emetic and one which is less irritating than the above is syr. scillse comp. in I/2 to 1 teaspoonful doses, repeated every half-hour until the desired effect is produced. Syrup of ipecac in doses of one teaspoonful, repeated every fifteen to twenty minutes, is also serviceable. When a child has extreme dyspnoea and it is not wise to administer an emetic by mouth, then a hypodermic injection of V20 grain of apomorphia dissolved in five or ten minims of sterile water injected deeply into the subcutaneous cellular tissue will usually provoke emesis. If this dose is not effectual in fifteen or twenty minutes, then another BRONCHO-PNEUMOKIA. 435 dose of apomorphia may be given. Tartar emetic in closes of V/,o grain, in sweetened water, may be given every hour until vomiting is produced. It is better not to change from one drug to another unless several doses have proven ineffectual. Flaxseed poultices are sometimes recommended when the secretions are very viscid. These have frequently proven efficacious in the hands of the author. In urgent dyspnoea great relief can be afforded by the appli- cation of dry cups over the affected areas of the lungs. A pneumonia jacket consisting of cheese cloth, which is worn next to the skin, then a layer of cotton-wool, and the whole covered with oiled silk or oiled muslin will serve to prevent chilling of the surface. Figs. 137 and 138' show diagrams of these jackets. Internal diffusible stimulations, such as %-grain doses of carbonate of ammonia, repeated every hour, are serviceable. Liq. ammon. anisati, in doses of from 3 to 10 drops, repeated every hour, is one of our best dif- fusible stimulants. If symptoms of collapse appear then active alcoholic stimulation must be resorted to, such, for example, as champagne, brandy, whisky, or wine ad lihitum. In addition' thereto, a sinapism over the front and back of the chest and mustard foot baths may be required. Hypo- dermic medication will frequently be found necessary, especially if the heart's action is feeble. One two-hundredth of a grain of nitro-glycerine injected hypodermically or caffeine citrate will sometimes work well. Strychnine sulphate in doses of ^/goo grain, gradually increased, repeated every three or four hours or oftener, will stimulate the heart's action. An excellent heart stimulant is to give 1 drop of tincture of musk every hour. If the cough is very troublesome, especially at night, and the child is in a fair physical condition, then codeine in doses of ^/oq to ^/k, grain for a child 1 year old, repeated every two or three hours, will relieve. Dionin is a remedy that has been used by the writer with considerable success in the treatment of various forms of cough in doses of ^/^o grain, repeated every three or four hours, for a child 1 year old. Stimulating expectorants such as syrup of senega, in doses of from 10 to 15 minims, may be advantageous. The vital point to remember is to support the system with nourishment. If the child will not take food per mouth, then rectal feeding consisting of nutrient enemas is demanded. Water should be given freely during the course of a broncho-pneumonia to stimulate the action of the kidneys. Pleukisy. An inflammation of the pleura is by no means rare in children. It is found very frequently post-mortem, although no evidence of the same existed intra vitam. It may be a primary condition. There are two distinct forms of pleurisy usually seen: 1. Pleuritis 436 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. sicca (dry pleurisy). 2, Pleuritis exudativa. The latter form. can .again be divided into (a) serous^ (&) sero-purulent, (c) purulent^, (d) lisemor- rhagic. The last mentioned is a rare condition. It is seen in traumatic con- ditions, in haemophilia, and occasionally when tuberculosis, is present. Dey Pleurisy. This form of pleurisy usually follows an exposure to cold, although it may follow as a secondary inflammation to the lung. There is usually an exudation of fibrin only. ^a\\o\\^\^e.O^'b^ Fig. 139. — Fever Curve in a Case of Dry Pleurisy. (Original.) Pathology. — The pleura is swollen and thickened, and there is an exu- dation of fibrin. Adhesions frequently result from these bands of fibrin between the opposite ^pleural surfaces. The pleura loses its natural luster. When the process ceases and the lymph is absorbed, the condition is called "dry pleurisy." The,, fibrinous bands between the pleura costalis and pul- monalis usually leave permanent adhesions. Symptoms. — The disease is usually ushered in with high fever, which may reach 104°' or 105° F. Cough is usually present. It is a short, hack- ing, irritating cough. It is accompanied with pain. As a rule, children cry during each coughing paroxysm. A characteristic symptom often noted is that a child suffering with pleurisy usually places its hand over the affected area during a coughing paroxysm. This lends support to the ribs and relieves pain. There is no expectoration. A friction sound or a fine, crepi- tant rale is heard over the affected area. There is vesicular breathing. The I'LKL'KISV WITH KFKLSIUN. 437 percussion is rarely abnormal. The tongue is usually coated. The bowels are constipated. The urine is scanty. The surface of the body is dry and warm. There is usually a gradual increasing dyspncea. The pulse-rate is increased; so also are the respirations. The symptoms resemble those of a pneumonia and can rarely be differentiated without a careful physical examination. There is usually pain on percussion over the affected area. The children do not wish to be handled, but prefer to lie quietly. The dia^osis depends on the symptoms above described. We must bear in mind the frequency with which pulmonary complications are asso- ciated. The prognosis is usually good, although adhesions frequently remain. Treatment. — Counter-irritation, such as cupping of the chest, the application of iodine over the affected area, or painting with cantharidal collodion, acts well. Strapping the chest with broad straps of adhesive plaster or the application of a very tight fitting bandage seems to sup- port the chest and relieve the cough. Calomel is indicated, especially if constipation accompanies this condition. Iodide of sodium, with very small doses of codeine, may be given at regular intervals to relieve pain. A full dose of codeine or morphine may be given at night if the cough is distress- ing or the pain acute. I have given from Vso to ^/oo grain of morphine hypodermically to a child 3 years old to relieve a severe cough. Pleupisy with Effusion (Pleuritis Exudativa). This secondary form of pleurisy is usually a complication or an exten- sion of the- infection in pneumonia. It is frequently met with in influenza and in infectious diseases. I have frequently seen pleurisy with effusion in the scarlet fever wards of the Eiverside Hospital. I have also seen pleu- risy complicating tuberculosis and rheumatism in children. Bacteriology. — In some cases the streptococcus, in others the staphy- lococcus, is present. A diplococcus has also been found and believed by some to be the cause of pleuritis. The pneumococcus has been found pres- ent, so that it is difficult to state which pathogenic microbe is the true cause of this condition. Whether this microbe gains entrance to the pleura from the lung by inhalation or through the skin, or whether the tonsil is the means of entrance of the pathogenic bacteria causing this disease, has not been definitely determined. We know that suppuration in other parts of the body, as, for example, in the abdomen or in the spine, can frequently carry microbic elements to the pleura and thus directly transmit the infec- tion. Pyogenic bacteria may be carried to the pleura through the lymph channels and by the circulation. ,^ - Pathology. — This form of exudative pleurisy is the one most frequently encountered. We rarely find both sides involved, although a double pleu- 488 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. iOZL r ULL UU21 99' 4 5? \:>oj\ <5\\b\s^<>.'^^ Hi S?^ 9fC// Wil a(3'(^(j(i ^h 7 IS n v. Fig. 140. — Fever Curve in a Case of Pleurisy with EflFusion. (Original.) risy is by no means rare. The pathological condition is practically the same as described in the chapter on "Dry Pleurisy." In this condition we have more or less serous effusion. The serum may be clear, it may be bloody, or it may be turbid. Serous effusions found in a healthy child are usually absorbed. Adhesions are frequently left in this form of pleurisy. Symptoms. — The fever may be high or low. Fever and general malaise accom- panied by a hacking cough will frequently be the only symptoms. I have frequently seen children brought to my clinic with the history of a cougli, no expectoration^ anorexia, with general weakness and ema- ciation, in whom a pleurisy with a large effusion was detected. Diagnosis. — The diag- nosis in very young children is at times difficult. It can only be made by a most careful physical examination of the chest. Physical Signs. — Before the effusion is marked, and during its absorp- tion friction sounds are heard over the inflamed area. After the effusion is present there are no friction sounds. There are an absence of rales, dis- tant bronchial breathing, and flatness on percussion. There is diminished breathing, so that the voice or the cry of the child will appear very distant. At the level of the fluid the voice has a tremulous sound, known as cegophony. There is a bulging of the intercostal spaces. The breathing is bronchial or tubular. Not infrequently the heart is displaced. A careful inspection of the chest will show that there is a loss of motion on the affected side during respiration. In some cases the diagnosis depends on the result of an exploratory puncture with a clean (aseptic) needle having a large caliber. One of the best needles for this purpose is one similar to that used for the injection of antitoxin. A puncture should be made after washing the skin with soap and water followed by alcohol or ether. The needle is then inserted about one inch. Sometimes it is necessary to make several exploratory punctures in order to find the liquid, especially so in the encapsulated form of pleurisy, where a small area is involved. After withdrawing the liquid the character of the same should be determined by examining it under the microscope. If pus corpuscles are found we should insist on an operation. EMPYEMA. 439 as no other Ireatnicnt will be satisfactory. Not infrequently a serous effu- sion will be al)sorbe(l by the exploratory puncture, so that the puncture is at times a very valuable therapeutic adjunct. Treatment. — Firm strapping of the chest with bands of adhesive plaster is useful; 5- to 15- grain doses of iodide of sodium, according to age, may be administered three times a day in milk, soup, or broth. Fresh air should be constantly permitted. If pain is absent gentle, but long inspirations and expirations (pulmonary gymnastics) are worth trying. By properly exercising the lungs we can stimulate nutrition to the parts and frequently assist in the absorption of an effusion. Fig. 141. — Diagrammatic Illustration of Heart and Lungs in a Left- sided Pleuritic Effusion, a. Heart, h. Compressed lung, area of bronchial breathing and crepitant rales, c. Effusion. (Original.) Dietetic Treatment. — N"o matter what form of treatment is instituted, nothing will avail so much as proper feeding. The dairy products — milk, eggs, and cheese — in conjunction with cereals and fruits, should form the bulk of the food ordered. Concentrated soups and broths are also useful. Empyema (Purulent Pleurisy). Etiology. — As a rule we find this disease following pneumonia or pleu- risy. It 18 a favorite complication of the infectious diseases, so that after a pneumonia in an acute infectious disease we must not be surprised to find an empyema. 440' DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. '..::■•. Bacteriology. — The bacteria most frequently found are the strepto- coccus; the staphylococcus, and the pneumococcus. Earely has the tubercle bacillus been found. - Pathology. — The surface of the pleura is covered with fibrin and pus and the cavity filled with a purulent exudate, the result of this inflamma- tio'H;:''" The piis settles to the bottom of the pleural sac. ::. ■■ Not infrequently both pleurae become involved, although the rule is to find but one pleura or part of it affected. When not treated the pus may rupture. into the Inng or burrow externally through an intercostal space. Symptoms. — The most pronounced symptoms are flatness on percussion and diminished respiratory sounds. Sometimes they are totally absent. There is also a loss of the vocal fremitus. At the level of the fluid the voice has a tremulous quality known as cegophony. Above the fluid the breathing is broncho-vesicular due to the com- pressed lung. Pleurothotonos is sometimes seen. There is an absence of expansion of the chest on the affected side. When this condition exists, on the left side it may displace the heart. / rely upon the examination of the hlood, in. addition to the physical signs given, as an important guid.e-'in determining the presence of pus in the system.. See.': article and illustration of "Blood Reaction of Pus" in the chapter on "BloO^d." Diagnosis. — ilf the fever continues after a ease of pneumonia, or pain in the chest persists accompanied by dypsnoea, cough, and sweats, then empyema should be suspected. W^hen the disease progresses the temperature frequently returns to normal or nearly so. The child shows symptoms of general exhaustion, emaciation, and is extremely anemic. Diarrhoea is a frequent sym.ptom in this condition. .Th-e physical signs above noted are usually positive. AVhen there is any idoubt, and in order to confirm the sj^mptoms pointing to an empyema, an exploratory puncture should be made. If the needle is sterile and sharp and the surface to be punctured is rendered-aseptic, then there is no risk in making one or more punctures to aid in^ establishing the diagnosis. , •;, Choice as to Where the Needle is to he Introduced. — My plan has always been -to find by percussion the area having the greatest dullness or flatness, and insert the needle after noting the following : — Points to he Noted ivhile Making an Exploratory Puncture. — The skin should be washed with soap and water, dried, and again washed with alcohol, and lastly with ether; The needle should be boiled about five minutes before being used. ; ,;:. I| the needle is introduced on the right side, due allowance must be made for dullness in the region occupied by the liver. Do not introduce. EMPYEMA. 441 the needle too near the region of the spine, l)ut choose rather an intercostal space in the axillary line or preferahly below the scapula on either side. If the needle is introduced on the left side do not push it too forcibly nor too deeply or hfeniorrhage may result. Sometimes the fluid is fibrinous and will not readily enter the caliber of the needle. If the needle is plunged too far and enters a dilated bronchus, due jillovvance must be made for a purulent seciction. wliich slioidd not bo niisliikcn lor oni[)y('ma. Fig. 142. — Illustrating a Severe Localized, Right-sided Empyema. Two ribs were resected. _ The child made a complete recovery. The thorax shows very slight deformity after the operation. (Original.) Prognosis. — ^I'his depends upon the general condition at the time of the operation. If the tubercle bacillus is found in the pus the prognosis is bad. The longer the disease existed the more doubtful the prognosis. If the condition is a sequela to a pneumonia or a pleurisy then the prognosis is good. Course. — The tendency of empyema in a child is to recovery. Out of 20 cases operated by me, 18 recovered in four to five weeks. One case recovered after six months of continued surgical treatment, and was op- erated three times. One case was ill over tw^o years, tubercle bacilli being found. This case belonged to the tuberculous type of empyema. 443 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Surgical Treatment. — When pus is located, the indication is to remove it. After painting the area with tincture of iodine an incision should be made at least two inches long through the skin, and parallel with the rib. If the pus is thin in character a simple intercostal incision carried into the pleura will evacuate the same. If the pus contains fibrinous coagula, it is better to resect one or two ribs. Care must be taken to preserve the periosteum in resecting the ribs. By this latter method we have complete drainage, and if the case is treated on general aseptic principles with drainage, gauze, and restorative treatment, the outcome is usually good. Points to be noted in empyema cases : — 1. Ancesthetic. — Do not use general anaesthesia if cyanosis, marked dyspnoea, or other severe toxic symptoms are present. Local angesthesia, such as chloride of ethyl or cocaine, can be used. I have frequently operated with the aid of chloride of ethyl. 2. Regarding Antisepsis. — When pus is located we must resort to the usual details of asepsis and antisepsis. The instruments should be rendered thoroughly aseptic and the child should be given a bath on the day of operation in addition to a thorough scrubbing of the seat of operation. The physician, if a general practitioner, should not operate if he has been in contact with an acute infectious case; neither should he operate if he has a case of erysipelas or diphtheria under his care. While pus is being evacuated, turn the child from side to side, to empty the pleural cavity. If the heart's action is poor this should not be done. A large-sized drainage tube should be inserted into the wound. The pleural cavity should not be washed with any fluid. It is important to have a cross-section of rubber tube or a large safety pin attached to the drain- age tube ; otherwise, as has already happened, the tube may be lost in the cavity. Excepting when large coagula are present, as in pneumococcus empyema, the syphon drainage (Kenyon method) may be recommended. This form of drainage is especially indicated in streptococcus empyema; however, this type is extremely rare in children. A male child, 4 years old, was brought to my office by Dr. M. Freid, with the following clinical history: The child's appetite is poor. He does not sleep well, and has a peculiar waddling gait. The left shoulder blade protrudes so that a decided deformity is noticeable. There was no further history. An examination of the child showed marked emaciation. Temperature lOOVs" F., pulse 120, respiration 38, breathing labored, heart sounds weak but clear. On percussion there was marked dullness and flatness over the central and upper lobe of the lung on the left side. An exploratory puncture made about the eighth inter- costal space showed pus. Owing to the weakened state of the child, it was necessary to operate without an anfesthetic. Ethyl chloride was used, an incision made, and two ribs resected. Thorough drainage was maintained with the aid of a drainage tube, and, with the addition of restorative treatment, the case made an uneventful recovery. CHRONIC EMPYEMA. 44:} Treatment. — The treatment consists in building up the system with tonics of iron, hypophosphites, codliver-oi], malt, sea-salt bathing, and fresh air, in addition to a nutritious diet, of which milk, eggs, and cereals should form the bulk. Stimulation will be urgently required. In other words, our aim should be to build up the body to withstand the shock of the operation, and at the same time to nourish and restore the general weakened condition. After-treatment. — Strict asepsis. Change dressings daily. Use clean drainage tube and fresh gauze. Eemember the danger of iodoform poison- ing in using large strips of iodoform gauze. Give nutritious food. Sometimes a change of air to the mountain? or seashore will aid in recovery. Fig. 14.3. — James Apparatus for Expanding the Lungs in Empyema. Eemember that 10 per cent, of all cases in which a simple incision is made do not require after-treatment. Ninety per cent, of cases require resection of the ribs and frequently additional surgical treatment for chronic empyema. James Apparatus. — Pulmonary gymnastics, such as inspiration and expiration, should be frequently practised to aid in the expansion of the iung after an operation for empyema. A clever device is known as the James apparatus, by which a colored liquid can be blown from one bottle into another. This may be given to the child as a toy, and is very valuable as a means of producing deep inspiration and expiration. Chronic Empyema. Neglected cases or those of long standing frequently require additional treatment. Adhesions will frequently form, preventing the normal expan- sion of the lung. A small opening or sinus containing exuberant granula- tions will be seen. In some cases seen by me pus has oozed for months. In a case of this kind nothing will do as well as a radical operation such as 444 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Estlander recommended (thoracoplasty). The adhesions must be broken up and thorough drainage allowed. When such a radical operation is per- formed, deformity usually follows. These cases belong to the surgeon. TUBERCULAK EMPYEMA. This condition, while rare, has been seen by me twice during the last five years. It is found in families where tuberculosis exists. We must bear in mind that a tubercular empyema may be the complication of what was formerly a non-tubercular type. Environment and heredity play an important part in the etiology of this condition. Just as a tuberculosis may follow the broncho-pneumonia of measles, so I believe that tubercular empyema may also develop. The following case will illustrate this condition as seen by me in consultation in New York City: — ■ M. J., 5 years old, ^Yas referred to be by Dr. Mehreiilander, with a history of cough, fever, and emaciation. The diagnosis of empyema was made and an exploratory puncture showed the presence of pus. With the assistance of Dr. Mehrenlander I performed a thoracotomy. As there were thick, croupous masses, two ribs were resected and a drainage tube inserted. In this case the wound discharged several months and an examination of the pus showed the presence of tubercle bacilli. With the aid of fresh air and restoratives, such as codliver-oil, creosote carbonate, and special attention to the out-door life, the child recovered. Family History. — The child's father and mother are living. Their occupation is janitor and janitress in a tenement, house. They receive in compensation for services free rent, so that gives them very unsanitary surroundings. The bedrooms are dark and very unsanitary. An older brother, 17 years of age, has acute apical tuberculosis. This older brother when brought to me for a slight cough showed no visible evidence of disease; in fact, he appeared well nourished. His sputum con- tained tubercle bacilli. We therefore have in the two cases just described a tuber- cular empyema associated with family tuberculosis. The coexistence of empyema and a family history of tuberculosis strengthened my opinion that, living under the same unsanitary conditions and associating together, these cases were most probably transmitted or communicated. The excellent results which have been reported during the last few years by the treatment with an artificial pneumothorax, and the injections of nitrogen, lend encouragement in the treatment of this fatal disease. Erom my own experience I strongly favor this method in every case in which tuberculosis exists. PART VII. THE INFECTIOUS DISEASES. CHAPTKiJ 1, FEVER.' This is a pathological process generally caused by the poisonous prod- ucts of bacteria, and characterized by a rise of temperature above the limit of the daily variation. It is further associated with an increase in the fre- quency of the heart and the respiratory movements, often with an increase in excretion of urea and ammonia in the urine and a diminution in the •alkalies and CO2 in the blood. - Some authors state that the cause of fever is the action of bacterial poison or of other substances on the heat centers, and that antipyretics or drugs which reduce the temperature in fever, do so by restoring the centers to their normal state by preventing the development of the poisons, aiding their elimination, or antagonizing their action. Thus it has been stated (supporting the latter view) that if the basal ganglia have been cut off (by section of the pons) from their lower nervous connections, fever is no longer produced by injection of cultures of bacteria which readily cause it in an intact animal — while antipyrine has no influence on the temperature. These experiments were reported by Sawadowski. Some observers have been unable to find any clear evidence of heat centers ; that is, of localized portions of the central nervous system specially concerned in the regulation of the body temperature. It is almost certain that some pyrogenic or fever-producing agent — cocaine, for example — acts indirectly through the brain or cord, and likely others affect directly the activity of the tissues in general, just as -some antip3Tetics or fever-reducing agents, such as quinine, seem to act imme- diately upon the heat-forming tissues, while antipyrine affects them through the nervous system. Variations in Temperature.^ — The temperature of the body is not con- stant. It varies with the time of day, with eating, with age, somewhat with violent changes in the external temperature (hot or cold baths), and even possibly with sex. ' For treatment of fever, see pages 474 and 475. -Stewart's Physiologj-. p. 44,*^. Article on "Animal Heat." 'The temperature as a diagnostic aid is described in Part I, page 11. (445) 446 THE INFECTIOUS DISEASES. The lowest temperature is recorded between 2 and 6 a.m. The highest at 5 to 8 P.M. There is a corresponding fluctuation of pulse-rate at the same time of day. Taking of food increases the temperature, but not more than one-half of a degree in healthy individuals. Entrance of food into the body in- creases metabolic activity, no doubt through entrance of products of diges- tion into the blood. Sex. — Females usually have higher temperature than males. Relation of Age to Temperature. — There is a relative imperfection between heat regulation in old people and young children; thus, young children are more liable to sudden increase in temperature as well as to chills. A fit of crying will send up the temperature. Sudden fright (slam- ming a door) will send up the temperature (J. L. Smith). Mosso reports that the rectal temperature rose three degrees in a dog rendered helpless with injections of curare. When injections of strychnine were given, this latter (strychnine) no doubt irritated the nervous system. He found that the presence of food was enough to cause the rise in the temperature of the dog. Thus we find that the usual fever-causing factors are : — 1. Toxins. 2. Ferments. 3. Products of waste which are absorbed in the lymphatics (detritus). We know that the regulation of the heat is brought about by the cen- tral nervous system, and we also know the influence brought about by the vasomotor (nervous) system in dilating and contracting the capillaries. The discovery of Aronsohn and Sachs, that by traumatism or irritation of the corpus striatum, an elevation of temperature is produced, is still a question, doubted by many distiiiguished observers. But it certainly does look as though a certain center or centers exist which influence the body temperature. Knowing then that other agencies besides disease ' cause an elevated temperature, the question arises : Are we justified in designating every rise of temperature as "fever"? Hardly. An elevation of temperature (above normal) should be designated as "hyperthermia." We know that the fever is caused by the absorption of infectious products which later cause a breaking down and loss of the red blood-corpuscles, breaking down of the tissues, and disintegration of albumin and its compounds, and produce symptoms pointing to distinct disorders in the human economy. Some authors have described fever under two headings or divisions : — 1. Septic. 2. Aseptic. As an example of a septic fever, we have that chronic poisoning of the human organism which takes place in chronic pulmonary tuberculosis, and FEVER. 447 even in this latter toxaemic process we find sudden rises of temperature, which must be explained by emotional means, or rather by nervous causes. In a tuberculous patient whose system is overwhelmed with toxins (chronic and continuous poisoning) we can readily understand why the thermic centers as well as all other centers could be easily influenced to cause a sudden rise in temperature responding to a slight emotion or fright. Let us now consider so-called "nervous" or, as it has been designated, "hysterical fever." The latter term we owe to the French authors (Pomme, Toussot, Baillon, Eiviere). By this we mean a febrile condition which is not caused by any inflammatory or other disease agency, and which is found in either very nervous, neurasthenic, or hysterical patients. Broussois (France) opposed this theory and believed this condition due chiefly to inflammatory changes in the ovary and uterus. Briquet showed by careful examination the fallacy of the foregoing statements in a series of noteworthy investigations. In 1888 Chaveau, in Paris, wrote a careful dissertation called "Fievre Hysterique," and divided this condition into several distinct groups. A characteristic point is the absence of gastric disturbance (digestive), show- ing that it was not a malignant disturbance. Chaveau looked to the cause of his cases in an abnormal excitation of the thermic center in sensitive (nervous) individuals. An accompanying factor he believes to be either traumatic or psychic disturbances. Wunderlich (Germany) long ago called attention to the fact that hysteria influences the temperature, and that in hysterical neurosis we find sudden elevations of temperature. It is a remarkable fact and one noted by many others that one side of the body shows this high temperature without any pathological condition manifesting itself. Rosenthal (Vienna) found distinct localized areas of redness with marked rise of temperature in this area, but found no general febrile disturbance. The patient was decidedly hysterical. Strumpell agrees that he has found very high temperatures, irregularly, but believes the patients simulated their marked hysterical and irritable condition. Ewald (Berlin) agrees that hysterical patients can produce high fever by reason of their excitement. Hale White (England) doubts that the thermogenetic functions should cause high fever, and cites instances which were known as hysterical paralysis. Cleman reported in the Clinical Society of London, 1883, a case of hysterical fever showing the enormous temperature of 111° F. at various times. Hale White believed that a mistake in reading the thermometer was made. 448 THE INFECTIOUS DISEASES. i 1 C4 CD- 'S « St e4 3 o 5 eo ■4 M 1 M>a •Sag 1 to 2 1 eo ii a* I" S eo 2 <» 1^ 1^ CO 1 jl 1 •hIII '5' a ^• (B HJD IH OS t>.3 3 C4 « WWW P5 II § i 1 a • il 3 1 1 5 2 a 03 3 I-? § s 1 1 o d -a bo a 'P. 5 .2|. ■SsS ^•ja S ft ?S30 o c? ^ 5|.3 fl o 1 "St i -fl ^ Mm ■as .9 m a-^ o a ^ O -•a O £ 3 ■ .3 . .2 - -fl 3 fc^ *3 1* fl:;; 0.2^ Oj3 ago W « fl s 2 a. a f 2 w c3 t^ a O c3 a ■» " fl 0) " S 1 .f4 9 S O .'-' o.T.g. ^ J; CS O >, <» 'a, '■' " *3 •e 1-3.2 g S§^5^ Pill pa ,S o« H-£ "-iS 3 fm-: 3 5 3 a-a §2 g2 II ** ft 1! C4 o Ph 3 .fl fl go " 60 fl h a a f j3 MOO '^ .2 Si > 3 Mr « §2 S fl-a n ^_ "-S CJ2.S ^ a >^ S S -3 a O (D o to e4 10 CO (U c3 m o^a • (-. ce -3 2 Lungs. Heart. Kidneys. Ears. Brain. Paralysis. (D oj .a teMW a .2 WO a 3 II S.a II a 2 .a ■3 Sore throat, weakness, lever. Pain on swallowing. Older children complain of headache. ^s§Sa bo; aj4 1 a 60 a •§ Br- os «l £2 d ■*^ 'S ^ '2 ils2 C3 C— > 2 111 '^ m c a WS-3 bb .2rf is » 3 5 ci m bbs* 2.2 5 n 03 tea o ^a-s. §2 .1 ° (u a c a5^g .2 ^^ Is C5 00.2, 3 ^ CJ T ;r a a „. c B.9 3 bo c . ■3 a .0 -3 v.. a'i Si a = K i-(0 I'r-E^oS §'2 -£332* if s a =3tj^ ^ . g 9 3 S-.S >. 5-3 omr;-3_SiE'3bO gL.C!^,03O.2»-oa: tj >>^ .„ c ■= - r « r'; = = a .- ii !< .'^ .H S a 0.3 •w a> 2; > bo- = Z c ^ a." ^■5bi2 5 " > a> 1 O s .3 a) CO 2 -3 1*. -3 10 CO C3 -a 5 "al t» . c ce c 'ir. a "3 .a 1. Q ft 0- a' bO 3 5 1 5 3 2 3 < 00 g «1 'u 5 03 a "v 450 THE INFECTIOUS DISEASES. Ughetti believes hysterical fevers exist, and cites, as proof of the same, fever in course of hysteria, chorea, epilepsy, and Basedow's disease. The greatest scientific contribution on this subject has certainly been the work of A. Sarbo in the University of Psychiatrie and Nervous Dis- eases in Budapest.^ He believes as a result of experimental study that the causation of fever should be looked forward to in the "central nervous system,'' and that the experimental discoveries of the thermic and vaso- motor centers seem to confirm this. This author believes that fever which has no organic lesion as a cause should be called functional fever, which is a condition found in hysteria, the latter a functional neurosis. It is interesting to record that Debone increased the temperature by suggestion to 101.2° F., or 38.5° C. Krafft-Ebing records temperatures by suggestion as high as 106.4° F. Sarbo concludes by saying that from his clinical observations a distinct hysterical fever exists. Hysterical fever can simulate by its exacerbation and remission such diseases as typhoid, malaria, tuberculosis, and meningitis. Some years ago much was expected from the antipyretic drugs — antl- pyrin, acetanilid, and phenacetin; and if it could have been shown that they distinctly improved the condition of the fevered patient it would have been a strong argument against the view that pyrexia is a defensive mech- anism. When fever arises and a distinct diagnosis cannot be made, the child should be put on the expectant plan of treatmerd. This will consist in cleansing the gastro-intestinal tract, regulating the diet, and noting symp- toms as they arise.' This is especially indicated when we believe the case to be, in the period of incubation, of an infectious disease. At such times the following recipe is a good antipyretic and will not depress the heart : — IJ Sweet spirit of niter 1% flui drachms Citrate of potassium 30 grains Syrup of lemon 4 fluidrachms Aquse q. s. ad 2 fluidounees A teaspoonful every three hours, for child 1 year old, I am indebted to Dr. William H. Guilfoy, Eegistrar of the New York Health Department, for many courtesies in the preparation of the statis- tics of the various infectious diseases. Bacterial Vaccines.^ The vaccine treatment of disease in children has many advocates. There are very many instances in which specific results may be attained ; on ^Published in the Archiv fiir Psychiatrie in 1891. ^ These vaccines are prepared in the Sherman laboratories of Detroit, and in the Mulford laboratories of Philadelphia. BACTERIAL VACCINES. 45 1 the otiier hand, we should not be disappointed when we meet with failures. The following class of cases lend themselves to this form of treatment: — How to Procure an Autogenous Vaccine. — Clean the surface of the skin with alcohol or tincture of iodine. Make a small incision with a sterile bistoury into the furuncle and remove 1 drop of pus, to inoculate the surface of a blood-serum culture tube. Send to a laboratory to be placed in an incubator. From thirty-six to forty-eight hours' time is required to have a vaccine made. Stock Vaccine. — If too remote from a laboratory, a stock vaccine of the staphylococcus variety may be used with excellent results. Local infections, as well as general systemic infections with fever, do not contraindicate the use of these vaccines. They may be injected regard- less of the temperature. Surgical treatment, and general systemic treatment of the bowels, kidneys, etc., should be continued just as though no vaccine had been used. Streptococcus infections from the pleural cavity, as in empyema, or from the middle ear in acute otitis have been treated with vaccines. The consensus of opinion found amongst competent clinical observers^ is that the streptococcus vaccine has not the specific virtues, nor does the vaccine give the same benefit, obtained from the staphylococcus vaccine. An injection of 50,000,000 to 500,000,000 dead bacteria is usually given. Of all vaccine therapy, the most brilliant results have been obtained with autogenous vaccines or stock vaccine of staphylococci; hence, in those diseases which owe their origin to a staphylococcus, vaccines should be used. In chronic suppurative processes in which subnormal conditions prevail, vaccine therapy will stimulate j)hagocytosis and thus aid in restoring normal conditions. In multiple fnrunculosis, in acne, and in otitis media due to the staphylococcus, vaccine should be used. In post-operative emp3-ema with low vitality and tendency to run a long course, vaccine therapy is iiidicated. In suppuration of the antrum of Highmore, or in recurring styes caused l)y staphylococci, vaccine therapy should be used. An injection of 50,000,000 bacteria constitutes the initial dose. The part is cleansed by tincture of iodine, and the injection given subcutaneously. Another injection of 50,000,000 bacteria should be given after three to five days, and if no improvement is noted at the end of ten days, then a third injection of 100,000,000 bacteria should be given. General Furunculosis. — ^A child 10 years of age was brought to my office with a series of furuncles that required incision. They healed after four or five days. Then new ones appeared. Surgical treatment was re- quired. In all, over a dozen had developed. I decided to have an autogenous ^ Howlaiul and Hoobler, Archives of Pediatrics, Sept., 1910. 452 THE INFECTIOUS DISEASES. vaccine made. The pns was examined and proved to be staphylococcus pyogenes aureus. An injection of a vaccine containing 500,000;,000 bacteria was given. These injections were repeated every other day until five were given. The child quickly recovered. These injections checked the develop- ment of new furuncles. Gronococcus Vaccine. — Injections of 50,000,00 to 100,000,000 bacteria of the gonococcus vaccine have been given by me daily until ten injections were given. No systemic reaction followed. The discharge lessened in some cases, it disappeared in others. The gonococcus however persisted. Typhoid Vaccine. — An injection of 25,000,000 typhoid bacilli may be given to a child, and repeated in one week, unless a severe reaction is noted. If fever occurs, wait ten days to two weeks before giving the second injec- tion. A third injection of 50,000,000 bacteria should be given ten days after the reaction following the second injection has subsided. Pertussis. — I have had excellent results with' the vaccine made from cultures of the Bordet-Gengou bacillus, by the Health Department of New York City.^ As a prophylactic three subcutaneous injections are usually given, one every third day. Children, 500 million, 1000 million and 2000 million; adults, 1000 million, 2000 million and 3000 million. For curative purposes, four to five injections are usually given, one every second or third day. Children under one year should receive 250 million, 500 million, 1000 million, 1500 million, 2000 million. Children over 1 year, 500 million, 1000 million, 2000 million and repeat last dose. As a rule this is sufficient, but, if no result is obtained, further injections may be tried as well as larger doses. A local reaction may occur and is without significance, disappearing in 24 hours. A general reaction, which is rare, would indicate that the inter- vals between injection should be lengthened and dose more gradually increased. Erysipelas Vaccine. — ^My results with vaccine treatment in erysipelas are excellent. I have seen a severe erysipelas improve after an injection of 50,000,000 bacteria the first day, 75,000,000 the second day, and 100,000,000 the third day. In profound toxemia with temperature ranging between 103 and 105 degrees I have injected from 50,000,000 to 100,000,000 bacteria of the erysipelas vaccine in an infant 1 year old.^ The dose was repeated every other day. Five doses in all were given. Streptococcus Tonsillitis. — G-ive an injection of 50,000,000 bacteria. If no reaction follows, repeat the dose on the following day. If no improve- ment is noted, give 100,000,000 bacteria on the third day. ^Vaccine furnished by the courtesy of Dr. Krumwied. ^ See clinical case in article on Erysipelas. BACTERIAL VACCINES. 453 B-abies Vaccine. — The Pasteur treatment has now been simplified and can be administered at home by simple vaccine injections. When a child has been bitten by a dog, no time should be lost, but the treatment imme- diately begun. The daily dose for injection is contained in an ampule. The treatment should be continued for twenty-one days. The New York Health Department sends out treatment by mail to physicians for their own patients. Full directions are sent in the mailing "'"' lltt^-^ >/.- ? V ^Z6«/VJ OlSEASt ^^ (y 19?-^. DATES OF OBSERVATIONS | ^^ / r 9 /d // /Z /3 /^ ^f /i n /r // J.0 ^/ .^^ ^3 -2^ -2^ ' Cent. hahr. aMTM AM ta AMiPM am:pm« m:pm am:pm am:pm Mn'm AM.'PM AM^PM AMiPM AM.'PM AM :pM am:ph am:pm|am:pm'am:pm ah:pm|am:pm>m:pmam:pm| 41° ~ ISf' inc '■ 2 los'-s ■1CH°"S : A l^'^ m'' 33'" ■to':! / /) ,/ Va 1 M ^^ ^A •102°-«! • ^ / ' J V ¥ V ir ^A 101°''' ■ t J V; ■a- v^ 1/ »»< ^ J ^: :fc ■n K: y l^ ■ \M '• ■'J • 3 V V:-^ t :\ : : • 3 \: W'~ ^OS"-! h^. - m Cor'-! ^• ^re \Ji '■ fl. V PuUe pcrml„„:> 1 ! 1$ ^^ v\^ i^? ^1t 1? ^1 (> ;^i^ '^l K 5' ^1? V,l^ ^Is, !l 1 1 Eapimtiona pcrmtnute i 1 1 * 1 ^ 1 1 ^{■^ ^rr> ^1 ^ :^; d^ ;^ 1 W :^: 1^ 1^ ■ 1 ^ 1 1 UrInM SZ: — — — — — — ^~ — — — — — — — — — JuJet^.^^ <>»»x2^''^^ *^£/t♦ m f— ' — — T'"' H 1 jy|-K 1 m 1 — ^ N ^ s 3 s ^ p ^ ^ ^ ^ 1 3 ^ ^ ^ 1 3 s ^ 1 .. E±S ~ — 1 ■ t==l 3^=:^ 1 — ' i 1 s n Eg 1 ^ s = ^ =J =a ^ i F= =ra 1 = 1 1 t= PULSt - ~ liar. 0*TO» Ot«(ASC 8 9 10 11 12 13 14 lb lb 1/ 18 19 20 21 22 23 24 25 1 Fig. 1.51. — Fever curve during the early period of Chronic Pulmonary Tuberculosis. The daily excursions are slight, and generally range between 102° and 104° F. (Original.) Fig. 1.52. — Temperature curve during the fifth month, when the disease is more extended and softening has taken place with the formation of cavi- ties. The temperature is more hectic in character. The morning tempera- ture may be normal or subnormal, while the evening temperature ranges between 103° and 105° F. (Original.) Pathology. — Osier states that small cavities are by no means rare in chronic pulmonary tuberculosis of children, but very large excavations are rare; thus in 265 cases noted by Barthez and Sanne there were 77 cases (479) 480 THE INFECTIOUS DISEASES. with excavation, chiefly in the upper lobes. In the analysis by Leroux of the cases of the late Parrot, in 219 children under 2 years of age, there were 57 instances in which cavities existed. In five of these the children were under three months. In long-standing cases hard, firm, fibrous tubercles are found, and sometimes cutaneous nodules. The pri- Fig. 153. — Chronic Nodular Tuberculous Broncho-pneumonia, {a, h, c, d) tuberculous foci of variable size and shape, corresponding to the in- filtrated alveolar system; (e) transverse section through an infiltrated occluded bronchiole; (f ) small arterial branch; (g) group of nodules under- going coalescence; (h) small unaltered bronchus; (fc) artery. X 6. (Ziegler.) mary lesion in a great majority of instances is a tuberculous broncho- pneumonia, taking its origin in the smaller bronchioles, leading to peri- bronchial nodules and subsequent peribronchial alveolitis. The lesions are similar to those met with in tuberculosis of adults — miliary tubercles, J)eribronchial nodules, caseous blocks, areas of softening and of fibroid induration, and cavities of various sizes. We do not see so frequently the PULMONARY TUBERCULOSIS. 481 invasion of the lung from the apex downward. The chief seat of disease may be in the central portion of the lung, or even at the base. In. tuber- culosis of the lymph glands the groups along the trachea and about the bronchi may be greatly enlarged and caseous, forming on section a very striking feature in the chronic pulmonary tuberculosis of children. Symptoms. — Chronic pulmonary tuberculosis in the child presents the same symptoms as in the adult. Usually a broncho-pneumonia will first be encountered, or the symptoms present will resemble those of a broncho- pneumonia. When fever persists and there are evidences of a general breakdown, such as malaise, loss of appetite, and emaciation with or with- out cough, then this condition must be suspected. When these children expectorate, the same resembles that seen in adults. Tubercle bacilli have frequently been found in the expectoration of cases under my care. Blood spitting in which the mucus is blood-stained has been seen by me. The blood is bright red in color. Epistaxis is sometimes seen during the course of the disease. The temperature ranges between 100° and 103° F. in the beginning of the disease; later on it assumes the real hectic character; thus, the temperature may be 99° to 100° F. in the morning, and 103° to 105° F. in the evening. Pleuritic pains are complained of in various parts of the chest. There is marked dyspnoea and frequently cyanosis. Osier states that some cases do not have any pain throughout the course of the disease. A general emaciation associated with muscular weakness and anaemia is usually seen later in the disease. Tubercular ulceration, of the intestine will frequently cause diarrhoea. In a child seen by me with chronic tuberculosis of the lungs, a general anasarca was present. Katie B., 8 years old, has been a very delicate child. She was breast- and bottle- fed, and lived in a tenement house. Family History. — 'The father was a drunkard and did not support his family; the mother is a frail, ansemic woman, although no evidence of pulmonary disease could be found. The child was late in walking, late in teething, and late in talking. Distinct evidence of rickets of the bones was everywhere noted. When 4 years old the child had measles, complicated with broncho-pneumonia, after which a cough remained. Tliree months after the measles the child still coughed and showed evidences of malnutrition. The cough persisted in spite of codliver-oil, malt extract, and iron, which were liberally given. As the family was poor, they could not take the child to the country for a complete change of air. I did not see the case again for two years, when I saw it through the courtesy of Dr. John H. Wurthman. At this time she had a cavitj^ at the apex of the right lung, was terribly emaciated, and complained of pain on breathing and suffered with marked dyspnoea. Pleuritic friction sounds were heard over small areas of the chest on both sides. The child had haemoptysis, besides a purulent expectoration. Tubercle bacilli were fouaid in the sputum. She died after a violent haemorrhage, from exhaustion and heart-failure. The treatment is the same as described for acute tuberculosis. 31 483 THE INFECTIOUS DISEASES. Pulmonary Gangrene. This condition^ fortunately, is very rare. Diagnosis. — This is made by the characteristic foul odor of the breath and the expectorated gangrenous material. I have seen a case of this kind during- my summer service at the Willard Parker Hospital in a child that suffered with laryngeal diphtheria complicated by broncho-pneumonia. The septic condition dragged on for weeks. There was a very putrid odor to the breath. The child finally died of sepsis. As a rule the diagnosis can only be made post-mortem. Treatment. — Eestorative treatment, consisting of light, nutritious diet, should be given and stimulants liberally used. Steam inhalations impreg- nated with beechwood creosote will modify the odor. Creosote carbonate can be given with the food in 5- to 10- minim doses, several times a day. CHAPTER Y. ACUTE TUBERCULOSIS (MILIARY TUBERCULOSIS ).i Tuberculosis is a specific infectious disease caused by invasion of the tubercle bacillus. The disease is disseminated by the same. Etiology. — Acute miliary tuberculosis is frequently seen in very young children. I have seen cases in bottle-fed infants under 1 year of age. It is' also frequently associated with tubercular meningitis. As a rule it fol- lows those diseases which devitalize the system, such as the acute infec- tious diseases. In prolonged diseases affecting the air passages, tubercu- losis frequently follows. Cows' Milk. — The majority of cases of tuberculosis are found in chil- dren brought up by artificial feeding. This implies that such children received cows' milk. The dangers of infection by or with the tubercle bacillus can usually be excluded inasmuch as nearly every woman boils the milk. The more modern woman of to-day, instead of boiling cows' milk, submits the food to a steaming process, either by using a sterilizer or a pasteurizer. The result is the same, namely, the destruction of pathogenic bacteria of all kind, including the tubercle bacillus. Such artificial feeding with cows' milk frequently results in gastro-intestinal derangement. Dys- peptic attacks rob the system of food required for the nutrition of bone, muscle and other organic structures. When such conditions persist then poor foundations are formed, resulting in rickets or marasmus. The tuber- cle bacillus easily gains entrance where subnormal conditions prevail, and secures a foothold that ultimately develops tuberculosis. Woman's Milk. — Human milk is intended by nature for the nutrition of infants. It offers decided prophylactic substances to the nurslings, for exajnple: . the nursing infant is very rarely afflicted with diphtheria or similar infectious diseases. This is most probably due to the immunity conferred by human serum and the antibodies or bacteriolysins which the serum contains during the nursing period. This also accounts for the rarity of pulmonaiy tuberculosis in children reared on woman's milk. The value of human milk has frequently been noted by me while studying this question in a children's clinic patronized by people living in the most con- gested district of New York City. The statistics of my cases of tuberculosis from the children's service of the German Poliklinik in New York City are very interesting. Five thousand children were examined at random for the presence of tubercular '■Tuberculosis of the bones, joints, and glands are described under separate articles. (483) 484 THE INFECTIOUS DISEASES. lesions. More than 4900 cases out of this number showed no sign of pul- monary disease; 1700 of these cases suffered with adenoids, phar^^ngeal disease, catarrh of the naso-pharyngeal tract, or infectious conditions due to poor ventilation and general unsanitary surroundings. The cases were taken in children from the first to the tenth year inclusive; 59 cases out of this whole number showed distinct evidence of pulmonary tuberculosis. Only 9 cases of this whole number showed the presence of tubercle bacilli in the sputum. The difficulty in procuring sputum' was an obstacle in making niore frequent examinations. Forty-three cases of this number had bone and joint tuberculosis in addition to evidences in the lungs. In two cases tubercular empyema was found. Five of these 59 cases had Pott's disease. Table No. 43. — Table showing Manner of Feeding in 59 Consecutive Cases of Tuberculosis, among the Poor. Manner of Feeding. Number of Cases. Breast milk (human milk) 2 Cows' milk 37 Condensed milk 18 Modified milk (laboratory) 2 ' Tuberculosis in children is so closely allied to scrofulosis that a great many authors believe them to be identical. There certainly are a great many characteristics common to both. On the other hand a close scrutiny of the pathology of the disease will show them to be distinctly separate. That scrofulosis will frequently be the medium through which, later on, tuberculosis develops, is well known and recognized. "In the tuberculosis of the new-born evidence shows that the maternal ovum may be infected from the mother, or by the paternal seminal fluid; later the embryo may be infected by the placental route or amniotic fluid when the mother is tubercular. These modes of infection, while theoretic- ally possible and occasionally actually authenticated, are nevertheless ex- tremely infrequent in practice. By whichever of the above-mentioned routes the bacillus has gained entrance to the foetal organism, there is no doubt that it may invade it and remain latent therein for an indefinite period. Unless the bacilli are actually found within the tissues, it is ex- tremely difficult to uphold the view that the infection has not been acquired after birth." The influence of raw meat on the evolution of experimental tubercu- losis has been described by Chantemesse and Cornil. Kichet and Hericourt published experiments showing the beneficial effects of raw meat in tuberculosis of dogs. Their observations were open to the objection that the quantity of meat given was not measured, and that the good effect obtained might have been due merely to the fact TLTBERCULOSIS. 485 that the dogs preferred larger quantities of raw meat than they would have eaten of boiled. To exclude this influence the following experiments were made. Six couples of dogs, each of the same weight and appearance, were taken. One of each couple was fed with boiled meat to satiety, the other was given an equivalent quantity of raw meat. Both were inoculated in the vein of the leg with tuberculosis. The dogs fed with boiled meat died at intervals varying from three weeks to four months. The necropsies showed general tuberculosis, more or less voluminous caseous granulations, and advanced fatty degeneration of the liver. Those fed on raw meat were killed at the same time. They were all plump ; they showed less numerous tubercles than did the others, and less voluminous and less caseous granu- lations. In another experiment a dog was inoculated with tuberculosis and given 750 grams daily of raw meat. He preserved his strength, weight, and healthy appearance. He was killed at the end of twelve months. The necropsies showed a small number of tubercles in the viscera and tuber- cular interstitial nephritis. He was on the way to recovery. Two monkeys were inoculated with tuberculosis. One was fed on the ordinary diet, and died at the end of 33 days of general tuberculosis; the other was fed on raw meat for 15 days before the innoculation, and lived for 49 days. Chantemesse and Cornil therefore conclude that the utility of raw meat diet in tuberculosis consisted not in overfeeding, hut in the anti-tubercidous quality of the diet. The transmissibility of tuberculosis by means of drinking milk from cows whose udders are tuberculous, is admitted by a great many authors. Behring believes that milk infection remains latent for years and then develops ti;berculosis. This he states accounts for the absence of the dis- ease in very young infants. Koch is authority for the statement that "bovine tuberculosis is an entirely different disease from human tuberculosis, and cannot be trans- mitted from a cotu to a human being." "Westenhoeffer believes that caries of the teeth and inflamed gums, as seen during dentition, permit the invasion of the tubercle bacillus into the lymph channels of the neck, resulting in cervical, bronchial, retrosternal, tracheo-bronchial, and finally mesenteric tuberculosis.^ Chiari, of Vienna, and Freudenthal. of Xew York, believe that the retropharynx which harbors adenoids is the point of entrance of the tubercle infection. This view has always been held by me, inasmuch as tubercular meningitis results most probably from an extension upward from the pliaryn.v, and downward, the infection enters through the cervical glands. Contact of the delicate, perhaps abraded, skin or mucous membrane ^Berlin Klin. Woch.. February 15. 1904. 486 THE INFECTIOUS DISEASES. of the young infant with tuberculous sputum may result in inoculation, as has been reiDeatedly shown in connection with ritual circumcision. The interesting observations of Lehmann show that sucking the wound after the ritual circumcision of Jewish children has caused tuberculosis. Baginsky reports a case of the transmission of tuberculosis to the eyebrow of a child by a tuberculous person. That tuberculosis may be transmitted by the process of vaccination on the arm cannot be disputed. There must be a certain disposition or predisposition to the develop- ment of this disease. Other factors which are prominent in this connec- tion are poor hygienic apartments; rooms in which sunshine is absent and in which foul air stagnates will certainly lower the normal resisting power of any and all individuals. When a child has passed through an acute infectious disease which has already lowered its vitality, then an infection with tuberculosis is more easily accomplished. Among such diseases which predispose to the development of tuberculosis are whooping-cough and measles. The same is also true in exhaustive diseases which drain the vitality of children for a long time, as, for example, after a prolonged attack of summer complaint. The disease frequently accompanies the nursing period, hence even the youngest child may become infected. Tuberculosis has so great a tendency to generalize itself in children that the question of the primary infection is not to be settled by the mere frequency of the lesions. The fact that children swallow their sputa is to be kept in mind. There is no question as to its infectiousness, while that of infected milk in the human species has not been absolutely demonstrated. Still's statistics show that in 25 cases taken consecutively, of children under 3 years, who did not expectorate, intestinal lesions were found in 19, while in a similar series, aged between 3 and 12, they were found in only 10. It would thus appear that autoinfection by the sputa in infants is a matter of serious importance. Bacteriology. — The germ can be traced to the blood and also the cells of the blood-vessels. This has been proven through studies made by Dou- trelepont, Lustig, Meisels, and Weigert. Demme found this specific germ in pus exuding from an eczema; the same is true about pus in otitis. Tuberculous affections of the tongue, of the nasal mucous membrane, of the thorax and tuberculous swellings on the lips of young girls have been described by Volkmann. Primary tuber- culosis of the thymus, of the heart, and of the vaginal mucous membrane have been published by Demme. A. Baginsky has described a series of cases of tuberculous perityphlitis, peritonitis, and enteritis. Tuberculosis of the testicles in children lias been seen and observed by him. The so- called scrofulous inflammatory conditions of the Joints and suppurative dis- eases of the bones, while being described as "scrofulous," are usually of a tuberculous nature. The internal organs suffer from the invasion of the TUBERCULOSIS. 437 tubercle bacillus in this connection. The lungs and the pleura, the peri- cardium and myocardium, the liver, spleen, and kidneys, the coverings of the brain, and the brain itself are frequently affected. The question of the transmission of the tubercle bacillus is one that is still debatable. Thus Jani reports in Virchow's Archiv, Bd. 103, p. 522, that the seminal fluid of tuberculous persons contains tubercle bacilli. The cases of tubercles in the foetus are described by Johne and Armanni.^ Bang, Lehmann, Bircli Hirschfeld, Eindfleisch, and Kossel are among those who have reported isolated cases of tuberculosis directly transmitted from parent to child. Hochsinger recently reported 3 cases which, he describes as congenital tuberculosis. These cases were associated with syphilis, and he believes that this disease is far more frequently transmitted than is gen- erally recognized. Thus it appears from the studies of Brandenberg, Lesage, Fig. 154. — Tiibercle Bacilli and Micrococcus Tetragenus {sputum). Gabbet's stain, Leitz ocular I, oil immersion Vi2- (d) tubercle bacilli; (h) micrococcus tetragenus. (Lenhartz-Brooks). and Wolff that the placenta is an exceedingly valuable culture medium for this specific micro-organism, and thus they account for the com- parative freedom of the foetus born to a tuberculous mother. Cornet and, more recently, Fliigge made extensive investigations show- ing the means of dissemination of the tubercle bacillus. We are indebted to them for our knowledge regarding the danger of sputum of a phthisical patient, and also regarding the manner of transmission of this disease. How susceptible very young children are can be shown by a case pub- lished by Wassermann,^ in which he reports the transmission of tubercu- losis to a child six weeks old by being in contact in the same room with a ^ Tenth International Medical Congress, Bd. 5. ^ Zeitschi-if t f . Hygiene, p. 353. 488 THE INFECTIOUS DISEASES. phthisical patient for eight days. Ivitasato^ reports the fact that tubercle bacilli die rapidly in the sputum, and he therefore does not believe the danger of the transmissibility of tuberculosis is as great as has been claimed. That contact with tuberculous patients is a very serious matter can be seen by a study of the literature. Mother's milk has been closely studied and the possibility of infection through this channel cannot be denied. Pathological Anatomy. — "We are indebted to Bayle, Buhl, Laennec, and Yirchow for the division and study of the pathological anatomy of this disease. These authors divide the conditions into two distinct j)arts : First, cheesy pneumonia; second, the real miliary tuberculosis. By the cheesy pneumonia is meant that form of a chronic destructive process ending in cheesy necrobiosis. By the miliary tuberculosis is meant that form of dis- ease commencing as a tiny nodular swelling, which starts in the connective tissue and is associated with the lymph bodies, having a tendency to form broken-down cheesy masses. The patholog}^ of this disease can certainly be associated with no greater name than that of Yirchow, to whom we are in- debted for the bulk of our knowledge of this disease. The tubercle is a small, grayish-white, translucent, sometimes yellowish body. The greatest masses consist of small, round cells about the size of a red blood-corpuscle, and large cells resembling epithelium. There are also giant cells. The giant cell, as a rule, can be found in the middle of these tubercles and is so closely identified with this condition that it has been looked upon as characteristic of this disease. The growth of the tubercle consists in the development of new masses arising from the giant cells. In these giant cells there are no blood-vessels, and as there is no nutrition they easily break down and form what is later on the beginning of cheesy masses, which, by absorption and a melting process, are the real beginnings of cavities. At times these masses result in chalk deposits. The question of the specific origin of the disease has been finally settled by the investigations of Koch, who proved the specific micro- organism known as the tubercle bacillus to be the j^athological factor. Biedert found 16 cases of primary intestinal tuberculosis among 3104 post-mortems. Heller found 7.4 per cent, of primary tuberculosis among 714 post- mortems in diphtheria, and a total of 19.6 per cent, of all varieties of tuberculosis among these 714 cases. Orth states that primary intestinal tuberculosis is exceedingly rare in Berlin because of the universal use of sterilized or boiled milk.^ ^ Zeitschr. f. Hygiene, Bd. 9, 1892, Heft 3. - 1 have collected and described a series of important observations on the association of cows' milk with tuberculosis. The pathologic of the cow's udder and the milk ducts are also described. (See chanter on "Cows' Milk.'") TUBERCULOSIS. 480 Fig. 155.— Tuberculosis. Horizontal section through the tuberculous lower lobe of the right lung of a two-year-old child. (a) caseous focus in the region of the an- terior border; (b) nontuberculous poster- ior border; (c) transverse section of bron- chus; (d,d^) caseated lymph glands; (e) pulmonary vein ; (f) point of adhesion of the vein e with the lymph f/Jand fZ'; (g) tubercle in the lymph vessels of the lung parenchyma; (h) periarterial; (i) peribronchial; f-k) perivenous tubercles; (I) lymph vessel tubercles of the pleura ; (iii) tubercle in its connective tissue of the hilus of the lung. X3. (Ziegler.) 490 THE INFECTIOUS DISEASES. Baginsky reports that he found 8 cases of tuberculosis that died among 871 nurslings at his Berlin hospital. These were all under ten months of age. On the other hand he found, among 266 children in the second yea'r, 13 died of miliary tuberculosis. One hundred and eighty-two children out of 611 died of miliary tubercvilosis between the age of 2 and 4 years. Out of 153 children examined between the age of 4 and 6 years, 6 had miliary tuberculosis. Fig. 156. — Acute Pulmonary Miliary Tuberculosis (Cut Sui-face of the Lung.) (a) so-called obsolete tubercle (old encapsulated caseous focus), (b) induration, (cj caseous, partly agminated nodules (transverse section of caseous bronchi.) (dj submiliary noncaseated tubercle in the true lung tissue, (ej tubercle of the pulmonary pleura. One half natural size. (Lang- erhans.) StilP considers these facts and offers some interesting statistics, based, not on clinical observation, but on post-mortem findings, for the solution of this problem. In 769 autopsies of children, tubercle was found in 269, or 35.2 per cent. Tuberculosis was the actual cause of deaths in 252, or 32.8 per cent. From those statistics, therefore, it can be roughly estimated that Clinical Jouninl, London. PLATE XVTI Disseminated pulmonary tuliorculosis Avitli collapsed right lung and a natural pneumothorax. Child four years old. TUBERCULOSIS. 491 about one-third of the deaths in childhood are due to tuberculosis in one form or other. While children are thus shown to be specially subject to this disease, they are not equally so at all ages, for Still shows that up to the age of 4 the percentage is as high as 71, and between 4 and 8 is still 22.5 ; after 8 it diminishes to 6.5. Moreover, the greater part of the tuberculosis under the age of 4 — 43.4 of the 71 per cent. — occuiTed in children under 2 years of age. This great frequency of tuberculosis in infancy has been used a^ an argument in favor of the idea of infection through milk, the primary lesion being in the digestive tract. It is true. Still says, that in- testinal tuberculosis is exceedingly common in children; it existed in 52 per cent, of his cases examined, but so also is that of the brain and meninges — 48 per cent. — and that of the lungs is far more frequent — 78 per cent. The total number of deaths reported as due to consumption in the United States during the census year was 109,750, of which 53,626 were males and 56,124 were females and the ratio of deaths from this disease to 1000 deaths from all Icnown causes was 109.9. In 1890 the correspond- ing ratio was 122.3. The death rate of the colored from consumption was nearly three times that of the whites, and that of the foreign whites was much higher than that of the native whites. For the last-mentioned class the death rate for those having one or both parents foreign was also much higher than for those of native parents. The death rate of males from tliis disease was considerably higher than that of females. The total number of deaths repoi-ted as due to consumption in the United States in children under 15 years of age, during the census years 1890-1900, was 8051, of which 3554 were males and 4497 were females. The death rate from consumption in the registration States was higher in the District' of Columbia (305.3), which was due mainly to the large colored population. The next highest rate in the registration States was in Rhode Island, where it was 195.3. The death rate from this disease was higher among males than females in the cities, but lower in the rural dis- tricts. Excluding the District of Columbia, the highest occurred among males in the city of New York (265.3), and the lowest among males in the rural districts of Michigan. The following table shows that the death rates due to consumption in white persons under 15 years of age were highest in those whose mothers were born in Italy (50.7), in France (47.1), and in "^other foreign" coun- tries (45.9) ; and were lowest in those whose mothers were born in Poland (11.4), in Bohemia (13.2-), and in Germany (26.6). J. Walker Carr reports statistics of necropsies on tuberculous children at the Victoria Hospital. He found 79 in which the disease most probably started in the chest and 20 in which it seemed to have begnn in the 492 THE INFECTIOUS DISEASES. Table No. 44. Color and Birthplace of Mothers. Under 15 Tears. White 31.8 Colored 246.0 Mothers born in — United States 27.5 Ireland 42.2 Germany 26.6 England and Wales 27.2 Canada 34.5 Scandinavia 32.4 Scotland 32.9 Italy 50.7 France 47.1 HungaiT • 38.6 Bohemia 13.2 Russia 26.7 Poland 11.4 Other foreign 45.9 Table Xo. 45. — Percentage of Deaths per 1000 from Consumption in ChiMren from 1 to 15 years of age {United, States). Age. 1900 Males. Under 1 year 1 year 2 years ] 3 years i 4 years ! Under 5 years j 5 to 9 years 10 to 14 years ' Females. Males. 1890 Females. IS.S 17.8 20.1 16.5 9.3 9.6 9.7 10.9 5.2 4.S 5.1 5.0 3.3 4.0 2.7 3.6 2.3 2.2 2.0 2.8 38.9 38.4 39.6 38.8 8.1 13.2 S.l 11.7 9.5 24.7 10.7 27.2 abdomen. Here the relation between the two forms of infection is as 1 to 4. In 26 children of early or limited tuberculosis, the thorax alone was affected in 12 cases, the abdomen in T, being in the proportion of 1 to 1.7. Of 53 tuberculous children under 2 years of age the disease most probably began in the chest in 43 and in only 5 certainly in the abdomen, the proportion in this case being as 1 to 8.6. Out of 27 children over 5 years of age, the disease began in the chest in 12, in the abdomen in 6, the relation being as 1 to 2. Bollinger, in his address at the International Tuberculosis Congress, of Berlin, m 1899, quoted with approval the record of autopsies by Heller (Kiel) of 248 tuberculous children. In 45.5 per cent, of the cases tuber- culosis involved the mesenteric Erlands. From these it was concluded TL liKKCl'LUSlS. ^f,;^ that milk played a leading role in the so-called transmitted tuberculosis of children. It is plain from what has been said, without quoting further statistics, that in some countries where bovine tuberculosis is very frequent, there is also a great frequency of tuberculosis in children. Bollinger concludes that '^"■'although the tuberculosis of cattle and swine does not stand in the first line as source and starting point of human tuberculosis, nevertheless — con- sidering their enormous distribution and progressive additions, and the great danger from the ingestion of the milk of tuberculous cows— they are cer- tainly for humanity the most important and the most dangerous of all animal plagues, and deserve the most earnest attention from the sanitarian and the state." Symptoms; — The more important symptoms noted in this condition are a general restlessness with a rise of temperature. Children frequently have little or no cough, but some difficulty with respiration for which no distinct physical signs can ])e found. The temperature will sometimes rise as high as 103° or 104° F., or it may suddenly become apyretic and assume a sub- normal tendency. The temperature usually seen is 101° F. The children appear very angemic and at times cyanotic, mostly on the cheeks and lips. Emaciation usually accompanies this "intermittent type of fever." To the inexperienced, the beginning of a miliary tuberculosis resembles mostly the clinical picture which so frequently accompanies intermittent fever. There usually is slight swelling of the peripheral lymph glands. . The spleen and liver will be felt enlarged. . The urine will give a slight diazo reaction, also an indican reaction. Xeither of these, however, are constantly present. We have what is commonly known as a "pre-tubercular anasmia," in which there is a general tendency to hreakdown, and pallor so well marked, for which there is no distinct group of symptoms. When such profound anajmia exists with slight variations of temperature, then tuberculosis may be in- ferred; hence this stage is regarded by some clinicians as the "pre-tuber- cular" stage. Occasionally the examination of the chest shows catarrhal symptoms and rhonchi as accompany an ordinary bronchitis. There is an absence of bronchial breathing and no distinct evidence of dullness on per- cussion. Frequently these symptoms increase in severity. Cyanosis may accompany this condition and the circulation may be so poor as to show cold feet and hands. Death occasionally follows this condition. The clinical picture here given is the one that is frequently seen in that type of acute miliary tuberculosis running a malignant and very short colirse. In this condition the children appear very pale and lose weight. There is distinct anorexia which alternates with hyperorexia. Dyspeptic symptoms, such as vomiting and diarrhoea, may alternate with constipation. Such children are usually very sensitive and inclined to be peevish and cry on the slightest provocation. 494 THE INFECTIOUS DISEASES » D'Espine's Sign. — This sign is of great importance in confirming the diagnosis of t-uberciilosis in its earliest stage. In. children old enough to repeat the words "three thirty three" the echo heard of the last word is very significant, and should, when present, be regarded as supporting the diag- nosis of tuberculosis. D'Espine studied^ a series of infants and children and noted that the whispered voice is not heard lower than the seventh cervical spine posteriorly. If the lymph-nodes are enlarged and the patient whispers "three thirty three" then bronchophony is heard over the upper thoracic spine as well. D'Espine's sign is best elicited^ when the arms are folded well across the chest, the head sharply flexed, and the patient sitting erect. Firm pres- sure should be made with the stethoscope as patient repeats "three thirty three." When the sign is positive the final "e" of the last word persists for a moment like an echo after the phonation ceases. This postphonal quality is the significant feature. Young children can often repeat the "tree" more easily than the usual phrase. Occasionally the spoken voice or cough brings out the echoing quality more than the whisper. A study of the above symptoms will show that there are no distinct typical symptoms which can be laid down as positively diagnostic. It is for this reason that so many other diseases are confounded with miliary tuberculosis until the same has progressed considerably. When there is marked cachexia accompanying nurslings for which there is no distinct reason, and especially so if the fever accompanying the same is an inter- m.ittent type, then we should not forget the possibility of our dealing with a case of miliary tuberculosis. Case I. A child, 2 years old, was brought to my children's clinic at the New York Post-Graduate Medical School and Hospital, with the following history: She was a bottle-fed infant raised on condensed milk. The bowels were always con- stipated. Has had one attack of cholera infantum when eleven months old which caused emaciation and general atrophy. Present illness dates back to three months ago when child had measles fol- lowed by a severe broncho-pneumonia. The cough has persisted, but mostly at night. There was no expectoration. Physical Examination. — Examination reveals an emaciated, very rachitic child, pigeon-breasted, with decided beaded ribs. There is also a kyphosis. The abdomen is distended (pot-belly). The superficial veins are enlarged, the head shows marked frontal, parietal, and occipital rickets. Cranio-tabes is also present, so that we can safely call this a markedly rachitic case. At the left apex there were heard coarse, mucous and sonorous rales, also prolonged expiration. The right lower lobe had several areas of amphoric breathing, also some friction sounds and prolonged ' harsh expiration. Percussion note was dull. The morning temperature in the rectum was 101° F., pulse 144, respiration 40. The appetite was poor, spleen enlarged, hands and feet cold, and the child perspired freely. ^D'Espine, Bulletin de I'Acad. de Med. Paris, 1907. -Stoll, Amer. Jour. Dis. of Children, Sept., 1915. TUBERCULOSIS. 495 Diagnosis. — Tuberculosis after morbilli. Family History. — The father died of tuberculosis when the infant was six months old. Tlie mother is still living and in apparent good health. Two other children in the same family show no evidence of illness. The family live in a rear house behind a tenement house. The weight of the child when first seen was sixteen pounds. Treatment. — An emulsion of the yolks of 6 eggs containing sugar, and 15 drops of creosote carbonate was fed each day. Buttermilk and the serum of bullock's blood was given in ^vineglassful doses several times a day. The child was sent to the country and ordered to live out of doors. The appetite improved and the cough lessened. From month to month the clinical symptoms gradually subsided and at the end of two years the physical signs in the lungs entirely disappeared, and her weight increased to 32 pounds. In this case tubercle bacilli were found in the suptum that was vomited after a severe coughing paroxj'sm. The case is well to-day. Case II. A girl, 12 years old, seen by me some years ago, was brought to my children's clinic at the New York Post-Graduate Medical School and Hospital. She was suffering with headache, cough, general malaise, poor appetitt*, and emaciation. She had been under the treatment of a physician who diagnosed malaria. The bowels were ii'regular, at times constipated, at other times diarrheal. The urine, light amber color, contained nothing abnomal. The child perspired freely at the slightest exertion, even after each paroxysm of cough. Previous History. — She was a bottle-fed infant. Had measles and broncho- pneumonia at 3 years. When 5 years old had had whooping-cough which lasted four months. Excepting an occasional cough no other symptoms were present. Family History. — The family history is good. Both parents are living and four brothers; all are healthy. The only history as to etiology is that this girl has lived in unsanitary surroundings, besides having a weakened state of the respiratory tract. Physical Examination. — ^At the first examination she appeared slightly icteric, the spleen was enlarged, the liver normal. There was a slight dullness at the apes of the right side, some mucous rales and harsh breathing. There was a slight expectoration, no history of haemoptysis. Nose bleeditig was complained of occa- sionally. The diagnosis was made by the presence of tubercle bacilli in the sputum. Each month her sputum was examined, and it was found that the sputum which was expectorated during the early morning hours, between 4 and 6 A.M., contained the greatest number of tubercle bacilli. After four months of treat- ment it was found that the bacilli in the morning sputum were so sparingly present that evidently some change was going on. The symptoms of headache and malaise disappeared entirely. The icteric condition disappeared. The epistaxis has not shoMTi itself within the last five months. A careful examination of the sputum four times a month has not shown a single tubercle bacillus. The treatment consisted in remo\ing the child from school and giving her a substantial diet of which proteins formed the chief part. The hygienic conditions were improved as much as the circumstances of the family would permit. I impressed the family with the necessity of removing the child to the country and she was given into the employ of a farmer, and ordered to be in the open air all of the time. Six months later I saw the case again. She had gained in weight. Her cough had ceased and the physical signs were lessened. The child lived in the country eighteen months. 496 THE INFECTIOUS DISEASES. At the end of this time there was no evidence of cough nor of the general malaise excepting the physical signs on auscultation and percussion. I haA^e seen this child in all about seven years and believe that she is quite healthy. The pulmonary symptoms have entirely disappeared. According to Loomis, tuberculosis and cavities in the lungs can and do heal. I have good reason to believe that in this patient, in whom we diagnosed apex tuber- culosis or a catarjhal tuberculosis affecting the apices of both lungs, this process was arrested in its incipiency. Diag'nosis. — Method of Obtaining' Sputum: In infants and 5^oiTng- chil- dren who do not expectorate, the following- method of obtaining sputum is suggested b}^ Findlaj^ of Glasgow : ''With a piece of gauze on the fore- finger, the pharynx, and especially the epiglottis, is irritated so as to induce coughing, and any expectoration that is coughed up is swept out of the mouth l_^efore it has time to be swallowed. The quantity thus obtained varies, but as a rule is sufficient for bacteriological examination." The diagnosis Avill frequently be very difficult, especially so if no data can be obtained which will complete our clinical picture. If the child has been exposed to tuberculous individuals then a suspicion may arise (if there is a tuberculous family disposition) of a possibility of the development of this disease. Frequently the symptoms are such as to resemble tj^phoid, but if there is an absence of roseola, if the diazo reaction is absent, and if the Widal reaction is absent, then miliary tuberculosis must be inferred. The ophthalmoscopic examination must not be looked upon as a positive criterion, for miliary tuberculosis may exist in spite of the absence of tuberculosis of the choroid. For differential diagnosis between tubercu- losis and syphilis, see chapter on "Syphilis." Tuberculides. Papulo-necrotic tuberculides are round, flat papules, brownish in color. They have a central whitish depression and are usually covered with a small scale. They may occur on any part of the body. Their most frequent loca- tion is on the forearm, thighs, the external surfaces of the legs, and be- tween the thighs. They sometimes occur on the face. With the presence of the papulo-necrotic tuberculides aided by a von Pirquet skin reaction we have one of the best means at our command of confirming the diagnosis of infantile tuberculosis. Even though the von Pirquet reaction is negative, the presence of tlie papulo-necrotic tuber- culides strongly favors a diagnosis of tuberculosis. TIallopeau in 1896 at the Third International Dermatological Congress brought out the value of this lesion. Tuberculin Eeaction an Aid to the Diagnosis of Latent Forms of Tuberculosis.^ Von Pirquet found that by inoculating the skin with a minute quantity of old tuberculin a local inflammatory reaction is produced. There is no ^ Complete literature and details published in the New York Medical Journal, October 19, 1907. PLATE XVIIL Papulo-necrotic Tuberculides in a r-liild two years old, seen dnring my service at the Willard Parker Hospital. A valuable diagnostic lesion of tlie skin. (Original.) TUBERCULOSIS. 497 fever nor general systemic disturbance after such inoculation. With the older method of Koch fever follovi^ed each injection. The technique is as follows: Wash the arm with ether and scarify three small areas, but not enough to produce a bloody surface. Into two of the scaj-ified areas inocu- late (similar to vaccination) diluted tuberculin of the strength of one part tuberculin with three parts normal saline solution. Leave the third scari- fied area without inoculation as a control. After twenty-four, rarely later than forty-eight, hours a local inflammatory reaction, about 10 millimeters in width, surrounding the inoculated area, denotes a positive reaction. In the last stages of miliary tuberculosis and tuberculous meningitis no reaction follows. The ophthalmo reaction^ is another method of diagnosis. Prog-nosis. — The success attained during the last few years- in the treatment of tuberculosis proves the scientific progress made. Several years ago this disease was considered hopeless. Modem physicians recognize the importance of treating the collapsed lung that has become so through unsanitai-y surroundings, in the light of cause and effect. The prognosis therefore will depend on the age of the patient, the stage of the disease in which treatment is commenced, and the v/ill power of the patient. The vitality of children and their ability to pass tiirough long periods of illness and finally recover should be remembered when the outcome of the case is considered. Severe forms of marasmus, with marked emaciation, apparently hopeless, finally recovered. I have also seen severe forms of apex tuberculosis in children that entirely recovered after proper hygienic and dietetic treatment was instituted. It is our duty to instruct parents and those in charge of children of the dangers, on the one hand, where treatment is neglected, and to picture to them, on the other hand, how successful other cases have been when the dis- ease was properly handled. Treatment. — Dietetic Treatment: Next to sunshine, fresh air, and pulmonary gymnastics comes nutrition. A child that is properly strength- ened with milk, buttermilk, cocoa, eggs, cereals, cheese, green vegetables, fruits, meats, and meat broths will certainly be better able to recover tlian one that is underfed. One Point Concerning Feeding. — Milk if given should not be repeated oftener than once in four hours. The yolk of a fresh egg may be added just before feeding. When soup is given the yolk of a fresh egg may be added to it. I frequently give the yolks of eight or ten eggs in twenty-four hours if the gastric condition warrants the same. Strict attention must be paid to the bowels so that we do not overfeed and produce a dyspepsia by overfeeding. If milk is not well borne it may be peptonized. ^ Calmette advises iising a Vioo per cent, dilution of tuberculin dropped into the eye. - "Tuberculosis and How to Combat It," prize essay by S. A. Knopf, is well worth reading. 82 498 THE INFECTIOUS DISEASES. General Treatment. — In the treatment of tuberculosis the most im- portant point to remember is that fresh air is the best lung disinfectant that we possess. No remedy will kill tubercle bacilli as quickly as sunshine and fresh air. This should be impressed on every family wherein a case of tuberculosis is found. The progress made in recent years by climatic treatment has demonstrated the fact that cavities in the lung will frequently heal under proper treatment. The open-air treatment has gained such a strong foothold that we do not encounter the same difficulties that we did years ago when recommending open windows night and day. The great bugbear of night air should be removed, because fresh air at night is equally as important as it is by day. Heliotherapy. — Exposing the body to sun baths in addition to living out-of-doors, preferably at an altitude of several thousand feet, are recognized as the strongest modem therapeutic measures employed. Statistics show the great advantage of heliotherapy in mountainous regions; on the other hand, we have excellent results at the sea level in tubercu.lous children.^ Pulmonary Gymnastics. — Deep inspiration and expiration will oxy- genate the lungs when regularly performed. Deep breaths taken in the mountains on which there are pine-needle trees will do more toward expanding and imp'egnating diseased or collapsed portions of the lung than will the inhalation of a hundred times that quan- tity of pine-needle oil in the close, stuffy room when diffused from an atom- izer. The hygienic treatment must not be confined to walking and breath- ing the pure air, but must be aided by tepid bathing and by stimulating the circulation of the blood by friction with a coarse Turkish towel. Sea salt can be added to the bath. When the feet or hands are cold they should be briskly rubbed until the blood circulates freely. Medicinal Treatment. — Codliver-oil internally should be tried. If it is not well borne it can be used by external friction over the whole body, daily for ten or fifteen minutes. This is the so-called codliver-oil bath. If codliver-oil is not tolerated, butter should be given in large quantities. Codeine in ^/iq- to V4- grain doses can be given, or heroin in ^/go- to ^/ss- grain doses, three times a day, may be given to relieve cough. For the relief of the night sweats sulphate of atropine, ^/ijo to ^Aoo ol a grain, three times a day, should be given. Toxic symptoms should always be looked for in the pupils when administering these drugs. A laxative dose of citrate of magnesia or calcined magnesia, 5 to 10 grains, several times a day, is useful. If blood is expectorated, then 5 to 15 drops of fluidextract of ergot can be given every few hours. In other cases 5 to 10 grains of powdered alum, repeated every few hours, may do good. I have also seen good results ^ See report of Dr. John Winters Brannan on Results with Heliotherapy at the Seaside Hospital, Coney Island, 1913. PLATK XIX Old Tuberculin, Undiluted Dilution — 1 : 4 Dilution— 1 : 16 Dilution— 1 : 64 Control, Not Inoculated Cutaneous Reaction Sliowing the Various Results with Concentrated and Diluted Tuberculin. Taken 48 hours after iudculatiou by Dr. H.muing, at the clinic of Escherich. PLATE XX Severe Cutaneous Reaction. Note the two places inoculated. The center is the control. (Escherich's clinic.) Scrofulous Reaction . Two outer places inoculated. The center is the control. (Escherich's clinic.) TUBERCULOSIS. 499 from 5- and 10- grain doses of gallic acid. Fluidextract of hydrastis cana- densis, 3 to 10 drops, several times a day, or hydrastinine hydroclilorate, Vioo grain, three times a day, may be tried. Tincture of iron, in 5- to 10- drop doses, is a good hemostatic; besides it is a valuable tonic. Stimulation is sometimes required. Gymnastics and exercise should be ordered. These must, however, be supervised, so that fatigue is avoided. Besides stimulating the circulation, exercise aids in the metabolism of food. We must not consider a case cured when all active symptoms subside, but must persist with climatic treatment for many years, to avoid a reinfection. Attention should be directed to the upper air passages and adenoids and tonsils removed if the slightest evidence of symptoms is noted. To prevent the recurrence of tuberculous infection we must remove the patient from his former surroundings and keep him away from therd after improvement is noted. There is danger of reinfection in taking a child from an out-door life of sunshine and fresh air back to an unsanitary home. We should impress the family with the importance of continuing thorough oxygenation of the lungs night as well as day, and keeping the skin healthy by frequent tub baths. Out-door exercise should be advised, both for its stimulating effect on the circulation, as well as for its value in aiding food metabolism. Tuberculin. — The use of injections of tuberculin for diagnostic as well as therapeutic results dates back to 1891, when Koch first announced clin- ical results. My experience with tuberculin at that time, through the courtesy of George F. Shrady, at the St. Francis Hospital, New York, was not very encouraging. I have also seen cases in which tuberculin Avas used through the courtesy of Prof. Adolph Baginsky, at the Berlin Chil- dren's Hospital. Baginsky has never encouraged the use of these injections. In his sixth edition of "Lehrbuch der Kinderkraukheiten," 1899, page 350, he says : "I do not believe that the injection of tuberculin, especially in very small children, is without danger. I am aware that Kossel, m Berlin, uses the injections very extensively and without ill results." In young children a dose of Vnoooo milligram should be given, and two weeks later followed by an injection of ^/osooo milligram. The injections should be given in the evening, and local as well as constitutional symptoms care- fully noted. These injections should be given about once a week and the dose gradually increased, so that at the end of two months V5000 milligram can be injected without producing severe reaction. CHAPTEE VI. DIPHTHEROID. This term we owe priiuaril}^ to the French. It was introduced into the German literature by Professor Baginsky, and, after him, by Escherich. This disease is caused by an infection resulting from a series of germs, chiefly streptococci or staphylococci. It is a disease which differs entirely from diphtheria. It is not a serious disease. There are no Klebs-Loeffler bacilli present. The usual evidences of systemic infection are absent. The child shows the clinical evidences of an infection in a milder form than is usually met with in diphtheria. The prognosis is good. The treatment should be directed toward restoring the normal condition of the body, and hence the saccharated carbonate of iron given in 5- to 10- grain doses, three or four times a day, is very useful. Locally, an astringent antiseptic gargle, consisting of equal parts of Dobell's solution and of warm water, to be used every hour for gargling, or a 1 to 5000 bichloride of mercury solution is very useful. Normal salt solution is also recommended. The nutrition of the body will be the means of restoring the functions to their normal state. It is important, therefore, to feed in regular inter- vals milk, soup, broth, and eggs, if they can be assimilated. If the child is a bottle baby "or a nursling at the breast, then a smaller quantity of food should be given, and if the same is not taken by the mouth then rectal ali- mentation will be urgently called for. It is wise to isolate each and every form of diphtheroid affection and thus prevent the possibility of the trans- mission of this infection. PsEUDO OR False Diphtheria. Under this general title are included all cases of pseudo-membranous or exudative inflammation of the mucous membranes in which the diph- theria bacilli are absent. Since Loeffler, in 18S9, first described a class of pseudo-membranous inflammations of the throat in which the diphtheria bacilli were absent and cocci present, it has been established that a certain portion of the inflammations of the respiratory mucous membranes, which closely re- semble the less characteristic cases of diphtheria, are not due to the diph- theria bacilli, but to cocci, especially to streptococci. It has been found that streptococci are commonly present in the throats of healthy persons, or at least in the throats of persons living in large cities, and that other forms of cocci, especially the pneumococci and staphylococci, are apt to be associated with them. These germs seem to live in the throat without creating any disturb- ance there, so long as the mucous membranes are healthy; but under cer- (500) PSEUDO-DIPHTHERIA. 501 tain conditions, as when the mucous membrane has been made vulnerable by exposure to cold or other deleterious influences, or by the poison of scar- let fever, measles, or some other disease, the streptococci, alone, or asso- ciated with other cocci, are able to attack the mucous membrane and to cause an inflammation. This may be of any degree of intensity, from a "imple inflammatory hypersemia to an inflammation with an extensive production of pseudo-membrane or with ulceration. Such inflammations when associated with the formation of pseudo-membrane are known as pseudo-diphtheria. The exudate or pseudo-membrane in pseudo-diphtheria is usually confined to the tonsils, but other parts, such as the larynx, pharynx, and nostrils, may be invaded. It has been found that the percentage of mortality in these cases is far less than in diphtheria, and that the disease is seldom, if ever, commu- nicated to others. The Proportion of Cases of Suspected Diphtheria which upon Exami- nation Prove to be True Diphtheria. — "As soon as careful investigation had demonstrated it was possible, with proper precautions, to separate by bacteriological examination the cases of the true from those of the false diphtheria, large numbers of cases suspected to be diphtheria were exam- ined bacteriologically. The reports from hospitals in which all cases of suspected diphtheria were examined, are of special interest as showing the proportion of cases of true to false diphtheria. The results from these hos- pitals are all the more valuable because they come from all parts of the various cities in which the respective hospitals were located, and hence f'pecial local- conditions were not likely to greatly influence the result ob- tained. Thus, Baginsky, in Berlin, found the diphtheria bacilli in 120 out of 244 suspected cases; Martin, in Paris, 126 out of 200; Park, in New York, 127 out of 244; Janson, in Switzerland, in 63 out of 100, and Morse, in Boston, in 239 out of 400. Thus, from 20 to 50 per cent, of the cases sent to diphtheria hospitals did not have diphtheria. "If we examine the reports of examinations made under some special conditions, as during an outbreak of some contagious disease in a hospital for children, we find the results may differ in a striking manner. "Thus, in 1889, Prudden made bacteriological examinations of 24 fatal cases of pseudo-membranous inflammation of the tonsils, phannx, and Jarynx. In none of these were the Loeffler bacilli found to be present. These cases occurred in two hospitals for children in ISTew York in whicH both scarlet fever and measles were at the time prevalent. During the past year we have examined the exudate from 46 fatal cases of suspected diph- theria occurring in these same institutions, and found the bacilli present in 44 of them." If scarlet fever and measles (but not true diphtheria) were prevailing in an institution, it is evident the bacilli would be absent from the pseudo- 502 THE INFECTIOUS DISEASES. membranes occurring in the throat as a complication of these diseases. All observers have found the mortality far higher in those cases in which the diphtheria bacilli were present than in those in which they were absent. In true diphtheria the mortality has been found to vary from £5 to 70 per cent., while in pseudo-diphtheria it varies from per cent, to 20 per cent. DiPHTHEEIA. Diphtheria is an acute infectious disease caused by the invasion of a specific micro-organism known as the Klebs-LoefSer bacillus. It is a disease characterized by the presence, locally, of false mem- branes, known as pseudo-membranes. The presence of pseudo-membrane is frequently caused by the strepto- coccus. The Klebs-Loeffler and the streptococcus varieties are identical in their clinical manifestations. Etiology. — This disease is most frequently met with in children, al- though adults are not exempt from it. It is met with in the newly born (Jacobi). It is most frequently seen between the fourth and tenth years. Children are especially disposed to this disease between the ages of 1 and 5 years. Baginsky reports a series of 2711 cases in which : — 84 occurred during the first year. 889 between the first and fourth year. 1411 between the fourth and tenth year. 318 between the tenth and fourteenth year. There is no difference in the sex regarding the predisposition to diphtheria : — 1311 in the above series were boys. 1400 were girls. Infection is spread primarily by contact. It can be transmitted through dishes, play toys, and furniture to which the Ivlebs-Loeffler bacilli adhere. Infections have been traced to water and milk which contained the diphtheria bacillus. We know that the Klebs-Loeffler bacilli adhere to the walls and ceilings of rooms. The etiology of diphtheria remained obscure until Loeffler discovered the bacillus in 1884. Kissing a child, sick or convalescing from diphtheria, is a direct method of contracting the disease. UnliedltUy Throats. — Diseased tonsils, or adenoid vegetations in the pharynx, are usually foci for the development and propagation of the Klebs- Loeffler bacillus. This has been repeatedly verified by me during many years of service at the Willard Parker and Eiverside Hospitals. Thus it would appear wise to put the throat in as healthy a state as possible in order to guard against the development of this disease. False diphtheria, in which there is a non-virulent germ present, fre- quently resembles diphtheria. DIPHTHERIA. 603 Hunt's differential stain and alpo tlie Neisser stain will differentiate the non-virulent from the virulent form of germ. Table No. 46. — Diphtheria Cases Under 18 Tears, Willard Parker Hospital. I •a a ei Under 1 Year. (N O rH 2 to 3 Years. M a (L> X -)> o CO 1 m » in O C3 111 X o o OQ as O CO 1-1 cd 3- DATES OF OBSERVATIONS | ^Q.]?\.. 6 7 8 9 10 11 12 13 Cent! Tahr. AM>M am:pm AMiPM am:pm am:pm am;pm[am;pm am'pm 39° ~ 38"" •8 •( -102°-* i?, • s •6 S"*"* ^•N .^ f^ -m-2 :/ f: \ 37 ~ •S •6 '99° • * ■ S • 6 : V k/ \, .i ■ 1 •• 1 ■ 36 ~ m ■■■: ■ i ■ s •0 97°- 2 • 8 • 6 ■ 1 96 -2 ^5 32 Puhe per minute ^•^ 3c5 1^ §1 licspiratityAS per minute ^ g5 Fig. 160. — Septic Type of Diphtheria Complicated by Myocarditis. The effect of the poison is shown on the heart. Note the pulse-rate, low- temperature and the rspiration. (Original.) Expistaxis is frequent. There is a general somnolence. A tendency to collapse, ending fatally. The diagnosis depends on the presence of a membranous exudate cover- ing the tonsils and pharynx. This type of disease is usually associated with nasal diphtheria. There is a foul-smelling discharge, .sometimes a marked gangrenous odor, from both nose and mouth. When the membrane exfoliates it is not uncommon to have severe epistaxis. The temperature ranges between 100° and 101°; at times subnormal temperatures are encountered. There is a tendency to collapse. Nasal Diphtheria. — The nasal infection may be an extension from the pharynx upward, or the disease may be confined to the nose and localized there. Vigorous treatment should be installed early in the disease. Owing 33 514 THE INFECTIOUS DISEASES. to the large amount of l}anphoid tissue in the naso-pharynx, the tendency to profound toxaemia from absorption should be remembered, and the toxin inhibited by early and active treatment. When there is a general infection, then greater attention should be paid to the condition of the heart. The. pulse is usually small and thready. The heart sounds are feeble; sometimes they are muffled. In other in- stances there is a tachycardia. The extremities are usually cold. If these Oct. 15 16 17 18 19 20 21 ' 22 Fahr. AM. PM. AM. PM. AM. PM. AM. PM. AM. PM. AM. PM. AM. PM. AM. PM. 8 . » . S* c^ "104° 2 .'.''S . ;2 e .>^ ~I03° - •"^ ■?l5S . \ .■^ ■ \ ■fi 4 ■ \ :-^ -102° 2 8 ^ -A |- '' \ / \ - 4 \/ -101° 2 V- 8 • ■ A - 6 7 \ -100° 2 \ 1 , - - 8 \ / \ • - 4 v.! "99° - \r •~^ 8 \ - 6 N • , y'^ V • . -9S° 2 Pulse c^ trv oo ^ ^.^ c> ^l <=> xn Xier Si L; Si s, ^^ villi. Resp. per il ej § § § ,§ § 03 g oo ^ 00 CO ■nan. tS Ozs. qs. qs. qs. qs. qs. qs. qs. qs. Dcfcc 1 11 1 1 1 1 1 1 Fig. 161. — Case of Nasal Diphtheria. George P. Willard Parker Hospital. Injected with 3000 units of antitoxin on the 15th, and 5000 on the 17th. (Original.) symptoms do not subside, and the affection spreads, then there may be later a total absence of the patellar reflexes. There may also be vomiting, a decided apathetic condition, and a slowing of the heart's action (brady- cardia) . George P., aged TVo years, admitted to the Willard Parker Hospital Oct. 15th; ill two days. General condition, fair. No pseudo-membrane was visible in the throat. The cervical glands were very much enlarged. There was a serosanguineous discharge from the nose; besides, the entrance to the nostrils appeared angry and excoriated. Bacteriological examination showed Klebs-Loeffler bacilli. Patient was allowed out of bed October 22d. PLATE XXI Case A. — Common Type of Diphtheria. Child three years old. Seen on fourth day of illness at the VVillard Parker Hospital. Exudate covering tonsils, pharynx, and uvula. Received in all 16,000 units of antitoxin. Throat clear on sixth day. Case discharged cured. (Original.) Case B. — Follicular Type of Diphtheria. Child seven years old. Seen on second day of illness at the Willard Parker Hospital. The mem- i)rane involved the lacunae of the tonsils. Note the close resemblance to follicular tonsillitis. Received in all 6,000 units of antitoxin. (Original.) Case C. — H.faiorrhagic Type of Diphtheria. Child seven and one- half years old. Seen on sixth day of illness at the Willard Parker Hospital. Tonsillar and post- pharyngeal exudate. Severe nasal and postpharyngeal haemorrhages during exfoliation of membrane. Received in all 15,000 units of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. Case discharged cured four weeks after admission. (Original.) Case D. — Septic Type of Dipjititeria. Child eight years old. Seen on the fifth day of illness at the \Yil1ard Parker Hospital. The pseudo- membrane in this case covered the hard palate and extended in one large mass down the pharynx, completely hiding the tonsils. (Original.) rfMM izz aTlJ^i n998 .I)fo 8'fX59^ MTtd^ Lrrfi'3 .AlaaiiTMia TOT'a^rTIliOMKdDf— lA atalO grriievoo sixibfizJI Jr.iiqeoJri -i-jixx!^ biiitli?/ sdt ijs essfilli io ^jpb rfiluol n .aizo^tWrixs io eiiftw OQQjSlj^Illjs ai i)9vi90s}i ^Bluvip^boiJ v^xj^tftdtfijefiBnoj < .[fini^hOf .bfitvo hs^isidostb aajsO .\rjjb rWxia no -usab ItBO-rifT .bio 8"iB9^ ff9V9a Jf^^JtrfO .AiaaH'r;^iCI ub sitT HAiuoujcol — ]a aEslo -mam 9ffT .IjsdiqaoH 'la^Iixil f)TB[[i7/ eili i/; a89n[Ir io \rj5b bn6o98 nio fi993 oi 90ffBfdm980f Sfeolu 9ff:[ stoT^ .afisnoJ Offl io mnuoBl ofli bayloyni Sfixirti (.[rjfri§i-iO) .crixoiBrtG io «iirt;/ 000^9 liji ni b9V£9993 .eWilliatjoi Tjslujilloi -sno bfiB fr9Y98 bliffO .AiaawvniiG. Tfo a'l/T oiaAiiaaoiA'nE.il — iO aaAO .luJiqeoH 79jl'rjs*x bi&llWJ arfi du asaafli to rub iliy.is no n998 .Mo stbst lljsf[ lK9Savifirfq-i8oq bnji tee^n 919T98 .9tp.br/x9, [/!9§n^ijsriq-*80q blpa iRlliaaoT siiiiis 000.51 IIr ni b9Yi909iI .enBidmsffti io fioy£r[oix9 'ftti'Hrb ^9gJr;fr-rioffi5etf hrirrof-^-rnr, f^iiib-UiOO%l/[ .889nni io ynF) (Fifiirf no 'tesb iiJOlxIT ...}.axia)tti«B io (.ffinighO) .noieernfbi! tiIV- f">f'^i f).9ltn'i:i)^imfl98ib obbv) noo8 .bfo ft-rr.9'^ Mgie blfflO .Ai^HtHliQ m-'m^-^Vf^^ — iS-«»i.O -obxr9aq miT .[nirqaoH T9>(7J5*I brfiffrW 9f{t 1b pe^nfff ioTBb iWrft-pffi no 9gXB[ ono fti bobrt9j-7:o h'-n q+Btfiq b'fRff 9fft f;wi7oo *i^no strfi "rrf oTfTsTrfrrirr' (.[finigiiOi Jtli gnrbhf '^l%3'4rt{rr:. PLA IK XXI /^^^^^ ^« l^^^^^^^^^^^^^^^^^^l H ' • .^w^ mJ 1 s ' D DIPHTHERIA. 515 The liver is usually very much enlarged and feels very hard on palpa- tion. In other cases there will be marked diminution in the quantity of urine. When urine is scanty and contains casts and blood, showing a dif- fuse nephritis, then it is not rare to find convulsions of a ura3mic character, resulting fatally. The sudden appearance of diarrhoea is frequently a very serious symptom, resulting in collapse and ending fatally. In other instances continuous crying may be the forerunner of earache resulting in suppuration. Not infrequently moist rales and bronchial breathing show evidences of broncho-pneumonia areas in the lungs, so that the general infection, of a child with diphtheria should be dreaded, owing to <90i- jTUNE dates of observations I May 26 27 28 29 30^ 31 I 2 3 4 5 6 7 8 9 10 11 12 13 Cent. Fakr. AM>M am:pm AMiPM AM. CM AH.-r^i am!pm am:pm AM^M AMifM AM m amIpm SM.PM An:pM ah;pm au:pm A;M ah:ph am:pm - .8 fi : : • : li l^- O <0° 106° -J !& ■« <« "- Si^ ft- lu- te: 5 •« 101° -^ : 3 ^? (0^ 30'' 103° • ' 15 A 102° 1 N l\ A /' A ■/^ A^° r \ g| W~ •s 101°' 5 A' f\ A t 1/ ^ / [. f ^ / k ■8 8 H)0°'? \ J v.\ 4 ^\ / 7 ii h / - ;« [ \ :J r V: ^7' 37" ' S / - »» : Pulat pn-mimtt, 1 "^ 35 3? u 3 f^ 32 35 ^1 ^2 t^^ 3 2 3 '^ ^:f (\i 00 3 ^ CO « ^ro 3 = u>ec per mf»ute loc «^ks; (/. fnint pignientat'on after four weeks. (After Park and Zingher, Amer. Jour. Dis. Children. April. 191(5.) PLATE XXIV Shows t\vo pspudoreactions forty-eiglit liours aft^r test, and a combined reaction. a, mild; h, marked; c, a combined jiositivc and ps<-udoreaction. (After Park and Zingber.) DIPHTHERIA. 521 diphtheria toxin is a direct toxic agent and by control tests of the blood- serum it has been found tbat a negative reaction is always associated vjith the presence of diphtheria antitoxin in the blood of the person tested. While, as a rule, a positive skin reaction is an indication of the absence of antibodies, some persons react positively for some unexplained reason who possess a greater amount of antitoxin in the blood than 0.03 units per cubic centimeter. It has been found that if a negative reaction follows the injection of a 0.1 cubic centimeter of a 1 : 1000 dilution of toxin, the individual tested has at least 0.031 units of antitoxin per cubic centimeter in his blood when Fig. 163. — Pneumonia Complicating Diphtheria. (Kind assistance of Dr. Edward H. Sparkman, Jr., at the Willard Parker Hospital.) A. Starting point of pneumonia, showing extent on third day. B. Focus which developed three days after A, showing extent on third day of the new focus. (Original.) tested by Homer's method. A person with a higher concentration of anti- toxin will react negatively to a smaller dilution of antitoxin and vice versa. Thus the outcome and the degree of reaction are dependent on two factors — • the strength of the toxin used and the presence of antitoxin in the blpod.^, As there is no antitoxin present in the blood in acute diphtheria, the use of the reaction for diagnostic purposes has been suggested. Tbus in a suspected case or questionable diagnosis a negative reaction — indicating the presence of antitoxin, would speak against the diagnosis of diphtheria. Differential Diagnosis. — In the very beginning of the disease, before the appearance of a pseudo-membrane, the diagnosis is beset with difl&culty. Thus, an acute catarrhal angina will show symptoms similar to those of diphtheria. Pre-memhranous Diphtheria. — When a child has been exposed to diph- theria, the careful daily inspection of the nose and throat is demanded. At 522 THE INFECTIOUS DISEASES. the slightest rise of temperature associated with an intense congestion of the pharynx and tonsils, antitoxin should be injected. The diagnosis of diphtheria can usually be made twenty-four to forty- eight hours before the membranes are visible. ■ A culture should always be taken, but too much reliance must not be placed on the bacteriological findings, because the Klebs-Loeffler bacillus may have invaded the deeper structures and not be present on the surface; therefore, cultures should be taken daily until the disease can positively be excluded. The cervical glands are usually swollen. Thrush sometimes resembles diphtheria, but can be differentiated by the fact that the small, whitish spots resembling curdled milk are scattered over the cheeks, lips, tongue, and gums, in addition to the uvula and pharjTix. Ulcerative tonsillitis^ resembling diphtheria has been described by Yin- cent. In this condition there is no tendency to spread. There is an absence of croup, and a culture taken shows the Vincent bacillus instead of the Klebs-Loeffler bacillus. Peritonsillar Aiscess. — In this condition we meet with a swelling or bulging forward of the affected parts. The uvula is sometimes displaced. There are very many active local s}Tnptoms, such as pain and difficulty in swallowing, and a nasal tone of voice. Not infrequently when an at- tempt to swallow is made the fluid regurgitates through the nose. When children are old enough to describe subjective symptoms, they will complain of chills and fever. The temperature is usually high, ranging from 102° to 105° F. The active symptoms subside the moment pus is relieved. Nature frequently gives a spontaneous evacuation of the pus. At other times it is wiser to give relief by making an incision and emptying the pus. A culture taken in this condition does not show the presence of the Klebs-Loeffler bacillus. Follicular Tonsillitis. — In this condition more than in any other form of disease we must ie careful regarding a positive opinion. There are follicular forms of diphtheria involving the lacunce of the tonsils which clinically so resemble diphtheria that even an expert cannot differentiate them. Table No. 51. — Complications Observed at the Willard Parker Hospital. 1910 1911 Number of Cases 1857 1558 Eye Complications. Conjunctivitis (Catarrhal) 105 51 Conjunctivitis (Diphtheritic) 7 3 ^Read article on "Tonsillitis.' DIPHTHERIA. 523 Ear Complications. Mastoiditis (Operative) 2 Otitis Media 135 112 Nasal Complications. Paralysis 8 13 Throat Complications. Paralysis (Pharyngeal) 112 28 Peritonsillar Abscess 14 9 Cervical Adenitis 318 101 Pulmonary Complications. Broncho-pneumonia 334 201 Lobar Pneumonia 6 5 Empyema 5 2 Cardiac Complications. Pericarditis 2 2 Myocarditis 110 100 Endocarditis 40 General Complications. Nephritis 20 30 Delirium 31 10 Vaginitis 110 129 Arthritis 5 6 Convulsions 5 5 Syphilis 4 The clinical manifestations of the benign form of follicular tonsillitis have already been described in the article on "Follicular Tonsillitis/' The differential diagnosis depends on the presence or absence of the Klebs-Loeffler bacillus. Complications/ — The most frequent complication met with is 'broncho- pneumonia. More deaths occur from this than from any other complica- tion. It is usually the extension of the disease from the larynx to the bronchi. When a septic form of diphtheria exists broncho-pneumonia usu- ally accompanies it. (See chapter on "Pneumonia.") Pleurisy with serous effusion frequently complicates this disease. Empyema not infrequently complicates. A number of these cases have been seen by me during my service at the Willard Parker Hospital. Otitis is occasionally met with as a complication of diphtheria. It is usually the result of a streptococcus infection through the nose or throat into the Eustachian tube. Myocarditis is the most frequent form of heart complication met with in diphtheria. Endocarditis and pericarditis are also seen in severe types of this disease. * For a detailed description of the various complications, the reader is re- ferred to the special articles on "Otitis," "Empyema," etc. 524 THE INFECTIOUS DISEASES. Meningitis is not often seen, though I have seen. 3 such cases out of a total of 35 at the Willard Parker Hospital during my service. About 10 per cent, of all septic cases have meningitis. Cerebral thromdosis and em'boUsm occasionally complicate diphtheria, and result in hemiplegia, convulsions, or aphasia. Thrombosis of the pulmonary artery of the heart may cause sudden death. This is usually accompanied by feeble heart's action the result of degenerative changes in the muscular walls (Holt). 190^.. DATES OF 03SERVATI0NS. | 6 7 8 9 10 11 12 isjw r5 Cent. Fakr mm Ai«;pM am:pm ANi:pM am;pm am:pmam:pm|am'pm AMiPM AMiPM •e • ■ • ■K - - • 'h A^^ \^ 30' ~ 38'" - - -103°: i • • • ^\ ^ J r V - ; -102°- • • • A A XI \ J V; V: ^ - - -101°- -/ 'y '\. /;~^ [ - - rino"- ■ ■ 2 37° - -m ■ ■ ! 3 5 36' -t)S°- Z ■ -97°- 8 G 4 2 -96° • 8 6 i 2 - Pulse per minute M t^ t^^ "3 ^ 5^ t^ ■> '^ ^^ 5-^ ^■- Respirations per minnle •r: oq cq c^ a5j CT) rQ-:i,-:tl fO^ ,9? Fig. 164. — ^Temperature Chart from a Case of Diphtheria complicated by Broncho-pneumonia (Step-ladder Type of Fever). (Original.) Ecemorrhages occur quite often. Bleeding from the nose and from the ear, also blood in the urine and blood in the stools, has frequently been seen by me. These cases are of the most severe type and usually end fatally. When the hfemorrhagic type is seen early, and the toxin in the circula- tion rapidly neutralized by the intravenous injection of antitoxin, the chances of recovery are greatly increased. Purpuric spots similar to that form of purpura met with in rheumatism were seen by me in septic cases, all of which ended fatally. Acute Renal Congestion.— This usually accompanies severe diphtheria. In many instances it is a forerunner of an acute nephritis. The earliest DIPHTHERIA. 525 symptoms noted are albumin and red blood cells. At times the urine may be scanty. The toxin filtering through the system attacks the kidneys as well as the heart, and it is important to make daily examinations of the urine, 80 that nephritis, if present, can readily be detected. The action of the kidneys during diphtheria is as important as the action of the bowels, because the retention of toxin may result fatally. If the urine is scanty the temperature will be higher, and, therefore, a mild diuretic, such as 5 to 10 grains of citrate of potassium, is indicated. IJlOi- CATES OF OSS£RVAT|0nS' .| 1 2 3 4 5 6 7 8 9 10 H Cent. FaKr. AH>M AM PM AM:ni AMIPM AMiPM AHlPH AMIPII AII^PII AMlPM AMlPM k»:rm 41° ~ - 40°" .» •« •106 -J •h il •; •8 •« •106° -a :^ V p P' i •8 ;« 104° •'» i /^ i li « [ s • : C) 39°" 38°~ •S io3°:l t • • t \: N ^A ■P / 3 •« "102''* :/ 4 > ^/l / • • • • •8 •« 101°-» V- •» .( ■100°' I ; 37°~ •8 ■6 ■ «-4 •09 -x ■ 8 88"^ r9H •« r ■ -8 •0 ' «• 4 -.97 -2 ; : Pulat per miwite II ^1 1? ■s§ §^ ^^ IS §^ ^ ^ BaplratlOK* per minuU 53? ^5 3? 'S'* jj Fig. 165. — Temperature Chart from a Case of Diphtheria complicated by Lobar Pneumonia. (Original.) The application of a warm-water bag over the kidneys also stimulates diuresis. Dry cupping over the kidneys repeated every twelve hours will stimulate the flow of urine. Moderate quantities of water should be given to flush the kidneys and eliminate toxin. Nephritis'^ is usually met with in septic cases, although it may follow as a complication of the milder form of this disease. Traces of albumin are frequently found during the course of diphtheria. This does not necessarily imply that we are dealing with nephritis. The presence of casts, in addition to the albumin, or. possibly blood, is necessary to strengthen the diagnosis of nephritis. *An excellent illustration of nephritis complicating diphtheria is described in the article on "Nephritis." 526 ^HE lifFEOTIOUS DISEASES. Diarrhcea due to a follicular ileo-colitis or acute gastric catarrh fre- quently complicates diphtheria. Diarrhoea, when present, is nature's method of eliminating toxins and should be looked upon as an aid in cleansing the system rather than as a complication. When diarrhoea is not present and the bowels are constipated, then sufficient hydragogue cathartics, such as calomel or compound jalap powder, should be prescribed to produce loose bowels. Diphtheritic Gastritis. — When membranous gastritis occurs it is usu-' ally a diphtheritic gastritis. Diphtheritic omphalitis is described in Chapter III, Part II. When membranous enteritis complicates diphtheria it is usually the result of a streptococcus or Klebs-Loeffler infection. «9.Q3. n /ju^uai 4 5 6 7 8 9 10 Cent. Fahr. ftM>M AMIPM am:pm am:pm am:pm AMlPM am:pn 40°" •i •1 104° -i '- ^ 'f s* 39' ■ •8 '. •' 103°': \ d \ ./ \ \ / \ •i •( ■102°-! \ \ f : \ /; t ■ \ • • 38°- •i •( 101° -i ': : * •8 •1 lOo"' s , : Pulse per minute a5 ^1 %\ liesptrationa per minute "5J (\3co -\' moderate cases were intramuscular or sub- cutaneous; for severe eases intraiiiuscular. subcutaneous or intravenous; for ma.lio-nant cases intravenous. Tlic dose of antitoxin for immunizing purposes was fixed at 1000 units. Severe Cases. — When we are dealing with a severe toxaemia with marked general depression and large masses of pseudo-membranes in the throat, 190*- DATES OF OBSERVATIONS | ^^ "^^ 38'~ 1 r •8 •6 -101°- 2 1/ V V V V . J [\ •8 •6 -100°- 2 i ^t \^ - ■8 - 0-4 -90 -i •rf V \. \ 37' ■ 8 •6 « aj •V 36 °~ -98' -2 § •" ■ 8 ;e -97°- 2 ♦a £3 - -i •6 w PulM per mliiiUe 3 ^ 10 (S IN (N ^ ^ ixJ 00 IN (-0 33 a|.o 3§ Rtsplratimta per minute O O a 02 C J2 IS cS IB 1 a< _o "3 01 O o .2 o a 1 1 2 1 1 .a 1 "3 a a -Si cs-*^ 'a 5 c Hi W.2 O o — ■ > SI o •S2 03 bO C3 g H > cS a. o a 3 m'3) ;.- a 2 .^ o 3 S)§ " a 3 -3 e-3) a-ja .c o m a iS3 1* a ^ 5 -a io^ u ^ af^ 3 -a t; a Ol >> bo's ^, cS Tin ©^ as ^^ be cS N >^ U a'-S 3-bb -1 a OJ >. ^ cS of =S M o e_ O cS M £?^§ }0 8Sb aqi :^B uoi^BnimB -xa iuabaa o t> CO lO CO o CO .^ •suouBqn^ni ' JO -OM ^ 1 w - " - - 'i" 1-t CO •pajBqmui naqAl ^ a II o =^ a (M--M O CO-— o CS OJ 'a_a CS 01 ■Tj a CS Ol o! 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H ■xas r '"^ . ^. . saaaaaaisu; l«5iH — ^ ^ ^. ►i* <5S ■^ fc'S ij ^ % _^ (N « lO r5 Tf lO ■^ CO X « -f OI CO Ol CO ic -^ -tco-*io-*STji.*oa •9niB{4; ^'as oJ^' w t^ 0-. » cv z-. o 5 to t~ 0x00 — ojwrintc 00 oo « rH — .1 — "OIOJO<0401(J5o1 "^ "^ " " " 560 TfiE INFUCtlOtJS DISEASES. A Study of the Condition of the Upper Air Passages Before and After Intubation of the Larynx. Also, an Inquiry Into the Method of Feeding Employed in the Cases.^ Laryngeal stenosis will frequently be relieved after one intubation and one extubation. There are other cases which require several intubations before a permanent cure results. I have examined a series of children that were operated upon several years ago. Two classes of cases have been selected. One series was seen at the Willard Parker Hospital, and the cases were intubated by the resident or assistant resident physician. The cases in this series cover the years 1896 to 1900, and were under treatment of Dr. B. Gr. Bryant and Dr. Somerset. First Series. Children Intubated in the Hospital. — The children ad- mitted to the Willard Parker Hospital belong, as a rule, to the laboring class of people. Exceptionally, the service at the, hospital receives patients of a better class. All of the children examined by me belonged to the tene- ment house district of New York City. The houses are densely crowded tenements having a minimum quantity of fresh air and sunlight. It is not unusual to see cases from such unsanitary surroundings ending fatally. These children are, as a rule, very anaemic and are extremely susceptible to infection. Hospital Cases : 10. 8 cases required one intubation 1 case required three intubations 1 case required four intubations Day of the Disease. 4 cases were intubated on the 2d day of illness 1 case was intubated on the 3d day of illness 2 cases were intubated on the 4th day of illness 1 case was intubated on the 5th day of illness 1 case was intubated on the 9th day of illness 1 case was intubated on the 14th day of illness One case intubated seven years ago has had no illness since. Four cases intubated six years ago are in excellent health to-day. One case has remained entirely well. One case had enlarged cervical lymph nodes. One case had pneumonia one year later. One case had pneumonia and paralysis and five years later had a second attack of diphtheria, but no laryngeal stenosis. Five cases intubated three years ago are in good condition to-day. Three had measles and bronchitis after recovery. One has not had a ^ Paper read before the International Medical Congress held at Madrid, Spain, April 26, 1903. INTUBATION. 561 day's illness since intubation. One case had a mild attack of croup two years after intubation, but did not require reintubation. Rachitis seems to play an important part in the causation of laryngeal stenosis, just as we know that rickets is met with in laryngismus stridulus. Eight cases out of the 10 reported in this series showed some form of rickets. There seems to be a certain predisposition for the development of laryngeal stenosis in children affected with diphtheria who are rachitic. Condition of the Throat. — In all of the cases of this series some form of chronic tonsillar or pharj^ngeal condition was found. Adenoids were also seen in 2 of these cases. Whether or no the hypertrophied tonsils seen in these cases were present at the time of intubation is not known. The fact that 8 cases out of 10 still showed enlarged tonsils, and 1 case, which makes 9 cases, reported having had a tonsillotomy performed, proves that hyper- trophied tonsils must have menaced the children's health before the diphtheria. Feedi/ng During Infancy. — It is certainly an interesting fact that all of the children in this series were breast-fed. When abnormal conditions, as rickets, scurvy, tuberculosis, syphilis, or other undermining disorders, exist, then recurring stenosis of the larynx might possibly be provoked by such chronic disease. These cases of recurring stenosis sometimes require months and, in rare instances, years of intubating until recovery takes place. I have fre- quently seen chronic tube cases while making my rounds in the wards at the Willard Parker Hospital. Intubation has, in America, entirely replaced tracheotomy for the relief of acute laryngeal stenosis. Eubber tubes are used exclusively for intubation. The old metallic tubes have long ago been discarded. Trache- otomy is used as a secondary operation, usually to cure "retained tubes." When laryngeal stenosis persists and the patient cannot get along without the tube, then a tracheotomy is frequently resorted to. Jennings, of Detroit, with an equally large experience, says that he has never met with the severer forms of the difficultj^, but that in two or three instances he has had to continue the intubation as late as the third week after the first insertion, before recovery was complete. His associate, Shurley, has never had any trouble with delay in the removal of the tube. G-alatti, in the article above referred to, states that he had 2 chronic stenoses in 31 intubations. He reports Eanke as having had 1 case in many hundred; Heubner, 1 in 250, and Bokay, 2 in 800. McNaughton, of Brook- lyn, says that he has had but few cases in many hundred, and these recovered at the latest within several weeks. 36 563 THE INFECTIOUS DISEASES. At the Nursery and Child's Hospital of New York City there have been no noticeably prolonged intubations. The New York Foundling Hospital has had 6 cases in a total of approximately 500. Investigation of the statis- tics at this institution forcibly illustrates the advantages in the use of the diphtheria antitoxin. The house physician complained to Dr. Eogers that before the introduction of this remedy his predecessors had always averaged at least one intubation a week, and thereby obtained much valuable experience; but about the time he came into the hospital, the rule was instituted that antitoxin should be given to every patient as soon as there was any suspicion of diphtheria. The result was that he had never in a year's service had a single opportunity to practice intubation on a living subject. The Dorsal Method of Intubation. — Elsewhere in this article I have referred to the dorsal method of intubation. The great advantage in this method lies in the fact that an intubation tube can be inserted in a child suffering with laryngeal stenosis with the aid of the mother or nurse alone. With the child lying on its back, the arms and feet pinned in a blanket or sheet to prevent struggling, any intelligent person can steady the head and hold the gag in position at the same time, while the physician has both hands free for the introduction of the tube. The older method required an assistant to hold the child in an up- right position, and a second assistant to stand behind the child's head to steady the same and to hold the gag in position. The experience gained in the hospital with both methods has led us to abandon the older method entirely. Second Series. Children Intubated in Private Practice. — The children of this series were seen in consultation with the family physician, excepting 1 case (Case 11),. which was referred to me for personal treatment. They belong to the better class of children, which implies better sanitary sur- roundings, better food and prompt medical aid when the first symptoms of illness are noticed. It was much easier to study this series of cases, as the physician in attendance, as a rule, gave me the required data. Case X should be excluded in this study, as the child coughed up its tube (auto-extubation) and died of asphyxia before the physician arrived. Case IX must also be excluded, as it was impossible to obtain satisfactory details concerning the progress of the case after it recovered from the diphtheria. 6 cases were intubated 8 years ago 1 case was intubated 7 years ago 4 cases were intubated 5 years ago 2 cases were intubated 4 years ago 2 cases were intubated 3 years ago 9 cases were intubated 2 years ago INTUBATION. 563 One of the cases in this series contracted scarlet fever and died two years after intubation. . So that 3 cases out of this series must be excluded leaving 23 cases from which reports have been received. Day of the Disease. •- ' 1 case was intubated on the 1st day of illness ■^ 11 cases were intubated on the 2d day of illness 9 cases were intubated on the 3d day of illness 2 cases were intubated on the 5th day of illness Number or Intubations Required. 15 eases required one intubation 2 cases required two intubations 3 cases required three intubations 1 ease required four intubations 2 cases required five intubations Length of Time the Tube was Worn. 1 case 26 days 2 cases 7 days 1 case 25 days 5 cases 6 days 1 case 22 days 8 cases 5 days 2 cases 14 days 1 ease 4 'A- days 2 cases 12 days The average length of time the tube was worn in the above 33 cases was 91/^ days or 338 hours. Rachitis. — In this second series of cases we are dealing with children brought up in excellent surroundings. In the families of the better class in New York City the majority of mothers do not nurse their own infants. Wet-nurses are not commonly employed. Thus the larger number of these children are to-day brought up by bottle feeding. It is, therefore, no wonder that in the present series of cases rickets due to malnutrition or inanition was very frequently encountered. The susceptibility of the rickety child has frequently been mentioned by many authors. In this second series of cases rachitis was associated in 19 cases. Condition of the Throat. — Not one of these cases had a normal throat at the time of the intubation. Adenoid vegetations, enlarged tonsils, and chronic rhinopharyngitis w^ere met with in almost every case. When the danger of a diphtheritic laryngeal stenosis in a child is considered, then it is certainly important to urge the removal of hypertrophied tonsils or adenoids if present, and to restore normal conditions in the rhinopharynx if possible. Greater attention should be bestowed on the nose, as the most fatal cases are those of nasal diphtheria in which general sepsis follows. After-effects Resulting from Intubation. — While some physicians have reported the existence of a bronchial catarrh during the first and second winter months following intubation, the majority of these 16 cases reported 564 THE INFECTIOUS DISEASES. absolutely normal conditions. Two cases have had pneumonia, in one child five years after intubation and in the other child three years after intuba- tion. One very interesting case in this series was a child (an idiot) 4 years old, seen in consultation with Dr. C. Hoffman. This was one of the most trying eases and required five intubations extending over a series of twenty-five days. The child made a splendid recovery. Such cases in private practice must be invariably supervised by a trained nurse. In this particular case careful feeding in addition to competent nursing was the means of saving the child's life. ISO 140 130 120 110 100 90 1 r 106 105 fy E 1— M i — ^ u E ME WE m[e ^Ey :n -2 -^ 1 eI^m __ EN E 1 :n EME^ME 10* 103" 102' 101' 100 99 98 35 30 1 1 I ^ ^ - - -o — < ^ i; 4Z-. :e < (- 3Z — 1 H 44 - EE E 1 ■X. -- 1 Et 'S- - '-- — - ^f-- "^ --J - -- -' , f- — •» 1 -^ ^ -jj pb =t: - ~~ rr: :: : Z1 = q: d N"T' " 4= w ^ ± E EE lz\ ~ __i-_ t= Iz E E: -- j_ 1 i 1 E EE EE: : = : ^4- -., ^ i ^ - -_ 1 -1^ ^ ^ ^E EE ^ ' t 5 i i F^^ ^5 Tfr ?a r E- -^^-.->s :=.-^- : 1 i = r ~ r \ E i E= — :E E -It; 2 S Es ;i 1 ^ r^'rtl^ m 20 16 1 E^ =E 1 P :X^ 1 Si ..^ ii I rhnT" EE EE I E: e:|^Ezz= Fig. 183. — LarjTigeal Diphtheria. Child 4 years old; mentally deficient. Seen in consultation wth Dr. C. Hoffmann. (Original.) Constant cougli or laryngitis lasting many months was' encountered in 4 cases of my series. All in all, there is no case in my series in which a distinct bronchial or laryngeal catarrh could be traced to or associated with the intubation. INTUBATION. 565 Rogers says: "As regards the etiology of postdiphtheritic stenosis of the larynx and retained intubation tubes, the views of the late Dr. O'Dwyer are, of course, worthy of the greatest consideration. Nevertheless, I believe they are wrong. He maintained that the condition was the fault either of the operator or of the instruments, which means careless or unskilled inser- tion, or the use of poorly constructed, and, therefore, improperly fitting tubes. Formerly, while he was experimenting with and perfecting his in- strument, he sometimes encountered ulcerations and granulations; and the 2 cases he reports of granulations at the Ijase of the epiglottis, where it impinged upon the head of the tube, might properly be counted in this class. At all events there is no other record of a similar occurrence from the u^e of the liard-riibher tube as at present made. It must be admitted, nowevei, that erosions and ulcerations are possible with a metal tube, as its surface soon becomes rough from a deposit of what is apparently calcareous matter. But WThether ulcerations and subsequent cicatrices may not be thus produced has very little to do with the matter, as they do not seem to be the usual cause of the stenosis in the reported cases. . . . And it is important, from a medico-legal aspect, as well as for the sake of intubation, to show that neither the operator nor tube, ordinarily, has anything to do with a possible postdiphtheritic stenosis. It is granted that lacerations and serious per- manent damage to the larynx can, of course, be inflicted by extreme lack of skill or care ; but to claim that this must have happened in all, or even some, of the cases of retained tube is not borne out by the facts. A certain amount of traumatism is necessarily inflicted at every intubation, and if, by any chance, a chronic stenosis follows, the traumatism is always blamed for it. That this is wrong, at least in the average case, is proved to my mind by the pathology of the condition. It is the same whether the stenosis follows intu- bation or a primary tracheotomy." ' • Causes of Recurring Stenosis. — Emil Kohl, in his inaugural address at Zurich, in 1884, described very fully the pathological condition of the larynx in cases of chronic postdiphtheritic stenosis with retained tracheal cannula. This article demonstrates most conclusively that not the least frequent cause of the difficulty is a chronic hypertrophic, subglottic laryngitis, a chronic thickening of the soft parts between the vocal cords and the lower border of the cricoid cartilage. The hypertrophy of the soft tissue was so marked that respiration, except through tracheal fistula, was impos- sible. These cases, of course, had never been intubated; and, therefore, the chronic inflammation within the larynx cannot be charged to the irrita- tion or traumatism consequent upon the insertion or wearing of an intuba- tion tube. Another and more frequent cause of the stenosis was shown to be granulations and cicatrices in the neighborhood of the tracheal wound or cannula. And the nearer the cannula was to the vocal cords the worse were 566 THE INFECTIOUS DISEASES. these complications. The vicinity of the upper end of the wound was more prone to granulations and cicatrices than the lower, as the upper end gener- ally involved or was close to the larynx, where the mucous membrane is more loosely attached than below. This bears upon the cause of the stenosis described in some of the reported cases of retained tubes which have finally been tracheotomized. If the tracheotomy has existed long enough, it, and not the original intubation, may have given rise to the cicatricial tissue. Incidentally, it may be noted that the number of devices described by Kohl for remedying a postdiphtheritic stenosis will illustrate the difficulties in the way of successful treatment other than by intubation. In speaking of the operative treatment of stenosis of the larynx follow- ing intubation and tracheotonw, Arthur B. Duel says: "The important points to remember: (1) About 1 per cent, of all patients intubated for acute laryngeal stenosis will 'retain' the tube. (2) The cause of the reten- tion is due, in the majority of cases, to chronic inflammation of the intra- laryngeal mucous membrane and hypertrophy of the subglottic tissues, and is not, as has been generally supposed, the result of granulation, ulceration, or cicatricial bands. (3) Autoextubation in these cases is the rule, and adds greatly to the danger where an experienced intubator is not at hand. As a result of this a large number of such cases are tracheotomized for safety. (4.) Where high tracheotomies are done, cicatricial bands are almost certain to form in the trachea or lower part of the larynx above the tracheotomy wounds.'' The points in treatment which should be emphasized are: (1) The largest sized tube possible should be inserted, under an anaesthetic. In case of contraction, rapid dilatation should be done by beginning with the small sizes and working up to the large special tube, which is to be left in place. This special tube should be as large as can be inserted, and the constriction below the neck only '^/^^ inch smaller than the retaining swell. (2) This tube should be left in, undisturbed, for six weeks at least. It should then be removed, and, if a cure has not been accomplished, it should be replaced for six weeks longer. To illustrate the above the following case may be cited : — Child B., 2 years old, was seen by me in 1895, in consultation with Dr. McConville, of Brooklyn. The child had had a severe pharyngeal, tonsillar and laryngeal diphtheria. The temperature was 101° F., pulse 140, respiration labored. Child cyanotic. I intubated with a No. 2 metal tube, which immedia^tely relieved the laryngeal stenosis. The general condition of the child improved greatly and three days later I was requested to extubate. Several minutes after extubation marked laryngeal stenosis recurred so that a second intubation was necessary. The child's condition again improved, and when normal conditions prevailed, in about four days I was again requested to extubate. Thus the child was intubated and extubated every four days for a month. As the family were unable to retain the services of a competent trained nurse, and as the child required frequent medical INTUBATION. 567 supervision, the case was transferred to the Gouverneur Hospital. Dr. Rogers treated this case as he does all of his "retained tube" cases by introducing the largest sized tube that can be worn, and allowing the tube to remain in situ four, five or six weeks before extubating. After one month of this treatment I was informed that extubation permanently relieved the condition and the child was dis- charged from the hospital cured. Paralysis of the Vocal Cords. — Very many cases have been reported by competent observers on both sides of the Atlantic. In America, Waxham, Eosenthal, Engelmann, myself and many others; in Europe, von Bokay, Trump, Egidi, Galatti, Massei, and Escat. Intubation in Hospital Practice. — ^There is a decided difference be- tween intubation in a hospital and intubation in private practice. In the Willard Parker Hospital, New York, there are always several physicians ready to intubate at a moment's notice. I have seen more than one case of mild stenosis treated with antitoxin; and careful dietary get well without intubation. Haste is not necessary, and each case must be carefully treated. Intubation in Private Practice is an entirely different matter. Johann von Bokay in his review regarding intubation published in the "Transac- tions of the Section on Diseases of Children," held at Hamburg, 1901, honors me by the following quotation^ : "Audi halte ich das Vorgehen von Louis Fischer, des hervorragenden intubators aus New York, fiir unrichtig, der sagt: Ich mache es mir zur Eegel — wenn ich sicher den Nachweis liefern kann, dass es sich um eine Diphtheria handelt und ich das Vorhandensein des Klebs-Loffler-Bacillus contatirt habe, die intubation sofort vorzunehmen, wenn sich die geringste Stenose zeigt." While his statement is partly true, it does require a slight modification. When a mild case of laryngeal stenosis is encountered in private practice, then judgment must be used regarding the time for intubation. The points to be considered are: the distance at which the patient lives, the amount of diphtheritic infection that we are dealing with, and the circum- stances of the people in which the case occurs. If the child is fortunate enough to be under the observation of a competent nurse, who can recognize the slightest increase in the stenosis, watches the condition of the heart, and calls the physician the moment the slightest danger arises, then the condi- tions are most satisfactory and we can wait with intubation ; otherwise we are compelled to intubate when slight evidences of stenosis appear. J do not ad- vocate i/ntubation the moment stenosis exists. In Case XXI of my series of private cases above reported, seen in consultation with Dr. Harry Weinstein, ^My rule is to intubate when the slightest stenosis exists, provided the clinical diagnosis of diphtheria has been verified by the bacteriological diagnosis. 5f)8 THE INFECTIOUS DISEASES. the stenosis of the larynx was treated by an injection of antitoxin, the child placed under the care of a competent trained nurse with detailed instructions regarding progressive symptoms. Twelve hours later, when the stenosis in- creased in severity, I was summoned hurriedly to intubate. In this case the child wore the tube six days, and required but one intubation to complete the cure of the stenosis. In America the majority of intubated cases occur in private practice. Yon Bokay states that according to Jacobi, only 5 per cent, of diphtheritic laryngeal stenosis are treated in the special (Willard Parker) hospital. The rest, 95 per cent., occur in private practice. The smooth rubber tube with or without metal lining is now generally used for the relief of laryngeal stenosis. Smooth rubber tubes, with a re- taining swell, the advantage of the same over the metal tube in not having calcareous deposits after being worn for weeks is certainly noteworthy. The corrugated rubber tubes which were introduced by me several years ago have certainly served me very well in many cases of "retained tube.^^ The follo^^'mg• case occurred in the practice of Dr. A. W. Newfield. The child was about 4 years old, and had suffered for several years with hypertrophied tonsils and adenoid vegetations, in addition to chronic pharyngitis. The family physician ad- vised the parents to have the throat operated owing to the danger of infection with diphtheria. This prophylactic measure was not carried out. I saw the case on the second day of illness, in consultation with Dr. NeM^field, and found diphtheria in- volving the pharynx and tonsils which spread A'ery rapidly to the larynx. The same day intubation was required to relieve a severe stenosis. The stenosis was so severe when I saw the child, and the pulse so weak, that it required a rapid intro- duction of the tube to afford relief. An injection of 3000 units of antitoxin was given. Three days later a second injection of 3000 units was made; so that 6000 units were injected in all. There was recurring stenosis when the tube was re- moved. It was necessary to intubate within ten minutes. Extubation was per- formed once every five days, and reintubation was necessary a few minutes to one- half hour after removing the tube. Rubber tubes only wei'e used in this case. After the second intubation an alum gelatine film was used on the tube. After the third intubation it was deemed necessarj' to use a corrugated tube dipped in a solution of hot gelatine containing 3 per cent, of ichthyol and alum. This tube was worn about five days. After the extubation the child breathed, well for about one hour without a tube. A mild form of stenosis was noticed and it was deemed safe to reintubate with an ichthyol alum gelatine film on a No. 4 corru- gated rubber tube. This tube remained about six days and was then removed. Stenosis did not recur and the case was discharged cured. Later on the adenoids and hypertrophied tonsils were removed and the child has been well since. Conclusion. — All the children in Isoth these series that recovered had been breast-fed. Tliis form of feeding must have had an important bearing on their bony development as well as their muscular structure. No chronic cough which could be attributed to the wearing of the tube was encountered. It was presumed by me at the outset of my investigation, that I might meet with a series of cases of chronic larjmgitis, chronic tracheitis and chronic bronchitis, dating back to the intubation. We know INTUBATION. * 569 that pressure of the tube has frequently caused decubitus; hence, it is pre- sumed that an inflammatory process might be invited from the wearing of the tube. Comparing an equal number of children of the same age and development who never suffered with diphtheria, nor were intubated, it was foimd that they suffered with pneumonia and other infectious diseases in the same proportion as children in my series of cases. This would seem to be a splendid argument in favor of intubation, as it shows two important points : — First. — The tolerance of the larynx to a tube for many weeks, one of my cases having worn a tube twenty-six days, another case twenty-five days. Second. — That a properly fitting tube constructed of rubber leaves no evidence of chronic inflammation directly traceable to the tube. In every one of my cases I questioned carefully if any catarrh originated from, or could be associated with, the wearing or removal of the tube, and received negative replies. Equally interesting was it to study the contour of the thorax and to see if the development of the thorax suffered by reason of these children wearing tubes. In spite of the fact that the large majority in the first series as well as in the second were decidedly rachitic, no deformity of the chest due to imper- fect oxygenization could be attributed to the effects of the intubation tube. An etiological factor and one on Avhich a great deal of stress has already been laid, is that 90 jDer cent, in my first series of cases suffered with chronic throat disease in some form, such as hypertrophicd tonsils, chronic pharyn- gitis, or adenoids. In some all of the above conditions were apparent. It is safe to presume that chronic throat disease invites infection, and I believe that there is a direct relationship between the seed and the soil. If children's throats are in a normal condition, then the risk of infection is reduced to a minimum. It is our duty, therefore, to urge all mothers to have diseased conditions removed, and thus try to prevent the infection of diphtheria, which is certainly a serious condition. Eecukein^g Laryngeal Stenosis Following Intubation AND Decubitus. Etiology. — This condition is primarily caused by forcibly pushing a tube into an oedematous or infiltrated mucous membrane. O'Dwyer says that it is caused by using a tube that is too large for the lumen of the larynx; usually in the hands of inexperienced operators. Metallic tubes that have been worn for a long time contain largo calcareous deposits — the latter are due to a deposit of lime salts contained in the diphtheritic mem- brane — and when removing such a tube during extubation, the mucous mem- brane is easily lacerated, and thus ulceration is caused thereby. One of the most important papers given to the profession was read by the late 5?0 TBE INFECTIOUS DISEASES. Joseph 0'Dw}'er.^ In his paper entitled "Eetained Intubation Tubes'^ be says: "The cause of persistent stenosis following intubation in laryngeal diphtheria can be summed up in the single word 'traumatism/ Paralysis of the vocal cord may possibly furnish an occasional exception to this rule." Thus an injury to the larjTix can be done by a tube that does not fit; it may result from an imperfectly constructed tubC;, or from a perfect tube that is too large for the lumen of the larynx^ although proper for the age, or from a tube that is perfect in fit and make if not cleaned at proper inter- vals. O'Dwyer states that the seat of the lesion that keeps up the stenosis is just below the vocal cords in the sub-glottic division of the larynx, or that portion of the organ bounded by the cricoid cartilage. Exceptions to this rule result from injury produced by the head of the tube on either side of the base of the epiglottis, just above the ventricular bands. The reasons given by O'Dwyer for the existence of the stenosis at this particular portion can best be explained b}^ the following : — Pathology. — Anatomically, normall}^, there exists a constriction in the cricoid region. When the mucous membrane infiltrates or gets cedematous it swells to such an extent and only toward the center, as the outside is sur- rounded by cricoid cartilage; and while swelling toward the center, me- chanically impedes respiration and thus calls for mechanical relief, i.e., intu- bation. O'Dwyer states that if a tube is forced into the larynx in a case of this kind, ulceration and sloughing of the tissues is inevitable, and in some instances necrosis of the cricoid cartilage can result from interference with the circulation. Our only safeguard in preventing too much mechanical injury as in the condition above cited is to introduce "a tube of small caliber." In the early stage of this form of cases the dyspnoea returns slowly; sometimes several days, or in some instances only a few hours, may pass before the former condition of laryngeal stenosis is recognized and the neces- sity for the introduction of a proper tube is demanded. When the dyspnoea returns slowly, it means that the lining membrane- of the lar}Tix cannot swell while the tube is in position because it is com- pressed between the tube and the cartilage. It requires some time for the re- appearance of the cedematous tissue, which drops into the chink of the glottis and obstructs the respiration, the latter condition being mechanically prevented as long as the tube was in situ. Exceptional cases have been re- ported where granulation tissue springs up from the antero-lateral aspects of the larynx just above the ventricular bands. O'Dwyer states that the origin of this growth is a slight ulceration or erosion of the mucous mem- brane at the points corresponding to the greatest transverse diameter of the shoulder of the tube from the pressure exerted during the act of swallowing. Paralysis of the Vocal Cords, although known to exist, is very hard to * American Pediatric Society, at Washington, May 6, 1897. INTUBATION. 571 diagnosticate without a proper laryngoscopic examination. Like other forms of paralysis it comes very late in the course of the disease, and if, after wearing an intubation tube for a short time, laryngeal stenosis recurs, it is safe to assume that paralysis of the vocal cords is not the cause of the immediately recurring stenosis. Fig. 184. — Case seen in consultation with Dr. S. M. Landsmann, Diphtheria. Laryngeal stenosis requiring intubation. Normal conditions and extubation on the fifth day. Two days later, on the seventh day of illness, a sudden high fever, due to over-feeding, required diet and calomel. Case recovered. (Original.) False Passage. — Eepeated forcible attempts at intubation will lacerate the tissues. It is not infrequent to enter the ventricles of the lar}'nx, pro- ducing a false passage by such forcible attempts at intubation. If a false passage has been produced, then laryngeal stenosis will not be relieved, and it is much wiser, if an expert intubator cannot be found, to immediately resort to tracheotomy. The great danger of collapse due to heart failure 572 THE INFECTIOUS DISEASES. must always be remembered; hence it is advisable that the operation, be it intubation or tracheotomy, should be done quickly, thus lessening shock. EXTUBATION, Eow to Extubate. — First step in the operation: place gag in position; locate the tube with the left index finger; guide the extractor along the i^..o.Z DATES OF OBSERVATIONS | ^EPT 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Cent. Fahr. am:pm am:pm am:pm am:pm AMiPM AM:pni AMiPM AHlIPM am: PHI AHlPM AMiPM AM.'PH ah:pm am:pn a°~ • 8 •« -106°: a 'i H :H •8 '6 -105°:^ ^1 1r % > j ^ 40°~ •S •6 104° '■ 2 <9 ^ J %. 3 39°~ -103° -2 • t % 4^ •8 -102°-* h □3 I 1 -> : ^ ^ 38°" •8 •6 -101°: 2 ^z (.J > V % •3 •6 -100°- 2 \ X ■A . /^ -V • > h ^ ^ 37" •8 •6 - 0-4 -90 -2 y vr: N -^ yA < / 1 •8 ^ -6 : «/. 36 ~ -9H' -2 ^ ■ -8 h97 -2 •8 • 8 -96° -2 '■ '■ Pulse per minute SI 03 ry U3 C 3? U3 od c — <^^ 35 3 1 Rtsp/ratims P per minute Ldoc cj rrjjorj 3^ ^4 1 Fig. 185. — Temperature Chart from a Case of Laryngeal Diphtheria. Excellent Result of Intubation and Antitoxin. Doubtful Prognosis. Re- covery. (Original . ) finger until the beak enters the lumen of the tube. Second step in the oper- ation: depress the handle of the extractor to hold tube firmly, and with- draw the tube slowly. (See Plate XXVI.) l^hen to Extubate. — Five days is a fair length of time for the tube to be left in the larynx. The following rules have served me best in a very large experience in hospital and private practice : — ■ Let the child's condition be the guide as to when to extubate. My advice is to leave the tube in the larynx at least four days, then remove the same. EXTUBATION. 573 The question to be considered is. Can the child undergo the shock of extubation, and, if need be, reintubation ? If the temperature is over 100° F., and the pulse-rate is small, rapid, and over 120, it is better to wait vrith the extubation. A rubber tube left in the larynx does not have calcareous deposits as we find them on the metal tubes; hence there is no danger in leaving a rubber tube in situ for several weeks. If the tube is plugged with mucus or membrane it may be necessary to remove the tube and clean it. A rattling or crowing sound in addition to laryngeal stenosis usually indicates this condition. At the Willard Parker Hospital there is no definite rule as to the number of days a tube remains in the larynx. Individual conditions govern the time of extubation. In some cases tubes are removed after forty-eight hours. The severity of the cases admitted to the hospital and the complication must be taken into consideration. Uncomplicated cases may be extubated any time between the third and seventh days when the oedema of the larynx subsides. In a few instances the child expels the tube without having recurring stenosis. This auto-extubation is occasionally seen ; it is Nature's method of removing a foreign body after the subsidence of the inflammatory condition. Choice Between Intubation and Tracheotomy. In cases where operation is indicated it may be said that intubation has steadily grown in favor, and its advantages, when it is indicated, are so obvious as to require no recapitulation here. On the other hand, conditions are sometimes present that render intubation impracticable or inadmissible, or at least render tracheotomy preferable. It is therefore desirable to keep clearly in mind the factors that determine the choice in favor of one or the other of these operations. This subject has received con- sideration in a study, by Drs. George Alsberg and Sigmund Heimann, of the cases of diphtheria, to the number of 4033, observed at the Kaiser und Kaiserin Friedrich Kinderkrankenhaus, in Berlin, for the ten years from 1891 to 1900. As a result of this analysis it is concluded that operative in- tervention in cases of stenosis of the larynx of slight and moderate degree should be obviated as far as possible by means of antitoxin and the employ- ment of sprays. Primary intubation is indicated in all cases of stenosis of the larynx of severe degree in which, so far as the clinical picture makes it appear possible, a cutting operation can be avoided. Primary tracheotomy is indicated in the presence of asphyxia and collapse, of pneumonia, of severe heart disease, of paralysis of the palate and diaphragm, of profound ana- tomic changes in the pharynx, as well as marked tumefaction of the entire pharyngeal structures when necrotic. 574 THE INFECTIOUS DISEASES. Secondary Tracheotomy is indicated when the symptoms of stenosis persist in marked degree with the tube in place, providing its lumen is not occluded, when pneumonia supervenes, and when paralysis of the palate and diaphragm supervenes. Intubation is not recommended in nursing in- fants by some writers on account of the diminutiveness of the parts and of the narrow lumen of the pharynx, but especially on account of the increased difficulty in feeding from the presence of the tube, which at this time of life is of vital importance. My personal experience is just the reverse, and my results have been excellent.^ Tracheotomy (In Acute or Subacute Laryngeal Stenosis). If laryngeal stenosis persists in spite of intubation, then secondary tracheotomy is indicated. When extensive csdema of the larynx exists, in which case intubation fails to relieve, tracheotomy may be required. I have frequently met surgeons who were well posted on tracheotomy, but were not familiar with the delicate modus operandi of intubation. If laryngeal stenosis threatens life, and the physician is not acquainted with the method of intubation, then by all means perform tracheotomy, rather than risk "experimental intubation." When emergencies arise they should be met by quick action. An in- teresting case of suffocation due to laryngeal stenosis was told to me by my friend. Dr. George P. Shrady : — A child suffering with croup suddenly collapsed and was thought dead, when Dr. Shrady, in the emergency, took a razor which was handy and made an incision into the trachea. He used a bent hairpin instead of a tracheaL dilator. The child breathed as soon as oxygen was admitted. The case recovered. Tracheotomies Performed {Willard Parker Hospital, 1911) with Day of Disease and Number of Days Tracheotomy Tube Remained in the Larynx. Total number of tracheotomies performed 4 Tracheotomized on first day of disease 3 Tracheotomized on second day of disease 1 Tracheotomy tube remained in larynx one day 1 Tracheotomy tube remained in larynx two days 2 Tracheotomy tube remained in larynx four days 1 - Result, 3 deaths; 1 recovery. Tracheotomies performed before admission 2 The Operation. — Ancesthetic: If time permits, a few drops of chloro- form should be given. If septic stupor exists then no anesthetic should be given. The high operation, "tracheotomie superieure," in which the incision is ^ See case of Baby R. in the practice of Dr. Kahrs, "Intubation in Private Practice." TRACHEOTOMY. 575 made in the upper portion of the trachea, is preferred to the lower operation, advised by Trousseau, known as ''tracheotomie inferieure." The upper portion of the trachea is quite superficial and it is best to make an incision, exactly in the median line, at least two inches in length. It is important to remember that the branches of the inferior thyroid veins are immediately under the place chosen for the operation; hence the parts must be carefully dissected with a blunt instrument, such as the back of a scalpel, until the trachea is reached. If there is severe bleeding the veins should be seized with a forceps unless emergency demands rapidity of action. The dissection should be continued until the trachea is reached. When there is considerable oozing of blood, and our view is thus obstructed, we must remember to keep in the center of the throat, which invariably brings us to the rings of the trachea. By placing the finger in the wound we will feel the respiratory movement of the trachea. When the trachea is reached Fig. 186.— Silver Trachea Cannula used in tracheotomy. Fig. 187. — Hard-rubber Trachea Cannula. it should be hooked up with a tenaculum and an incision made large enough to admit the tracheotomy tube. The rush of air, so-called tubal sound, characteristic of intubation is also heard when tracheotomy is properly performed. After-effects of the Tracheotomy Tube. — The presence of the tube in the trachea invariably excites cough. This expels loose membranes and other viscid accumulations. High fever sometimes follows this operation, although as a rule the temperature will only reach 101° or 102° F. The pulse-rate should be carefully observed; a gradually increasing pulse-rate during the first three days after the operation is a very bad sign. Complications.- — Broncho-pneumonia and nephritis are to be feared, for they frequently terminate fatally. The treatment of complications is the same as though the disease existed independent of the operation. After-treatment. — Careful aseptic methods must be the rule from the moment the child's stenosis is relieved. The infection of the wound will always be an added source of danger. As the majority of cases of trache- otomy will be performed for extensive pseudo-membranous stenosis, we must remember that septic diphtheria per se may cause death independent of the 576 THE INFECTIOUS DISEASES. added danger incident to the opening of the trachea. All oozing of blood must be checked ; pressure with sterile gauze saturated with Monsell's solu- tion has served me well. I have also used gauze dusted with a powder con- sisting of : — ■ IJ Europhen 7 parts Alum 3 parts To Chech Hcemorrhage. — The local application of adrenalin solution, 1 to 5000, is very valuable during the operation. The internal cannula should be removed and cleansed every two or three hours, wiped dry and replaced. In rare instances it may be necessary to cleanse the cannula less frequently. This can best be determined by watching the respirations and instructing the trained nurse as to when the caliber of the tube requires cleansing. Noisy, rattling sounds due to the presence of mucus in the tube do not necessarily mean that the cleansing of the cannula is urgent, if the child is quiet or asleep. If the child is restless and turns its head from side to side, and usually mucous rattling is heard in addition, then it is an indication for cleansing the tube. Cleansing the Wound. — Each day following a tracheotomy, it is advisa- ble to place the child on the operating table, withdraw the tracheotomy tube and replace it with a new one. A writer states that "after the second or third removal the larynx should be examined to see if it is free and there is no further use for the cannula.'' My experience with tracheotomized cases has not been as good as that, for rarely have I seen a tracheal cannula that could be dispensed with, although antitoxin was administered, in less than seven to twenty-one days. The severity of my cases may account for the difference in experience. At times, in spite of the greatest amount of care, even in the hands of experi- enced operators, cicatrices of the trachea resulting in permanent contraction or exuberant granulations at the site of incision will require the continued use of the tracheotomy tube, as in cases described in the article on "Intuba- tion," known as "retained-tube cases." CHAPTER VII. RUBELLA (ROTHELN, GERMAN MEASLES, FALSE MEASLES). EuBELLA is an exanthematous eruption simulating measles. Oorlett's description of rubella is so classic that I give it word for word.^ "Eubella is a mild form of infection which always follows a benignant course and first appears as a general or constitutional disease, accompanied by a slight rise of temperature and slight feeling of illness. In this it conforms to the other affections of this class. "The local manifestations, while partaking of the character of those observed in both scarlet fever and measles, are distinct, and possess an individuality which, as a rule, may be recognized by the trained eye. "Etiology. — While we have no exact knowledge of the cause of the disease and in what respect the virus differs from that of other diseases to which it bears the closest resemblance, yet we do know that it is contagious, and always gives rise to a like disease : in short, conforms to the type. "It occurs but once in the individual, from which we infer that it is self-protective, while it affords no protection to or modification of measles or scarlatina; nor has it appeared that they offer any protection against rubella. It must be remembered, moreover, tha,t even mild forms of the various exanthemata are self -protective. The fact that the patient has had at some previous time either scarlet fever or measles, or both of these affections in a well-marked degree, often leads to its recognition. Some- times, even before its true nature has been definitely settled in the mind of the medical attendant, the disease disappears. "Like the other exanthemata, it always appears in the form of an epidemic, which seems to bear little or no relation to epidemics of other diseases, such as scarlet fever or measles." Bacteriology and Pathology. — Owing to the mild character of the dis- ease, the pathological changes have not been studied. There are certain changes seen in the skin, described by Thomas. Nothing definite, however, can be stated. Bacteria in the blood of children suffering with rubella have been described by several authors; these are by no means pathognomonic of this condition. "It sometimes occurs independently; again, two or more of the epi- demic exanthemata prevail at the same time. It must be admitted that ex- traneous conditions of weather and possibly of sanitation predispose in a like degree to all. Though epidemics of nibella seem to occur at less fre- quent intervals than do those of either scarlatina or measles, there can be no doubt that very many epidemics of rubella escape recognition, and are re- ^ For a very minute description of this disease the reader is referred to Corlett's "Treatise on the Acute Exanthemata." Published by F. A. Davis Company. 87 (57Y) 578 THE INFECTIOUS DISEASES. garded as mild or aberrant forms of one or the other of the first-named affections. While the author believes, with Atkinson, that unless more exact methods are adopted in the study of the exanthemata there is still danger of endless confusion, and that the practice of relegating all mild or otherwise anomalous forms of measles or scarlatina to rubella is, as it was thirteen years ago, far too prevalent; yet the remedy lies in giving to this important group of affections a more conspicuous position than it now holds in the curriculum of clinical instruction.^' The period, of incubation is usually from fifteen to eighteen days. In New York City cases of rubella are excluded from school for one week, at the end of which time they will be readmitted on a medical certifi- cate. Children in the family who have had the disease may remain in school. Symptoms and Diagnosis. — ^The symptoms may be so mild that they are frequently overlooked. The prodromal symptoms appear a few hours before the rash is seen. Some authors state that in the majority of cases they are wholly absent. I have frequently seen catarrhal symptoms such as coryza, in addition to suffusion of the eyes, on the day previous to the eruption. Throat symptoms, such as congestion and swelling of the tonsils and fauces, are usually seen. 'Cough and hoarseness may also be present. The buccal mucous membTane does not have an enanthem. Forchheimer^ describes what he considers a characteristic enanthem in rubella which appears simultaneously with the exanthem and remains from 12 to 14 hours. Its favorite location is on the soft palate, sometimes extending to the hard palate. It consists of small, discrete, dark-red but not dusky papules, which soon disappear, leaving no trace behind. The rest of the mouth may or may not be congested. Sometimes there is anorexia and occasionally nausea or vomiting. J. Lewis Smith describes convulsions seen in the disease. The temperature varies between 100° and 101° F., rarely higher. The tongue is not as thickly coated as in measles, although the papillas may be enlarged. These projecting papillae appear on the tip of the tongue. The characteristic strawberry tongue is absent. Sneezing may be present and coryza may be absent, or vice versa. Thierfelder^ states that "swelling of the subauricular and superior jugu- lar lymphatic glands may be looked upon as a constant prodromal symptom.'' Atkinson^ says "enlargement of the superficial lymphatic glands of the neck may be the most striking symptom, and sometimes attracts attention several days before the beginning of the eruption." ^ "German Measles," Twentieth Century Practice of Medicine, New York, 1898. i' Thierfelder : Greifsw. Med. Beitr., B. ii, Ber., p. 14, 1864. 'Atkinson (loc. cit., p. 23). RUBELLA. 579 Corlett* says "his cases show adenopathy in 9G per cent., of which the maxillary and superficial or post-cervical were the most frequently in- volved; next the occipital, posterior and anterior auricular; and sometimes the superficial inguinal, axillary, and the e])itrochlear. In the neck the inflammation may he sufficiently severe to interfere with free movement, and in two or three instances it has given rise to marked ccdema of the sur- rounding parts." Suppuration of the glands is never observed. The lymphatic ganglia are also involved in the regions affected. The spleen is seldom involved. Pauline M., 6 years old, was brought to my office in an apparently good con- dition. 1 was told that the child had a rash on her chest and back, and that the temperature was 100° F. in the rectum. There was sneezing, but no cough nor bronchial symptoms. There was an enlargement of the glands on both sides of the neck along the posterior border of the sterno-mastoid muscle. The buccal mucous membrane, pharynx, and tonsils were but slightly inflamed. The conjunctivae were of a deep pink color. The rash was scattered over the abdomen and chest and was erescentic in its arrangement, similar to that seen in measles. The highest tempera- ture reached was 101° F., in the evening, pulse was 100, and the respiration 24. The treatment consisted in giving a mild laxative and liquid diet. Strict isolation was insisted upon. The eruption remained about three days. The child recovered without any complication. The Eruption. — The rash is first seen on the face and scalp. It is described as "faint pinkish macule, at first discrete, but sometimes becoming more or less confluent within a few hours." The eruption spreads down- ward to the neck and upper part of the abdomen until the uj)per and lower extremities are covered. The palms and soles are usually associated in this general eruption. The eruption reaches its full development after one or two days. It spreads slowly and fades on the face wdien it is about reaching its height on the lower extremities. Hardaway believes that this dissimilarity in the appearance of the eruption is a valuable means of distinguishing ru- bella from measles. "The individual lesions are sometimes perceptibly ele- vated and vary in size from a pin-head to a small bean." They are often slightly elongated or irregularly round in shape, with an ill-defined border, and disappear completely on pressure. Unlike measles, they show no tendency to form groups, clusters, or crescents, and in some cases manifest a feebler predilection to coalesce. Sometimes, however, when confluent they extend at the periphery, coalesce, and form extensive areas, when the re- semblance to scarlatina may lead to an error in diagnosis. "Usually the plaques thus formed are found only on certain parts, while on the remaining portions of the body the eruption presents the more usual appearance. The color is always lighter than that observed in scarlet * Corlett, "A Treatise on the Acute Infectious Exanthemata," p. 356. 580 THE INFECTIOUS DISEASES. fever, and in a strong light the slight elevations which correspond to the original lesions may be discerned. Further, the eruption is fairly uniform in color and may be described as of a faded rose, or pink tint^, never, in my experience, presenting the fiery red of scarlatina nor the dusky, bluish red of measles," Subjective Symptoms. — These are usually so mild that children do not complain. I have seen cases of rubella in the Kaiser and Kaiserin Frederick Hospital, in Berlin, while making rounds with Professor Baginsky, which were of a very mild nature and in which hardly any subjective symptoms were complained of. The Fever. — A peculiarity of this condition is that the fever does not correspond with the eruption, in intensity. Von Nymann studied 119 cases OAT£ 11 iZ 13 iU- iS TEMP. FAHR. •g M E M £ M £ M £• M E loi' :t :i /oo' '•% i. r^ -'''^^ ^ ^^^ ''""^ w H ^^^ ^= Fig. 188. — Temperature Chart. Case of Rubella. (Original.) of rubella. He found that 58 cases showed no rise in temperature. In the remaining 61 cases the temperature was as foUows: — In 39 cases the highest record was 100.4° F. (38.0° C.) In 14 cases the highest record was 101.3° F. (38.5° C.) In 6 cases the highest record was 102.2° F. (39.0° C.) ' In 2 cases the highest record was 103.1° F. (39.5° C.) Fever never remains more than four days unless some comjjUcation ex- ists. The pulse and respiration do not show much change, but usually cor- respond with the temperature. Sometimes a slight albuminuria is present. , Desquamation. — A general desquamation is absent. Just as the rash spreads from place to place and is regional in character, so also is the desquamation regional. There is therefore no distinct stage of desquama- tion that can be applied to the disease as a whole. Differential Diagnosis. — The following distinctive points are taken from Corlett: — "First. — That rubella is sometimes feebly contagious, while measles is always violently contagious. RriJELLA. 581 "Second. — The prodromal stage is always short and quite insignificant in rubella, while in measles it continues from three to four days. "^'Third. — In measles the prodromal stage is usually accompanied by marked constitutional symptoms, with catarrh of tlie upper air passages, lacr}iuation, photophobia, and a more or less characteristic eruption in the mouth, which appears from twelve to forty-eight hours before the cutaneous exanthem. In rubella no characteristic prodromata are observed, and only at the beginning of the eruptive stage is there usually a slight hyperemia of the conjunctiva?, of the faucial mucous membrane, and rarely of the upper air passages. On the soft palate and uvula there is sometimes a punctate or faint macular enanthem, which by some is considered distinctive. Even in mild cases of measles the disturbance of the mucous membranes is more severe than in severe cases of rubella, and there is always, so far as I have observed, a bluish or skim-milk tint to the mucous membrane of the mouth, which I have never found in rubella. In rubella, sore throat is present in nearly all cases, while in measles sore throat is uncommon. "Fourth. — The eruption in rubella appears most frequently on the first and second day, rarely later. It often disappears from parts first attacked before other regions become involved. It is of a pale red or pinkish color, very rarely assuming a dusky tint, and the individual spots are surrounded by a faint areola, thus obscuring the outline of the lesion. The spots are papulo-macular, for the most part round or slightly oval in shape, and present no tendency to form crescents or groupings. Sometimes by coalescing they unite to form extensive areas, which in all cases, either at the periphery or on more remote parts, are associated with the discrete, small macules which give character to the eruption. The rash rarely lasts longer than three days, and most frequently it disappears on the upper part of the body on the second; while in measles the eruption almost always appears on the morning of the fourth day, sometimes on the third, and rarely earlier. In measles the color is of a dark or purplish red, and the lesions are well defined, with normal skin intervening. They enlarge at the periphery and show a marked tendency to form groups and crescents. These are especially marked on the face, neck, and upper part of the trunk. In all cases the individual lesions are larger than in rubella ; so that the whole surface of the body may be involved at the same time, consequently, it remains longer than that of rubella, lasting from four to five days, or longer, when defervescence begins. "Fifth. — In rubella the superficial lymphatic glands of the neck are nearly always involved, being swollen and sometimes painful ; while in measles marked or painful enlargement of the glands of the neck is decidedly uncommon. "Sixth. — In rubella the temperature may be only slightly above the normal at any time during the course of the disease, and it rarely exceeds 582 THE IXFECTIOrS DISEASES. 102° F. (38.8° C). Nor is the temperature curve in any way characteristic of the affection. Further, it is usually of short duration and rarely contin- ues beyond the second or third day. In measles fever is always present and the temperature is sometimes high. There is an initial rise of temperature during the prodromal stage, which usually subsides, returning just previous to the appearance of the eruption, and attaining its maximum at the height of the efflorescence. The fever may continue until the seventh or eighth day. "Seventh. — Eubella is seldom accompanied by complications or fol- lowed by sequels, while in measles complications are common and constitute the most serious feature of the disease.'^ In studying the above we can readily see that measles is very frequently mistaken for rubella. Scarlet fever has a small punctate rash very uniform in character. The temperature, and the characteristic throat and tongue Will usually differentiate this condition. Syphilis is frequently mistaken for rubella, but the absence of the characteristic initial lesion will aid in establishing the true diagnosis. Be- fore making a positive diagnosis we should see that our patient is not suffer- ing from a drug eruption. Complications. — These are rarely seen. The disease is so benign that it rarely leaves any after-effects. Eecurring rashes have been described by various authors, hence, a relapse is possible. This second rash does not differ in character from the first. The contagious nature of this condition has been well established. Hatfield reports^ that of 196 children in an asylum, 110 were affected. Corlett believes that it is as contagious as measles, but the contagium retains its vitality longer and hence resembles scarlatina. The infectious nature of this disease has been studied by Ed- wards, who found that 75 per cent, of cases in an epidemic in Philadelphia could be traced to infection from the bunks of ships. Course. — Eubella runs a mild course. Cases seen by me during an epidemic in the winter of 1903-1904 remained ill about three to four days, rarely five days. Some authors state that children with rubella are ill one and two weeks. Pro^osis. — This is always good. With good sanitary surroundings, aided by careful diet, recovery always takes place. Treatment. — A child with rubella should be put to bed and kept con- fined until all evidence of eruption has disappeared. A liquid diet should be prescribed. The gastro-intestinal tract must be watched ; the bowels and kidneys assisted if necessary. ^ Chicago Medical Examiner, August, 1881. DUKE'S DISEASE. 533 Duke's Disease (Fourth Disease). Many authors dispute the existence of a fourth disease^ and maintain that abortive types of scarlet fever or abnormal types of rubella are the symptoms observed in so-called fourth disease. The existence of a separate exanthematous eruption has been brought before the profession many times. As early as 1885 Filatow, a Russian, outlined the symptoms of a fourth disease. The characteristic symptoms are an incubation period varying between nine and twenty-one days, thus resembling rubella. The eruption, according to Duke, is of an erythematous character and is seen on the face, especially involving the skin surrounding the mouth. There are no pharyngeal or tonsillar patches visible. The tongue does not show the characteristic strawbeiTy appearance of scarlet fever. There is an absence of fever in most cases, and the active symptoms subside after two or three days. The lymph nodes in the neck, axilla, and inguinal region are palpably swollen. Following the eruption there is a fine, mealy desquamation. . CHAPTEE VIII. MEASLES (MORBILLI, RUBEOLA). Measles is an acute eruptive disease associated with fever. It is caused by the invasion of a specific micro-organism the character of which has not yet been definitely determined. Bacteriology. — ^Anderson and Goldberger have settled the question of the period of infectivity of the blood in measles. By inoculating monkeys with human blood from patients suffering with measles they find that the period of infection is greatest Just before, and for about twenty-four hours after, the first appearance of the exanthem. At the end of about twenty-four hours from the first appearance of the eruption, the infectivity of the blood appeared greatly reduced and became progressively less thereafter. The virus of measles belongs to the ultra-microscopic group. Aronson and Som- merfeld found that the toxicity of the urine was increased in measles. Thus, if 2 c.c. of urine from a case of measles were injected intravenously into a guinea-pig, the pig died immediately with the symptoms of anaphy- lactic shock, or else became extremely ill. While this same toxicity can be found in children suffering with the fourth disease, and also with the serum disease, no such toxicity was found in urine from cases of scarlet fever, pertussis, typhoid, and tuberculosis. Aronson and Sommerfeld concluded from their experiments that the urine test will be a strong differential point in diagnosis between scarlet fever and measles. It would be important to note that the virus has not been demonstrated in the mealy desquamation. Etiology. — Measles is a contagious and to a less extent an infectious disease. It is usually communicated direct from person to person. Inter- mediate contagion is comparatively rare. Contagion is possible three or four days before the rash appears on the skin, and continues until desquama- tion has ceased. Children differ as to their susceptibility, some contracting the disease by very short exposure, while others require a longer and more intimate contact. The disease can be more readily conveyed in poorly ventilated or crowded apartments, schools, and kindergartens, where many children are intimately associated. Period of Incubation. — The period of incubation ranges between nine and fourteen days, the average being eleven days. Some authors^ give eighteen to twenty-one days as the period of incubation when measles occurs a second time. ^Graham: Article on "Measles/' Morrow's "System of Dermatology," 1894, vol. iii. (584) PLATE XXVII Earliest Symjitom of ^Measles. Can be seen several days before eruption on body appears. Characteristic bluisli-wliite speck on a rose- colored background. ^Minute Avhite dots separated from one anothei', best seen on inside of cheek. Tliey are very dense near the teeth; more discrete away from the teeth. Strong snnlight or reflected light will aid in locating them. MEASLES. 585 In New* York City cases of measles are excluded from school until five days after the appearance of the rash, at which time, if he is otherwise well and all catarrhal discharges have ceased and the cough has disappeared, he may return. Children and other members of the family who have had the disease may continue in school, provided the quarantine at home is properly observed. Children and other members of the family who have not had the disease, and are immediately removed to another residence, may return to school at the end of fourteen days, the usual limit of the period of incubation. Pathology. — In a study of the early mucous lesions in the mouth Slawyk found that the epithelial cells were thickened and in some in- stances had undergone fatty degeneration, No specific micro-organism has been found in the lesions. Frequently there is a tendency to the formation of ulcers, which extends to the deeper parts. Unna called attention to the thrombosis of superficial vessels of the skin in a severe type of measles re- sembling smallpox. "When gangrene existed, streptococci were always pres- ent. Cornell and Babes report a special form of pneumonia beginning as an interstitial pneumonia and later giving rise to a fibrinous effusion into the alveoli. It involves the lymphatic system, the interlobular and interalveolar tissue. The toxic effect of the measles virus resembles pathological changes noted in diphtheria. They can be found in the central nervous system. No doubt, the toxin generated by a specific organism similar to that of the Loeffler bacillus found in diphtheria causes the degenerative changes. Symptoms. — Prodromal Stage or Period of Invasion: The first symp- toms are those of an ordinary coryza, sneezing, dry cough, and watering of the eyes (lachrymation), with photophobia. Moderate fever, temperature from 101° to 102° F., rarely higher during the first day. There is some- times vomiting. This condition lasts about three days and is followed by the character- istic eruption. This eruption is first seen on the face or neck on the morning of the fourth day. Very young infants show extreme irritability and rest- lessness. The tongue is covered with a white fur. The papillse are red and swollen. They are not as conspicuous as in scarlet fever. There is intense dryness and thirst, with marked anorexia, and usually constipation. The temperature shows great variability. Wunderlich, Thomas and von Jurgensen, who have studied the temperature exhaustively, state that it cannot be considered characteristic, owing to its frequent variations. The temperature, after having reached 102° or even 104° F., will on the second day of the disease drop to nearly normal. There is usually a morning re- mission to the temperature. The temperature in a characteristic case is sometimes deceptive, so that after three or four days of illness there may be a sudden activity of all symptoms with a rise of temperature. The tem- perature frequently reaches 105° F. 586 THE INFECTIOUS DISEASES. Early Symptoms of Measles. — The absence of the thick epidermic cover- ing which masks the first pathological manifestations iri the skin (exanthem) is more readily seen on the delicate mucous surfaces (enanthem). The enanthem in measles has long been known. It has been studied by Willan, in 1806; by Heim, in 1812; in Diinglison's "Cyclopsedia of Practical Medicine/' in 1854; by Trousseau, in 1866. Niemeyer's "Prac- tice of Medicine," 1876, vol. ii, p. 528, mentions Rehn, who studied an erup- tion in the cheek, gums, lips, and fauces. Rilliet and Barthez, 1854, and Monti, in 1873, devote considerable attention to the prodromal enanthem of measles. Flindt, of Denmark, describes it at length in the "Sundheds-collegium," as follows: — ■ "First day of the fever : A slight, diffuse erythema of the throat. "Second day of the fever: A fairly dark redness without marked oedema of posterior pharyngo-palatine arch and tonsils, which on the anterior palatine arch (arcus glosso-palatinus) and velum palati is some- what less deep in color and of an irregularly diffused or mottled appearance. On the evening of the second day of the fever the mucous surfaces of the tonsils, and the posterior palatine arch, have undergone but little or no change, appearing as a uniformly red erythema, with slight oedema. On the anterior surface of the soft palate, and the posterior part of the hard palate, as well as occasionally on the remaining normal mucous surfaces, a distinct enanthema appears. The lesions are round or irregular in shape, of a bright-red color, having an ill-defined margin, with little or no elevation at this time above the surrounding surface. They range from a pin-head to a lentil in size, and occur singly, or are scattered irregularly over the surface. In places there is a tendency for the lesions to cluster in groups and to become blended. "They acquire a peculiar appearance on account of numerous small, white, glisteniag points (simulating minute vesicles), which occupy the middle of the small, red macules. These manifestations in the macules are irregularly grouped. One can see and feel the minute vesicles elevated above the surrounding areas. The palpebral conjunctiva is hypersemic in its entire extent. Besides the reticular and macular reddening of the con- junctiva, which is due to the disposition of the conjunctival vessels, there are also small, glistening, miliary elevations similar to the elevations in the palate. "Third day of the fever: The mucous surfaces of the buccal cavity, which up to this time have been only slightly hypersemic, are now found to be invaded by the lesions previously described. These latter are strongly marked over the entire anterior surface of the velum palati, the glosso- palatine arch, and usually also over the contiguous two-thirds of the hard palate. The red spots are sometimes very numerous, at other times isolated, MEASLES. 587 and again, by blending, they form irregular figures of a stronger red than previously seen. Here and there a faint appearance of the previously described vesicle-like formations is seen projecting above the surrounding surface. On the other hand, they may also be found on the apparently normal mucous membrane. Similarly grouped spots with whitish vesicles now also appear on the inner surface of the cheeks, especially on the part opposite the juxtaposition of the upper and lower molar teeth. "As a rule, the gums and the inner surface of the lips retain their nor- mal color, or at most are only slightly hypersomic. It is, indeed, seldom that the eruption appears on these parts. The tonsils and both pharyngo- palatine arches still remain red. ''The palpebral conjunctiva retains its deep-red color, but no spots are visible, excepting the minute vesicles previously described. At this time the eruption breaks forth on the skin. On the evening of the third day there is little or no change perceptible. "Fourth day of the fever: On the palate and inner surface of the cheeks the spots stand out prominently, while in many places there is a tendency to merge by enlargement of the individual lesions, and on the surfaces last invaded they are more copious than ever. The conjunctival exauthem is now disappearing. On the evening of this day there is no change noted. "Fifth day of the fever : The exanthem in the buccal cavity is more marked than heretofore. Frequently at this time there appear faint-reddish spots on the mucous surfaces of the lips, even extending to the exposed cutaneous margin. On the gums they are seldom present and never distinct. The hypergemia of the posterior fauces remains unchanged. The skin exanthem begins to fade, and the temperature falls. "Sixth day of the fever : The exanthem of the mucous surfaces is no longer visible, except a slight diffuse redness of the palate and the inner surface of the cheeks. Fever ends." This characteristic enanthem is seldom absent. Slawyk^ found it present in 90 per cent, of all cases examined. Koplik described these symptoms- and to him belongs the credit of having popularized the enanthem. It is generally known as Koplik's sign. The spots are best seen on the inside of the cheeks opposite the molar teeth, although I have seen them very clearly defined on the mucous mem- brane of the upper lip corresponding to the incisors. The patient must be examined in a strong sunlight or with a good electric light. A 3^e]]ow gaslight, for instance, is very unsatisfactory. Differential Value of tliis Sign. — This enanthem is of great value in diiferentiating measles from other exanthemata, notably, however, from ^Slawyk: Deut. med. Woch., April 28, 1898. ^Archives of Pediatrics, December, 1896; Medical Record, 1898. 588 THE INFECTIOUS DISEASES. antitoxin rashes, drug eruptions, and eruptions associated with toxaemia from gastric fevers. Period of Efflorescence {Eruptive Stage). — ^The eruption usually ap- pears on the fourth day of the disease. Sometimes it appears as early as the third and sometimes as late as the fifth day. The first spots appear on the forehead or the temples, behind the ears, and on the sides of the neck. Later, spots appear about the eyes, mouth, and chin. When the rash is at its height then a crescentic character, first described by Willan, will be noticed. The constitutional disturbances increase in severity. The cough is more pronounced and there is a decided interference with the respiration. Nosebleed is quite frequent. Constipation is usually followed by very loose bowels. The Rash. — The rash is of a dark-red, sometimes a purplish, color, of a round, oval or irregular shape. The skin between the rash remains intact, although the face has a puffy, oedematous appearance. The eruption extends over the trunk and extremities, including the palms and soles, the arms and legs, the forearms and legs being the last to become affected. When the rash reaches its height the constitutional symptoms subside. It is not infrequent to see a normal temperature two days after the rash has completely covered the body. In some instances there is a crisis, although the usual rule is for the temperature to fall gradually by lysis. A sub- normal temperature frequently follows and accompanies the period of con- valescence and until the patient is normal. The catarrhal symptoms continue to increase in severity with the devel- opment of the rash. There are moist rales heard on auscultation. The sputum as well as the nasal discharge becomes sero-purulent. A bronchitis or a pneumonia should be suspected, if the respiration is exaggerated. The pulse-respiration ratio will he found of great value in diagnosing latent pneumonia. The urine will show the excess of urates, and sometimes transitory albuminuria or hyaline casts may be found. The diazo reaction is sometimes noted, but it does not teach us anything of value in either the diagnosis or prognosis. This stage of the disease rarely lasts more than from four to six days. Stage of Desquamation, or Convalescent Period. — The eruption on the skin of the face, neck, and upper part of the chest fades and there is a slight, branny desquamation. This is less marked than in scarlet fever, and is so fine on the trunk and extremities that it may be unobserved. It is best seen on the sides of the nose, temples and chin. Large, flaky scales are rarely met with in measles. After the eruption disappears, a certain amount of pigment remains for a week or two where the rash existed. Atypical or Anomalous Conditions. — Certain symptoms of normal measles vary in different epidemics, although the majority of cases present distinct clinical features. Predisposing factors, such as rickets and scurvy. MEASLES. 589 possibly tuberculosis, will frequently alter the type of the disease or modify the symptoms. Edgar^ reports an epidemic of 423 cases in which 123 adhered to the regular type. Abortive Type. — We occasionally see a child with catarrhal symptoms and an eruption lasting but one or two days, after which the child is as well as ever. Such cases will frequently baffle the physician because of the irregular course. These cases belong to the abortive type. Typhus Fever. — Typhus fever frequently resembles measles. There is an absence of the catarrhal symptoms common to measles. The eruption is more marked on the body, less marked on the face. In typhus there are severe nervous and cerebral manifestations which rarely exist in measles. In measles the eruption is macular or papular and arranged in irreg- ular, crescentic groups, and begins on the face. In typhus the eruption is rarely seen on the face and is petechial in character. Anaphylaxis.^ — Morbilliform rashes frequently follow the ingestion of certain albuminous foods, so that some children will be covered with an eruption resembling measles when partaking of eggs or meat. Other chil- dren will have a severe eruption after an injection of horse-serum. This subject has been described in detail in the chapter on "Diphtheria." The characteristic feature of an anaphylactic reaction (morbilliform type) is the absence of the catarrhal symptoms. There is no conjunctivitis nor cough, which latter always accompanies true measles. The temperature rises the day preceding the eruption, and returns to normal on the appearance of the exanthem. Mild Forms. — Measles may be present without catarrhal s3rmptoms. In such cases fever may be slight or absent. In other cases the catarrhal symptoms are severe, while the cutaneous exanthem is almost wholly absent (morbilli sine morbillis). Such cases might readily escape notice unless they partake of a series during an epidemic in which both the mild and the severe type are found. Relapsing Form, or Second Attach. — A relapse is said to occur in rare instances after the exanthem has disappeared. When the second rash appears there is a return of fever and also the other constitutional symp- toms. Eecurring measles is often a very serious matter, owing to the already weakened state resulting from the first invasion. Corlett doubts the so-called relapses and believes that they are due to a direct reintoxication by the specific virus. Severe or Malignant Forms. — ^Malignant measles is that form in which there is a very high fever, rapid pulse, labored breathing, and great prostra- ^Can. Med. Record, December, 1892. ' See "Anaphylaxis in Diphtheria." 590 The infectious diseases. tion. The fatal issue most frequently occurs on the second day of the exanthem. We frequently meet with a typhoidal or a toxic form in which the symptoms are of a most malignant character. The mouth becomes parched and the tongue brown and dry, resembling a typical typhoidal cpn- dition. The bowels are loose and the quantity of urine diminished. Convul- sions resulting from the general toxsemia are very common. It is usually fatal and rarely ends in recovery. Where there is severe respiratory dis- turbance, with difficult breathing, it is called the suffocative form. In this form we have principally cough and expectoration with severe dyspnoea. The patient is cyanotic. Mucous rales are heard early in the disease, and it not infrequently ends in a broncho-pneurnonia. Hcemorrhagic forms, known as the black measles, are frequently de- scribed. The mild form of hsemorrhagic measles has been described by various authors. Edgar reports 200 cases out of 423, or 47 per cent, of the hsemorrhagic form. Holt found it in 5 per cent, of his cases. The cutane- ous exanthem assumes a dark bluish or purplish tint, which gradually deep- Table No. 59. — Showing 503 Cases of Measles and Qomplications, Treated in the Eiverside Hospital, New York City, During the Months of January to July, Inclusive. No. of Cases. Uncompli- cated Measles. Measles and Diphtheria. Measles and Pneumonia. Measles, Scar- let Fever and Diphtheria. Measles and Scarlet Fever. 1904 Gases Deaths Cases Deaths Cases Deaths ""ases Deaths Cases Deaths Cases Deaths Jan. 34 4 31 1 2 2 1 1 Feb. 70 8 62 1 7 6 1 1 Mar. 133 14 111 2 9 6 4 4 2 1 7 1 Apr. 103 15 84 8 8 10 7 1 May- 106 16 77 2 13 4 13 8 1 1 2 1 June 37 8 23 7 3 1 30 7 5 4 July 20 5 12 3 5 Total Cases 503 400 49 41 4 9 Total Deaths 70 6 30 2 2 MEASLES. 591 ens as the process continues, to a bluish-black color. Frequently the whole body shows a tendency to bleed. Thus the mucous surfaces are implicated, giving rise to epistaxis, bleeding from the gums, dysentery stools and haemorrhages from the genito-urinary tract. Where a tendency to haemor- rhage exists, as in haemophilic subjects (bleeders), they are especially predis- posed to the hemorrhagic form. Fig. ISO. — A Case of ]\Ia]ignant Measles, complicated by Diphtheria and ending with Empyema. Male child, 3 years old. Septic from beginning. Fatal termination. Seen in my service at Riverside Hospital, New York City, (Original.) Complications. — Pulmonary: There seems to be a predisposition to pulmonary disease, commencing with a bronchial catarrh, especially in those children with feeble resisting power. The inflammatory condition extends into the smaller ramifications of the bronchial tubes, causing capillary bronchitis. When this occurs it should be viewed with alarm. The child shows dyspnoea and ad3Tiamic symptoms, owing to difficult oxygenation. 592 THE INFECTIOUS DISEASES. The Larynx. — One of the most frequent and fatal complications met with in children is laryngitis. This may be : — (a) Spasmodic. (h) Phlegmonous. (c) Membranous. The last named complication is the one most frequently met with, espe- cially in institutions. It is most common during the eruptive stage as early as the third or fourth day. The symptoms are the same as those met with in laryngeal diphtheria accompanied by stenosis of the larjmx. The Klebs-LoefQer bacillus is sometimes found on bacteriological ex- amination of the pseudo-membrane. It can be found in 6 to 10 per cent, of all cases of membranous laryngitis. .5MT ^ 77 DATES OF 0B3ERVATI0H8 DATES OFV AU&I25 26 2 7128 29 30 31 \ 2 3 4 5. 6 7 8 '9 10 n 12 13 14 ' 15 16 r 7 CaU. «*•. UtM UL'nu in/iX.n iUtra lain ucn iM-n u:ni u:mi aCni iM-m UM urn urn fca:ni ui>a MM ucn um jLmyitkm-n uilriui n tr' im:! • ' IfB-i • •^ :. ai'\ ' ;A '■h / \ »•" w^i/l t /. \: f V 1 ': ^ •: ! wilM 1 '■- Sv V ^ iA '-i " ia":| '■ lA {-■ y^ .A iA il m'\ '■ iV r^ \^ n •fl ; 1 37^ as*" 'a'\ ■ \1\ / ,M y^ : -: I: 1/: W-1 ir : V M •> . . . , 1 m-'-ii ■ i| ■; ' ^ Ml a U3 q ev ^l'^ §ai| ■51 3i 3u: ^Z ^i as as 1? 3 11 3? 3S 1 = SI ^ ^:^\^i^t^^%^. 55 1^35 ^2 13? 3tc ^«: 3^ E^^ ^5 IJ 1 g^ ^■1 1^ 1^ qua II ^^^ Fig. 190. — Temperature Chart from a Case of Measles Complicated by Broneho-pneumonia. Seen during my ser^dce at the Riverside Hospital, New York City. (Original.) Broncho-pneumonia. — This is the most frequent and the most fatal complication of measles. Houl^ found it in one-fifth of all of his cases. In the Xursery and Child's HosjDital of Xew York, Holt observed it in -±0 per cent, of all cases. This infection can invariably be traced to the presence of various organisms of which the pneumococcus of Friediander, and the micrococcus of Friinkel play a conspicuous role. There is marked retraction of the chest in addition to the usual signs of pneumonia. The physical examination shows widely disseminated sub- crepitant rales which soon give way to definite resonance, bronchial breath- ing, and fine crepitations. In j'oung children its onset is acute, with rapid pulmonary congestion, and it usually terminates fatally within two or three * Wien. klin. Rund., 1897, vol. xi, p. 833. MEASLES. 593 days. When tlie condition extends over a more subacute course, it may lead to caseous pncuinonia or pulinouary tuberculosis. Case I. Kate A., aged twenty-one months. Child was admitted to the Riverside Hospital August 25, 1904, in fairly good condition, with temperature 104° F., pulse 136, respiration 3G. Sick since August 22d. Child had a moderately severe cough on admission. On August 2Gth cough increased in severity, breathing short, rapid and labored. Physical examination showed only a few coarse rales at upper part of chest posteriorly, with slight dullness, but no bronchial breathing. i9.oA. 1 fiu & 29 30 31 1 2 3 4 Cent. Fahr. AM>M am:pm AMiPM am;pm am;pm AM PM AMiPK 39° ~ •8 • i ] 38'~ •8 •c -101°- 2 \ ^ 1 • •8 •6 -100° -2 :\ / ^ • i f 37 °~ •8 •6 - oM -00 -is V; ^ A • 8 •6 \r \ t^'onnal 36 ~ ■9H' •'■i V. \ ./ -^ . -8 •0 - o" 4 -97 -2 •8 -96 -2 . I - Pulae per minute IT 5 c 1 u: c TS n M >^ >H t» >H H >* o (N iC 00 a •a O o O o o o o o O o o d3 P iH +3 CO TP lO «5 t> CO o (N lO Male 870 7 39 80 105 76 90 87 87 113 65 69 62 1910 Female 914 11 40 82 93 81 109 92 80 126 84 78 38 Total 1784 18 79 162 198 157 199 179 167 239 149 147 90 Male 705 9 28 60 65 72 84 90 45 69 104 38 41 1911 Female 947 9 58 75 100 90 110 99 90 160 37 69 60 Total 1652 18 86 135 165 162 194 189 135 229 141 97 101 Age. — The greater number of cases occur between the ages of 5 and 10 ; next in frequency, 2 to 5, Then the frequency gradually diminishes. Stage of Incubation. — Authorities differ as to the length of time that usually elapses between the exposure to the disease and the appearance of symptoms. The usual rule" is from a few days to a week, although exceptions will extend the time to several days longer. Eichhorst and von Leube give it from four to seven days. Individual susceptibility plays an important part in scarlet fever as well, as we have seen in other diseases. Henoch maintains that we cannot form an idea of the severity or mildness of an attack by the early symptoms. Table No. 62. — Statistics of Cases, of Scarlet Fever Treated in the Riverside Hospital, New York City. Ye r. Number of Cases. Deaths. Mortality Per cent. 190:3 .... 1904, Jan. to Oct. 835 718 76 46 9.1 6.4 Bacteriology. — ^The distinct specific cause of scarlet fever is unknown, in spite of immense scientific work. A specific micro-organism first de- scribed by Class^ is a non-capsulated diplococcus, appearing occasionally in ^New York Medical Record, September, 1899, p. 330. SCARLET FEVER. a 601 Fig. 192.— a, "Inclusion Bodies," case of Scarlet Fever. A, Neutro- phile granules. 6, "Inclusion Bodies," case of Scarlet Fever following ex- tensive burns of the body. {Kolmer.y 602 THE INFECTIOUS DISEASES. Tabie No. 63. — Scarlet Fever Cases Treated at Willard Parker Hospital. 1910 1911 1912 Number of cases treated 2302 1984 2127 Total number of deaths 247 211 179 Percentage mortality 10.7 10.6 08.41 Total number dying within 24 hours .^. . . . 19 Percentage mortality 0.8 Total number dying within 48 hours 36 38 27 Percentage mortality 01.5 01.9 01.2 streptococcic form, pol5anorphous in character. It is constantly found in the pharynx in scarlatinal angina. Baginsky and Sommerfeld^ found a streptodiplococcus in the pharynx and blood in scarlet fever which they believe to be the etiological factor in that disease. As yet scarlet fever cannot be reproduced in animals, and hence this microbe must be looked upon as the probable causative factor. Owing to the immense amount of research work being done, the day is not far distant when the specific factor of all infectious diseases will be discovered. Pathology. — The gross and histological lesions found post-mortem in scarlet fever depend essentially upon two processes: first, the action of the scarlatinal toxin, associated with the changes seen in any acute febrile dis- ease ; and, secondly, they may occur as a result of a mixed infection due to entrance into the organism of the streptococcus pyogenes, the staph54ococcus pyogenes aureus or albus, the pneumococcus, and, rarely, other micro-organ- isms. So long as the specific agent concerned in the scarlatinal infection remains obscure, it must be impossible — in many instances at least — to determine, in a given case, which of these two elements is the predomi- nant one. In cases succumbing early in their course to the intensity of the poison, before the development of secondary infections, we must assume the changes present to be due to the specific scarlatinal virus, while in those which prove fatal later, associated with grave throat lesions, streptococcic angina, etc., the possibility of an added etiological element in the lesions present after death must be admitted ( Corlett) . The Blood. — The diagnostic importance of inclusion bodies in scarlet fever has been confirmed by many observers, A true scarlet fever can fre- quently be determined by the presence or absence of the inclusion bodies. Thus, the absence of the inclusion bodies means serum exanthem and not scarlet fever. Inclusion Bodies. — Inclusion bodies were described by Dohle in 1911. These bodies are found within the cytoplasm of the polymorphonuclear leucocytes. Since then Kretschmer, in Berlin, and Nicholl and Williams, in New York, have not only confirmed these findings, but lay stress on ^Berlin, klin. Woch., No. 22, 1900, p. 588. SCARLET FEVER. 603 the diagnostic value of these bodies in scarlet fever. These bodies occur early in the disease, usually during the first five days of the infection. A simple blood smear on a clean slide and stained by Giemsa or Wright and Jenner method will bring them out. Kolmer reports 30 cases of serum sickness showing urticarial rashes ten days after admission to the Philadel- phia Hospital; not one showed the presence of inclusion bodies. Twelve cases of measles were examined and all were negative; 1 case of rotheln, negative. Of eleven cases of erysipelas examined inclusion bodies were pres- ent in 7. Inclusion bodies seem to be present not only in scarlet fever, but also in other streptococcus infections. In diphtheria inclusion bodies are frequently noted. As a rule, in the early stages of a rash following an in- jection of antitoxin the absence of the inclusion bodies speaks in favor of serum exanthem and against scarlet fever. Bowie^ reports 167 cases with a total number of 714 counts. Of these, 77 were differential to determine the relative percentage of the three main varieties of leucoc5i^es. The following is the summary of his conclusions : — 1. Practically all cases of scarlet fever show leucocytosis. 2. The leucocytosis begins in the incubation period, very shortly after infection ; reaches its maximum at or shortly after the height or severity of the disease, and then gradually sinks to normal. 3. In simple, uncomplicated cases the maximum is reached during the first week, and the normal generally some time during the first three weeks. 4. The more severe the case the higher is the leucocytosis, and the longer it lasts; the milder the case the slighter the leucocytosis, and the shorter time it lasts. 5. A favorable case of any variety of the disease has always a higher leucocytosis than an unfavorable one of the same variety. 6. The temperature has no effect on the leucocytosis. 7. The polymorphonuclear leucocytes are increased relatively and abso- lutely at first, and then fall to the normal, the lymphocytes acting inversely to this. This cycle of events occurs in simple cases within three weeks. 8. Eosinophiles are diminished at the onset of the fever. They in- crease rapidly in simple favorable cases till the height of the disease is past, then diminish, and finally reach the normal some time after the sum total leucocytosis has disappeared — in short, when the poison has all been elimi- nated. 9. The more severe the case the longer are the eosinophiles subnormal before they rise again. In fatal cases they never rise, but sink rapidly toward zero. 1 Reported in Berlin, klin. Wochenschrift. (No. 31, 1897.) 604 THE INFECTIOUS DISEASES. 10. The leucocytes, in complications, go through a cycle of events similar in all respects to that of the primary fever as regards both sum total and differential leucocytosis, and the same laws govern the behavior of the leucocytes in both cases. In regard to the diagnosis of scarlet fever, the simple counting of the leucocytes gives little aid. A differential count, however, may be of aid, for scarlet fever is one of the few acute infectious diseases where one finds an increase in the eosinophiles early in the disease and the persistence of that increase for some time. With regard to prognosis, the examination of the leucocytes seems likely to be of some practical value. In scarlatina simplex, if the case be severe, and the leucocytosis be high and rising, one may predict a favorable course ; and conversely, if it be low and stationary, one may expect a tedious case. Eegarding the differential count, if the eosinophiles show a relative increase, the augury is good ; if they are normal or siibnormal after the first day or two, then the case will in all probability be a severe one. Further- more, as long as a relative increase of eosinophiles is present one cannot be sure that some complication will not ensue; whereas, if the eosinophiles have come down to normal in the usual way, one may be free from anxiety in this respect. Symptoms. — The onset is usually very sudden. In young children the attack is preceded by a convulsion. Vomiting is an early symptom. Tongue. — The tongue has a whitish fur and the papillae will be found elevated and very red. It has the so-called "strawberry" appearance (see Plate XXYIII). The throat, especially the tonsils, will be found intensely congested and dry. Sometimes a severe diarrhoea is the first symptom. The pulse is full and rapid, from 120 to 140 beats per minute. The tem- perature on the first or second day is about 102° F., rarely higher. Glands. — Enlarged inguinal glands are a characteristic feature of this disease. The submaxillary lymphatic glands at the angle of the jaw are swollen and tender on palpation. The mucous membrane of the mouth is reddened. The pharynx, tonsils, and the uvula are injected. Monti^ calls attention to an enanthem in scarlet fever which is seen late on the first day or early on the second. It is a diffused, mottled reddening, which begins upon the uvula, spreads quickly over the hard and soft palate, covering the pillars of the fauces, and finally the mucous membrane of the cheeks. The Urine. — ^There is febrile albuminuria present, which disappears as the temperature declines. The urine is scanty and high-colored. The Hash. — This appears usually within the first twenty-four hours. It is first seen upon the neck and chest — less often upon the small of the back. It is a bright-scarlet pin-point flush, and occupies the sites of the hair follicles. The rash extends from above downward, spreading in a ^vT^hrb. f. Kindh., vol. vii, p. 227. j'l.ATK xxvrn strawberry Tongiie in Scarlet Fever. Painted from a case in the Riverside Hospital. The body rash is shown in the Frontispiece. (Original.) Beefy Tongue in Scarlet Fever. The tongue has a glazed appearance. The papillae are enlarged. This type is usually seen when desquamation begins, after the rash has faded. Painted at the bedside from a case in the Riverside Hospital. (Original.) SCARLET FEVER. eoi few hours to the arms; usually in twenty-four hours it reaches the trunk, legs, and abdomen. (Study frontispiece.) A point to note is that in con- trast to measles and smallpox it is much less marked upon the face and cheeks. The immediate neighborhood of the nose and mouth remains free from the eruption; and has a peculiar pallor, a marked contrast to the parts affected by the eruption. The dorsal surfaces of the hands and feet show the eruption. The palmar and plantar surfaces, though frequently injected, do not usually show the true punctate scarlatina rash. The rash shows great variations. While it may show large or small, faintly scarlet colored patches lasting but a short time, the opposite more pulse-tempJhour 2 :: <>j in oD — CO = CN a 1 05 = in (D O - £) f-~ ', \ 1 140 104 E y^ 1 \ f ; '} \ u ; 135 _ in- V ■'■' , '\ /' '^ V I \ V V / 7 -^ \ ', P 1 ISO 1 03 = ; 1 / V f V \ V / /■ i r 125 E .■■ v " / 1 120 102 = 1 15 E --J-.-ip 1 1 1 If IL iE 1 1 1 1 p _ Fig. 193. — Septic Scarlet Fever with Myocarditis, Suppurative Arthritis, Double Purulent Otitis, General Pyaemia. Case seen in consulta- tion in private practice. Child 4 years old. (Original.) frequently occurs. When it is diffuse it may be of an. intense scarlet or almost purple color. (See frontispiece.) It frequently shows a tendency to stain the tissues, and minute haemorrhages may occur with the formation of petechias. Septic Scarlet Fever. — ^This type is most commonly met with in chil- dren. The symptoms are of a more severe type. There is high and con- tinued fever, with involvement of the pharynx and tonsils. Prostration is the vital symptom, showing the evidence of severe infection. There are marked cerebral symptoms, such as extreme restlessness, convulsions, or mild delirium. In this type we usually have persistent vomiting associated with general apathy. The fever rises suddenly to 105° F., or 40.5° C, or higher. The pulse becomes very small and rapid, from 140 to 160 per minute, al- though at times 200 per minute. The tliirst is extreme, the tongue is dry and gums parched. The tliroat, especially the tonsil, is deeply injected 606 THE INFECTIOUS DISEASES. and frequently has scattered foci of exudate on the surfaces. The urine is concentrated, and invariably contains albumin. Hsemorrhag^c. — This is the most malignant form and is very rare. The disease is very abrupt in its onset. The temperature reaches 105° to 107° F., and sometimes higher, within the first few hours. The pulse is greatly accelerated and is weak and intermittent, The cheeks and lips are blanched and may show cyanosis very early. The urine is scanty, high-colored, and albuminous, or may be completely suppressed. There are marked cerebral disturbances, such as convulsions and active delirium. Frequently we have marked dyspnoea, the respiratory rhythm being short and quick, due usually not to any change in the lungs at this time, but probably to irritation of the respiratory centers, according to Ausset. Ataxic and adynamic forms are characterized by early and pro- found constitutional depression, due to the effect of the toxin on the nerve centers, the symptoms rapidly assuming a typhoidal type. In the hsemorrhagic forms the exanthem acquires a dark-purplish hue. Small petechia, varying in size from a pin-head to a lentil, appear scat- tered irregularly over the body. The blood oozes from the gums, the sputum even being tinged with it, while epistaxis may be severe. Blood may be discharged from the bowels or the stools may be tarry in color. Bleeding is frequently seen from the genito-urinary tract or the urine shows the presence of blood. This form of disease is usually encountered in very feeble infants under 2 years of age and is invariably fatal. Scarlatina Sine Exanthemata. — Cases frequently occur in which every evidence of scarlet fever exists, but there is no eruption. Henoch states that he believes the eruption is always present and thinks that it is occa- sionally overlooked. The eruption is frequently of such an evanescent char- acter that it entirely escapes notice, but a subsequent desquamation and nephritis will usually strengthen the diagnosis. A case of scarlatina sine exanthemata was seen by me in the family of Dr. J. Lurie„ of New York City. A child about 4 yea/rs old had been in apparent health. There was no history of vomiting nor any gastric disturbances. No history of ex- posure to scarlet fever. When examined by me I found no evidences of scarlet fever. The throat was somewhat congested, but had no patches, nor was there any evidences of necrotic membrane visible in any portion of the throat. The lymphatic glands of the neck were not enlarged. The urine was very scanty and contained more than 50 per cent, by volume of albumin. Blood was also present in large quantity. There were also hyaline, epithelial, and granular casts present when a drop was examined under the microscope. The child's urine was greatly diminished in quantity, hardly a tablespoonful being passed at one sitting. Diuretin and citrate of potash acted very well as diuretics, and later the secretion of urine was normal in both quality and quantity. At times it seemed as though the urine consisted of pure blood. Later the child developed an otitis media, which was preceded by a rise in temperature. The child made a good convalescence and is perfectly well to-day. PLATE XXIX Scarlet Fever, Willard Parker Hospital. 1. Fiirfuraceous Desquamation. 2. Circinate Desquamation. 3. Flaky Desquamation. (Courtesy of Dr. Howard Fox.) SCARLET FEVER. 607 Scarlatina Papulosa. — Small, slightly elevated papules of a dark-red color develop at the site of the hair follicles. They are more readily de- tected by the finger than by the eye, and are observed twelve to eighteen hours before the ordinary scarlatinal rash appears. Scarlatina Variegata. — ^This form is marked by an extremely irregular distribution of the eruption, frequently associated with the development of well-defined macular areas of an intense red color, situated at the site of the hair follicles, and in many instances simulating the exanthem of measles. Scarlatina Sine Febre. — Among extremely mild cases of scarlatina in- stances are frequently seen in which, after a slight initial rise, the disease Fig. 194. — Unusually Severe Desquamation. (Original.) Willard Parker Hospital. progresses without any subsequent elevation of temperature above 98.5° to 99° F., every other symptom being present, but in a mild degree. Henoch reports 4 cases out of 175 with irregularities of temperature. Feve? of an inverted type has been reported by Henoch, who noted the tem- perature curve quite the reverse of normal, in which the temperature was higher in the morning than in the evening. Scarlatina Sine Angina. — This form of scarlatina has very slight throat symptoms or so insignificant as to appear almost absent. A slight conges- tion of the throat is visible, and usually a faint enanthem is present early in the disease. The tonsils are not enlarged, but tliere is an almost constant enlarge- ment of the papillce at the tip and edges of the tongue — an important diag- nostic aid. Desquamation. — The desquamation of the skin in scarlatina begins over those areas on which the rash was first seen, namely, the thorax and 608 THE INFECTIOUS DISEASES. neck. Thus, we will frequently find evidences of desquamation on one part, while another part of the body has distinct traces of the rash. Character of the Desquamation. — On the neck, face, and trunk the epidermis peels ofE in fine, flaky scales. This is known as desqimmatio furfuracea. This is similar to the desquamation found in measles. The extremities, about the hands and feet, show the characteristic desquamation. The epidermis peels off or can be stripped off in shreds of varying lengths. This is known as desquamatio memtmnacea or lamellosa. Duration of Desquamation. — ^This varies greatly and is influenced by the severity of the infection and the intensity of the eruption. It persists longest where the epidermis is thick, namely, about the hands and feet. At times it will be necessary to soak the hands and feet, then mb them with pumice stone to hasten the removal of the epidermis. The length of time for complete desquamation may be from sis to eight weeks. It may be of a shorter or longer ■ duration. Eepeated des- quamation is not uncommon, so that we can say there is secondary and, less frequently, tertiary desquamation. Complications. — Scarlatina with Other Exanthemata: Mixed infec- tions are frequently noted. Measles, chicken-pox, or smallpox are met with. Corlett depicts a case of scarlatina with chicken-pox. Mixed infections have been seen many times during my service in the scarlet fever wards of the Eiverside Hospital — scarlet fever and whooping- cough, scarlet fever and measles very often, scarlet fever and diphtheria as well. The Throat. — Scarlatina is usually seen very early in the pharynx and fauces. This takes place whether we are dealing with a mild or severe in- fection. We know that certain pathogenic bacteria, such as streptococci, are invariably found during the course of scarlatina.^ Many bacteriologists agree that the Klebs-Loeffler .bacillus is usually absent, though there are many cases of true diphtheria complicating scarlet fever. Several cases of diphtheritic angina have been seen by me while on service at the scarlet fever wards of the Riverside Hospital. Lemoine found the streptococcus pyogenes in 93 cases out of 117 studied by him. The Klebs-LoefQer bacillus was found in addition in 5 cases of this series, and the bacillus coli communis in 9 cases. Angina Pseudomemhranosa {of Streptococcic Origin). — False mem- branes upon the tonsils or pharjTix are seen in the severe and septic tj^es of this disease. It is simply a necrotic inflammatory deposit. On the second day the mucous membrane of the phar}-nx is intensely reddened and con- gested. The tonsils, which are much inflamed and swollen, show scattered. ^ See elaborate clinical and bacteriological studies made by Baginsky and Sommerfeld, in Archiv fiir Kinderheilkunde, 1900, and Berlin, klin. Woch., No. 22, 1900, p. 588. SCARLET FEVER. 609 Ui n„ it li *°l 1 1 ^",11- •,l 1 rr z H '5 1 g > o z > J: > o ;^ CO :l ? s„_ ?.".-. ^ \>.... 1„_ !is3 So._- fei-i ?;- > X .... .... .... _^' --- > H O -n O 1 H O z ;•! ir.o ■M 130 -=; o ■24 50 5» •12 134 -^ Z £ £ lO 30 138 ==• L'l 128 ^ ■' CO 120 / m 122 — - --■ S -— .... — ... ... > Z CO i:i 120 CO 124 <' £ -Cw 30 UiO ■^ M no ' N Z _Z. Z Ol ^C 120 2L' 114 — -._- ENDOC/^RDITl's CD .10 ]:io LOUD BLOWI,NQ 24 120 -— __.. ' — - SYSTOLIC ^URMj ^i._ ... z 5 -J 2-1 118 22 114 — ... c y — .... ... .... .... z z 00 ro 120 on 11(1 < z 1 z N3 24- 114 DISCHARGE 24 114 «c__^ 1 z N3 Xi 124 o* OOUBLE 22 24 130 132 c ^^^ OT.j.S > z z z z to CO ^^ 4^ :=* 22 134 .... ...... _._ ^^ ^ .... ... ... 30 130 22 12D .... ^. z to ' 30 128 >- 24 120 '' > z z to 30 110 24 92 — . ..... .._. <^. — - .... ...J .... ... ... z to 24 lie 24 110 C -^ — ...J .... ... ..... ... z 5? N) 00 30 110 22 110 — - -i .... ... _.._ > z to U3 30 110 24 100 < "5." — — ..... .... .... ... > z CO O 32 M 22 lOU — ___< ""v" -- .... > z CO 32 108 "■-SI-aVt" DOMP^ICATlloN 30 90 — ..<, ^ ." ^ERV PRONjOUNCED z ■0 z - 30 110 28 104 --- < "■~-i - - .... .... .... .... ... -- z |N3 24 100 _24_ 20 08 100 — ... \ .... ... z CO 24 90 .... — — - ..... -— ... z z J^ 30 ,110 28 100 .s — z 1 CJl 20 108 ^ 20 100 « - -^ > z z 05 22 114 x 24 108 — ..... < ,--- ... .... ... > z ^ 22 100 24 108 < > 00 22 104 1 24 110 _.. ... U3 22 100 22 102 .... i ■■- .... NOTE IRRE RULS iULAf 'f'"ra E " " ... z •D o 32 104 30 no ... - ..\> V- ■-■• LOWEST 9 HiGHEST So' ... ... .... > I :i 30 130 30 100 > to 24 90 Fig. 195. — Chart showing temperature and complications in a case of scarlet fever. From Author's service at the Riverside Hospital. 39 6i6 THE INFECTIOUS DISEASES. irregular patches of gray or grayish-white exudate, completely occluding the tonsillar crypts over a more or less limited surface. One or both tonsils may be affected. In many instances the pharyngeal inflammation from the beginning shows an extreme grade of intensity. This may spread over the posterior pharyngeal wall, the hard palate, and the mucous membrane of the posterior surface of the cheek; also, to the posterior nares and the Eustachian tube, with resulting extension of the inflammatory process to the middle ear. There is a very foul odor to the breath, and usually a thin, acrid secretion from the nostrils, causing excoriation, fissures, and, rarely, rhagades. The nostrils may be occluded and' the mouth held open in an attempt to breathe. Angina Scarlatina Membranosa {of True Diphtheritic Origin). — ^This should be regarded as a true diphtheritic complication and treated as diph- theria (see chapter on "Diphtheria''), Otitis. — The extension of the infection from the pharynx through the Eustachian tubes has already been mentioned. As a rule, the younger the child, the greater the danger of otitis. According to Bader and Guinon, the mild or catarrhal form occurs in 33 per cent, of all cases of scarlet fever, and the purulent form is less common, occurring in 4.5 per cent, of all eases. Caiger, reporting 4015 cases of scarlet fever, noted ear discharge in 11.05 per cent. In a series of 397 cases observed by me, including severe, malignant, and all complicated varieties, there were 82 middle-ear dis- charges, 68 purulent and 14 catarrhal. About 20 per cent, of all cases seen by me had middle-ear trouble. It is important to have the middle ear examined when high fever persists during an attack of scarlet fever. Persistent high fever in a case of scarlet fever occurred in my private practice. It was also seen by Dr. J. W. Brannan and by Dr. Dench. After an examination of the middle ear, a thorough incision of the drum membrane liberated pus and relieved the temperature for a time. The hand will frequently be carried to the head or ear. The neigh- boring lymphatic glands are enlarged, palpable, and may be tender. After a few days, unless relieved by incision, the tympanic membrane ruptures spontaneously. The symptoms then usually subside. When, however, the inflammation becomes purulent (otitis media suppurativa), then the con- dition is serious, owing to the possibility of deafness arising. Empyema of the mastoid antrum,'^ resulting from chronic suppurative otitis media, occurs in a small percentage of cases. With the establishment of a communication between the tympanic cavity and the cells of the mas- toid, there is usually a slight decrease in the amount of discharge from the ^Read article on mastoid (chapter on "Otitis"), page 815. SCARLET FEVER. 611 Table No. 64. — Complications in Scarlet Fever. Willard Parker Hospital. Year 1910 1911 1912 Number of cases 2302 1984 2127 Eyk Complications. Conjunctivitis (purulent) 86 68 1 Conjunctivitis (gonorrhoeal) 14 13 3 Conjunctivitis (catarrhal) 28 142 84 Ear Complications. Mastoiditis (operative) 14 25 Mastoiditis (non-operative) 8 37 25 Otorrhoea ( purulent) 180 194 249 Otorrhoea (diphtheritic) 5 14 Throat Complications. Positive throat cultures on admission 358 33 117 Requiring intubation 11 7 74 Intubation cases recovered 8 Tonsillitis 89 74 Regurgitation 27 22 Adenitis (cervical) 512 274 120 Cardiac Complications. Endocarditis 32 61 49 Myocarditis 29 41 56 Pericarditis (with effusion) 2 5 1 Pericarditis (fibrinous) 3 4 3 Bradycardia 25 16 Irregularity 125 369 Nephritic Complications. Albuminuria 391 357 281 Nephritis (marked) 53 34 51 Uremic convulsions 11 9 8 General Complications. Arthritis 85 145 148 Delirium 17 95 72 Erysipelas 11 1 11 Pneumonia 34 160 114 Empyema 4 3 4 Measles 86 94 Typhoid on admission 4 3 1 Antitoxin rashes Morbilliform 10 21 Scarlatiniform 38 15 Urticarial 30 45 Erythema multiforme 47 27 612 THE INFECTIOUS DISEASES. ear. The temperature rises to 104° F., or higher, and shows a marked fluctuation of a remittent character. There may he rigors. If old enough the child will complain of pain in the mastoid region with tenderness on palpation over the mastoid process. The pulse becomes rapid and irregular. These symptoms continue from day to day, and unless an operation is performed these cases will end fatally, due to the development of meningitis. More rarely an inflammatory swelling appears behind the external ear — situated over the mastoid — associated with a rise of temperature, local tenderness, with more or less forward projection of the ear, and occasionally local suppuration, with abscess formation, takes place. Mastoid Infections. — The virulence of the streptococcus and the pneu- mococcus must always be remembered. In addition to the streptococcus, some cases will show the presence of the staphylococcus. In one of my cases seen recently, we encountered an almost pure culture of bacillus pyocyaneus. This latter condition is extremely rare. These bacteria always accompany both the severe and mild forms of infection and predominate in the nose and throat. The proximity of the Eustachian tube permits these bacteria to penetrate into the deeper struc- tures and thus reach the mastoid. It is therefore important to have in mind the ease with which a middle-ear disease may begin. When fever persists, daily inspection of the ear should be made. If the temperature rises and the child shows discomfort and pain, and there is the slightest bulging or redness of the tympanic membrane, no time should be lost, but an incision made. Many cases of otitis will yield promptly when the drum is incised and pus drainage established. When tenderness exists over the mastoid, an ice- bag or a cold-water coil will afford relief. After the incision of the tympanic membrane warm saline irrigations, three times a day, are indicated. This will clean away all the discharge, and prevent the incision from closing. When thick, tenacious discharge is pres- ent which cannot be washed away, it must be wiped away by means of an applicator mounted with dry absorbent cotton. While some otologists ad- vise plugging the ear with absorbent cotton, I have had better results by allowing free drainage. A case of this kind occurred in the private practice of Dr. R. W. Reid, of New York City, with whom I saw the case in consultation. The child had a very severe attack of scarlet fever. It was of a septic character. Necrotic membranes could be seen over the pharynx and tonsils. There was persistent fever. The child was decidedly rachitic. The case was complicated with an acute nephritis. The urine was very scant and was loaded with albumin and casts. Later the right ear dis- charged pus very freely. When I saw the child there was a superficial swelling over the mastoid which pushed the ear forward. The inflammatory condition was local and due either to SCARLET FEVER. fil3 periostitis or to a local adenitis, remotely dependent on the middle ear suppuration. An incision made liberated a large quantity of pus. The child died of general septi- csemia following toxic nephritis. Angina Ludovici (Tippet Neck). — This may occur about the fifth day of the disease, though more connnonly seen early in the second week of the attack. The skin is indurated, glossy, and may pit on pressure, though it may give no sense of fluctuation. The process may be limited to the .angle of the jaw or involve the entire neck; it may extend downward to the clav- icles and upward along the sides of the face and head, rendering the head almost if not wholly rigid. The diffuse cellulitis of the deeper tissues con- stitutes one of the gravest complications of scarlet fever, proving almost invariably fatal. Death results from a rupture of one of the large vessels, the jugular vein or internal carotid artery, or, as a result of thrombosis or embolism, with fatal meningitis or pyaemia. The greater the toxaemia, the more pronounced the lymphatic enlargement. The Lymph Glands. — The neighboring glands are enlarged and tender on palpation. The infiltration of the glands may be extreme, and in rare instances an excessive infiltration of the cellular tissue of the neck occurs, which becomes hard and indurated, and occasionally renders the head im- movable. Phlegmonous Inflammation of the Neck — Diffuse Cellulitis.^ — Scham- berg studied the glands in 100 cases of scarlatina. He found the maxillary glands enlarged in 95 per cent, and the submaxillary glands enlarged in 36 per cent, of his cases. The posterior cervical glands were found enlarged in 77 per cent, of the cases. Sometimes the parotid glands are also in- volved. Frequently the inflammatory condition persists and suppuration occurs, resulting in so-called phlegmonous inflammation. Even when freely incised there is danger of pus burrowing beneath the connective tissue. Sometimes a rapid and diffuse cellulitis with excessive infiltration of the deeper tissues is associated with the suppurative process. Retropharyngeal abscess occurs occasionally.^ Bokai found 6 cases out of 664 cases of scarlet fever. Schamberg, in a study of the lymphatic glands in scarlatina, found the various groups enlarged in the following proportion in 100 cases : — Inguinal glands 100 per cent. Axillary 96 per cent. Maxillary 95 per cent. Posterior cervical 77 per cent. '•Schamberg: Annals of Gynsecol. and Pediatry, December, 18S9, vol. viii, p. 39. ' Jahrbuch f. Kinderheilkunde, vol. x, p. 108. 614 THE INFECTIOUS DISEASES. Anterior cervical 44 per cent. Submaxillary 36 per cent. Epitroc'hlear 26 per cent. Sublingual 25 per cent. As a result of the analysis of these 100 cases he finds that the maxillary glands commonly attain the largest size, and also most frequently undergo su23puration. In all cases examined on the second and third day of the disease the enlargement of the lymphatic glands was well marked. Scarlatinal synovitis (so-called scarlatinal rheumatism or pseudorheu- matism) is occasionally met with. Ashby^ met with this condition in 2 per cent, of his cases. Hodge found synovitis in 117 out of 3000 cases studied, or 3.3 per cent. There are two distinct forms : — (a) Simple catarrhal or serous synovitis. (h) Suppurative or purulent arthritis. The streptococcus pyogenes has been found in both forms in pure culture and combined with other micro-organisms. This complication occurs more often in children over 5, and is rarely met with in children under 3, according to Holt. The symptoms met with are: Pains in the affected joints, swelling, which may or may not be marked with slight impairment of motion, some redness, and a slight rise in temperature. Owing to an effusion of serum, large joints, such as the knee and shoulder, remain swollen many weeks. When suppuration develops in the involved joint, Henoch claims that it is due to emboli, following septi- caemia. The Kidneys. — There are three forms of involvement of the kidneys in scarlatina : — 1. Transient febrile albuminuria and the interstitial catarrhal ne- phritis. 2. Septic nephritis. 3. Post-scarlatinal nephritis. Transient albuminuria occurs in three-fourths of all cases of scarlet fever. It does not differ from a "febrile albuminuria" seen in all acute infectious diseases associated with high temperatures. It has no special significance. Catarrhal nephritis not infrequently occurs in the first week in cases of moderate severity. The urine contains, besides albumin, degenerated epithelial cells, mucous cylindroids, and rarely epithelial or even hyaline casts, occasionally a few red and white corpuscles. ^British Medical Journal, 1883, vol. ii, p. 514. KCAJtLET FEVER. 615 Clinically, we have slight evidence of oedema. Pathological changes frequently take place witlioiit a trace of albumin or without the presence of casts. Such cases have been reported.^- Bepiic Nephritis. — Where the scarlatinal virus causes a general tox- aemia, and we have grave throat symptoms accompanied by necrotic de- posits on the tonsils and pharynx, there are always swollen glands. Ne- phritis develops from the intensity of the infection caused mainly by the streptococcus pyogenes. In many instances death occurs before well-de- fined symptoms of nephritis are made out. In such cases there is no dropsy and ursemic symptoms are absent. In rare instances the urine is normal during the entire attack until a post-niorteni shows the existence of nephritis. J]AY|t : « 2 k-^ • Pi LU =3 \- at UJ UJ H 105 5 ? ' ;/ t 104- ^^ /; s 103 iX / / IS ^ 10^ y i C 1 ft ' s < ji 101 \ /\ V y \ / \ / ^ ^ a u 100 \ / i, ^^ /\ / / \ N '\ 99 \ _ s ; \\ \ ,, / s S v' NORM/ t 5)8 R LSE \l * o ■i rl : iz \l c « « tg <^ 5^1 1! 1 ' J o a a c c c ;; N Q ■ ^? I ■* c \ '■ I 7, S ^ C c C c 5 a :^ " ■RESF^ Sgl ?s? 53S S?i 3 3 = S fl S ,: \ ?i2S 22 J s ^ = ■ tj a % ?i 33; l 5 » jr 2 ; =is ipif, ^S g? ■ s z X s s 3 an Fig. 196. — Septic Nephritis from Riverside Ilospitiil. Post-scarlatinal Nephritis. — When the acute symptoms subside and nephritis develops it is called post-scarlatinal nephritis. This nephritis is not always glomerular. Jurgensen's statement that the effect of the in- flammatory irritant depends not only upon its virulence (toxicity), but upon the length of time during which it acts upon a given local site, is extremely interesting and important. The symptoms may l)e sudden, although if daily examinations of the urine are made a gradual diminution in the quantity secreted in twenty-- four hours will be noted. The child who has seemed a])parently well and convalescing becomes pale, is restless and irritable, and if old enough complains of headaches, \ ^Corlett; "Treatise of Infectious Kxantlieinata,'' p. 201. 616 THE INFECTIOUS DISEASES. thirst, and loss of appetite. Constipation may be present. Vomiting is usually an early symptom of nephritis. The earliest symptoms of nephritis are: rise of temperature, occur- rence of oedema, however slight, involving particularly the lower eyelids, with distinct puffiness of the eyes. Sometimes the whole face is swollen and bloated. The feet and legs are oedematous, so also the scrotum. and penis in the male, and the labia majora in the female. Such oedema may also be seen on the dorsum of the feet and upon the knuckles. There is pitting on pressure. BOUND EPITHELIAL CELLS re0 bLOOD CORPUSCLES PROBABLY FROM CONVOLUTED [ i TUBULES , ,^ f~-"r~--^ EPITHELIAL AND SPUS CAST EPITHELIAL CELL PROBABLY FROM VAGINA HYALINE CAST ' PUS CORPUSCLES Fig. 197. — Drop of Urine from a Case of Post-scarlatinal Nephritis seen in consultation by the Author. (Original chawing.) The urine is greatly diminished in quantity, so that several teaspoonfuls only may be passed in twenty-four hours. The reaction is acid. Specific gravity is from 1.006 to 1.065, the latter being rare. The amount of urea is under 2 per cent. Albumin is present from 0.5 to 1 per cent, and higher. The diazo reaction is of no value in scarlet fever. Microscopically. — There may be present hyaline, epithelial, granular and blood casts, fragmented renal epithelium, white and red blood-corpus- cles; the latter in varying numbers; uric acid and oxalic acid in crystal- line and amorphous form, and more or less granular debris. Cases are seen now and then in which almost normal conditions of the urine prevail and still nephritis exists. Nephritis usually exists a few weeks, although obstinate cases may continue for months and even years. SCARLET FEVER. 617 Great care sJiould he exercised in giving the prognosis in cases of post- scarlatinal nephritis. Uraemia, when occurring during nephritis, is a grave symptom. It is usually preceded by vomiting, stupor, and peculiar twitch- ings of the facial muscles. The pulse is slow; the temperature subnormal; the tongue is dry. Sometimes just the reverse exists and there is high fever, very frequent and small pulse; the respirations are short and hurried, and the skin dry. Convulsions may develop, clonic in character, of varying intensity, in- volving the face and extremities as a whole. Sometimes only distinct groups of muscles are involved. Cyanosis is marked, complete suppression of urine follows, coma ensues, and usually these cases end fatally. Anasarca is frequently associated with or subsequent to oedema. We frequently have serous exudations into the serous cavities — pleura, pericar- dium, or peritoneum. CEdema of the lungs, sometimes oedema of the larynx, results, and is usually fatal. Mayr mentions oedema of the pia mater and ventricles of the brain. The Diagnosis. — When fever exists accompanied by an inflamed throat and an eruption over the body, then the diagnosis of scarlet fever can be made. Later on we have desquamation. The most characteristic early symptoms of a typical scarlet fever are : Intense redness of the faucial mucous membrane, sore throat, early and persistent vomiting, fever, thirst, and increased pulse-rate. The tongue is very characteristic — strawberry appearance. (See Plate XXVIII.) Sometimes an attack of scarlatina is ushered in by convulsions. Older children complain of an intense headache. There is marked constitutional depression and aching of bones. Von Leube maintains that vomiting occurs more often as an initial symptom in this than in any other disease, excepting pneumonia. There is nothing peculiarly characteristic in the early temperature of scarlet fever. It remains elevated after a sudden rise, and subsides gradually by lysis toward the end of the first week. Drug Eruptions. — Great care must be taken to learn if a child has received belladonna, opium, quinine, or antipyrin. These drugs give an eruption similar to scarlet fever. We should always learn if such drugs have been given before making a positive diagnosis. Course. — Scarlet fever usually runs its course in about six weeks from the beginning of illness. The febrile stage usually subsides during the first week, rarely later than the tenth day. It is spread by cases in the early stages of the disease. Such children usually complain of headache, nausea, and vomiting. A superficial examination or a careless examination of these "spoiled stomachs" has frequently been the cause of the spread of scarlet fever, children being permitted to go to school. In the pre-exanthematous type the diagnosis is difficult unless the throat is carefully inspected. No 618 THE INFECTIOUS DISEASES. child should be permitted to attend school until the last evidence of desqua- mation has disappeared. Prognosis. — It is very difficult to determine the outcome of a case, especially at the beginning of scarlet fever. A mild rash may have serious complications and a severe rash may run a very mild course without com- plications. Individual susceptibility plays an important part in forming an opinion as to the outcome of any case of scarlet fever. The following symptoms should influence an unfavorable prognosis: continued hyper- pyrexia; continued vomiting; delirium or other cerebral symptoms, such as convulsions or stupor; an irregular anomalous or poorly developed rash, if intense, suggests extreme virulence; an extremely rapid and feehle or irregular pulse. Great stress should always be laid on the condition of the heart. Other complications, such as broncho-pneumonia, or diphtheria, or kidney disease, should be noted as very serious complications. Treatment. — Isolation and Care: In New York City cases of scarlet fever are excluded from school for at least five weeks, or until desquamation is complete and all purulent discharges have ceased. If quarantine is ob- served by the family, children and others who have had the disease may return to school. If children or other members of the family who have not had scarlet fever are immediately removed to another address, they may return to school at the end of five days if in the mean time they do not develop the disease, but they must present a special school certificate issued by the department. If they continue to reside at home, they cannot return to school until the case of scarlet fever has been officially discharged by the Department of Health. Hundreds of physicians, students, and nurses observe cases of scarlet fever without coming into direct contact with the patient, and no infection takes place. When, however, physicians and nurses are exposed to the patient's cough or come into direct contact with the salivary secretions from the nose or mouth, then such persons run the risk of infection. Hygienic Treatment. — The temperature of the room should be from 68° to 73° F.^ Fresh air must be admitted; hence proper ventilation is imperative. In winter the patient should be well protected from draughts. Sunshine is imperative, although the eyes should be shielded from direct sunlight. A tepid sponge-bath can be given every morning, and also in the evening, especially if there is profuse perspiration. The child's linen should be changed once a day. When the eruption causes itching, the body should be rubbed with cold cream, carbolated vaseline, or the following recipe is very useful : — IJ Calamine 1 drachm Ung. aq. rosse 1 ounce M. et ft. ungt. Sig.: Apply over the body once or twice a day. SCARLET FEVER. 619 Forchheimer advises the addition of menthol, 1 per cent., to relieve itching. This can be added to the above. Oeneral Treatment. — Stimulate ttie Emunctories: The bowels should always receive attention, whether constipated or not; a dose of calomel or several winegiassfuls of citrate of magnesia or villacabras, in wineglassful doses, three times a day, will be found very serviceable. .Lemon juice in the form of lemonade is very serviceable in stimulating the secretion of urine, and also for quenching thirst. The citric acid cer- tainly has a beneficial, effect on the throat. I have always seen the best results from l-eeping' the bowels loose and the Iddneys active. That we eliminate toxic products in this manner no one can deny, and we certainly can do no harm by this preliminary treatment. Fever. — The use of tepid water as an antipyretic measure is the safest means of reducing fever without depressing the heart. Each fever should be studied by noting how much depression is caused by it — how the child stands the temperature. If the child appears bright and cheerful and there is little constitutional disturbance from high fever, then cool sponging or tepid packs may be ample; if, however, there is marked de- pression, then a warm bath may serve our purpose much better. When a bath is used, the child should be immersed in a tub of water having a tem- perature of 90° F., and after the patient is immersed add cold water or ice until the temperature of the water is reduced to 80 F. In all a bath should last about three minutes, not longer than five minutes. It is important to watch the pulse while the child is in the bath. The temperature should be taken before and about ten minutes after the bath to note the fever. We can then see what effect has been produced. Such baths may be repeated in three, four, or six hours, depending on the individual requirements. An ice-cap may be placed on the head after the bath. The treatment of fever is of the greatest importance. When there are stupor, drowsiness, and delirium, the tepid bath will be indicated. Cold packs and cold sponging are also valuable. Antipyrine, phenacetine, and quinine are extolled by some and condemned by others. When used they should always be combined with musk or camphor, or given with coffee to counteract the well-known cardiac depression caused by the antipyretics belonging to the coal-tar series. In the treatment of high temperature in scarlatina and infectious dis- eases, injections of sulpho-carbolate of soda, 10 grains to a pint of cool water (temperature, 70° F.), is one of the best means of reducing fever. These injections should be repeated every three or four hours. (Read also the "Influence of Serum on the Temperature," page 637.) Fever caii also be reduced by the use of the following mixture : — ■ 620 THE INFECTIOUS DISEASES. 5 Tinet. aconiti 20 drops^ Spir. mindereri 2 ounces Syr. limonis 1 ounce M. Sig. : TeasjXKjnful every hour until sA\-eating is produced, for a child 5 to 12 rears old. Younger children one-half the dose. Weak Pulse. — ^When the first soiind of the heart becomes weak, or the two sounds lose their normal tone, stimulation must be commenced. The same is true if the pulse is weak; ^/loo grain of strN'chnine can be given every three hours, or oftener. if necessary. It must be borne in mind that children tolerate strjx-linine in toxgemic conditions in \Qvy large doses. It is a good |3lan to give coffee with the strA'Chnine or to combine it with caf- feine or musk. Digitalis is indicated if the pulse is weak and of low ten- sion. It should not be used continuoush', as it irritates the stomach, and in its stead tincture of strophanthus should be used. Champagne or whisky is tolerated in extreme^ large doses. Henoch considers camphor one of the best stimulants when given hj^podermically every two or three hours : — IJ^ Camphor 1 gram Ether 10 grams Sig. : Use hypodeiinically. Coma. — In coma the snbcutaneous use of sodium-caffeine-benzoate stunulat-es the heart and arouses the cliild from stupor. It also stimulates diuresis. When bloody urine exists in addition to gallic acid, suj)rarenal extract or its alkaloid, adrenalin, can be used in very small doses. Spartein sulphate, ^/4 to % grain, injected hj^odermically, Avith dis- tilled water, is useful in cardiac weakness. W^hen meningeal s}Tnptoms, such as delirium, cannot be relieved by hot baths and bromides internally, then the application of several leeches behind tlie ears, over the mastoid, will be very useful. Xepliritis. — AVhen the first symptom of nephritis appears we must aid the kidneys, skin, and bowels by eliminative treatment. In this manner only can the blood-pressure be reduced. The child must be kept in bed, well blanket-ed. The diet should consist of milk, milk and seltzer, milk and cereals, and buttermilk. If the stomach is irritable, then the milk should be peptonized. When extreme repugnance to milk exists, then chocolate may be substituted or some vanilla flavor added to the milk. For thirst give whey, lemonade, or orangeade. To stimulate diaphoresis, hot baths aided by hot packs will be serviceable. The temperature of the bath should be 100° to 110° F. The child is immersed from five to ten minutes. The surface of the body must be continually rubbed during the bath. The pa- tient when taken out of the bath is placed between hot blankets for one hour, so as to aid diaphoresis. To give the hot pack the child should be wrapped in a blanket wrung out of hot water, temperature 100° F., and SCARLET FEVER. 621 then covered with a dry blanket, over which is placed a rubber cloth. The blanket can also be covered with oil-silk. The pulse should be watched during the bath, and the child should at once be removed if signs of weakness appear. The Hot-air Bath. — Place the child in bed and cover with two blankets. On either side place hot-water bottles or hot bags of sand so protected that the child cannot be burned. Over these place a rubber cloth or a raincoat. Over the rubber place another blanket. Sweating occurs very easily and Fig. 198. — Coffey's Glass Apparatus Devised for Hypodermic Saline Injections. The temperature of solutions can be seen and regulated by the thermometer. A second thermometer shows the temperature of the solution as it enters the body. This apparatus can also be used for colonic flush- ings by removing the needle and attaching a rectal tube. very quickly in this manner. In an emergency the ordinary flat-iron can be used, instead of the hot-water bottles, for a hot-air bath. Pilocarpin and jaborandi are such cardiac depressants that they are merely mentioned to be condemned. Nitroglycerine is very valuable. When a general dropsy appears, the danger of effusion into the serous cavities must be borne in mind. When necessary the effusion should be relieved by aspiration. The quantity of urine passed is the most important point which should ffuide us in determininjr the result of the treatment. 622 • THE INFECTIOUS DISEASES. Liquids should not be forced under the impression that we are stitn- ulatiag diuresis. Experience has taught the Staff of the WHlard Parker Hospital that we can stimulate the kidneys by careful dieting, and by restricting liquids. The following case occurred during my service, and will illustrate the treatment. Mary S., 5 years old. was ill three days before admission to the Riverside Hos- pital. Diagnosis: Scarlet fever. Her diet consisted of milk 96 ounces in twenty- four hours. She later received also soup and cereals. An injection of 10,000 anti- toxin units was given. Three days later the child complained of painful joints. The diet was restricted to milk. The urine showed a specific gravity of 1018, contained free blood and abundant granular casts. Diagnosis: Acute renal congestion. Medication consisted of agurin 5 grains every four hours, nitroglycerin ^/loo-grain one-half hour before hot bath. Liquids were forced. The pulse became weak. Strychnine Vso-grain, whisky 1 dram, was ordered. The following day many course granular casts and much free blood were found in the urine. Whisky was discontinued. The diet until this time consisted of 96 ounces milk in twenty-four hours. Nephritis and oedema present. About 32 ounces of urine was voided in twenty-four hours. The following day liquids were restricted to 22 ounces; in addition cereals, bread, prunes, and peaches were given. The total urine passed within the twenty- four hours was 35 ounces. Following day same diet was given; total urine passed was 40 ounces. Thus by restricting liquids we aided diuresis. If the quantity of urine increases and the percentage of albumin de- creases, then our patient is improving. The disappearance of blood cor- puscles and casts denotes improvement. One of the best drugs to aid diuresis is diuretine, to be given in doses of 3 grains for a child two years old, and gradually increased until 5 grains per dose is administered. This drug should be given at least three times a day to stimulate the kidneys. Another drug highly recommended by Baginsky is acet-theocine. It can be given in the same dosage as diuretine and the dose repeated several times a day. In a certain class of cases agurin acts well, and can be recom- mended, because it does not disturb the stomach. Now and then I have noticed that marked vomiting followed the administration of almost any drug during the course of nephritis; hence, great care should be taken not on that account to condemn a drug during the course of nephritis with toxic or ursemic sjnnptoms. Vulvo-vaginitis Following Scarlet Fever. — At the Eiverside Hospital during the summer of 1903, out of 100 cases of scarlet fever there were 15 cases suffering with vulvo-vaginitis. In these there was a well-marked purulent discharge upon the deeper parts of the vulva and at the vaginal opening, with some redness and irritation. With this there was a distinct rise of temperature and some constitutional disturbance. The cases all yielded promptly to treatment, proving especially amenable to simple astringent solutions rather than to more active germicides.^ ^ Reported to me by Dr. G. L. Nicholas, Resident Physician. SCARLET FEVER. 623 It is not uncommon to find cases of vulvitis and also vaginitis occurring in the scarlet-fever wards for which there is no adequate explanation. Vulvo-vaginitis as seen at the Riverside Hospital occurs as a distinct complication to scarlet fever. "When it occurs it shows a distinct rise of temperature and also a peculiar constitutional disturbance. When this is contrasted with the symptoms of a catarrhal otitis the similarity of both conditions must be apparent. Not only do we have similar bacteriological findings, but the infection manifests itself in a rise of temperature and general systemic disturbance. While an occasional case of true gonorrhoeal disease may arise in which the Neisser gonococcus will be found, from a large clinical experience in both hospital and private practice, I must say that such cases are very exceptional. Prognosis. — The prognosis is usually good, although we must bear in mind that if these cases are neglected serious results may follow. Infection may spread from the urethra into the bladder and from the bladder into the ureters, and infect the kidneys. Hygienic Treatment. — In this disease more than in any other the strictest attention to hygienic rules is demanded. If it is an infant that is so afflicted, the pads should thoroughly cover the vulva and be saturated with a weak solution of bichloride. This pad should be adjusted with the aid of a T-binder. If there is severe itching from excoriation and the child has a tendency to scratch, the hands should be guarded so that the infection cannot be carried from the genital tract to the eyes. Local Treatment. — Labarraque's solution is a very valuable remedy. It may be used in a 5 per cent, solution. My plan has been to add about 1 ounce of chlorine water to 1 pint of lukewarm water and irrigate morn- ing and evening, noting the effect. If the discharge is not lessened thereby, the injection should be given three times a day. Astringent solutions, such as sulpho-carbolate of zinc, sulphate of zinc, or sulphate of copper, using 1 grain to the ounce, are useful. When there is intense itching it is a wise plan to instill a 2 per cent, ichthyol-glycerin solution into the vagina after the same has been thoroughly washed with one of the above astringent solutions. Argj^rol, 25 per cent, solution, has been used as an injection several times a day with remarkable success at the Willard Parker Hospital by the resident staff. The vaccine treatment consists in injections of gonococcus vaccine. These injections are given subcutaneously in doses of 50 million and re- peated daily until 1000 million dead bacteria have been injected. There is no specific action following these injections. My experience in some cases has been good, in others disappointing. The discharge was diminished ; in some cases it disappeared. The gonococcus, however, persisted. 634 THE INFECTIOUS DISEASES. Endocarditis or Pericarditis. — The heart requires careful watching, especially if symptoms of rheumatism appear. Sudden death will frequently occur from heart-failure. A case of this kind was seen by me in consultation with Dr. S. Straus, of New York City, in which a child desquamating with scarlet fever had myo- and endo- carditis. There was a general anasarca. The pulse became very weak during the hot-air bath. The child died suddenly. It is very apparent, therefore, that the hot-air bath is not without its dangers. Otitis} — The escape of pus from the external auditory canal is by no means rare. The extension of a bacterial infection — streptococcus inflam- mation — from the pharynx through the Eustachian tube can sometimes be aborted by local treatment. Too great stress cannot be laid on the active antiseptic treatment of the nasopharynx as a means of prophylaxis. When earache occurs, no matter how slight, then the ears should be examined. It is better to call an aurist to make sure of the diagnosis and treatment, rather than risk the dangers of mastoid inflammation, with the possible extension of a meningitis and a fatal outcome. Until then, local treatment, such as the application of a hot-water bag to the ear, or cotton inserted into the ear, will afford temporary relief. The danger of using cocaine should not be forgotten, although it is a valuable remedy, When pus is evident, as shown by the bulging of the membrane, then a paracentesis should be •performed, and the cavity irrigated with boric acid solution, or 1 part of hydrogen peroxide and 5 parts of sterile water. The ear should not be packed with gauze, but should be permitted to discharge and drain freely. Eestorative treatment, such as has been previously mentioned in conjunc- tion with nephritis in this chapter, is indicated. Salt-free Diet.^ — ^When the kidneys are affected, their activity is diminished, and an excess of salt is stored in the tissues. As each molecule of salt requires a certain quantity of water to hold it in solution, such water will be abstracted from the tissues, giving rise to the dropsical condition. By giving a diet which is free from salt, we can decrease the oedema. Generally speaking, during the febrile stage and until the end of the second week, an exclusive liquid diet of milk or milk and barley water should be given. If milk is not well digested, then whey should be tried (see "Dietary"). Later, beef soup, mutton or chicken broth, buttermilk, all gruels, fruits, fruit jellies, toast, weak tea, weak coffee, cocoa, and chocolate. For thirst — Appollinaris, Vichy, and lemonade. The tendency to nephritis seems to be lessened by giving our patients a milk diet ; hence this fact must be borne in mind. Steak juice and egg albumin, diluted with water, can be given later on. ^ Read also chapter on "Acute Otitis Media." ^L'Echo Medical du Nord, January 20, 1907, p. 25. SCARLET FEVER. 625 Restorative treatment, such as iron, strychnine, malt extract, and cod- liver-oil, should be given after the symptoms of nephritis subside. The child should be kept well protected for at least two months after the first symptoms appear. As soon as the temperature falls to the normal point we can give : — IJ. Mist, ferri et ammonii acetatis, Glycerini aa 1 fluid ounce Aquse q. s. ad 4 fluid ounces M. Sig. : A teaspoonful or more every three hours, in water. DATES OF OBSERVATIONS 4 5 6 7 8 9 10 Cent. Fahr. AMiPM am:pm ANlPKl am:pm AMiPM am:pm AM'.PM 41°" 40°~ .8 •6 ; •8 •8 •6 ■104" -2 : 39°" •8 •6 ■103° -^ \h •/* A •8 i02°-* I 1 ^ \A • 1 38°" •8 •6 -101°- » '■: V \;^ / V' •8 •6 -100°- 2 ■• 03 \ 37 °~ o 6 &. T-t W < -M • •8 •6 -99°- 2 CD • p— »• • 8 •6 g : 36° -9» -t fi • •8 •0 o' i -97 -2 1/ •8 • 6 -96" -2 - Pulse per minute liespimtiona per mviute ^00 N(0 Fig. 199. — ^Temperature Chart from a Case of Scarlet Fever Treated with Antistreptococcus Serum. (Original.) Or Basham's mixture may be given : — IJ Tinct. ferri chloridi, Acidi acetici dil aa 1 fluid drachm Liq. ammonii acetatis 6 fluid drachms Aquse q. s. ad 6 fluid ounces M. Sig.: Tablespoonful three times daily for a child six years old. 40 626 THE INFECTIOUS DISEASES. Serum Treaimewi^Antistreptococcus serum has been extensively used. It has its opponents and some who extol its virtues. Baginsky^ reports- a series of 48 cases treated with serum, of which 7 were fatal, a mortality of 14.6 per cent. A clinical study of the value of antistreptococcus serum was reported by me^ in a paper read before the Section on Pediatrics of the New York Academy of Medicine. 200. — Method of Kasal Syringing emploAed in tlie Scarlet Fever Ward of the Riverside Hospital. (Original.) Antistreptococcus serum (Aronson's^) was sent to me in the winter of 1902-1903. The serum proved very successfitl in a series of cases in my private practice.* Through the courtesy of Professor Escherich I saw a number of cases that were treated by Moser's antistreptococcus serum at the Children's Hos- pital in Vienna while in Europe in May, 1903. All of these serum cases did remarkably well. I was impressed by the ^ Berlin, klin. Woch., 1896, No. 33, p. 340. ^ "Value of Antistreptococcus Serum," May 12, 1898. ' I am indebted to Messrs. Sohering & Glatz for sending me sufficient serum for clinical trial. *New York Medical Record, March 7, 1903. SCARLET FEVER. 627 excellent results, especially by the distinct fever crisis, after the necessary dose of serum was injected. The preceding chart is the record of a case occurring in my private practice. The specific action of antitoxin in diphtheria is far greater compara- tively than the action attained from the use of antistreptococcus serum. The Temperature. — The effect of the serum on the temperature shows that it did inhibit bacterial products. Within twelve to twenty-four hours after the serum injection I have seen a distinct crisis in the temperature. In other cases the temperature was gradually reduced by lysis. (Fig. 199.) Another interesting observation in most cases is the disappearance, almost melting away, of the necrotic membranes after the fourth day. The glands of the neck were swollen and subsided with the disappearance of the throat manifestations. The vital point consisted in a strengthening diet in addition to strict hygiene. I feel warranted in advocating the use of this serum in the treatment of scarlet fever. Medicinal Treatment. — The Throat: When children are old enough to use a gargle they should be given a mild antiseptic solution, such as table- salt solution, using a pinch of salt to a wineglassful of lukewarm water. Gargle every hour. A spray consisting of normal saline solution directed against the pharynx and tonsils every hour is useful. If spraying is difficult, then the throat may be swabbed with cotton dipped in saline solution. High tempera- ture will frequently subside if the nasopharynx is properly irrigated. The septic accumulations are very serious and cause profound toxaemia unless cleansed thoroughly. Tincture of iodine or Lugol's solution carefully applied to the tonsils and pharynx, once only, is advised. Local applications of 50 per cpnt. resorcin solution in alcohol, applied on cotton several times a day, are also advised. Nasal Douching. — My preference has always been for mild saline douches. Hold the child firmly and cleanse the nares with a nasal tip attached to a fountain syringe, at a height of no more than two feet. Per- manganate of potash, several crystals to a pint of water, is very good when there is foetor. I^ Natrium sozoiodol, Flor. sulphur of each, equal parts. M. For insuflQation into the nostril three or four times a day. This seemed to exert a very beneficial effect on the necrotic tissue, causing a clearing of the throat. If the treatment causes nausea or vomiting, then the sozoiodol natrium can be given internally in the following manner : — 638 THE INFECTIOUS DISEASES. I^ Natrium sozoiodol 2.0 Aquae 100.0 M. Sig.: Teaspoonful every hour. Swollen Lymph Glands. — In septic scarlet fever with necrotic pseudo- membranes in the throat, the adjacent Ij^mph glands will he swollen. At times there is an extensive oedema and infiltration extending into the glottis, which can result in asphyxia. Such cases will be benefited by the use of thorough inunctions of Crede ointment.^ It must be distinctly understood that no result will be noted unless the ointment is rubbed into the swollen glands at the angle of the jaw for at least fifteen minutes. This can be repeated several times a day. I also have used inunctions along the spine to promote absorption over a greater area. This has proven very eflBcacious in many cases. Forchheimer advocates the use of sterile normal salt solution subcu- taneously. This is done to stimulate diuresis and also to aid in the elimi- nation of toxins. In my own practice I have found marked benefit from irrigating the colon with a rectal tube introduced about six inches, using several pints of normal salt solution at a temperature of 100° to 105° P. This is a very rapid and convenient method in an emergency, especially when one is hampered by necessary irrigators and needles, as we require only an ordinary fountain syringe and the rectal catheter connected with it. Immunity from Diphtheria. — An injection of 500 to 2000 antitoxin units will confer immunity from diphtheria in a case of scarlet fever. Diphtheria. — If diphtheria complicates scarlet fever, then the usual treatment of diphtheria should be instituted (see chapter on "Diphtheria"). At the Eiverside Hospital every case of scarlet fever is injected with 500 to 1000 diphtheria antitoxin units as a prophylactic measure. By this means Dr. Eichardson believes that we have reduced the complication of diphtheria in about 50 to 75 per cent, of all cases. Septic Scarlet Fever. — In septic cases where the system is overwhelmed with toxin, we frequently have extreme prostration, rapid pulse rate, and temperature ranging between 100° and 101°. In other cases the tempera- ture may rise to 104° or 105°, all depending on the disturbance of the thermic center. It is in this class of cases that we welcome almost any remedy. Convalescent Human Blood-serum. — The intramuscular injections of convalescent blood-serum, as a therapeutic agent, have been extensively used both in this country and abroad. It is especially indicated where septic conditions exist. I have seen cases of septic scarlet fever at the Willard Parker Hospital injected with 200 to 300 c.c. of serum from cases ^ Schering & Glatz, agents. New York City. SCARLET FEVER. G29 in tlic fourtli and fifth weeks of convalescence.^ Within twenty-four hours after the injection a rapid full in temperature is noted. Sometimes the temperature falls by lysis. 'I'iiis iherapcutie measure is sufficiently impor- tant to encourage its use whenever possible. Intravenous injections of 0.2 to 0.3 gramme neosalvarsan rendered very good results. Out of 12 hopeless cases injected, 7 recovered. Since the introduction of neosalvarsan, the technique of preparation has been greatly simplified. The neosalvarsan is dissolved in sterile water, and is ready for injection. For a young infant under 1 year 0.1 gramme of neosalvarsan is dissolved in 20 cubic centimeters of sterile water and injected into the jugular vein. An older child, 2 to 4 years, may receive 0.2 gramme of neosalvarsan in 40 cubic centimeters of sterile water. Owing to the small size of the median basilic vein at the bend of the elbow, it may be necessary to incise the skin and expose the vein to insert the needle. My preference has been to inject into the jugular vein. The technique is simple if the neck is properly supported. No systemic effect is noticeable after these injections. By using the neosalvarsan we avoid the complicated preparation which was necessary in the use of salvarsan. An illustration of the technique of injecting into the median basilic vein may be seen on page 536. A series of cases of severe scarlet fever^ in which profound toxEemia existed were injected with neosalvarsan. In a case of severe noma compli- cating scarlet fever an injection of 0.2 gramme of neosalvarsan was given with excellent results. There is no specific drug or serum in use today, so that too much should not be expected from neosalvarsan. Transfusion. This therapeutic measure is indicated in a series of devitalized cases wherein the blood-supply is weakened. Septic cases, no matter wdiat the cause, are adapted' to this form of therapy. ■ Infants suffering with maras- mus and inanition respond to this form of treatment. In cardiac weak- ness following or during the course of an influenzal penumonia I have had exceedingly good results from its use. I^ikowisc, this procedure has served me in infants weakened by prolonged diphtheria, the toxic type, as well as in toxic forms of scarlet fever. This method consists briefly in withdrawing from the donor, with tlie aid of a blunt-pointed steel needle and a record syringe, as many ounces of l)lood as desired for the transfusion. To prevent coagulation of the blood ^ These cases were injected during my service by the StatV of tlie Research Laboratory. = Reported at the International Medical Congress, London, 1913, Section on Diseases of Children, 630 THE INFECTIOUS DISEASES. a citrate of soda solution is added to it, and the whole kept at blood heat, in a sterile beaker until needed, or with the aid of TJnger's apparatus direct transfusion can be done. Hust, in 1914, used a human blood transfus.ion by adding citrate of soda and glucose to the blood. Citrated blood was also recommended by Weil in 1914, who used 1 per cent, sodium citrate solution. E. Lewisohn found that 0.2 per cent, solution of sodium citrate will keep the blood fluid. His experiments with human blood transfusion were performed at the Mt. Sinai Hospital in New York. The important fact gleaned from these experiments is that the addi- tion of the citrate of soda prevents clotting. The technique of the injection has been described by Dr. A. Zingher in the Medical Eecord, March 13, 1915. A suitable donor must be chosen. We have encountered no dfficulty in procuring one of the parents or uncles to give eight to twelve ounces of blood. The donor must be free from syphilis or tuberculosis. If time permits, and the case is not a desperate one, we should determine if the serum of the donor agglutinates or hemo- Ij'zes the patient's red blood-cells or vice versa. This method is described by Ottenberg and Epstein. In emergency cases as met with by me it was impossible to take the time to study the agglutination and hemolysis of the donor's blood. Ottenberg states that while it is better to test each donor's blood, he believes that danger exists inj but 2 per cent, of all cases, or one in fifty. The technique of transfusion is so simple that it can be successfully carried out in most cases by the general practitioner in the patient's home without any elaborate paraphernalia. IBiut all must be done with sterile and aseptic technique. The donor is placed in a recumbent position. A piece of rubber tubing and an artery clamp acts as a tourniquet above the elbow. To a 30 c.c. record syringe a steel needle one and one-half inches long is attached and inserted into the tense median cephalic vein. A syringeful of blood is aspirated. The needle is left in situ. The barrel of the syringe detached, and the blood quickly emptied into a large beaker containing two and one- half) c.c. of a 10 per cent, solution of sodium citrate. To keep the needle free, with the aid of a small record syringe, inject a few drops of a 1 per cent, sodium citrate solution. Too rapid depletion is not safe, and may result in a sudden cerebral anemia. It is much safer to allow the circula- tion of the donor to be re-established before withdrawing the second syringe- ful of blood. After each addition of blood to the citrate solution the beaker must be thoroughly shaken, in order that the citrate may become thoroughly mixed with the blood. Choice of Vein in an Infant. — There are four places adapted for this method: (1) the median cephalic, (2) the median bacillic, (3) the jugular, and (4) the longitudinal sinus. The longitudinal sinus has been suggested by Tobler and Helmholz. SCARLET FEVER. G31 Marfan as early as 1898 advised the use of this route for the intravenous administration of salt solution. Owing to the ease with which one can enter the sinus through the anterior fontanelle it seems as though Nature had left this opening as an emergency for this course of treatment in infants. In many of my cases the median cephalic vein was used. This being a very small vein in infante, it was necessary to make a small incision and expose the vein in order to inject the blood. The patient receives the blood directly into the vein. Baby W., born Jan. 4, 1915, was asphyxiated at birth and resuscitated with the aid of a pulmotor. It was a forceps case. Suffered cerebral haemorrhage. Prognosis hopeless. Received breast-feeding, but was so weak that its first cry was noted when 1 month old. Always regurgitated or vomited its food. The infant when I first saw it was 7 weeks old, and weighed 714 pounds. It had an irregular, thready, and in- termittent pulse, was fed with difficulty, was listless and cyanotic. The stools con- tained undigested particles of cheese and mucus. The circulation was bad, extremi- ties cold, the heart soimds were feeble. Eight ounces of citrated blood were transfused. An uncle of the infant was the donor. The blood was injected in the median cephalic vein. There was slight improvement in the color of the skin during the transfusion. On the following day the infant was brighter, had more color in the cheeks and ears, began to notice objects, and appeared more natural. Gained 6 ounces during the first week after the transfusion. The second week gained 6 ounces more. The child is now over 2 years old, and normal in every respect. Eegarding the effect of normal blood during an acute infectious dis- ease much has yet to be learned. In some instances the blood of con- valescents from scarlet fever^ wa& utilized for both intravenous and intra- muscular injections in the severer forms of scarlet fever, and it seems that tliere is more specific bactericidal power in the hlood of a convalescent than there is in the normal human blood. This leads Ottenberg to state that the blood of persons who have recovered from an infectious disease or who have been artificially inununized has specific properties not only in the antibodies of the plasma, but possibly also in the cells. Observation and Treatment of the Donor. — -The pulse of the donor requires careful supervision, whether we draw blood with, a syringe or othenvise ; less supervision, however, with the syringe method. Most of the men wdiom I have seen did best when they were blindfolded, as the sight of blood invariably caused nausea, and sometimes syncope. The pulse is invariably slow^ed, and should be watched for signs of collapse. We in- variably stimulate the circulation after withdrawing eight ounces or a pint of blood by giving the donor one-half pint of milk with the yolk of egg added, or warm broth, or coffee, to which the yolk of Qgg is added. Xo other stimulation was necessary. It is important to have the donor rest at least an hour after withdrawing the blood. Influence of Fever. — A decided drop in the temperature followed in each of six transfusions (transfused cases). In one instance the tempera- ture dropped from 104° to 100° within six hours. In another instance the ^Park and Zingher, Treatment of Scarlet Fever with Fresh Blootl from Con- vales^eent Patients: New York State Journal of Medicine, March, 1915. 632 THE INFECTIOUS DISEASES. temperature dropped three degrees within six hours by lysis. This decided antithermic effect could be accounted for in no other way excepting directly due to the influence of the fresh blood-supply. Ottenberg and Libman have made a similar observation on the influence of transfusion on fever. "Of particidar interest is the transfusion on the fever which is such a conspicu- ous feature of a large number of cases of pernicious anemia. It has been found in over 60 per cent, of the cases (in one report as high as 80). In 5 of the 6 febrile cases we investigated the fever disappeared after trans- fusion. This phenomena is not peculiar to this form of anemia^ for among 16 other cases of anemia due to a variety of causes (including infections) febrile before transfusion, 8 became afebrile after it. These observations lend strong support to the view that there exists a fever dependent upon anemia as such, the so-called anemic fever. Transfusion is the best remedy for pernicious anemia; it never cures, but it leads to remissions in about half the cases." The Advantages of Syringe Transfusion. — ^There are decided advan- tages in the direct or syringe method as advised by Lindeman, Zingher, and others. There is no traumatism, no pain, and a decided absence of shock. The most important point, however, is that -the exact amount transfused is known. Another advantage of the syringe method is that the donor's blood can be removed, mixed with an anticoagulant such as citrate of soda, and then taken to the patient. This majr be an important factor in securing blood from a donor who is sensitive about going to a hospital or who does not care to come in immediate contact with the recipient. This latter may be an important point if the patient (recipient) has an acute infectious dis- ease which coidd be'' transmitted to the donor. From the communication here presented I feel justified in making the following deductions :— 1. That this is a very useful method of therapeutics. 2. That it can be used in the private house as well as the hospital. 3. That very little assistance is required. 4. That manj^ marasmic and underfed infants, and especially cases of secondary anemia, are adapted to this treatment. One striking point was forcibly brought out in the marasmic case under consideration. The infant's temperature was subnormal, the extremi- ties cold. A' general cyanosis was evident in the lips as well as fingernails and toenails. . The circulation was stagnant. Within a few hours after the transfusion the cyanosis was lessened, the body temperature rose one degree, and this improvement continued and aided the general nutrition. I am, therefore, encouraged to believe that transfusion should be added to our therapeutic measures in marasmic infants. It is a great pleasure to acknowledge the valuable association of Dr. A. Zingher and Dr. Abrahams, of the Eesearch Laboratory, and the co-op- eration of the Resident Staff of Willard Parker Hospital, in furnishing clinical assistance and bedside notes. CHAPTER X. VARICELLA (CHICKEN-POX). Varicella is a specific infectious disease of an acute character. The eruption consists of vesicles, which appear in successive crops. The attack lasts in all from four to fourteen days. After one attack the child is usually immune during the rest of its life. Fig. 20L — Pustules surrounded by an inflammatory areola. From the service of the Willard Parker Hospital. (Courtesy of Dr. Howard Fox.) Etiolo^. — This disease is seen only in young children; the older the child, the less liable it is to have chicken-pox. Nurslings are frequently afflicted. Hutchinson states that in his experience adults are almost absolutely immune from this disease. In my own practice the majority of cases seen by me have been in children between the second and tenth years of age. Pathology. — The pathological lesions are confined wholly to the epi- dermis. "The vesicles contain granular fibrin, a moderate cellular exudate, cellular debris, and serum ; this differs markedly from the exudate in variola, which is usually very rich in cells, especially plasma cells. The pock in varicella is shallow, rarely involving the papillae of the cutis, and as its con- (633) 634 THE INFECTIOUS DISEASES. tents are absorbed, the superficial covering is cast off in the form of a brownish scab, sometimes with marked pigmentation, but no resulting scar. The occurrence of a scar following the varicella lesion is occasionally seen." Diagnosis. — The distinguishing features of varicella are: "(a) Its mild prodromal symptoms, which may be wholly absent. (&) The appear- ance of the eruption on the trunk, where it is usually more abundant than on the face and hands, (c) The multiform character of the eruption, its superficial position, comparable to drops of water sprinkled over the skin, and its appearance on the same region in successive crops, (d) Its mild constitutional symptoms and short duration ; the disease usually terminates within from five to fourteen days, (e) Varicella is mildly infectious and always gives rise to a like disease." A nursing infant, about five months old, refused the breast, and seemed to show a general malaise. The infant had previously enjoyed good health. The nursing was regularly carried out and the bowels were normal. The temperature was 100° F. There was no cough. On the second day of this malaise several vesicles appeared on the abdomen and back. Later, some vesicles appeared on the buttocks, thighs, and in the roof of the mouth. There was no constitutional dis- turbance and on the third day of illness the infant again nursed as usual. Several successive crops appeared, and each eruption remained about three days. Local treatment consisted in dusting the parts with cornstarch. Bathing was prohibited and small doses of calomel were given. No complications followed. Differential Diagnosis. — ^This disease may be confounded with variola, as some mild cases of variola resemble chicken-pox. "The superficial strata of the epidermis are principally involved, and a serous exudate, which is frequently the first sjnnptom of the disease, occurs at this point, resulting in a transparent, thin-walled vesicle, while in variola the shot-like, deep- seated induration and subsequent vesicular formation are sufficiently dis- tinctive to warrant a differential diagnosis. The lesions in varicella, as a consequence, are easily destroyed, and when seen present a transparent, beady appearance, some of which, having ruptured, leave excoriated areas ; whereas in variola it is impossible to rupture the lesions so as to evacuate the entire contents vtdthout numerous punctures or by totally destroying the diseased area." In variola we have more uniformity of development : first papules fol- lowed by pustules and ending iii desiccation, leaving black crusts. In chicken-pox we find a varying of lesions at the same time, so that we may have macules, vesicles, and pustules at one and the same time. In variola the eruption is thickly seen on the face and hands, the exposed portions of the body. In chicken-pox the eruption is seen on the abdomen and back; the parts protected by clothing are usually first covered. When called to doubtful cases the following points are worth noting: — Umbilication is seen in smallpox; it is absent in chicken-pox. "The length of time since vaccination, and whether or not the patient has ever VARICELLA. 635 had chicken-pox. Smallpox is extremely seldom encountered within three or four years after vaccination, while after that time the number of cases of varioloid or abortive smallpox steadily increase. Chicken-pox, like smallpox, occurs but once in the same individual. Prodromal symptoms are always present for several days, usually three, in variola; absent or of a few hours' duration in varicella. "The temperature often renders valuable aid in differentiating between the two diseases. In variola it rises rapidly, and even in mild or abortive cases usually reaches 103° to 104° P., when, on the appearance of the rash, a crisis takes place and it falls to the normal within a few hours, where it may remain throughout the remainder of the disease. Varicella, on the Bcite 1 2 3 "T 5 6 7 "s^ 9 "^ lor 100' 99° m E m E M E M £ M £ M E IVI £ M E M £ M £ ' \ i\ 1 1 1 V /^ fk v ^ A / \ f 1 \l ' A J V \ n 1 \ ^ / V V' r. -y k /> / .» — V "^y k- _^ ^ ^ ._ i» — — - — Fig 2 32.- -T em per atvi re Cu rve in V ari cell a. (C )rig jins ii.) contrary, is seldom ushered in with fever, but the temperature usually rises one or more degrees as the eruption develops. When the case is seen for the first time after the eruption has appeared and, as often occurs, no definite history can be obtained, other symptoms must be relied upon," ■ Varicella may also resemble impetigo. Impetigo is first seen on the face, especially about the mouth and nose. It is also seen on the hands. In studying the regional appearance of the eruption one can readily see the transmission and inoculation from face to hands and vice versa. This condition is never met with in chicken-pox. Impetigo may last weeks and months. Chicken-pox rarely exists more than two weeks. Impetigo is contagious and not infectious. Chicken-pox has been successfully inocu- lated. Progptiosis. — The prognosis is invariably good. I have never heard of a fatal case of chicken-pox. Complications should, however, be guarded against and not invited by carelessness. 636 THE INFECTIOUS DISEASES. Treatment. — A child suffering with chicken-pox should be put to bed and strictly isolated. Healthy children should not come into contact with a case of chicken-pox for at least two weeks. The diet should be liquid, and feeding should be given at regular intervals. The bowels should be loose, and if necessarj^ stimulated by the aid of a laxative. For the eruption flannels and woolens should be avoided, and a cool, loosely fitting linen or muslin shirt or go"«Ti should be worn. It is safe to 1. DATES OF OBSERVATIONS 1 t7/ [//• iO y/ IZ 13 iff- /^ i6 Cmt. FaXr. AM>M am:pm AMiPM am:i>m AMiPM AMiPM am:pm «°~ .« -106. J •8 -105-8 • / : iO°~ - •* J04-2^ u u s 5 / K 39°~ •8 •« n A •8 ;« i02°-2 1 s •| : ' 38°" •8 •i "l01°-J CO ■V. V •8 .« -100° -2 J ■ \ \ D7°" •8 ■8 - 6-4 -99 -i 1 N V- ■t •« \ A 36 ~ -98 -8 V ^■ \y - ■ -8 -.97°- 2 •8 •« - 0-4 -96-2 Fig. 203. — Erysipelas Following Varicella. Locally, pure alcohol in which 1 : 2000 bichloride mercury was dissoh'ed Avas applied on the erysipela- tous surface continually. Case recovered. (Original.) proliibit the daily bath until the eruption has disappeared. I . prefer to dust the skin with some bland dusting powder, such as talcum, cornstarch, or rice powder, several times a day. Iron and tonics may be given later if required. Locally, a paste made by mixing bicarbonate of soda with cold water and applied to the chicken-pox is cooling. Baby B., five months old, was attended by me in January, 1905. The infant had a severe form of varicella with gastric disturbances, such as vomiting and diarrhea. On the sixth day after the apix'arance of the chicken-pox the infant gcj-atched its ^rm, On the following day there was a temperature of 102° and a VAMCELLA. 637 diiruse swc'lli]!^,' surrounded the upper arm. There was marked tenderness and pain on the slightest motion. The swelling increased. The arm became reddened and a diffuse erysipelas was diagnosed. The temperature increased to 105.8°. Treatment. — Local treatment consisting of evaporating cooling lotions; lead and opium wash and bicliloride were used without any marked benefit. Crede ointment was rubbed into tlie axillary glands several times a day. An injection of 10 cubic centimeters of antistreptococcus serum (Aronson) seemed to have very good effect. The cooling lotions were continued, but within twenty-four hours after the serum injection the temperature came down by lysis and after four days the temperature was normal. The case recovered. CHAPTER XI. VARIOLA (SMALLPOX). This acute infectious and contagious disease is frequently seen in un- vaccinated children. It is rarely met with in children that have been prop- erly vaccinated. I have seen smallpox in very young infants and children that wer-e unvaccinated during my service at the Riverside Hospital in the summer of 1902. Fig. 204. — Two children in the Municipal Hospital of Philadelphia, one unvaccinated, and the other vaccinated on day of admission; the crust still visible on the leg. This child remained in the hospital, with its mother who was suffering from smallpox, for three weeks, and was discharged per- fectly well. The unvaccinated child, admitted with smallpox, died. (From "Acute Contagious Diseases," Welch & Schamberg.) Etiology. — The etiological factor, most likely a specific micro-organ- ism, has not yet been found. Among unvaccinated children between 1 and 10 years of age, some authors state that 58 per cent. die. During the Sheffield epidemic, of 2892 unvaccinated children under 10 years of age living in infected (638) VARIOLA, 039 houses, 7.8 per cent, were attacked. JJuring the Warrington epidemic 54.5 per cent, of unvaccinated children under 10 years of age were attacked. It is a curious fact that the resistance of chihlren is less than that of adults. Nursing infants frequently have mouth, nose, and throat com- plications, which seriously interfere with their feeding, causing death. There are three types of variola: — Taiu.k No. no. 1. Natural 2. Haemorrliagic 3. Modified. Discrete Confluent Semi-confluent Purpuric Hsemorrhagio Exudative (Anomalous Corymbose < Discrete when the erui>t:on is scattere;! i Confluent when the eru;)tiou s thick and \ flows together. / Semi-conflaent when the eruption is discrete \ in some parts and confluent in others. Corymbose when the eruption forms groups or clusters on various arts of Ihe body. T]ie mode of infection is most probably a micro-organism which exists either in the vesicles, pustules, or crusts. It may be carried in the air so that infection may take place at some distance from the body. Some au- thors believe that the blood of smallpox patients contains the poison. Small- pox can be transmitted directly from person to person. It can also be trans- mitted from bedding or clothing worn by an infected person. Entering a room during the pustular and desquamative stages is sufficient to commu- nicate the disease. Symptoms. — In young children the disease is usually ushered in with convulsions. The pulse-rate ranges between 130 and IGO. The respira- tion is labored and increased in frequency. Curschmann believes that these symptoms are due to an irritation of the respiratory centers. The temperature rises rapidly and continuously without the morning remission. Beginning with 102° or 103° F. on the first day of illness, the temperature soon reaches 105° F. (40.5° C.) until the eruption appears. With the first appearance of the eruption, the temperature frequently drops to normal. This symptom of fever occurs in no other exanthematous eruption. The Eruption. — "Eeddish specks or dots developed into papules re- sembling flea-bites appear about the second day. After the papules have 640 THE INFECTIOUS DISEASES. attained the size of a small pea their summits gradually assume a trans- lucent glazed appearance which indicates the formation of a vesicle. As this enlarges a central depression or umbilication takes place which is looked upon as characteristic of the smallpox lesion. If punctured a small amount of mucilaginous serum exudes. The eruption is not confined to the skin, but is met with in the mucous membrane on the mouth, throat, and nose. Bate 2 3 4 5 6 7 8 9 10 11 12 J;^ MEMEMEMEMEME ^ l~ jyiiEMEMEMEMEME ^Q5«_LJ — L^ 1 1 1 1 ft LL ZpL I04.' 4- I \ iA-:*' ^ E - 103 +- I i _^ "JOS" C \ f\ t-O -)— ioi° ^ Ta tu - t- -A. t t^ ^3_ C y 57 3 ^ — =v V _ QR° ... T Fig. 205. — ^Temperature Curve in Variola. (Original.) Stage of Suppuration. — On the sixth day of the eruption there is a decided yellowish tint, due to the presence of pus cells or polymorphonuclear leucocytes resembling cream. The face usually presents an erysipfelatous redness. Stage of Decline. — About the twelfth day of the eruption there is a spontaneous rupture of the pustules. After the contents are thus evacu- ated, or by absorption, we see evidences of desiccation. The pustular con- tents dry up and the pustule dies, leaving a blackish crust. These blackish or brownish" crusts appear first where the eruption took place. We there- fore first note this condition on the arms, palms, and soles. The crusts separate from the body between the sixteenth and twenty-first days. Desquamation of a furfuraceous character takes place, lasting from VARIOLA. nu one to two weeks. After this condition has disappeared the patient may be regarded as cured. Differential Diagnosis. — Corlett describes the great resemblance of smallpox to typhoid i'ever in its early stages, in a case seen by him. A strong Widal reaction was found, besides a bronchitis. Measles frequently resembles smallpox. Catarrhal symptoms always present in measles are absent in smallpox. The lesions in measles are Fig. 206— Smallpox in a Child that was Vaccinated During the Incubation Period. Vaccination performed five days before the appearance of the variolous eruption. Little or no modification. (Kindness of Dr. J. F. Sehamberg.) flat, soft, and velvety to the touch. The papnles of smallpox are small and feel like shot imbedded in the skin. Scarlet fever sometimes resembles variola of a mild form. The premonitory symptoms of variola are very severe, and last two or three days, whereas those of scarlet fever are mild, last a few hours, and not in- frequently are entirely overlooked. The rash in scarlet fever appears on the upper part of the body, chest, cheeks, and neck. In variola a scar- latinal form of eruption is seen on the lower part of the abdomen and on the inner surface of the thighs. It is bright and fiery red m scarlet fever and dull red in variola. The conspicuous papillae or strawberry tongue is present in scarlet fever and absent in smallpox. Impetigo is frequently mistaken for smallpox. Corlett describes the presence of supposed impetigo in Ohio in 1898 which gave rise later on 642 TT-IE INFECTIOUS DISEASES. to an epidemic oi smallpox. Thus it is apparent that there is a great resemblance between impetigo and smallpox, and vice versa. Chicken-pox is frequently mistaken for smallpox. I have already out- lined the differential points in describing chicken-pox (see chapter on "Varicella"). Syphilis may sometimes be mistaken for variola. A study of the temperature and pulse and careful observation for several days will usually clear up the diagnosis. In variola the eruption assumes a pus- tular character on the palms and soles. The Prognosis and Course are always bad in unvaccinated children, es- pecially in the very young. In the vaccinated the prognosis is always good. A series of cases was seen by me, during the summer of 1902, in the smallpox wards of the North Brothers' Island Hospital. Out of twelve children seen not one had been vaccinated. One child was infected by its mother. As a rule the course extends over three weeks, rarely lasting four weeks. Complications of the nose, mouth, and throat of a catarrhal nature are occasionally seen. The outcome of the cases seen by me was quite good in spite of the severe character of the disease. Complications. — Swelling of the mucous membrane, such as oedema of the glottis, bronchitis, and broncho-pneumonia, frequently complicates variola. The eruption plus secretion, when present in the throat, are the cause of great irritation, and give rise to a hacking cough. Suffocatory symptoms may follow oedema of the glottis. Otitis of a purulent nature is frequently seen. It is usually accompanied by severe neuralgic pains. Treatment. — The best sanitary surroundings, fresh air, and the strict- est possible isolation are advisable. The local application of a solution of glycerine and carbolic acid will tend to relieve the itching, and to soften the crusts. The bowels should be kept thoroughly cleansed, and the patient made comfortable by a tepid pack if the temperature is high or if delirium is j)resent. An ice-cap and cold colon flushing will render the patient more comfortable. If cardiac depression exists, stimulation with musk, cam- phor, or champagne is advisable. Eegarding sanitary measures the New York Health Department requires the immediate removal of a case of this kind to the smallpox hospital. The disinfection and thorough fumiga- tion of everything which was in contact with the case must be remem- bered if we wish to prevent the spread of the disease. Vakioloid (Modified Smallpox). The symptoms are milder, the papules less in number, and the gen- eral condition shows an infection of a lesser type than we see in variola. Variola. 643 , Fig. 207 — Mild Discrete 8niiillpox in mi riivat'einateil Girl. Note absence of lesions upon the trunk. (Kindness of Dr. J. F. Scham- berg.) 644 THE INFECTIOUS DISEASES. The febrile symptoms may be the same as we see in true smallpox. The attack is shorter. The severity of the symptoms depends on the length of time since the last vaccination took place. Vaccination (Vaccinia). This disease can be induced by inoculating the arm or leg with bovine or human virus. By inducing this disease we protect against smallpox. The serum employed is usually taken from a calf suffering with vaccinia or cow-pox. By inoculating the body with this cow-pox we produce kn. im- munity which protects against smallpox. During my service at the'^Eiver- side Hospital;, I have frequently seen infants that had never been vaccinated suffering with smallpox. I have never seen a case of smallpox;^ an infant previously vaccinated. When we consider the ease with which we can confer immunity and protect the human body against smallpox, then, it seems nothing less than criminal to permit an innocent human being to go about unvaccinated. Symptoms. — From five to ten days after inoculation a red areola is seen around the wound. Inflammatory symptoms are marked.' The neighboring lymph glands are swollen. An eruption resembling measles or scarlet fever sometimes follows vaccination. ^ It usually involves the arms, neck, and chest; in rare cases it involves the whole body. It most commonly occurs between the eighth and eleventh days after vaccination. The temperature is rarely above normal and there is no constitutional disturbance. The Complications. — ^Eare complications are erysipelas and cellulitis. Abscesses are usually the result of carelessness or iafection. This infection usually takes place at the time of inoculation or may result from dirt or scratching with dirty nails, or other filthy habits. (Read chapter on "Varicella.'^ Syphilis and tuberculosis are mentioned as accidental infections, but I have never seen or heard of a hona fide case resulting from vaccination. Varieties of Vaccine. — (a) Humanized. , (&) Bovine. Humanized vac- cine is rarely or never used. By using hum^n virus the chance of conveying S3rphilis or other disease ha^ been thought possible. Therefore, the bovine virus has been given preference. Where to Inoculate. — Usually on the arm, although the leg is some- times preferred for females. The upper third of the arm is the part usually chosen. When preference is shown for vaccination on the leg in female infants, the lower anterior outer third should be chosen. Good vaccine virus will take on almost any part of the body. Method of Inoculation. — The parts to be inoculated should be cleaned with soap and water; also the operator's hands. After thorough drying of the parts with cotton, a sterile needle should be used for scarification. A PI.ATK XXX Conlhii'iit Type of Smallpox. Seventh day of vaccination. Vaccinat^-d too late — (hiring incubation period. (Courtesy of Dr. Schaniberg.) VACCINIA. 645 small area of epidermis should be removed, but no blood should be drawn. No antiseptic should be used to clean the part to be inoculated; otherwise, we destroy the vaccine virus. Welch and Schambcrg/ in a series of cases, call particular attention to the great difference in the death-rate between the vaccinated and the un- vaccinated patients. Those who were vaccinated in infancy and showed good scars gave the remarkably low death-rate of 2.61 per cent., as against the high death-rate of 28.17' per cent, in the unvaccinated. There is no doubt that all those who showed either good or fair scars were successfully vaccinated. If we consider them together, the death-rate is 4.84 per cent. In making a comparison between the vaccinated and unvaccinated cases, it is scarcely fair to include vaccinated, all the cases showing poor scars, as very many of them, doubtless, were never successfully vaccinated. Patients who had been vaccinated seven days, or less than seven days, before the appearance of the eruption of small-pox gave a death-rate of 35.71 per cent., while those who had. been vaccinated for a longer period than seven days before the outbreak of the efflorescence gave a death-rate of only 14.28 per cent. Treatment. — The vaccinated area should be covered with a square piece of sterilized gauze held in place with strips of adhesive plaster. This dress- ing should not be removed for one week. In some cases a shield or protector containing a piece of gauze will keep the inoculated area clean and dry and the clothing from adhering. The rules of asepsis are very important in vaccination. If the skin is thoroughly scrubbed, so that no bacteria remain, then an infection will probably be ruled out. If, on the other hand, asepsis was not carried out, then vaccinal ulcers will result. Local treatment consists in saturating the gauze with antistreptococcus serum several times a day. To retain the moisture of the serum, the gauze is covered with oiled silk. Sexton- reports very successful results from this treatment. Vaccinia. This acute condition is characterized by an eruption following the inoculation of lymph. When lymph is taken from a seropurulent eruption on the teat or udder of a cow, it is called cow-pox. Some authors believe that vaccinia is a modified form of smallpox. Symptoms. — An eruption resembling measles or scarlet fever sometimes follows vaccination. It usually involves the arms, neck, and chest; in rare cases it involves the whole body. It most commonly occurs between the eighth and eleventh days after vaccination. The temperature is rarely above normal and there is no constitutional disturbance. There is no treat- ment excepting cleanliness. Internally, a mild laxative may be given. 1 Therapeutic Gazette, June 15, 1902. 'Archives of Pediatrics, Feb., 1913. CHAPTEE XII. TYPHOID FEVER. Typhoid fever is an acute infectious disease caused by the invasion of a specific micro-organism, known as Eberth's typhoid bacillus. Etiology. — ^Typhoid is rarely seen in infants. It is most frequently seen in children over 5 years of age. In a series of 97 cases described by Henoch : — 2 eases occurred during the 1st year 21 cases between the 2d and 5th years 59 cases between the 5th and 10th years Von Steffens in a series of 148 cases reports : — 2 cases occurred during the 1st year 28 cases between the 3d and 6th years 34 cases between the 6th and 9th years I have seen typhoid fever in an infant 1 year old which was infected by its mother. Baginsky describes an epidemic of typhoid seen by him in Germany in which 16 cases were under 10 years of age. Infected water and infected milk appear to have caused this disease more than any other factor, Baginsky mentions flies as an occasional source of infection. The New York Health Department, in a circular of information con- cerning the urine in typhoid fever, directs attention to the fact that "the typhoid bacilli are present in almost incredible numbers, estimated at many millions per cubic centimeter." These germs find a suitable culture medium for their propagation in the intestinal tract. They are very easily found in the faeces in the living state during the height of the disease. The entrance of the typhoid bacillus into the gastro-intestinal tract, whether it is in food, liquid or solid, is responsible for the disease. It is true that a receptive condition may exist. A child having had a series of gastro-intestinal attacks is more liable to an infection than one whose diges- tive tract is normal. Eickets and a general debilitated condition certainly favor the development of typhoid. Typhoid fever occurs most frequently in the fall of the year. I have seen more cases of typhoid in children during September and October than during the rest of the year. During the fall and winter of 1902 and 1903 some of the worst cases of typhoid with haemorrhages occurred. Bacteriology. — ^The typhoid bacillus resembles the bacillus coli com- munis, and is found chiefly in the lymphoid tissue of the small intestines, especially in .Peyer's patches, where it produces a specific inflammation. The bacillus is found not only within the intestines, but in the glands as well. Neuhaus found the bacillus by puncturing the roseolar eruption and examining the blood therein. It has also been found in laryngeal (646) TVPIIOID FP]VER. 047 ulcerations during typhoid. The bacillus was also found in the purulent meningitis accompanying typhoid, so that we can be reasonably certain that the bacillus abounds in almost every part of the body. The action of typhoid bacillus on the human system is toxic. Brieger isolated a poison from the typhoid bacillus, which is called the typlio- toxin. Pathology. — The pathological findings consist in an inflammatory condition of the mesenteric glands ; besides these the solitary and agminated glands of the ileum and colon liot only show evidences of swelling, but when the disease pfogreg^es it frequently ter- minates in ulceration ^nd necfosig. Occasionally the glands will show a softening and pus will develop. The spleen is usually very large and soft, and quite pal- pable. When the disease lasts several weeks and there are evidences of a distinct toxgemia, the poison will cause a marked degeneration of the kidneys and liver, also affecting the heart muscles, which, later, will be found very soft and flabby. Morse^ reports several cases of fatal and infantile typhoid. Fecial and Infantile Typhoid. — In re- gard to foetal typhoid he says that the ty- phoid bacillus can transverse the abnonnal, and possibly the normal placenta from mother to foetus. Other organisms may also pass in the same way. Infection of the fretus results. Because of the direct entrance of the bacilli into the circulation, intrauterine typhoid is from the first a general septicaemia. For this reason, and possibly also because the intestines are not functionating, the classical lesions of intrauterine typhoid are wanting. The fcrtus usually dies in utero or at birth as the result of the typhoid infection. It may be born alive but feeble and suffering from the infection. It SO, death occurs in a few days without definite symptoms, ^Archives of Pediatrics fpr December, 1900. Yiff. 20S. — Typhoid Infantum in a 2-Year-Old Boy. (a) Soli- tary follicle; (b) small agmin- ated gland; (c) Peyer's patch. General medullary infiltration, no ulceration. Natural size. (Langerhans.) 648 THE INFECTIOUS DISEASES. It is possible that the foetus may pass through the infection in utero and be born alive and well. There is, however, no proof that this happens. Infection does not always occur. The pregnant woman does not neces- sarily transmit the disease to her child. As to infantile typhoid Morse concludes that except for the lessened exposure in the first year through food there seems no obvious reason why typhoid should be less frequent in infancy than in later life. Nevertheless, judging from the small number of cases reported, it is less frequent. It may really be less frequent, or only apparently so because the disease is not recog- nized, being mistaken for other conditions. Bacteriological examinations in large series of autopsies on infants and the use of the Widal serum test in large numbers of sick babies seem to offer the best means for determining both the frequency and the character of the disease at this age. The accuracy of the diagnosis in many of the earlier reported cases must be regarded as very doubtful, and hence no satisfactory conclusions can be drawn from them. Analysis of the more recent and certain cases seems to show that the symptoms of infantile typhoid are essentially the same as in adults, but that the course is shorter and the mortality greater. These conclusions may be inaccurate, however, as it is possible that they are based on the severe cases alone, the milder cases having escaped notice. The pathological changes in the intestines are, as a rule, insignificant. The contrast between them and the severity of the general symptoms is striking. The probable explanation is that in the infant as in the foetus, but to a less degree, the disease is a general rather than a local infection. The serum reaction occurs in infantile as in adult typhoid. There are no data as to whether or not it occurs in foetal typhoid. Immunity. — The agglutinating power may or may not be present in the blood of infants born of a woman with typhoid. If present, it is trans- mitted from the mother to the child through the placenta. It is possible, however, that it may be formed in the child in response to toxins trans- mitted through the placenta. The agglutinating principle can pass through the normal placenta. Part of it, however, is arrested in the passage. Whether or not it is transmitted seems to depend on the strength of the agglutinating power in the maternal blood and the length of time during which the placenta is exposed to it. It may be transmitted to the nursling through the milk. It may appear in the infant's blood in less than twenty-four hours. It lasts but a few days after the cessation of nursing. It is always weaker in the milk than in the maternal blood and always weaker in the infant's blood than in the milk. This weakening of the agglutinating power is due to the obstruction to its passage in the mammary gland and in the nursling's digestive tract. The chief factor governing transmission is the intensity of the power in the maternal blood. A subordinate but important factor is some unknown TYPHOID FEVER. 549 condition in the digestive tract. If the power in the maternal blood is weak and the obstacles great it may not be transmitted. Symptoms. — The symptoms are usually very obscure in children. Vomiting and sometimes diarrhoea are the earliest symptoms. In other cases constipation may be an early symptom. The so-called pea-sdup diar- rhoea seen in adults and older children is rarely met with in young infants. Convulsions frequently usher in an attack of typhoid fever. In older children, those able to complain will usually give subjective symptoms, which may aid materially in making the diagnosis. A constant headache, for example, will always show a severe form of infection, and may bo the only symptom which will be constant. The period of incubation varies from five to fourteen days. We can safely say it is rare for the period of incubation to extend over three weeks. TJie Temperature. — The temperature is one of the mam indications of typhoid. It rises at night and falls in the morning, the morning fall being less and the evening rise greater for the first week (step-laddder type) until the maximum is reached. The temperature shows fairly regular oscil- lations, morning fall and evening rise for about a week. It then returns to normal at the end of the third, sometimes at the end of the fourth or fifth week. The temperature drops by lysis, never by crisis. Secondary fever is rare in children. It is not unusual to find a mild form of typhoid terminating normally at the end of two weeks. During the second week of the disease when the temperature remains fairly constant, the diagnosis will be much easier, although a positive diag- nosis from the temperature alone should not be made. The temperature in a mild form of typhoid in an infant varies between 101° and 103° F. during the first week, or even the second week, of the disease. Severe cases may show a temperature of 105° F., or even higher, during the first week of the illness. The temperature may show peculiar variations. We may have a sudden rise extending over a period of six weeks instead of three weeks. This prolonged pyrexia sometimes denotes complications. If the tempera- ture has ranged between 103°, 104°, or 105° F., and suddenly drops to normal or subnormal, then we must suspect either an internal ha3morrhage or look for a perforation. Sudden variations in the temperature, as a very sudden rise or fall, must always be looked upon with suspicion. There is no crisis in typhoid as there is in pneumonia. The Pulse. — The pulse is usually increased in frequency and ranges between 130 and 160 per minute. The force and rhythm are good unless some complication arises. The pulse is usually small and compressible, and there is very low tension in fatal forms of the disease. The Tongue. — The tongl^e is coated with a whitish, more rarely a brownish, fur. This coating extends down the center, although the whole 650 THE INFECTIOUS DISEASES. tongue may be covered. The mouth, appears very dry, and the patient sometimes complains of intense thirst. The abdomen is usually distended with gas and there m marked tym* panites on percussion. Gurgling and tenderness on palpation in the ileo- CEecal region is not to be looked upon as an important symptom. The Spleen. — The spleen cannot be relied upon as a diagnostic aid in children. While it may be enlarged in some instances, we frequently find that it is not palpable in many cases of severe typhoid. Coughs and Bronchial Catarrh. — One of the earliest symptoms in ty- phoid is bronchitis. In the beginning when we have but cough and fever the diagnosis will be quite difficult. Typhoid frequently simulates pneu- The Nervous System. — In profound tox- icity the nervous symptoms present will be muttering, delirium, and a semi-comatose condition. Not infrequently rigidity of the muscles of the neck is present, so that the difi;erential diagnosis from meningitis will be difficult. The nervous symptoms fre- quently resemble those seen in tubercular meningitis. Acute tuberculosis may some- times resemble typhoid. Extreme Emaciation. — Children fre- quently show emaciation during typhoid for the following reasons : — 1. The constant fever. 2. The low vitality owing to mal- nutrition. 3. The system being constantly drained when diarrhoea exists. Diagnosis. — In every case of fever in which a diagnosis cannot be made, a. drop of blood should be examined for the presence of the Widal reaction. This reaction is always a trustworthy evidence of the presence of typhoid, and a negative reaction later than the tenth day is strong but not absolutely convincing evidence of the absence of typhoid. The test is of greater value in the case of an infant than an adult, as we can exclude the occurrence of a previous attack. Some writers state that the reaction is seen earlier in children than in adults. It should not, however, be the only means of making a diagnosis. It is well known that this reaction will occur months and sometimes years after the patient has recovered from typhoid, hence great caution should be used in relyiDg on this diagnostic measure exclusively. Widal Test for the Diagnosis of Typhoid Fever.^^The investigations Fig. 209. — Stages in Widal Reaction. (After Robin.') 1 This method is described by the New York Health Department. TYPHOID FEVER. 651 of Griiber, Witlal, and others, published in 1890, showed that the blood of persons, sutl'ering from or having recently had typhoid fever, contains, as a rule, after the fifth day of the disease, substances which, when added to a broth culture of the typhoid bacilli, arrest the characteristic move- ments of these organisms and cause them to become clumped together in masses. The results of a very large number of examinations made here in New York and elsewhere show, that if the blood contains agglutinating sub- stances in sufficient amount to cause a prompt and marked reaction, when one part of serum or blood solution is added to 10 parts of a broth culture of the typhoid bacillus, the presence of a previous or existing typhoid in- fection may be considered as extremely probable, and that if these sub- stances are present in such an amount as promptly to produce the reaction, when 1 part of serum or dried blood solution is added to 20 parts of the culture, the presence of a previous or existing typhoid infection may, for diagnostic purposes, be practically considered as established. In estimating the diagnostic value of a negative result from this test, we must remember that the reaction is rarely, if ever, present until at least four days after the appearance of symptoms; that it is occasionally absent in cases of typhoid fever until the third or fourth week, or even until con- valescence is established; that when developed it may disappear after a few days, and that no definite relation between the severity of the disease and the degree and time of development of the substances causing the reaction has been established. For these reasons a single negative result in any suspected case only renders doubtful the existence of typhoid fever. In those cases in which the reaction is absent after the ninth day, it may be reasonably assumed that the large majority will not prove to be typhoid fever, and the absence of the reaction in all of several different cases of a suspected group, or after repeated examinations in any single case, affords evidence of very decided value in excluding the diagnosis of t3q3hoid fever. Directions for Preparing Specimens of Blood. — The skin covering the tip of the finger is thoroughly cleansed and then pricked with a clean needle deeply enough to cause several drops of blood to exude. Two large drops are then placed on the glass slide, one near either end, and allowed to dry without being spread out on the surface of the slide. After they have dried, the slide is placed in the holder and returned in the addressed envelope to a culture station, or mailed to the laboratory. The diazo reaction should be looked upon as a valuable aid in making the diagnosis. It is described in detail in the chapter on "Urine,^^ page 883. The Eruption. — The eruption consists of lenticular-shaped, rose-col- ored spots. They are small and slightly elevated. These rose-colored spots appeer at the beginning of the second week. The eruption lasts about ten days, although the spots last from two to three days and are succeeded by 652 THE INFECTIOUS DISEASES. a new crop. They are seen on the thorax and abdomen, although at times over the whole body. Leucopcenia if present strongly supports the diagnosis of typhoid. In the International Clinics 1909, I report a series of cases in which the white blood cells ranged between 4000-6000 at the beginning of the disease. Differential Diagnosis. — Malaria frequently resembles typhoid. A dif- Fig. 210.: — Typhoid Fever.— Severe haemorrhages. Fatal result. (Original.) ferential diagnosis can easily be made by an examination of a drop of blood for the presence of plasmodia. The administration of quinine is a diagnostic test of practical im- portance. An irregular or iniermittent fever which yields promptly to quinine is certainly not typhoid. In malaria, the temperature will be found to touch normal at some time in the twenty-four hours. Cholera Infantum. — Many cases of supposed cholera infantum fre- duently prove to be typhoid fever. I have seen many cases in midsummer TYPHOID FEVER. 653 with a temperature of 102° ¥., having roseola, with vomiting and diar- rhoea, in such cases the diagnosis depends on the presence of the Widai reaction. When diarrhoea! symptoms and fever are present in the early stages of typhoid fever it is extremely difficult to make a diagnosis. This applies especially to the first week of the disease before a Widal reaction can be made. I have invariably examined the urine for the presence of indican (see page 880). When the symptoms are due to intestinal autointoxication or fermentative conditions in the intestine, then a positive indican reaction is present. If the diazo-reaction is absent and indican present, we can exclude typhoid fever. Internal Iloemorrliages. — Holt reports a series of 946 collected cases in which haemorrhage occurred in 30 cases, about 3 per cent. The ma- jority of these cases were over 10 years of age. I have frequently seen haemorrhages in children between 5 and 10 years; never under 5 years. Case I. — A case of typhoid in a boy 16 years old, seen in consultation with Dr. Rayewsky, had a series of haemorrhages which ended fatally. The origin of this case was supposed to be an infection from eating raw oysters. The boy was a telegraph messenger and ate some oysters in the street, after which he showed signs of fever, and' intestinal symptoms. No other etiological factor was ascertained. The boy was in good health and suddenly became ill after eating this meal of oysters. Symp- toms of gastric fever, with diarrhoea; temperature of 101° to 103° F. gradually appeared. The symptoms increased from day to day until delirium and general coma were present. The fever was difficult to conti'ol in spite of cold tub bathing. The boy weakened from constant pyrexia— appeared to convalesce — when a severe haemor- rhage occurred. An ice-bag was laid over the abdomen, and opium given internally. The colon was flushed with alum and water. Nothing seemed to control the bleeding. Case II. — A girl, 10 years old, was seen in consultation with Dr. H. Wein- stein. She had been sick about three weeks when seen by me. She was apparently convalescing when she had a haemorrhage of a very alarming nature. The doctor told me the child lost more than one pint of blood. The pulse was about 130 and very feeble in character. The child was deathly pale and seemed to be in collapse. Whisky and strychnine were ordered as restoratives. The child complained of chills and was thoroughly wrapped in warm blankets and hot-water bottles were applied to her feet. A teaspoonful of powered alum added to a pint of cold water was in- jected into the rectum and colon. Paregoric in 1.5 drop doses was ordered every hour. The nurse was instructed to watch the pupils and the pulse and to discontinue the drug as soon as the systemic effect of the paregoric was manifested. Ice-crciini was ordered internally and small pellets of cracked ice. The child recovered after careful dietetic and restorative treatment. IniesUndl Perforation. — Intestinal perforation is very rare. It is met with in about 1 per cent, of all cases. A sudden fall in the temperature with collapse, rarely vomiting, followed by tympanites, are symptoms indi- eatiug perforation. Laparotomy Wlien Perforation Occurs. — The skill of the surgeon will frequently save life when hasmorrhages occur. In a case of typhoid which 654 The ii^ECTious diseases. progresses favorably during the third and fourth week, a stidden collapse should be an indication for an immediate operation. I have seen death follow a case of this kind. These cases are usually hopeless and our only chance consists in resorting to an immediate operation. Complications. — Aphasia is occasionally met with. Morse reported 31 cases. Insanity is rarely met with as a sequel to typhoid. Chorea is fre- quently seen. I have met with a case having a severe form of choreiform movements which lasted more than a year, following the attack of typhoid. Otitis media is frequently met with in children. It is very important to watch the ears during an attack of typhoid. Less frequent complications are gangrenous inflammation of the mouth or genitals, pericarditis, endocarditis, peritonitis, pyaemia, abscesses, and furuncles. Abscess of the liver has been reported by Bokai. Pulmonary tuberculosis has been known to follow typhoid. Prognosis and Course. — The prognosis is more favorable in children than in adults. Tympanites, if accompanied by vomiting, is a bad sign. When there is general depression and nervous symptoms then the prog- nosis is bad. Singultus is usually a bad sign. Bleeding should always be looked upon, especially if repeated, as a bad sign. The strength of the child, its assimilation of food, and the condition of the heart should be the means of arriving at the proper prognosis. Complications should always be regarded as a serious matter. The prognosis is grave if the child has passed through a typhoid and is in an exhausted condition, and unable to cope with a new complication. Baginsky states that in a series of 68 cases treated by him in the hospital, 6 died, a mortality of 8.8 per cent. In children typhoid may terminate in two weeks. It may extend', over three weeks or even four weeks. Mild cases of typhoid resem- ble an attack of acute gastric fever. Cases are occasionally seen in which, the disease terminates abruptly within ten days. As a rule older children, show the adult type of fever and the disease runs its course of three, four,, or six weeks. Infantile typhoid may show severe gastric symptoms, such as vomiting, and very little diarrhoea. The course, therefore, is peculiar to infants and entirely different from that seen in the older child. The following case was seen by me some time ago. A woman, 35 years of age, was taken ill with typhoid fever of a very severe type. She nursed her infant during the first week of her fever. The infant was then 1 year old. The physician ordered the infant weaned. About one week later the infant had fever, vomiting, and diar- rhoea. , An examination of the blood gave a positive Widal reaction. The infant recovered in about fifteen days. The mother died of hsemorrhages during the third week of her illness. Treatment. — The specific nature of the disease due to the infection of a specific germ, has caused investigators to seek a typhoid antitoxin. As yet no definite progi-ess has been made in this direction, although inves- TYPHOID FEVER. 655 tigators have from time to time announced the discovery of a healing serum.^ In the absence of a specific serum we must confine ourselves to the treat- ment of indications. In the beginning a good dose of calomel, Yg to 1 grain, repeated several times a day, is indicated. Fever Treatment. — The best antipyretic is the cold bath and cold pack. The bath must be properly given to be effective. A large bath-tub should be procured, large enough to hold the child at full length. This should be half-filled with water at a temperature of 90° F. Cold water or, in summer, ice should be added until the temperature is gradually reduced to 70° F, This is an agreeable method, as we avoid the sudden shock so dreaded by children when suddenly immersed in cold water. The dura- tion of the bath should be from three to five minutes. The temperature of the child should be taken before and after the bath. The child's body should be rubbed continuously while in the bath so as to stimulate the circulation, especially so when the water is cool. If the child^s pulse is feeble, administer a stimulant such as hot coffee or whisky before the bath. Watch the pulse carefully, and if the slightest sign of weakness is noted, remove the child immediately from the bath and place in bed with hot-water bottles to its feet. The bath should be repeated every three or four hours or oftener, if the temperature requires it. If the temperature is not modified lower the temperature of the bath. Antipyretic drugs, such as napthaline, benzoate of soda, quinine, anti- pyrin, antifebrin, phenacetin, and lactophenin, are useless in combating fever when compared to cold baths and cold packs. All antipyretic drugs of the coal-tar series are such cardiac depressants that they should never be prescribed without combining them with camphor or musk. Of all anti- pyretic drugs I prefer phenacetin. One of the best antipyretic measures is the injection of several pints of cold saline solution through a catheter into the colon. Too much hydrostatic pressure should not be used. The irri- gator should be held about one foot over the child's body; the temperature of the water should be between 60° and 70° F. Flushing the colon with cool saline solution may be repeated every three or four hours if a good effect* is apparent. When great exhaustion and a weak pulse exist, then ^/a teaspoonful or a teaspoonful of alcohol may be added to the irrigation. The main point to remember in the treatment is to support the child so that the strength will be maintained and the heart's action not im- paired. With this object in view nothing is better than restoring vitality by the aid of concentrated food. When there is great exhaustion the admin- istration of a normal salt solution per rectum, or its use by hypodcrmoclysis,* should be remembered. One or two pints of saline solution administered ' Einhorn, of New Yo);k, has reported beneficial results from the use of anti- typhoid serum. * This is ilhistrated in detail in the chapter on "Scarlet Fever Treatment." 656 THE INFECTIOUS DISEASES. per rectum, with the hips elevated, is frequently the means of stimulating diuresis, thus eliminating the poisons of the toxins through the kidneys. Great care is required in giving the saline in the form of hypodermoclysis. The strictest asepsis should be maintained. A large aspirating needle attached to a fountain syringe (Fig. 198) is well adapted in an emergency. These saline injections may be repeated every six or twelve hours if required. Hygienic Measures. — Owing to the infectious nature of the discharges passing from a typhoid patient, the prime requisite is the thorough disin- fection of all stools and urine. If there is cough or sputum, the same must also be thoroughly disinfected. In fact all discharges should be received in a vessel containing a strong solution of javelle water (chlorinated lime) or a 5 per cent, carbolic solution. A strong solution of copperas should be thrown into the toilet from time to time while a typhoid patient is in the house. All bed linen, handkerchiefs, and dishes coming in contact with the patient should be soaked in a bichloride solution for at least one-half hour before being washed. Sunlight is of the greatest importance in a room having a typhoid patient. We can do more disinfection with sunlight and fresh air than we can with medication. The Food. — All food must be liquid; no solid food should be allowed. In the beginning whey, strained soups, and broths should be ordered; later strained gruels, cocoa, acorii cocoa, and chocolate may be given at intervals of two or three hours. In some cases albumin water, made by beating the raw whites of two eggs with sugar and water, is useful. I frequently give the whites of six eggs per day. Milk, buttermilk, kumyss, whey, or junket may be given, alternating with soups and broths. When stimulation is required the yolk of egg can be combined with sherry or Tokay wine. When drugs are given it is best to combine them with soups or broths. When severe dyspeptic symptoms exist, predigested milk, peptonized with the aid of pancreatin and soda, must not be forgotten. When milk idio- syncrasies exist, then the yolk of a raw egg added to barley water, rice water, or almond milk (made by blanching almonds with hot water) can be substituted for milk. When thirst exists, unfermented grape juice or water acidulated with dilute phosphoric acid or dilute hydrochloric acid is very grateful. Ten drops of either dilute acid can be added to a tumblerful of sweetened water, and this given whenever the child is thirsty. These acids have a very good effect on febrile affections, and are especially indicated when diarrhoea exists. Feeding in Convalescence. — The great danger of hasmorrhage should always be borne in mind ; hence it is advisable to abstain from giving solid food for several weeks after convalescence is thoroughly established. Soups thickened with sago, farina or barley, and pea and lentil soups can be given. The yolk of a raw egg can be added to the soup. Milk may be thickened with zwieback. The main diet should be milk and cocoa or chocolate. TYPHOJD FEVER. (jo7 Somatose may be added to milk or sou]). Plasmon is also beneficial. Bovinine, liquid pcptonoids, panopeptone, eucasin, or tropon, in teaspoonful doses added to milk, are very valuable during the convalescent period. Valentine's meat juice given in milk or soup is nutritious, or Mosquera's liquid beef (made by Parke, Davis & Co.) can be added to each soup or milk-feeding. Drug Treatment. — If cerebral symptoms exist, then an ice-bag should be applied to the head. When there is severe restlessness and insomnia, with twitchings of the muscles, then injections of 3 to 5 grains of chloral hydrate should be tried per rectum. These injections are best given in starch water. Five-grain doses of sulphonal or trional, repeated in two hours if necessary, is sometimes very effectual. " If there is no effect, then V:.'4 grain of morphine may be administered hypodermically for a child 2 years old. If the child is 1 year old, then V^g grain may be given, and repeated in several hours, if necessary. The greatest care must be maintained if haemorrhage exists. Bismuth is a very valuable drug; the subnitrate in 5 to 10-grain doses, and the beta-naphthol, in 5 to 10-grain doses, may be repeated every few hours as an antifermentative. Tannalbin or tannigen, in doses of 5 to 15 grains, can also be given every two hours. If the hsemorrhage is very severe, then an injection con- taining 30 drops of Monsell's solution added to a quart of cool water, or a teaspoonful of alum, may be added to a pint of water. These injections can be repeated every three or four hours until the haemorrhage ceases. Ice-bags should be kept continuously on the abdomen at the slightest sign of hasmorrhage. Guaiacol carbonate, in 5 to 10-grain doses, repeated every three or four hours, is a very good antipyretic. Creosote carbonate, 1 drop for each year; for a child 1 year old, 1 drop; for a child 5 years old, 5 drops, three times a day, is one of the best intestinal antiseptics. When severe tenesmus, associated with flatulence and very loose stools, exists, then the best remedy will be 1 or 2-drop doses of turpentine, com- bined with several drops of paregoric. The oleoresin of turpentine in 1 or 2-grain doses, can be combined M'ith V^o grain of extract of opium for a child, 5 years old, in the form of a suppository. This can be repeated several times a day if the symptoms are not improving. Prophylaxis. — The injection of typhoid vaccine as n iii'oi)liyhu-tic has been described in Part VII, page 445. 42 CHAPTER XIII. EEYSIPELAS. This is an acute infectious and contagious disease. It is characterized by an inflammatory condition of the skin, the subcutaneous tissue, the lymph spaces, and the lymph vessels. Etiology and Bacteriology. — We are indebted to Fehleisen for a study of the bacteriology of this disease. Fehleisen found the streptococcus present, so that it is positively identified as the cause of the same. The disease may also originate from a staphylococcus aureus. ^■^•iu ^^^Z^Oh^ Fig. 211. — Ectogenous Streptococcus Infection. Eczema and erysipelas of the scalp in a child 1 month old. (Bacteria carmine stain) ; (a) cutis; (6) subcutis ; (c) lymph vessels filled with streptococci, surrounded by an inflam- matory area ; (d) epithelial covering; (e, /) elevated horny layer; (g) strep- tococci. X50. (Ziegler.) TJie invasion of the micro-organism takes place through an abrasion of the skin caused by scratching with a dirty finger-nail. It is very rarely epidemic, but can spread easily from patient to patient. A case of ery- sipelas is a source of great danger in a hospital ward. (G58) ERYSIPELAS. Cu)9 Pathology. — Tliere is an indltration of the tissues and they are usually swollen from an accumulation of serum. Under the microscope we can find pus cells in the serum. When this condition is noted abscesses will be found. In other cases gangrene will be present. Tliere is nothing char- acteristic found in the lungs, heart, kidneys, spleen, or liver which would be distinctly pathognomonic. The usual conditions found in sepsis are seen here. Pneumonia is sometimes met with as a complication. Symptoms. — The ■usual type of erysipelas met with in children is known as erysipelas migrans. This is known as the wandering type because it spreads rap- idly from diseased to healthy parts. The tem- perature in the begin- ning varies from 102° to 103° F., and may rise to 104° or 105° P. Septic cases usually show a much lower tem- perature. I have seen cases of a decided sep- tic nature in which the temperature was 99° P. for several days. The pulse-rate varies between 120 and 150. The flush is of a deep red color and ■usually very shiningo Complications. — The oedema usually seen on the skin is a very fatal complication in erysipelas affecting the air passages. In such cases oedema of the glottis will result fatally. Prognosis. — This depends upon tlie time when the case is first seen and chiefly upon the condition of the child at the time of the infection. If the child is well nourished and has been breast-fed, the prognosis is good. Treatment. — A dose of rhubarb and soda or 5 to 10 grains of phos- phate of soda should be given. The destructive tendency of tlie pathogenic bacteria on the blood should be remembered ; hence large quantities of nor- mal saline solution should be given, by injection, into the colon. The strictest hygienic measures must be used. The internal administration of Ddte 2 3 4 5 6 7 8 9 10 1 104° 103° 102° lor 100° 99° 98° M E M E M E M E M E M E M E M E M E IV 1 — . :s; i r y ^ ^ / V 1 / 1 / 1 ( / h" •t 1 t 1 / 1 y 1 A 1 f\ 1/ \ * ' ' ' k V ^ v» •s ■ >. ^^ ^^ ^^ ^ ^_ ^_ ^ ,^ „„ _ __ Fig. 212. — Fever Curve in Facial Erysipelas. (Original. ) 560 ^E INFECTIOUS MSEASES. A Study of the Condition of the Upper Air Passages Before and After Intubation of the Larynx. Also, an Inquiry Into the Method of Feeding Employed in the Cases.^ Laryngeal stenosis will frequently be relieved after one intubation and one extubation. There are other cases which require several intubations before a permanent cure results. I have examined a series of children that were operated upon several years ago. Two classes of cases have been selected. One series was seen at the Willard Parker Hospital, and the cases were intubated by the resident or assistant resident physician. The cases in this series cover the years 1896 to 1900, and were under treatment of Dr. B. G. Bryant and Dr. Somerset. First Series. Children Intubated in the Hospital. — The children ad- mitted to the Willard Parker Hospital belong, as a rule, to the laboring class of people. Exceptionally, the service at the, hospital receives patients of a better class. All of the children examined by me belonged to the tene- ment house district of New York City. The houses are densely crowded tenements having a minimum quantity of fresh air and sunlight. It is not unusual to see cases from such unsanitary surroundings ending fatally. These children are, as a rule, very anaemic and are extremely susceptible to infection. HospiTAX Cases : 10. 8 cases required one intubation 1 case required three intubations 1 case required four intubations Day of the Disease. 4 cases were intubated on tlie 2d day of illness 1 case was intubated on the 3d day of illness 2 cases were intubated on the 4th day of illness 1 case was intubated on the 5th day of illness 1 case was intubated on the 9th day of illness 1 case was intubated on the 14th day of illness One case intubated seven years ago has had no illness since. Four cases intubated six years ago are in excellent health to-day. One case has remained entirely well. One case had enlarged cervical lymph nodes. One case had pneumonia one year later. One case had pneumonia and paralysis and five years later had a second attack of diphtheria, but no laryngeal stenosis. Five cases intubated three years ago are in good condition to-day. Three had measles and bronchitis after recovery. One has not had a '■ Paper read before the International Medical Congress held at Madrid, Spain, April 26, 1903. INTUBATION. 561 day's illness since intubation. One case had a mild attack of croup two years after intubation, but did not require reintubation. Rachitis seems to play an important part in the causation of laryngeal stenosis, just as we know that rickets is met with in laryngismus stridulus. Eight cases out of the 10 reported in this series showed some form of rickets. There seems to be a certain predisposition for the development of laryngeal stenosis in children affected with diphtheria who are rachitic. Condition of the Throat. — In all of the cases of this series some form of chronic tonsillar or pharyngeal condition was found. Adenoids were also seen in 2 of these cases. Whether or no the hypertrophied tonsils seen in these cases were present at the time of intubation is not known. The fact that 8 cases out of 10 still showed enlarged tonsils, and 1 case, which makes 9 cases, reported having had a tonsillotomy performed, proves that hyper- trophied tonsils must have menaced the children's health before the diphtheria. Feeding During Infancy. — It is certainly an interesting fact that all of the children in this series were breast-fed. When abnormal conditions, as rickets, scurvy, tuberculosis, syphilis, or other undermining disorders, exist, then recurring stenosis of the larynx might possibly be provoked by such chronic disease. These cases of recurring stenosis sometimes require months and, in rare instances, years of intubating until recovery takes place. I have fre- quently seen chronic tube cases while making my rounds in the wards at the Willard Parker Hospital. Intubation has, in America, entirely replaced tracheotomy for the relief of acute lar}Tigeal stenosis. Eubber tubes are used exclusively for intubation. The old metallic tubes have long ago been discarded. Trache- otomy is used as a secondary operation, usually to cure "retained tubes." When laryngeal stenosis persists and the patient cannot get along without the tube, then a tracheotomy is frequently resorted to. Jennings, of Detroit, with an equally large experience, says that he has never met with the severer forms of the difficulty, but that in two or three instances he has had to continue the intubation as late as the third week after the first insertion, before recovery was complete. His associate, Shurley, has never had any trouble with delay in the removal of the tube. G-alatti, in the article above referred to, states that he had 2 chronic stenoses in 31 intubations. He reports Eanke as having had 1 case in many hundred; Heubner, 1 in 250, and Bokay, 2 in 800. McN"aughton, of Brook- lyn, says that he has had but few cases in many hundred, and these recovered at the latest within several weeks. 36 CHAPTEE XIV. MALARIAL FEVER (INTERMITTENT FEVER— PALUDAL FEVEE— AGUE). This is a specific infectious disease due to the invasion of a distinct germ belonging to the class of protozoa. It is known as the plasmodium malariffi. "The disease is contracted b}' the inoculation of the human sub- ject by the infected mosquito. The plasmodium malarise passes through one cycle of its development in the body of a variety of the mosquito known as the anopheles cleviger.^' We find this disease in Southern Eussia and in Italy; in our own Southern States as well. In the Korth of Europe and the Xorth of Amer- ica it is rarely found. The disease is usually seen in swampy regions and where bad drainage exists. It is also seen in the tropics. The influence of the weather is interesting. While in summer, spring, and fall cases occur frequently, in extremely cold weather they are very rare. Bacteriology and Etiology. — Laveran, in 1880, discovered the specific germ which causes this disease in the blood of infected individuals. In America, Councilman, Abbott, Osier, and many others have confirmed Laveran's observations. There are several types of fever. First. — The middle forms: (a) tertian, double tertian (quotidian); (h) quartan fever and its combinations. Second. — The more severe, often more or less irregular fevers which occur in America and in Italy, most commonly at the end of the summer and fall, called the gestivo-autumnal fever of the Italians. The tropical ma- laria of the Germans. This type of fever includes the so-called remittent malarial fevers as well as most of the cases of pernicious malaria and other malarial cachexige. Tertian Fever. — Golgi's description and differentiation of the micro- organism of the tertian and quartan type of malaria have remained prac- tically unassailed. "If we examine the blood from a case of tertian fever just after the paroxysm, we find in certain of the red blood-corpuscles small, round, colorless bodies which appear to have a slight depression in the center, and when stained in dry specimens show a paler central area with a darker periphery. These bodies examined in the fresh specimen show active amoeboid movements. A few hours later the organism will be found to have increased somewhat in size, and to contain a few, fine, brownish pigment granules which dance actively under the eye, the motion probably being due to undulatory movements in the protoplasm. On the dky between the paroxysms the bodies will be found to have about half- filled the red corpuscles. They are still actively amoeboid, and the number of pigment granules has considerably increased. The red corpuscle at this stage will be seen to be a trifle larger than its unaffected neighbors, and to (662) MALARIAL l-EVER. (;03 be considerably decolorized. On the day of the paroxysm the organism has entirely filled and almost destroyed the red blood-corpuscle, which is rep- resented only by a faint pale rim about the full-grown parasite, if, indeed, it has not entirely disappeared. The pigment granules may show at this stage a very active motion, but the amoeboid movements of the organism as a whole are but little marked. At the time of the paroxysm an interest- ing change takes place; the pigment gathers together in a more or less solid clump, usually in the center of the organism, while the rest of the protoplasm looks somewhat granular and shows a suggestion of lines radiat- ing outward from the center. This appearance gradually changes, the lines becoming more distinct, until finally we see the central clump of pigment surrounded by from fifteen to twenty small ovoid or round glistening seg- ments, each one having a central more refractive spot, and resembling Fig. 213.— Malaria Plasmodia; Ter- Fig. 214. — ^Malaria Plasmodia; Trop- tian Type. Plehn-Chenzinsky's Stain. leal Form. Romanowsky-Xocht Stain. X 1000. X 1000. strongly the hyaline bodies which we see immediately following the chill. This segmentation of the organism is always coincident with the paroxysm, and the presence of the blood of a segmenting body is a sure indication that the paroxysm is present, or is about to occur. Immediately following the paroxysm fresh hyaline bodies appear in the red corpuscles. Though the invasion of the corpuscles by these fresh segments has never been actually observed, the evidence that this occurs is so strong that we can safely accejpt it as a fact. Besides these forms we see not infrequently small or large extra cellular pigmented bodies; that is, organisms resembling exactly those within the red blood-corpuscles, excepting that they are free in the blood current. These may be seen at times to break up into several smaller bodies, while at other times they may show a long, tail-like, non-motile process GGi THE INFECTIOUS DISEASES. containing sometimes a few jVgment granules. They are probably organ- isms which have escaped from the red corpuscles, or full-grown bodies which have broken up; they are considered to be degenerative forms. At times also we find the so-called flagellate bodies. Their development from the pigmented organism may indeed be observed, the pigment of the full- grown body becoming very actively motile, then collecting in the center of the organism, while several long, thread-like fiagella burst out of the body and move actively about among the surrounding corpuscles. Some- times we may see one of these flagella which has broken away from the organism and is moving rapidly through the field. This is also thought by the Italians to be a degenerative process. The characteristics of this form of organism, which is observed in tertian fever alone, are so marked that with a little study of the parasite one can make a definite diagnosis of the type of fever from an examination. of the blood alone. Date 1 1 2 3 , L, 4 I -■ 5- ' A. M. Hook P. M. A .» 3 6 9 3 M P. M. A 9 I» 3 6 9 - 3 « M. P. M. 1 A. M. P. M. A 9IJ369 53 69U3«9 36 M. P. M 9 12 3 69 *» <^ 06 05 « A ri. " /^r- ' / V /A '\ 0, \ i \ 0, X 1 \ / \ A 00 ^ -- / \ / ^ 99 ^ / \ „-^, r- ,8 Kr^ = -^^; -\: - ^- ^^ t 97 i^ — ^^ --^^ ^ ^^'- 96 _ ±: Fig. 215. — Tertian Fever (Intermittent Fever). Typical malarial tem- perature, usually seen in the spring and early summer. Onset with vomit- ing, diarrhoea and chills, accompanied by a well-marked rigor, and coldness of the extremities. (Original.) TliG Parasite of Quartan Fever. — "Quartan fever is not at all common in this country, but in the few cases which the writer has observed the or- ganisms differ distinctly from the tertian parasite, and show accurately the characteristics described by Golgi. Here the first stage of the organism is similar to that observed in tertian fever, excepting that the amoeboid move- ments are not so active. As the body develops, the rods and clumps of pig- ments are larger and darker than those in tertian fever, while the amoeboid movements of the organism are relatively slight. The full-grown forms are materially smaller than in tertian fever, Avhile the red blood-corpuscles, instead of being expanded and decolorized, appear at times shrunken about the body, and of a somewhat deeper old-brass color (messingfarbe). In MALARIAL FEVER. no: segmentation the organism divides into from six to ten different parts in- stead of twenty to thirty, as in the tertian form. The Organisms of the /liJslivo-aiUuinnal Fevers. — "The organisms asso- ciated with the a'stivo-autunmal fevers have heen carefully studied, but much remains to be done, ])articalarly in this country. "There is some difl'erence of opinion as to whether there are not two types of organism associated with these fevers. Some Italian observers divide them into the quotidian and tlie malignant tertian organisms. Tlie differences made out by the Italians arc, however, very slight, and have not been observed in this country. In the first place we see just after the paroxysm small hyaline bodies which may or may not be actively amoeboid; these can sometimes be distinguished in that they are generally somewhat smaller and have oftentimes a characteristic ring-like appearance. In the early stages — during the first week, for instance — of an attack of this form. 2)AT£ / It 3 ft- s 6 / FAHR. M £ n e: M E M £ M £" M £■ M £ •/06* ■105° ■103,' 'ten' . 99' 9sr 91' -ft= =*= F y ■- — ■ — 1 n ^ n ^ m ^ ?^ 1 ^ =r^= Fig. 216. — Quartan Fever (Double Tertian). Onset with vomiting and convulsions. Convulsions usualh' accompany each paroxysm. Restlessne33 associated with cyanosis and coldness of extremities. These cases are usually seen in the late autumn. (Original.) we may see only the hyaline, mipigmented forms; but commonly, if we observe carefully, we may sec some time after the exacerbation of tem- perature, shortly before the l)eginning of another, bodies which are a trifle larger than tliese smallest hyaline forms and which contain one or two very minute pigment granules lying near the periphery. Just before or during the paroxysm we may see bodies with a small central clump of motile or non-motile })igment granules lying usually in cells which are more or less shrunken and crumpled, and of a deeper color than the normal corpuscles (messingfarbe). These bodies are generally not half as large as the red corpuscles. After the first week or ten days of the disease, or after treat- ment has l)een begun, we see. however, certain very characteristic and easily recognizable forms which ni-e only seen with this type of fever. These are, first, round or ovoid bodies about the size of a red corpuscle, a little smaller or a little larger, with clear, rather liighly refractive, waxy-looking proto- G66 THE INFECTIOUS DISEASES. plasm, and coarse dark pigment granules, which are nsually collected in a ring or a mass in the center of the organism. The granules are usuall}^ very slightly motile. At one side of the body we often see a small bib-like attach- ment which may show a slightly yellowish color. On examination this proves to be the remains of the red blood-corpuscles in which the organism has de- veloped. In association with these are seen crescentic bodies, the proto- plasm of which shows the same characteristics as that in the forms above described, while the pigment is collected in the middle in a similar ring or bunch, and is but slightly motile. On the concave side of these crescents one may also often see a bib-like attachment, just as in the ovoid forms. At times during the examination of the fresh specimen we may see the change from an ovoid body into a crescent take place, The development of D.U: 1 .2 3 4 5. 6 1 A. M F. M, A. M. P. M. A M. V. M. A. M. P. M. A. M. !• M. Hoars H ||369II3'9 3*9 "3»9 3'9'J3'9 .l'9"3»9 }69"3*9 loSo 107 ,06 1 - . r^ FA \ l\ ' ^ .__ - ^ i /" A , \ - N r^ \ ' ^ i V, ._ - - ^ ".^ 4 :^ ^- I 5 - ^qr "^ ^J \. t \ -^-==="=i""--i^^=====^^=====^^.^^^^^= — * — — J— P * ^ -. '-- >. «'=' • ft73 .= "Z o a -cor lien sta rfec ft+S oj '2 £^-ft o — •/■ b a O a; tH O S OJ -^ ^ ^ -^ -/ Red freq darl p— 1 to c5 .- O Pi 53 ra ft f-l ei c3 fLi p 5»C ft ,a a -43 ft^ o o N O 4J tH ;»3 o^ a 1 !='.tl ^5 O O o .2 o ^ o a r/l ni a ft a fe ^(■'^ EC pi += ^S o O a a V I O N-d ^ <» 2 o o ■*^ a s S 03 a -12 « "=1 ' O [« eS ■ a -g ai =3 g g fc^ a o' W O — CO < a.sii 1=1 o a^ ^e-^ fl aj T, ^ -p ^ I " '■ 'ft "3 -P r^-S 9 S ^ O ^fl " S m X! a> a; CO •9 G flj > a aJ H S =2 § i ft9 =3 S 3 t^ia (B '^ C £ •^ a m a o ai a) o) ^ rH fr- p- <^ a ft a >^S > ? ^2- a t< c3 to .ir' o o ffi o a> u a -^ fc J C ft a c3 2 6b ft a -S aj • - a eS Oh cr ft 'S .1:2 -1 D -ft J8A9J !^U9!4!41UU9';UI 9|draiQ :3 u i: jaA9j^ l«nuiuc>nv-OAijs;j'- .xo 4nimi>ii«j^ 670 THE INFECTIOUS DISEASES. "Crescents are always an evidence of cestivo-autumnal fever^ and never occur in the quartan or tertian type. They are from eight to ten micro- millimeters in length and from two to three micromillimeters in breadth, are half-moon shaped wlien typical, but vary greatly, oftentimes appear- ing almost straight. They contain pigment sometimes scattered, but oftener found clumped in the center, and usually vsathout motion. With a good light and an accurate adjustment the shell of the red blood-cor- puscle can be seen extending from the poles of the crescent, showing that this parasite is distinctly an intracellular formation. Crescents are dis- tinctly an evidence that the infection has lasted a number of days, — five or six — and they will not be found in any specimen before that time. The unpigmented quotidian parasite shows not many variations from the fore- going type, except that it is free from the pigment, though the crescents formed from this variety may show pigmentation. The malignant tertian parasite is pigmented and, in fact, much like the pigmented quotidian. It grows to segmentation once in forty-eight hours, and is amoeboid in the ad- vanced stage ; the pigment is active and the entire organism is larger. Prob- ably no better idea can be given concisely of the different characteristics of these parasites than by reproducing the table of Mannaberg.'^ (See p. 669). Symptoms. — In very young children there may be convulsions, restless- ness, cold extremities, and yawning. The pulse is full and rapid. The tem- perature may reach as high as 105° F., or even higher. After this febrile stage the body is covered with a profiise perspiration, ending in sleep from exhaustion. Diarrhoea is ocasionally met with in this condition, and is prob- ably the result of secondary infection. Bronchitis is occasionally seen. The paroxysm of fever occurs when the protozoa matures and begins to divide. This process repeats itself about every twenty-four hours in the tertian type of intermittent fever most frequently seen in this country. If children are carefully observed, then the onset of a paroxysm is frequently seen by a severe cyanosis affecting the nails. This would correspond to the chill seeji in the older children. Slight albuminuria or hematuria fre- quently accompanies malaria. There is no disease that can be mistaken for the tertian type of malaria when it is remembered that there is a sick day with fever, etc., and an alternating apparently healthy day. An enlarged spleen is usually present. Diagnosis. — This can be most positively made by an, examination of the blood. So many symptoms present in malaria, such as lassitude, pains in the bones, headache and fever, simulate other diseases, that only the posi- tive finding of Laveran's protozoa in the blood will complete the diagnosis. Differential Diagnosis. — If there is a doubt as to the differential diag- nosis between tuberculosis and malaria, the specific effect of a few doses of quinine will easily show the presence or absence of malaria. The blood test is, however, conclusive. MALARIAL FEVER. 671 A boy, 6 years old, was brought to me at the children's service of the German Poliklinik with a history of headache, fever, and pain in the bones. The boy ap- peared rather icteric. His mother said that he had lost weight during the last two weeks. He perspired freelj% had a good day and a bad day. The fever appeared in the afternoon. The examination showed a well-nourished boy, lungs normal, a slight hiemic murmur at the apex of the heart which was also heard in the vessels at the neck. The spleen was palpable and slightly enlarged. The appetite was poor, the bowels moved sluggishly. The child was restless at night. The examination of the blood showed the presence of the ordinary tertian parasite. Quinine in 3- grain doses was given every four hours, and 6 grains were given three hours before the expected attack, which in this condition was between 1 and 2 o'clock in the afternoon. Fifteen drops of cascara sagrada were administered before breakfast of each day. The treatment was continued for ten days. Tlie boy then complained of buzzing in the ears, evidently due to cinchonism. Quinine was given every second day and Fowler's solution in 3-drop doses was administered on alternate days. Strengthening food was given and the child made a complete recoverj'. Quinine was given once every three days after the first month. The child took an ocean voyage and was perfectly well in two months. Iron was then given for several months as a tonic and the treatment discontinued. Prognosis. — This is usually good. If malaria is neglected severe an- aemia follows, and if pernicious malaria results it ma}' end in death. In this country the specific effect of quinine and the change of climate usually gives successful results. Treatment. — A patient suffering with malaria should, if possible, be removed to a different climate. A change from the city to the country. or vice versa, is very beneficial. Next in importance to change of air is the specific effect of quinine. Five grains of quinine (0.3) can be given to a child 3 years old. The hydrochlorate of quinine is the most effective. Owing to its disagreeable taste it can be given in tablet form, after which a mouthful of coffee or chocolate can be given. "When quinine is refused by mouth, then a 10-grain dose in the form of a suppository can be given three times a day, per rectum. The hest time for administering quinine is about three hours before the expected attack. The bisulphate of quinine is a soluble and convenient form to use. It is very important to keep the bowels open and the kidneys active. Fifteen to 30 drops of fluid extract of cascara sagrada can be given in a palatable menstruum every morning, so that the action of the bowel is assisted. In true malaria, I have found especial benefit in administering whisky well diluted with water, or given in milk. Apart from its nutritive properties, it certainly has decided anti- septic properties. If malaria persists in spite of continued treatment, then arsenious acid in doses of ^/-^oq or ^/j-q grain, can be administered three times a day. Fowler's solution, in doses of 1 to 5 drops, should not be forgotten. Jacobi recommends ergot in doses of 20 to 50 drops every day for weeks. When it is not well borne he combines it with quinine or arsenic. I have never been able to see the slightest benefit from the use of ergot, although I have tried it in many cases. I believe Jacobi's results were good when he combined the ergot with the quinine because the quinine was given. CHAPTER XV. , SYPHILIS. This is a specific disease most probably caused by the invasion of a micro-organism called SpirocJiCBta pallida. The disease in infancy is the same as that in adults. There are two forms of the disease: — 1. Inherited s}'philis. 2. Acquired syphilis. Etiology. — The most frequent modes of infection are : — By nursing from the breast of a syphilitic wet-nurse. Eating from the dishes of syphilitic patients. Unclean surgical instruments; for example, when an infant is vac- cinated, or during the operation of circumcision. The Trojismission of Syphilis in Utero. — An infant in utero may be infected directly through the circulation in the placenta. If the mother acquires syphilis during the ninth month of her pregnancy, the same will not infect her child nor modify its development. A healthy infant in utero can be infected by passing through a syphilitic genital tract of its mother during labor. When the ovum is infected with syphilis, which frequently happens at the time of conception, it may terminate in the death of the foetus, re- sulting in an abortion or in the birth of a still-born child. If the child lives it may suffer with cachexia, and a few weeks later present the char- acteristic skin-lesions. The father can infect the mother for three or, at the most, five years after his chancre. The father may infect the foetus as late as twenty years after his chancre, when for years he has presented no signs of syphilis. The mother may have a series of syphilitic pregnancies resulting in miscarriages or in s^-philitic infants, without at any time herself presenting any s3-philitic manifestations. In the same couple the severity of the infection transmitted to the fatus tends to decrease with succeeding pregnancies. Thus it is the rule for the mother to have at first several abortions, then a child born dead, and finally a living child showing the evidences of inherited s^'philis. Children born later usually suffer less severely, Ijut this "law of decreases" (Diday) is not without nu- merous exceptions; sometimes the third or fourth child suffers more than the second. In other families children of one sex suffer more than those of the opposite sex. In twin pregnancies one may be affected while the other apparently escapes. The apparent escape of the mother of syphilitic infants by a syphilitic father has been accounted for on the supposition (67 9' SYPHILIS. 673 f that she undergoes a mitigated infection derived from the foetus. Coutts^ has pointed out the theory that she absorbs from the foetus a syphilitic anti- toxin ; this would account not only for her apparent immunity, but also for the gradual decrease in the severity of the disease in later pregnancies. If the mother be infected but not the father, death of the foetus is the most likely result. If the child is born alive it will probably suffer from in- herited syphilis. If both parents have suffered from manifest syphilis, the chance of abortion or still-birth is greater. Golles's .Law. — In 1837 Colles wrote that "A new-bom child affected with inherited syphilis, even though it may have specific lesions in the mouth, never causes infection of the breast which it sucks if it be the mother who nurses it, although continuing capable of infecting a strange nurse." The substantial truth of this dictum has not been seriously questioned, though various explanations have been offered. Butyric-acid Test for Syphilis.^ — This test depends on the precipitation of globulin, either in the blood-serum or in the cerebrospinal fluid. The Noguchi test consists of the following: — From one-tenth to two-tenths c.c. of cerebrospinal fluid, which is absolutely free from blood, is mixed with one-half c.c. of a 10 per cent, solution of butyric acid in normal saline, and boiled. Then one-tenth c.c. of 4 per cent, sodium hydroxid solution is quickly added, and the whole boiled for a few seconds. A granular or floccular precipitate means a positive reaction. The precipitate appearing within a few minutes indicates a large increase in globulin, while a weaker reaction may not appear for an hour or two, two hours being the time limit. If this test gives the spinal fluid only a slight opalescence or tur- bidity and no granular precipitate, then we can consider the fluid normal after the usual time limit has been reached. With the cerebrospinal fluid, a positive reaction occurs in any case of syphilitic or parasyphilitic affection; also in all acute or chronic in- flanmaations of the meninges, whether due to the meningococcus, the tubercle bacillus, the pneumococcus, the streptococcus, or the influenza bacillus. In the early stage of poliomyelitis the reaction is also positive. In acute luetic meningitis the presence of Treponema pallidum in the cerebrospinal fluid will serve to exclude other forms of meningitis. In hydrocephalus, the cerebrospinal fluid gives a positive butyric-acid test in cases which are of syphilitic origin. In pneumonia, with an in- creased amount of cerebrospinal fluid without iuflanmiation of the meninges, the fluid does not give a positive butyric-acid test. * "Some Aspects of Infantile Syphilis." Hunterian Lectures, London, 1897. ^I am indebted to Dr. Hideyo Noguchi for assistance in the preparation of this article. 43 674 THE INFECTIOUS DISEASES, The test is most valuable in differentiating between inflammatory and non-inflammatory conditions of the meninges in children. The blood-serum test is too complicated to be tried outside of a highly equipped laboratory. Pathological Anatomy. — In obscure inflammatory lesions involving the meninges or spinal cord, it is necessary to submit the spinal fluid as well as the blood to the Noguchi or the Wassermann test. While the Noguchi test is very sensitive, one should not fail to utilize the Wassermann to confirm the presence or absence of a positive reaction. In acquired syphilis changes are the same in the child as in the adult. Fig. 218. — Spirochseta pallida. Macerated skin of foetus. (Courtesy of the Rockefeller Institute, New York.) In hereditary syphilis there are certain constant changes present in the bones. These changes are confined to the shafts of the long bones and to the cranial bones. The pathological changes are not confined to 'the epiphyses, but the diaphyses are also swollen. The ends of the bones are swollen. The inner portion of the periosteum shows swelling and hypersemia. The circulatory apparatus shows thickening of the arterial walls as well as of the veins. Owing to this degeneration there is a tendency to bleeding. (See clinical case described in this chapter.) Catarrhal manifestations showing implication of the respiratory tract. SYPHILIS. 675 and also the gastro-intestinal tract, can be noted. The liver, spleen, and pancreas are enlarged. The lymph glands of the entire body are enlarged. Symptoms. — When catarrh is troublesome in children and not amen- able to ordinary treatment, syphilis should be suspected. It is surprising to find the frequency with which nasal and nasopharyngeal catarrh is asso- ciated with syphilis. I have not yet had occasion to regret asking a direct question of a parent in whom I suspected syphilis, if such parent is told that we must know his previous history, for the benefit of his child. Gastro-intestinal Tract. — The gastro-intestinal tract is the one that will frequently show the manifestations of syphilis. An infant will not appear to thrive nor will it digest, in spite of the most careful dietetic meas- ures. Syphilitic lesions of the liver, pancreas, stomach, and intestine are simply all part of the infection. Anti-luetic treatment will frequently do more good in a few days or weeks than months of rigid diet. Thus it is apparent that in order to do good in this disease we must seek to remove the cause. When a persistent diarrhoea will not respond to the ordinary treat- ment of careful diet and medication, then suspect syphilis. When diar- rhoea such as a mucus-colitis persists without fever after careful dieting, then syphilis may be suspected. The following case will illustrate congenital syphilis : — An infant about one week old was seen by me. It was the fourth child of apparently healthy parents. Three children had previously died, and this fourth child was born at full term. The mother noticed that the child cried incessantly and was very restless. The child had had sniffles since birth. It was breast-fed and appeared to suffer with colic and hunger. The stools were grass-green and con- tained mucus and curds. The palms and soles had a pemphigus. The skin had a yellowish tinge. The nose was excoriated from the discharge. The anus had deep cracks — the so-called rhagades. Around the mouth were also rhagades. The spleen was enlarged and palpable. The lymph glands were not enlarged. Tlie chill did not seem to thrive. The finger nails showed distinct evidences of the disease. The bones of the fingers and toes showed the presence of dactylitis syphilitica. The diagnosis of congenital syphilis was made. The mother had plenty of milk, but was compelled to wean the child owing to a typhoidal condition to which she suc- cumbed. The infant was bottle-fed, and when about five weeks old developed a large abscess on the forearm which was incised under an anaesthetic by Dr. Geo. F. Shrady. One week later a series of metastatic abscesses formed over the abdomen and on the back. The child died from inanition and general sepsis when about nine weeks old. Hemorrhages from the nose and mouth, and bloody stools due to ulcer- ation of the intestinal tract are frequently reported. Uracek has reported haemorrhages in the different internal organs caused by syphilis in the infant. Umbilical hjemorrhages are sometimes due to syphilis, according to Eotch. 676 THE INFECTIOUS DISEASES. The following case will illustrate bleeding in the new-bom : — An infant suffered with a severe form of marasmus and athrepsia. It did not develop. Examination of the mucous membrane of its mouth, gums, and fauces showed distinct patches. The child was attended by Dr. Honor, of New York City, who referred the case to Dr. W. Freudenthal for diagnosis. The case was also seen by me and I concurred in the opinion expressed, that the patches were non- diphtheritic and were most likely due to syphilis. Several days later Dr. Freudenthal and myself were again called to see this child owing to an extensive nasal haemor- rhage. In spite of the most active local treatment, the use of haemostatics, such as adrenalin, and the use of styptics internally and externally, the infant died from exhaustion. The attending physician. Dr. Honor^ subsequently stated that he had found distinct evidence of syphilis. SMn Lesions. — The skin lesions develop soon after those of the mu- cous membrane. The eruption consists of small, round, pink macules, which disappear on pressure. While the eruption may be on the abdomen and lower limbs, it not infrequently is found all over the body. At times the eruption resembles an erythema and is copper-colored. Sometimes the eruption is papular; it is not infrequent to find condylomata around the mouth or anus. These cond3domata are very contagious. Pustules are frequently seen as early as two months. This eruption can be differentiated from eczema by the characteristic absence of itching that always accom- panies eczema. Furuncles are usually found in poorly nourished children. The infant usually has the appearance of a shriveled old man. The Teeth. — The teeth in congenital syphilis, instead of appearing at the sixth or seventh month, may not appear until the fourteenth or fif- teenth month, and even later. These teeth are usually carious. Congenital Syphilitic or Hutchinson's Teeth. — This variety of dental abnormality is important, because, as Hutchinson says, "It is,,, if taken alone, by far the most valuable of the signs by which we recognize in adolescence the effect of inherited syphilis." The characteristics of these teeth are not sufficiently known, and abnormal and peculiar teeth of other kinds are often erroneously regarded as proofs of congenital syphilis. The main points about "Hutchinson's teeth" are as follows : — 1. It is always the permanent teeth which are affected. The tem- porary teeth in syphilitic infants often decay early, but they present no special peculiarities of form. 2. The characteristic peculiarities which distinguish these central incisors are as follows : They are dwarfed, being too short and too narrow ; and sometimes the portion of the upper jaw from which they grow is also arrested in growth. They often stand somewhat apart and slope toward one another. They are unusually rounded on section; they are "pegged" and they are notched. The notch is usually shallow and the dentine is exposed at the bottom of it. It is formed by the breaking away of the imperfectly developed central portion of the edge. The teeth are generally SYPHILIS. 677 not of a good color, and they are abnormally soft, so that by the time the patient is 20 they may be ground down like those of an old man. The first molars are next in diagnostic importance to the upper cen- tral incisors. When characteristic they are spoken of as "dome-topped." Their sides slope toward the center, over which the enamel is defective. As Fig. 219. — Syphilis. Child 14 years old. A productive periostitis enclosing the shafts of the long bones. Absolutely characteristic of syphilis. might be expected, syphilitic teeth not infrequently present the character- istics of mercurial teeth in addition to their own peculiarities. Diagnosis and Differential Diagnosis.^ — The clinical history will be the guide in congenital syphilis. The history of previous abortions and still- born children will aid in establishing a diagnosis. The cachectic skin, the wrinkled mouth, and rhagades at both mouth and anus will materially aid in establishing a diagnosis. ' See "Blood in Syphilis," page 685, 678 THE INFECTIOUS DISEASES. Table No. 68. — Differential Points Between Syphilis and Tuberculosis. (Morrow.) SYPHIUS. TTJBEBCUIiOSIS. Exhibits a marked predilection for the Is almost exclusively situated in the long bones; its habitual localization is epiphysis, rarely affecting the shaft, in the diaphysis and almost always at its terminal extremity. There is a marked enlargement of the The tumefaction is due less to increase bone by more or less voluminous osseous in the size of the bone than to oedema- tumors or hyperostoses, with little or no tons infiltration of the soft structures, involvement of the soft parts. There is little tendency to suppuration The pyogenic tendency is marked, and necrosis. Osteocopic pains with tendency to The pain is dull and hea^^, not aggra- nocturnal exacerbation are pronounced vated at night; sometimes there is en- features, tire absence of acute painful symptoms. The osseous lesions rarely react upon The osseous lesions often determine a the general system. marked impairment of the general health, grave complications, hectic fever, cachexia, etc. In dactylitis there is little involve- In dactylitis the swelling is due more ment of the soft parts, the swelling to an (edematous infiltrated condition of being caused by the enlargement in the the soft tissues than to enlargement of size of the bone. the bone. Breaking-down of the tissues and ulceration are more apt to ensue. At times pseudo-paralysis will be present; sometimes coryza, hoarse- ness, inflamed eyes, and persistently running ears. The Wms&rmann Reaction. — In suspicious cases the blood should be examined to see if we get a positive Wassermann reaction. Luetin Test. — This reaction devised by Noguchi is apparently specific for syphilis. It is useful after the spirochete can no longer be demonstrated, and when the Treponema pallidum still survives in the body. As a rule 90 per cent, of hereditary syphilis gives a positive reaction. Under 1 year the reaction is indistinct; from 2 to 6 years it gradually increases. Late cases are almost always positive. Exceptions are few. Cases with a strong Wassermann reaction and clinically unfavorable cases give a negative reaiction. An emulsion of pure culture of Treponema pallidum is prepared and 0.057 cubic centimeter is injected under the skin by means of a fine needle. If a red, indurated papule forms after twenty-eight to forty-eight hours, surrounded by a diffuse zone of redness, the reaction is positive. This redness increases for three to four days, then disappears within a week. A slight rise of temperature may accompany this reaction. "The diagnosis between syphilis and rachitic bone lesions may become of great importance. Epiphyseal swellings occurring under six months are apt to be syphilitic. In syphilis the epiphyseal swelling may be unilateral, but it is always symmetric in rachitis. In doubtful eases the swelling must SYPHILIS. 679 Fiff. 220. Fig. 221. Fig. 222. Fiff. 2-23. Figs. 220-223.— Syphilitic Teeth. Various types of hereditary syphilitic teeth, as described by Hutchinson; also parenchymatous keratitis. Note that the upper central incisors show the positive evidence of syphilis. (Courtesy of Dr. Hugo Neumann.) 680 THE INFECTIOUS DISEASES. be subjected to specific treatment. Rickets and syphilis may coexist in the same case. There is almost invariably enlargement at the costochondral articulations in all cases of rickets, which is absent in syphilis.-" Prognosis. — This depends upon the condition of the child at the time treatment is commenced. Such children have very little or no vitality. Hereditary syphilis can be transmitted to healthy children, so that the precaution of strict isolation should be remembered. Treatment. — ^The therapy of sj^philis has undergone a radical change since the introduction of salvarsan. Through the courtesy of Prof. Ehrlich, Fig. 224. — Congenital Syphilis Before Injection of Salvarsan. (Original.) I received a liberal supply of salvarsan, also known as dioxydiamidoarseno- benzol or "606." ISTo case should be injected until a positive Wassermann reaction has been obtained. The choice of the technique of the injection is one of preference, although the intravenous method seems most popular because of better results. The following doses are recommended : For an infant 1 year old, an injection of 0.06 gramme, to be followed in one week by an injection of 0.1 gramme (intravenous method) if no severe systemic reaction follows the first injection. For a child 5 years old an injection of 0.1 gramme, followed one week later by an injection of 0.2 gramme. Complica- tions must be guarded against. When we recall that one-third of salvarsan consists of arsenic, then the toxicity of the same is well brought out. By the intravenous method we diffuse the efficiency of this drug into the circula- tion and prevent the cumulative effect which usually follows the intramus- cular injection, SYPHILIS. 681 In one of my cases^ severe necrosis of the tissues in the gluteal region was followed by a series of deep abscesses. In addition thereto, a multiple neuritis developed which involved the lower limbs and persisted until five months after the injection was given. The syphilitic ulcerations and condylomata around the vagina and anus improved after three or four days and practically disappeared. This child was 18 months old and received 0.3 of an alkaline solution of salvarsan injected into the gluteal region. B. L., six years old, a former patient of Dr. Tunick, was admitted to the babies' ward of the Sydenham Hospital. The mother had an innocent infection. Fig. 225. — Appearance of Lesions One Week Aft«r Injection of Salvarsan. (Original.) The child showed distinct evidences of syphilis. Two years previous a gumma of the left testicle existed, and said testicle was removed. At time of admission he had very marked superficial veins, periostitis, and gumma of the left knee-joint. The Wassermann reaction and the Noguchi reaction were positive. All serological examinations were made by Dr. D. M. Kaplan. One injection of 0.3 salvarsan, in a neutral solution, was given, with aseptic precautions in the left buttock. No local reaction followed. The child made a brilliant recovery. The swelling in joint subsided after three days. The boy walked in one week and was discharged two weeks after admission. Local Treatment. — The safest method of administering mercury is in the form of bichloride baths. These baths can be given in a wooden 'Reported in the Journal of Americap Medical Association, February 11, 1911, 682 THE INFECTIOUS DISEASES. tub, in which enough water is drawn to cover the child's body. From 5 to 10 grains of bichloride can be added to this tub of water. Infants up to 1 year can be bathed from ten to twenty minutes every day. The presence of eczematous or other skin eruptions would not contra- indicate giving these baths. The inunction of chemically pure mercurial ointment well rubbed into the axillae, knee-joints, or the thighs will materially aid in bringing this drug into the system. For the relief of syphilitic warts nothing is better than: — IJ Bichloride 10 parts Alcohol 100 parts Apply with absorbent cotton several times a day. Internal Treatment. — Internally calomel and bichloride or the tannate of mercury can be given in suitable doses. It is advisable to give the child from 1 to 5 grains of iodide of sodium, according to age, to alternate with the mercurial treatment. Care should be taken that stomatitis is not developed in nurslings. If, however, stomatitis has developed, then active and persistent treatment with chlorate of potash solution, locally, will be found effectual. It is self-understood that hygienic treatment in addition to careful diet is just as important as the specific drug treatment. Feeding. — A diet of milk, eggs, cereals, fish, and fruit should form the basis of nutrition. The reader is referred to the articles on "Marasmus" and "Eickets" as a guide to the method of feeding necessary to reconstruct a weakened child. PAKT VIII. DISEASES OF THE BLOOD, GLANDS OK LYMPH NODES, AND DUCTLESS GLANDS. CHAPTER I. INTRODUCTORY. The Blood.^ The red corpuscles (also known as the erythrocytes). The red cor- puscles of the blood are more numerous at birth than in later life. Hayem and Helot found that when the umbilical cord was not tied until its pulsa- tions ceased, a greater number of red corpuscles were found than in cases where immediate ligation was performed. Leder and Hutchinson, com- paring the new infant's blood with that of its mother, found that the blood of the infant contained a larger number of red corpuscles. The following table will show the difference in blood count by various writers : — Table No. 69. Hayem averaged 5,360,000 Sorensen Otto Bouchat and Dubrisay . . . . SchiflF (one case) Gundobin Elder and Hutchinson . . . , Schwinger greatest at birth. 5,665,000 6,165,000 4,300,000 6,658,000 6,700,000 5,346,560 The difference varies between 350,000 and 500,000 per cubic milli- meter. Gundobin believed that the concentration of the blood was caused by loss of water through the lungs. Schiff found the same condition; he also states that the number of corpuscles decreases when the child is put to the breast. The number of red corpuscles begins to fall after the second day. In one case Schiff studied the number in the morning and evening during the first fifteen days of life ; he found the number declined irregu- larly. The first day's count was 7,628,000 ; the last day's count was 4,565,- 600; the average for the fifteen days was 5,828,465. According to Schwinger and Gundobin, there is a decrease in the number during the first year ; after this there is an increase up to the eighth *I am indebted to Stengel and White, Archives of Pediatrics, April, 1901, for many valuable points in the preparation of this article. (683) 684 DISEASES OF THE BLOOD. or twelfth year, when the number becomes approximately that of adult life. Sex makes no difference in the count of the red corpuscles in infancy. Size. — The red corpuscles vary greatly in size at birth and during the first few days of life. Hayem found variations between 3.25 fx and 10.25 ^ and Ix)OB found the size varying from 3.3 r/ to 10.3 m. Gundobin claims that the hemoglobin is more firmly attached to the cell stroma in the new- bom infant. He also calls attention to the great number of small-sized corpuscles. The Ecemoglohin. — According to Morse, Elder, Hutchiason, Taylor, and Eotch, haemoglobin is increased at birth, but the percentage declines rapidly during the first few days of life. According to Eieder, there is an excess of 25 to 30 per cent, at birth compared with infants after feeding has begun. Specific Gravity. — This varies just like the haemoglobin. At birth the specific gravity is high. Monti found the specific gravity at birth 1060 Eotch found the specific gravity at birth 1065 Hoch & Schlesinger found the specific gravity at birth .... 1066 Moelle found the specific gravity at birth 1060 The specific gravity may not vary for weeks or months in healthy children. The White Blood Corpuscles (Leucocytes). — Leucoc}i;es are found in greater number at birth than in later life. This excess in number has fre- quently been, spoken of as a normal condition. It is also called the physio- logical leucocytosis of the new-horn. Table No. 70. Physiological Leucocytosis. Pathological Leucocytosis. 1. Leucocytosis of the newborn. 1. Inflammatory and infectious leuco- cytosis. 2. Digestion leucocytosis. 2. Leucocytosis of malignant disease. 3. Leucocytosis due to thermal and 3. Toxic leucocytosis. mechanical influences. 4. Thermal leucocytosis. 4. Experimental leucocytosis. Pathological Conditions. — In disease the first change noticed will be a reduction in the percentage of haemoglobin, and also in the number of erythrocytes. There are smaller forms of red corpuscles called microcytes. Nucleated Red Corpuscles (Erythrohlasts) . — These cells have been found in primary and secondary anaemias by many observers. They have also been found very abundant in syphilis, rachitis, tuberculosis, pseudo- leukaemia, and osteomyelitis, Leucocytosis. — In leucocytosis an increase in the number of leucocytes is found in the blood of anemic children. It is also found in toxic and THE BLOOD. 685 inflammatory conditions. Myelocytes are more frequently found in the blood of children than in adults. Cabot and Engel ascribe a bad prog- nostic significance in pneumonias and diphtherias to their presence. Acute colitis causes concentration of blood, with considerable leu- cocytosis. Inflammatory leucocytosis is classified, according to Cabot, as follows : — 1. Infection mild; resistance good; small leucocytosis. 2. Infection less; mild; resistance good; moderate leucocytosis. 3. Infection severe; resistance good; very moderate leucocytosis. 4. Infection severe; resistance poor; no leucocytosis. Table No. 71. Red hloodr corpuscles. Leucocytes. Birth 5,900,000 21,000 Seventh day 5,000,000 15,000 First year 5,000,000 10,000 Sixth year 5,000,000 7,500 (Coles.) Proportion of Leucocytes in Adults and Infants. Adults. Infants. Small uninueleated 24 to 30 per cent. 50 to 75 per cent. Large uninueleated 3 to 6 per cent. 6 to 14 per cent. Multinucleated or neutrophils ... 60 to 75 per cent. 28 to 40 per cent. Eosinophile cells 1 to 2 per cent. % to 10 per cent. In studying a series of blood counts in babies, Warfield found the younger the infant the higher the leucocyte count. Gundobin and Carstanjen found that the increase is due chiefly to an excessive gain in the polynuclear neutrophiles. Infectious Diseases. — In diphtheria, scarlatina, pneumonia, and ery- sipelas the polymorphonuclear cells are greatly increased (Weiss and Gun- dobin). Gundobin found an increase in the number of leucocytes before the eruption in scarlet fever, measles, and erysipelas. In typhoid fever the number of leucocytes is decreased ; there may be also a decrease in ' the number of red corpuscles and in the percentage of hgemoglobin. The num- ber of leucocytes is relatively increased. The polymorphonuclear cells are decreased. Pneumonia. — Leucocytosis is usually present in this disease. When it is absent the prognosis is grave. Sypliilis. — In hereditary syphilis an ansemia is found with a decrease of the red corpuscles and great degenerative changes (poikilocytosis). In syphilis we find microcytes and macrocytes and nucleated erythrocytes. Myelocytes are also found. Eosinophiles are also met with in this condition. Bronchitis. — A slight leucocytosis with especial increase of the lympho- cytes or mononuclear cells. 686 DISEASES OF THE BLOOD. Gastro-intestinaX Disease. — The condition of the blood varies accord- ing to the extent of the process, the duration, and the existence or non- existence of diarrhoea and vomiting. Profuse diarrhoea and vomiting may for a time thicken the blood by loss of water. Weiss shows an increase of the leucocytes and transitional leucocytes. Rachitis. — ^There is usually a reduction in the number of red corpuscles, a decrease in the percentage of haemoglobin, and an accompanying leueo- cytosis according to von Jaksch. STcin Diseases. — There is an increase in the number of eosinophiles. The cause of the same is unknown. Nervous Diseases. — In the functional disorders of childhood the blood findings are those of a moderate anaemia. Burr has found that the blood in chorea is not as a rule anaemic. In my own examinations (Fischer) the opposite result has been found, and I believe that in prolonged chorea a distinct leucocytosis can be found. Blood Reaction of Pus. — The glycogenic reaction of the blood has fre- quently been described in literature. The first complete paper on this subject was published by Dr. M. Goldberger and Dr. Siegfried Weiss.^ This diagnostic aid is of value when a questionable diagnosis exists. ( When an abscess exists, especially if it is localized, there is invariably a marked leucocytosis, even in limited suppurative foci. In the subcutaneous or interstitial connective tissue there is always a high leucocytosis. Ewing found marked leucocytosis in the active stages of otitis and all suppurative processes which subsided rapidly after the operation. There was one exception in abscess of the liver with mucopurulent exudate. Iodine Reaction (lodophilia). — This reaction consists in slight or intense reddish-brown granules and a diffuse brown coloring of the entire protoplasm. The protoplasm of the polynuclear neutrophile leucocytes shows a marked affinity for iodine. This intracellular iodine reaction is present in purulent conditions and persists as long as suppuration is present. It has an important diagnostic bearing when abscesses are deep seated. Cabot and Locke^ obtained uniformly positive reactions in septicemia, pneumonia, empyema, and suppurative appendicitis; in serous pleural effusions and in catarrhal appendicitis the test was negative. In about one-half of the cases of enteric fever examiued by these writers the test was positive, usually, only in those complicated by haemorrhage, perforation, furanculosis, or lung lesions. These studies have been more recently sub- stantiated by Gulland.^ The following table, prepared by Casper Sharpless, will assist in the differentiation of the blood : — "■ Wiener klinisehe Wochenschrift, No. 25, 1897. * Journal of Medical Research, 1902, vol. vii. • British Medical Journal, 1904, vol. i. PLATE XXXI louoiMiiLiA. Pus Reaction of Blood. Coverglass Specimen of Blood in a Case of Suppurative Appendicitis. a, Polynuclear leucocytes; 6, polynuclear leucocytes containing many irreg- ular granules of glycogen; c, extra-cellular iodine-stained masses, giving the reaction of glycogen. a, Pus corpuscles without iodine reaction; b, pus corpuscles, iodine reaction. (Original.) THE BLOOD. Table No. 72. 687 Disease. Leucocytosis. Lymphocytes. Neutrophiles. Red Cells. Hjemoglobin. Typhoid Fever Absent Relatively increased Decreased Decreased Proportionately decreased Typhoid with complications Present • Increased Decreased Proportionately decreased Scarlet fever . Present Decreased Increased Decreased Proportionately decreased Measles. . • • Absent No change No change Small pox . . Marked on third day Increased Much de- creased Proportionately decreased Erysipelas . . Marked Increased Decreased Proportionately decreased Diphtheria . . Marked Earely increased Increased Slight de- crease Proportionately decreased Influenza . . . No change No change No change Typhus fever No change No change No change Follicular tonsillitis Moderate No change Acute rheu- matism . Moderate Increased Markedly decreased Markedly decreased Septicaemia . ■ Marked Increased Markedly decreased Proportionately decreased Abscess. . . , Marked Increased Decreased Proportionately decreased Meningitis . Marked Increased Slightly decreased Proportionately decreased Peritonitis • • Marked Increased Slightly decreased Proportionately decreased Pericarditis . . Marked Increased Slightly decreased Proportionately decreased Pleurisy . . Marked Increased Slightly decreased Proportionately decreased Malaria . . Absent Eelatively increased Decreased Decreased Proportionately decreased Pneumonia ' . Appendicitis Marked Marked Decreased Increased Decreased Proportionately decreased • In pneumonia there is a decrease of the eosinophiles and in scarlet fever an increase. Table No. 73. Reaction Absent in Serous pleural efi'usion. Reaction Present in Empyema. Suppurative appendicitis. Catarrhal appendicitis. Enteric fever when complicated by fu- Enteric fever when uncomplicated. runculosis or pulmonary lesions. Gonorrheal arthritis. Rheumatic arthritis. Influenza. Pure tuberculous abscesses. Cerebrospinal meningitis. Sepsis ( septicemia) . 588 DISEASES OF THE BLOOD, The persistence of this reaction after the incision of a pns cavity sug- gests, frequentl}^, imperfect drainage. The staining solution as advised by Goldberger and Weiss^ is as -follows:— ' lodin 1 Potassium iodid 3 Distilled water 100 Mix and add sufficient gum arable (about 50 parts) to make a syrupy mixture. With a camePs-hair brush a layer of this solution is painted over the surface of the dried unfixed blood film, upon which it is allowed to act for from one to five minutes. The excess is then removed by blotting with a bit of filter paper, and the specimen is mounted in cedar oil. Or, as Wolfl! advises, Zollikofer's method may be used : placing the fresh film for a few minutes in a stoppered bottle containing crystals of pure iodine. In films thus treated the iodine reaction is recognized by a slight or intense, diffuse brown coloring of the entire protoplasm, or by the presence throughout the protoplasm - of numerous intensely stained, reddish-brown granules, the latter change being the more common. In normal blood the protoplasm of the leucocytes is stained a pale yellow and the -nuclei remain almost colorless. I Antibacterial Action of the Blood. — According to Halliburton, ^ "the power of the blood to destroy bacteria was first discovered when an effort was made to grow various kinds of bacteria in it; the blood was believed to be a suitable soil for this purpose, but it_ was found to have the opposite effect in many instances. The chemical characters of the substances which kill the bacteria are not fully known. Evidence appears to favor the leuco- cytes as the origin of this bactericidal substance. These substances are called alexins, but the more usual name now applied to them is that of bacteriolysins. The bactericidal power of the blood is closely related to its alkalinity. Increase of alkalinity means increase of bactericidal power. Alkalinity is probably beneficial, because it favors those oxidative processes in the cells of the body which are so essential for the maintenance of healthy life. Normal blood possesses a certain amount of substances which are inimical to the life of bacteria. When a person gets run down there is a diminution in the bactericidal power of his blood. However, a perfectly healthy person has not an unlimited supply of bacteriolysin, and, if the bac- teria are sufficiently numerous, he will fall a victim to the disease which they produce. In the struggle he will form more and more bacteriolysin, and if he gets well, it means that the bacteria are vanquished, and his blood ^ Wien. klin. Wochenschr., 1897, vol. x. ' Paper read before the British Association for the Advancement of Science. THE BLOOD. 689 remains rich in the particular bacteriolysin he has produced, and so will render him immune to further attacks from that particular species of bac- terium. Every bacterium seems to cause the development of a specific bacteriolysin. Immunity can more conveniently be produced gradually in animals, and this applies, not only to the bacteria, but also to the toxins they form.^* The Blood in Fever. — There is a decided reduction in the number of red cells during fever. "Whether the fever destroys the red cells or causes them to be unequally distributed in the body is the question. Maragliano demonstrated a contraction of arterioles during the height of a febrile process, followed by dilatation during defervescence. He was able to verify these results by noting the effect of antipyretics (Ewing). Salkowski demonstrated an excess of potassium in the blood during fever, thus favoring the view that the red cells are destroyed. Senator, von Jaksch, and others have shown that febrile processes are regularly marked by diminished alkalescence of the blood. When diphtheria anti- toxin is injected, the alkalinity of the blood is increased for about twenty- four hours. The progressive loss of albumin is probably associated with every fever, but occurs in a marked degree when the fever is of an infectious origin. Diminished resistance of the red cells occurs in the majority of fevers and depends on a variety of factors. Variations in alkalinity are frequent and considerable in fever, but are not proportional to either the toxicity or to the height of the temperature (according to Ewing). The question is. Why do almost all micro-organisms which are harmful to the body raise its temperature ? and the suggestion has been made that the rise of temperature is a defensive mechanism, or, in other words, pyrexia is like phagocytosis or chemiotaxis, in some way harmful to the fever- producing micro-organisms or their toxins. It does not follow from this view that the higher the temperature of the body the better the prognosis, for the higher temperature might be taken to indicate that the dose of infection was very severe, and that, therefore, the body did all it could to resist the invasion; nor, on the other hand, would it follow that if the temperature did not rise much, the dose of infection was slight, for it might be that the body was feeble and had but little power of raising its temperature, and therefore defending itself. It is generally believed, and in all probability correctly, that many cases of typhoid fever are benefited by cold sponging or by a cool bath. Many have hastily concluded that the bath does good because it lowers the temperature. But this is probably incorrect. In the first place we must remember that the cold sponging or bath does more than lower the tem- perature; it diminishes the delirium, the tremor, and the prostration. In any of these ways it would do good. But, further, Eoque and Weil claim 44 690 DISEASES OF THE BLOOD. to have shown that "in typhoid fever left to itself the toxic products manu- factured by the bacillus and organism are eliminated in part during the illness. The urotoxic coefficient is double the normal^ but this elimination is incomplete and is only completed during convalescence, for the h5^3er- toxicity continues for four or five weeks after the cessation of the fever. In typhoid treated by cold baths, the elimination of toxic products is -enor- mous during the illness. The hypertoxicity diminishes as the general symp- toms mend and as the temperature falls, so that when the period of pyrexia and convalescence sets in the elimination of toxins has ceased.'' • So we learn that it is by no means certain that in typhoid fever the benefit of cold baths is due to their antipyretic influence alone, but also to the elimination of toxins. We see that clinical medicine affords no evidence that anti- pyretics are useful in fever. CHAPTER 11. Diseases of the blood. Anui;mia. A DEFICIENCY ill tlio number of red blood-cells or of the haemoglobin is known as anaemia. As a rule there are two distinct forms : first, con- genital; second, acquired. Congenital Form. — The foetus in utero is frequently anaemic owing to the inherited disease of its mother. Such diseases are blood disorders like syphilis, or where a general devitalization occurs, as seen in tuberculosis. If the mother while pregnant passes through a severe form of diphtheria, typhoid fever, or any other infectious disease, it may result in anaemia of her offspring. Malarial infection of the mother may also result in an anaemia of the baby. A severe haemorrhage due to an operation on the mother during the last period of her pregnancy may cause an ansemia of the baby. Acquired Form. — This form is due to either an. infection of the baby or to toxic conditions acquired after birth and independent of the mother. Most cases of acquired anaemia seen by me are the direct result of mal- nutrition. I have referred in detail to this condition in the chapter on "Scurvy" and "Eachitis." Splenic Anemia (Splenomegalic Cirrhosis of Liver; Banti's Disease). The characteristic features of this disease consist in progressive enlarge- ment of the spleen, later in the disease cirrhosis of the liver with ascites, and jaundice. Etiolo^. — An intoxication is probably the cause of this condition. Whether it is gastric or intestinal is not easily determined. Pathology. — There is a hyperplasia and fibrosis of the spleen, secondary anaemia, and cirrhosis of the liver as a terminal development in some cases. Symptoms. — As a result of hemorrhages, such as hsmatemesis or in- testinal bleeding, there is a secondary anaemia. Bleeding may not only be confined to the stomach and bowels, but it may also be due to gastric erosions or varicose veins in the oesophagus. In some cases the gums will bleed. There is usually jaundice because of the cirrhosis of the liver, associated therewith anorexia. Constipation or diarrhoea may be present. The examination of the blood shows nothing definite excepting a leukopaenia and a relative lymphocytosis. There is also a hsemic murmur which is systolic. The slightest exertion will be followed by tachycardia. The urine may con- tain albumin, but no casts, although blood- and pus- cells have been found. The temperature is rarely above 100° in the evening, and is usually about 99° in the morning. The course of the disease is chronic, the treatment purely symptomatic. (691) 692 DISEASES OF THE BLOOi). Secondaet Anemia, Canses. — Toxic influences frequently destroy the blood corpuscles and also the hsemoglobin, hence angemia results. When haemorrhage takes place then anaemia frequently follows. Malaria and whooping-cough seem to affect children more than adults. Other diseases, such as rheumatism and endocarditis, in fact, most of the acute infectious diseases, cause anaemia. Improper hygiene, and more frequently improper food, should not be over- looked as causative factors. Symptoms. — A pale white skin and waxy appearance of the nails is the usual clinical picture. Children do not appear bright. They take no interest in their surroundings, and do not wish to play. Loss of appetite and tendency to constipation frequently exist. Diagnosis. — This is usually determined by the condition of the blood. Prognosis. — The origin of the angemia should be the guide in deter- mining the outcome of this condition. Great care should be used in ven- turing an opinion, unless we are sure of the origin and can remove the cause of same. Treatment. — Fresh air, food (chiefly proteids), and restoratives, such as codliver-oil, lipanin, iron. Fowler's solution, and malt preparations, are indicated. Wine or champagne is sometimes valuable. Pernicious Anemia. This rare condition is sometimes seen in children. Etiology. — It may follow simple anaemia so that it would appear as the result of a continuation of malnutrition. Many theories are offered. Tape-worm, syphilis, and rachitis are believed to be the factors causing this condition. Pathology. — Hunter first reported the presence of a deposit of iron in the hepatic cells. There is also an angemia of the internal organs. Soine- times capillary haemorrhages are seen in the various organs. Fatty degen- eration is also described as a frequent pathological finding. General Symptoms. — These are the same as previously described in the article on anaemia, although all symptoms are of a more severe type. ' Epi- staxis, in addition to local purpuric spots, denotes the tendency to htemor- rhages. An interference of the return circulation to the heart is manifested by oedema of the feet and ankles. The urine contains neither albumin nor casts. Special Symptoms. — The blood will furnish the real means of diag- nosis. The haemoglobin may sometimes be as low as 20 to 30 per cent. The erythrocytes are reduced in number; 2,000,000 is a fair average red blood count in this condition, although Lenhartz^ refers to a reduction of 'Lenhartz — "Clinical Microscopy," page 156. F. A. Davis Co., 1904. IM.ATE XXXII A. — Progeessive Pernicious An.emia. The ease ended fatally in six Aveeks; cause unknown; possibly in connection with typhoid fever. Ehrlich's triacid stain. Zeiss ocular 1, oil immersion Vi2- o, normal erythrocytes; b, megalocytes; c, microcytes; d, marked poikilocytosis; e, megaloblast; /, polynuclear neutrophilic leucocyte. (I>enhartz-Brooks. ) B. — LiENAL (Splenic) Leukemia, a, noi-mal erythrocyte: /). nucleated erythrocyte, nucleus eccentrically situated; c, polyniiclcar neutropliilic leuco- cytes; rZ, eosinophilic (myelo) cell. The eosino]ihilic cell at the top has been ruptured and the granula dispersed. Two small greenish-blue nuclei, perhaps small lymphocytes. (Lenhartz-Brooks. ) C. — LiENAL (Splenic) Leuk/EMTa. a1. megaloblast; a. normal erythro- cyte; a2, megaloblast. with anremic degeneration; ft. polynuclear leucocytes; c, "marrow cells" (myelocytes); d. large lym])hocyte. (Lenhartz-Brooks.) 7). — AcT^TE LErK.T;AriA. This picture is made from two different, rapidly fatal, clinically similar cases. The upper portion is stained with Ehrlich's stain with eosin-hematoxylin; the lower portion is stained with the Plehn- Chenzinsky's stain. (Lenhartz-Brooks.) LEUKEMIA. 693 erythrocytes as low as 400;,000 to 800,000. There is also an enormous poikilocytosis. In this disease there is a greater reduction in the number of red blood cells (oligocythemia) than in any other disease. LEUKiEMIA (LeUKOCYTH^MIA). In this condition we have a reduction of the red corpuscles and a cor- responding increase in the white blood cells. Cellular forms called lymphocytes not otherwise found in health are present in the blood. Virchow calls this condition "white blood." Ehrlich calls it a leucocytosis of a chronic type. Etiology. — This is unknown. Some authors, Roux and Lowit, describe asporozoa in the blood as well as in the leucocytes and in the spleen. Other writers believe that there is a predisposition in syphilitic and rachitic chil- dren. Unsanitary surroundings and injury to the spleen are decided etio- logical factors. The following classification is given by Ehrlich: — (a) Lymphatic forms. (b) Myelogenous and splenic forms. Lymphatic Form. — When the colorless corpuscles are as large as a normal erythrocyte then an involvement of the glandular system can be diagnosticated. Myelogenous and Splenic Forms. — If large cells appear then bone- marrow and the spleen evidently participate. When large mononucleated leucocytes are found then the bone-marrow is probably involved. If, in the field of the microscope, three to five or more cells filled Math strongly re- fractive spheroid granules are found, the splenic involvement should be suspected. Pathology. — The lesions are confined to the bone-marrow, lymphatic glands, and spleen. The spleen is enormously enlarged, sometimes filling half of the abdominal cavity. Sometimes it is soft, and at other times very hard on palpation. It has a dark red color. In the lymphatic form any or all of the external glands of the body may be affected ; thus the cervical, maxillary, bronchial, mesenteric, or inguinal glands may be involved. There is a simple hyperplasia found in the glands. The liver is usually enlarged from an infiltration with lymphoid tissue. The lymphoid tissue in the tonsils and the thymus gland have the same changes. Haemorrhages are not infrequent. Symptoms and Diagnosis.^The disease is usually ushered in by a severe hemorrhage, after which proround anaemia and a general weakness are noted. The spleen is alwa3^s enlarged and the lymphatic glands are palpable. The glands are movable, but never tender on palpation. The liver is usually enlarged. In the beginning there is little or no fever, although later in the 694 DISEASES OF THE BLOOD. disease the temperature may rise as high as 103° F, Sometimes from in- volvement of the liver there will be dropsy of the feet or a general anasarca. Haemorrhages from the nose, mouth, stomach, and bowels frequently com- plicate this condition. From the loss of blood fainting spells may occur. The Blood. — The characteristic feature is an increase in the number of leucocytes. The normal ratio between the red and white corpuscles varies between 1 to 500 and 1 to 1000. In leuksemia the ratio is so altered that we may have one colorless corpuscle to twenty, or even to five, red corpus- cles. Some authors report a ratio of one red to two white corpuscles. The eosinophiles are frequently increased many times their normal number. A characteristic feature is the presence of large and small mono- nuclear lymphocytes. Ehrlich describes a large mononuclear nutrophilic staining cell which normally exists in the bone-marrow, and is found in the myelogonous form of leukaemia. It is called the myelocyte. Treatment. — The nutrition of the child must be carefully considered. Albumin and the cereals should form the main portion of the food. All vegetables should be ordered. If the child can be taken out of doors, then the same should be insisted upon. Strict attention to hygienic details will greatly assist in modifying this condition. Medication. — Iron, arsenic, in the form of Fowler's solution, cod- liver-oil; and malt extracts should be given. If there is anorexia then strychnia or nux vomica should be given. PSEUDO-LEUK^MIC An^MIA OF TnFANCT (An^MIA INFANTUM Pseudo-Leuk^mica) . Von Jaksch was the first to describe this disease in 1889. It is an infantile anaemia characterized by the following conditions : — 1. There is a marked enlargement of the spleen. 2. A slight enlargement of the liver and the lymph nodes. 3. A marked reduction in the number of red corpuscles. It is usually a secondary anaemia rather than a primary disease. Etiology. — The disease is usually found in infants and children be- tween 6 months and 4 years of age. Monti and Berggrun collected 16 cases in 1893. Pickets, congenital syphilis, chronic intestinal catarrh, and tuberculosis were found in cases collected by Fischl. Pathological Anatomy. — The spleen is enlarged and rather firm. Histologically, the changes are those of simple hyperplasia of all elements, while the sinuses contain no excessive number of leucocytes. Baginsky found many eosinophile cells in the spleen. The changes in the viscera are described by Von Jaksch, Eppinger, Luzet, Baginsky, Audeoud, and Rotch. CHLOROSIS. 695 The marrow, according to Luzet, is diffusely reddened and moist and shows evidence of excessive multiplication of the red cells. The Blood. — Leucocytosis is an important symptom. The white blood cells number between 20,000 and 50,000. Other cases (Baginsky) between 40,000 and 122,000. According to Monti, the proportion of white cells to the red may be as 1 to 100 or 1 to 15. Symptoms. — After a prolonged gastro-intestinal disease an infant will appear very anemic. Fever is not usually present. When fever is pres- ent the cause of the same will usually be found other than in the spleen. Icterus is sometimes present. There is a decided loss of appetite and the bowels move sluggishly. The skin has a yellowish color and is intensely anemic. The abdomen appears distended. The liver is slightly enlarged. The lymph glands are palpable. The spleen is very much enlarged and occupies the left hypo- chondrium, reaching at times to the crest of the ilium. Prognosis. — ^The prognosis is poor, although recovery does take place in some instances. A case of this kind seen by me has shown marked im- provement under anti-rachitic and restorative treatment. Treatment. — ^Tonic doses of iron, quinine, and strychnine served me well. Codliver-oil and the glycerophosphites of lime and soda are indi- cated. Phosphorus has been recommended by some. The bowels must be thoroughly cleansed, and the general peristalsis stimulated. Nux vomica, in 1-minim doses three times a day, when anorexia and gastric atony are present. Fresh air and general hygienic management, in addition to a supporting diet, will do more toward building up and restoring the system than all medication combined. Chlorosis. Chlorosis, sometimes called chloroanasmia, occurs in girls about the period of puberty. There is extreme pallor of the mucous membrane, pale and greenish tint to the skin, and a pearly eye. Associated therewith is extreme lassitude, a tired feeling, and either suppression or irregularity of menstruation. There is a venous hum which can be plainly heard in the vessels of the neck. On the slightest exertion there will be dyspnoea, pal- pitation, and dizziness. As a rule, such children do not emaciate; they are rather well nourished. Owing to a freaky appetite, the bowels are irregular and usually constipated. The urine frequently contains indican, and some observers believe that the intestinal toxtemia is an important factor in the causation of this disease. Etiology. — Sedentary occupation associated with lack of exercise, or poor hygienic surroundings, may induce this condition. Nervous girls, susceptible to mental influences, such as fright or worr)', are more prone 696 DISEASES OF THE BLOOD. to the development of this condition than robust, healthy girls. Auto- intoxication is certainly a factor, as I have frequently seen chlorosis in girls suffering with chronic constipation. Pathology. — ^Distinet pathological lesions cannot be attributed to this condition. In some cases ulcer of the stomach is associated, and this latter condition may be fatal. Symptoms. — The appetite is poor and such girls invariably crave for sour and spiced foods to stimulate the appetite. Constipation is almost al- ways present. Headache and other nervous symptoms are also present. Such girls are very emotional, and cry and laugh very easily. They are very sensitive. A venous murmur can usually be made out in the vessels of the neck. There is a blowing systolic murmur which can be heard over the heart in the mitral region and also in the region of the pulmonary artery. Venous thrombosis is most frequently seen in the femoral veins, and vari- cose veins are sometimes seen over the thighs and ankles. Menstruation is irregular and the flow is scanty or very profuse and sometimes painful. There is a decrease in the percentage of hasmoglobin and also a decrease in the number of red corpuscles. The red cells may be reduced to 4,000,000. The spleen may be slightly enlarged, but on this symptom no reliance can be placed. A puffiness of the face or oedema of the ankles due to a sluggish return circulation is occasionally seen. When localized areas of pain are complained of in the region of the stomach, then gastric ulcer should be suspected. Diagnosis. — Chlorosis is met with in girls only at or about the period of menstruation. This is its characteristic diagnostic feature. Such chil- dren, as a rule, are fat and look well nourished. Prognosis. — ^This is always good, although the disease may last several years. If chlorosis is a forerunner of tuberculosis or gastric ulcer, then a fatal termination may occur. The outcome of a case depends on heroic restorative treatment. Treatment. — Hygienic Treatment: Eemove the child from its imme- diate surroundings, from the city to the country. If chlorosis occurs in a girl living at a boarding-school, in a convent, or in a girl working in a factory, the hygienic conditions demand: — 1. To sleep in an airy room with the windows open at night. 2. Discontinue working, or studying if at school, to procure mental rest. 3. Change the entire mode of living, so that there is neither care nor worry for the chlorotic girl. Exercise. — Gentle exercise, walking, swimming, the lighter exercises of physical culture followed by a shower-bath and massage are valuable. Fric- tion with a coarse towel after the daily sponge bath is useful to stimulate the circulation. Reading or sewing at night must be forbidden. CHLOROSIS. 697 Nutrition. — To stimulate metabolism nothing equals food. Proteins in the form of milk, meat, eggs, cereals, cream, butter, and clieese should be liberally given. All fresh fruits may be allowed. Regularity in feeding must be demanded, although a drink of milk, buttermilk, cocoa, or zoolak may be taken between meals. Fif. 226. — Blood from a Case of Chlorosis. Girl 16 years of age. Red cells appear pale (achromia) and vary considerably in size. (Original.) Medicinal Treatment. — Soluble preparations of iron, such as ovoferrin or peptomangan, may be given in teaspoonful doses after each meal. Arsenic in the form of Fowler's solution or arsenious acid may be combined with the iron. The arseniated hgemaboloids have been tried by me with good result. Maltine with or without hypophosphites may be tried three times a day. Codliver-oil, morrholine, or lipanin may be tried in teaspoonful doses three tim.es a day given after meals. The sun bath or the electric light bath may be tried in conjunction with the above-described treatment. CHAPTEE III. ACUTE RHEUMATISM (POLYARTHRITIS). This disease is sometimes known as rheumatic fever, also as inflam- matory rheumatism. It is an acute, infectious, but non-contagious disease. The infection is characterized by an inflammation which localizes in the joints, and travels from joint to joint, evidently through the circulation. The most frequent complication is endocarditis. Etiology. — The specific factor is evidently a micro-organism. A great many observers have studied this subject, among them. Ley den, Sahli, Achalme, Eiva, Triboubet, Coyon, Singer, Jaccoud, and many others. A bacillus described as an anaerobic, with more or less motility, similar to the anthrax bacillus, has been described by Achalme. This bacillus, when in- jected into animals, has reproduced symptoms resembling rheumatism. Thus this observer believes he has found the specific agent causing this disease. Other causes have been described as the result of defective assimila- tion, which produces lactic acid or combinations of it. Another theory is the so-called nervous theory, in which the nerve centers are primarily affected by cold, and the local lesions are atrophic in character. This nervous disturbance brings about hurtful metabolism, so that the nitrogenous products, instead of being converted into urea, are transformed into uric acid and other poisonous products which cause these symptoms. Whether or not heredity bears any relationship to the cause of this disease may be considered by the fact that in two-thirds of the cases, dis- eases of a similar type can be traced to the ancestors. Gouty parents will usually have rheumatic children. The disease is very common in children, and has also been observed in nurslings. Eheumatism occurs more often in the spring of the year. When the disease has commenced, it usually lays the foundation for future attacks; in other words, one attack of rheumatism predisposes to future attacks of the disease. The tonsils have frequently been looked upon as the seat of entrance of this disease; thus acute tonsillitis has frequently been followed by acute articular rheumatism. In the same manner endocarditis has frequently followed an attack of tonsillitis. It is therefore safe to assume that the rspecific entrance of an infection can originate in a diseased tonsil. Packard has described a series of cases of endocardial inflammation (698) ACUTE RHEUMATISM. 699. following tonsillitis. He regards a serous inflammation as due to the germs or other toxins entering the circulation through inflamed tonsils. Bacteriology. — Triboulet and Coyon^ give the results of their bac- teriologic examinations in 11 cases of acute articular rheumatism. They discovered in all these cases a diplococcus or diplobacillus which they state cannot be well described as to its cultural peculiarities, as its growth is so irregular. The organism exhibits great plesiomorphism and resembles most closely in character the diplococcus pneumoniae, but differs from it in that it can be kept alive for a considerable length of time, and that it is not patho- genic for mice. The organism is extremely pathogenic for rabbits, and the authors give a detailed account of its effects on a rabbit. The animal died twenty days after intravenous inoculation. Death was due to heart failure resulting from an absolute mitral insufficiency. During life there was an oscillatory temperature. The autopsy showed fresh pleuritis and pericarditis, and an acute vegetative endocarditis with tremendous masses of vegetations on the mitral valve. The vegetations microscopically showed many diplobacilli similar to those originally inoculated, and cultures from the organs also showed it. Other rabbits inoculated with smaller doses from other cases showed irregular fever, disturbances of the heart, and pleurisy, but did not die. Symptoms. — The symptoms are entirely different from those met with in adults. The fever is not so high, usually between 100° and 102° F. The swelling of the joints is moderate, and there is not the redness and inflammation visible to the eye as we see it in adults. The pains are not severe in all cases, and there are less joints involved as a rule than we find in adults. We therefore meet with a great many cases of rheumatism that walk around suffering slight pains. Sometimes the lower extremities are affected, at other times the disease is limited to the upper extremities. A child may walk apparently lame or an infant may cry when put on its feet, Jacobi years ago directed the attention of the profession to the necessity of carefully watching every case of so-called "growing pains.'' He believed, and correctly so, that the majority of these cases were in reality rheumatism. The most frequent symptoms are vomiting, fever, gen- eral malaise, anorexia, in addition to multiple arthropathy. Rheumatism a Seauela to Tonsillitis. — ^That rheumatism is irequently a sequel to tonsillitis has been noted by many observers. Packard, of Phila- delphia, has reported a scries of cases in which the throat was first affected and later heart disease was distinctly manifested. Emil Mayer, of New York City, has also reported a series of cases in which the tonsils were the Comptes Rendus de la Society de Biologie, February 4, 1898. JOO DISEASES OF THE BLOOD. portals of infection. This is certainly not a theory when we study the primarj' infection and follow it up with its secondary result. Sir Willoughby Wade^ says, in relationship between tonsillitis and rheumatic fever, he believes that tonsillitis is a primary infective disease of the lacunas; rheumatic fever a secondary disease arising from the absorption of microbes or their products into the system. Knowing this to be a factor, it would only seem proper to treat every tonsillitis as vigor- ously as possible. Acute Contagious Articular Rheumatism. — G. B. AUari reports 3 cases which were characterized by contagiousness and at the beginning of tlie disorder with angina of the throat. In the fourth case the angina re- appeared with every reappearance of exacerbation of the articular symptoms. Bacteriological investigations of the exudate on the tonsils showed in each case a streptodiplococcus which was almost identical in structure and be- havior with that found by Mayer in the same affection. Animals inoculated with this micro-organism developed lesions in the joints. Suhcutaneous Tendinous Nodules. — Barlow and Warner described this manifestation of rheumatism in 1881 as oval semi-transparent fibrous bodies like boiled sago grains. They are most frequently met with at the back of the elbow, over the malleoli, and at the margin of the patella. Occasionally on the extensior tendons of the hands, fingers, and toes, or over the spinous processes of the vertebrag. They are composed of fibrin, cells, and fibrous tissue. They vary in size from a pin-head to a small bean, though some- times beiiig as large as an almond. They may remain for months, although they frequently disappear in a few weeks. Cheadle states that they can be seen if the skin is tightly drawn. Cheadle has also shown the intimate rela- tionship between erythema and rheumatism. Purpura. — This is frequently met with in the course of rheumatism. It is a rash of a deep purplish hue and is most probably a result of rheu- matism. Complications. — The most frequent form of complication is endocar- ditis. Fully 75 per cent, of my cases met with in a large outdoor practice showed this form of complication. This complication has frequently been the first symptom that led to the discovery that our patient had rheuma- tism. Pericarditis is rarely seen in children under 7 years of age. It is usually associated with endocarditis. Pleurisy, peritonitis, or meningitis may complicate rheumatism. Chorea frequently associates itself with rheumatism, so that a great many authors believe that there is an intimate relationship between rheumatism and chorea. • British Medical Journal, 1898. ACUTE RHEUMATISM. 701 Holt states that in a series of cases of chorea observed by him, 56 per cent, gave evidence of the rheumatic diathesis. Prognosis and Course. — The course of rheumatism depends on the treatment. i*ains in tlic joints sliould never be regarded as a trivial matter. How frequently do we see a child suffering with what the mother calls "growing pains," and a few weeks or months later we note shortness of breath due to heart trouble, usually endocarditis. It is better to put a child to bed than to run risks of such a serious complication. The prog- nosis depends on the care bestowed, although we know that this disease has a tendency to assume a chronic course. Plowever, a case with proper treat- ment should recover entirely. The inflammatory stage lasts from ten days to two weeks. Cases of inflammatory rheumatism complicating scarlet fever or diphtheria lasting between three and eight weeks have been seen by me during my hospital service. Kheumatism in children assumes the course of a general infectious malady. The intensity of cardiac complications cannot be approximated by the intensity or mildness of articular manifestations. Many authorities state that the percentage of cardiac complications is between 81 and 87 per cent. Lethal termination will frequently show pericarditis, hence the im- portant deduction is to prevent such complications, if possible, by proper prophylactic treatment. Treatment. — The first thing to do is to put the child in bed. The patient should be kept in bed until every particle of pain and fever is gone. 1. When the disease is localized we can treat the same and try to destroy as much of the pathogenic infection as possible. 2. The important point would be to restore the subnormal condition at the time of the invasion of these infective germs, and prevent thereby the absorption of the toxins generated from these micro-organisms. 3. Watch for possible complications. While it is true that we can limit by local treatment the spread of active infective processes, on the other hand, when the body is weakened from anieraia, or from other de- pressing influences, this infection will spread in spite of the most vigorous local treatment. Eest must be enjoined, more so in children with this disease than in most other diseases. We must aim to have the most perfect physiological repose. In this Avay we have the longest interval between the systoles and we keep down the blood pressure. , Prophylactic Treatment. — In trying to prevent rheumatism the h)'- giene of the skin requires careful attention. The body should be properly protected, due allowance being made for sudden changes in the weather. Too much clothing means overheating. Perspiration induced thereby in- vites this disease when the surface is suddenly chilled. Overheated apart- 702 DISEASES OF THE BLOOD. ments render children peculiarly susceptible to this disease. Proper ven- tilation, without incurring any draught, is urgently demanded. Cool or tepid bathing or sponging has a very good efEect on the skin. Unneces- sary and useless hardening of children^ by exposing them to cold baths in cold rooms, without proper protection, will certainly invite this disease. Dietetic Treatment. — Milk and milk foods; cereials and fruits, espe- cially acid fruits ; broths and all soups made from meat are indicated. For thirst, buttermilk, and all fermented milks, seltzer and milk, alkaline waters, lithia, apollinaris, white rock, lemonade, and orangeade. Medicinal Treatment. — The alkaline treatment known as Fuller's method has been abandoned many years ago. The first thing to do is to cleanse the gastro-intestinal tract. A wineglassful or more, depending on the age of the child, of citrate of magnesia, repeated every two hours, until its effect is produced. Ehubarb and soda, 5- to 10- grain doses, or calomel, is valuable. Salicylate of soda, 3 grains every three hours, for a child 3 years old. Older children in proportion. This treatment should be con- tinued two or three days, if the drug is well borne : — IJ Natr. salicylat 1 draelim Elix. lactopeptin 2 ounces M. Sig. : One drachm every three hours may be given. Salol or salophen, in doses of 2 to 5 grains, is indicated. Aspirin or novatophan in doses of 3 to 10 grains may be given every three hours. Cotton saturated with the oil of wintergreen applied over the affected joints, the whole covered with oil-silk, is recommended. Fever. — Fever requires the same treatment in this disease as in all others. Cold sponging of the surface will do good. Restorative Treatment. — ^The profound ansemia caused by this disease is an indication for early restorative treatment. We should therefore aid nutrition by giving cream, butter, and, if tolerated, codliver-oil, with or without malt. Iron and iodide of sodium are good restoratives. Fellows' syrup of the hypophosphites may be tried. The application of leeches, blisters, or sinapisms sometimes does good. Ice-bags applied over inflamed joints will reduce swelling, remove heat, and have a very soothing effect. An ice-bag applied over the heart if endocarditis complicates has served me quite well in some cases. For the management of heart complications, see chapter on "Heart Diseases." It is vital to stimulate the action of the kidneys. For this reason I have previously mentioned the alkaline mineral waters. If a diuretic is indicated none is better than Basham's mixture. See formula in cha|)ter on "Scarlet Fever," page 627. The following ointment is useful applied on gauze to the affected joint : — MUSCULAR RHEUMATISM. 703 B Methyl salicylate 1 part Vaseline 10 parts Mix. Apply morning and evening. Warm Bathing. — By adding sulphur in the form of kalium sulphuret, about 1 ounce to an infant's bath-tub of water, and bathing the affected joints at a temperature of 95° to 100° F., is sometimes very grateful and well borne. It is not advisable to make sudden changes in the local treat- ment. If ice-bags have been used and are well borne, they should be continued. Sulphur baths, so also pine-needle baths, are very grateful in the evening, and sometimes promote sleep. When pains are very severe, full doses of codeine or chloralamid may be given. It is seldom that so much truth is contained in a single sentence as in the following from Cheadle: "The various manifestations of rheumatism massed together in the case of adults tend to become isolated in the case of children, so that the whole phenomena are distributed over years instead of weeks or months, and the history of a rheumatism may be the history of a whole childhood " Muscular Kheumatism (Myalgia). This painful condition is rarely seen in children. It is characterized by pain when the muscles affected are brought into play. When the dis- ease affects the muscles of the neck it is called acute torticollis. When the intercostal muscles are affected it is called pleurodynia. When the lumbar muscles are affected it is called lumbago. Peculiar contractions of the muscles frequently follow persistent muscular rheumatism and sometimes cause permanent deformity (see chapter on "Torticollis"). Infants so affected usually cry when the group of muscles involved are moved. There is no fever present. R. K., 16 years old, was attacked with a severe tonsillitis. The cervical glands ■were enlarged and tender on palpation. Creosote inhalations and iinguentuni Cred6 rubbed into the glands of the neck relieved this condition. Two days later after going out into the street she had violent muscular pains involving the back, groin, and muscles of the thigh. It was a distinct lumbago and a general myalgia. There was also a painful sciatica. With the aid of massage and the internal administra- tion of 5 grains (0.3) salophen every four hours these pains gradually subsided. After these pains left there were pains involving the intercostal muscles, so that we had a lumbago followed h\ pleurodynia. Rest in bed, warmth, and massage relieved this condition permanently. Treatment. — Local treatment consisting of massage aided by gentle faradic electricity is very useful. Warm, moist fomentations, such as flax- seed meal poultices, are very soothing and seem to do good. The internal administration of salicylate of soda has not seemed to benefit my cases. Codeine in Vio to ^/15-grain doses, repeated every two or three hours, can 704 DISEASES OF THE BLOOD. be given "imtil the pain ceases. In some cases chloral hydrate combined with bromide of sodium vill afford relief. Eubbing the affected muscles with ol. hj'oscyamus seems to relieve. ToKTicoLLis (Wrt-nece:). This condition is caused by the spasm of one sterno-cleido-mastoid muscle. Sometimes there may be a spasm of the posterior cervical muscle, including the trapezius. Etiology. — Congenital torticollis is a rare condition. When it is present it is due, according to Whitman, to a constrained condition in utero. More common "than the congenital condition is the acquired torticollis. The following is Whitman's classification: — 1. The acute. 2. The chronic. Acute torticollis (traumatic torticollis) may be divided into three classes : — (a) "Stiff neck/' due to "cold" or to rheumatism. (h) Distortion caused by strain or other injuries. (c) Distortion due to irritation of the peripheral nerves as following "sore throat/' or secondary, to enlarged or suppurating cervical glands, and the like ("reflex torticollis"). The ordinary stiff-neck is of but slight importance. The traumatic wr\--neck is efficiently treated by support. Eeflex torticollis is by far the most important of the forms of acute torticollis, and it is the usual cause of persistent distortion. Chronic Torticollis. — From the clinical standpoint, both the congenital and the reflex torticollis, after the acute stage has passed, are forms of chronic torticollis; the class includes also those forms in which the onset has not been accompanied by pain. Rachitic torticollis^ usually a postural or compensatory distortion caused by deformity of the spine. Ocular torticollis, caused by defective eyesight. Psychical torticollis, a functional or hysterical deformity. Spasmodic torticollis, a convulsive tic — rather a form of nervous dis- ease than a simple deformity. Any irritation of the spinal accessory nerve or its branches may bring on this spasm. Whitman^ gives the following statistics of 264 cases ex- tending over nineteen years, torticollis from Pott's disease not being in- cluded: Males, 109; females, 155; congenital, 32; under 2 years, 33; from 2 to 10 years, 153; over 10 years, 46; acute (less than two months' * Report for Hospjital of Ruptured and Crippled, New York. PURPURA. 705 duration), 77; chronic, 60, of which number 32 had lasted over two years or longer. Holt believes that an enlarged cervical lymph gland irritating the spinal accessory nerve can bring on this spasm. He also mentions malaria as a cause. I have observed similar conditions. In several of my cases the spasm was present when malarial infection existed, and subsided when quinine was given. Torticollis has also been observed by me after the sudden chilling of the body. Symptoms. — The head is drawn to the affected side. If the trapezius is affected there is slight rotation of the head, but if the trapezius is not affected the head is rotated toward the healthy side. A child 6 years old was taken on an open ear. She was in a healthy condition, appetite good, bowels regular, ajjparently notliing wrong. She complained of being cold and on the following day had a wry-neck. Salicylate of soda, in 5-grain doses three times a day, and massage of the sterno-cleido-mastoid with spirits of campiior seemed to relieve the pain. The best r&sult was obtained by the use of a mild faradic current. The condition lasted about nine days. The child was discharged cured. The above case illustrates the form commonly described as rheuma-, iism or "rheumatic torticollis." Treatment. — Medicinal and Local: Early treatment means success. Delayed treatment means disappointment in most instances. When specific causes exist, such as malaria or rheumatism, they should be treated by specific remedies. In every case warmth, as flaxseed poulticing and mas- sage, will do good. Sometimes the application of iodine over the affected muscles will do good. Surgical Treatment. — Lorenz describes the fine results attained by sub- cutaneous intentional rupture of the sterno-cleido-mastoid muscle to cure obstinate wry-neck in children. The subject lies with a hard cushion under the shoulders, the head and neck unsupported. The shoulder is drawn down at the same time and it is thus possible to tear the muscle by gradual de- hiscence, followed by over-correction. Parents accept this operation much more readily than when the knife is used, and the dehiscent fibers heal under the intact skin with little if any cicatricial formation. The cure has been ideal and permanent in all his cases. PURPUKA. Haemorrhages into the skin or mucous membrane are designated as purpura. When small they are called petechial ; when large they are called ecchymoses. Purpura is frequently associated with the infectious diseases. Martha B., 7 years old, was brought to the Willard Parker Hospital August 31, 1903. She had been ill two days before admission. The diagnosis of nasal diphtheria was made. On admission the pulse was 1.58. Two days later it dropped to 90, and on the third day the pulse-rate sank from 96 to 66. A general purpura was notice- 45 706 DISEASES OF THE BLOOD. l^-Oi- .DATES OF OBSERVATIONS . | Ayfr 3/ i A J ^ s Cent. Fahr AM>M am:pm AMiPK am:pm am:pm am:pm 7 89'" ■103° •: •f i02°*s i\ 38° ~ •i ■vn'-i m :' ioo-'s ^^ h •8 ■ -6 99 -i V \ /S 37° C -.1 : V r-^ >«•' Iformal -9S -2 - ■ -8 •( ^97°-i • per minute It 0310: do CO Ot: a Respirations per minute ^ o^ ^ N able. There were bluish discolorations of the skin visible on the extremities. Dr. Burckhalter, the resident physician, called my attention to a hsematuria. The case ended fatally. purpuea hemorrhagica (morbus Maculosus Werlhofii.) This is the most severe form of purpura. The lesions are a series of hsemorrhages confined to the naueous membrane and skin. On the skin purpuric spots are seen which de- note hemorrhages. These haemor- rhages are seen in the lower and up- per extremities ; also on the face and abdomen. The conjunctival mu- cous membrane shows ecchymotic areas. The gums bleed easily and there are haemorrhagic areas on the soft and hard palate. Hematuria and haemoptysis are sometimes seen. Diagnosis. — The only disease that might be taken for purpura is scurvy, but the general history of the case associated with malnutri- tion will clear up any doubt. Treatment. — Eest, iron, small doses of ergot and hydrastis internally, lemons, oranges, and a nutritious diet. Aromatic sulphuric acid in 5-drop doses, several times a day, should be remembered. Purpura Kheumatica (Peliosis Rheumatica: Schonlein's Disease). The association of haemorrhages with affections of the joints charac- terizes this disease. It has frequently been noted that there is tenderness in the joints during the course of simple purpura. But the more pro- nounced form of fever, in conjunction with swellings and tenderness of the joints, 'plus the characteristic appearance of the subcutaneous haemor- rhages appearing in purpuric spots, differentiate peliosis from simple pur- pura. Associated with this rheumatic affection we frequently have extravasa- tions of blood and serous effusions into the joints, giving a decided fluc- tuating feeling. One very important point is the fact that cardiac lesions do not complicate this condition. Cases of this kind have frequently been reported, and Baginsky lays stress on the non-existence of heart lesions in this affection. Fig. 227. — Malignant Purpura Compli- cating Nasal Diphtheria. General sepsis. Toxic JNephritis, meningitis, myocarditis. Note pulse. Fatal. (Original.) PURPURA. -VQt The following case came under my observation^: — A child, George P., about 9 years old, was attacked with pains in his feet and cried when attempting to walk. He had had some very violent exercise during the four or five weeks preceding this attack by riding a bicycle as much as four and tive hours daily. The mother stated to me that he had frequently complained of joint pains, but she attributed them to "growing." She noted, however, that after bicycle riding the boy's pain was much more intense. His general condition was otherwise healthy. The examination gave me the following status: — A very well nourished boy: muscular and adipose tissues quite well developed, and very tall for his age. His weight was 84 pounds. The examination of the thorax showed both heart and lungs normal; no cough; heart sounds regular, strong; pulse, 96. The temperature was 100.2 in the rectum, and respiration 36. The tongue was slightly coated ; appetite good ; bowels always inclined to constipa- tion; but recently since riding the bicycle, very much improved. Intellect free, and the boy is mentally well developed. The examination of the joints showed severe tenderness and swelling in both knees and ankles; slight pain on palpating or rotating the hip joint. The most marked tenderness and swelling was found at the knee joints. The upper extremi- ties — shoulder, elbow and wrist — were perfectly normal, as far as palpation and inspection could demonstrate. The eruption on the skin was of a purplish or bluish color, and looked like a distinct subcutaneous haemorrhage. It was confined to the lower extremities, covering almost completely the inner portions of both thighs, the ankles, and more esj>ecially the calves of both legs. The spots were very irregular in outline, in some places confluent, resembling more particularly the eruption of morbilli. The child was put to bed, the joints were rendered. Immobile by applying woolen roller bandages over them, and locally over each joint some salicylic collodion, 10 per cent., was applied with a camel's-hair brush. The main point in the treatment which I laid stress upon was to have absolute rest, and it was for this reason that I put the child to bed, that I painted salicylic collodion, and that I put a roller (flannel) bandage on the legs and covered both limbs from the toes to the hip joint. Internally I gave ergotine, V50 grain every four hours, besides 15 drops of tinct. ferri acet. feth. in water after each meal, three times a day. The spots gradually changed from a deep bluish color to a brown; then after ten days to a light yellowish color, and after twenty-seven days they could scarcely be seen with the naked eye. This case has a very interesting clinical history. The question that arose in my mind was: Did the violent exercise on the bicycle cause the inflammation of the joints and possibly also the subcutaneous ha?morrhages? On looking over the previous history of the child, I found that he had been well nourished, breast-fed until eleven months, and then weaned ; commenced walking at 1 year, and talking at same age. Dentition began at seven months, and when eight months had two lower and two upper incisors; the child had seven teeth at eleven months, at time of wean- ing. There is no sign of rickets, althoiigh there is a large belly, rather pendulous, and the previous history of constipation. The ribs are noi-mal, the long bones well developed; spine and thorax as good as desired. I could obtain no data concerning time of closure of fontanels. There is no history of hipmophilia; no previous bleed- ing; no epistaxis; no haiuioptysis; both parents of the child living, and both * Pediatrics, vol. ix, No. 10, 1900. 'J'08 DISEASES OF ' THE BLOOD. healthy. The child, has had measles, complicated, with bronchitis, when 3 years old, lasting in all about one month. No disease previous to this; no summer complaint, and nothing since that time. There is no evidence of scurvy; teeth are well developed, perfectly normal; the glims are healthy. The mother had two other children — one now nursing and one 4V2 years old. She has had no miscan'iages ; no reason to suspect lues. I believe the etiological factor in this case was the traumatic element, namely, the violent exercise causing both the hsemorrhages and the inflammatory affection of the joints. Henoch's Puepuea. Hsemorrhagic areas confined to the abdomen and lower extremities are sometimes seen. There is also vomiting and abdominal symptoms, such as diarrhoea (bloody stools) and colicky pains. There is marked distension of the abdomen and pains in the Joints. This condition resembles that which has already been described in the article on "Purpura Eheumatica.'' . LlTH^MIA (LiTHUEIA). Haig and Eachford have given us a very clear conception of this con- dition, which is simply an excess of uric (lithic) acid in the blood. Haig designates this condition as uricacidgemia. Other writers call it lithuria. Eachford calls this "leucomain poisoning." Etiology. — When this condition is met with in children, we can usually look to the lithgemic ancestors for the origin of the disease. Imprudent diet, such as excess of prdteids, may be a factor. Sedentary life and lack of proper metabolism invite this condition. The alloxuric bodies are ex- creted by the skin, kidneys, and intestinal canal. These bodies are removed by the kidney cells from the blood into the urine. When they are in excess they must, therefore, have been present in solution in the blood before their elimination. The presence of uric or lithic a.cid, xanthin, hypoxantliin, hetero- xanthin, and paroxanthin are the factors causing this trouble. We are still in the dark concerning the manner in which these bodies act. If the kidneys are diseased these bodies are retained and the skin is called upon to do the M^ork which the kidneys fail to do. Thus it is that hot baths which promote diaphoresis eliminate through the skin, in addi- tion to stimulating the action of the kidneys. Symptoms. — The new-born lithasmic infant frequently eliminates an excess of urates during the first few days of life. In such infants crystals of uric acid may be precipitated into the tubules of the pyramids of the kidney. Jacobi says tliat these uric acid infarctions may subsequently be w^ashed out of the tubules and serve as the nuclei of urinary calculi, Nocturnal incontinence is frequently a symptom of lithamia. True PLATK XXXIII Henoch's Purpura. Note ecehyniotic spots on lower extremities. (Original.) UTB.JKMIA. 700 arthritic gout resulting from uratic deposits in the tissues about the joints is very rare in childhood. Fever, crying while the child passes urine, scanty urine which usually deposits a reddish sand on the diaper, and irritation of the external genitals are the symptoms which appear at the time of urination. The urine is very acid and we speak of this condition as "a uric acid form of lithaemia." Sometimes there are gastro-enteric manifestations, such as vomiting, head- ache, gastric pain, convulsions, a sickening odor of the breath, and consti- pation. These gastric symptoms bear no relation to improper diet. They are usually met with in children who are carefully guarded as to the diet. Such children are extremely nervous and irritable. Eczema is a very com- mon manifestation of this condition. Unless a proper understanding of this condition exists it will persist and be difficult to relieve. The urine in lithaemia is high colored; the specific gravity increased. On standing, there is a sediment of red sand (urates). If the urine is examined immediately after a paroxysm then the poisonous xanthin bodies previop'^ly mentioned may be found present. Transient albuminuria is occasionally met with. Treatment, — The diet is the most important part of the treatment. Cereals must be given ; beef juice, soups, broths, and fruits. No alcoholics should be given; in fact, all rich and heavy articles of food must be ex- cluded. Meat must be given sparingly. Salads and gravies are objection- able. Infants require massage. This passive form of exercise will stim- ulate the circulation. If children are old enough to exercise, then exercise should form an important part of the treatment. Drug Treatment. — Calomel should always be given in the commence- ment of the treatment. We must aid in keeping the bowels loose during the whole course of treatment. Salicylate of soda and salol are useful eliminatives. Phosphate of sodium and benzoate, especially if eczema exists, are valuable. Alkaline waters, such as white rock and apollinaris, may be given ad libitum. The Carlsbad waters have the same eliminative effect. Dilute hydrochloric acid or dilute phosphoric acid in 3 to 5-drop doses before meals is es- pecially indicated when severe headache and gastric symptoms exist. Urotropin in 3-grain doses may be given in tablet form, HEMOPHILIA. This is usually an inherited condition. It is characterized by a ten- dency to bleed, hence the term "bleeder" is applied to this class of cases. Whole families are found in which this tendency to bleed exists. Pathology. — The walls of the l)lood-vessels show no alteration, either macroscopically or microscopically, "The swelling of the joints is due to haemorrhages into the articulations and into the surrounding tissues. The 710 DISEASES OF THE BLOOD. tissues are blanched from loss of blood." The surface of the body shows petechige or bruised patches. Symptoms. — The appearance of the child does not always disclose the tendency to bleed. It is only when an operation is performed, or an in- jury exists, that alarming and frequently fatal hasmorrhages are seen. Epistaxis is the most common symptom noted. Swelling of the joints resembling rheumatism is frequently seen. The bleeding takes place from the capillaries, most often an oozing which may continue for weeks. The subjects of haemophilia are sensitive to cold. In the chapter on "Syphilis" I have already described a case of bleed- ing in which the lesions of syphilis were present. Annie G., 13 years old, was breast-fed in infancy. She had diphtheria when 1 year old. Had pertussis when 2 years old, which lasted nine weeks. Has had pneumonia twice. No history of rheumatism given and has had no other infectious disease. Eistory of Bleeding. — ^Has always been troubled with haemorrhages. The nose bleeds at the slightest provocation. Blood spitting is quite common. The slightest irritation of the bowels with looseness is associated ^vith blood in the stools. Large varicose veins are found over the legs. There are a number of scattered nsevi. Not infrequently the veins of the legs bleed daily for a period of twenty or thirty days. The Heart. — There is a loud systolic murmur heard in front and behind, and transmitted to the side. This endocarditis is a sequela to the attack of diphtheria. The child's weight when seen by me was 67 pounds. Stypticin seemed to do more good than ergot internally. Hydrastinine hydrochlorate, Ve grain three times a day, seemed to check the bleeding during another attack. When last seen by me the child was developing fairly well. ProgTiosis. — This depends on the frequency of the haemorrhages and the child's general condition. In 152 cases reported by Grandidier more than one-half died before completing the seventh year, and only nineteen attained majority.^ Treatment. — All operations, no matter how slight, should be avoided if possible. Even the extraction of a tooth must be seriously considered, owing to the danger of bleeding. The diet should consist principally of vegetables and fruits. When bleeding occurs, immediate treatment, consisting of ice and Monsell's solu- tion, should be used locally. Internall}^, gallic acid and hydrastine, % grain, repeated every three or four hours. If intestinal haemorrhage exists, colon flushings of iced water, temperature of 50° F., containing 1 drachm of alum to 1 pint of water, may be tried. An injection of 15 to 35 cubic centimeters human blood serum is an excellent haemostatic. If this cannot be secured then an injection of 15 to 30 cubic centimeters of sterile horse serum may be given. In the case of a ''bleeder," recently seen by me in the Babies' Wards of the Sydenham Hospital, one injection of horse serum controlled the haemorrhage due to a paracentesis, after all locq,! means failed. * See article in "Starr's Textbook," CHAPTER IV. DISEASES OF THE GLANDS OR LYMPH NODES. The Thymus Gland. This long lobulatcd gland is similar in structure to the salivary glands. It lies in the anterior mediastinum, immediately behind the manubrium of the sternum. The thymus readies its full development during the second year, after which it gradually disap2:)ears. The function of the thymus is still a question, although it is believed to have a function similar to the spleen. Sudden death has frequently been attributed to an enlarged thy- mus. Tuberculosis involving the thymus gland is occasionally seen in cur- rent literature. Status Lymphaticus, This condition is found in rachitic children, and is of especial interest because of the enlarged glands at the angle of the jaw in addition to the adenoids in the vault, of the pharynx, and enlargement of the lingual tonsil. The cervical, bronchial, axillary, or the inguinal glands are enlarged. There is also a tendency to swelling of the parts. Enlarged lymph nodes at the angle of the jaw and hyperplasia of the connective tissue of the nose and pharynx are seen. The thymus gland is very much swollen, and this is believed to be the cause of sudden death in many cases. Escherich believes that the pathological condition of the thymus gland causes a form of acute intoxication resulting in cardiac syncope and paral- ysis. This condition must not be confounded with scrofulosis. Escherich has reported a case in which laryngeal spasm occurred thirty times a day. In such cases the danger of asphyxia should be borne in mind. The condition is of importance because of the danger involved during the administration of an anaasthetic. The following case was seen by me in consultation with Dr. A. W. Newfield during the summer of 1904: — The infant was breast-fed, hnt did not soem to nurse well. The lymph nodes at the angle of the jaw, the groin, axilla, and various portions of the scalp could be plainly felt. The child had laryngeal spasms. Had had as many as twenty-five or thirty attacks of laryngismus stridulus. The adenoid tissue at the base of the tongue was enlarged. There was also a mass of adenoids in the posterior nares. The posterior pharyngeal wall was studded with fungous granulations. The infant had a very short, thick neck. The nurse in charge was always afraid the infant would die during these spasms. It was necessary to gavage to sustain life. By (711) 712 DISEASES OF THE GLANDS OR LYl^'IPH NODES. pumping some of the breast-milk and using cows' milk for alternate feedings we gradually strengthened the infant. Codliver-oil inunctions were ordered to aid in the nutrition of the body. When such a condition is found, great care must be exercised so as not to lower the vitality of the patient, but rather to stimulate nutrition by giving arsenic in the form of Fowler^s solution in addition to iodide of sodium. Diseases of the Thymus Glakd. In rare instances the thymus gland may persist until the twentieth year or even later in life. When such a condition exists, mechanical pressure has caused dyspnoea of a serious nature. Asthma has been reported by some clinicians in which an enlarged thymus was found; hence the term "thymic asthma." Sudden death has occasionally been caused by an enlarged thy- mus. This has been especially noted in children with rickets. Abscesses have been reported in the thymus by Dubois. Syphilis and tuberculosis have rarely been found. Eeich says: "The absolute dullness of the thymus, as determined by light percussion, is irregularly triangular in outline, the base being made by the outline connecting the two sterno-clavicular articulations, the blunt apex situated at the level of the second rib or slightly below it, and the sides a little beyond the edges of the sternum. The larger half of this triangle of dullness usually falls to the left side. When the limits of dull- ness, as given above, vary by one or more centimeters, or obscure the pul- monary resonance between the upper line of cardiac dullness and the lower lateral limits of thymus dullness, an enlargement of the thymus is probable. The thymus dullness is present until the end of the fifth year, after which it is inconstant." Diagnosis. — ^The diagnosis of diseases of the thymus gland is frequently impossible. An infiltration or swelling of the area surrounded by the thy- mus gives rise to symptoms of dyspnoea, from pressure upon the pneumo- gastric nerve. The same symptoms are also found when the thymus itself is enlarged. When the lymph glands in the anterior mediastinum are swollen, dullness on percussion is rare unless there is a cheesy infiltration of the lymph glands, according to Eeich. Treatment. — Symptomatic treatment only should be instituted. The iodide of sodium in very large doses may be tried. Acute Adenitis. . This inflammatory condition of the lymphatics is quite common. It is usually caused by an infection, or an abrasion of the skin, permitting m infection in or about the glands affected. ADENITIS. 713 The cervical glands are most frequently affected. Inflammatory conditions in the nose, throat, the mouth, or on the skin give rise to these swellings. The axillary glands are frequently swollen, due to septic absorption following vaccination. The glands of the thigh and the inguinal glands are commonly affected when there are irritations or inflammatory lesions involving the genitals, or the lower extremities. Pathologry. — ^The glands show swelling and infiltration with inflam- matory products. The immediate tissues are usually involved. Very fre- quently the swollen glands resolve. At other times there is an excessive migration of white cells so that the glands break down and abscess results. Symptoms. — The glands per se may show inflammatory symptoms, such as fever, tenderness, and swelling. It is wise to examine the adjacent parts to be sure that the glands are not a secondary inflammatory condition. For example, in diphtheria the neighboring glands are usually swollen. If the gland only is involved, we have no evidence of reddening or inflammation. When inflammation exists involving the neighboring tissues, a reddening of the skin takes place. Such cases usually have fluctuations, or soft areas can be made out. The glands are swollen, at times reaching the size of a hen's egg. The diagnosis is very easily made. The prognosis depends on the condition of the child at the time of infection. If tuberculosis exists, the prognosis is bad. The prognosis of acute adenitis in conjunction with acute exanthemata is usually good. Treatment. — (a) Abortive; (b) surgical. Abortive. — ^The inunction of Crede ointment has served me very well. A piece of the salve about the size of a bean should be well rubbed into the swollen gland. The rubbing should be continued at least ten minutes. Sometimes a leech applied to a gland will reduce the swelling. An ice-bag will reduce swelling and sometimes prevent suppuration. Belladonna oint- ment and ichthyol, 10 per cent., with lanoline is sometimes useful. Surgical Treatment. — ^When fluctuation is felt, hot fomentations with flaxseed meal will be very grateful. An incision should be made, with aseptic detail, pus evacuated, and the wound packed with iodoform gauze. Later restorative treatment, such as malt, iron, codliver-oil, or the syrup of the iodide of iron, should be given. Chronic Adenitis. Not infrequently we meet with children who have swollen glands last- ing months and years ip. whom po evi^ieng^ of tuberculosis or syphilid exists. 714 DISEASES OF THE GLANDS OR LYMPH NODES. This is usually due to repeated attacks of inflammation following acute adenitis, or it is the result of chronic inflammation of the skin. Pathology. — ^The glands show an increase in their cellular and con- nective-tissue elements. They undergo a true hyperplasia. Symptoms. — The symptoms consist in a swelling of the glands without inflammation or tenderness. In chronic adenitis the glands do not break down; hence suppuration is absent. In conjunction with chronic enlarged glands, we find hyperplasia of the tonsils, so that we invariably have en- larged tonsils and adenoids in such conditions. Diagnosis. — ^The diagnosis should be made after sjrphilis, tuberculosis, and other infections, such as diphtheria and scarlet fever, have been ex- cluded, so that we can be sure no specific or infectious disease is the origin of the trouble. The progniosis is usually very good. Treatment. — ^The treatment consists in removing the cause. Middle- ear inflammation, scalp disease, and pediculosis should be vigorously treated. Adenoids and diseased tonsils should be removed. Thus the treatment is narrowed down to removing the cause if possible and relying on restorative treatment, fresh air, and good nutritioii. Tubercular Adenitis. This condition is due to an invasion of the tubercle bacillus, resulting in a tubercular manifestation of the glands. It was formerly believed to be "scrofulosis." The pharynx and tonsils seem to be the point of entrance, as the glands in the cervical region are usually affected. Pathology. — ^The glands undergo a caseous degeneration which fre- quently results in abscess. At times we meet with tubercular lesions in various organs of the body. In the glands we note that they are studded with miliary tubercles and also find the tubercle bacillus therein. Symptoms. — The glands enlarge in various parts of the body; most frequently the cervical glands are affected. It is usually a very slow process, extending over months; sometimes years. During this time, from the long- continued inflammation, evidence of a continued illness is shown. When these abscesses form they heal very slowly and frequently leave sinuses or ragged scars. Henry G., 2% years old, was brought to my children's service with a history of recurring swelling on both sides of the neck and also behind the ear. The child was bottle-fed during infancy and had always suffered with dyspeptic trouble and constipation. He has had furunculosis of the scalp, which necessitated incisions, during the second year. Was troubled with tonsillar and catarrhal trouble ; also double otitis. The glands of the neck are swollen and frequently break down and discharge pus. The temperature is not elevated. This suppuration is known as the cold abscess type. The general condition is fair. The child is taking maltine with hypophos- TUBERCULAR ADENITIS. 715 phites. A restorative diet of cereals, cream, butter, eggs, etc., is given. Attention to hygiene and out-door life is the most important part of the treatment. Diagnosis. — This can easily be made when we consider the character of the glandular swelling, their tendency to caseation, and to suppuration. When the pus is examined, tubercle bacilli are invariably found. Differential Diagnosis. — In the beginning this disease is difficult to diagnose. We can exclude syphilis by the history of the parents. When Fig. 228. — Case of Cervical Adenitis in which a Positive von Pirquet Reaction Appeared. (Original.) the history is not obtainable, resorting to anti-syphilitic treatment will materially aid in eliminating the diagnosis of syphilis. In Hodgkin's dis- ease the glands do not suppurate. In simple chronic adenitis there is no suppuration. Treatment. — Attention to hygienic details is of prime importance. The diet should consist of restorative foods in which proteins and fats abound. Restorative medication, such as iron, codliver-oil, iodide of sodium, and arsenic, and syrup of iodide of iron are the most useful drugs to be considered. 71i6 DISEASES OF THE GLANDS ANB LYMPH NODES. Read also the treatment outlined in the chapter on "Acute Miliary Tuberculosis." The surgical treatment of tubercular adenitis should consist in the total removal of the suppurating glands, using aseptic precaution, rather than to rely on slow spontaneous evacuation of pus by Nature, Mumps (Specific Parotitis). This is a specific febrile disease, characterized by inflammation of the salivary glands. . Etiology. — This disease is prevalent all over the world, occurring usually in the form of local epidemics. It is more marked during the cold and wet seasons than in the summer. Children between 10 and 15 years of age suffer most. Boys are more liable to be attacked than girls. Infantile parotitis is frequently met with. The nursing infant is not exempt from this condition. The perietd of incubation, counting from the exposure to infection and the appearance of the disease, varies from fourteen to twenty-five days. It is usually about three weeks. In New York City, children suffering from mumps are excluded from school until the swelling has entirely subsided. Children of the family who have not had the disease are excluded until the medical inspector recom- mends re-admission. Children in the family who have had the disease may remain in school. How the Disease is Spread. — Contact seems to be the method of con- veying the disease from person to person. School children and families are thus infected. Pathology. — The disease is most likely due to an infection by a micro- organism. The salivary glands are probably the seat of invasion. Symptoms and Diagnosis. — The disease begins with fever lasting two or three days. The temperature may reach 104° F., although the usual tem- perature is about 101° F. The fever may be so pronounced that delirium accompanies the same. The most pronounced symptom is pain and ten- derness in one parotid gland. The gland becomes swollen. The swelling occupies the space behind the angle of the jaw and below the ear, spreading forward on the cheek, and downward along the neck. The edge is ill de- fined, and the swelling itself is doughy to the touch. Goodhart has reported cases in which the swelling was severe and the patient breathed with his mouth open. In such instances the tongue is dry and brown, but no serious import should be given thereto. The swelling is confined to that portion of the neck between the Jaw and the stemo-cleido-mastoid muscle. The center of the swelling is im- mediately under the lobe of the ear. MUMPS. 717 The swelling becomes so extreme and the pain so acute that the patient can hardly do more than separate the upper and lower jaw. The submax- illary gland on the same side becomes affected within a day or two and there is a large swelling below the jaw. Soon afterward the opposite parotid and submaxillary glands may also become involved. Goodhart states that a swelling of the cervical lymphatic glands may be the only local signs of mumps. There is usually a general malaise. The swelling lasts four or five days and then subsides. Suppuration never results. The amount of saliva secreted is not lessened. In many cases it may be excessive. Differential Diagnosis. — The glandular swelling in mumps has fre- quently been mistaken for diphtheria. In the latter disease the parotid glands are not affected. The patient rarely encounters difficulty in opening the mouth, even when the cervical lymph glands are enlarged. The differential diagnosis between mumps and diphtheria must be made by a careful inspection of the fauces and tonsils and noting the ab- sence, or presence of membrane. There are other conditions which may be accompanied by parotitis. In enteric and other fevers in various disorders of the abdominal cavity, one or both parotids may be inflamed. In these conditions, however, sup- puration of the parotid gland may ensue. Prognosis. — This is almost always favorable. Goodal and Washbourn state that during ten years in England and Wales there were but eighty deaths registered among the entire population. These authors suspect diphtheria as the cause of most of these deaths, reported as mumps. Complications. — The most disagreeable complication is orchitis. This usually commences when the disease has progressed several weeks. It is accompanied by fever, sometimes chills. The body of the testicle and not the epidermis is involved. As a rule ice-bags or leeches aided by rest will relieve this condition. The attack usually lasts several days, but may be prolonged several weeks. Treatment. — Local: Hot fomentations, consisting of ground flaxseed meal to which a few drops of laudanum have been added, are very grateful and well borne. They are to be applied between two thicknesses of cheese- cloth. These poultices should be renewed at intervals of one-half hour. Among the newer local remedies, antiphlogistine, warmed and applied in the form of a salve, has been advocated. The occasional application of a leech at the site of the swollen parotid will be found advantageous in some instances. An ice-bag can sometimes be used to advantage. The local application of tincture of iodine can be recommended. 718 MUMPS. The inunction of : — B Unguentum belladonna 6 drachms Unguentum hydrarg. ciner 3 drachms M. Ft. ungt. To be rubbed in swollen glands every three or four hours, may be tried. Another drug which is quite serviceable is ichthyol, to be applied sev- eral times a day, in the following manner: — IJ Ammonium sulpho. ichthyol 2 drachms Lanoline 1 ounce M. Ft. unguentum. To be thoroughly rubbed in swollen glands. The local application of a 5 per cent, iodoform collodion painted over the inflamed region, several times a day, or a 10 per cent, salicylic collodion applied several times a day is at times beneficial. The inunction of a 15 per cent, iodide of potassium ointment will be indicated if there is a suspicion of syphilis in the case. Constitutional Treatment. — Rarely do we require internal medication in this disease. If, however, there is high fever, sponging the surface of the body or cold packs are indicated. The internal administration of a mild laxative, such as citrate of magnesia, is grateful and beneficial. Five-grain tablets of rhubarb and magnesia will be required if consti- pation exists. Owing to the infectious nature of this disease, the first rule should be to isolate. The isolation should be thorough and continued at least ten days from the beginning of the illness. CHAPTER V. DISEASES OF THE DUCTLESS GLANDS. Cretinism (Myxcedematofs Idiocy — Myxgedema). Cretinism is a form of 'idiocy associated with pachydermatous cachexia. Etiology. — In my own cases psychical disturbances in the mother seemed to result in cretinism. Worriment and fright seemed to have some etiological relationship to the development of myxoedematous idiocy. In two cases of mine the mother suffered with mental depression, con- stant worry, and hysterical symptoms during pregnancy. Pathology. — We are indebted to Fletcher Beach for a series of careful post-mortem investigations which have thrown considerable light on the nature of this disease. We know that cretinism is due to the absence of the internal secretion of the thyroid gland. In some instances the gland is congenitally absent. This condition also results when the thyroid gland is removed by surgical means. It is safe, therefore, to assume that the loss of the function of the thyroid gland causes cretinism. Holt believes that cretinism is in some instances associated with goiter. This disease occurs sporadically in our country. Symptoms. — The characteristic manifestations are very apparent dur- ing the first year of a child's life. Sometimes distinct evidences of cretinism can be seen as early as the third month after birth. The child is short in stature and light in weight compared to the normal infant. The extremi- ties, particularly the fingers, are short and thick. The lips are thick. The tongue is broad and thick, and constantly protrudes from the mouth. The fontanel is late in closing. The nose is broad, flat, and upturned. The nostrils are wide open. The hair is coarse and straight (straw-like). Den- tition is delayed, and when the teeth do appear they are very poorly formed. The skin of the entire body is thick and dry, but does not pit on pressure. The infant is stupid, and it is very noticeable that we are dealing with deficient mental development. In the supra-clavicular regions there are regularly formed pads of fatty tissue, so that the neck is short and thick (Tuttle). The thyroid gland cannot be felt unless it contains a tumor. The abdomen is large and prominent and an umbilical hernia is frequently present. Constipation of a very obstinate character is usually met with and persists for a long time. The temperature is subnormal. The th}Toid gland (719) 720 DISEASES OF THE DUCTLESS GLANDS. is absent or cannot be felt. In palpating the thyroid region we can feel the trachea. In some cases there is a hypertrophied hypothenar eminence on the palms of the hands. The face in all cases has 'the prognathous expres- sion (Koplik). Diagnosis. — The value of an early diagnosis in this condition is more important than in any other disease with which we are brought in contact. The diagnosis can usually be confirmed after a short period of thyroid treat- ment. The specific results of treatment are more apparent in this condi- tion than in any other infantile derangement with which we are con- fronted. Case I. — Frances P.^ was referred to me by Dr. L, F. Haas. She was the seventh child of this family. All the other children were perfectly normal. The labor was normal. The child was born before the doctor arrived. Family History. — The father is healthy. The mother is strong and healthy. During the pregnancy the mother constantly cried on account of family trouble. Her husband was out of work. The mother frequently had hysterics. Similar psychical disturbances were never present while pregnant with the six other children, who are all strong and healthy. History Given by the Mother. — The mother noticed that the child had short limbs. That she was not bright mentally. That when 1 Va years old she could neither walk, talk, nor support her head. The tongue was very thick and protruded almost constantly while awake, as well as when asleep. The hair did not grow. The nose was short and flattened. The skin Avas yellowish and dry. The child had a jaundiced appearance. Constipation since birth. The bowels were moved with difficulty. The infant was breast-fed until it was fifteen months old. Up to this time there was no sign of dentition. She was taken to the Babies' Hospital, which necessitated her being weaned from the breast. She remained in the hospital about two weeks. When sixteen months old, one month after thyroid treatment was commenced, the -first tooth appeared. The child was successfully vaccinated at the end of the first year. During its first year and up to the time that it was taken to the hospital, it did not suff'er with any infectious disease. My first examination was on December 8, 1902. The child at that time was 2 years, 2 months old. The following conditions were found: — The child can neither walk nor talk. The tongue is very thick and protrudes constantly. The lips, the eyelids, and the skin of the face are thickened, coarse, and rough. The nose is short and flat. The skin has a yellowish jaundiced appearance. The fontanel is widely open both anteriorly and posteriorly. The face is broad and the eyes are set very wide apart. There is a marked depression on each side of the temporal bone. There is a marked frontal protuberance. The child had nine teeth when twenty-two months old. As previously stated the first tooth appeared one month after the thyroid treatment was commenced, or when the child was sixteen months old. The body is well developed — fat. There is no evidence of rachitis. The chest and spine show evidences of good nutrition. The length of the body was 50 "/j centimeters, or about 20 inches. The secretions of the body were very torpid. Constipation of a very obstinate form was encountered. There were several fatty growths in the sterno-cleido-mastoid muscle. ^ Three cases of cretinism were presented by me at the Section of Pediatrics of the New York Academy of Medicine, February 11, 1904. CRETINISM. 721 Spobadic Cbetinism. Fig. 229.— Child. years, 2 months, nal.) Fig. 230.— Same child. Seven months after continued thy- roid treatment. ( Original. ) Fig. 231. — Same child. Age 3 years, 9 months. One year and seven months after continued thyroid treatment. (Original.) •?■?, DISEASES OF THE DUCTLESS GLANDS. The child had a violent fear of water, so much so that the mother had difficulty in bathing her. The hair is. very thick and straw-like. The thyroid gland cannot be felt. The pulse was 90 and of a full bounding character. There was a subnormal temperature which wa-s never higher than 98° F. in the rectum in the evening. Respiration was 16 while quiet and 24 while crying. The ui'ine showed traces of indican, evidently due to the constipation. No albumin or sugar was found. Micro- scopically no uric acid crystals; no casts, and no bacteria were found. T\Tien the treatment was first commenced, 1 gi-ain of thyroid was given three times a day. This dose was rapidly increased so that after the first week the child took 2 ^/j grains three times a day. The heart Avas carefully watched and no disturbance noted from the quantity of thyroid given. In addition, 10 drops of pure codliver-oil was given three times a day. Cereals, milk, chicken soup, broths, and acid fruits, such as oranges, lemons, and cranberries, were ordered. Fresh air and bathing, with vigorous friction, concluded the hygienic treatment. Under this vigorous treatment the child developed A^ery fast. The length of the body was .58 ^/2 centimeters at the end of the first month of this treatment. The growth, therefore, in one month amounted to 8 centimeters or 3 Vs inches. The obstinate constipation was improved and the bowels became regular. The teeth have appeared at regular intervals. The facial expression has changed. The child now commences to walk, as also to talk, she says "mamma" and "papa." The fear of water and to be bathed is past. She no longer cries when she sees water. At the end of 1 year, the length of her body is 85 centimeters or 33 V2 inches, so that she has grown in 1 year 341/2 centimeters or 13^2 inches. The child is still taking thyroid and is progressing favorably. Table No. 74. — Length and Growth of Body. Age. Length of BoJt. Gain in Growth of Body. 2 yrs. and 2 mos. 2 yrs. and 3 mos. 3 vrs. and 3 mos. oOJ centimeters (19jf inches) 58y centimeters (23^^ inches) 85 centimeters (33 J inches) 1 mo., 8 centimeters (3^ inches) 12 mos., 34J centimeters (13J inches) Case II. — Rosie H., born .January 1, 1902, now over 2 years old, was first seen by me when she was eighteen months old. Family History. — Father living, is somewhat dyspeptic. Has no specific disease. The mother is a very nervous woman, otherwise in good health. Tliis is her first child. She has had one other pregnancy of eight months which was still-bom, believed to have been an asphyxia neonatorum. No miscarriages. No lues. Child's History. — She was breast-fed for seven months, later she received equal parts of milk and water. When first seen by me at the age of eighteen months, she was still fed on equal parts of milk and water. There has always been severe constipation, and streaks of blood have frequently been seen, in the stool from severe tenesmus. The examination of the child at that time showed coarse, sparse hair, and a very rough skin. The tongue and the lips' were very thick. The tongue always protruded from the mouth; breathing was' difficult. There was constant snoring, and the mouth was ahvays open. The thorax was decidedly rachitic; there was a funnel-shaped depression, and also a kyphosis and an umbilicated hernia. The child could neither stand nor talk. There was no evidence of teething. The appetite was poor. The temperature was subnormal, 98 Vo" in the rectum. The pulse was CtlEHNlSM. 723 Sporadic Cretinism. Fig. 232.— Oliild. Age 1 year, 5 months. (Origi- nal.) Fig. 233. — Same child. Age 2 years. (Original.) Fig. 234. — Same child. Age 3 years, 5 months. (Orig- inal. ) Fig, 233. Fig. 234, 724 iDiSEASES OF THE DUCTLESS GLANDS. 100, small, and feeble. The heart sounds muffled. A hsemic murmur was plainly heard at the apex and also in the vessels of the neck. It was impossible to seciu-e a specimen of urine for examination. A drop of blood was examined and showed a decreased number of red blood-corpuscles and a marked leucocytosis. The diagnosis made was sporadic cretinism. The circulation was poor and there was a slight oedema constantly present. The feet and hands were frequently cyanotic, and always felt cold. The anterior fontanel was widely open. Growth was stunted as the length of the body was only 55 centimeters. The naked weight when 1 V2 years old was 11 pounds 13 ounces. When first seen by me there was neither muscular nor bony development which could be considered normal. At eighteen months the child had had no teeth. At twenty-two months the first tooth appeared. The muscles of the body were limp and flabby. The child could not support her head nor was there good support to the spinal column. The patellar reflexes were but slightly present. Treatment. — The treatment consisted in giving fresh, raw milk warmed to body temperature. In addition to the milk, steak juice, orange juice, potato flour, and the usual antiscorbutic remedies were ordered. Fresh albumin, using the raw white of Qgg, and vegetable proteids, such as pea soup and lentil soup, were very well assimilated. Tlie medicinal treatment consisted of two drugs. Thyroidine was given in doses of V2 gi'ain three times a day, and gradually increased until 3 grains were given three times a day. The other drug was Fowler's solution given in 1 di'op doses, increased to 3 drops three times a day. It is now about six months since the treatment was commenced. The child has grown in length from 55 centimeters to 69 centimeters and the weight has increased from 11 pounds 13 ounces to 17 pounds. Case III. — Rosie N. was first seen by me on June 28, 1902. She was then seventeen months old. Family History. — Father is healthy. No family history of tuberculosis, syphilis, or any other taint. The mother is in good health and has never had any serious illness nor miscarriage. This was her first pregnancy. The mother's condition was good, there was no traumatism nor any psychic disturbance. The infant was born without the aid of instruments. It was a perfectly normal delivery. The mother menstruated while nursing the infant. Personal History.— The infant was nursed about sixteen months. She did not seem to thrive since she was three months old. Severe constipation had always existed, and was present when I first saw her. She could neither stand, walk, nor talk. Backwardness in development was very apparent. Spasmus nutans was present. The fontanel was widely open. She showed no signs of intelligence. The hair was coarse and straight. The extremities were short. The growth stunted. She presented a squatty appearance. The skin was rough, thickened, and large eczematous patches covered the aitns and legs. The child was sent to me by Dr. L. Weiss, who had her under his care for the relief of the eczema. The lips were thick. The tongue was thick and protruding. She had two lower incisors; no other evidence of dentition. The facial expression was senile and corresponded with that of a tj'pical cretin. She was restless by. day and suffered with insomnia by night. The urine was examined and contained no albumin nor sugar. Slight traces of indican were seen, microscopically nothing pathological. The blood examination showed four million six hundred and twenty thousand (4,620,000) red blood-cor- puscles, and seven thousand two hundred (7200) white cells. The percentage of haemoglobin taken with Gower's instrument was about 40 per cent. As digestion was very poor I decided to syphon off the gastric contents two hours after a meal and to examine the same chemically. CRKT[NISM. 725 Feeding. — The feeding wius barley water. About 5 cubic centimeters were syphoned off, which showed traces of peptones, starch, and sugar; HCl was absent by (Junzberg's test. I am indebted to Mr. Charles LaWall for his assistance in the chemical analyses of the gastric contents, made a number of times. E(jual parts of milk and barley water were fed every few hours. Thyroid treatment was conuiieneod ; '/2 grain of the de.siccatetl powdered thyroids was ordered Fig. 235. — Crjtinism. Age 7V4 years. Height 261/^ inches. Front view. F:g. 236.— Cretinism. Height 261^ inches. Aui' T^i years. Liack view. three times a day. The dose was gradually increased and the child now receives 3 grains three times a day. There was no cardiac disturbance from this dose. Lemon juice, orange juice, raw albumin, and vegetable soups were ordered. The child's condition improved. The specific effect of the thyroid was very apparent. Case TV. — GTissie S.,^ 7 years and 3 months old when she came under my obser- vation. She was born January, 1897. She is the oldest of four children. The other children are to all appearances healthy, as are also the parents. ^ I regard this case as the most complete type of cretinism that I have ever seen. The notes were kindly furnished by Dr. A. E. Isaacs, in whose practice the case occurred. 726 DISEASES OF THE DUCTLESS GLANDS. Family History. — The mother claims to have had a severe fright during her sixth month of pregnancy, and attributed the child's mental deficiency to this psych- ical disturbance. There is no history of any condition similar to this child's on Fig. 237. — Cretinism. Same case. Age 8 years. Height 33% inches, gain 6% inches. Fig. 238. — Cretinism. Same case. Age 8 years. Height 33% inches, gain 6% inches. Back view. either side of the family. Parents are natives of Russia. They are 13 years in this country, and do not know of any such disease in their native country. The parents are not related. Feeding. — The child was breast-fed for about two years. She did not receive any other food during this period. When the child was thirteen months old the i-iother's menstruation returned. The mother continued to nurse the child until the end of the second year, although she continued to menstruate every month. Nothing unusual was noticed about this child until the end of her first year. She cried ver^' little and slept a great deal. At about 1 year of age parents noticed that she differed from other children of the same age. No teeth appeared. She CRETINISM. 737 made no attempt to walk or stand. Never laughed or smiled, was always apathetic and took no inteiest in hor surroundings. Tliere was no appreciable growth in height from 1 to 7 years. The same dresses always fitted her. In her fifth year she was for a period of six months very cross and restless, but this disappeared as it came, without any known cause. Pig. 239.— Cretinism. Same case. Age 9 years. Height .37% inches, gain 41/^ inches. Front view. Fig. 240.— Cvtatinism. Same case. Age 9 years. Height 37% inches, gain 4% inches. Baclv view. She cut hor i)iolKor teeth at 3 years of aije and the rest at 4 years. She has never had convulsions or any other sickness except measles when 4 years of aofo. She began to stand on her feet with assistance when 3 years old. She did not speak a word until 5 years old, from which time till I took charge of her she could say TU> more than "papa" and "mamma." - When she came under my observation, she was 26 Va inches high. She weighed 728 DISEASES OF THE DUCTLESS GLANDS. 25 V3 pounds and was quite stout in proportion to her height. Her head was large in proportion to her body. The lips Avere thick. The nose flat and depressed between the eyes. The neck was very short. No sign of enlarged thyroid, large blue eyes, teeth in fair condition, complexion dark, hair dry and of a rusty black color. ^ Fig. 241. — Cretinism. Samu ca-.-. AgL 11 years. Height 39% inches, gain 2 inches. Front view. Fig. 242.— Cretinism. Same case. Age 11 years. Height 39% inches, gain 2 inches. Back view. Hearing, sight, and smell apparently good. Voice not out of the ordinary. The extremities were short and thick, lower ones were bow-legged. The ends of the bones were large. The belly was larore and its prominence exaggerated by a decided anterior curvature of the spine. Intelligence was almost nil, temperament very CRETINISM. 729 irritable, does not cry, but becomes very angry. She never asks for food, eats little and only what is given to her. The bowels were constipated, moving only once in two days. She never asks to pass stool or water. Had external haemorrhoids, which bled occasionally. When awake was constantly sitting. Cannot walk alone and only a few steps when assisted. She slept well. Pulse was 96 and regular. Has had no treatment for three years. Previous to this time parents had hetta all over with her and tried everything suggested, without avail. On January 25, 1897, I put her on 3 grains, once a day, of desiccated thyroids (Parke, Davis & Co.). On February 18th dose was increased to 4 grains daily, but after a week the dose had to be reduced to 2 grains, as the pulse rose to 120 and the chUd became irritable. Otherwise, some improvement was already noted in her general condition; she could stand better and moved her bowels daily. After anotlier week (March 6th) the dose was increased again to 3 gi-ains daily and was continued so till I saw her on March 21st, when I found her pulse 144, strong and bounding. She had become considerably thinner, having lost 1 V2 pounds in weight in spite of the fact that she had gained 2 inches in height. This gave her a much more natural appearance. She also had a more intelligent facial expression, talked mere and decidedly better, walked a short distance M'ithout assistance, and ate better. On account of' the accelerated, pulse and loss of flesh, I decreased the thyroids again to 2 grains daily. From this time on there was a gradual improvement in all the symptoms. By the middle of April she was running about the streets, playing with other children, and asked for her food. In May she began to tell when she wanted to move her bowels, gradually gained in intelligence, spoke more and articu- lated better. The dose of the thyroids was gradually increased until she A^'a'fe taking 5 grains daily (July), which she continued for more than a year and a half without any symptoms of intoxication. I had the honor of presenting her before the Society'^ in 1898 after one year's treatment, when she had gained 6 V* inches in height. The privilege was accorded me again in 1899 when she had gained an additional 4 V2 inches. The average growth of a normal child of her age is less than 2 inches a year. SJie had gained over eleven (11) inches in tioo year's. As interesting as this case is so far, the most significant and interesting part of it comes now. I lost track of the patient in January, 1899, and she took no medicine from that time until I saw her again in December, almost a year later. My note- book records the fact that there was no increase in height and that her general appearance was not good. Although I ordered the thyroid extract it was not given again until I saw the patient one-half year later, on June 1st, 1900, and again there was no increase in height or improvement in general condition. The patient's next visit was in February, 1901, when she reported that 5 grains of the thyroid had been given daily from June 1st to December 24th. Measurement showed a gain of 2 inches in height ( 39 V2 ) • Her general appearance was much better and she had been going to school for a few weeks. If any proof be necessary as to the efficacy of the thjToid principle in cretinism, or as to the thyroid gland and its secretion being essential to the proper physiological workings of the human body, the history of this case supplies it. Take the one symptom of stature. From 1 to 7 years of age, Avithout the administration of thyroids, there was no increase. From 7 to 8 years, with thyroids, there was a growth of 6 V< inches. From 8 to 9 years, also Avith thyroids, there Avas a growth of 4 'A inches. From 9 to 10 years, without any thyroids, there was no growth. From * Eastern Medical Society, New York City. 730 DISEASES OF THE DUCTLESS GLANDS. 10 Va to 11 years, with thyroids again, 2 inches were gained- All other manifesta- tions of this cretinic condition underwent corresponding fluctuations with the ad- ministration of the extract, but changes in stature being the most evident, serve best to illustrate the progress of the case. To contrast her previous with her present condition as well as to show her appearance during the period of her improvement no better means could be utilized than the accompanying photos. The first pair was taken in February, 1897, the second in 1898, the third in 1899, and the fourth in February, 1901. She is now sufficiently intelligent to go to school. She plays as a child should and her general health is very good. She has yet the physical marks of her previous condition in the peculiar features, the short neck, and the spinal curvature with the abdominal prominence, though they have all' improved, especially the spine and the abdomen. Her height is about 12 inches short of what it should be at her age, 11 years, but if the rapid rate of growth continues she will gain a good part of it. September, 1901. — Has taken little medicine. Height about the same. April 27, 1902. — Has taken medicine one and one-half months sincei last visit. Height, 41 Vi inches ; goes to school. September 4, 1902. — Has taken 5 grains daily since April 27th. Looking and feeling well. Losing flesh, feels cold at night, hands tremble when taking things to mouth since six weeks. Pulse, 188. Height, 41 V2 inches. Discontinued thyroids three weeks. I saw case on December 20^ 1902. No thyroids since last week. Patient is gaining flesh, shivering (trembling) stopped. Pulse, 72. Goes to school, has mastered her figures only, (is almost 13 years old). Ordered 2 V2 grains thyi'oid daily. When last seen, April 20, 1904, the mother stated the girl had been going to school for the last two years. Very little mental progress has been made during this time. She reads an elementary primer and can remember figures. Has taken thyroid but four months out of the last sixteen months. Her height is 43 V4 inches. She has gained in the last sixteen months about two inches. Her pulse-rate is 72. Progfnosis and Course. — The sooner treatment is instituted the better the result. When this condition is neglected, children become worse and worse until finally they are beyond medical aid. It must be borne in mind that thyroid must be given for years if last- ing results are to be obtained. Children will go backward at once if we discontinue our treatment, even though the same has been continued for some years. An interesting study is the continuous growth including men- tal development plainly seen in the illustrations of cases in this chapter. Treatment. — The most important part of the treatment consists in administering from 1 to 5 grains of the dessiccated extract of thyroid. This replaces the active priiiciple of the normal thyroid gland. I have used with very good success thyroidin, from ^/g to 2 grains three times a day, with equally good result. Great care should be taken to watch the pulse-rate while giving thy- roid. The pulse will sometimes increase from twenty to forty beats after the administration of 1 or 2 grains of thyroid. The moment we find an exaggerated pulse-rate, it will be necessary to reduce the dose of thyroid EXOPHTHALMIC GOITEK. 73I * at least one-half. A flabby, fat child will at once lose weight, and an impor- tant feature of successful treatment is an increase in height. Thyroid Iniplanldtion. — Implantation of sheep's or lamb's thyroid (heterogeneous), or from the human being (homothyroid), has been advo- cated by some. In one case of mine, operated by Dr. Howard Lilienthal, the implantation of lamb's thyroid was tried. Several pieces were im- planted in the peritoneal cavity. Some improvement was noted. We must not, however, blindfold ourselves to the belief that when we supply the missing internal secretion, namely, thyroid, that we have ful- filled all indications. The diet must be regulated and the child given a large portion of pro- teids — milk, meat or meat extracts, fresh beef blood or roast beef juice, orange juice, fresh eggs, and all cereals must be given as body builders. Fresh air and a general attention to the hj^gienic condition of the child are very important. Massage, gymnastics, and exercise should not be over- looked. If the appetite is poor 1 to 2-minim doses of the tincture of nux vomica will do good. Butter and codliver-oil are valuable adjuncts. Exophthalmic Goiter (Htperthyrea_, Basedow's Disease, Graves's Disease). This disease has occasionally been seen in children. It is supposed to be due to a hypersecretion of the thyroid gland. Sachs believes that hered- ity is a more important factor than excitement or fright. Epileptic and alcoholic parents certainl}^ predispose to this condition in children. Symptoms and Diagnosis. — There are three symptoms of importance which should be noted : — 1. The enlargement of the thyroid. 2. Palpitation of the heart (tachycardia). 3. Protrusion of the eyeballs (exophthalmus). The blood tension, is increased, hence hemorrhages from the nose, stomach, or intestines are quite common. Disturbances of vision due to the exophthalmus are never described. The thyroid enlargement is usually bilateral. Muscular tremors are also noted. The diagnosis is easily made by recognizing the symptoms above described. There is a physiological hyper- aemia of the thyroid which is entirely different from goiter. Prognosis. — Cases seen by me have all assumed a chronic tendency. I have never known death to occur directly from this condition. When death occurred it was due to some complication. Treatment. — Spartein sulphate, strophanthus, digitalis or belladonna combined with iodide of sodium may be tried. The galvanic current is strongly advised by some writers. Recently x-ray treatment has been 732 DISEASES OF THE DUCTLESS GLANDS. used in conjunction with the above-mentioned drugs. The danger of x-ray dermatitis should be remembered by those having little experience with light treatment. The use of thyroid has been suggested, but it has failed to do good in my hands. t Acute Thyroiditis. Inflammatory conditioEs such as abscess have been described as a com- plication of the infectious diseases. The migration of streptococci or other pyogenic bacteria may give rise to suppurative inflammation. The treat- ment is surgical. Abnormality or the Thyroid. Syphilitic gummata and tuberculosis have been found in rare instances. Malignant disease involving the thyroid has been reported among infantile disorders. Diseases of the Adrenal Glands. Pathologists have frequently described hgemorrhages into the adrenal glands in the new-bom infant. Diseases -per se, excepting cancer, have not been described. There is still considerable to be learned concerning tlie physiology of these glands. Addison's Disease. This rare condition is occasionally described. Literature records about twenty cases in all. Symptoms. — The symptoms of the disease consist of a deep-yellowish or bronzed pigmentation of the skin. It is found on the exposed parts of the body, such as the hands and head. The mucous membranes of the mouth and vagina are also pigmented. White areas of skin are scattered over the body. Vomiting, diarrhoea, and nervous symptoms are noted. Anaemia is usually very marked. Diagnosis. — In the diagnosis of this condition it is necessary to exclude pigmentation of the skin due to metallic poisons, such as argj^ria, from the internal administration of nitrate of silver. Arsenic and lead have been reported as causative factors of bronzed skin. Prognosis. — ^While most authors report the outcome as fatal, some few recoveries have been noted. In a case seen by me recovery took place after several years of treatment. Treatment. — We have no specific treatment for this condition. Some authors advise the administration of the raw or cooked adrenal glands of the sheep. The dry extract in tablet form has been isolated and 1-grain doses of this extract may be given three times a day. When the gland itself is used, one-half to one gland may be given in twenty-four hours. The value of hygienic and dietetic measures I regard as more impor- tant than medication. PART IX. DISEASES OF THE NERVOUS SYSTEM. CHAPTEE I. FONTANEL. The posterior fontanel is usually closed at the end of the second month. The anterior fontanel normally closes between the sixteenth and twentieth months. If the fontanel is open at the end of the second year, then rickets or other abnormality may be considered. A fullness of the anterior fontanel and bulging of the same at the end of the second year is pathological. (See chapter on "Hydrocephalus.") Premature closure of the fontanel fre- quently occurs in microcephalus and also in congenital idiocy. This prema- ture closing interferes with the proper growth and development of the brain. Shape of the Head. — Peculiar shapes of the head are met with unde' perfectly normal conditions. An interesting study is the series of outline sketches of the head which show the modifications in form produced 'by labor and also the normal sketches of the head. , Circumference. — The average circumference of the head at birth in 446 full-term infants taken in about equal numbers from the Sloane Maternity Hospital and New York Infant Asylum, quoted by Holt, was as follows: — Average circumference of the head, 231 males.. 13.90 inches (35.5 centimeters) Average circximference of the head, 251 females 13.52 inches (34.5 centimeters^ Total 446 infants. 13.71 inches (35.0 centimeters) Auscultation of the Anterior Fontanel. — A bruit is occasionally heard over the anterior fontanel. (Plates XXXIY, XXXV.) It is a blowing sound similar to that heard in the vessels of the neck during anaemia or in oblorotic girls. I have described this condition in the chapter on "Eachitis.'' Percussion of the Skull. MacEwen, in his treatise upon the pyogenic infective diseases of the brain and spinal cord, says : "When the lateral ventricles are distended with serous fluid, as would be occasioned by cerebral tumors pressing on the fourth ventricle, or by occlusion of the veins of Galen or otherwise, the per- cussion note is markedly altered, the resonance being greatly increased. (733) 'j'34 Diseases of ^fiii nervous sysMM. OuTUNE Sketches of the Head, Showing the Vaeious Diametees. Fig. 243. — Sagittal, Section of Normal Head of Seven and One-half Months' Foetus, Half Natural Size. (After Ballantyne.) Fig. 244. — ^Normal Head as Seen from Above, Half Natural Size. (After Budin.) Fig. 245.— Sagittal Section of Nor- mal Head, Half Natural Size. (After Budin.) Fig. 246.— Sagittal Section of Head Immediately After Normal, Easy Labor, Half Natural Size. (After Ballantyne.) Besides the increased resonance, there is an important feature which may be demonstrated : The percussion elicited at a given spot on the cranium, such as the pterion, varies according to the position of the head. AVhile the per- son sits with the head upright, the most resonant note is brought out by percussion toward the basal level of the frontal bones and the squamous OUTLINE SKETCHES OP THE HEAD. 735 OuTUNE Sketches of Head of Infant, Showing the Modifications in Form Produced by Labor, etc. Fig. 247. — Sagittal Sec- tion of Head Immediately After Labor (0. D. P. Position). (After Bal- lantyne. ) Fig. 248. — Sagittal Sec- tion of Head Immediately After Labor, Half Nat- ural Size (O. D. P. Posi- tion). (After Budin.) Fig. 249.— Sagittal Sec- tion of Head of Infant Six Days Old, Half Natural Size. (After Ballantyne.) •^36 DISEASES OF THE KEHVOUS SYSTEM. portion of the parietal. If the patient hangs his head to one side, so that one parietal is placed fairly below the other, the greater resonance is found on percussion of the lower parietal. Eeverse the position and the same note is elicited on the opposite side of the head, which is now the lower, the greater resonance being found at that part of the skull nearest the lateral ventricles, and which for the time is at the lowest level. "These observations tend to indicate that the quality of this note is not dependent on the mere density of the diameter of the cranium, but to a large extent upon the consistence or arrangement of the intercranial con- tents relatively to the osseous walls. . . . The exact mechanical quality of the note is difficult to describe, but, when heard, it conveys the idea of hollowness. One such case, in which the above phenomena were clearly marked, was observed to a conclusion. The percussion note was not so clear at first as it ultimately became, the resonance increasing as the disease advanced. "In tumors of the cerebellum it is an aid to diagnosis, and when present with abscess it points to an involvement of the cerebral fossa." The Beain.^ In the new-bom the dura mater is closely adherent to the skull, so that extravasations between the dura mater and the skull are unknown. Fluid in the Subarachnoid Space. — In infancy and childhood more fluid is found in this space than in adult life. McClellan believes that "hydrocephalus due to an excessive amount of fluids in the ventricles of the brain may be caused by the closure of a small opening in the pia mater which is found at the inferior boundary of the fourth ventricle known as the foramen Magendie.^' Blood-vessels of the pia mater are so delicate that blood pressure, trau- matism, etc., may cause haemorrhage into the subarachnoid space, resulting in monoplegia, haemiplegia, or diplegia. Growth and Development of the Brain. — From birth until the seventh year is reached the brain grows very rapidly; after the seventh year the growth is slow. Weight of the Brain. — The weight of the brain of the new-born infant is one-third that of the adult. In male and female children it is approxi- mately the same at birth, although later on the male brain grows more rapidly than the female. When a child is between 7 and 8 years of age, the brain reaches the adult size and weight. There is from this time on a slight increase in the weight up to the twenty-fifth year. Vierordt states that the increase of the brain after the seventh year is ^ The development of the senses is described in Part I, chapter on the "New-born Infant." PLATE XXXIV Tront View of tlio F(Pt;il Skull, showing the antorior foiitaiiollo ami the coronal and frontal suture:*. (Grandin & Jarman.) PLATE XXXV Top View of the Foetal Skull, showing the anterior fontanelle and the frontal, coronal, and sagittal sutures. (Grandin & Jarman.) PLATE XXXVI Posterior View of the F(¥tal Skull, showing the posterior fontanelle and the lambdoidal and sagittal sutures. (Grandin & Jarman.) REFLEXES. 737 due to an increase in the thickness of the cortex and in the size of the cortical constituents. Difference Between Infantile and Adult Brain. — The fissure of Sylvius in its relation to the spherio-parietal and squamous sutures occupies a higher position in childhood than in later life, Symington and McCkdlan, in studying frozen sections of the brain of children under 7 years of age, found the Sylvian fissure above the squamous suture and covered by the parietal bone. Fissure of Rolando. — The position is the same in the infant as in the adult. The Cerebellum. — This is much smaller in the child than in the adult in comparison with the cerebrum. The convolutions of Uie brain are more shallow in the infant than in the adult. The depressions or sulci between the convolutions are not so deep in the infant as in later life. The special centers of the brain are not fully developed in the infant (Taylor and Wells). Eeflexes. Excess of Reflex Action. — In acute mania, in cerebritis, and in acute meningitis we have excessive reflex action. In chronic hemiplegia an in- crease of the reflexes associated with ankle clonus is found on the affected side. In hydrophobia, transverse myelitis, insular sclerosis, and in tetanus we have an exaggeration of superficial and deep reflexes. Attention is directed to the chapters on "Tubercular Meningitis" and "Epidemic Cerebro- spinal Meningitis" for clinical illustrations of the reflexes. Diminution of Reflex Action. — The reflexes axe lessened and sometimes absent in melancholia. Extreme pressure in the cranial cavity or in the spinal canal will reduce the reflex act. Whenever a degeneration of mus- cles or nerves takes place, such as in diphtheria or other speciflc diseases, the reflexes will be lessened. The reflex is reduced or wanting in acute anterior poliomyelitis. BahinsTci Reflex. — In the new-born baby this reflex has frequently been noted under normal conditions. Instead of normal flexion of the toes, which is accomplished by irritation of the soles of the feet, we have in dis- ease a hyperextension of the great toe. This symptom is regarded as pathognomonic by some authors. I have frequently found this symptom present in tuberculous meningitis^ and regarded it as a valuable diagnostic aid. (See clinical case, article on "Tubercular Meningitis.") Reaction of Degeneration. — "In health a faradic current of sufficient strength applied to the nerve produces a continuous contraction of the mus- cle; the galvanic, a momentary contraction when the current is made and broken only. When the nerve is diseased a stronger faradic or galvanic 41 738 DISEASES OF THE NERVOUS SYSTEM. current is needed to produce contraction, until finally, when degeneration has taken place, no current which can be used produces any contraction. In health either current applied to the muscle produces contraction; the response both to the galvanic current and to the f aradic is quick, being in both instances due to stimulation of the nerve-endings. With lesion of the nerve and consequent degeneration of the nerve-endings, the faradic cur- rent produces no contraction, but since the galvanic current is capable also of stimulating the muscle fibers themselves, a contraction follows appli- cation, though more slowly than when the nerve-endings are healthy. After the degeneration has progressed to a certain stage, which is reached the earlier the more severe the case, this response of the muscle fibers to the galvanic current becomes more ready than in health. To this quantitative change is added a qualitative change. In health, the weakest galvanic cur- rent which causes contraction of the muscle does so when the current is made with the negative pole on the muscle (kathode closure contraction, K. C. C). When the nervous mechanism has degenerated a contraction may occur with as weak or with a weaker current when the positive pole is on the muscle (anode closure contraction, A. C. C), and contractions may occur also with the same current when it is broken (anode opening contrac- tion, A. 0, C, and kathode opening contraction, K. 0. C.^). To this altered qualitative and quantitative reaction of nerve and muscle to the electric currents the term "reaction of degeneration" is applied. It is not always as definitely marked as is above described. When the damage to the nerve is slight, the irritability of the nerve to both currents may be retained, and the only evidence of the existence of a reaction of degenera- tion is increased muscular irritability to the galvanic current, with some change also in the order of contraction to the poles (qualitative change). On the other hand, in very chronic changes the loss of irritability proceeds pari passu in nerve and muscle, and the reaction of degeneration is not to be observed. "With the regeneration of the nerve, recovery of function takes place, the rate of recovery depending mainly on the severity of the lesion. Vol- untary power is first regained, then the galvanic reactions become normal, and lastly, the faradic. "Anaesthesia, which is the eventful result of degeneration of a sensory nerve, may be preceded by a condition of hypergesthesia. The anaesthesia is often incomplete, especially in the hands and face; in a mixed nerve a lesion, capable of producing paralysis of motion, may be accompanied by little loss of sensation. Trophic changes seem seldom to occur in children as an accompaniment of lesions of sensory nerves.^' •The normal order is: K.C.C., A.C.C., A.O.C., K.0.0. CHAPTER II. CONVULSIONS (ECLAMPSIA). Convulsions occur mostly in infancy. After the seventh year of life they are very rare. The brain grows more during the first year than in all later life. This rapidity of growth is in itself, according to some writers, an important predisposing cause of functional derangement. Etiology. — The Exciting Causes. — The predisposing causes may be grouped under the name of "central." They are: — 1. Diseases having a high temperature. • 2. Diseases accompanied by vascular stasis. 3. Diseases characterized by anaemia and exhaustion. 4. Toxic causes. 5. Organic central lesions. 6. Functional disturbances of the brain, such as epilepsy. Of all the manifold predisposing causes of convulsions in young chil- dren, the most important one is the natural instability of the nervous cen- ters, characteristic of early life, and associated with the non-development of voluntary centers of the cortex; hence it is that age is a most important factor in the etiology of convulsions; and under 2 years is recognized as by far the most susceptible period. Statistics show that over 60 per cent. of deaths from convulsions, up to 20 years, occur in infants under 1 year of age. Convulsions are not only more common in infancy, but much more fatal than later in life, and for reasons that are very apparent. It has been stated by some good observers that males seem to be more suscep- tible than females; statistics seem to justify this conclusion, but it has been suggested by others that inasmuch as more males than females are born each year, the larger number of deaths in males may thus be recon- ciled, for surely it would be contrary to reasonable expectation, as females are more delicately organized, while the exciting causes are probably about equal. The Peripheral Causes. — The peripheral causes are rachitis; gastric disturbances, such as acute catarrhal gastritis ; intestinal worms : foreign bodies in the ear and nose, causing reflex convulsions; scalds and burns, and mental disturbances, such as fright, will induce convulsions. Lewis says: "Convulsions are in all probability due to an exaltation of the hirer nerve-centers; or more frequently, to a suspension of the inhibitory power of the higher cerebral centers" — or both of these conditions may exist at (739) '".■40 DISEASES OF THE NERVOUS SYSTEM. the same time — and further, "It remains to be said that we are still very much in the dark as to the immediate processes producing convulsions." "Infants have their nervous system in process of rapid development — only the component but undifferentiated parts of which are in great activity, ready to receive and re-energize limitless new impressions." At birth, the lower centers only are developed, and control is limited until the higher centers become competent to exert inhibition; hence in the earlier months of life convulsions are common, and less so after two years. Improper feeding may be looked upon as the most frequent cause of convulsions. A child that is improperly fed and suffers with a subacute or chronic form of dyspepsia, suffers with a deficient structure. Such struc- tural weakness resulting in rachitis, is a cause for that most common form of spasm known as laryngeal spasm and tetany. Toxemic conditions re- sulting from bacterial infection are a most frequent cause of convulsion. Pathology. — The development of the nervous system is not complete at birth. Very little light is shed upon convulsions by post-mortem findings. Usually after death from con-snilsions there is an effusion or haemorrhage found or there is a venous stasis in the brain. When death occurs from laryngospasm it results from suffocation. The condition of the brain in the beginning of an attack of convulsion is one of anjemia. This is shortly followed by a nervous hypersemia. The brain and meninges are usually found intensely congested and engorged. Sometimes punctate haemorrhages can be found. The lungs are also deeply congested and the right heart is generally distended with dark clots (Holt). Symptoms. — There is usually a loss of consciousness. The "onset is sudden. A child may appear perfectly well up to the time of its convulsion and then suddenly the arms and legs become stiff, the eyes -fixed and staring or rolled up under the lids. Eespiration is usually arrested, the head is retracted; finally the whole body becomes rigid. The above named symptoms belong to the tonic stage. ■ It is usually followed by clonic con^oilsions more or less severe and prolonged, affecting the upper and lower limbs, the face and eyes. Sometimes the tonic and clonic convulsions are few and the whole spasm may last less than a minute. Some children show no sign of illness after the attack is over, and appear perfectly normal. The attack may recur at short intervals. The child may then become comatose and die before proper treatment can be instituted. It is important to examine the urine. The possibility of a nephritis should not be overlooked. Diagnosis. — It is usually very simple to differentiate from epilepsy, which is most frequent after the third year. Convulsions usually are the first symptoms of the invasion of an acute disease. Scarlet fever, pneumonia, malaria, gastritis, and meningitis' may be ushered in with convulsions. Measles is sometimes preceded by convul- CONVULSIONS. 741 sions. Pertussis in which there is cerebral congestion may cause convul- sions. Bronchitis,- membranous laryngitis, and laryngismus stridulus are sometimes preceded by convulsions. Do not suspect teething or worms as a cause of convulsions until all other causes have been eliminated. Treatment. — The treatment of convulsions consists of controlling the spasm. Inhalations of chloroform or sulphuric ether should be cautiously used, regardless of the age of the infant, until convulsions cease. Chloral hydrate and bromide of sodium, with some starch water, should be injected into the rectum; 5 grains each of chloral and bromide with a tablespoonful of starch water should be used and repeated every hour until the spasms are controlled. Leeching by the application of one or two leeches behind the ears is valuable to relieve cerebral congestion. We can also drain blood from the frontal sinus by the application of one or two leeches at the alas nasi. A mustard foot-bath should likewise be used until hyperannia of the skin is produced. While the feet are suspended in mustard water an ice-bag or a cold cloth shodd be applied to the head. A cliild, 4 years old, was suddenly seized with convulsions, clonic and tonic spasms involving the face, arms, and legs. From the history I learned that the cliild had overloaded its stomach, was very feverish, and thirsty. A mustard foot- bath was ordered and a rectal injection of: — IJ Sodium bromide 10 grains Chloral hydrate 5 grains was injected into the rectum with two tablespoonfuls of thin starch water. One or two inhalations of chloroform were given to relieve the con^^llsions. The diagnosis of acute catarrhal gastritis was made and the convulsions attributed to a general toxaemia. When t!ie convulsions ceased the stomach was washed with two quarts of warm water to which two tablespoonfuls of salt had been added. Food was discontinued and an interval dose of: — IJ Sodium bromide 5 grains Chloral hydrate 2 grains was given every hour xmtil the child was in a deep sleep. Twelve hours after the convulsions first began, thin soup and broth were ordered. The child was well in two days. To control convulsions : — IJ Sodii bromidi 5 grains Chloral hydrate 5 grains Starch water 1 tablespoonful Mix thoroughly and inject, if possible, into the colon, through a small rubber catheter. Repeat every hour until convulsions cease. Lumbar puncture, the technique of which I describe elsewhere, is one of our most valuable tberapeutic measures. By withdrawing 20 to 30 cubic centimeters of cerebrospinal fluid, I have seen marked benefit therefrom. The intracranial pressure which was relieved by this procedure, lessened the 743 DISEASES OF THE NERVOUS SYSTEM. irritability of the child and promoted sleep. In a case of auto-intoxication due to gastric fever, with a temperature of 105° Y. and over, in a child about eighteen months old suffering with, continued convulsions, the follow- ing order of treatment was carried out : First, a colonic flushing to empty the bowel ; second, a tepid, pack over the thorax ; third, a lumbar puncture, withdrawing about 35 cubic centimeters of colorless cerebrospinal fluid; fourth, a diet of whey, and plenty of water was followed by an amelioration of all the symptoms. Headaches. Various forms of headache are encountered in children. As a rule very little reliance can be placed on headaches complained of by young children. There are four kinds of headaches which are most frequently seen in older children : — 1. Eeflex headache. 3. Headache due to general systemic cause. 3. Headache of local origin. 4. Headache due to brain lesions. Reflex Headache. — In chlorotic girls or in anaemic children headache is a common symptom. During menstrual disorders girls will usually com- plain of headaches. Hundreds of cases of headache due to eye strain have been seen bv me in school children. These children complain of headache during and after school hours. The headache disappears during the night and the children never complain of headache in the morning. Most of these cases have been referred by me to an oculist, who as a rule finds astigmatism. The treatment consists in relieving the eye strain by wearing eyeglasss. Headache Due to General Systemic Causes. — Headache due to auto- intoxication resulting from impacted faeces is frequently encountered. Eheumatic children and children of gouty parents frequently complain of headaches. Such headaches are frequently found in lithsemia. The gen- eral constitutional treatment consists of a diet of vegetables, and fruit. No meat should be given. Five to 15 grains of citrate of potash will usually benefit this condition. A laxative should always be given if head- ache is due to constipation. Exercise and outdoor play will aid this condition. Headache Due to Local Origin. — Children frequently complain of headache which is due to intra-nasal neoplasms. At other times such local causes as supra-orbital neuralgia, due to neuralgia of the fifth cranial nerve, will cause an intense headache. In the latter instance gentle mas- sage or a mild current of faradic electricity will relieve. In severe cases the internal administration of Vsoo grain of Duquesnel's aconitia, three times a day, will relieve, In persistent headache it is advisable to have the ears SPASMUS NUTANS. 743 carefully examined by a competent aurist. The frequency of middle-ear disease should be borne in mind. Headache Due to Brain Lesions. — In older children headache of a persistent character, associated with vomiting, should always be looked upon as suspicious of cerebral trouble. A case of this kind is reported by me in the chapter on "Cerebro-spinal Meningitis.^^ In older children suf- fering with persistent headache it is advisable to examine the fundus of the eye to see if a choked disc is present. In one of my cases a tumor of the cerebellum was diagnosed in this manner. Migraine (Sick Headache: Hemicrania). This is a headache confined to one side of the head, associated with dizziness and generally vomiting. Causes. — Overworked school children of a nervous type usually have these attacks. Children suffering with dyspeptic attacks are more fre- quently the victims of migraine. An indoor life in a crowded apartment will cause this condition. Eye strain is frequently the cause. Treatment. — Have the eyes examined and correct any abnormality, if present. The diet should be regulated and a laxative dose 10 to 20 grains of phosphate of soda should be given. The value of bromide of soda in Seltzer water, with or without caffeine, should be remembered. Spasmus Nutans. This condition is frequently associated with rickets. It is characterized by an involuntary and uncontrollable head shake. Etiology. — It may be associated with or follow traumatism. Fright and other psychical disturbances may cause this condition. Heredity plays an important part in its development. It is usually found associated with rickets. In a case of mine presented to the Section on Pediatrics of the New York Academy of Medicine,^ spasmus nutans was associated with sporadic cretinism. Symptoms. — In some cases we see a continuous nodding, in other cases the motion is rotary. In rare cases both motions, nodding and rotary, may co-exist. Nystagmus, which is a movement of the eyes, rhythmical and oscillatory, either vertical or horizontal, may also be present. Prognosis. — This depends on the cause of the same. As a rule the prognosis is good. Treatment. — If rickets is the cause give the child anti-rachitic treat- ment. If it is associated with cretinism, as in the case reported by me, then give thyroid treatment. A change of air and general restorative treat- '§ee Proceedings of New York Academy of Medicine fof 1904. 744 DISEASES OF THE NERVOUS SYSTEM. ment are also beneficial in these cases. Electricity is not indicated and should not be used. Massage may be tried. Speech Defects, Stuttering. — ^This is a condition due to a series of contractions and spasms of the muscles concerned in speech. According to Scripture, the essential pathological fact is a special state of mind. Pseudo-stuttering. — ^This symptom is found in hysteria, cerebral spastic- ity, athetotic conditions, aphasia, and some forms of amyotrophic lateral sclerosis. Lisping. — There are various types of lisping. Organic lisping is caused by a defect in the teeth, tongue, palate or ears. We may have negligent lisping due to a faulty perception and execution of sounds. This condition may be found in normal children as well as in those of deficient mentality. The necessity for proper medical supervision in the treatment of this class of cases is forcibly expressed by Scripture,^ who maintains that the speech organs must be examined by a physician familiar with the anat- omy of the nose, throat, and larynx. In addition thereto, neurological training is necessary for a proper understanding of stuttering. Such cases should be sent to a proper clinic, where speech defectives can be classified according to their individual defects. Choeea (St. Vitus' Dance). This is a neurosis characterized by irregular, involuntary movements of the muscles. It usually affects the muscles of the extremities, face, and tongue. As a rule, these movements are not present when the child sleeps. Etiology. — As a rule, this disease is most prevalent between the ages of 7 and 14 years. Chorea generally occurs in bright, precocious children. It is seen more than twice as frequent in girls as in boys, and the dispro- portion becomes even greater after puberty. It is extremely rare in dark- skinned races. Chorea rarely becomes chronic, although it recurs in about one-third of the cases. It is more likely to recur in girls. Fright and shock are frequently the causes of this disease. Steven Mackenzie^ reports 439 cases. The largest number of attacks occurred in the thirteenth year. 34 per cent, occurred between 5-10 years 43 per cent, occurred between 10-15 years 16 per cent, occurred between 15-20 years *The Care of Speech Defectives, Medical Record, Feb. 22, 1913. •British Medical Journal, February, 1887. CHOREA. 745 Sachs reported a case seen in a child under 1 year of age, and several cases seen in children between 2 and 3 years of age. The reported con- genital cases are usually mistaken instances of organic cerebral disease. Sinkler found that of 328 cases 232 were females and 96 males. Gowers studied the statistics of 1000 cases and found 365 in boys and 635 in girls. Morris J. Lewis, of Philadelphia, studied 717 cases and found that the largest number occurred in March, the next largest number in May, and that the curve corresponds with the rheumatism curve. My own experience is that we have an equal number of cases occurring in the spring and fall, depending on the amount of study and the sedeniary life induced hy too much school. In a large children's service among the poor tenement population, out of 100 cases of chorea examined by me, 80 cases occurred in females; 20 cases in males. All of my cases were school children who were apparently well when their chorea commenced. Overstudy in School. — Sturges, in London, has given considerable at- tention to the question of overstudy, and he believes that it is an impor- tant etiological factor in the causation of this condition. Overstudy (ap- parent) may mean only inability to study due to, lack of mental concen- tration. Chorea frequently follows the infectious diseases. It is seen after scarlet and typhoid fever. I have seen chorea of a very severe type follow a fright and also after bad dreams, in school girls. Eeflex causes, such as phimosis, pin worms, and delayed menstruation, are cited by some authors. Reflex Causes Due to the Eye. — I have usually sent children suffering with chorea to the eye specialist to see if improvement could not be ob- tained by using eye-glasses. I believe that headaches due to astigmatism can be relieved, so also can astigmatism be modified when suitable glasses are prescribed. I do not believe that the chorea per se was cured in a single case. I do not refer to those cases of habit spasm so frequently seen in nervous children, but I refer to distinct chorea. Vaginal discharges will frequently excoriate the vulva. This produces itching, and the scratching therefrom frequently induces masturbation. This is a frequent forerunner of chorea. Eeflex conditions, such as adenoids and polypoids, have been reported from time to time. The reflex causes are overestimated. Adepoids are more likely to in- duce tics rather than chorea. Neurotic make-up plays a distinct predisposing r61e (neuroses or psy- choses in family) , 746 DISEASES OF THE NERVOUS SYSTEM. Table No. 75. — The Association of Chorea with Rheumatism. Steiner reports 252 eases 4 suffered with rheumatism Sachs reports 70 eases 8 suffered with rheumatism. Sinkler reports 279 cases 37 suffered with rheum.atism Crandall and Holt report.. 146 cases 63 suft"ered with rheumatism. Fischer reports 100 cases 25 suffered with rheumatism Twenty-five Per Cent, of my Cases had Undoubted Rheumatism. — By rheumatism I include cases that complained of pains in or around the joints. At times they were described as "growing pains" by the parent. Frequency of Endocarditis. — Valvular lesions have been seen by me in chorea without any antecedent joint lesions. The ease with which rheu- matism is overlooked in children makes the clinical history as given by parents doubtful. It is, therefore, possible that there are many more cases of rheumatism associated with chorea than are reported. Association with Tonsillitis. — Of the 100 cases of chorea previously reported by me, more than 80 cases had enlarged tonsils. It seems quite probable that the tonsil is the point of entrance of the pathogenic bacteria which cause chorea, and most probably rheumatism and endocarditis. Pathology. — There are no distinct pathological lesions which can be attributed to chorea. Sachs says that the pathology of chorea is still a great mystery. Not that autopsies are wanting, but there have been so many different post-mortem findings described that each writer may be said to have his own views. concerning the pathology of chorea. Symptoms. — Chorea usually begins with prodromal symptoms. The children as a rule are very irritable, depressed, and cannot hold their arms or legs quiet. They complain of pain in various parts of the body. The main symptoms which attract the attention of parents or nurses are motor disturbances. These consist of involuntary twitchings affecting various muscles or groups of muscles. The muscles of the hands, the legs, the facial muscles, and the tongue show this choreic twitching. At times there is a decided interference with speech. A point worth noting is that the child cannot control these movements voluntarily. The greater the effort to con- trol these movements, the more the twitching will be noticed. Sachs em- phasized the fact that in doubtful eases choreic movements of the tongue will often prove the nature of the disease. This I have frequently been able to verify when it was a question of habit spasm or true chorea. There is a certain awkwardness which is typical in a choreic patient. This can be noticed when the child attempts to do anything. Choreic movements do not occur as a rule in the night when the child sleeps. The pupils are fre- quently dilated. Children are sometimes punished at school for restlessness which is the beginning of true chorea, and it is only later in the disease that the true character of the same is detected. In some cases but one-half of the body (hemi-chorea) is affected. In other cases choreic movements are CHOREA. 747 stronger in the upper than in the lower extremities. Children seem to suffer muscidar weakness and there is loss of muscular power. A peculiarity of chorea is that in spite of the constant muscular twitching there is little exhaustion. The reflexes show no abnormality. Condition of the Heart. — Very frequently a systolic murmur has been heard during the course of chorea. This systolic murmur persists for months after the last symptoms of chorea disappear. Pains in the, large joints are frequently described. I have invariably noted a slight rise in the tem- perature (101° F.) when the joint pains or endocarditis existed. When chorea appeared without evidences of cardiac or arthritic complications the temperature invariably remains normal. Fannie S., 11 years old, was a very anaemic girl. She had been sick for two months with tonsillitis and influenza. She was compelled to stay away from school, and in order to catch up with her class, studied very hard, especially at night, until she passed, her examinations. History Given by Mother. — The child complained of headache, her appetite was poor, the bowels constipated. She was restless by day and did not sleep well at night. She had nervous twitchings of the arms and legs. The fingers were never still. She did not appear contented at anything. Her eyes were examined by an ocu- list, who prescribed eyeglasses. He said the child had eye strain. The mother believed there was a slight benefit after wearing the glasses. When the child was brought to me, there were distinct evidences of chorea, with twitchings of the face, the tongue, the hands and the legs. Four drops of Fowler's solution was prescribed, three times a day, and gradually increased until 7 drops were given three times a day. All school and study was stopped. Cold sponging and a cold shower was ordered every morning and evening. Cereals, vegetables, milk, and fruit were given. All meat was stopped. An active outdoor life and all quiet games and sports were recommended. Under this treatment the symptoms gradually sub- sided and the child recovered. One year later the same symptoms returned, and it was found that the cause of the relapse was overstudy. I prescribed "remove the cause," namely, take the girl away from school. Course. — The usual course of this disease is from six to ten weeks, although it may extend to four months. I have seen cases in which there was a severe attack in the spring, which seemed to disappear entirely dur- ing the summer, and suddenly reappear with greater intensity in the fall. Prognosis. — The outcome of a case of chorea is usually good, especially so if we are dealing with intelligent mothers and nurses. The prognosis is bad if endocarditis or other organic lesions are associated. Treatment. — Best Treatment. — It is useless to attempt to modify se- vere or mild chorea without enjoining absolute rest in bed. The eyes should be protected from a strong light; or the room should be darkened by drawing the shades. In some cases I have kept children in bed for one week before the twitchings ceased. In severer cases it may be necessary to keep a child in bed at least two or more weeks. The southing iiifuence of this absolute rest in bed will do more good than all the drugs combined, 748 DISEASES OF THE NERVOUS SYSTEM. Hygienic Treatment. — A child should be removed from school and thus guarded against all psychical disturbances. Cold sponging of the en- tire body and cold spinal douches have been found very beneficial. The diet should be light and very nutritious. All cereals should be given (see diet list for a child from 3 to 10 years old, page 154). Meat should be avoided, although meat soups and white meat or chicken may be permitted. Later fresh air and quiet out-of-door exercise, games, and sports are necessary adjuncts in the treatment of this disease. Medicinal Treatment. — Iron and arsenic should always be remem- bered in the treatment of this disease. We can begin with 4 or 5 drops of Fowler's solution, three times a day, and watch the systemic effect, with gradually increasing doses until 10 drops, three times a day, are given. Great care should be used to avoid arsenical poisoning when large doses of Fowler's solution are given. In some children a peculiar idiosyncrasy exists which renders them liable to systemic poisoning. Semple has re- ported multiple neuritis following the use of arsenic in the treatment of chorea. I have seen multiple neuritis in a rachitic child having chorea minor. The child received 4 drops of Fowler's solution for six weeks. When the arsenic was withdrawn, the neuritis subsided. Of the prepara- tions of iron on the market, neoferrum in doses of 1 or 2 teaspoonfuls has served me very well. Another preparation which I have frequently used is the liquor ferri peptomangan (Gude) in doses of a teaspoonful, three times a day, after meals. Ferratin, 5 to 10-grain doses, three times a day, after meals, is also beneficial. Antipyrin and bromide of sodium may also be used in some cases. When chorea is associated with rheumatism, the salicy- late of soda in 3 to 5-grain doses, or salipj^rin in the same quantity, may be given three or four times a day. Some authors advise against the use of chloral hydrate; my personal experience with 3-grain doses of chloral hydrate given morning and evening has been very good. If choreic twitch- ing does not improve after several weeks of persistent treatment, then a cold pack may be tried. A sheet wrung out in cold water at a temperature of 60° F. should be wrapped around the child for one hour every morning and evening. Not only have I seen a soothing effect on the nervous system from these packs, but they frequently promote sleep. That electricity is of value in this condition is doubted by many. I have seen one or two cases in which excellent results were obtained from the use of a weak galvanic cur- rent over the spinal nerves. On the other hand I have frequently seen no effect whatsoever from the treatment with mild or strong galvanic currents. Sachs recommends hyoscyamin in tablet form, Vjoo grain, when rest- lessness and insomnia exist. Hyoscyamin should only be administered in the afternoon and evening. Massage is sometimes of value in conjunction with electricity; it has a soothing effect on the nervous system and stimu- HYSTERIA. 749 lates nutrition. It is especially valuable at night and I have seen a j^ro- found sleep follow thorough massage of the body. Hysteria. It is an important matter to recognize this condition when met with in children. It is rarely seen in children under 7 years of age, although cases are on record of distinct hysteria having been met with in infancy. In my experience children rarely simulate disease. I have seen children imitate an invalid mother and complain of imaginary pains and aches at the same time and in the same portions of the body as the mother. Very neurotic children, susceptible children, and children having bad habits, such as masturbation, are more prone to develop hysteria. Charcot maintained that hysterical persons are hysterical because they are mentally degenerate. Pathology. — Hysteria is not a fatal disease, hence we have no specific pathological lesions. The theory concerning the mobility of the neuron, while very interesting and scientific, does not explain the hysterical par- oxysms. Hysteria is not a psychosis as is generally supposed. There are no known demonstrable lesions. While in some cases the whole brain seems disturbed and involved, in other cases but one-half of the brain is involved. Symptoms and Diagnosis. — Paralyses occur in hysteria which simulate those due to central nervous disease. As a rule, however, they disappear. The hysterical paroxysm usually follows close upon an aura. It "sometimes comes on suddenly, although it may be preceded by a spell of laughing or crying. Children old enough to complain describe a "lump in the throat" similar to the "globus hystericus" which occurs in the adult. ►Some symptoms closely resemble epilepsy. Headache is complained of at times. The scrisaming and shouting gradually cease as the attack subsides. The following description given by Taylor and Wells describes the attack so closely that I repeat it: "The patient sinks down or falls prone upon the back, with the limbs extended and rigid, but with the fingers and toes flexed; the eyes are usually rolled slowly from right to left, or crossed; the jaws are firmly closed; the breathing becomes slow and labored, and later hurried, the face flushed or bluish, the neck turgid; the cardiac action becomes more rapid and forcible, and consciousness is almost, but never entirely, lost. Sensation is much obtunded, and abolished in some portions of the body. Soon clonic movements succeed — a tremor affecting the muscles of the trunk, extremities, and face. This alternates with electric-like startings, during which the patient may fling himself furiously about, or actually out of bed. Presently this stage ends with sighs, and is followed by a short sleep." Some authors describe a series of dramatic movements. There may be opisthotonos. The child may have a bowing of the lumbar curve so that it rests upon its head and heek ^50 DISEASES OF THE XER VOL'S SYSTEM. There may be a series of attacks recurring so that as many as two hundred paroxysms have been recorded by Sachs. I have seen a severe form of hysteria with over ten paroxysms during one hour. Some tender areas frequently noted in children, over the ovaries and spine in girls, and the testicles of boys, are very sensitive. Some authors claim that pressure over these areas will sometimes invite an attack of hysteria; on the other hand pressure over these same sensitive areas will sometimes stop an attack. Tomiting when it does occur is a very serious symptom. We do not have the same forms of tremor as are seen in adults. Borborigmus (rumbling gas in the intestines) is occasionally heard in this condition. Epidemics of hysteria are frequently described. J. ]\Iadison Taylor describes one occurring in a church home at Philadelphia. I have fre- quently seen children in one locality suffer with various manifestations of hysteria, in which we could easily trace the origin to one particular child. Prognosis and Course. — The duration of the disease depends on the surroundings of the child, ilild hysteria will sometimes disappear after a change of scene and air of several weeks. In some instances a case may last years or through the child's whole life. It is always well to remember that hysteria is difEicult to cure. If a child is sensitive and subjected to impressions from a neurotic family, then a cure will be difficult. The outcome of any ease of hysteria depends on the character of the surroundings and on the mental influences with which the child is brought in contact, rather than on drug treatment. Case I. — A girl 9 years old was brought to me for the relief of headache. She complained of a continual headache night and day. The appetite was poor, the bowels moved sluggishly. She was restless during the d&y, and had insomnia at night. She complained of bad dreams. She looked haggard and worn, as though she were convalescing from some severe illness. She was anaemic and had cold extremi- ties. Heart, lungs, liver, and spleen were normal. She was a very restless child with marked hyperaesthesia. The patellar reflexes were exaggerated. Subjective Symptoms. — The child complained of pain in every part of her body. On being asked, "Does your side hurt?"' she answered, '"Yes, my pains are in the side and in the back, just like my mother's." I referred the child to an oculist for an opinion as to the eyes, and his answer was: nothing abnormal, no astigmatism. The child cried on the slightest provocation, and was also almost convulsed with laughter for trivial matters. The diagnosis was hysteria. The child had a headache, or a backache, and always complained of some ache. It was quite evident that the child's hysteria was due to suggestif/n by the mother, icho was an invalid. The treatment consisted in removing the child to an aunt in a neighboring city. amid healthy surroundings. Iron was ordered to build up the system, and bromide of soda in lO-grain doses was given every night for one week, later every other night. Electricity, the baths, and massage were used vdih great success. In three months the child had rosy cheeks, slept well, was cheerful, and did not complain of any pain. It was strange, however, that when taken back to her mother, she immediately re- MULTIPLE NEUKITIS. 751 lapsed into hor former habit of complaining. We determined to remove her per- manently, and she remained well for over a year when I last heard of her. Case 11.' — General Hysteria and Nervous Vomiting. — A girl 12 years old was brought to my children's clinic for the relief of vomiting. She was very nervous and complained of pains all over her body. She complained also of pains in her stomach before and after eating. Her mental condition was poor, the hands and feet were cold. She complained of epigastric pains for the last six years. From the mother I learned that the child was frightened by a dog and since that time she has been very sensitive to the slightest impression. The gastric contents were syphoned off after a test meal and a hyperchlorhydria was found. The urine con- tained acetone. The treatment of this case was most successful when large doses of bromides were given. Treatment. — Study the cause or causes, and remove them if possible. Change the surroundings of the child by removing to a cheerful but quiet home. If the case occurs in the country, bring the child to the city. In any event the main point should be to change the entire scene and sur- roundings. If a child is in an institution, remove it from the same if it is at all possible. The person in charge of the child should be either a very intelligent mother having a positive influence over the child, or a mild-mannered trained nurse. All orders of the physician should be strictly obeyed without having the child feel that vigorous treatment is being used. This psychosis requires educational treatment as has just been described. Hygienic Treatment. — If the child is old enough, a walk should be ordered several times a day. The bicycle and horseback are valuable ad- juncts. The sponge bath or the tub-bath aided by a cold shower or spray chiefly over the spine, head, and neck, have very tonic properties. Hydrotherapy properly used is one of the most valuable aids in pro- moting a cure. Nothwithstanding the shock of a cold spray, the same should be ordered winter or summer. After the bath the body should be rubbed vigorously, or better yet, massage should be given. I have always found a very soothing effect on the nervous system by giving gentle but thorough massage. Another reme- dial agent which must be used regularly is electricity. This should be used daily by means of a mild faradic current, one electrode to be applied over the spine, the other over the phrenic nerve. If no benefit is noticed after this treatment is tried, then static electricity can be used. Multiple Neuritis (Polyneuritis). This is frequently termed a peripheral neuritis, as it is an affection of the terminal branches of the nerves. It usually affects all the nerves *This case was presented by me to the Section on Pediatrics, Academy of Medicine, February 14, 190 L 753 DISEASES OF THE NERVOUS SYSTEM. of the limbs on both sides of the body. Starr gives the following classifica- tion : — "1. Toxic cases due to the action of a poison derived from without the body. These poisons are alcohol, carbonic oxide gas, bisulphide of car- bon, the coal-tar products, especially sulphonal and trional; and nitro- benzol; also, arsenic, lead, mercury, copper, phosphorus, and silver. "2. Infectious cases due to some agent acquired or developed within the body, as an • accompaniment or sequel of diphtheria, grippe, typhoid, typhus, malaria, scarlet fever, measles, whooping-cough, smallpox, erysipe- las, and septicgemic conditions, including gonorrhoea and puerperal fever, epidemic forms of beriberi or kakke, and leprous neuritis, "^'3. Cases due to general diseased states of the body whose origin is undetermined, such as rheumatism, gout, diabetes, anemia, marasmus, gen- eral malnutrition consequent upon tuberculosis, syphilis and senility, car- cinoma, and local malnutrition produced by arterial sclerosis. "4. Cases due to exposure to cold and developing spontaneously with- out known cause." The most common type of multiple neuritis met with in children is either the diphtheritic type or that resulting from poisons in the blood, such as the prolonged administration of Fowler^s solution (arsenical poi- soning) . Symptoms and Diagnosis. — Multiple neuritis may come on suddenly or the onset may be gradual. The special senses are rarely involved in this condition. The motor symptoms are as marked as the sensory. Paral- ysis comes on first as a muscle weakness, and gradually increases until dis- tinct paralysis is present. The extensor muscles of the wrist, hands, and feet give the wrist-drop and the foot-drop. Very rarely the muscles of all four extremities in addition to the muscles of the trunk and neck are in- volved. The knee-jerk usually disappears early when neuritis follows diph- theria. The paralyzed muscles are relaxed, flabby, and atrophied. An important symptom is that faradic excitability is absent and that the mus- cles respond to a galvanic current only. This symptom is identical with that found in acute anterior poliomyelitis. The reaction of degeneration is present. There is usually no incontinence of bladder and bowel. Atrophy is another prominent symptom. The condition is similar to that seen in poliomyelitis. There may be other vasomotor disturbances such as uni- lateral flushing of the skin, or small areas may show a high glossy flush. This last symptom was very prominent in one of my cases. An oedema of the affected parts is described by some authors. As a rule the areas affected are very sensitive, so that we have distinct hyperaesthesia. In other cases the opposite condition prevails and there are areas of local anaesthe- sia. The disease may be ushered in by a fever. The temperature may rise PAYOR iNOCTURKUS. 753 to 103° or 104° F., and remain several days. The pulse-rate is correspond- ingly increased and may reach 140 or IGO. Gastric disturbances associated with diarrhoea may be present. The spleen is frequently enlarged, and an examination of the blood will show a distinct leucocytosis, the latter condition when neuritis is a sequela to an infectious disease. Course and Prognosis. — As a rule, multiple neuritis lasts from several weeks to several months, and then ends in recovery. The cases seen by me associated with chorea in which arsenical poisoning took place, invariably unproved when the drug was withheld for a short time. Rarely does the paralysis remain permanent. The prognosis can best be gauged by noting the electrical reactions. If the reaction of degeneration is present after the disease has lasted several months, then a permanent lesion must be suspected. If, on the other hand, there is only a slight difference in the reaction following the use of the faradic current, then a complete recovery may be expected. Some cases, although severely atrophied, will ultimately recover. If myelitis complicates this condition, the prognosis is serious. Treatment. — The system should be strengthened with proper nutrition. The patient should be made as comfortable as possible. If severe pains exist, then large doses of bromide should be given, with or without codeine, until all pain is relieved. In some cases the local application of warmth over the affected limb is very soothing. I frequently use a warm Imth at night, which is very soothing and promotes sleep. Gentle friction and massage are beneficial. Eestoratives, such as cod- liver-oil, maltine with hypophosphites, and iron should be used. The syrup of the iodide of iron is a good restorative. Butter, cream, and cereals are excellent tonics. Strychnine and nux vomica are valuable if the appetite is poor; otherwise they have no specific value. Pavok Noctuenus (Night Terrors). Children apparently healthy will sometimes awaken from a sound sleep and shriek or scream. Etiology. — In this condition children usually show some disturbance of the stomach or bowels which may have been the exciting cause of the night terror. Eeflex irritability is frequently caused by intestinal worms, by adenoid vegetation, or in the male child by an elongated -prepuce, or by phimosis. Such children usually possess a neuropathic constitution by inheritance. Henoch states that some children may have hallucinations during the day. These attacks occur but once during the night, and after reassuring the child that there is no danger, it will again fall asleep. Symptoms. — Some children awaken frightened and screaming, while others will grasp anything within reach in a bewildered manner. They 48 754 DISEASES OF THE NERVOUS SYSTEM. frequently imagine that animals are in the room. The effect of too rigid discipline will sometimes show itself by bad dreams at night, and in a distinct hysterical symptom, such as fright and terror. Course and Prognosis. — If these night terrors are associated with mild nervous attacks during the day, or if they partake of the nature of epileptic attacks, then a cautious prognosis should be given. The inclination to serious brain or nervous trouble must always be remembered; therefore, no opinion should be ventured until a case has been properly observed. Treatment. — Children having night terrors should be removed from school to insure perfect tranquillity. There should be a distinct change of scene, a change from the city to the country, or vice versa, will" be bene- ficial. Any reflex cause, if present, should be attended to, and, if possible, removed. Fresh air, out-of-door life, and restoratives are indicated. Such children appear less frightened if they sleep in the room with an adult, and are thus reassured that there is no danger present. Cold or gradually cooled bathing or a spray over the spine will tone the nervous system. It should be used in a warm room daily. Five grains of sodium bromide may be given before retiring. Masturbation ( nanism ) . This habit is very frequently seen in children. I have seen it in girls as well as in boys. Causes. — Any irritation of the genital tract that will cause itching may be the origin of masturbation. In boys an elongated prepuce, or friction from phimosis, may give rise to this condition. Very acid urine may cause excoriation and thus invite this bad habit. Excoriations at or near the external meatus may be the starting point. We see this condition quite frequently in girls when preputial adhesions due to smegma or dirt cause an irritation of the clitoris or when pin worms wander from the anus to the vagina; thus worms frequently set up an irritation resulting in mas- turbation. A diaper if too tightly pinned can set up an irritation, especially in female children. Symptoms. — Children usually place their hands on the genitals and masturbate. They sometimes rub their thighs together until exhausted. During this friction their face will be flushed and they appear irritable. Such children suffer with profound ansemia as the result of this habit; and from loss of sleep. Older children, especially boys, will masturbate chiefly at bedtime. They are peevish, irritable, and very sensitive. An infant about nine months old was seen by me in consultation with Dr. L. P. Harris, of New York City. The mother complained that the child continually rubbed its thighs. The face was flushed during the rubbing; later the child would fall asleep as though from exhaustion. This condition seemed to occur chiefly when Masturbation. 755 the child was placed on the bed or held on the lap. An examination of the genitals showed that they were very red and excoriated from the constant irritation. The progfnosis is usually good if the habit is detected early and the cause removed if one exists. On the other hand, some eases will persist in spite of careful treatment, and nothing but heroic measures will effect a cure, as the following case will illustrate : — An infant, female, was brought to me for the relief of this condition. The child had masturbated continually for several months and was so emaciated that the parents were alarmed. The condition was so bad that the child masturbated whenever the thighs were put together. A pad was improvised to separate the thigh-j and local applications of lead water on cotton were placed over the genitals to reduce the irritation. Large doses of bromides were administered to control irritability in the ner\'ous system. The child was kept in a stupor for several days without having the condition relieved. The symptoms persisted and we finally were compelled to remove the child to the St. Marks Hospital where Dr. H. J. Garrigues suggested per- forming a clitoridectomy. This case was published in extenso in Archives of Pediatrics, May, 1899. The child made a perfect recovery. The habit did not reappear. Treatment. — Eemove the cause if any exists. All irritants, such as worms or eczema, should be treated. If an enlarged prepuce causes this condition, remove it. If a vaginal discharge exists, treat it with astrin- gents, and thus avoid irritation. If worm's are present, injections of quassia will dislodge them (see chapter on "Worms"). In older children we must remove the child from bad company, and sometimes it will be necessary to change the entire surroundings of a sensitive but well-meaning child. An ocean voyage is beneficial. The system should be strengthened by giving iron and strychnine. Clean habits, a rigid hygiene, and a daily bath are necessary. Strict supervision by night as well as by day with the aid of a trained nurse will do more good than medicine. Children once detected v.'ith this bad habit must never be permitted to sleep with their hands under the bedclothes. Circumcision is one of the most valuable means of curing this habit. In females, especially in little girls, stripping the clitoris and cleansing the smegma, if present, will frequently modify this habit. If the habit persists in spite of this treatment, then a radical operation — clitoridectomy (see clinical case given) — may be required. CHAPTER III. SPASMOPHILIA. The modem conception of tetany, true laryngeal spasm, spastic apncea and convulsions is that they are one and all part of the clinical picture known as spasmophilia. The condition is characterized by an irritability of the nervous system.^ It is most commonly met with in early childhood, and distinguished by galvanic and mechanical hyperexcitability of the peripheral nerves ; both tonic and clonic convulsions are frequently associated. Etiology. — There is a diminution in the quantity of calcium salts in the brain, and a corresponding increase in calcium phosphates in the urine. Fig. 250. — Tetany. Characteristic attitude of the hands resembling a rider reining in his horse. Note attitude of tlie toes. The wrists are rigid and flexed. The elbows are free. The fingers are flexed at the meta- carpophalangeal joints. In this case facial irritability was best seen by constant spasm in the orbicularis palpebrarum. (Original.) Musser and Goodman found a high percentage of ammonia in the urine, rarely below 5 per cent. This output of ammonia bears a distinct relation to tetany. Berkley and Beebe believe that the parathyroids are concerned in furnishing enzymes which are of importance in the intermediary metab- olism of nitrogen. Jacobson found an increase of ammonia in the blood and believes that such ammonia is sufficient to cause tetany and tremors. The removal of the parathyroids alone causes tetany. For this reason the extract of the thyroid gland has been advocated for the relief of this condition. Von Pirquet^ has noted specific conditions: that in the normal in- fant the anodal opening contraction does not occur with less than 5 'Sedgwick, J. P.: St. Paul Medical Journal, Oct., 1912. *Von Pirquet: "Galvanische Untersuchungen an Sauglingen," Verhandl. d. Gesellsch. f. Kinderh., Stuttgart, 1906. Bergmann, Wiesbaden, 1907. (756) SPASMOPHILIA. 757 milliamperes. In spasmophilia the contraction by application of the Stinzing normal electrode applied over the median or peroneal nerves can be pro- duced with less than 5 milliiimperes upon the anodal opening. The reactions upon anodal closing and cathodal closing and opening are also frerjuently obtained with less current than in the normal child; that is, with less than two for cathodal closing, three for anodal closing, and five for cathodal opening. By studying these -reactions we have been able to learn that the under- lying condition — namely, spasmophilia — is responsible for most of the con- vulsions in children, true laryngeal spasm, tetany, and spastic apnoea. Thus, we may state that if an anodal or cathodal opening contraction with a current less than 5 milliamperes is present, it shoius that spasmophilia, latent or active, 'is present. This condition is most common after the fourth month and is rarely found after the second year. Symptoms and Diagnosis. — Gastro-intestinal derangements in the artifi- cially fed infant are responsible for most, if not all, forms of spasmophilia. Active symptoms of spasmophilia frequently disappear when an improperly artificially fed infant is put to the human breast. If we tap the muscles of the jaw, a slight contraction of the face ensues. This is known as the facial phenomenon, and was first described by Chvostek. The contractions are first seen in the orbicularis palpebrarum. The contraction resembles that caused by the sudden passage of a galvanic current. It is sometimes more marked on one side of the face than the other, and in some cases it is more noticeable in the upper — in others in the lower — half of the face. A similar contraction of the inner end of the eyebrow may often be caused b'y tapping on the temple. The wrists are rigid and flexed. The elbows are free. The fingers are flexed at their metacarpophalangeal joints. There may be a constant spasm, jerking in character, continually present. A similar phenomenon is known as Trosseau's sign; if the arm is com- pressed by an elastic band the muscles of the fingers and sometimes of the forearm pass into the tetanic condition. Course. — The course of this disease is given by some authors as from a few days to several weeks. In one case observed by me at the Willard Parker Hospital (see Fig. 250), the tetanic spasms lasted for more than two months. "Other cases seen by me lasted but a few days or weeks at the longest. Prognosis. — ^The prognosis is excellent if the cause of the tetany is a gastro-intestinal disorder. There are instances in which death has ensued from laryngeal spasm or from general convulsions. When a very frail infant has severe tetany of the upper and lower extremities with retraction of the head, then the prognosis is bad. 758 DISEASES OF THE NERVOUS SYSTEM. Treatment. — The deficiency of calcium sajts has given us a clue to therapeutics, showing that probable imperfect metabolism of certain mineral salts is responsible for this condition. The thyroid gland has been successfully employed in the treatment of tetany. It may be administered raw or in the form of a dried gland in doses of 1 to 5 grains per day. Thorough cleansing of the gastro-intestinal tract is demanded. Por a child 1 year old, a 3-grain compound jalap powder, combined with ^4 grain calomel, may be given on awakening, and repeated if necessary the following morning ; ^/og^ grain phosphorus dissolved in one-half teaspoonf ul of cod- liver oil may be given three times a day after meals. The diet should consist of skimmed milk, expressed beef juice, chicken, or lamb broth thickened with barley or farina, steamed rice or farina, arrowroot boiled in milk, puree of peas, stewed fruit, bread, crackers and butter. Meat and eggs should be eliminated from the diet. Water may be given liberally. Tetanus (Lock Jaw). This acute infectious disease is caused by the invasion of a specific micro-organism. Etiolo^. — 'Any open wound on the surface of the body can be the point of entrance for these pathogenic bacteria. There are some parts of our country in which the disease exists all the year round, provided the factors which cause the same, filth and dirt, are brought into play. A child infected with tetanus can transmit the disease ; hence this should be bcfme in mind while a case is under treatment. Bacteriology. — Nicolaier in 1884 found a specific micro-organism in the soil from which he infected animals and produced tetanus. He also found this germ present in patients affected with tetanus. In 1898 Kitasato demonstrated this bacillus in pure culture. It was also found in infants suffering with tetanus. TVom the pure culture Kitasato and Behring produced an antitoxin. The toxin generated by tetanus is a deadly poison. Kitasato found that an animal which was infected and left alone died in one hour. .Pathology. — Distinct lesions of tetanus cannot be demonstrated patho- logically. An open wound and evidences of a general septic infection can usually be found. Hgemorrhages of the brain or smaller hsemorrhages in various parts of the body may exist. If the umbilicus has been the point of entrance, the wound will not heal. Symptoms. — In the new-born the first symptom noticed is the refusal to take the breast. Owing to the rigidity of the muscles, the jaws will be -found stiffened and feel hard to the touch. The same spasmodic stiffening will be made out in the other parts of the body. After a sudden stiffening TETANUS. 759 the muscles usually relax. Muscular rigidity appears in paroxysms and may come on every few minutes. The temperature varies between 101° and 104° F. or there may be hyperpyrexia reaching 107° F. The pulse is small, feeble, compressible, and very rapid. Symptoms of malnutrition, such as emaciation, are very evi- dent. Stadtfeldt reports 88 fatal cases; 83 of these died between the ages of six and ten days. The following case illlustrates tetanus seen in private practice : — A female infant fifteen days old was seen by me suffering with fever. The nurse said that she refused the breast. The infant was in good health apparently up to this time. The appetite was good, the bowels regular, no gastric disturbances existed. On examination the umbilicus was found inflamed and suppurating. The temperature was 102° F.; the pulse 160. The jaws were fixed. The infant had spasms, which grew more severe when she was handled. The body relaxed for a few minutes at a time. The treatment consisted in cleansing the wound with strict asepsis, dusting europhen powder on the umbilicus, and protecting the same with a sterile bandage. The rectum and colon were flushed with warm saline solution. An injection of 5 cubic centimeters of antitetanus serum was given with the usual antitoxin syringe. As no effect was evident from the injection, a second injection of 5 cubic centimeters was administered twelve hours later. Symptoms of improvement followed and the child recovered. A second case of tetanus was one caused by scratching an open wound situated near the nose, while playing with a canary bird. Symptoms of tetanus appeared two days after infection. This case was also seen in consultation by Dr. George F. Shrady. Large quantities of tetanus antitoxin were injected with no beneficial result. The case ended fatally. In this case the infection was traced to some canary birds which were in the same room as that occupied by the family. Prognosis and Course. — The duration of fatal cases is seldom more than one or two days. Those tending to recovery usually extend from one to three weeks. While occasionally cures are reported, five out of ten seen by me have ended fatally. I have seen cases, both in this country and abroad, injected with sufficient antitoxin, end in recovery. Treatment. — An injection of 30 cubic centimeters tetanus serum should be given, and repeated every twelve hours until the toxic sjinptoms improve. In addition thereto, the bromides of potassium and sodium, chloral hydrate, belladonna, and opium are among the anti-spasmodics used. It is essen- tial to give large doses or no effect will be produced. Calabar bean has been lauded by some authors and can be given hypodermically. The literature records a great many cases where the antitoxin was in- jected directly into the brain. In the new-bom baby this method should be used, as there is no obstacle to the introduction of the needle through the open fontanel. Jn one case treated by me the antitoxin was injected through the ante- rior fontanel. 760 DISEASES OF THE NERVOUS SYSTEM. Epilepsy. Epilepsy is frequently seen in very young children. Some writers state that it develops in children approaching puberty. I have seen epileptic spasms in children under 1 year of age. Etiolo^. — Children whose parents are drunkards, or where nervous diseases exist, are predisposed to this condition. According to Berkley, 33 per cent, of these cases give a historj^ of alcoholism in one parent. Eachitic infants are frequently seen with -epileptic seizures, so that it is quite pos- sible that they are predisposed. Children who have suffered with convul- sions in early life frequently have epilepsy later in life. This has led some authors to believe that convulsions and epilepsy are as cause and effect. Undoubtedly many cases of this kind exist. Statistics prove, how- ever, that one-half of all eclamptic children have no further nervous dis- eases in later life. Hence, we must not claim that if an infant suffers with eclampsia it mtist necessarily hecome an epileptic. An injur)' to the head, fright, or sunstroke may possibly cause this dis- ease. Some authors state that epileptic convulsions are intimately asso- ciated with adenoid vegetations, phimosis, and masturbation. Foreign bodies in the nose, throat, and ear may occasionally be predisposing factors. Other writers believe that menstrual disorders will provoke epilepsy. 'The etiolog}^ of idiopathic epilepsy is mainly to be sought in alco- holism in the parents, which induces a defective organization of the brain structures in the descendants. Inherited syphilis is a less frequent factor. The signs of inheritance are chiefly seen in the departure from the normal in the skull formation, microcephalus, macrocephalus, as well as asym- metries of the skull and facial bones. Flatness of the cranial arch is found in a considerable proportion of epileptics, particularly among the males. Signs of rickets are especially frequent in epileptic children. Aronsohn, in a study of heredity among 508 epileptics, found a history'- of neuro- pathic disease in the parents in 33 per cent. Females showed a stronger tendency to inherit the disease than males, 33 per cent, against 30 per cent. The disposition on the part of the mother to transmit epilepsy is greater than that of the father (391/2 against 29 per cent, of inherited cases). Where both parents were hereditarily burdened, 63 per cent, of the children inherited the disease. In 82 per cent, of the inherited cases, the disease began before the twentieth year of life. Wildermuth, in 145 cases of early epilepsy, found inherited tendencies in 49 per cent., drunkenness on the part of the parents contributing nearly one-half (21 per cent.) of the examples. Traumatism in early life furnishes a small number of cases of epilepsy. Among 210 patients assembled by Wildermuth antecedent injury to the head had occurred eight times. In the majority of the trau- matic cases, the seizures followed the injury within a few days or weeks. EPILEPSY. 761 seldom after months. Epileptiform seizures and their sequelae are some- times found where there has been antecedent meningitis, porencephalia, or cerebral haemorrhage in infancy; they may also result from acute infec- tious processes, but in these instances they are to be regarded not as be- longing to true epilepsy, but as the symptomatic expression of a coarse, irritative cerebral lesion" ('Eerkley). Pathology. — Gowers states that the disease is probably located in the gray matter of the cortex. It should be regarded as a muscular spasm, the result of the sudden overaction or discharge of the nerve cells.^ Of 1450 cases of epilepsy studied by this same writer, 12 per cent, began during the first three years of life, and 46 per cent, between the tenth and twentieth years. An interesting point was brought out by Herter and Smith,^ who studied 238 specimens of urine taken from 31 epileptics. They noticed that in 72 of these observations there was excessive in- testinal putrefaction, as shown by the presence of ethereal sulphates in the urine jvst before the occurrence of the spasm. These authors were war- ranted, therefore, in their conclusion, that there is a distinct association between the intestinal poisoning and the epileptic seizures. We can readily see that the treatment of any case of epilepsy must be followed along the lines just described. Symptoms. — There are two kinds of attacks usually met with: first, the grand mal; second, the petit mal. Grand Mal Form. — ^The attack may come on gradually or it may be sudden. Children old enough to complain frequently have a warning of the attack known as the aura. This aura consists in a series of symptoms, such as a twitch in the leg or the face, constituting a local spasm described by some authors as a "motor aura." Then again there may be abnormal sensations, such as a tingling or numbness in any part of the body, until the patient suddenly falls with the spasm. There may be an unusual tremor or a shivering sensation, and the patient may fall to the floor with a sharp cry, having the jaw set and all the muscles of the body in tonic spasm. The eyeballs are usually rolled upward. After a few seconds, dur- ing which the skin is cyanotic, a second stage follows, in which there are clonic spasms. There may be involuntary spasms of the bladder and bowel. In the clonic stage the muscles frequently contract and relax violently. Not infrequently the tongue is apt to be caught between the teeth and is bitten. There may be frothing at the mouth. Very marked rigidity of the sterno-cleido-mastoid. The head may be thrown backward or it may be twisted to one side. The extremities may relax and then become rigid again, and the cyanosis gradually disappears. Children usually fall into ^Gowers: Diseases of the Nervous System, Amer. Ed., 1888. * New York Medical Journal, August and September, 1892. 763 DISEASES OF THE NERVOUS SYSTEM. . a deep, sleep as though exhausted after the end of the clonic stage. This isleep lasts hours at times. Children old enough to describe symptoms will jstafte that, they have no knowledge of what has happened. They awake just as children do after a deep chloroform narcosis. Petit Mai Form.- — This is a milder type of the condition above de- scribed. The attacks, instead of lasting minutes and hours, usually last but a few seconds. The child does not fall, but may sit quietly during the seizure until it passes off. - An aura is absent in this condition. , The attacks not infrequently happen several times a day. ; They may also occur at night. In some children we have both varieties. Diiferential Diagnosis. — Epilepsy is frequently confounded with hys- . teria. In hysteria there is partial consciousness. In epilepsy there is a loss of consciousness. The biting of the tongue and symptoms, such as the nocturnal appearance of the attacks, will aid in establishing the diagnosis. There is usually a dilatation of the pupils. An epileptic may have an attack in inopportune places, such as the street or on a hot stove, whereas a case of hysteria usually selects a place indoors, entirely out of danger. Prognosis and Course. — This disease does not follow. a regular course. The usual interval between seizures in the very beginning may be months. Eegular intervals of epileptic attacks may be every two or four weeks. In some severe cases seen by me the attacks came on every day. It is not unusual for epileptic seizures, to come at night only. When such is the case, the diagnosis is very difficult. The outcome depends on the condition of the patient. A child may be seized: with an attack while on the street and be killed by an accident. In- stances are. on record where epileptics have fallen into the water ^nd were asphyxiated during the spasm. Traumatic epilepsy will occasionally be cured by surgery. Generally speaking, the cases of epilepsy seen by me did not do well Ts^ith surgical treatment. Treatment. — A case of this kind should never be left alone, owing to the danger of accident during the epileptic seizure. If a cause exists, such a.s, adLenoid vegetations or phimosis, the same should be radically treated. I hav^ej previously mentioned the resultsipf Porter's examinations of the urine; thus,' we find, that the products of indigestion are usually found in epilepsy. . • Dietetic , Treatment. — Arguing from this point of view, the stomach and bowels must not only be constantly supervised, Wt the lightest kind of nutrition that will yield strength shpuld be ordered. The action of the ,1 bowels must be frequent. The slightest constipation should not be per- , mitted. - .r:.;: Cereals, vegetables, and fruits, in fact, the lightest kind of dairy products, should be ordered. Meat and similar stimulating nutrition should EPILEPSY. 763 be enjoined. Water and liquids should be freely given. Neither alcohol, tea, nor coffee should be allowed. , ,, ..;■,,■,-' • ., jh-. Hygienic Trea/men^.— Children so afflicted should be kept out of doors as much as possible. They should not attend schopl. They should have cheerful surroundings and avoid all .ii«=eless e.\;citement. They should be given a bath daily and a proper amount of sleep. Drug Treatment. — Sodium bromide seems to be the drug par excel- lence in the treatment of this disease. Children can take as large if not larger doses of bromide than adults. I have frequently given 10 grains of bromide of soda to a child 1 year old, and repeated the same several times a day. We must study the tolerance of every child by carefully increasing the dose until the physiological effect of the same is produced. Seguin advises giving large doses early in the morning, small doses during the day, and large doses at night. The reason for the large dose at niglit is the fre- quency with which the attacks appear in the night. Belladonna is advised by some authors. Chloral hydrate is frequently useful \y.hen combined with the bromides. I sometimes use arsenic alone "when the bromides cause '-).. —J ... acne. Crotalin is the dried venom taken from the fangs of the American rattlesnake. It is well spoken of by some writers in the treatment of this disease. It is injected into the back of the forearm in Vaoo-grain doses. Restorative treatment should be combined with this anti-spasmodic treatment. The system should be st;-engthened by giving iron and strych- nine. The use of malt extracts and , codliver-oil will be found beneficial. Regarding the surgical treatnient of epilepsy, Sachs says : — "In a case due to a traumatic or organic lesion an early operation may prevent the development of cerebral sclerosis. If an early operatiqn is not done, the occurrence of epilepsy is a warning that secondary sclerosis has been established and an operation may prevent it from increasing. Opera- tion must include the removal, of the diseased area; here, if all other parts are normal, a cure m^y result. Under favorable conditions a few cases of epilepsy may be cured by surgery and many more improved." , - Surgical Treatment. — Geo. W. Jacoby advises as a prophylactic meas- ure to operate early, that every head injury or suspected fracture ^should'be trephined. Thus, an operation is indicated in suspected organic focal dis- ease of the brain. If meningeal haemorrhage due to, traumatism is siis- pected, an operation will do good if performed early. Concerniug the ex- cision of a piece of the cortex to remove a scar, he does not believe any permanent benefit is derived therefrom, because a larger scar results. B. Sachs and A. Gerster^ give the following summary: An opera- tion is permissible in traumatic epilepsy when the case is not over 1 or ^American Journal Medical Science, October, 1896. • ■ r^o^.TST 764 DISEASES OF THE NERVOUS SYSTEM. 2 years old. When there is a depression of bone, the operation is indi- cated at a later period, but should not be delayed. Trephining alone is sometimes sufficient. If the disease is of short duration, a part of the cortex may be incised. The complication of infantile cerebral paralysis, if the case be recent, is no contraindication to the operation. It must not be performed in epilepsy of long duration. Acute Myelitis. This condition consists in a diffuse inflammation resulting in destruc- tion of spinal elements and the softening of the cord. Etiology. — It is not a rare condition, but is most frequently seen as a complication of the infectious diseases. Chilling of the surface of the body seems to favor the development of this condition. Some authors state that it follows metallic or other chemical poisonings. It is frequently associated with spinal trouble, such as Pott's disease. Injury is frequently given as a cause, hut syphilis is the most frequent cause. Pathology. — Macroscopical : The cord is seen thickened and sur- rounded by hypersemic meninges. The substance of the cord is much softer than normal and sometimes resembles pus. Frequently small, punc- tate haemorrhages and even larger extravasations of blood can be seen microscopically. In severe disintegration of the cord, the microscopical findings are useless. It is in the mildest forms that pathological changes can best be studied. In the dilated blood-vessels we find leucocytes and granules of myelin. Corpora amylacea are frequently seen. Symptoms and Diagpiosis. — The symptoms depend on the portion of the cord tissue involved, and on the severity of the process. In syphilis we have a slowly developing condition weeks and months before myelitis symptoms pointing to this condition can be noticed. If children can complain they describe a sense of weight in the legs, which gradually increases, so that in a few days the limbs are entirely palsied. Convulsions and delirium have frequently been noted. When the reflexes are anatom- ically related to the affected segments they disappear, and below that level they are increased; after a few days, if the cord has been entirely de- stroyed at the inflammatoi'y focus, the reflexes are entirely abolished (Church). Provided the posterior roots and meninges are involved, pain in the back and limbs is a prominent symptom, but rarely is of an ex- cruciating character at the onset. At the upper level of the inflammation some pain is the rule, which gives rise to a band or girdle sensation and a zone of hypersesthesia about the abdomen or chest. This sign, with the paralysis, definitely localizes the upper limit of the lesion, but if it be in the lower cervical region this sensation passes down the arms and is not so sharply defined. Lesions in the cervical region are also marked by impli- cation of the cilio-spinal center, with consequent dilatation of the pupil. ACUTE MYELITIS. 765 Continuous priapism is then, too, a usual occurrence, and the intercostal muscles and heart may be affected. Below the lesion, and depending upon its intensity, there are variations in sensibility to all forms of stimulation, from slight blunting to the usual complete anaesthesia. Sensations of drowsiness and aching in the paralyzed and anaesthetic limbs are some- times mentioned; and cramps and drawing up of the limbs frequently occur early, and later are the rule. Distinct muscular atrophy related to the portion of the cord affected takes place, but in the trunk it is not readily discernible. The paralyzed limbs during the first few days are abnormally warm, but soon present a subnormal temperature; sluggish circulation and emaciation ensue, with cedema of the feet and legs if the limbs are left any length of time in a pendent position. If the lesion is low down, the atrophy is a marked feature and the reaction of degeneration is present. Under the influence of pressure, bed-sores form on prominent por- tions of the body and limbs, and this very early. In some cases within the first week immense sphacelization may take place over the sacrum, which cannot be explained by pressure and the moisture from the urine, but im- plies a dystrophic condition of cord origin. Trophic symptoms (bed-sores) are especially liable to occur when the lumbar cord is the seat of the disease. Prognosis and Course. — The course of the disease is chronic. The condition varies but little. The symptoms get worse and worse until death ends the trouble. From a few weeks to a few months may terminate the disease. At times if it is associated with or dependent on Pott's disease, im- provement may be expected. Sometimes myelitis is caused by syphilis either in its active form or due to a syphilitic neoplasm. It is rare in such conditions to effect a cure. Treatment. — If specific conditions such as syphilis exist, then anti- luetic treatment is required. Iodide of sodium can be given in very large doses, 5 to 50 grains per day. The general indications, such as attention to the stomach and bowels, must be met and stimulated if required. It is im- portant to feed a patient in this condition with very nutritious food. Coun- ter-irritation over the spine is advisable. For this purpose tincture of iodine or mustard will be useful. I insist on absolute rest in bed (water bed if possible) and in frequent change of position. Ckronic Myelitis. This condition is usually the continuation or the prolongation of acute softening of the cord. It is here that we find bed-sores as well as disturb- ances of the bladder and bowels. Treatment. — The treatment consists in what has been previously ad- vised in the acute condition. Life can only be prolonged by giving tone to the system with proper food. 766 DISEASES OF TH-fe NERVOUS SYSTEM. .: Malformation of the Spinal Cord (Spina Bifida). The ihosi; frequent liialformation seen is spina bifida. It affects the vertebral canal and. ends in a protrusion of a small or large soft tumor filled with serum. ,This sermii is a clear, yellowish liquid similar to cerebro-spinal fluid. We are indebted t6 Humphrey^ for an accurate description of this lesion. He says:' "Spina bifida is due to an early failure in development, in most cases before the cord is segmented from tlie epiblastic layer from wliich it is developed. , Hence, it remains adhereiit to ' the epiblastic cov- ering, and the structures which should be formed between the cord and the Fig. 251. — Case of Spina Bifida.' Spontaneous cure. Male cliild, 6 ' '-'- years old. Now^, suffers with paralj'-'Sis of both legs. Well nourished. No 'T evidence of hydrocephalus. (Original.) skin are developed. For this reason we have in the wall of the sac a fusion of the elements of the cord, nerves, meninges, vertebral arches, muscles, and integument. If the error in development occurs later, the cord and nerves may be attached to the sac, but not intimately fused with it; in still other cases the cord does not enter the sac at all. The malformations may occur before the central canal is cl(5sed, or, if closed, it may reopen from the accumulation of fluid. It is probable that the accumulation of fluid first occurs, and that this prevents the union of the parts of the vertebral arches. "Although the tumor is generally associated with a bifid spine, this is ,not necessarily the case. The protrusion may take place through the inter- ^ Lancet, March 28, 1885. HEREDITARY ATAXY. 757 vertebral notch or foramen, or there may be a fissure of the bodies of the vertebrae, and an anterior tumor projecting into the cavity of the thorax, abdomen, or pelvis, spina bifida occulta. The principal anatomical varieties are meningocele, meningo-myelocele, and syringo-myelocele." The following case of spina bifida occurred in. my private practice. A boy, 6 years old, was brought to me with a history of having a very large growth in the lumbar region. The sac burst spontaneously. Since that time the boy has a double paralysis, and also suffers with incontinence of urine and fseces. He was brought to me for the treatment of the paralysis. The general condition was good and he appeared well nourished. There was no evidence of hydrocephalus. Treatment. — ^The treatment of spina bifida is surgical. I have seen a number of successful cases. Hereditary Ataxy (Friedreich's Disease).^ This condition is caused by degeneration of the posterior columns of the spinal cord. As a rule several members of the family are affected. Etiology. — This disease is usually seen at or about the period of puberty. Measles, scarlet fever, or any other acute infectious disease may precede the development of this condition. Pathology. — The lesions seen are: "Sclerosis in the posterior columns (columns of Groll in their whole extent, and columns of Burdach in their upper part), in the direct cerebellar tract extending laterally into the column of Gowers, in the lateral columns (crossed pyramidal tracL), in the gray matter (columns of Clarke, and posterior horns). In some cases dilatation of the central canal has been observed." Symptoms and Dia^osis. — The motor system shows tlie most charac- teristic symptoms. The patient stands with the feet far apart. The body sways and there is an unsteadiness while trying to maintain the equilibrium. The gait resembles that of an alcoholic intoxication. A tremor of the hands and head and choreiform movements affect the same parts. Paralysis and emaciation may be present. The tendon reflexes are absent as a rule, but their presence does not speak against the diagnosis in the early stage of the disease. The eyes show nystagmus. There is no optic atrophy. There is vertigo. The speech is slow. The intellect seems impaired. There is a peculiar clubbing of the feet. The foot is short. The toes are over- extended, the instep high and hollow. The Babinski phenomenon, or hyper- extension of the big toe, may be the first symptom of this condition. The prognosis is grave. The disease lasts years. Treatment. — The disease runs its course, although electricity and restorative treatment plus massage may be tried. The disease usually ends fatally. ^ I am indebted to Williams's excellent monograph for some points in this article. 768 DISEASES OF THE NERVOUS SYSTEM. Poliomyelitis (Infantile Spinal Paralysis). This disease is characterized by a sudden onset of fever, then paralysis, usually followed by muscular atrophy and imperfect bone development, sometimes by deformity. The recent studies of Flexner and Koguchi^ show that poliomyelitis is due to a distinct micro-organism which can be isolated from the human poliomyelitic virus. The micro-organism exists in the infected and dis- eased organs; it is not, as far as is known, a common saprophyte, or asso- ciated with any other pathological condition; it is capable of reproducing on inoculation the experimental disease in monkeys, from which animals it can be recovered in pure culture. Besides these classical requirements, the micro-organism withstands preservation and glycerination as does the t <\.,g^i^g»||i^ Fig. 252. — Mi:ro-organism Causing Epidemic Poliomyelitis. Separate Globoid Bodies. X 1000. (Courtesy of Dr. S. Flexner.) ordinary virus of poliomyelitis within the nervous organs. Finally, the anaerobic nature of the micro-organism interposes no obstacle to its accept- ance as the causative agent, since the living tissues are devoid of free oxygen and the virus of poliomyelitis has not yet been detected in the cir- culating blood or cerebrospinal fluid of human beings, in which the oxygen is less firmly bound, nor need it, even should the micro-organism be found sometimes to survive in these fluids. , Now that the specific cause of infantile paralysis has been found, it is but rational to assume that a specific serum or vaccine will be made, such being possible, we may then hope, with specific treatment in the pre- paralytic stage, to prevent the paralysis. Childhood is the age most susceptible to an infection of poliomyelitis. During the epidemic of 1916, New York City had over 9000 cases. The death rate was about 26 per cent. Connecticut and Maine each has nearly 700 cases. New Jersey about 3500 cases, Pennsylvania about 1300.- cases, and New York State, exceluding- New York City, about 2800 cases. ^Journal of Experimental Medicine, vol. xviii, No. 4, 1913. POLIOMYELTTTS. 769 Patholog-y. — One of the facts now established is that the inflammation of the cord is always accompanied by an inflammatory process in the pia mater. The patholo<^ii-al process in the cord itself is primarily depejident upon vascular changes, and secondarily, upon changes in tlie cells, both ganglionic and interstitial. The vessels of the cord, medulla, pons, basal ganglia, and even the cerebral cortex are dilated and engorged, and in the cord, medulla, and pons the capillaries are distended to more than twice tlieir normal caliber. This hyperaemia is found at all levels of the cord irrespective of the intensity of the other inflammatory changes. It is now firmly established that the pathological process in acute poliomyelitis is one which is primarily dependent upon the vascular and interstitial tissue changes and that the ganglion cells are secondarily affected. (I. Strauss.) 1 — ee. Fig. 253. — Poliomyelitis. Sclerosis and cicatricial atrophy of the left anterior horn of the fourth cervical nerve after acute anteior poliomyelitis. (a) Nomal anterior horn witli ganglion cells. (6) Atrophic anterior horn. ( Ziegler. ) According to Peabody, Draper, and Dochez, "These three facts, cellular exudate, hoamorrhage, and edema, . , . may perhaps be regarded as the primary reaction of the nervous system to the virus of poliomyelitis.'"^ "... the damaging effects can be assumed to result in part from the direct pressure on the nerve cells of hoemorrhages, edema, and exudate." These observations were made at autopsies. Symptoms and Diagnosis. — From a study of the epidemic prevailing during the summer of 191G, the following classification seems justifiable: — First. T]ie Ahortive Type. — These are the cases responsible for the spread of the disease, for the large majority, owing to the mildness of their symptoms, are passed uimoticed. They may be termed the "carriers" of this infection. The temperature may rise no higher than 101 and last but one or two days. The child will be apathetic, complain of headache, and have extreme 49 770 DISEASES OF THE NERVOUS SYSTEM. lassitude. He may also complain of pain in tlie arms and legs. In some forms of the abortive type the symptoms will pass after one day, the child will regain his appetite, and be as bright as usual. The reflexes may be slightly exaggerated, but there are no other eyidences of paralysis. Second. Gastroenteric Type. — In this type we have vomiting, ano- rexia, fever; temperature ranging between 102 and 105 degrees, pulse rang- ing between. 100 and 140, extreme lassitude, pain on moving the arms or legs, pain in the back of the neck, headache, and a general apathetic condi- tion. The sclera of both eyes show engorged blood-vessels, the eyes stare or are fixed, the pupils respond slowly, the patellar reflexes are exaggerated or are lost, the child appears to be in a stupor or semicomatose condition, "usually followed by paralysis. Third. Respiratory Type. — In the milder forms of this type we have symptoms resembling rhinitis with fever ranging between 103 and 104 degrees, cough, peevishness, restlessness, and general prostration. In the severer forms we have symptoms resembling bronchopneumonia : high fever; shallow, frequent respirations ranging between 50 and 80 per minute, pulse of 130 to 150 per minute, extreme lassitude, weakness or absence of knee- jerk, and evidences of profound toxsemia. Paralysis of the respiratory cen- ters frequently follows. Fourth. Bulbar Type. — In the bulbar type we have inability to swal- low or speak, marked rigidity of the sternocleidomastoids, with intense pain in the head and neck, moaning usually preceded by convulsions, both tonic and clonic in character. The muscular system of the arms and legs show intense rigidity. The Kernig sign is sometimes present, and more fre- quently marked hyperextension of the big toe (Babinski) is noted. The pupils respond sluggishly and are unusually contracted. AH the symptoms of a meningitis, such as a tache cerebrale and Brudzinsky's sign described elsewhere are present. In the early stages the patellar reflexes may be slightly present, but later are absent. The plantar reflex is usually present. The cremaster reflex slightly present. Paralysis usually takes place after the febrile condition subsides. The duration of the fever is from three to six days, although I have seen cases in which the fever persisted ten days. Preparalytic Symptom. — During^ the febrile stage, if the child is care- fully observed, we can frequently note an important symptom which has been described by Colliver^ as a preparalytic symptom. It is a peculiar twitching, tremulous or convulsive movement. It usually affects a part of whole of one or more limits, the face or jaw. It may also affect the whole body. In the beginning the symjitoms may last less than one second, and may not recur oftener than every hour or so. Later the spells lengthen to a few seconds, and recur at shorter intervals. The condition is sometimes ^Journal of the Amer. Med. Assoc, March 15, 1913. POLIOMYELITIS. 771 accompanied by a peculiar cry, similar to the hydrocephalic. During the convulsive movement the child is apparently unconscious, with eyes set for a few seconds. A similar symptom has been described by Professor ^'ette^,l of Paris. This preparalytic symptom, if noted, will serve as a warning of the approaching paralysis, and when observed, the limb should be strength- ened by support. Fig. 254. — Paralysis, of the muscles of the back, trunk, and neck. Cannot sit unsupported. (Original.) Fig. 255. — Paralysis of the spinal muscles. Intercostals, showing in- volvement of the serratus magnus. (Orignal.) Eruption. — In many cases a pin-point erythema (scarletiniform) scat- tered over the chest, abdomen, and flexor surfaces of arms was seen. Some- times the rash appears as urticarial blotches or wheals, principally on abdomen, back, thighs, and arms. In these cases toxic, gastric, or gastro- enteric symptoms are found. Another type of eruption seen is the mor- billiform type. The eruption crescentic in character is found on face, neck, thorax, and a few scattered areas are seen on the arms and legs. The erup- tion usually lasts from tlii'ee to ten days, and fades with the fever, ' British Jour, of Children's Diseases, Dec, 1913. 772 DISEASES OP THE NERVOUS SYSTEM. Lumbar puncture^ should be made to verify the diagnosis. Fifteen to 25 cubic centimeters of spinal fluid should l)e withdrawn. If the fluid comes out under great pressure, then 50 to 100 cubic centimeters may be withdrawn. According to the findings of the New York Board of Health,^ the spinal fluid in poliomyelitis is usually clear and increased in amount. The albumin and globulin are increased in varying degrees, and there is usually a good reduction of Fehling-^s. The cellular increase ranges from slightly above normal to over 900 cells per cubic centimeter. Early in the disease the cells may be 50 per cent, or more mononuclears. Later there is usually 90 per cent, or more mononuclears. There are frequently large mononu- clear cells that seem somewhat characteristic of these fluids. Treatment. — Through the needle left in situ Meltzer advises the injec- tion of 2 c.c. of a 1 : 1000 adrenaline solution. The adrenaline injection may be repeated every four hours during the first day, and if improvement is noted, every six hours, and later every twelve hours on successive days. Muscular rigidit}^, accompanied by pain, is best relieved by warm sul- phur baths. The crude sul|)huret of potassium, 4 ounces to a tub bath at a temperature of 103°, will frequently relax the body and promote sleep. In some cases it will be found necessary to prolong the bath fifteen to twenty minutes to produce an effect. These baths should be given morning and evening for at least one week. Serum Treatment. — ^Fifteen cubic centimeters of blood serum from a convalescent or immunized case of poliomyelitis should be injected intra- spinally by the gravity method as soon as procured.^ One injection of, serum is usually sufficient, although the same dosage may be repeated in twenty-four hours if no improvement is noted. I, have used intraspinal irrigations of normal saline solution at a temperature of 110° to 112° in a series of cases with excellent result. Several moribund cases responded promptly to this form of treatment. The needle is introduced between the fourth and fifth lumbar vertebrae, and as much as possible of the spinal fluid withdrawn. Thirty to 100 cubic centimeters have been withdrawn at one time. After draining, 30 cubic centimeters of the saline solution is injected. This is repeated three times. After the third drainage, 15 cubic centimeters of blood serum from a convalescent case is injected, the needle withdrawn, and the puncture sealed with a drop of collodion or medicated adhesive plaster. ' Tlie technique and illustration of lumbar puncture is described on page 789. ''Josephine B. Neal, Archives of Pediatrics, August, 1916. ''This method was advocated by Dr. Aj Zingher, of the New York Board of Health, Research Department, during the epidemic of 1916. I have had excellent results with the same. POLTOiMYKLITIS. 773 In tlie bulbar type witli extreme prostration and coma, where it was impossible to feed by mouth, I liave used injections of warm saline solution, 250 cul)ic centimeters, every four to six hours, by hypodemioclysis. In one ease of coma with inability to swallow the child received 250 cubic centi- meters of saline solution in the loose cellular tissue of the abdomen with excellent results. Hot saline colonic flushings at a temperature of 110° to 115° were given to su])plement the hypodermoclysis. Fig. 256. — Paralysis of the left leg and foot. Typical drop-foot. Note position' of the foot in standing — dne to paralysis of the quadriceps muscles. (Original.) In older children ^'^musclc training'^ is conunended and the child guided through aeti\e exercises, so that atrophy from non-use is prevented. A comparison of this latter method of muscle active treatment, rather than the muscle passive treatment, which latter results from splints, braces, and plaster casts, shows a decided leaning toward the muscle active treat- ment. Patience and persistence will be rewarded by success after weeks and months of this treatment. The child's brain must be in sympathy with its movements; hence, the passive exercises, such as gjTiinastics or massage, are far inferior to a method by which the child can be instructed in the performance of various exercises in wliich the body and mind 774 DISEASES OF THE NERVOUS SYSTEM. • co-ordinate. It has been found by clinical experience, and such, cases have been reported by Teschner and others, that a muscle, be it ever so atrophied, can be redeveloped by a system of carefully planned exercises. Electricity or galvanic current' may be used in conjunction vs^ith massage, but gentle massage will accomplish just as much, and more than violent rubbing by inexperienced hands. Medicinal Treatment. — Intramuscular or intravenous injections of one-half the usual dose of salvarsan given as a restorative may be tried. The dose should be repeated every week until the systemic' effect of the sal- varsan is manifested. Intramuscular injections of strychnine in doses of ^/loo grain every other day gradually increased until ^/go grain can be given to a child 5 years old, younger children in proportion. Arsenic in the form of Fowler's solution may be given in doses of I to 5 drops three times a day. The treatment must be directed toward elimination of toxin as much as possible. Urotropin (which liberates formaline) may be given in 2- to 3- grain doses several times a day. Hot packs over the affected parts have a stimulating tendency. Bestorative treatment should consist in giving concentrated food, such as milk, yolk of egg, broth, and gruel. Seabaths will aid in restoring normal conditions. The treatment must be persisted in for months. Prevention of Drop-foot. — ^\Vhen it is evident that a group of muscles is weakened, a support is necessary. Tubby says that recovery is always hindered and even entirely prevented in a stretched muscle, whereas when it is relaxed the reverse is the case. Therefore, in order to obtain the best result in an affected muscle, relax it to its fullest extent and massage it. Elongated muscles are earliest restored to j)ower and use by maintain- ing them slack. Muscles not paralyzed will contract. George W. Jacoby recommends, as a prophylaxis for drop-foot, placing the foot in rectangular position by means of bandages and splint to prevent contracture. Never even allow the weight of bed clothes on the foot. In cases of drop-foot or drop-wrist, tenotomy may be required, but this should be left to the judgment of a conservative orthopaedist. Muscle transplantation is advised after paralysis is firmly established. Eeb's Palsy. This is commonly known as obstetrical paralysis, and is caused by pressure exerted on the brachial plexus during birth. One or both arms may be involved. Brachial plexus paralysis is amenal^le to treatment. An interesting case of this kind occurred in the practice of Dr. D. P. Waldman, of this cit}', with whom I saw the case in consultation. The infant was bom after fllllOXIC IXTEliNAL ]ni)ll(»("KI'llAIAS. 775 Fig. 257. — Case of Chronic Internal Hydrocephalus. Note the position of the eyes and the globular shape of the head. Aspiration of the ventricles every week gave 50 to 60 cubic centimeters of a perfectly clear fluid. (Uriginal.) Fig. 258. — Front view of same case. Note position of eyes and ears. This is a characteristic expression of hydrocephalus. (Original.) 776 DISEASES OF THE NERVOUS SYSTEM. an unusually protracted labor with complete unilateral paralysis involving the right arm. With the aid of general manipulation and faradic elec- tricity the case completely recovered. The duration of the attack was, from onset to cure, about three months. Treatment. — The treatment, as a rule, consists in using gentle massage daily ; also a mild faradic current every other day. If there is no response to tills treatment within ten days the galvanic current should be tried. Tub baths at temperaure of 102° F. duration one minute should be given prior to each massage. Hydrocephalus. This is an accumulation of serum in the head. External Hydrocepltalus. — ^^"hen the effusion is between the dura mater and the pia. Internal Eifdrocephalus. — When the lesion is in the ventricles of the brain. The latter condition is most commonly seen. Acute Hydrocephalus. This condition usually follows basilar meningitis. In acute hydro- cephalus the effusion is not large. Some authors state that no more than three or four ounces of serum are present. Cheoxic Ikterxal Hydrocephalus (Water on the Bbain). This condition must not be confounded with tubercular meningitis. Etiolog'y. — ^The cause of primai^ror secondary internal hydrocephalus is very difficult to determine. In some instances syphilis has been given as the causative factor. An interesting paper has appeared by D^ Astros,^ who describes 12 cases in which hydrocephalus was associated with syph- ilitic lesions, so that the condition was congenital. By some, chronic hy- droeei^halus is believed to be due to tuberculosis. Pathology. — "The changes in the brain result from the gradual accu- mulation of fluid in tlie ventricles. The septum lucidum is usually broken down, and all the avenues of communication between the ventricular cav- ities are greatly enlarged. The continuous distention results in a gradual thinning of the brain substance which forms the ventricular walls; often these are found only one-fourth of an inch in thickness, or even less than this, the cortex being a mere shell." The brain appears anseraic, so that the gray and white substances re- semble each other. The bones of the skull show the lesions very plainly. The sutures are separated in some cases. Where premature ossification has taken place, the head instead of being very large, is very small. This is called a microcephalic condition. Sometimes spiua l3ifida is associated with this condition. ^Kevue Mensuelle des Maladies de 1' Enfancej Chapter IX, pp. 481 and 543. HYDROCEPHALUS. 777 Symptoms. — Tlie first symptoms that attract attention are, that the head is increasing; in size; that it seems very heavy; that the chihl appears stupid'; tliat it does not notice things, but stares continuously. The fore- head is very high, the lontanel (listended and bulging. On palpating, the soft fluctuating liquid can be felt. The sutures are very wide apart. The pupils are usually enlarged, some- times contracted. Convulsions are frequently present. While the head enlarges the body emaciates. Prognosis and Course.^ — ^This dis- ease usually terminates fatally al)out the seventh year. In rare instances the condition may extend through life with impaired mental faculties due to the brain trouble. Cases that have been reported cured should be viewed with suspicion. Treatment. — Aspiration has been tried by many, with no apparent bene- fit. I have never seen a good result follow the aspiration of the liquid, be- cause the fluid returns very rapidly, so that nothing is gained by the operation. Blistering, counter-irritation, strapping, and lumbar puncture have been tried by me with no apparent success. Iodoform collodion has been recommended by some. In a ease seen in consultation with Dr. L. Harris, of this city/convulsions were relieved by lumbar puncture. Jlereurial inunctions and large doses of iodide have been tried. If s.yphilis is the cause, then some benefit may be expected from specific treatment. Meningocele. When there is defective ossification in the bones of the skull and some l)art of the membranes of the brain protrudes, it is called a meningocele. Some writers believe it is caused by an intra-uterine hydrocephalus. These tumors generally contain cercbro-spinal fluid in the bag of membrane. When pressure is exerted over the swelling, the liquid will be emiitied into the brain. Sometimes cerebral symptoms will result from this mani- festation. Encepiialocelb (Cerebral Hernia). In this condition there is a protrusion of the brain substance in addi- tion tatlie membrane. This protrusion takes place tiirough the frontal and Fig. 259. — Hydroceplialic cal- variuni (or skull-cap), widely gaping fontivnels and sutiires. One-half natural size. ( Langerhans. ) 778 DISEASES OF THE NERVOUS SYSTEM. occipital bones. It is ■usually a congenital deformity. If the tumor con- tains a portion of a dilated ventricle and is filled with cerebro-spinal fluid, it is called a hydro-encephalocele or hydro-encephalo-meningocele. A case of this kind was seen by me some time ago in which the tumor protruded through the occipital bone. It was a congenital deformity. Distinct pulsation could be felt. The tumor increased in size when the child cried. Convulsions resulted from forcibly pushing the tumor into the cranial cavity. Fig. 260. — Ericephalocele. Infant 1 day old, admitted to my hospital service, having a globular tumor in the occipital region of the head. The tumor measured SYo centimeters from above downward, and 8% centimeters from side to side. The autopsy was performed by Dr. John Larkin. (Original.) Treatment. — 'The injection of 1 drachm of Morton's fluid after aspira- tion of some of the liquid contents may be tried. Morton's fluid : — IJ Kali iodide 30 grains Iodine pure . 10 grains Glycerine 1 ounce M. Inject 1 drachm after each aspiration. If no improvement is noted after some time, surgical treatment should be tried. Ctclops. This is a very rare condition and consists of the child having but one orbit, which is situated in the middle of the forehead at the root of the nose. PORBKCEPHALY. This consists usually of a defective development, leaving a hole in the brain. It is a congenital disease and may be located in any portion of the brain. CHAPTEK lY. ' TUBERCULAR MENINGITIS (BASILAR MENINGITIS). This is usually a secondary condition. It is not a primary disease of the meninges. In infants, tubercular meningitis usually follows bone tu- berculosis, tuberculosis of the lymph nodes or joints, and not infrequently a tubercular otitis may extend and involve the meninges. Etioiogy. — The association of adenoid vegetation and the probable entrance of the tubercle bacillus through the lymph channels of the neck is the most probable means of infection.^ (See article on "Acute Tubercu- losis.") Bacteriology. — There is no question about the association of the tubercle bacillus with this infection. It can be found in the spinal fluid withdrawn by a lumbar puncture. Other pathogenic bacteria may also be found. In one case reported by me we foimd the diplococcus intracellularis in addition to the tubercle bacillus. Pathology. — The chief pathological condition is a growth of miliary tubercles. Associated with these we frequently find tubercular nodules of variable size, and in almost every case they are the products of ordinary inflammation of the pia mater — hTuph or pus — ^together with an accumu- lation of fluid in the lateral ventricles of the brain. Holt says : ^'Frequently there are tubercles in the pia mater of the upper portion of the cord. The miliary tubercles appear as small gray or white granules, situated along the vessels of the pia mater. When few in number they are usually located at the base, especially along the Sylvian fissures and in the interpeduncular space. When numerous, they are most abundant at the base, but are also seen scattered over the convexity in small groups. In about half of my autopsies they have been limited to the base, and in no case were they seen exclusively at the convexity. Tubercles are often found in the choroid coat of the eye. The amount of lymph and pus present is rarely great, and never ecjual to that seen in simple acute meningitis. It is often a matter of surprise at autopsies to find the lesions so few, after verv marked symp- toms. The inflammatory products are most abundant at the base. In addi- tion to the patches of greenish-yellow lymph, there are adhesions between the lobes of the brain and thickening of the pia. In cases which have lasted for several weeks, the pia mater in places is often very much thickened. '■This view is maintained by W. Freudenthal, of New York. (779) 780 DISEASES OF THE NERVOUS SYSTEM. owing to cell infiltration and the production of new connective tissue, and it is studded with miliary tubercles, sometimes with small yellow tuber- culous nodules; frequently there is arteritis, which is sometimes obliterat- ing. "In the most acute cases the brain substance immediately beneath the pia is intensely congested, slightly softened, and shows under the micro- scope a superficial encephalitis. The lateral ventricles "are usually distended with clear serum, . sometimes with serum containing flocculi of lymph or Fig. 261. — Tuberculous Spinal Meningitis. Longitudinal Section of Spinal Cord and Posterior Roots, (a) Spinal cord; (&) pia mater; (c) subarachnoidal space; {d) arachnoid; (e) posterior roots, cellular infiltra- tion and containing isolated swollen axis cylinders; (f) vessel with cellular infiltration and proliferated wall; (g) cellular exudate in subarachnoidal space; (i) swollen axis cylinder. X45. (Ziegler.) pus; the amount present varies from one to four ounces in each ventricle, being always greater in the subacute cases. The walls of the ventricles may be softened. The distention of the ventricles leads to flattening of the convolutions from pressure against the skull, to bulging of the fontanel, and sometimes to separation of the sutures, if they are not completely ossi- fied." PLATE XXXVII Disseminated Pulmonary Tuberculosis in a Two-year-old Child having Tubercular^ Meningitis. (Courtesy of Dr. Wm. H. Stewart.) TUBERCULAR MENINGITIS. 781 Tuberculous nodules varying in size from a small pea to a walnut are frequently seen associated with meningitis in older children, but not so often in infants. These nodules may be connected with the meninges, or they may be situated within the brain substance, usually in the cerebellum. The larger ones are classed as brain tumors. Inflammatory products are rarely found in the spinal canal. Course. — The course of tubercular meningitis is from three to ten days, although the symptoms may last from four to eight weeks, or even longer. Child B. W., 5 years old. Father a physician and healthy. Mother healthy. Had just returned from the country in apparent good health. Was sent to school and seemed bright mentally and physically. Was a well-nourished child. Had had no previous illness excepting a disordered stomach. The first symptom of her present illness was headache. Had a coated tongue, loss of appetite and a slight rise of tenipei-ature, from 100° to 101° F. The temperature was very characteristic. (See chart.) The parents suspected a slight dyspeptic attack and gave her a laxative. Her diet was also corrected. In spite of cleansing the stomach and bowels, the headache persisted and reached such an acute stage that the child cried and moaned continuously, and did not sleep. When I first saw the case the symptoms of an acute gastric catan-h were so evident that nothing further was suspected. The headache persisted in spite of bromides. The child complained of ringing in the ears. Had twitchings of the arms and legs. The bowels assumed a normal color and consistency. An examination of the eyes with the ophthalmoscope was first made by Dr. H. Jarecky and later by Dr. Henry S. Oppenheimer, who found vision good, no choked disk — engorgement of veins only — slight reaction of pupils. No evidence of tubercular disease was found. In the beginning of this illness the symptoms of headache were very prominent. The child appeared quite rational and the diagnosis of supra-orbital nfuralgia was made. Dr. George W. Jacoby, who saw the case at my request, early in the disease believed that we were dealing with meningitis. Later on, however, the symptoms were positive. Dr. Abraham Jaeobi, who saw this case later in consultation, diagnosed meningitis. At his suggestion leeches were applied and they afforded quite some relief. The head- ache reappeared with renewed vigor and remained incessant throughout the period of illness. Owing to the continued pain it was decided to relieve the intra- cranial pressure by lumbar puncture. I aspirated 45 cubic centimeters of clear spinal fluid, which was sent to Dr. Billings, of the New York Health Department, for examination. He reported the presence of the tubercle bacillus and the diplococcus. Dr. B. Sachs confirmed the diagnosis of tubercular meningitis. Strabismus was also present. Tliere was marked facial paralysis. Nausea and vomiting occurred. There were spasms and tmtchings, also a hsemiple^ic paralysis. There was also a unilateral flush on the cheek and other well-marked evidences of vasomotor disturbances. The child was either soporose, in a semi-stupor, or crying and screaming with pain in the head. A distinct red streak remained when the skin was stroked with the finger nail, the so-called tache cerebrale. The Babinski reflex was also present. There was spastic rigidity of the entire body. The eyes were half open. Respiration was labored, at times — Cheyne-Stokes respiration. The pulse was small and compressible and varied between 80 and 160. The child died of extreme exhaustion and inanition, after suffering about ten days of. terrible agony. 782 DISEASES OF THE NERVOUS SYSTEM. Symptoms and Diagnosis. — An irregular and intermitting pulse with Clie}aie-Stokes respiration and slight elevation of temperature are amongst the early sjinptoms of this disease. The pupils show irregularity; not in- frequently one pupil will be dilated, while the other may be a pin-point. Fig. 262. — Case of Tuberculous Meningitis, well marked, ending fatally. (Original.) Vomiting is an early s}Tnptom in many cases, and may continue in spite of rigid supervision of the diet, so that an organic lesion will be suspected. The vomiting is usually projectile in character. Later in the disease, the temperature ranges from 100° to 103° or even higher. The pulse may TUBERCULAR MENINGITIS. 783 vary between 80 and 160 beats per minute. The respirations are increased and irregular in character, labored or sighing. Tache Gerebrale. — ^The tache cerebrale is frequently present. This is produced by drawing the finger-nail quickly over the skin of the abdomen, arm, or leg, when a sharp, bright mark remains for several minutes. Some symptoms come on very slowly. Intense headache is complained of and is usually supra-orbital in character. In the case referred to in this chapter the symptoms were masked for a number of days. The eyes usually show tubercles in the choroid. In the case reported here, although the eyes were examined by two competent oculists, no evidence of disease could be found. Strabismus as well as facial paralysis are frequently seen as evi- dence of paralysis. Twitchings are frequently noticed. The BabinsJci reflex is very often present. The child sleeps with its eyes half open. There is marked evidence of vasomotor disturbance, such as unilateral flushes, and spastic rigidity of the entire body is repeatedly seen. Lumbar puncture will usually show a clear cerebro-spinal fluid. In this fluid the tubercle bacilli can be located. In some cases other pathogenic bacteria — for example, the streptococcus — can be found. Inoculation of skin with tuberculin — von Pirquet test — is helpful in making the diagnosis. The prognosis is bad. I do not know of a single case of distinct tuber- cular meningitis that finally recovered. Treatment. — Lumbar puncture should in all cases be performed. For details regarding technique of lumbar puncture see chapter on "Epidemic Cerebro-spinal Meningitis." Tapping the fourth or fifth ventricle will certainly relieve intra-cranial pressure. No more than 15 to 25 cubic cen- timeters should be withdrawn at one aspiration. I look upon this as a very valuable diagnostic as well as therapeutic measure. The head should be shaved, and an ice-bag or ice-coil applied continuously. Next in impor- tance several leeches should be applied behind the ears, over the mastoid process of the temporal bone. Cerebral engorgement can also be relieved by applying leeches to the ala) nasi; this will drain the blood through the frontal sinus. Eectal medication should be remembered. Large doses (5 to 10 grains) of sodium bromide and sodium iodide should be given until quiet is insured. The bowels sliould be cleansed by a thorough irrigation with glycerine and water. Iodoform collodion (10 per cent.) can be applied to the scalp, thoroughly, once or twice. Inunctions with uugiientum Crede or mercurial ointment, at the nape of the neck, rubbed into the lymphatics, for at least twenty minutes several times a day, will frequently do some good. Peptonized milk, whey, soups, broths, zoolak, and buttermilk are indi- cated. Under no conditions should solid food be administered. If the 784 DISEASES OF THE NERVOUS SYSTEM. child is in a coma^ rectal feeding must be resorted to. (For details see chapter on "Eectal Feeding.") Ceeebeo-spii^al Meningitis (Acute Mexixgitis, Spotted Fevee^ oe Maligxaxt Pukpueic Fever). Cerebro-spinal meningitis is an acute infectious disease characterized by a sudden onset of s3'mptoms. Bacteriology and Etiology. — The presence of the dijDlococcus intra- cellularis of Weichselbaum is usually the causative agent of this disease. In a few cases, streptococci; in others, pneumococci have been found. Weichselbaum states that he believes the meningococcus is frequently present and lies dormant in the crypts of the tonsils and pharynx. For this reason he believes that, wlien a lowered vitality exists due to subnormal conditions, then the meningococcus gains access through the h'mph channels to the meninges and sets up an acute and sudden infection. In addition to the presence of the meningococcus in the tonsils, this pathogenic microbe is frequently found in the nose from whence it probably gains access through the frontal sinuses and reaches the brain. The meningococcus can be trans- mitted and an infection disseminated by direct contact with infected secre- tions containing the diplococcus intracellularis. Weichselbaum does not believe that the sudden appearance of a case of cerebro-spinal meningitis, in an otherwise healthy locality, is extraordinar}!- when the etiological con- ditions, such as the possibility of harboring this diplococcus in the nose and throat, are remembered. Pathology. — In the early stage of this disease we note h}^erEemic conditions in the brain and spinal cord. When the disease has progressed, the arachnoid appears cloudy, especially along the course of the blood- vessels from which a purulent exudate oozes. This purulent exudate in- volves all the tissues of the convexity and frequently extends to the base in the meshes of the pia and between it and the cortex. The fluid in the ventricles is as a rule increased, and may contain small flocculi of fibrin. Haemorrhage is frequently noted in this region. The joints show evidences of septic inflammation. The spleen is frequently enlarged. Evidences of infection and sepsis are present in all parts of the intestinal organs of the body. Multiple abscesses may occur, and not infrequently parenchymatous degenerations involve the kidneys, liver, and spleen. Purpuric spots of mottling, so frequently seen on the outside of the body, may sometimes be seen more distinctly in the internal organs. Climatic Conditions. — The greatest number of cases occur during the winter months, while sporadic cases are seen in the spring, summer, and fall months. PLATE xxxvTrr «^ .^ 41^ «l f^ ^ 1J **^#; ^c* 1^ / :Mciiingococci in Pus-cells, Spinal Fluid. Characteristic Intracellular Arrangement. CEREBROSPINAL MENINGITIS. 785 Table No. 77. — Deaths from Ccrebro-Flpinal Meningiiifi in Children under 15 years. 'New York City— 1902-1907. Year. Old New York City. Greater New York City. 1002 156 221 1903. 168 225 1904 806 1056 1905 2775 1906 1032 1907 828 Symptoms. — During the epidemic there were three classes of cases encountered: first, a mild type; second, a severe type; and third, an abortive type. Mild Type. — In this class of cases there is a slight rise of temperature, generally malaise, and perhaps vomiting. Abortive Type. — This type is usually seen in strong children who are able to withstand a severe infection. By reason of their health they are infected in a lesser degree, as shown by their symptoms and the rapidity of their convalescence. The onset is usually sudden, and I have seen meningeal symptoms subside within ten days with no sequelae. This happened in a case of a child with undoubted cerebrospinal meningitis, in which the diagnosis was confirmed by the bacteriological examination of the spinal fluid. Rhinitis with catarrhal discharge from the nose is sometimes an early symptom in this disease. Ehinitis is frequently found in the abortive type of the disease. The danger of having the meningococcus in the nose consists in the ease with which this pathogenic bacterium can enter the frontal sinus and thus give rise to encephalitis. In the abortive type of this disease there frequently is a nasal discharge in which the meningococcus intracellular is can be found long after the rhinitis has disappeared. The ambulatory cases are the ones which disseminate this infection because they carry the pathogenic bacteria from house to house. Severe Type. — In the severe type there is a sudden onset of symptoms. In older children a distinct chili is usually the first symptom noted. The skin feels hot. The temperature rises anywhere between 10'2-105° F. (38.8 and 40.6° C), in the rectum. The pulse varies; it may be slow or very rapid. The respiration is irregular in character, sometimes sighing, and labored, but most frequently Cheyne-Stokes in character. Later on there is vomiting, pain in the head, in the frontal or occipital regions, and pain at the back of the neck. There is moaning and frequently delirium. Vaso- motor disturbances, such as the flushing of one ear or one cheek, are 50 786 DISEASES OF THE NERVOUS SYSTEM. occasionally seen. The tache cerebrate is usually noted when stroking the breast with the finger nail, as a distinct hypersemia follows and remains for several minutes. The tendons are very sensitive to the slightest pressure. The patellar reflexes are usually absent. When the thigh is flexed on the abdomen and we try to extend the leg there is considerable latent contraction, the so-called Kernig sign. This symptom alone should not be depended upon. Hyperextension of the big toe produced by stroking the sole of the foot, the so-called Babinski reflex, is not always present. It is also fre- quently noted in perfectly healthy children. In a series of fifty children examined by me, the Babinski reflex was found in forty. Brudzinski's neck sign in tuberculous and other types of meningitis is present in 100 per cent, of those ill with either cerebrospinal meningitis, serous or pneumococcous meningitis. Technique to Elicit NecJc Sign. — The head is forcibly flexed with the left hand while the child is lying flat on its back; with the right hand, pressure is exerted on the chest to keep the child from being lifted. If the sign is positive, both legs will flex on the thighs and the thighs on the abdomen. The identical collateral sign consists in flexing the leg on the thigh and the thigh on the abdomen, when the opposite lower member will assume the same position. The normal cytology of the cerebrospinal fluid varies from to about 7 lymphocytes per cubic millimeter. In any meningeal irritation, acute or chronic, the lymphocytes increase in number. They may be increased in- definitely up to thousands. In a number of cerebrospinal fluids from infants, examined by Kaplan, he found that in the tubercular forms the lymphocytes predominate. In the other acute meningitides of children the polynuclears and lymphocytes claim about equal or nearly equal relations. It is marvelous how readily the polynuclears diminish if the case shows the slightest tendency to improve, and, vice versa, they increase as the inflammatory process grows worse. Pari passu with the polynuclear increase the Fehling reaction disappears. This point is extremely important, as there are a number of cases of tubercular meningitis where the tubercle bacillus cannot be found even if the antiformin or the Jousset method is used. In these instances I consider the copper-reducing substance in the cerebrospinal fluid as highly suggestive of the tubercular nature of the meningitis. The non-reduction of the Fehling solution or the appearance of a violet color change instead, in Kaplan's opinion, is significant of the non-tubercular nature of the affection unless a mixed infection is at hand. In case a double infection is demonstrated microscopically, the invader that has the upper hand in the infection usually reflects upon the behavior of the cerebrospinal fluid with the Fehling solution. If it is the tubercle bacillus it will reduce; if it is PLATK XXXrX Cerebrospinal IMeningitis. Autopsy showed a ycllowisli-green. muco- purulent exudate, cheesy in character, covering the anterior two-thirds of the cerebrum. Tiie fluid obtained by lumbar puncture as well as that by intraventricular aspiration sliowed a p\ire inlluenza bacillus. The autopsy was performed by Dr. John Larkin, The fluid examined by Dr. Sophian and Dr. ISI. D, Kaplan. CEREBRO-SPINAL MENINGITIS. 787 another ofganism it will not. The latter phenomenon is due to the fact that it produces a marked increase in the polynuclears, which in some way are responsible for the non-reduction. The importance of cerebro-spinal fluid examinations in paediatrics needs no emphasis. Either constipation or diarrhoea may be present. The bladder acts well, although enuresis may exist. In some cases there is a marked retention of urine. The joints are usually swollen, simulating rheumatism. There is also a distinct petechial eruption in some cases. Out of a series of twenty- two eases seen by me, six had distinct petechia. In six others the skin had a distinct eruption resembling scarlet fever. Owing to the spots present in this condition, the disease was frequently tenned "spotted fever." The pupils are usually dilated; they are sometimes irregular. I have seen cases during the epidemic of 1905 in which one pupil showed marked dilatation, while the other pupil was contracted to almost a pinpoint. Strabismus is a frequent symptom. Occasionally we note nystagmus. Photophobia is a frequent symptom. In one of my cases the child cried whenever a lighted candle was brought near the eyes. Opisthotonos is usually present. The severe rigidity of the sternocleidomastoid muscle in addition to the marked rigidity of the arms and legs forms a very prominent symptom during the course of the disease. , Owing to these severe contractures we usually note constant moaning, most likely induced by the pain caused by the said contractures. Diagnosis. — A positive diagnosis of this disease can be made by examin- ing tbe fluid drawn by lumbar puncture. As a rule the spinal fluid is turbid or opaque. We do not find the spinal fluid clear and transparent, as it is seen in tuberculous meningitis. The presence of the characteristic diplo- coccus intracellularis described by Weichselbaum is usually noted. In rare cases the streptococcus and the pneumococcus have been found, but these latter are the exception. The bacteriological diagnosis, according to Weich- selbaum, depends on the diplococcus being Gram negative, or decolorized by Gram. It is important to remember that the Micrococcus caiarvhalis is fre- quently found in the nasal passage; hence, great care must be exercised to differentiate the same, both in its relation to Gram staining and also in its morphological characters. The following two cases will serve to illustrate the method of treatment : — Case I. — Emilio Gr., four months old, was admitted to the Sydenliam Hospital, January 6, 1909. Family history negative. Personal History. — Normal delivery. Full term. Bottle-fed since birth. Present illness began two weeks ago with twitehings of the muscles. One week ago mother noticed retraction of the head. There had been no vomiting. The baby had moaned almost constantly. Physical Examination. — ^Head showed bald occiput. The anterior fontanel was open and slightly bulging. The pupils were equal and slightly contracted. There 788 DISEASES OP THE NERVOUS SYSTEM. was marked retraction of the head, amounting to opisthotonos. The chest showed poor expansion. There was a systolic murmur heard at the apex of the heart. The lungs over left base, posteriorly, showed small areas of dullness, bronchial voice, and breathing. The abdomen was retracted. The liver and spleen were not palpable. There was marked rigidity of both arms and legs. The reflexes were exaggerated. Kernig's sign was not elicited. Lumbar puncture showed turbid fluid in which the Diplococcus intracellularis was found. The duration of the disease was thirty-six days. By means of ten lumbar punctures, I aspirated 146 cubic centimeters spinal fluid, and in nine intraspinal injections, I injected 245 cubic centimeters Flexner serum. The average injection was about 30 cubic centimeters. The child made a complete recovery without any sequelae. Case II. — Intraventricular Method of Serum Injection. — Dora B,.,^ two months old, was admitted to the Babies' Ward of the Sydenham Hospital, October 2, 1909 ; she was a well-nourished, breast-fed infant, having had no previous illness. There was a sudden onset with vomiting, loss of appetite, rigidity of head, neck, and extremi- ties, rolling of the eyeballs, insomnia, and convulsive movements. The anterior fon- tanel was open one-half inch in diameter, and slightly bulging. The posterior fon- tanel was almost closed; The pupils were equal, and reacted sluggishly to accom- modation and light. The thorax, ears, and throat were excluded as a possible source of disease. On the fifth day after admission, and on two succeeding days, lumbar puncture was performed resulting in dry tap. With the three successive dry taps, the symp- toms of rigidity, opisthotonus, fever, and twitching increased. On October 20th, I decided to tap the lateral ventricles by entering the ante- rior fontanel at the right angle.^ The aspiration needle, about 8 centimeters in length, was introduced downward and toward the median line, at an angle of about 20 degrees, to a depth of about 4.3 centimeters, the needle entering the lateral ventricles near the median line. About 15 cubic centimeters of turbid purulent fluid were withdrawn, which was identified at the Rockefeller Institute as a meningo- coccus intracellularis. The ventricles were then irrigated with normal saline solu- tion, at body temperature. The excess fiuid was allowed to drain out through the needle, and 25 cubic centimeters of Flexner anti-meningitis serum were slowly injected into the ventricles. During the injection of the serum the infant changed in color from a waxy pallor to a uniform red fiush all over the body. One-half hour after the injection of the serum the infant still remained flushed, perspired profusely, and had some frothing at the mouth. Otherwise the general condition was good. The temperature was 98° F.; respiration, 80, and pulse, 120. On October 21st, the ventricles were again irrigated with 40 cubic centimeters of normal saline solution, and 20 cubic centimeters of serum were injected. October 24th, the child's general condition was very poor. Opisthotonos was marked. The body rigidly bent in the form of a bow. The arms were rigidly extended and the palms everted outward. October 25th, and during the following week, daily injections of 30-50 cubic centimeters of serum were injected either into the ventricles or, on two days, into the spinal canal and lateral ventricles. The total amount of Flexner serum injected was 180 cubic centimeters; the total amount retained in the ventricles and spinal canal was about 100 cubic centimeters. The child made a complete recovery. ^ This case was presented at the Section on Pediatrics, New York Academy of Medicine, March 10, 1910, * See Plate XLI. IM.A'I'K XI. Cerebrospiiial Mciiiiicfitis due to the Tnfliu'iiza llaeilhis. A, A. Anterior oorcbvum covered witli a thick iiiiico-purulent exudate. B, H. Normal eerchnini. C. Sujx-rior lonjiitiidinal siiui?;. D. Reltceted iiiteguiuejits. Ihthalmology, 1886, No. 4, p. 441. * Griff ord : Archives of Ophthalmology, vol. xxv, 1896, p. 314. *Veasey: Archives of Ophthalmology, vol, xxxviii, 1899, p. 301. MKMBRANOUS CONJUNCTIVITIS. 821 Treatment. — Clean the eye by clipping small pledgets of absorbent cot- ton into lukewarm water, or dip the cotton into a 2 per cent, solution of borax. A medicine dropper can be filled three or four times with a solution of: — a. Formalin ^ 1 to 2000 Sig.: Wash or bathe the eye with this formalin solution every four hours. Very hot water applied on pledgets of sterilized cheese-cloth will re- duce the inflammation of the lids. In other cases, cold lead and opium wash will be very soothing and have a similar effect. We can prevent the lids from sticking together by applying vaseline at night. Purulent Ophthalmia (Ophthalmia Neonatorum). This is a purulent conjunctivitis of the new-born infant. It may be seen several hours, or sometimes appears several days, after birth. The amount of pus secreted is very large. When the lids are separated pus will be liberated. Etiology. — It is usually caused by an infection in the maternal pas- sages containing the gonococcus during labor. The pneumococcus has also been found in some cases. These pathogenic bacteria are carried directly into the eye, either by the secretions or by means of infected sponges or towels. Bacteriology has proven that all causes excepting distinct germ infection must be eradicated. Symptoms. — The lids appear red and swollen. The upper lid fre- quently overhangs the lower and the infant is unable to open the eyes. Stephenson states that 10 per cent, of children so affected remain totally blind. Of 446 cases of ophthalmia occurring in the practice of seven phy- sicians quoted by Stephenson, gonococci was found in 72.83 per cent. In Stephenson's own cases, out of 45 affected, 30 showed evidence of the gono- cocci, or 66.5 per cent. Preventive Treatment. — The Crede method is now universally used. As soon as the infant is born and the face wiped clean, the following solu- tion is dropped into the eye: — It Nitrate of silver solution 2 per cent. Sig. : It is best to let it fall from a medicine dropper on the eyeball. A slight inflammatory reaction is occasionally seen and if treated with a cold solution of formalin, 1 to 2000, disappears quickly. Membranous Conjunctivitis (Diphtheritic Conjunctivitis). We occasionally see membranous patches on the surface of the con- junctiva. This membranous deposit is sometimes distinctly diphtheritic, ' Formalin is a 45 per cent, solution of formaldehyde. Formaldehyde itself is a gas and a strong escharotic. 822 DISEASES OF THE EYE. a culture taken showing the jDresence of the Klebs-Loeffler bacillus. To differentiate clinically between the" diphtheritic and non-diphtheritic type is sometimes impossible. I have seen membranous conjunctivitis at the Willard Parker Hospital in which the disease clinically resembled diph- theria and still the Klebs-Loeffler bacillus was absent. In one case seen by me the streptococcus alone was present. The clinical history of the case is an important guide in the diagnosis. If another case of diphtheria exists at the same time in the same house, the question of transmission should have weight in making the diagnosis. Every case of membranous conjunc- tivitis requires a careful inspection of the fauces. If croupous laryngitis is present, then a greater probability of diphtheria is warranted. Symptoms. — A grayish-yellow patch can be seen on the conjunctiva. The lids are very tender and swollen. They feel hard and thick on palpa- tion, and cannot be everted. Ulceration or sphacelation of the cornea usually follows. The same systemic disturbances may be noted as are found in diphtheria affecting the throat. There is usually fever, glandular en- largement, loss of appetite, general prostration, and cardiac disturbances, as has been described in the chapter on "Diphtheria.^^ Prog"nosis. — A very guarded prognosis is necessary, as the outcome of the case depends upon the care bestowed and the time when the case was first seen. If the disease has been established a long time, a greater de- structive tendency must be presumed than if the case was seen when it first originated. Treatment. — First isolate. The communicable nature of this disease must be remembered. The family and friends should be warned of the danger. Local Treatment. — If the eyes are thick and swollen, an ice-bag or ice-cold pledgets of cotton soaked in bichloride, 1 to 2000, should be ap- plied. They should be renewed every five to ten minutes night and day, to produce a good result. In other cases warm, moist applications will alleviate pain and also reduce inflammation. Specific Treatment. — Diphtheria is diphtheria whether it is in the eye or in the throat, hence an injection of 5000 units of antitoxin should be given regardless of the age of the child. The same internal treatjjient which is described in the chapter on "Diphtheria'^ is recommended if we desire successful results in these cases. Granular Ophthalmia (Trachoma). The characteristic feature lies in the development on the palpebral conjunctiva of the so-called "sago grains.'' Granular lids must be carefully considered owing to their disastrous tendency. GRAM L'LAR (JIM ITIlAl.AllA. 823 The following table, slightly modified from Stephenson ('"Epidemic Ophthalmia/' 1895) gives the dilferential diagnosis between folliculosis of the conjunctiva and trachoma: — Table No. 80. FALSE OR FOLLICULAR GRANULATION. 1. Oval or roundish transparent bodies the diameter of which never ex- ceeds from 1 millimeter to 1 Va milli- meters. Of a faint yellowish hue, ar- rangeil in rows parallel to the lid border, and discrete. Most marked in inferior retrotcirsal fold. 2. Little or no change in the structure of the conjunctiva. TRACHOMA. 1. Round, opaque, ill-defined bodies, of giuyish-white color and extreme friabil- ity. Firmly and deeply embedded, in the conjunctiva, their diameter not in- frequently reaches 2 millimeters or more. Tendency to become coulluent and form masses or areas of trachomatous ma- terial. Most numerous and larger in upper retrotarsal fold. 2. Structural changes always present. 3. Papillary hyi^ertrophy of upper lid slight. 4. Tarsus never implicated. 5. Disappear spontaneously generally and leave no scar. 3. jMarked hypertrophied papillae of upper lid generally present. 4. Tarsus often involved. 5. Spontaneous cure may occur, but only by cicatrization, which may be slight or extensive according to the amount of tissue involved. 6. No ptosis. 6. Ptosis nearly always present in some degree. 7. No pannus. 7. Keratitis in the form of pannus or ulcer in about 25 per cent, of the cases. 8. No trichiasis, entropion, or cica- 8. Fi'equently leads to trichiasis, en- tricial contraction of the cul-de-sac. tropion, or shrinking of the cul-de-sac. 9. Most frequent in persons under 20 years. 10. Non-contagious. 9, May occur at any age. 10. Conditionally contagious. This disease may frequently assume an epidemic nature. Dur- ing the last two years hundreds of cases have suddenly appeared in our city. The ease with which all infectious diseases spread in the congested portions of our city applies to trachoma. For this reason school-children and inmates of institutions and hospitals should have the eyes carefully inspected on admission to exclude trachoma. In our country the native American Indian suffers from this disease, so do the Irish, Polish, Italians^ 824 DISEASES OF THE EYE. and the Teutonic races. It is therefore quite probable that this disease is spread more or less among all races. One race is exempt;, namely, the negro. Treatment. — Of all methods, expression is the method generally used. The morbid tissue is thereby dislodged and removed. Actual cauterization, galvano-cautery, or the solid nitrate of silver stick is mentioned by some, but should be used only by those familiar with the eye. The advice that I give in my office to patients suffering with trachoma, is to recommend them to an eye specialist. Fig. 280. — Trachoma, Showing Round, Opaque Bodies in Upper and Lower Lids. "Sago grain" type. From a photograph — frequent type seen in children. (Original.) Blepharitis. This disease is characterized by a sub-acute or chronic inflammation along the margin of the lids. Two classes of cases might be noted. First, those in which slight crusts appear on the edges which, when cleared off, show no loss of sub- stance; simply reddened margin. This would include the cases of mar- ginal eczema, so called. Second, those cases which, when cleared of crusts, show ulceration. The first class of cases seek treatment for cosmetic results. There is no pain, only a slight discomfort exists. These cases are all aggravated by exposure to> dust, wind, heat, or long spells of work. The second class of cases is more serious. At first they present a dusky margin and gluing together of eyelashes, due to excessive secretion, which HORDEOLUM. 825 gradually progresses. Beneath the crusts ulcers form. Excoriations and pustules about the hair follicles interfere with the growth, so that the lashes fall out or become stunted. The vascularity continues, increasing the thickness of the lids with new connective tissue. Tlie gradual contraction of this new scar tissue leads to evcrsion of the lids with resulting epiphora, or overflow of tears, presenting a disagreeable, raw-looking surface. Treatment. — Generally speaking, the treatment consists of removing the crusts or scabs l)y any warm alkaline lotion, such as bicarbonate of soda, or biboratc of soda, 10 to 20 grains; aqua3, 1 ounce. Massage of the lids with red or yellow oxide or white precipitate, 2 to 8 grains ; vaseline, 1 ounce, should follow. A mild ointment should be used — a strong one in- creases the irritation. All re- fractive errors must be cor- rected. Epilation of the lashes sometimes promotes a cure when commenced in the early stages of the disease. The general condition of the patient must be looked after, and iron, arsenic, codliver- oil, or similar tonics and hy- gienic treatment as indicated should be prescribed. Hordeolum, or Stye. This disease is character- ized by an inflammation of the connective tissue about a hair follicle along the lid margin. A hard, circum- scribed, inflammatory nodule forms, which may suppurate. Occasionally, it remains as a hard lump, and still in other cases the lid becomes swollen and oedematous. A close examination, however, will show the inflammatory spot, which as soon as it appears yellowish should be incised and the pus evacu- ated. Treatment. — The general treatment consists in hot applications to favor resolution. To prevent successive crops, the massaging of the lids with an ointment of hydrarg. ox. flav., ^/^ to 2 grains ; vaseline, 2 drachms, has an excellent effect. The infection from the pus may be prevented by the use of argyrol in a 5 per cent, solution, one drop two or three times daily. Fig. 281.— Method of Everting Eyelid. (After Davis and Douglass.) 826 DISEASES OF THE EYE. These successive styes show some disease of the lid margin^ as blepha- ritis, some derangement of the general system, or eye-strain, especially in hypermetropia. Phlyctei^iilab Conjunctivitis. This affection is one of childhood and is seen in malnutrition after the acute exanthemata; also in marasmic or scrofulous children. Small elevated spots, papules, or pustules the size of a mustard seed are found in this condition. When the epithelial covering is shed they become superficial ulcers. They are either single or multiple, and appear as pinkish, yellowish, or grayish spots. There is very often a great dread of light — photophobia — which leads to spasms of the lids — ^blepharospasm. There are also at times pain, burning sensation, and lachrymation. Treatment. — Local treatment consists of bathing with a saturated solu- tion of boric acid. If any excoriation exists at outer canthus, touching it with nitrate of silver generally effects a cure. If the symptoms show that the condition is subacute or chronic then stimulating applications are required, as: — IJ Hydrarg. ox flav 4 to 8 grains Vaseline 1 ounce M. and apply three times a day. I have had excellent results by touching the affected parts lightly with a solid stick of alum or copper. If there is much corneal involvement: — 5 Atropin sulph V2 grain Aq. dest 2 drachms Sig. : One drop in the eye once or twice daily may have to be used. For the blepharospasm, a force I opening of the lids, an occasional drop of a 2 per cent, solution of cocaine, or a sudden plunging of the head in cold water will relieve the condition. General Treatment. — This consists in the hygienic care of the child and tonic treatment. The eyes should be kept clean and open, dark glasses should be worn if necessary. No dark room, bandages, or eye shields should be allowed. The bowels should be regulated. The diet should be looked into. All sweets interdicted, meat given occasionally, and milk foods or- dered. Give plenty of fresh air, outdoor exercise, and bathing. Tonics, such as codliver-oil, syr. ferri iodide, str}^chnine, etc., should be given. CHAPTER III. DISEASES OF THE SKIN. Eczema. This eruptive disease is very frequently seen in infants as well as in older children. Etiology. — Irritation, be it an irritant soap or an irritant discharge, can give rise to eczema. Eczema is frequently an external manifestation of toxic conditions. The frequency with which eczema is seen in children with dyspeptic conditions certainly invites consideration. Children having rickets are frequent sufferers with eczema. Some' authors believe that pathogenic hacioria can enter the shin and set up eczema. While this ap- pears plausible, it remains to be proven. It is found associated with de- ficient elimination from the skin in the unclean, in dyspeptic conditions when the stomach and bowels are not properly functionating, and also when the kidneys do not properly act. I have frequently seen children with a facial eczema which appeared when oatmeal was given and disap- peared when the same was stopped. Eczema may be due to reflex irrita- tion. Holt says that cases which accompany dentition and those due to genital irritation can be called reflex. This disease can be either localized (regional), as when it is confined to the face or between the thighs, or it can be general or universal. Symptoms. — There is always an' intense itching or burning with the appearance of the eczema. On the cheeks it usually begins with "small red papules, later these coalesce and there is a moist red surface, exuding serum or sero-pus." Children scratch and thus usually produce bloody streaks. The crusts have a yellowish-brown appearance. There is a red- ness, thickening, and always scaliness of the skin. The glands in the im- mediate neighborhood are usually swollen ; they rarely lead to suppuration. Eczema frequently spreads from the face to the forehead and the neck, and I have seen it involve the whole head. Inrant G. S., seven months old, was nursed about six weeks at his mother's breast. He was then fed on top milk and barley water. As this disagreed he was given barley water. He then had dyspeptic, greenish stools, and the feeding was changed to milk and rice water, which seemed to agree qiiite well. He gained steadily one-half pound every week for the next three months. He was at the seashore all summer and had no evidence of summer complaint. \^nien seven months old he was slightly constipated and with it had dyspeptic fermentation. His appetite was poor. It was necessary to stimulate the bowels to produce proper evacuations. (827) 828 DISEASES OF THE SKIN. Teething appeared at about the eighth month. At the same time the child had a severe attack of influenza of the gastric type, with high fever, anorexia, and gastro- intestinal atony. At this time a scaly and papular eczema appeared on one cheek and rapidly spread to both cheeks. With the application of a bland ointment con- sisting of zinc oxide and vaseline it disappeared. One week later I again saw this child with a relapse of high fever and dyspeptic symptoms, and a severe eczema covering an area larger than before. It was very red and angry looking and weep- ing in character. A gauze mask saturated with calamine and zinc lotion (3 per cent.) produced a marked improvement, besides relieving the itching. Internally I gave rhu- barb and soda tablets in addition to cutting down the quantity of milk one-half of the previous strength. After three weeks of this form of treatment I was able to return to the former full milk feeding and the eczema did not return. CALAMINE LOTION. IJ Pulv. calamini 2 parts Pulv. zinci ox 2 parts Glycerini 1 part Aq. calcis 30 parts Treatment. — Another cooling and antipyretic lotion that has served me very well is the following: — IJ Phenol 20 drops Zinc oxid 3 drachms Calamine 2 drachms Glycerine ■ 4 drachms Liq. plumbi subacet. dil 1 ounce Lime water q. s. ad 6 ounces The following are suggested: — • IJ Zinc oxide 2 drachms Amyl '. 2 drachms Naphthalan 1 ounce Apply "at night. (Dr. John Fordyce.) unna's soft zinc paste. U 01. lini, Aq. calcis, Zinci ox., Cretse of each, equal parts. Bland, unirritating applications, such as rice powder, zinc oxide, stearate of zinc, talcum, or cornstarch, are very cooling, and seem to act by absorbing the heat and moisture if any be present. Bathing in Eczema. — I have frequently found an apparently cured case of eczema break out anew Avith a red blush and eczematous patches after one ordinary cleansing bath was given. In the acute stages water should be omitted. Applications of a 5 or 10 per cent, calamine and zinc salve or lotion, as described in the clinical case above given, are very beneficial. ECZEMA. 829 Soap should never be used. When hard crusts cover the surface of the skin and cannot be softened by the ordinary application of salves, the fol- lowing treatment should be instituted : A bland bath consisting of one pound of oatmeal in a cheese-cloth bag, thoroughly soaked in hot water for at least one-half hour, and enough water added to bathe the eczematous parts. After thorough soaking in this oatmeal bath the calamine and zinc or a 2 per cent, boric acid and vaseline ointment should be applied. One bath only should he given. The salve should be applied three times a day for at least one week. Irritating ointments, or those containing tar, should be avoided in the acute condition. Eczema Eubrum. The eczematous blush affecting the face may be mistaken for erysip- elas. Erysipelas usually occupies a smaller area, generally on the bridge of the nose. High fever usually accompanies erysipelas; this will easily dif- ferentiate the condition. The treatment is the same as that outlined in the article on "Eczema.'' SALICYLIC-SULPHUB PASTE. IJ Ac. salicyl 1 part Sulph. depur 5 parts Petrolati 25 parts Zinci oxid 10 parts Amyli 10 parts ICHTHYOL OINTMENT. IJ Ammon. sulph. ichthyolat 5 parts Aq. dest 5 parts Adeps benzoat 15 parts Adeps lanae 25 parts Crusta Lacta. To soften the milk crusts which form on the scalp of infants, applica- tions of the following will loosen the crusts, after which they may gently be combed away: — IJ Olive oil % ounce Castor oil % ounce Salicylic acid 4 per cent. Eczema Intertrigo. In fat children where two opposing surfaces of skin are in contact, such as between the thighs or toes or in the armpits, a red form of inflam- mation frequently ensues. It is sometimes accompanied by a thin, foul- smelling discharge, which may be serous, but very rarely is purulent. This condition is more apt to be noticed in the unclean. 830 DISEASES OF THE SKIN. Treatment. — Eemove the cause by separating the parts. Sprinkle freely with talcum, zinc oxide, lycopodium, fullers' earth, or any good infant's powder. In severe cases separate the parts by placing a sterile pad of cheese-cloth on both sides of which zinc salve is smeared. All warm clothing should be avoided. When severe excoriation results from dis- charges and is not checked by the application of bland salves, then cool lead and opium wash applied for a day or more is soothing and will reduce the inflammation. When infected conditions occur, apply: — IJ Hydrarg. ammoniate 10 grains Lassar's paste 1 ounce Eryti-tema. Local irritation such as might be caused by a mustard plaster or the friction of a dress, producing a "chafe," or irritating secretions, such as a purulent ophthalmia or acrid discharge from the nose, produces this ery- thema. It is frequently seen in infants on the buttocks from lack of clean- liness. When seen on the buttocks it may be mistaken for syphilis. Ery- thema is easily differentiated from syphilis by the absence of snuffling of the nose, of the ham-colored eruption, and of the inelastic, cracked appear- ance of the soles and palms. Urticaria (Hives; ISTettle Eash). This inflammatory condition of the skin appears very suddenly. No special portion of the bod)'- is exempt; thus, it may occur on the face, abdomen, or extremities. It consists of irregular-shaped blotches called wheals. When these spots disappear they leave no trace behind. There are several varieties of urticaria. Urticaria annularis occurs in rings. Urticaria figurata occurs in spirals. Urticaria vesiculosa has vesicles on the summit of the wheal. Urticaria bullosa is a bullous development on summit of wheal. Urticaria papulosa is a wheal combined with a papule. Urticaria, tuherosa are giant wheals. Urticaria hcemorrhagica is a combination of urticaria with purpura. Urticaria pigmentosa is a pigmentation following the wheals. The form most frequently met with in children is likely due to (a) ptomaine poisoning; (h) the result of some toxin in the system. Causes. — Shell-fish, strawberries, and frequently cereals seem to be the cause of urticaria in some children. There is usually some gastric or gastro- intestinal disturbance at the time of the appearance of this rash. There seems to be a peculiar idiosyncrasy in some children to quinine and to HERPES ZOSTER. 831 other drugs which will bring out an attack of urticaria. A great many children have severe urticaria after an injection of antitoxin. (Read article on "Antitoxin Rashes.") Insect bites will sometimes cause this condition. Symptoms. — There is severe itching, and scratching will frequently develop a new rash. Fever sometimes accompanies this condition. Urti- caria once seen is very easily recognized and is not hard to differentiate. The prognosis is usually good. We must remember that children prone to idiosyncrasies will have urticaria quite frequently; thus, it will depend on the diet as to whether or no the rash remains away. Treatment. — ^The first thing to do is to cleanse the gastro-intestinal tract with one or two teaspoonfuls of castor-oil, followed with 1 drachm of rhubarb and soda every three hours until the stools become loose, and the condition is improved. Locally. — The severe itching can best be allayed by making a paste of bicarbonate of soda and cold water. Rub this paste into the hives. A cool tub bath, containing several ounces of bicarbonate of soda, will fre- quently relieve the itching. Evaporating lotions, such as lead and opium wash or a weak solution of vinegar and water, are soothing to some cases. In other cases the following will give relief : — R Resorcin 1 part Menthol 1 part Phenol 1 part Alcohol 200 parts M. Apply with cotton. Large quantities of water should be given for thirst. It will also aid in eliminating toxins through the kidneys. Herpes Zoster (Shingles). "This is an acute inflammation consisting of a group of vesicles. It is mostly seen over a surface of skin corresponding to a definite nerve tract. It is accompanied by neuralgic pain." Symptoms. — As a rule, there is a broad band of vesicles corresponding to the affected area, usually following a nerve tract along the limbs or along the borders of the ribs. It develops very rapidly and frequently resembles an erythema. The crop of vesicles is frequently so thick that they almost touch one another. Prognosis. — As this is a self-limited disease, the prognosis is good, although neuralgic pains may persist for some time after the disappearance of the eruption. Treatment. — Avoid irritant salves and use cooling dusting powders, such as bismuth, cornstarch, wheat flour, or powdered zinc oxide. The 832 DISEASES OF THE SKIN. affected part should be covered with linen or gauze, not flannel or wool. To allay intense itching or inflammation use calamine and zinc lotion (see chapter on "Eczema"). Chloasma (Tinea Yersicolor; Liver Spots). This is a very mild form of eruption in which brown patches of skin are seen. It is caused by the invasion of a fungus. Treatment. — The application of white precipitate ointment or 1 per cent, bichloride in alcohol has served me very well in removing the same. Psoriasis. This is a chronic inflammatory disease affecting the extensor sur- faces. It consists of a red, scaly patch in which white, silvery scales abound. Etiology. — There is no specific factor, as it is found in both the rich and poor, although it frequently follows malnutrition of the body such as we see after the acute infectious diseases. This condition also fre- quently affects children of gouty parentage. Symptoms. — ^The extensor surfaces are usually affected; hence the dis- ease will be found on the extensor sides of the arms and legs. The sym- metrical arrangement of this eruption on both sides of the body is a char- acteristic condition. Prognosis. — This should always be cautiously given. As the disease has a chronic tendency, it may remain for years unless actively treated. Treatment. — Locally : — IJ Chrysarobin 2 to 10 per cent. Petrolatum 1 ounce or as a varnish IJ Chrysarobin 2 to 10 per cent. Liquid gutta percba or traumaticine 1 ounce B Salicylic acid .T 4 drachms Chrysarobin 2 scruples Painted on daily, until reaction follows. Whenever treatment is given, it must be continued until every spot has disappeared ; otherwise the condition will relapse. The primary infectious agent is the streptococcus; later we have the staphylococcus. Systemic Treatment. — No one must expect to cure this disease unless the emunctories are properly looked after. We must keep the bowels loose, and the kidneys active. The dairy products should be permitted ; also meat, vegetables, and fruit. PEDICULOSIS. 833 Eestorative treatment such as codliver-oil, iron, and arsenic should be given liberally. In this disease arsenic proves itself of great value. Ar- senic need not be feared and can be given to children in very large doses. Fowler's solution, in 3- to 10- drop doses three times a day, is usually sufficient. Impetigo. This infectious and contagious disease is characterized by an eruption which may appear on any part of the body. It is most frequently seen on the exposed parts, usually on the face and hands. Symptoms. — There may or may not be fever at the onset of the erup- tion. The eruption usually commences on the face and hands. It is easily communicated. Treatment. — ^A tub-bath consisting of kali sulphur (one ounce), dis- solved in a porcelain or wooden tub full of water. The temperature of this bath should be about 100° F., and the duration of the bath about five minutes. This bath should be repeated every night, before retiring, for one week. If the sulphur bath cannot be used, then apply a 10 per cent, ammoniate mercury ointment rubbed up with zinc oxide. The following lotion may be applied several times a day : — IJ Zinc sulphate 3.5 parts Copper sulphate 1 part Aqua 100 parts Pediculosis. Among the neglected or unclean we frequently see this condition. It is caused by the invasion of a parasite, the pediculus capitis. There is usually an eczematous condition and the adjacent glands are swollen. The habitat of the pediculus is in the hair, but it causes eczematous patches by irritation. Pediculosis is often complicated with impetigo. It spreads to the face and makes a picture of impetigo. The infection is primarily streptococcus, secondarily staphylococcus. Treatment. — First, remove the hair, if at all possible; if not, saturate the hair with petroleum, but avoid the scalp. This should be left on five or six hours, after which the scalp and hair should be saturated with equal parts of ether and tincture of delphin to loosen the nits, which can then be removed with a fine comb. The hair should then be thoroughly washed with soap and water. Miliaria Papulosa (Lichen Tropicus; Prickly Heat). This variety of skin disease is frequently seen in summer. It consists of bright-red papules on the summits of which there are very tiny vesicles ; at times pustules may also be seen. The eruption is usually confined to 63 834 • DISEASES OF THE SKIN. those parts which are warmly clad, so that the abdomen, chest, and the extremities are most frequently covered. Eczema frequently follows this condition, and if severe scratching takes place, local infection ending ia furunculosis may occur. The other parts of the body which do not have the eruption usually show extensive perspiration. This eruption comes and goes very quickly. It is frequently mistaken for scarlet fever. The absence of fever, the appearance of the tongue and throat, and the absence of the prodromal symptoms will easily differentiate this condition. Treatment. — Ehubarb and soda or a dose of calomel at the beginning. If the kidneys are inactive, then 10 to 20 drops of sweet spirits of niter should be given, and repeated two or three times a day. For the intense itching' the application of a paste consisting of bicarbonate of soda and water will stop the itching. The body should be made comfortable by removing all warm clothing. A tepid alkaline bath, temperature 70° F. — ; a bath to which several ounces of bicarbonate of soda have been added — is very grateful and will give quick relief. After the bath, dry the body thoroughly and dust cornstarch or wheat flour with talcum or zinc oxide, and let the child sleep with as little clothing on as possible. If im- provement does not follow within twenty-four hours, then the application of the following salve will relieve itching and reduce the inflammation : — I^ Zinc oxide 1 draclim Calamine 1 drachm Cold cream 1 ounce M. Apply three times a day. Miliaria Eubra (Strophulus Infantum; Eed Gum). This rash is the result of an irritation due to perspiration. It con- sists of red papules, sometimes having tiny vesicles. It is usually seen on the cheeks of an infant and always upon the side on which the infant sleeps. The treatment is the same as that given in the article on "Miliaria Papulosa." SUDAMINA. Sudamina are small, pearly bodies occurring during fever or exhausting diseases. They are usually seen over the sweat ducts. They are easily absorbed and fresh crops take the place of these tiny vesicles. Lentigo (Freckles). i This is a very common affection of the skin. It is usually seen in children over 5 years of age, and most especially in those having blonde or red hair. The skin is certainly more sensitive to sunlight in such cases, and successive crops of freckles frequently appear after exposure to the light. FURUNCLE. 835 The treatment consists in protecting the skin against exposure to the light. The freckles can be removed by a mild form of counter-irritation, such as the application of a 1 per cent, solution of bichloride of mercury. Apply on cotton to the affected area for three or four successive hours. This form of counter-irritation destroys the skin, causing it to desquamate. The new epidermis which appears is free from this pigment. Seborehgea. This is a very common condition of thick, dry, crusty formation which occurs on the head of infants. It most frequently involves that region surrounding the anterior fontanel. There are two varieties: (a) sebor- rhoea oleosa; (&) seborrhoea sicca. Some authors state that if the vernix caseosa in the new-born is allowed to continue, it passes into a seborrhoea and may eventually become an eczema. When carefully examined, sebor- rhoea will be found to consist of epithelial cells, fat, and chiefly dirt. There are no inflammatory symptoms. When the scales are removed the skin is usually found normal. Treatment. — The following is recommended: — !R Salicylic acid 15 grains Vaselin 1 ounce M. Rub the scalp thoroughly several times a day and leave on overnight. Wash scalp with soap and warm water the following morning. If necessary repeat several evenings and wash in the morning as above directed. Sulphur soap is useful in this condition. The officinal ointment of sulphur can be rubbed into the scalp if this condition recurs. Furuncle (Boil). This inflammatory condition occurs around a hair follicle or a gland of the skin. It is most likely caused by scratching, during which process there is an infection of the follicle with pyogenic bacteria such as staphy- lococcus pyogenes aureus. Frequently we see boils scattered through the scalp in large crops. At other times they occur singly. A boil begins as a small, red spot in the true skin, very tender, and growing larger and larger. On palpation the center is soft and there is a tendency to sup- puration. After suppuration has taken place, and the boil emptied, the swelling subsides. A furuncle has but one point of suppuration, whereas the carbuncle has many. A furuncle is usually a small swelling. A car- buncle very large, frequently several inches in diameter. Treatment. — Aseptic surgical details are demanded in each and every instance. The scalp should be shaved. The area of the skin involving the furuncle should be washed with carbolated soap and water, and subse- quently with water. A free incision should be made, the pus liberated, and the part dressed with sterile gauze. When furuncles recur, then specific 836 DISEASES OF THE SKIN. results can be obtained by an injection of an autogenous vaccine made from the patient's pus. The staphylococcus pyogenes vaccine can be injected in doses of 500 million daily. No more than five or six injections will be needed to effect a cure. I have also had good results with stock vaccine^ in injections of 200 million, with an initial dose of 100 million. Iron, codliver-oil, and other restoratives are indicatedj The value of nutritious food must not be overlooked. Chronic Pemphigus.^ This frequently follows the acute condition. It resembles the acute disease in producing a succession of crops of buUse. The prognosis depends on the condition of the child at the time when it was first attacked. If the infant is underfed, and its vitality lowered thereby, then active restorative treatment should be instituted or the ease will be lost. Treatment. — The blebs should not be ruptured. They should be al- lowed to dry. The surface of the skin in the immediate neighborhood should be protected by a bland, non-irritating ointment, such as zinc salve or diachylon salve. Sprinkling powder of zinc oxide, borated talcum, or cornstarch should be used. If the bullae rupture, the serum should be absorbed with a little cotton and the neighboring parts protected from the excoriating effect of the contents of the ruptured bullae. Careful attention must be given to the stomach and bowels. If necessary, a mild laxative should be given. The diet should be regulated both as to quantity and quality. JSTjevus. There are two kinds of nsevus usually seen: (a) pigmentary; (6) vas- cular. Pigmentary occur as small, rounded stains, which are either yel- lowish or dark brown. The cutis is raised, thickened, and frequently sur- rounded with a tuft of hair. They are most commonly seen on the face, neck, and hands. Vascular natvi may be level with the skin or appear as tumors which project beyond it. The former is due to an excessive development of the capillaries of the skin. Commonly met with, it is of a purplish hue, although it may be brick-red, claret-red, or a livid-hlue color. They are most commonly seen on the face and neck. Treatment. — Blistering or caustics are recommended for the cure of this condition. I have frequently seen marked benefit from linear scari- * Purunculosis vaccine or polyvalent staphylococcus vaccine. Parke, Davis & Company. * See article on "Pemphigus Neonatorum." TINEA TONSURANS. 83? fication by the Paquelin cautery. A radical operation should be considered if this milder form of treatment is unsuccessful. Tinea Tonsurans (Ringworm). This disease is caused by the trichophyton tonsurans. When located ©n the scalp it is called herpes tonsurans; when on other parts of the body it is known as herpes circinatus. Microscopical Appearance. — Squire says: "Under the microscope the stump of the hair appears ragged on either of its ends. Instead of break- ing with a clean fracture, like healthy hair, the broken ends are digitated. The structure of the hair is greatly altered; its fibers are separated longi- tudinally, and the intervals filled with the spores of the trichophyton. On the surface of the hair are clusters of the same spores. The magnified piece of hair looks something like a bundle of faggots, with a number of berries sticking in clusters to its sides and ends, and stuffed here and there into its interstices. The spores of the trichophyton are rounded, have a well-defined outline, and measure about Vsooo i^ch across. In the earlier stages of the disease, when the hair has not yet become so brittle as to make it impossible to extract the root, it can be ascertained that the knob of the hair, as well as its root-sheath, is invaded by the spores of the tri- chophyton." The disease commences with more or less itching and redness of some parts of the scalp ; sometimes there is swelling. The hair growing on these patches loses its polish, and becomes dull. It is also brittle and easily breaks off near the root. This breaking off of the affected hairs gives the patch the appearance of having been lately shaved. There is a furfuraceous des- quamation plainly seen on the scalp. The hair follicles become erect and the patch assumes a goose-skin appearance. The margin of the patch is abruptly defined. There are usually several patches seen on different por- tions of the scalp. If we attempt to pull out the hair stumps by means of a tweezer, we will note that only a portion of it comes away, leaving the hair root in the skin. Treatment. — X-ray treatment was introduced by Sabouraud and Noire as a remedy that is promptly curative in ringworm of the scalp. Their method is based upon one measured application of this agent, sufficient to produce depilation, this latter ensuing two or three weeks after exposure, and without producing, at the most, more than the mildest x-ray erythema. Care must be exercised so that the slightest reaction is not exceeded ; other- wise there is risk of permanent baldness. It is not a method to be used by those inexperienced in the use of the x-ray. The essence of the method of Sabouraud and Noire (who use static machines for generating the current) consists in giving one exposure suj0&- ciently long to produce depilation, yet not long enough to produce ill 838 . DISEASES OF THE SKIN. effects. This is done by employing some means of measuring the quantity of rays, and by keeping the vacuum of the tube at a point equal to about 3-inch spark gap. Full directions of this treatment can be found in Stel- wagon's "Diseases of the Skin," 1910. The following method is also of value : — Remove the superficial scales with the tincture of green soap, or by the use, for a day or two, of the pure green soap spread upon a piece of lint. Corrosive sublimate in 1 per cent, solution may be applied once a day, or the tincture of iodine, or carbolic acid in glycerine, 1 to 16, or the white precipitate ointment may be employed. I prefer the chrysarobin collodion painted over the patch every day or every other day. Kaposi's naphthol ointment is recommended by Lassar. Tar or sulphur ointments or Lassar's paste may be employed in obstinate cases. Morris's thymol-chloroform oil is also beneficial. morris's thymol-chloroform oil. B Thymol 1 part Chloroformi 4 parts 01. olivse 12 parts Or:— SUBLIMATE SPIRIT. IJ Hydrarg. chlor. corr 1 part Spts. vini rect 500 parts Or:— TANNIN-SULPHUB PASTE. Ij( Acidi tannici 5 parts Lac. sulph 10 parts Petrolati 50 parts Zinci oxidi 17.5 parts Amyli 17.5 parts Or:— CHRYSAROBIN COLLODION. IJ Chrysarobini , . 1 part Collodii flexile 10 parts Vereuca (Warts). These small tumors of the skin are frequently met with in children. They may resemble a bunch of carrots (verruca digitata) or they may resemble a cauliflower. In size they vary from one-sixteenth to one- eighth of an inch in height. They frequently are seen on the face, neck, and hands. They produce no discomfort and are not serious. Treatment. — Freeze the parts with ethyl chloride or ether. Pick the wart with a sharp curette. Another painless method consists in cauterizing first with pure carbolic acid, on top of which fuming nitric acid is applied. GANGRENE. 839 In using the latter caustic method, the surrounding parts should be pro- tected with vaseline. Burns (Combustio). We frequently see burns of various degrees in children. They are usually caused by hot water, steam, acids, or alkalies. An intensely inflamed area surrounding a blistered surface is usually found. Pain and sometimes shock are noted. In some cases fever and a rapid increase in the pulse are noted. Violent reaction such as convulsions frequently occur in weak and rachitic children if a severe burn has taken place. This depends upon the amount of surface involved and on the condi- tion of the child at the time of the accident. Some children survive exten- sive burns with good care. As a rule a cautious prognosis should be given, owing to the risk of infection and danger of shock. Treatment. — Strict asepsis should govern the opening of all blisters. Cornstarch, wheat flour, europhen, or dermatol may be used locally. In addition thereto, linseed-oil and lime water, or calamine and zinc lotion (see chapter on "Eczema"), is very valuable. Air should be excluded by applying an ointment consisting of 10 per cent, ichthyol, 1 per cent, menthol, or % per cent, phenol with vaseline. In some cases Fordyce advises the use of 1 per cent, picric acid ointment over which narrow strips of oiled silk are placed to prevent the dressings from adhering. Cover with sterile gauze and bandage. Gangrene (Superficial GrANGRE"NE). This condition affecting the skin or extending to the deeper structures is characterized by a bluish-black discoloration resembling a deep form of cyanosis. Causes. — It is a destructive condition following the acute infectious diseases, especially scarlet fever or measles. Traumatism or pressure inter- fering with the circulation of the blood or robbing the extremity of its nutrition may result in a destructive gangrene. The following case of traumatic gangrene occurred in my practice; it was a traumatic gangrene due to interference with the circulation: — Baby A., ten months old, breast- and bottle- fed, was referred to me by Dr. A. Meyer. I found a temperature of 105° F., pulse 180, respiration 60. There was com- plete consolidation of one lobe of the left side. Bronchial breathing was plainly heard and there was dullness on percussion. The diagnosis of lobar pneumonia was made. With the aid of cold packs and small doses of strychnine, the child's condition improved. As I left the city, the case was treated by Dr. Khodoflf, who gave me the following memoranda: — "The nurse administered a high rectal enema by suspending the child with a towel around the thighs. The circulation was thereby interfered with. I believe the 840 DISEASES OF THE SKIN. thrombosis, which appeared at about the saphenous opening, was of traumatic origin due to this interference of the circulation. The course 'of the gangrene was as follows: A bluish-purple spot about the size of a ten-cent piece appeared at the saphenous opening. The child previous to this showed indications of pain. It was fretful, tossing about, and very restless. The gangrenous area increased on the following day. It was decided to wait for a line of demarcation, as the child appeared to be in a state of collapse. On the third day after the first sign of gangrene Ddte. 1 2 3 ^ V 5 6 7 8 9 10 II 12 13 1 160 150 140 i 106° 105° VI EP ^E MEM EME Mi :me)\ /lEM E M E ME :m E m|e M E d — • 1 3Zl ■ a) ■H \ 1 i^ It P \ ^ it 1 V _ ^ s. 1 103° 102° 101° 100' 99° 98° T( ] H U 1 r 1 / y 1 1 ^ \ A 1 \ I \ /I \ EE^ 1 1 /I t 1 iV f \ t 1 f V 1/ \ r 1 .[ V t _ \ 1 T] rz. i 1 \ K 1 tt 1 1 \ r 1 f \ \ 1 1 1 T If / w - 4- _JL / V 1 . ^ TV \ i 7 [ L_ -1 t d u L i ^ t t I t , ^ 1 _ _ ^ _ ^ ^ ^ ^ ^ ^ Fig. 282. — Case of Gangrene Following Lobar Pneumonia. Gangi-ene appeared on the tenth day of disease, due to a careless method of suspending the child by a towel around the thighs, which resulted in thrombosis, ending fatally. (Original.) appeared, a rapid spreading took place upward along Poupart's ligament and con- tinued above and involved the umbilicus." When I again saw this case the gangrene involved the whole abdomen. The temperature was 102° F., the pulse very feeble, and the child in a state of collapse. It was necessary to stimulate and feed per rectum. The child died in eommlsions. Prognosis. — The prognosis is always bad, although surgery may be the means of amputating a gangrenous extremity and saving the rest of the body. Treatment. — ^There is no medicinal treatment worth trying. Surgical relief is our only hope. SCABIES. 841 Symmetrical Gangrene (Raynaud's Disease). This is an obscure condition in which the gangrene is symmetrical. Etiology. — It is caused, no doubt, by the invasion of pathogenic bac- teria. Infectious diseases which devitalize the body are believed to pre- dispose to this condition. Injury and haemorrhages, such as epistaxis, have been forerunners of this condition. Symptoms. — When acute there is fever and enlargement of the spleen, hgematuria, or hgemoglobinuria. The affected part feels cold and appears bluish; sometimes there are vesicles containing a sero-purulent fluid. This condition lasts from two to three weeks, although it may extend over many months. The disease ends in mummification and gradual decay of the affected parts. The toes, fingers, ears, or tip of the nose may be the seat of this affection. Prognosis. — A cautious prognosis should always be given. While records of cures exist, the diagnosis may always be questioned. Treatment. — General restorative treatment, concentrated foods, and hygiene should form the basis of treatment. The skill of the surgeon may eradicate the gangrenous parts. Scabies. This is a contagious disease caused by the female acarus burrowing into the skin. The characteristic features of this disease are that it is found between the fingers, in the axillae, on the flexor surfaces of the wrists, and also around the genitals. The eruption is either a papule or a vesicle, some- times a pustle. There is an intense itching, and secondary infection results from scratching. Several children in the same family will usually be found so affected. The prognosis is always good. Treatment. — A hot bath, to thoroughly soak the body and soften the epithelial scales, should be ordered. An inunction of Vg unguentum hydrarg., 2/3 vaseline should follow the bath. Sulphur soap may be used in addition to sulphur ointment if no benefit results from the foregoing treatment. Epicarin is unirritating and is of value in parasitic affections of the skin. Precip. sulphur sprinkled between the sheets at night affords relief. An excellent method advised by Fordyce is, first, a cleansing bath, fol- lowed by applications of the following: — IJ Balsam Peru 1 drachm Sulphur ^2 drachm Betanaphthol 10 grains Petrolatum 1 ounce - M. Sig. : Apply on affected areas. Repeat treatment three successive nights. Strict supervision must be kept up for at least ten days. CHAPTER IV. MALIGNANT AND NON-MALIGNANT GROWTHS.^ Abnormal growths are frequently seen in children. Some of these are malignant, while some are benign. We must not suppose that children do not have malignant disease. I have seen malignant sarcoma involving the whole of the left lung which crowded the heart into the right axillary space. Spindle-oell Sarjdoma of the Thoeax.2 Gustav L., a male child of about 8 years, was first seen by me in July, 1900. His mother gave the following history: — He was breast-fed about ten weeks and owing to a diminution in the quantity and quality of her milk, she was forced to wean the child. He then received sterilized milk. This food was given until the child was weaned from the bottle at about the end of his second year. When about six months of age, a large, glandular swelling commenced behind the right ear, which necessitated an incision. The attending physician said it was an abscess. At this same time, he had a severe attack of gastric fever. This required careful dietetic treatment. Cow's milk was continued in a more modified form. At age of 1 year the child was attacked with measles, accompanied by a catarrhal bronchitis. Some cough remained and when the child was 2 years old he had a severe attack of pertussis. When the child recovered, he remained well until he was 3 V2 years old, then he Was infected with scarlet fever lasting two months. Thus the child passed his infancy with some gastric derangement, followed by measles, pertussis, and scarlet fever. He did not have croup or diphtheria. "Family History. — This is good. The parents of this patient are both living, and apparently strong and healthy; they have two other boys, well and strong. There is no. history of syphilis, rheumatism, gout, tuberculosis, epilepsy, nor anything of a malignant nature in the family, excepting this fact which is extremely noteworthy, that the grandfather had a sarcomatous tumor, which ended fatally. "Examination. — The patient was brought to me for the relief of a number of tumors on the front of the thorax, which felt quite hard on palpation. At times a distinct sense of fluctuation could be made out, and when examined By an exploratory puncture, a few drops of thin, yellowish serum was obtained. These tumors have been very troublesome for the past few years. They have caused severe dyspnoea. The physician who treated this boy in Hamburg believed that the growths contained "■For complete list surgical works should be consulted. " Read before the Section on Pediatrics, the New York Academy of Medicine, April 10, 1902. (842) SAKCOMA OF 'J HE THORAX. 843 pu9. This statement was made to the family. The physician made an exploratory puncture and was rewarded by a few drops of thin, seroas liquid, as in a puncture I made and obtainetl no pus. ''The size of the growth as seen extemally is about 15 centimeters in length and about G to 7 centimeters in circumference. (See Fig. 283.) There is marked dullness on percussion e.xtending over most of the left side. The tumor is surrounded bj' a network of veins, intensely engorged with blood. There is mediastinal pressure. As far as can be seen and palpated, the growth occupies that region of the thorax usually occupied hy the heart. The giowth varies in size from week to week. ''The heart has been pushed to the right side and occupies the right axilla. The apex beat is heard about two finger breadths below and to tlie right of the right nipple. (See figure 284.) "The pulse is 144,. small, feeble, quite in*egular and eii.sily com^jressible. The respiration is irregular, of the Cheyne- Stokes type, and frequently sighing. It is usually about 50-52 in a minute; the temperature is always above normal and varies from 100° F. in the rectmn, morn- ing, to 101 Vo" in the evening. Tliere is always a febrile tendency. "There is constant dyspnoea and also extreme cyanosis of the lips, fingers and toes. The child is very pale and in a very anaemic condition. There is extreme pallor of the conjunctival membrane, the gums, and the mucous membrane of the lips." Owing to the extreme amount of weakness caused by anorexia, the child was compelled to remain in bed most of the time for the last year. Dyspnoea was so great that the child slept in a sitting posture. The child was very nei-vous and trembled when he was touched. He was very bright mentally. There was con- stant and rapid emaciation. Concen- trated food was given, which the patient took quite well. There was extreme hypersesthesia of the skin. The digestion was quite good, and altjiough the bowels moved sluggishly, they did not require much medicinal treatment. Fiuit and fruit juices acted as laxatives. There was a cur\'ature of the spine from left to right, most marked in the dorsal vertebra. The urine was examined several times. It showed no evidence of pus or blood, no albumin and no sugar. There was a slight indican reaction. No acetone, no casts, no morphotic elements, microscopically. The case w^as hopeless from a medical standpoint, as the groArth was constantly increasing. The child suffered constantly from insortinia and great dyspnoea, requir- ing constant soporifics and narcotics. In spite of the grave prognosis, the family hoped that s\irgical measures might afford some relief. Fig. 283.— Spindle-cell Sarcoma. The prominence of the tumor shows by contrast the emaciation of the body. (Original.) 844 ABNORMAL GROWTHS. As the tumor frequently appears to show a distinct pointing, this latter condition suggesting fluid, an anaesthetic was given with the assistance of Dr. J. W. Wurthman. The anaesthetic was badly borne and I succeeded with diflficulty in making two exploratory punctures. An x-ray examination, to verify the clinical data, was made by Dr. C. Beck, to whom the case was referred. The heart could be plainly seen pulsating on the right Fig. 284.-— Anterior View of the Tumor. Showing al«o the position of the displaced heart and the enlarged veins. (Original.) side. No definite satisfactory data could be learned concerning the tumor, on account of the restlessness of the patient, and the child was removed to St. Mark's Hospital and operated. The child died soon after the operation. A specimen of the tumor, removed during the operation, was sent by me to Dr. Mandlebaum, for a pathologic examination. He reported the tumor to be a spindle- cell sarcoma in a rather active state of growth, on account of the large number of mitoses present. The fluid contained simply red blood cells and no pus. HYPERNEPHROMA. 845 Sarcomatous growths in children are quite rare, though met with from time to time. Thus Mauderli, in the Children's Hospital of Basle, Swit- zerland, reports for the last twenty years that he treated a total of 10 patients : 7 boys and 3 girls, of whom 4 were under 3 years of age, 3 were between 3 and 6 years, 1 was between G and 9 years, and 2 were between 9 and 12 years. As but one case of malignant sarcoma was met with in this hospital in the course of the last twenty years in children as old as the case here reported by me, I feel justified in adding mine to those already recorded. The interesting points about my case were: (1) The displaced heart, the heart being immediately behind the right nipple. The pulsations and apex-beat could be distinctly felt and seen about two finger-breadths below the right nipple. (2) The intense dyspnoea caused by pressure of the tumor. (3) Constant cyanosis and oedema of the limbs, due to interference with the return circulation to the right side of the heart. Caecinoma. Carcinoma is occasionally found in children. Malignant growths of this kind have been diagnosed and verified by microscopical examinations. Hypeenephroma. Literature records many cases of hypernephroma in children. The fol- lowing. case^ was seen by me in a boy 16 years of age: The case was brought to me with a history of hsematuria. The bloody urine was noticed several weeks, and was probably due to injury caused by carrying some boxes, while working on a farm. No apparent discomfort nor pain was evidenced for many weeks, when a small swelling developed over the region of the spleen. Subjective symptoms, such as pain, were described and there was a slight rise in temperature. The swelling increased from day to day. A radiogram was taken by Dr. Caldwell. The diagnosis of tumor was made and the pa- tient was operated by Dr. John Erdman. The tumor was removed and proved to be a hypernephroma. Eadiograms of the long and flat bones revealed a series of tumors in the spine, scapula, and femora. The patient died of emaciation and exhaustion within a year. Lipoma. Fatty growths are occasionally seen in children. They occur on the scalp, on the back, and I have seen them on the buttocks. They require the same treatment as fatty growths in adults. (See article in the section on "New-born Baby" on "Congenital Sacral Tumor.") ^ For complete clinical history of this case see Archives of Pediatrics, Novem- ber, 1914." 846 ABNORMAL GROWTHS. Enchondromata. These hard growths are usually found on the fingers and toes. They are found in the neighborhood of the joints, with which they are closely allied. A case of this kind which had several tumors removed occurred in my practice : — Mary B., 10 years old. Family History. — Father healthy. Mother died of carcinoma of the uterus. Has one sister, who is healthy and married. Patient's History. — Was breast-fed during infancy. Suffered with no gastric or enteric disorders. Had measles when several years old. Is not subject to any chronic disease. Her extremities are normal excepting the affected hand. The Fig. 285. — Enchondromata Involving the Thumb and Index Finger. (Original.) mother stated the tumors had been present soon after birth. They were not painful, nor did they cause discomfort, so nothing was done until the child reached this age. The case was referred by me to the surgical service of Dr. S. M. Landsman, who re- moved the giowths. The case made a perfect recovery. ■ , ■ Spina Bifida. Abnormal growths are frequently found in the lumbar region asso- ciated with the spinal cord. They are frequently seen in cases of hydro- cephalus. A case of spina bifida is reported in the chapter on "Malforma- tions of the Spine." Angeioma. Angeioma. — Large vascular growths are occasionally seen in children. A case of this kind was seen by me,, which I describe in the chapter on the "New-born Baby," page 57. GRANULOMATA. 347 Papillomata. This growth is occasionally seen in the larynx of infants and children. It may be congenital. Symptoms. — Marked dyspnoea is usually a prominent symptom. This dyspnoea increases with the enlargement of the growth. There is also a husky voice, which increases in severity. The symptoms are very marked at night, but are much less, and frequently disappear entirely, during the day. Cough may also be present, but no expectoration. There is no fever. The diagnosis is usually made by a laryngoscopic examination. When the same symptoms appear for weeks and months, a laryngeal growth should be suspected. Treatment.— Eemoval of the growth with an angesthetic is absolutely necessary. The danger in removing the growth should always be borne in mind; hence the surgeon should be prepared to perform a tracheotomy if necessary. Intubation of the larynx will relieve the difficult breathing; at the same time there is danger of pushing some of this growth with the tube, thus obstructing the caliber of the same. Eelapses are common. Granulomata.^ These growths are frequently seen at the site of the wound following a tracheotomy. They resemble a mass of exuberant granulations. Prof. A. Eosenberg, of Berlin, collected 231 cases of laryngeal tumors in children. Some of them were subjected to tracheotomy; others received endo-laryngeal treatment preceded by tracheotomy. In another series of cases persistent endo-laryngeal treatment was resorted to without perform- ing tracheotomy. This latter method yielded the better results. ^ In Part II, page 35, will be found article on "Granuloma.' PART XI. DISEASES OF THE SPINE AND JOINTS. Pott's Disease.^ This disease derives its name from Percival Pott, who described it in 1779. "It is a chronic destructive process which begins in the bodies of the vertebrae. The bodies of the vertebrae support the weight of the body. As the disease progresses the weakened parts give way, and the upper seg- Fig. 286.— Pott's Dis- ease ( Langerhans ) . Ky- phosis of dorsal vertebrae, the result of caseous .tu- berculous periostitis and osteomyelitis. Destruc- tion of three thoracic ver- tebrse. Two-thirds na;t- ural size. ment inclines forward. An angular posterior projection, TcypliosiSj is formed which is the characteristic xieformity of the disease." Etiology. — "Pott's disease may appear at any period of life, from earliest infancy to old age, but like all forms of tuberculosis of the bones, it is most common in the first ten years of life, and 50 per cent, of the cases begin between the ages of 3 and 5 years, inclusive. "The lower segment of the spine, including the dorso-lumbar region, is most often involved. Cervical disease is relatively infrequent (cervical, ^ The table of differential points between Pott's Disease and Rickets will be found on page 321. (848) POTT'S DISEASE. 849 7 V2 per cent.; dorsal, G8 per cent.; lumbar, 24 per cent.). The death rate is at least 25 per cent. The course of the disease is most protracted in the middle region; it is shortest in the cervical region, its duration vary- ing in favorable cases from two to five years. ''When the local resistance overcomes the tendency to degeneration, the process of repair begins. The tuberculous products are absorbed or enclosed, and ankylosis between the two segments of the spine is estab- lished by means of a union, in part fibrous, cartilaginous, and bony. Firm union is long delayed, and the deformity may increase long after the disease has become inactive" (Whitman). Pathology and Bacteriology. — "The first indications of disease are most often found beneath the fibro-periosteal layer of the anterior longi- tudinal ligament. From this point the granulation tissue advances along the course of the blood-vessels into the adjacent bone, extending from one to another until several bodies are more or less involved. The disease is accompanied, in many instances, by an abscess, which may be of suffi- cient size to cause special symptoms; or the tuberculous process may find its way to the posterior part of the vertebral bodies and thus involve the spinal cord, causing paralysis. Abscess is most common as a complication of disease of the lower part of the spine, where it may be detected in at least 50 per cent, of the cases. Paralysis most often complicates disease of the upper dorsal region, appearing in about 10 per cent, of the cases in which this part of the spine is involved. The primary infection is no doubt due to the entrance of the tubercle bacillus.^^ Anatomical Landmarks. — "The atlas is on a line with the hard palate. The axis is on a line with the free edge of the upper teeth. The transverse process of the atlas is just below and in front of the tip of the mastoid process. The hyoid bone is opposite the fourth cervical vertebra. "The cricoid cartilage is on a line with the sixth cervical vertebra. "The upper margin of the sternum is opposite the disc between the second and third dorsal vertebrae. ' "The junction of the first and second sections of the sternum is op- posite the fourth dorsal vertebra. "The tip of the ensiform cartilage is opposite the lower part of the body of the tenth dorsal vertebra. "The anterior extremity of the first rib is on a line with the fourth rib at the spine, the second with the sixth, the fifth with the ninth, the seventh with the eleventh. "The scapula covers the second and the seventh ribs, its lower angle being opposite the center of the eighth dorsal vertebra. "The root of the spine of the scapula, the glenoid cavity, and the interval bet^vcen the second and third dorsal spines are in the same plane. *'The most constant landmark from which to count is the spinous 850 DISEASES OF THE SPINE AND JOINTS. process of the fourth lumbar vertebra^ which is on a line with the highest point of the crest of the ilium. The umbilicus is near the same plane. "The tip of the coccyx is opposite the lower border of the symphysis pubis." Symptoms. — If the upper part of the spine is affected, a stiffness of the neck usually exists. If the lower part of the spine is affected, limping will be noticed, hence awkwardness in walking in very anasmic children should always be looked upon as suspicious. "The limitation of motion due to muscular spasm, to pain, and to the local disease is an important factor in diagnosis. This, together with the deformity, may be demonstrated by bending the patient's body directly forward to the fullest extent. An object is next placed on the floor, and the patient is directed to jjick it up. If this is done awkwardly by squat- ting or kneeling, it demonstrates weakness and stiffness. The patient should next be placed prone upon a table, and the surgeon should test the flexibility of the spine by lifting the legs and swaying the body from side to side. The range of extension at the hips may be tested at this time by holding the pelvis against the table with one hand, while the thigh is over- extended with the other. This is the test for the slight degree of psoas contraction that is often present on one or both sides in disease of the lower region. "The flexibility of the upper part of the spine may be tested by vol- untary and passive movements of the head in various directions, and the range of motion of the occipito-atlo-axoid joints by holding the neck while the patient nods and turns the head from side to side. "The character and the extent of the deformity, if it be present, should next be investigated. K"ote the contour of the spine. Any change from the normal are, in childhood, suspicious circumstances. N'ote the elastic- ity of the spine. If when the child is bent forward the spine forms a long, regular, even curve, disease is unlikely. If there be a break in the outline, and if one part remains rigid and another bends, disease may be suspected." Pott's disease in the lower region of the spine presents the following characteristics : — 1. Pain. — The pain is referred to the lower part of the abdomen, to the genitals, to the loins, or to the thighs. 2. Gait. — JThe waddling gait which has been described under general symptomatology is characteristic of disease in this region. In some cases there is a limp. 3. Attitude. — Usually an abnormal erectness and sometimes an ex- aggerated lordosis; in some instances a lateral inclination of the body. Unilateral psoas contraction and the attendant limp are often present. 4. Stiffness. — Muscular rigidity of the lumlDar region interferes directly with almost every attitude and movement. The effect of this POTT'S DISEASE. g^i stiffness and of the accompanying weakness may be demonstrated by the popular method of asking the child to pick up a coin from the floor. In this region of the spine the symptoms are usually well marked before the stage of deformity, flexion of the legs, the effect of psoas contraction, and abscess are present in perhaps a third of the cases. Pott's disease of the middle region is characterized by the following peculiarities : — 1. Pain is referred to the lateral region of the thorax or to the front of the body. It is a common symptom. It is noted after sudden move- ments or after compressing the chest, as when the child is suddenly lifted from the floor. 2. Respiration. — If the disease is at all active, a grunting respiration is usually present, especially after exertion. This is the most characteristic of all symptoms, especially so in young subjects. 3. Attitude. — This is not always distinctive, but usually there is a peculiar shrugging squareness of the shoulders; occasionally a lateral in- clination of the body. The head is often inclined backward. The neck seems short on account of the elevation of shoulders. 4. Deformity. — The deformity is usually prominent and it appears early in the disease. 5. Complications. — The most common complication of dorsal disease is paralysis, abscess being less frequent than in the lumbar region. Flat chest and chicken breast may be secondary deformities. Pott's disease of the upper region presents the following peculiari- ties : — 1. If the uppermost cervical vertebrae are diseased, the pain is referred to the head, particularly to its lateral and posterior aspects. In disease of the middle cervical region it is referred to the neck, or to the shoulders or chest. 2. The weaTcness and stiffness are manifest by the attitude. The head cannot be turned freely. If the disease be in the occipito-axoid region, the nodding and rotary motions are restricted. The chin is often depressed and slightly turned to one side. Lateral distortion resembling torticollis usually occurs when disease is nearer the middle of the cervical region. 3. The bony deformity is often slight or absent, but thickening of the tissues about the spine and local sensitiveness to lateral pressure are usu- ally present. Eetro-pharyngeal abscess is not uncommon when the atlo- axoid region is involved. Complications. — (a) Abscess; (b) Paralysis: About 25 per cent, of all cases have abscess. An abscess situated in the atlo-axoid region often burrows into the retro-pharyngeal space. It may involve the cranial cavity when this occurs; symptoms of meningitis will be noticed. When an abscess forms from disease of the middle cranial region it usually opens 853 DISEASES OF THE SPINE AND JOINTS. on the side of the neck, before or behind the sterno-cleido mastoid region; When abscess follows disease in the dorsal region it burrows through the thorax. It can be detected by the physical signs accompanying pain (see chapter on "Empyema"). When it burrows downward it may give rise to an iliac or lumbar ab- scess. "In disease of the lumbar region, the abscess, if superficial to the ilio-psoas muscle, may point in the neighborhood of the anterior superior spine, or pass through the inguinal ring. The true psoas abscess first dis- tends the niac region, and then passing into the thigh, appears in Scarpa^s space. In large abscesses of this character the pus may find an exit in the loin at the triangle of Petit, or in the gluteal region through the. sacro- sciatic foramen. "In rare instances the abscess may find an opening within the body, and burst into the lungs, the intestines, or elsewhere. "As a rule abscess causes but little difficulty in diagnosis, because it is a late symptom, appearing after the diagnosis of Pott's disease has been established. It is more often an early symptom in the upper and lower regions of the spine, but in any event it is always accompanied by symp- toms of the underlying disease of the spine." Paralysis. — The symptoms of Pott's paralysis are "an awkward stumb- ling gait, weakness, and finally an inability to stand. The lower limbs are . 'stiff' at times. The reflexes are increased. Control of the bladder may be retained, but often there is active incontinence; that is, the bladder emp- ties itself from time to time. If the pressure is directly upon the reflex centers in the lumbar enlargement, there may be passive incontinence or dribbling of urine. If the pressure is below the reflex centers, the bladder is not affected, and the symptoms of numbness and weakness resemble those caused by neuritis." Differential points concerning abscess : — 1. Abscess of the cervical region must not be confounded with the symptoms of enlarged tonsils, adenoids, or with so-called croup. It must also be distinguished from the simple acute abscesses of this region. 3. Abscess of the thoracic region is to be distinguished from those secondary to disease of the lung or of the chest wall. 3. Abscess in the loin or inguinal region may be mistaken for the acute or chronic abscess due to : — , , p . , . . . j" These are usually of acute onset and are ac- ^ companied by constitutional disturbances. C There may be secondary rigidity of the spine, (h) Perityphlitis. J but no deformity, as is usual in Pott's dis- [^ ease at the stage of abscess formation. (c) Sacral or iliac disease. The symptoms of Pott's disease are lacking. (d) Hernia. POTT'S DISEASE. 853 The paralysis of Pott's disease must be distinguished from 1. Simple weakness. 2. Injury to the cord, 3. Tumors of the cord. 4. Syphilitic disease of the cord. The weakness and stiffness caused by Pott's disease in the lower region may be simulated by lumbago, rheumatism, sciatica, and by the effect of injury or strain. Lumbago, rheumatism, and sciatica are uncommon in childhood. They are usually of sudden onset. Sciatica is usually uni- Fig. 287. — Pott's Disease. Case of Harry F. (Original.) lateral; the pain of Pott's disease is usually bilateral. Strains and other injuries have, as a rule, a well-defined history. Prognosis. — This should be cautiously given. "While most cases seen by me ended fatally, several cases improved and recovered entirely. Years of patient treatment are necessary, and occasionally the most severe cases may end in recovery. Harry F., 4 years old. Family Histori/. — Fatlier and mother are imhealthy, weak and veiy poor. One child has died of summer complaint. Another, two years yoimger, is inclined to cough, and was operated by me for empyema. 854 DISEASES OF THE SPINE AND JOINTS. Personal History. — The child was born and has since then lived in a tenement house, in a densely populated section of the city. He was a bottle-fed infant, and has been constipated since birth, although he suffers with diarrhoea in summer. Has always been a frail and sensitive child. Has had measles and bronchitis, and is constantly troubled with some catarrhal affection. The child was late in walking, late in talking, and late in dentition. The general development shows backwardness when compared with a normal child. A slight deformity of the spine was first noticed when the child was about 2 years old. It has increased in prominence since that time. There is no distinct evidence of tuberculosis that can be made out in the lungs. The glands are not enlarged, there is no cough or expectoration. No evidence of fever. The treatment consisted in giving codliver-oil and creosotal internally from 2 to 5 drops, three times a day. Friction of the body and general hygienic measures were instituted. Great stress was laid on the nourishment of the body. Cream, butter, eggs, cereals, and vegetables have been given constantly. Orthopedic Treatment. — For the relief of the deformity, a supporting brace fitted to the body like a corset, similar to a Bradford frame, had been used for over six months with little improvement, therefore the case was sent to Dr. Ashley for a plaster-of-Paris corset. This treatment has been very successful, and the child is progressing favorably. Treatment. — When piis is present nothing but surgical treatment should be considered. Surgical treatment is not always necessary. The majority of cases require support by means of (a) spinal splint; (h) spinal brace; (c) plaster jacket. Either of these must be- properly applied by a competent surgeon. I have seen some very disagreeable accidents due to a too tight plaster corset. For details in connection with the application of braces or plaster jackets the reader is referred to text-books on orthopsedic surgery. Medicinal Treatment. — This consists in giving restoratives such as codliver-oil, iron, and arsenic. Creosotal can be given with the codliver- oil. A rigid diet such as cream, butter, milk, cereals, eggs, vegetables, and fruits is indicated. If the child lives in the city a change to the seashore or to the moun- tains will sometimes improve the chances of recovery, Flatfoot in Childken, Children are not born fiatfooted. Very heavy children are predis- posed to flatfoot, especially if rickets is present. Laxity of the knees is usually found associated with this condition. Treatment. — Careful orthopaedic treatment is necessary. This usu- ally consists in wearing a properly fitting shoe in which the arch is sup- ported with the aid of a stiff steel or celluloid plate. At times a soft pad of felt only is necessary. E. W. Lovett, of Boston, has contributed to the literature of this subject, and the reader is referred to his writings for details on this matter. SCOLIOSIS. 855 Spinal Curvature. The spine of a new-born infant is almost straight, but from the time the child begins to walk erect, curvatures arise in the direction forward and backward which are normal and physiological, viz., a curvature with the convexity forward in the region of the neck, backward in the dorsal region and forward in the lumbar region. Kyphosis. Kyphosis is also known as round-back. It is an increase in the normal curvature in the dorsal region of the spine. It is a non-inflammatory con- dition and is amenable to treatment. The increase in the curvature back- ward is called round-back, kyphosis arcuata, increase in the curvature forward, saddle-back, lordosis. The cause is usually faulty position assumed at school or at home, and associated therewith weakness of both muscles and bones. I have elsewhere in the article on rachitis, also in the article on Pott's disease, described this condition. The treatment depends on the cause. If it is due to rachitis, restorative treatment is indicated. Iron, hypophosphites of lime and soda, and codliver oil are the drugs to be given. In addition to drug treatment, fresh air and out-door life must be given before gymnastic exercises are considered. Deep breathing with arms raised and extended forward and backward, in a cool room, should be a daily routine. Tlie exercises should not be carried to a point of exhaustion; usually ten to fifteen minutes is sufficient to produce a good reaction. If the kyphosis is due to tuberculosis of the spine an open-air life should be recommended. The treatment of tuberculosis in general applies very forcibly to Pott's disease, but we must remember that, be the kyphosis due to an atony of the muscles or to a general systemic weakness such as rachitis, such cases will relapse unless the daily exercise is continued. Scoliosis. Every permanent deviation to the side, in the spine, is called lateral curvature or scoliosis, and is the fonn most commonly met with of all deformities of the spine. Scoliosis may be called cerv'ical, dorsal, or lumbar scoliosis, depending upon which part of the back is bent. The curvature may include only a few vertebrce, or the spine in its entirety. Two or more cun^atures may simultaneously be found in the same person. Scoliosis can, further, be right-sided or left-sided, according to the convexity of the lateral curvature. Scoliosis has a pretty constant course. Although no exact limit can be fixed, scoliosis may be suitably divided, from a s}T2iptomatological point 856 DISEASES OF THE SPINE AND JOINTS. of view, into three degrees of development. The slightest forms of scoliosis can develop into the most severe: it is impossible, however, in every case to foretell whether a scoliosis will be stationary at a certain stage or whether it will further develop itself. A scoliosis of the first degree may, to the unpractised, be difficult to detect, as no clear curvature of the spine can be observed. The existence of the scoliosis is characterized by a slightly forward arching or bulging-out of the lateral contour in the region of the chest. Scoliosis of the first degree Fig. 288. — Scoliosis due to faulty Fig. 289. — Same girl; arms folded. Note posture at school. difference in scapulae. (Original.) is noted whenever the patient takes a standing or sitting position, but it disappears in a hanging or lying position. A scoliosis of the second degree can also disappear, as long as the patient takes certain positions or per- forms certain movements which counteract the form of scoliosis in ques- tion; pressure on the convexity of the curvature may also bring the spine back to a straight position. A scoliosis of the first degree is called simple, primary, or C-formed. G-enerally the primary scoliosis appears as a right- convex dorsal scoliosis or as a left-convex lumbar scoliosis, A scoliosis of the second degree arises in the following manner: that to the primary curvature, after a time, another unites itself — a secondary. SCOLIOSIS. 857 compensatory or so-called anti-curvature; in consequence of this formation the scoliosis has become 8-formed. A scoliosis of the second degree differs also from one of the first degree in that the curvature does not now quite disappear in a hanging or lying position, not always in taking certain bodily positions, nor by means of pressure on the convexity of the curvature, but the spine is, however, still mobile; so that the curvature in the given position is diminished, in consequence of which the scoliosis can be treated success- fully also in this stage. The third degree of development in scoliosis is arrived at by the for- mation of several deformities of the spine itself and of the adjacent Ixjnes, whereby the scoliosis becomes permanent or -fixed, po that the curvature of the spine itself in this stage cannot be treated. The attendant symptoms of shortness of breath, disordered circulation and intercostal neuralgia must, on the other hand, often be treated. The scoliosis in this degree is called kypho-scoliosis. When a scoliosis develops itself, the vertebrce undergo a most radical change from a pathological point of view, and this change is not easy to detect, but the alterations in the ribs, with respect both to form and position, is the surest symptom from a purely clinical point of view. Through the uneven pressure to which the vertebrae are exposed in a scoliotic spine, the side directed toward the concavity of the curvature will be slower in growth, while the side directed toward the convexity will de- velop itself normally. The consequence of different development will be that the vertehne will gradually assume the form of a wedge, with the point of the wedge directed toward the concave side of the scoliosis. From a clinical point of view the greatest change is to be found in the ribs, so that an incipient scoliosis is most easily detected in the change the chest undergoes in its entirety. The special alterations in the ribs ac- company those of the vertebrae. For example* those ribs that correspond to the convexity of the scoliosis will be separated from each other, while those that correspond to the concavity will become compressed and even atrophic. The ribs on the convex side will develop a considerable increased flexion of their posterior extremitj'^, and diminished flexion of their anterior extremity. A change of position of the sternum does not so frequently occur, but in the above-named form of scoliosis, in some cases, the lower end of the sternum deviates toward the left, i.e., toward the concavity of the curvature. In a well-marked scoliosis the pelvis will, in consequence of the uneven weighing, also be crooked and asymmetrical, especially in more severe lumbar scoliosis, as then the os sacrum also takes part in the spinal curvature. As regards the muscles of the spine, the change in the same was for- merly considered to be very considerable, and it has even been considered 858 DISEASES OF THE SPINE AND JOINTS. as being the origin of the scoliosis. In well-marked scoliosis the long dorsal muscles that run over the convexity of the curvature become stretched and even atrophic, perhaps mostly in consequence of the rigidity of the spine and the consequent inactivity of the muscles. The shoulder-hJade is removed from its normal position by the change in the chest. The shoulder-blade on the convex side is pushed forward by the increased posterior bulging out of the ribs in the direction upward, backward and outward from the middle line ; the shoulder-blade on the con- cave side sinks, because the ribs on this side will be less curved posteriorly, and the shoulder-blade draws nearer to the middle line. When muscular weakness due to faulty nutrition exists, we have a predisposition which asserts itself in a faulty posture, such, for instance, as an incorrect writing position or various kinds of female handwork. Infantile paralysis, by virtue of its arrested development, will cause a shortening of the affected leg, and thereby be a factor in the development of a spinal curvature in the lumbar region. In children, faulty position in standing, as, for example, standing on one leg or sitting so that the body weight rests on one buttock, is a conmion cause of lumbar scoliosis. Eulen- burg states that rachitic scoliosis is found in 50 per cent, of cases during the second year of life, 25 per cent, during the third year, and from the fourth year a decrease down to the sixth year. When a general rachitis exists or when we note the presence of a pigeon-breast or a funnel-shaped breast, in such children one is likely to meet with a rachitic scoliosis. Pleurisy with effusion is another cause of scoliosis. If the effusion remains, or results in a pj'Othorax from the shrinking of the lung and sinking of the diseased half of the chest, there will result a scoliosis in the dorsal region, having the concavity toward the healthy side. A radiograph is the most exact method of recording the curvature, and studj^ing the therapeutic results. Prophylaxis. — In the very young child it is almost impossible to prevent scoliosis when the bodily structure is weak, as in rachitis. In the older child, where the effects of faulty position in sitting or standing can be explained, it is frequently possible to prevent scoliosis. Girls between the ages of 8 and 15, especially those who desire to shine by contrast in societj', are frequently overburdened with home-work, needle-work, painting or piano practice which frequently requires hours of patient sitting. It is this class of cases in which, by overstrain, the spine is weakened and curvature results. Treatment. — Only simple curvatures, or those resulting from weak muscles, faulty habits or position shall be considered. Curvatures resulting from congenital or pathologic anomalies, caries of the spine, tuberculosis, etc., should be sent to the orthopedist. Begin with good breathing exercises. Train the habit of posture. Give PLATE XLTTT X-ray of Congenital Dislocation of Hip. SCOLIOSIS. 859 genei-al liglit exercises for muscle building and stimulation of the circulation, respiration, and digestion. It is impossible to lay down rules which can apply to every case of scoliosis. Thus, a scoUmis of the first degree will do very well by strictly supervising and preventing the faulty position while at school or at home. In addition tlieix'to, g3'ninastic exercises to develop and strengthen the muscles of the h-dvk and chest will quickly solve tin's problem. In addition to the niechanienl treatment, restoratives such as iron, hypophosphites, and Fig. 2UU. — in cervical scoliosis, sicie flexion in the region of the neck can best be obtained by having a boom or crutch placed under the arm-pit, at a height to obtain a firm support. This position should be retained from three to five minutes. Fig. 2!)1. — Exercise adapted for lateral curvature. Patient sits on a stool in such a manner that the anterior bent leg rests on the floor, while the whole of the buttocks and the upper leg rests on the stool. This position is maintained while ten to twenty deep breaths are drawn. codliver oil should be given. Eresh air and out-door exercises should form the basis for the tonic which will help to assimilate food and thus strengthen the bone and muscle. A scoliosis of the second degree or scoliosis of the third degree requires not only the restorative treatment above mentioned, but, in addition thereto, mechanical treatment. Such mechanical treatment consists in the temporary support given to the spine by plastei'-of-Paris cast, or, in many cases, the cui'vature can be corrected with the aid of a spinal brace. Such brace or plaster-of-Paris support is utilized to correct the curvature, an(i 860 DISEASES OF THE SPINE AND JOINTS. when the mechanical appliance is removed gymnastic exercises are given to restore the tone of the muscles and aid in the circulation which is disturbed while the mechanical appliance is used. The gymnastic treatment should be supported by massage. Hanging is especially indicated in cases of kyphosis. The spine and spinal muscles are stretched into their normal position by the weight of the patient's body. Fig. 292. — Sitting-han-ging with rod is principally used for round-back, but also to advantage in scoliosis. The nurse stands behind the patient and offers slight resistance to the rod as the patient stretches his arms, and resist- ance is still offered when the arm ex- tension has reached its maximum, so that the patient is obliged to keep a stretched and corrected bearing of the body. This position should be main- tained from one-fourth to one-half min- ute. Eepeat ten to fifteen times. Fig. 293. — Resistance, especially adapted for young children. The pa- tient places his hands in the groin with the four fingers together forward, the thumbs directed backward, thus, by putting the extensors of the arms into action, causing a lifting of the trunk, while stretching takes place at the same time in the spine. The mother or nurse stands at the side of the patient and sees that he carries his shoulders backward as far as possible; slight pressure in the middle of the back and over the crown of his head encourages still greater exertion, i.e., the move- ment is changed from a purely active one to a movement of resistance.^ ^ I am indebted to Dr. Anders Wide's Hand-book of Medical and Orthopaedic Gymnastics, published by Funk & Wagnalls, for the illustrations in this article. HIP-JOINT DISEASE. 861 The hands, separated from each other by the width of the shoulders, take hold of the pole or trapese, placed or held at such a height that the feet do not touch the ground when the arms, trunk, and legs are fully extended. With heels together and knees straight, have patient bend body for- ward until the hands touch the floor in front of the toes, or come as near to the floor as possible, then raise the body to standing position. Eepeat slowly ten to fifteen times. Abbott^ and others have advised an overcorrection of the curvature to secure normal conditions. Many orthopedists have told me that while this is a painful method it has its advantages. Others have advised against the overcorrection. The method seems best adapted for the very young where marked elasticity of the spinal column still exists. Morbus Coxarius (Hip- joint Disease; Tubercular Hip-joint Disease). Coxitis, commonly known as tuberculosis of the hip-joint, is not easily diagnosticated in the primary stage. The age is no hindrance to the development of this disease, as it usually appears between the fifth and tenth years. Coxitis can be found in apparently healthy children showing no sign of scrofulosis. 1. They complain of tenderness. 2. Impediment of locomotion of the affected extremity. 3. The change of the position. 4. Local changes in the region of the joint. Symptoms. — The pain is one of the earliest symptoms and expresses itself by a feeling of tenderness in the affected joint or in the knee. . The knee is quite characteristic in this affection and serves a good center for deception. In the knee no changes are directly noticeable; there is no impediment to locomotion. When the pain can be located in the knee- joint the pathological process in the hip-joint is usually fully developed. When children complain of pain in the knee-joint, it is always wise to examine the hip. One of the most characteristic symptoms is the in- variable cry at night. The child will cry frequently and will suddenly awaken at night, tviih pain along the thigh not pointing to a distinct spot, hut showing that the pain is diffused along the leg; this symptom is rarely absent in true coxitis. ^Abbott, N. Y. Medical Journal, April 27, 1912. 862 DISEASES OF THE SPINE AND JOINTS. At the earliest stage of coxitis tlie pain is trivial^ but instinctively the patient tries to use the healthy limb and not the unhealthy one. This is one of the causes of limping. When tenderness can actually be located, then locomotion is also limited. When this exists, difficulty in abduction and adduction appears. When examining by grasping the affected limb with one hand and supporting the small of the back with the second hand, a distinct resistance of the muscles can be felt. Fig. 294. — Tuberculous Coxitis — Front View. Fig. 295. — Tuberculous Coxitis- View. -Side TUEEKCULOUS COXITIS (DOUBLE). C. M., 10 years old, girl. Duration of disease, in left hip six years, a,nd right hip five years. No history of exanthematous diseases. Treated at the Post- graduate for seven months in orthopedic ward. An erasion of disease in left hip at this time. Examination. — Right hip flexed to 90°, left hip flexed to about 95°. Right hip in adduction 10°, distinct spasm of the adductor muscles. Left hip in adduction 35°, slight spasm of the adductor muscles. Motion in right hip 10°, in left hip 20°. Right great trochanter two inches above Nelaton's line. Apparently no abscesses. Left trochanter almost denuded by erasion, only slightly above Nelaton's line. Many abscess scars, all healed. Treatment. — ^Modified Gant on: right side, forcible correction of the left side, with tenotomies. Congenital Dislocation of the Hip. This is the most frequent form and the most important of the con- genital dislocations. Illustrations Figs. 294 and 295 are furnished through the courtesy of Dr. Dexter Ashley. CONGENITAL DISLOCATION OF THE HIP. 863 Etiology.— Faulty development of the acetabulum and the head of the femur combined with laxity of the capsule and possibly pressure upon the flexed thigh are supposed to be the causes of this condition. The dis- placement is usually upon the dorsum, although it may take place forward or upward. It is most frequent in females. Whitman states that 85 per cent, occur in females. It is usually seen unilateral. I have seen many cases bilateral. Sometimes a peculiar family predisposition seems to exist, as several children in the same family have this deformity. Fig. 296. — Congenital Hip Dislocation. Cases occurred in the practice of Dr. Dexter Ashley. Symptoms. — Unilateral Dislocation.. — 'The child limps when it begins to walk. The abdomen is very prominent. There is an abnormal lordosis. The buttocks appear enlarged. The thighs are usually separated and there is an increased breadth of pelvis. Shortening is difficult to detect in the beginning of the disease, but if the child groAvs older and the condition has been neglected, then a shortening of several inches may sometimes be detected. Such children are easily fatigued. Bilateral Dislocation. — The pelvis is broadened and the thighs are far apart when the patient stands or walks. The limp is exaggerated and the child waddles. The lordosis is very marked. 864 DISEASES OF THE SPINE AND JOINTS. Treatment. — Eeplacement by traction, by extreme abduction and flexion with prolonged fixation in the attitude of extreme abduction, known as the Lorenz treatment, is frequently successful. In some cases the above treatment is unsuccessful and a radical operation must then be performed. G. L., male, 9 years old; A. L., female, 6 years old; H. L., female, 4 years old. Three out of five children in one family, of Irish parentage. No previous history of lameness. G. L., double posterior dislocation; muscular; great telescopic motion; right side has a shortening of 2^ inches, left side 2% inches, as per Nelaton's line; head and neck apparently well developed ; thighs flexed, adducted and rotated inward ; marked lordosis; walking ungainly and laborious; limited motion in abduction and extension; feet inclined to be flat; can stand in almost normal position except lordosis. Skiagraph reveals very well-developed neck on each side, the right inclined to coxa varus; head on each side inclined to be conical; acetabula rather shallow, but well formed otherwise. Advised no operation as the child was too old, and the circumstances of the family would not admit of good after-treatment. A. L., right posterior dislocation; distinct limp; limb carried slightly in ad- duction; shortening IVo inches; neck short and straight, or coxa valgus. Skiagraph verifies above observations, and shows an apparently poorly formed acetabulum, with considerable thickening. Preternatural mobility in all directions except abduction. Operation advised and performed. Transposition secured. H. L., 4 years old; posterior dislocation; % inch shortening; limp well marked; neck and head rather short but of normal angle; preternatural mobility in all directions except abduction. Skiagraph reveals short head and neck, apparently well-formed acetabulum. Operation performed. Very good result, but might have been improved upon if child had been brought in for after-treatment. Knee-joint Disease. This is a chronic tuberculous inflammation due to an osteitis of the femur or tibia. It may begin as a synovitis similar to hip-joint disease. Etiology. — Traumatism is usually the exciting factor, as in hip-Joint disease. Pathology. — The pathological lesions are those of tuberculosis. The tubercle bacillus is usually found, although it may be absent. The lesions spread and sometimes cause complete destruction of the joint. A char- acteristic swelling noted in tuberculous knee-joint is caused by an infiltra- tion of the soft parts with a gelatinous substance which must be attributed to a tuberculous process. Symptoms. — Children old enough to complain will describe pain when moving the joint. A limp is noticed when walking. A swelling of the joint gradually appears. The knee assumes a flexed appearance which is quite typical of this condition. As a result of the swelling in the joint, motion is limited, and the pain at times is very severe. Fever may or may not be present. In a ease seen by me recently, although a large quantity WRIST-JOINT AND ELBOW-JOINT DISEASE. 865 of pus was present, no fever could be detected. This condition was one of the usual "cold abscess type." Diagnosis. — ^This depends on the limitation of motion, on the swell- ing, and on the pain. It does not resemble rheumatism owing to the affec- tion being limited to one joint. In rheumatism there is fever, at times very high fever, inflammation, swelling, and a sudden onset of symptoms. Just the reverse condition is found in knee-joint disease. Prognosis. — The prognosis as a rule is good. Fully 90 per cent, of cases recover, according to Moore. When, however, cases are neglected, ankylosis of the knee-joint results. Treatment. — Eest in bed, assisted by proper hygiene and a good sup- porting diet, constitute the general line of treatment to be pursued by the general practitioner. The deformity requires careful orthopaedic treat- ment. A case of this kind usually requires a knee-splint or a plaster cast. It is self-understood that only one competent to do this should guide the treatment. For details regarding the application of knee-splints, etc., the reader is referred to works on orthopaedic surgery. Diseases of thei Ankle- joint and Taesds. Tubercular disease frequently affects the ankle and tarsus. The same pathological manifestations described in hip and knee-joint diseases are found here. Symptoms. — As a rule a limp will be noticed. Associated with this there is swelling of the joint, limitation of motion, and in some cases fever ; in other cases, atrophy of the muscles of the leg. The superficial veins are usually enlarged. Diagnosis. — The slow onset of the symptoms associated with swelling and the limp on walking will usually aid in establishing the diagnosis. It is important to exclude rheumatism by carefully examining other joints of the body. The diagnosis rests upon the disease being limited to one joint in addition to the symptoms above described. Prognosis. — The prognosis is usually good. Cases usually recover under proper management in six to nine months. Treatment. — ^The samei treatment described in the article on knee- joint disease applies here. The parts should be given absolute rest. This can be secured by the use of plaster-of-Paris casts. The rest of the treat- ment is restorative. Wrist-joint and Elbow-joint Diseases. This condition is rarely met with in children. When, however, tuber- culous manifestations exist the symptoms are the same as described in other tubercular joints. 866 DISEASES OF THE SPINE AND JOINTS. Treatment consists in securing rest and immobility of the parts with the aid of plaster casts. Pus, when present, requires surgical relief. The outcome of these cases is as a rule good. Joseph S., 10 years old, has been under the treatment of Dr. Dexter Ashley, to whom I am indebted for the illustration. The child was in an extremely ansemic condition, heart and lungs normal, no evidence of tuberculosis. Family history good. Local evidence of tuberculosis involving the elbow-joint, so-called bone tuberculosis. The boy was able to run about, and excepting this arm seemed to be in a fair physical Fig. 297. — Tubercular Elbow-joint. condition. A comparison of the healthy elbow-joint with the diseased joint is quite interesting. Dr. Ashley's treatment consisted in strict aseptic dressings, tight bandaging, a bandage to support the return circulation, and general restorative treat- ment. Acute Arthritis (Infectious Osteitis: Acute Purulent Synovitis: Acute Epiphysitis: Acute Osteomyelitis). This is an acute inflammator}^ condition involving a joint. It is always suppurative from the beginning; it is therefore a form of pyaemia. It is an infection originating at the bone in the medullary canal or in the joint. ACUTE ARTHRITIS. 867 Etiology. — This condition may follow the acute infectious diseases, especially those which show a tendency to suppurative processes. It most frequently follows measles, scarlet fever, and empyema. There seems to be no reason to believe that this disease owes its exist- ence to syphilis, tuberculosis, or scrofulosis. Some authors state that a history of traumatism has preceded this infectious disease. Bacteriology. — Cultures taken of the purulent discharge usually show the presence of the streptococcus pyogenes or the staphylococcus. The point of entrance for the pathogenic bacteria may be either the skin, if abraded, the umbilicus, or the tonsil. In this manner the bacteria gain entrance to the circulation. Symptoms. — Distinct swelling of the joint can be made out, although the inflammatory condition is deep-seated. The joint is red and inflamed and has a glazed appearance. Fluctuation can be felt if properly palpated. The usual symptoms of inflammation, such as high fever and chills or rigors, are present. The joints most usually affected are best judged by studying Town- send's collection of cases: — Hip 38 cases Knee 27 cases Shoulder 12 cases Wrist 5 cases Elbow 4 cases Ankle 4 cases Fingers - 2 cases Toes 1 case Sternoclavicular 1 case Diagnosis and Differential Diagnosis. — ^The diagnosis is easily made if we remember the rapidity with which this condition develops. It may resemble rheumatism, but the acute onset with the fever and the suppura- tion makes it easy to exclude rheumatism. Syphilis may resemble arthritis, but the fever and suppuration are never present in syphilis. Prognosis. — If the disease extends rapidly death may occur in a few days. The outcome of the case depends on recognizing the disease in its early stages, and on the rapidity with which the suppurative condition is relieved. Treatment. — The treatment is surgical. With aseptic care and atten- tion to surgical detail, pus should be evacuated and the joint properly immobilized. To prevent deformity fixation of the joint should be remem- bered. Restorative treatment should, consist in giving arsenic, maltine with hypophosphites, in addition to concentrated food and general hygienic care. The surgical treatment should be given into the hands of a surgeon. PART XII. MISCELLANEOUS. CHAPTER I. DIETAKY. Bevebages. Albumin Water. — Stir the whites of 2 eggs into % pJnt of ice-water, without beating; add enough salt or sugar to make it palatable. Such a mixture is one of the best foods we hare for substitute feeding an infant with digestive disturbances when we wish to temporarily stop all milk-food. Almond-milk. — Take two ounces of sweet almonds, scald them with boil- ing water; after a few moments express them from the hulls; then pour the hot water away. Put the blanched ahnonds into a mortar and pound them thoroughly, and add either 2 ounces of milk or 2 ounces of plain water. After this is thoroughly mixed, it is to be strained through cheese-cloth, and the strained liquid will be the almond-milk. Arrowroot Water. — Add 2 tablespoonfuls of arrowroot to 1 pint of water ; allovr it to simmer for half an hour, stirring it constantl}^ Barley Water. — Take a tablespoonful of pearl barley, grind it in a coffee-grinder, or pound it in an ordinary mortar; add 1 quart of cold water, and allow it to simmer slowly for about an hour. Strain and add enough water to make .1 quart. Beef Juice. — Expressed beef juice is obtained by slightly broiling a j)iece of lean beef and expressing the juice with a lemon-squeezer. One pound of steak yields 2 or 3 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. Cocoa.^ — For each large cup take a teaspoonful of cocoa and a tea- spoonful of sugar; mix to a paste with a little boiling water or milk; add balance of milk or milk and water, as richness is desired. Let it boil a minute, as boiling improves it. Chocolate (Unsweetened), — Eor each breakfastcup take 1 division, break in small pieces, and allow to melt; add milk or milk and water, as ^ A palatable and digestible form of cocoa is mamifactured by Hershey, of Pennsylvania. (868) DIETARY. 869 richness is desired. Stir constantly. Bring to a boiling point and set aside to simmer. Sugar to taste. Eggnog. — Heat some milk to a temperature of 150° F., but do not allow ike inilk to boil. When cold, beat up a fresh egg with a fork in a tum- bler with some sugar; beat to a froth, add a dessertspoonful of brandy, and iill up tumbler with the warm milk. Oatmeal Water. — Take a tablespoonful of ordinary oatmeal, and add 1 pint of water. Allow it to simmer slowly for one hour and strain. Add enough water to make 1 pint. The same directions apply to making a household mixture of farina-water, and sago-water, using the same propor- tions as above. Rice Water. — One ounce of well-washed Carolina rice. Macerate for three hours at a gentle heat in a quart of water, and then boil slowly for an hour and strain. It may be sweetened and flavored v/ith a little lemon- peel. Useful in diarrhoea, etc., when the flavoring is best dispensed with, and a little old cognac added. Yolk of Egg Lemonade. — Take the beaten yolk of 1 egg and add to it the juice of ^/g lemon. Let stand five minutes, thus drawing off the raw taste of the yolk of egg. Add 1 teaspoonful of sugar and 8 ounces of water. White of Egg Orangeade. — Take the juice of 1 orange and 1 ounce of water, insert an egg whisk, and when the orangeade is in full agitation, add slowly the white of egg. Continue the whisking for two or three min- utes more. Add 14 teaspoonful of sugar. White of Egg Lemonade. — Leftwich^ advises the following for a nutri- tive drink for febrile and wasting diseases : — IJ Lemons , 2 White of eggs 2 Boiling water 1 pint Loaf sugar to taste. The lemon must be peeled twice — the yellow rind alone being utilized — ^while the white layer is rejected. Place the sliced lemon and the yellow peel in a quart jug with 2 lumps of sugar. Pour upon them the boiling water and stir occasionally. When cooled to the ordinary temperature, strain off the lemons. Now insert an egg whisk, and when the lemonade is in full agitation add slowly the white of egg. Continue the whisking for two or three minutes more. While still hot, strain through muslin. Serve when cold. The white of egg will be found to impart a blandness which makes the addition of sugar almost unnecessary. This drink is very useful in the febrile diseases of children. It may be given simply as a lemonade, without mentioning the eggs, and will * Edinburgh Medical Journal. 870 MISCELLANEOUS. thus be readily taken by the children and difficult patients. It also pos- sesses antiscorbutic properties, which replace those lost from milk by boil- ing and sterilizing. Soups and Broths. Chicken Broth. — Cut up a small chicken, put bones and all, with a sprig of parsle}^, salt, 1 tablespoonful of rice, and a crust of bread, in a quart of water and boil for one hour, skimming it from time to time. Strain through a coarse colander. Keller's Malt Soup. — Take of wheat-flour 50.0 (about 2 ounces). To this add 11 ounces of milk. Soak the wheat-flour thoroughly, and rub it through a sieve or strainer. Put into a second dish 20 ounces of water, to which add 3 ounces of malt extract; dissolve the above at a temperature of about 120° F., and then add 10 cubic centimeters (about 2 ^/^ drachms) of 11 per cent, potas- sium bicarbonate solution. Finally mix all of the above ingredients, and boil. This gives a food containing: — Albuminoids 2.0 per cent. Fat 1.2 per cent. Carbohydrates 12.1 per cent. There are in this mixture: Vegetable proteids 0.9 per cent. The wheat-flour is necessary, as otherwise the malt soup would have a diarrhoeal tendency. The alkali is added to neutralize the large amount of acid generated in sick children. Biedert emphasizes the importance of giving fat, rather than reducing its quantity, in poorly nourished children, and cites the assimil ability of his cream-mixture or of breast-milk in under- fed children as proof of his assertions. The author has used this malt soup most successfully in the treatment of athrepsia (marasmus) cases in which the children were simply starved. Mutton Soup. — Cut up fine 2 pounds of lean mutton, without fat or skin. Add 1 tablespoonful of barley, 1 quart of cold water, and a teaspoon- ful of salt. Let it boil slowly for two hours. If rice is used, in place of barley, soak the rice in water over night, if it is to be boiled in the morning. Oyster Broth. — Cut into small pieces 1 pint of small oysters ; put them into ^/o pint of cold water, and let them simmer gently for ten minutes over a slow fire. Skim, strain, and add salt. White Celery Soup. — Take ^/o pint of strong beef -tea; add an equal quantity of boiled milk, slightly and evenly thickened with flour. Flavor with celery seeds or pieces of celery, which are to be strained out before serving. " Salt to taste. DIETARY. 871 Puddings and Desserts. Calf's-foot Jelly. — Thoroughly clean 2 feet of a calf, cut into pieces, and stow in 2 quarts of water until reduced to 1 quart; when cold, take off the fat and separate the jelly from the sediment. Then put the jelly into a saucepan, with the shells and whites of 4 eggs well mixed together ; boil for a quarter of an hour, cover it, and let it stand for a short time, and strain while hot through a flannel bag into a mould. Flavor with lemon. Saked Apples. — Core and pare 2 tart apples; fill the core-holes with sugar; grate over the apples a little nutmeg; add a little water to baking- pan and put in oven and bake until the apples are soft. Serve with rich milk -or cream. Sprinkle with icing sugar, if not sweet enough. Cornstarch Pudding. — Take 1 pint of milk, and mix with it 2 table- spoonfuls of cornstarch; flavor to taste; then boil the whole eight minutes; allow it to cool in a mould. Custard Pudding. — Break 1 es:g into a teacup, and mix thoroughly with sugar to taste; then add milk to nearly fill the cup, mix again, and tie over the cup a small piece of linen; place the cup in a shallow saucepan half-full of water and boil for ten minutes. If it is desired to make a light batter pudding, a teaspoonful of flour •should be mixed in with the milk before tying up the cup. Infant's Gelatine Food. — About 1 teaspoonful of gelatine should be dissolved by boiling in ^/o pint of water. Toward the end of the boiling 1 gill of cows^ milk and 1 teaspoonful of arrowroot (made into a paste with cold water) are to be stirred into the solution, and 1 to 2 tablespoonfuls of cream added just at the termination of the cooking. It is then to be mod- erately sweetened with white sugar, when it is ready for use. The whole preparation should occupy about fifteen minutes. Junket of Milk and Egg.— Beat 1 egg to a froth and sweeten with 2 teaspoonfuls of white sugar. Add this to ^/o pint of warm milk; then add 1 teaspoonful of essence of pepsin (Fairchikl) ; let it stand till it is curdled. The above is useful in typhoid and similar wasting diseases. Junket. — Add 1 teaspoonful of liquid rennin to 1 pint of milk. Mix and heat until the steam rises. Pour into cups and set aside to cool. Flavor with vanilla if desired. Or, to a bowl containing 8 ounces of cool milk, add 1 teaspoonful of pepsencia (Fairchikl). Mix thoroughly. Place bowl in pan of boiling hot water, two minutes. Remove, and let stand until jellied. Predigested Eggs. — Break a fresh egg. After thoroughly stirring add to it 2 grains of caroid powder and stir thoroughly. The yolk is at once changed into a limpid liquid and soon, though not so quicklv, the albumin is completely dissolved. This is done at a temperature of 70° to 80° F. Predigested Rice. — Take V^ pound of rice, add water, and boil until soft. Break grains by passing through a colander. Take, of bana-diatase. 8^2 MISCELLANEOUS. 8 grains/ and dissolve it in 1 ounce of water and add to the rice, which must be kept warm, but not hot. Let stand for two hours at a temperature of 105° F. When rice is thoroughly softened, season with salt, sparingly. Add a little cream if desired. Serve hot or cold. Rice Pudding. — Boil a teacupful of rice, drain off the water; add a tablespoonful of cold butter. Mix with it a cupful of sugar, a quarter tea- spoonful of ground nutmeg, and a quarter teaspoonful of cinnamon. Beat up 4 eggs very light, whites and yolks separately; add them to the rice; stir in a quart of sweet milk gradually. Butter a pudding dish, turn in the mixture, and bake one hour in a moderate oven. If you have cold cooked rice, first soak it in the milk, and proceed as above. Sago Pudding. — Same as above recipe, sago being substituted for rice. Soft Custard. — Take of cornstarch 2 tablespoonfuls to 1 quart of milk; mix the cornstarch with a small quantity of the milk, and flavor; beat up 2 eggs. Heat the remainder of the milk to near boiling; then add the mixed cornstarch, the eggs, 4 tablespoonfuls of sugar, a little butter, and salt. Boil the custard two minutes, stirring briskly. Tapioca Cream. — Take 1 pint of milk, 2 tablespoonfuls of tapioca, 2 tablespoonfuls of sugar, 1 saltspoonful of salt, and 2 eggs. Wash the tapioca. Add enough water to cover it, and let it stand in a warm place until the tapioca has absorbed the water. Then add the milk and cook in a double boiler, stirring often until the tapioca is clear and transparent. Beat the yolks of the eggs. Add the sugar and salt and the hot milk. Cook until it thickens. Eemove from the fire. Add the whites of the eggs, beaten stiff. When cold, add 1 teaspoonful of vanilla. Modified Cov^^s' Milk. Humanized Milk. — A pint of milk is set aside until the cream rises, and this cream is skimmed off and kept. To the milk remaining is added enough rennet to curdle it. The whey is strained off the curd and added, with the previously separated cream, to a pint of fresh cows' milk. This is known as humanized milk. In some infants it will be well borne during the first three months, and to this can be added farinaceous liquid for dilution if required. Pasteurized Milk. — This is really partially sterilized milk, and consists in heating to a temperature of 140° F, instead of 212° F,, this heating to be continued from ten to twenty minutes. Pasteurized milk should only be used during the twenty-four hours following this process. A good apparatus for this purpose is Kilmer's pasteurizing apparatus. ^American Ferment Company, DIETARY. 873 Predigested or Peptonized Milk. — ^This is milk in which the proteins are changed to peptones, or, in other words, digested, by the addition and action of pancreatic ferment. This process may be stopped when partially performed, giving a product of which the taste is not objectionable; or it may be carried on to complete peptonization, when the product has a very bitter, disagreeable taste. Method. — To partially peptonize milk, add to 1 pint of fresh cows' milk and 4 ounces of water, 5 grains of pancreatic extract and 15 grains of bicarbonate of soda. Allow this to stand at a temperature of 105° to 115° P. 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 continue for one to two hours. After this time the addition of acid produces no coagu- lation. 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 unwise to continue its use over too long a period, as then the infant's stomach, being called on to do no work, be- comes enfeebled from disuse, and gradually unable to perform its proper function. Whey. — By coagulating 1 pint of fresh (raw) milk by adding a tea- spoonful of essence of pepsin, and allowing this to stand, solid curd is formed, swimming in a liquid (whey) . This Jias the following composition : Proteins, 0.86 per cent. ; fat, 0.33 per cent. ; sugar, 4.79 per cent. ; salts, 0.65 per cent. ; water, 93.3 per cent. When such whey is added to milk for an infant under 6 weeks take, of whey, 2 parts; milk, 1 part. This can be increased until equal parts of milk and whey are used for a child several months old. Preparation of Sweet Whey. — Sweet whey is best made by the follow- ing method : For each pint of whey needed take 1 quart of raw milk or fat-free milk, heated to 37.7° C. (100° P.), and add 8 cubic centimeters (3 drachms) of the essence of pepsin or some of the preparations of liquid rennet. This will precipitate the casein in the form of a curd, which is then broken up with a fork; the fluid which remains is the whey. This is strained through two thicknesses of boiled cheese-cloth and one thick- ness of absorbent cotton and slowly cooled to a temperature of 10° C. (50° P.), and kept on ice until needed. If the whey is to be mixed with cream, it must first be heated to 65.5° C. (150° P.), in order to kill the rennet enzyme. Whey mixtures should not be heated above 68.3° C. (155° P.) if one wishes to keep safely under the coagulation-point of the lactalbumin. Add 1 teaspoonful of cane-sugar to each pint of liquid. 874 MISCELLANEOUS. Miscellaneous. Milk Toast. — Take 1 cupful of milk, y^ teaspoonful of cornstarch, y^ teaspoonful of butter, 2 slices of dry toast, 1 saltspoonful of salt. Scald the milk. Add the moistened cornstarch. Melt the butter in a saucepan; when hot and bubbling, pour in the hot milk slowly, beating all the time until smooth. Let it boil up once. Then add the salt. Toast 2 slices of bread. Pour the thickened milk over the slices. Let it stand a few minutes. Serve. Scraped Beef. — Scraped beef is prepared by scraping with a dull knife some raw or underdone lean beef. Add salt and serve on bread or biscuit. Scrambled Eggs. — Take 2 eggs, a pinch of salt, 2 tablespoonfuls of milk, and a small piece of butter. Beat the eggs lightly, add the salt and milk. Put the butter into a saucepan; when melted and hot, add the eggs. Stir until of a soft, creamy consistency. Serve on buttered toast. Soft-boiled Eggs. — Drop 2 eggs into enough boiling water to cover them. Let them stand on the back of stove, where the water will keep hot, but not boil, for eight minutes. An ^gg to be properly cooked should never be boiled in boiling water, as the white hardens unevenly before the yolk is cooked. The yolk and white should be of jelly-like consistency. CliAPTEll 11. THE EXAMINATION OF THE GASTRIC CONTENTS IN CHILDREN.^ Chemical Examination. - Afteu tlie removed chyle is filtered it is ready for the following tests :— Hydrochloric Acid. — Free hydrochloric acid turns Congo-red a deep blue color; but as the presence of large quantities of lactic and other or- ganic acids gives the same reaction, and as the phloroglucin-vanillin (Giinz- burg's reagent) does not respond to the organic acids, it is better not to depend upon the simpler Congo-red test. One or two drops of the filtered stomach-contents are placed on a white porcelain dish; the same amount of the reagent is added and thoroughly mixed with a glass rod ; the dish is then gently warmed over the flame. The appearance of a bright cherry- red color on the edge of the residue indicates the presence of free hydro- chloric ficid. To IQ cubic centimeters of the filtered chyle add 1 drop of phenolphthalein solution; to this add drop by drop from the burette a decinormal solution of potassium or sodium hydrate until after thoroughly stirring, a pink color persists; now read carefully the number of cubic centimeters of the alkali solution used, multiply by 10 and 0.00365 (the decinormal factor of HCl) and the result is the percentage of HCl. If suf- ficient material is at hand, the estimation should be repeated to avoid pos- sible error. Lactic Acid (IJffelmann's Test). — One drop of the solution of ferric chloride is added to 30 cubic centimeters of the V2 P^r cent, carbolic acid solution; this is diluted till a transparent amethyst blue color is obtained. A few drops of the fluid to be tested added to a few cubic centimeters of this solution in a test-tube, change the amethyst-blue to a canary-yellow if lactic acid be present. On account of the presence of various other substances this test is sometimes not distinctive when the untreated chyle is used. A more certain procedure is to add to 10 cubic centimeters of the filtered chyle in a test-tube 110 cubic centimeters of ether; shake thoroughly; ' V/ith a soft flexible catheter I syphon the gastric contents about two hours after feeding; if the stomach is irritable and children vomit, then the vomited material is used. ^ I am indebted to Boas' valuable book on "Diseases of the Stomach" for many points in the chemical examination and methods used. (875) 376 MISCELLANEOUS. allow the ether to separate ; decant the ether into a clean test-tube ; place the test-tube containing the ether in a glass of warm water till the ether has evaporated; add 5 to 10 cubic centimeters of distilled water to the residue, and test as above for lactic acid. Propeptone. — To 5 cubic centimeters of chyle, add 5 cubic centimeters of saturated solution of sodium chloride and 2 drops of acetic acid. A cloudiness or precipitate indicates propeptone, especially if the precipitate disappears on heating and returns on cooling. Peptone. — Filter out any propeptone from the last named; add an excess of sodium hydrate solution ; mix thoroughly and add 1 or 2 drops of a weak solution of copper sulphate {^/^ per cent.); the appearance of a violet-red or old-rose color indicates peptone. This is the so-called biuret reaction which most peptones and albumoses give. Pepsin. — For this test we require uniform, small pieces of coagulated albumin; these should be little circular slices of hard boiled white of egg, 1 centimeter in diameter and 1 millimeter in thickness, which may be preserved in glycerine. One of these discs is placed in a test-tube containing 5 cubic centimeters of filtered chyle and kept at a temperature of 99° F. ; if it has been already shown that hydrochloric acid is absent, 1 drop or 2 of dilute hydrochloric must be added. The tube is observed every twenty to thirty minutes to note the progress of digestion and the time required for complete disappearance of the egg albumin. Rennet. — Add a few drops of chyle to 5 or 10 cubic centimeters of milk and place tube in water at a temperature of 99° F. Motility. — The motility of the stomach may be tested in various ways; probably the salol-test, although open to many objections, is the most used. This test finds the foundation for its use in the fact that salol is not absorbed until it reaches the alkaline secretions of the intestine, by which it is decomposed. The test is untrustworthy when the stomach secretion is alkaline. The time between ingestion and the appearance of salicyluric acid in the urine is noted by examining the urine at intervals of one-half and one hour after taking 15 grains of salol (immediately after meal). If salicyluric acid be present in the urine, the addition of a few drops of a solution of ferric chloride gives a violet color. If the appearance of the test be delayed longer than an hour or an hour and fifteen minutes, the motility is usually considered below normal. CHAPTER III. URINE. Method of Collecting Urine. In collecting urine from an infant we can apply a pad of sterile ab- sorbent cotton or a flat sterile sponge to the vulva. After urination the urine absorbed can be filtered into a bottle. If the urine thus secured is rot sufficient for examination, the method can be repeated several times. In boys the smallest size rubber ice-bag can be drawn over the genitals and a specimen secured in this manner. If for any reason this method cannot be carried out, and it is vital that the examination be made, then an infant's size catheter may be used to draw off the urine. The First Urine. The first urine drawn by catheter is acid, almost always clear and but slightly colored. During the first four or five days it is more or less cloudy from the presence of epithelial cells from the urinary passage, and uric acid salts. The specific gravity averages about 1012. The sediment always contains normal epithelial cells, various forms of uric acid crystals, and now and then hyaline casts. The amount of urine is small (Morse). This is due in part only to the insufficient supply of milk, as the amount is also small in bottle-fed infants. It increases rather rapidly about the fourth day, 20 to 50 cubic centimeters being passed in the first three days, and about 100 cubic centimeters on the fourth day. In the second week it averages between 200 and 300 cubic centimeters. The proportion of water eliminated in the urine to that taken in the food is greater after the fourth day, averaging 22 per cent, to 25 per cent, before, and 50 per cent, to 60 per cent, after. The urine of hreast-fed hahies almost never contains indican, that of the artificially fed baby usually but slight traces. Urobilin is never pres- ent in that of the breast-fed, seldom in that of the artificially fed. It does not contain albumin, and sugar is absent with the ordinary reagents. The sediment is slight, and consists entirely of cells. One-third to one-half gram of urea per kilo of body weight is said to be passed in twenty-four hours. Figures are of but little use, however, as the amount of urea varies with the character of the food. It is pretty certain, nevertheless, that from 40 to 50 per cent, of the nitrogen ingested appears in the urine. The amount of urine is relatively large. It varies between 200 and 500 (877) 878 MISCELLANEOUS. cubic centimeters from one to six months, and between 250 and 600 cubic centimeters up to 3 years. The urine (d the new-born is rich in sodium chloride, which salt diminishes with age. During the first and second months of life it is in the same proportion as in adults. From the third to the fifth year, com- puted by kilogram weight, the amount is 0.57 gram; at 11 years, 0.44 gram, and at 16 years, 0.18 gram. Phosphoric acid is seldom found, but when met with it is always in very minute quantity. Uric acid is present in the earliest urine, and the quantity regularly increases up to the third day, when it rapidly diminishes. On examining the kidneys of a new-born, the papillae will be found filled with a reddish substance which obstructs the urinary ducts; this, as is well known, is nothing more than uric acid infarction and has no pathological significance. Parrot and Eobin found urate of soda, sulphate of calcium, mag- nesium, potassium, benzoic acid, allantoidin, and mucin, and Cruse denies the presence of sugar, oxalate of calcium, or hippuric acid. Creatinine and indican are not found in the urine of the new-bom or wet-nursed. Xanthine is relatively abundant in cases of nephritis. In infantile atrophy, as may be presumed, the quantity of urine is far below the normal; it is yellow, acid reaction, often contains organic deposits, sugar, albumin and an excess of urea and phosphates. In icterus neonatorum the urine is pale-yellow, and contains urates, epithelial cells, and yellow masses of pigment. The urine of infants with scleroderma is reddish, acid with uratic deposits, and slight excess of urea. Albumin. The i^resence of albumin is always of importance, although not always due to an inflammatory process of the kidneys. It is often the sign of a simple congestion in athrepsia, cholera infantum, general or intestinal tuberculosis, intestinal catarrh, typhoid and scarlet fever. "A small amount of albumin in the form of nucleo-albumin is almost constantly present in the urine during the first four days of life. It often persists for two weeks, and not infrequently for two months. There is much ditference of opinion as to the cause of this albuminuria. It has been attributed to the changes in the circulation at birth, to hyperaemia resulting from the changes in the metabolism after birth, to renal disease in the mother, and to irritation from uric acid. It is doubtful if any of these explanations are correct. The latest investigations show that albu- minuria is no more common in the children of women suffering from nephritis or eclampsia than in others. If uric acid is the cause, its action URINE, 879 is probably as a chemic rather than as a mechanic irritant. Many observ- ers regard this albuminuria as physiologic. It is hardly safe to consider it so, however, until more is known about metabolism, the changes due to nourishment, and disturbances of nutrition in the new-born. Whatever the cause, it is certainly not a serious condition, and ought not to be looked upon as the forerunner of chronic nephritis in later life." In older children the presence of albumin in the urine is always pathological, except when it is the physiological result of the administra- tion of certain drugs (tincture of iodine, etc.). A slight amount of albumin may be found in nephritic colic due to the stimulus which the uric acid exerts upon the renal parenchyma. At other times, when present, there is an actual inflammation of the kidneys, as in scarlatina and diphtheria; there may be an amyloid degeneration without its being possible to discover any albumin in the urine. Sometimes children will be found pale, the urine perhaps abundant or diminished in quantity; it will contain albumin, a few hyaline casts, uric acid and epithelium, yet they will have good appetite, will play and appear otherwise quite well. Others become languid, lose their appetite, complain of headaches, painful micturition, and will pass a turbid and sedimentous urine. In these cases albumin soon appears. The more severe cases suffer from anuria; partial cedema will occur in the eyelids, on the dorsum of the foot, etc. The next day the amount of urine will have been 50 to 100 grams in twenty-four hours. This will increase, perhaps, never to return to the normal. The color of the urine in Bright's disease will be variable, according to the amount of blood which it may contain, of acid reaction, and average specific gravity of 1010 to 1015. Under the microscope we find red and white corpuscles, haematin, renal epithelium, hyaline or granular casts, uric acid crystals, fat globules, and detritus. Chronic nephritis may be the result of an acute affection complicating scarlet fever. In these cases children suffer but little and seldom show more than a few oedematous spots. These forms of kidney involvement are rather rare, and eases which have been diagnosed as such have, on autopsy, proven to have been cases of amyloid degeneration due to syphilis, malaria, rachitis, struma, or tuberculosis. In the mild forms of diphtheria the urine suffers no change what- ever, but in the general infection, even in the early stages, albuminuria is found, which is a fairly positive evidence of systemic infection. If the urine diminishes in quantity and blood corpuscles are found under the microscope we may feel sure that the diphtheritic process has invaded the kidney, or else that a nephritis complicates the diphtheria. "In rachitis, albuminuria is comparatively rare; the quantity does not 880 MISCELLANEOUS. change materially, but the calcium salts have been found in marked dimin- ution. Marchand and Lehman have discovered lactic acid present. The phosphates and chlorides are in very small quantities. The urine of leu- kaemic patients at times contains albumin and many lymph corpuscles as well as hyaline casts. The uric acid and hypoxanthine are in greater quantity. ^'Diabetes mellitus has been met with at a very tender age. "In a case of pseudo-hypertrophic paralysis Dennen reports marked glycosuria. "Hsemoglobinuria is found in Winckel's disease, and the same as in adults, in malaria, syphilis, and as a result of exposure to cold. "Haematuria and pyuria have no special significance beyond that which they have in adults. "Uric acid is in excess during the first week and is a physiological phenomenon; later on, deposits of urates and uric acid appear in the course of serious diseases of the digestive apparatus. Under other circumstances, the oxidation of nitrogen- ous substances being diminished (by dis- eases of the respiratory or central nervous system), deposits of oxalate of calcium occur. "Infarcts of uric acid may be found even up to the seventh or eighth week. Children will strain, make repeated ef- forts and cry out during urination; the diapers will be found stained with a darker urine than usual; the edges of the wet surface Mail be seen reddened by a yellowish-pink sandy deposit. A careful analysis of this urine regularly shows an excess of uric acid, many epithelial cells, a few pus corpuscles, and mucus and traces of albumin. Quite frequently the urine is so acid as to produce such pronounced evidences of pain on the part of the infant as are met with in the nephritic colic of adults. "When tubercle bacilli are present in urinary sediment, the diagnosis of tuberculosis of the kidneys, ureters, or bladder may be positively made. Care should be exercised not to confound the tubercle bacillus with the smegma bacillus, which may often be present in the same specimen of urine and which stains like the former, though it decolorizes differently. * It can be procured at Eimer & Amend, chemists' supplies, New York City. Fig. •298. — Urino-Pyknometer,^ for estimating the specific gravity of small volumes of urine. URINE. 881 "The epithelium found in urinary sediments is often of great import- ance in determining in what part of the genito-urinary tract tlie lesion exists, and a knowledge of the histology of these organs will sometimes prove invaluable. "The presence of echinococcus, filaria, etc., determines the exact nature in those diseases. "Dysuria is not always a manifestation of renal or vesical disease, since a high fever may at times originate it. In such cases children complain or cry out on attempting to urinate. "This symptom belongs as well to affections of the external genitals such as phimosis, urethritis, congenital anomalies of the urethra, those of the labia minora in females, etc." Specific Gravity. — The specific gravity of the urine is best taken with a hydrometer. If the urine is very scanty an instrument called the urino- pyknometer, devised by Dr. Saxe, should be used. It has the advantage of giving the specific gravity when only 1 drachm or 3 cubic centimeters can be procured. Test foe Albumin. Place in a test-tube about half a teaspoonful of pure water, in which dissolve one of the potassio-mercuric iodide tablets and one of the citric acid tablets. To this solution gradually add, drop by drop, the urine. If a gelatinous precipitate occurs, it may consist of albumin, an alkaloid such as quinine, or peptone. To determine which of these three sub- stances was originally present in the urine, heat the contents of the tube to the boiling point and note if the precipitate is redissolved. If such be the case, the precipitation was due to peptone and not albumin, as the latter would be coagulated and would not be dissolved. If the precipitate consists of a compound of the reagent with an alkaloid, it will be dis- solved completely upon the addition of alcohol, a result which would not occur if the precipitate consisted of albumin. The potassio-mercuric iodide test is exceedingly sensitive, and whenever the results are negative, no precipitate occurring upon the addition of the urine, it is positive evidence of the absence not only of albumin, but of peptone and alkaloids as well. It is only in such cases where a precipitate occurs that it becomes necessary to apply alcohol and heat tests to determine the character of the precipi- tate. Directions for Use. — In testing urine for albumin with nitric acid, fill the large tube of the horismascope two-thirds full of the urine, which must be made perfectly clear and transparent, if necessary by filtration. Then pour into the funnel tube 25 or 30 minims of nitric acid, which will pass down through the capillary tube and form a layer underlying the urine. 66 882 MISCELLANEOUS. If albumin is present, a distinct white zone will presently appear at the point of contact, sharply defined against the black background, the amount of albumin being indicated by the density of the opaque ring. Sometimes air will remain in the capillary tube of the instrument, preventing the acid from running down the tube. It is always best to see that the tube is free from air before pouring in the acid. If air is present, it can generally be driven out by merely tilting the instrument or it may be driven down the tube by placing the thumb or middle finger on top of the funnel so as to cover it completely and pressing quickly and forcibly so as to cause a few bubbles of air to pass through the urine. In the use of the horismascope in applying the nitric-acid test for albu- min, these advantages are secured: 1. The acid when it comes in con- tact with the urine is of full strength, rendering the test much more delicate than as ordinarily applied. 2. The reaction is not liable to be obscured by separation of uric acid or acid urates, such separation not taking place in the horismascope until after a considerable interval. 3. The black and white back- grounds of the instrument render much more distinct the effects produced by the reagent. 4. No especial skill is required on the part of the operator. The faintest visible trace of al- bumin as shown by the nitric acid test may be stated to be ^/go per cent. One-fourth of 1 per cent, is just suffi- cient to make the albumin layer opaque when viewed from above. If larger amounts are present the percentage may be approximately estimated by diluting the urine until the opacity is reduced to that corresponding with 0.25 per cent. There are many other tests which can be advantageously made by introducing the reagent from beneath, allowing it thus to form a distinct stratum underlying the fluid to be tested. In testing a specimen of urine it is always best to first determine its reaction. For this purpose red and blue litmus paper should always be at hand. A small piece of each kind of paper should be added to the specimen and the result be observed. If the urine is alkaline the red litmus paper Fig. 299.— The Horismascope or Albumo- scope. A uew instrument for determining the presence and amount of albumin in theurine. No liability of the acid mixing with theurine. The slightest visible trace of albumin can be in- stantly detected against the dark background. Color reactions due to urinary and biliary pig- ments are clearly shown against the white backgrjund. URINE. 883 will turn blue, and if it is acid the blue litmus paper will turn red. It is very important that when testing lor sugar the urine should be slightly alkaline, and when testing for albumin it should be slightly aci'l. In order to render the specimen slightly alkaline or slightly acid according to the test that is to be applied, sodium carbonate tablets and citric acid UiMets should bo used. Robert's Albumin Test. IJ Sat. sol. magnes. sulph. (c. p.) 5 ounces Nitric acid (c. p.) 1 ounce This test is a cold one, viz. : put about 1 cubic centimeter of solution into medium-sized test-tube — incline on a steady rest on an angle of 45 degrees. With a slender pipette allow the filtered urine to be tested — to flow very slowly down the side of the tube. It will float above test solution. Use about 1 cubic centimeter of urine. Examine in front of the window by daylight, with aid of black background. A sharp clear-cut, white line will appear at contact line if albumin is present. A wide band of white is not always indicative of albumin, neither is a narrow zone above in the urine, which may be due to mucus. The sharp, clear-cut zone is distinctive. A New Test for Albumin.^ — This new and simple test is based upon the following facts : — 1. Albumin is coagulated by carbolic acid. 2. Equal volumes of non-albuminous urme and a mixture, composed of equal parts of carbolic acid and glycerine, form an emulsion which clears up entirely upon agitation, leaving a perfectly transparent and highly re- fractive liquid. 3-. Equal volumes of albuminous urine and the above mentioned carbol- glycerine solution, when mixed together, produce a white turbidity, which remains, in spite of agitation, and does not precipitate on standing nor redissolve. The test is very sensitive, distinctly showing the presence of 0.1 per cent, of albumin in the urine, the degree of turbidity being proportionate to the percentage of albumin contained in the urine. Test. — Two cubic centimeters of carbol-glycerine solution are poured into a small test-tube, and 2 cubic centimeters of the filtered urine are added. Mix thoroughly with a glass rod, or agitate. If a clear, transparent liquid results, there is no albumin present; but if the slightest turbidity is noticeable the urine is albuminous. The Diazo Reaction in Urine. — The diazo test Mas suggested by Ehrlich, in 1882, as a valuable diagnostic measure in tj^Dhoid fever, al- though he admitted the occurrence of this reaction in a few other con- ditions shortly to be considered. ^Fuhs, Medical Record, March 8, 1902. 884 MISCELLANEOUS. The diazo reaction depends upon the fact that if sulphanilic acid (amidosulphobenzol) be acted upon by HNO, diazosulphobenzol is formed, which unites with certain aromatic substances occasionally present in the urine to form aniline colors. Eriedenwald has recently reviewed the literature of this reaction, and showed that many of the contradictory results obtained by some observers are due to failure in carrying out Ehrlich's methods in performing the test, which is best accomplished as follows: — To obtain diazosulphobenzol in a perfectly fresh condition sulphanilic acid is kept in solution with hydrochloric acid; to this sodium nitrate is added, whereupon HISTO is liberated and diazosulphobenzol is formed. Process. — Two solutions are prepared, as follows: — 1. Two grams of sulphanilic acid, 50 cubic centimeters of hydrochloric avid, 1000 cubic centimeters of distilled water. 2. A 0.5 per cent, solution of sodium nitrite. In performing the test, 50 parts of No. 1 and 1 part of No. 2 are mixed, and equal parts of this mixture and of) the urine in a test-tube are rendered strongly alkaline with ammonia. If the reaction be positive the solution assumes a carmine-red color, which on shaking must also appear on the foam. Upon standing for twenty-four hours a greenish precipitate is formed. The test must not be considered positive unless a distinct red colora- tion extends to and includes the foam on shaking. Indican. To two inches of urine in a test-tube add ten drops of strong hydro- chloric acid and two drops of fuming nitric acid, allow to cool ; add one-half inch of chloroform and shake up thoroughly. If indican is present, the chloroform, when it again sinks to the bottom of the test-tube, will be tinged either blue or red. Fallacy. — ^Albumin interferes with the test — if present remove same by adding acetic acid, boiling, and filtering off the coagulated protein. Jaffe's test consists in mixing 10 cubic centimeters of strong hydro- chloric acid with an equal, volume of urine in a test-tube, and, while shak- ing, add drop by drop a perfectly fresh, saturated solution of chloride of lime, or chlorine water, until the deepest obtainable blue color is reached. The mixture may next be titrated with chloroform, which readily takes up the indican and holds it in solution, and the quantity present may be approximately estimated according to the depth of the color. If the urine contains albumin it should be removed before applying this test, otherwise the clue color, often arising from the mixture of hydrochloric acid and albumin after standing, may prove misleading. TEST FOR SUGAR IN URINE. 885 Test for Sugar (Glucose) in Ukixk. The best test for sugar is furnished by the indigo and . P.) drop by drop; a wliitc precipitate of iron phosphate forms fii"st, but ahnost immediately if acetoacetic acid be present, the liquid becomes deep purple-red, the color being discharged again on warming. Acetone Test. Legal's Test. — A few drops of a fresh solution of sodium nitroprusKside are added to the urine and a saturated sodium hydrate solution until a distinct alkaline reaction is produced. After the purple color produced by their addition has been succeeded l)y a pale yellow, carefully add a few drops of a saturated acetic acid. If a briglit purple or carmine color appears, the presence of acetone is proven. Bile Pigments. Gmelin's Test. — Upon a white porcelain slab put one drop of the urine and close to it a drop of fuming nitric acid. At their point of coalescence a play of colors — yellow, green, red, and blue — will occur if bile pigments are present. Chlokides. The tests for chlorides are dependent upon the formation of silver chloride on adding a solution of silver nitrate to a urine previously acidu- lated with strong nitric acid. This is to prevent the formation of silver phosphate. A ten per cent, solution of the silver salt is used, and an exactly similar test is to be made on normal urine as a control. Any reduction in an amount sufficient to be of diagnostic value can be made out by, the dif- ference in bulk of the precipitate of silver chloride formed in the two test- tubes. Albumin must be removed before applying tlie test. CHAPTEE IV. BACTERIOLOGICAL [MEMORANDA.^ Demonsteatiox of Tubeeci.e Bacilli ix Sputum. With a forcejos pick out a thick, purulent j)ortioii of the sputum. Make a thin spread between a slide and a cover-glass. Allow this to dry thoroughly in the air or it can be dried by holding it several inches above a Bunsen burner. Stain with several drops of Ziehl^s solution and heat it over a Bunsen burner : — Ziehl's solution: — IJ Fuchsin 1 gram Alcohol 10 giams Carbolic acid 5 grams Water 100 giams After heating wash the cover-glass in water, and lastly add several drops of Gabbet-Ernst solution: — 3 Methylene blue 2 grams DUuted sulphuric acid (25 per cent.) 100 grams Einse this solution off the cover-glass, dry between filter paper, and mount with Canada balsam. Under the immersion lens the tubercle bacilli will be stained red, and all other bacteria will have the blue background. Aqueous Solutions. — Aqueous solutions of methyl violet, gentian vio- let, fuchsin, and the other aniline dyes are prepared by adding 1 cubic cen- timeter of the saturated alcoholic solutions of the desired dye to 20 cubic centimeters of distilled water. This will impart a decided color to the liquid so that a pipette full will be barely transparent. The true aqueous solutions are made by dissolving the dyes in water, but these are weak and not so effective as those prepared from the alcoholic solutions. These solutions deteriorate in a short time. The carbol-fuchsin and alkaline methylene blue will keep a little longer, but they require to be filtered occasionally. ^ The reader is referred to works on bacteriology (such as Lenhartz-Brooks) for blood examinations in malaria, ansemia, leukaemia, aiid for the Widal reaction of the blood in typhoid fever. (888) BACTERIOLOGICAL MEMORANDA. 889 GONOCOOCUS. With a platinum loop pick out a thick purulent portion of the dis- charge. MaJvG a tliin ppread between two slides. Drj^' in the air or over a IBiunscn burner. Cover preparation with aniline gentian violet solution (preferaljly fresh) for five minutes, pour off excess of stain and cover with Gram's solu- tion for two to five minutes. Gram's Solution. IJ Iodine 1 gram Potassium iodide 2 grams Distilled water 100 grams Decolorized with 95 per cent, alcohol until no further traces of the stain can be washed out of the ^preparation. Wash in w^ater and counter- stain with an aqueous contrast st-ain, preferably Bismarck brown. Wash in water, dry and examine under oil immersion lens. The gonococci will take the counter stain. DiPLOcoccus Pneumonia. With a platinum loop pick out a thick portion of the sputum. Make a thin spread between two cover-glasses. Immerse in a watch—glass of aniline gentian violet for ten minutes. Pass through w^ater, and place in Gram's iodine solution for five minutes. Wash in alcohol until no further color comes away. Place on edge to dry. Mount in Caaada balsam. Klebs-Lokffler Bacillus. Bacteriological method of diagnosis is given in detail in chapter on "Diphtheria." Bacillus stains well with Loefflers alkalinej methylene blue. Streptococcus. Usually found in purulent ear, eye, or nasal discharges, sometimes in vaginitis. With a platinum loop pick out a thick portion of the discharge. Make a thin spread between two slides. Dry in the air or over a Bunsen burner. Stain with methylene blue or fuchsin solution. Mount in Canada balsam. Meningococcus. Lumbar puncture fluid in cerebrospinal meningitis should be spread between two cover-glasses and dried over a Bunsen burner. Stain and mount as for gonococcus. CHAPTER V. ANESTHETICS IN CHILDREN. NiTEOUs Oxide and Ether. The ideal anesthetic for children is a combination of nitrons oxide and ether. Whenever it is possible one skilled in its administration should he employed. The responslMlity of attending to a major or minor opera- tion is so great that unless one shilled in the administration of an ances- thetic is employed there may be serious after-effects. To properly guard the heart and respiration requires experience, and no surgeon should un- dertake to do both, excepting in extreme emergencies. Fig. 300. — Gas and Ether Inhaler. Walter K., 5 years old, was given a mixture of nitrous oxide and ether by Dr. Culler. The child was anaesthetized without a struggle. I removed the adenoids and hypertrophied tonsils. The child showed no evidence of shock. There was slight nausea. No other evidence of gastric disturbance. There were no after- effects. Chlorofoem. Chloroform vapor is decomposed into chlorine and hydrochloric acid by the presence of the common gas flame, and may thus give rise to irri- tating effects upon the respiratory organs. (890) ANiESTHETICS. 891 When employed it should be administered by the drop method. By this method, combined with fresh air, the danger is miiiijuized. The statis- tics of Dr. George Gould, of Philadelphia, and the Lancet Commissioner, prove that chloroform anassthesia causes more deaths than ether as an anaesthetic. Ethyl Chloride. This is an excellent anaesthetic and can be administered as a spray on a chloroform mask. I have frequently used it in my hospital service to remove adenoids, tonsils, and for a circumcision. Ethyl chloride is a rapid and safe anaesthetic. Local AmvstJiesia. — Ethyl chloride, as a spray, until the part is frozen, is sufficient to open an abscess, for a lumbar puncture, or even an empyema, in a sensitive child or where general anaesthesia is contraindicated. The inhalation of ethyl chloride is also of great advantage where a short ancestliesia is required, as, for instance, when a paracentesis of the ear is to be made. An advantage of ethyl chloride over ether or chloroform is that it is not followed by nausea or vomiting. Ether. Sulphuric ether, used alone as an anaesthetic in children, may be considered. It requires a much longer time to produce its effect, although it has no depressing effect upon the heart. Statistics show that in 300,175 administrations of ether there were 18 deaths. Out of 638,461 of chloroform, there were 160 deaths, showing the following ratio : — - Chloroform mortality 1 to 3,749 Ether mortality 1 to 16,675 We therefore see that ether is by far the safer anaesthetic. Weir states that "ether narcosis is safer, even though the kidneys are slightly affected.'' Ether is frequently combined with oxygen, and, as previously stated, with laughing gas, and forms in the latter combination flie safest aiiasthdic for children. Regarding the Effect of Ether in Affections of the Air Passages. — Affections of the air passages following ether narcosis are usually the result of aspiration of infected mouth contents. Ether causes a slight increase of mucous secretion. It has no irritant action on the tracheal or bronchial mucous membrane. When bronchitis or pneumonia exists, greater care must be taken owing to the increased secretion produced by the ether, as stated above. When nitrous oxide is given we avoid the irritant effect just described. In adenoid operations, give nitrous oxide until cyanosis is seen, then give ether ; the change relieves cyanosis at once. 892 MISCELLANEOUS. Lymphatic Enlargement in Children. — Most deaths occur in children in which the lymphatic condition exists — ^the so-called lymphatic diathesis. The Children's Clinic at Graz. during the last twenty years^ shows that records of fatalities with chloroform always revealed the lymphatic hyperplasia, which is the principal feature of the so-called constitntio lym- phatica. (Eead chapter on "Status Lymphaticus.") Ewing believes the above conditions prevail in America. Lartigan's report of the Eoosevelt Hospital shows that death came after ether as well as after chloroform, in children affected by the lymphatic constitution. The presence of universal enlargement of the hmph nodes without direct inflammatory cause, hypertrophied tonsils, adenoid hyperplasia, tendencies to ansemia. weakness of pulse, irregular heart's action, along with insufficient development of the heart and large blood-vessels, show that the lymphatic condition exists. Local or Ixtea-spixal Ax^sthesia.^ Corning, of Xew York, about twenty years ago found that anesthesia could be produced in the lower part of the body by injecting cocaine in the lumbar region of the spine. The patient is placed in a sitting position well bent forward, and firmly held during the injection. The skin should be cleaned in the usual antiseptic way, followed by an ethyl chloride spray. This renders the introduction of the needle practically painless. A point one-half inch to either side of the median line and midway between the spinous process is taken, and the needle pushed forward, inward, and upward. Special effort is made to keep away from the central part of the spinal canal by a close relation of the needle point to the dura. The instrument used is of the simplest kind. A small-sized, steel aspirating needle with a short-beveled pointed end, having a well-fitted hjrpodermic barrel, answers every purpose. As nearly as possible the same amount of cerebro-spinal fluid is allowed to escape as of the injection medium which is to he introduced. The injection is given slowly, usually taking one and one-half to two and one-half minutes. Often the flrst evidence that the cocaine is taking effect is some dilatation of the pupils or a slight nausea. Since the introduction of novocaine we have a much safer local anses- thetic. Owing to its being less toxic than cocaine we do not have the dis- agreeable constitutional s}'mptoms so prevalent during the administration of cocaine. There is an absence of nausea and vomiting and an absence of the dilatation of the pupils. The clinical researches of Braun and Bier have demonstrated that novocaine produces more profound and more lasting anaesthesia than * The technique of lumbar puncture is described in article on "Aleningitis" (page 789). ANESTHETICS. 893 cocaine. When applied locally it has no irritating qualities. From one- half to 1 cubic centimeter of the 1 per cent, novocaine-suprarenin was suf- ficient to procure complete anaesthesia for four hours. Novocaine when combined with suprarenin^ offers our best means of producing local anaesthesia. This combination produces far less toxicity than cocaine. It is dispensed in tablet form and is readily soluble in water. Novocaine produces no by-effects and causes no mydriasis. This method has been especially valuable where circumcision is to be performed, or where the examination of the bladder is to be made. In children I have frequently found considerable nausea and vomiting fol- lowing the use of cocaine; the same is also true of eucaine. The analgesic effect of eucaine is in some cases as good i as that of cocaine. Dose Bequired. — Five, rarely 10 minims of freshly prepared 2 per cent, cocaine solution are required. The solution should be freshly pre- pared for each case, by dissolving the eucaine or cocaine in sterile water. It is well to remember that there are certain toxic effects noted in some children. This should be borne in mind, and individual idiosyncrasies noted. ^ Novocaine tablets can be procured in various strengths through Farbwerke Hoechst Co., New York. CHAPTEE VI. DISINFECTION. The modern conception of the transmission of such infectious diseases as diphtheria, scarlet fever, measles, and cerebro-spinal meningitis has re- sulted in a complete reversal of the methods of fumigation, isolation, and quarantine. The Health Department of the city of New York has, as recent as July, 1913, i-ssued orders that: "On account of the practical absence of danger from bedding used by the patient, the removal of such bedding for disinfection after the termination of cases of diphtheria, scarlet fever, measles, cerebro-spinal meningitis and poliomyelitis should be discontinued. In exceptional instances where the family or physician insist upon steriliza- tion of bedding, it will still be performed by the department. In special cases, where proper and efficient fumigation cannot be performed by reason of the nature of the premises, bedding will be removed after the termination of these diseases, and bedding will also be removed in cases of small-pox." The best disinfectant is sunlight and fresh air. There is no danger from the air of the room in which the patient suffering from diphtheria is confined. There is danger in the secretions from the nose and mouth, or i£ there is a mouth to mouth contact with a patient suffering from diphtheria. The 'presence of insects in the sicTc room, especially flies, should be guarded against as much as possible, in view of the fact that they may act as carriers of the disease. No food should be allowed to stand uncov- ered in the sick room, as in certain cases pathogenic organisms may gain access and multiply therein. Sputa are best disinfected by steam sterilization, together with the sputum cups. The addition of 15 grams of sal-soda to a liter of water materially aids the process of cleaning. TJrine and fceces are best treated together by means of milk of lime. In this we possess the most valuable agent for the disinfection of typhoid and cholera stools. This agent is prepared as follows: To unslacked lime, placed in a jar, as much water as it will absorb is added. The unslacked lime is stirred up with 4 parts of water to form the milk of lime, and this is mixed intimately with the discharges until the mixture gives a strong alkaline reaction (tested by litmus paper). Chloride of lime, to be effective, must contain 25 per cent, of avail- able chlorine. Six ounces to the gallon of water represents the standard solution. Carbolic acid, unless in combination with sulphuric, and corrosive sublimate are not suitahle for the disinfection of stools. Discharges can also be disposed of by burning after being mixed with sawdust. Water-closets are best disinfected by chloride of lime solution. (894) CHAm^ER VTT. THE ADMINISTRATION OF DRUGS TO CHILDREN. A FEW points concerning the use of drugs in children should he noted : — 1. Give the minimum dose of a drug in the heginning of a disease. 2. Administer the drug in a palatable form. 3. The soluble tablet triturates should be administered, as they com- bine a minimum quantity with solubility and palatability. 4. Remember the idiosyncrasies of drugs and guard against toxic doses by watching the effect of a drug in any given case. 5. In some specific diseases such as diphtheria, give a sufficient quan- tity of antitoxin to obtain a therapeutic result. 6. Certain drugs, for example, belladonna, calomel, quinine, strych- nia, bromoform, and alcohol, tvJien cautiously administered can be given in very large doses. It is only necessary to note the physiological effect and then to give the drug until its point of tolerance is reached. Accuracy in dealing with poisons is very important in children. It is surprising to see the difference in size of various teaspoons on the market. I advise using a medicine glass, which is graduated with teaspoon, etc. (895) CHAPTER VIII. LOCAL REMEDIES. Cold Compresses. Cold compresses may be made out of linen or cheese-clotli folded sev- eral times and wrung out in ice-water. If there is any abrasion of the skin, 1 part of glycerine should be added to every 5 parts of water. If con- stant cold is wanted, compresses should be changed frequently. Hot Compresses ok Fomentations. Hot compresses or fomentations are made by wringing out a piece of flannel in hot water. As this is oftentimes hotter than the hands can stand, the flannel may be placed in a towel, two ends being kept from the water and then wrung out in the towel by twisting the ends. In apply- ing fomentations they should not be hotter than can be borne by the face of the mother or nurse. To retain the heat they may be covered with oil silk, oil paper, or oiled muslin, and then with a dry towel. Eenew when cool. Poultices. A poultice is intended to supply heat for a greater period than a fomentation. It should not be more than one-half inch in thickness. A flaxseed poultice is made as follows; A sufficient quantity of water is heated, and when brought almost to the boiling point, the flaxseed meal should be added slowly, stirring all the while to avoid lumping. The meal may be added until it has the consistency of hot mush, too thick to flow. This may be spread on a piece of linen or cotton cloth, the edges turned over slightly and the part to which it is to be applied next to the body must be covered with an old handkerchief or thin piece of linen. See that it is not hot enough to burn the skin. The poultice should be larger than the affected area. Afterward cover with oil silk or paper to keep out the air, and then bandage in place. This can be renewed every hour or so. Have everything ready when the poul- tice is made, as it quickly cools when exposed to the air. Turpentine Stupes. Turpentine stupes are found very useful in cases of abdominal pain. A piece of flannel is wrung out in hot water, the same as in a fomentation, (896) LOCAL REMEDIES. 897 except a little soap or oil added to the water. A little turpentine should then be sprinkled evenly over the surface of the llaund, about oO drops to each square foot or a teaspoonful may be added to the water. Apply the same as a fomentation. Mustard Plasters. Mustard plasters for infants should be made with 1 part of mustard to 3 or -1 parts of flour or flaxseed meal. Add warm water and stir until of the proper consistency. Spread thinly on a cloth and apply directly to the skin. It is to be kept on until the skin is reddened, not blistered. Ginger Poultice. Ginger poultice is made in the same way as that described for the making of mustard plasters, and has its advantages in that it will not blister. Cantharidal Collodion. In using the cantharidal collodion care should be exercised to remove all moisture and excretions from the skin before applying, otherwise the cantharidin, being soluble in water, will not come into contact with the skin. One of the most convenient methods of preparing the skin for the application of cantharidal collodion is to wash the part with vinegar or dilute acetic acid. Venesection (Blood Letting). Local hJood Jetting is frequently a valuable therapeutic aid, especially in meningitis and in cerebral pneumonia, in fact, wherever symptoms of cerebral hypersemia are noted. Convulsions are sometimes prevented by relieving congestion with the aid of a few leeches. Baginsky reports the value of venesection as a routine measure in certain types of diseases, such as continued convulsions, in which relief can be afforded by this means. The skill of the surgeon is necessary, for we must consider the possibiKty of infection while opening a vein. Dry Cupping. The application of dry cups is useful in marked dyspnoea. It is there- fore indicated in asthma, broncho-pneumonia, and in pulmonary oedema, t\\o cups may be applied on each side posteriorly for several minutes. If relief is afforded, they can be applied once every twelve hours. B7 CHAPTEE IX. RECTAL :SIEDICATIOX IX CHILDREN. TThex the stomach is irritable in 3'ouiLg children I prefer to medicate per rectum. The gastric mucous membrane will sometimes show an in- tolerance for drugs. It is advisable, especially in exhaustive diseases, such as diphtheria, t^-phoid fever, and the intestinal disorders, to support the strength of the body with nutrition. In such cases vomiting may be pro- voked by the administration of drugs. Children will frequently object to taking medicine, and it is painful to watch the struggle between mother and child while attempting to force the medicine into the infant's mouth. In such cases, especially in very j'oung infants with whom we cannot reason, the rectum should be chosen as the proper charmel for the introduction of the drug. The rectum absorbs slowly but sureh'. The following drugs may be given per rectum and the doses gradually increased : — Aconite may be given in suppository, but shows its action only in large doses. We must therefore administer it in repeated small doses to obtain its effect. For example, we may give 1 or 2 drops of the tincture in a suppository- to a year-old child. Belladonna acts as an excellent sedative in cough, and exerts a very favorable influence on the m-uscle fiber of the intestine. We may use ^/g minim of extract of belladonna in twenty-four hours, divided into three or four suppositories, for every two years of age. Bromides r^hould be given in doses of 3 grains for each year of life, in two suppositories: '/^ grain if it is to be continued. In severe spasm we may give two grains for each year of life, in two suppositories rapidly fol- lowing each other; for example, in laryngismus stridulus. Caffeine is usually injected subcutaneously. It may, however, be administered in a suppository with equal parts of benzoate of sodium. For example, one and one-half grains to a suppository, using two daily for each year of the child's life. Digitalis. — Powdered digitalis is with difficulty absorbed by the rec- tum. The tincture should, therefore, be used. The maximum dose for each year of life is 4 drops, divided into two suppositories. Iodine and its preparations are exceptionally well borne by the rectum, and 'fully absorbed. Three grains for each year of life, in two supposi- tories, is the maximum dose; ^/^ grain if it is to be continued. (898) RECTAL MEDICATION. 899 Mercury should only exceptionally be given per rectum, and then only in tiio i'oriM of calomel, ''/^ grain in a suppository for each year of life. Nux Vomica. — One-sixth of a grain for every two years, in three sup- positories. Strychnine should only l)e given to children over 10 years of age. Salicylic Acid. — Seven and three-quarter grains for each year of life^ in divided doses (three or four). Quinine is best given in suppositories. The daily maximum dose is 2 to 3 y.j grains, in two suppositories, for each year of life. Antipyrine may be given in the same dose as quinine. Opium. — Pulvis opii may be given in suppositories, in doses of Voo grain for each year of the child's age, and this dose may be repeated in s-evere cases every two hours. Toxic symptoms should be carefully watched for, and the use of the remedy discontinued on their appearance. These doses are small ones and may be increased. CHAPTEE X. PRESCRIPTIONS FOR VARIOUS DISEASES.- Feveb. I^ Sweet spirit of niter l^^ fl. draclims 6|0 Citrate of potassium 30 grains 2j Syrup of lemon 4 fl. drachms 15 Aquse q. s. ad 2 fl. ounces q. s. ad 60 M. Sig. : A teaspoonful every hour. Repeat 3 doses. For a child 3 years old; younger children y^ teaspoonful. 5 Tr. aconite rad 16 drops gtts. 16] Spir. mindererus 2 ounces 60 [ M. Sig.: % teaspoonful every hour. For a child 2 to 4 years old. To COBBECT FLATUI.ENCE — ^A iMiLl) LAXATIVE. Vf, Magnesia usta 1 drachm 4 Pulv. rhei 1 drachm 4 Saccharum 2 grains M. and divide into 12 powders. Sig.: 1 powder in a teaspoonful of water every two or three hours Pebsistent Diaebhea, with Tubekcuiab Symptoms. IJ Guaiacol carbonate. Sig. : 1 to 2 grains three times a day. For a child 1 year old. Entebo-colitis. R Tinct. kino 20 minims gtts. 20 1 Misturse cretse comp 1 drachm 4|0 Aqua q. s. ad 2 ounces q. s. ad 60 M. Sig. : Teaspoonful every three hours. Colitis, with Pain. IJ Tinct. opii camph 10 minims Bismuthi subnit 2 grains Aquae calcis q. s. ad 4 drachms M. Sig.: Teaspoonful every two hours. (900) gtts. 10 12 q. s. ad 16 PRESCRIPTIONS. 901 M, Atonic Dyspepsia, with Constipation. Tinct. nucis vomicae 15 minims Pulv. rad. ipecacuanhae 1 grain Pulv. rad. rhei 10 grains Sodii bicarbonas % drachm Aquae q, s. ad 2 ounces Sig. : Teaspoonful before each feeding. gtts, 15 06 6 2 s. ad 30 SUMMEE DiABBHEA. IJ Calomel tablets Vio grain Sig.: 1 every twenty minutes for three doses. For a child 1 to 2 years old. Followed by: — IJ Mist, rhei et soda 2 ounces Sig.: Teaspoonful every hour, for three doses. Following day give: — IJ Bismuth betanaphthol. Sig.: 5 grains, in water, every two hours. Or:— B Mist, creta. Sig.: Teaspoonful every two hours. Or:— R Bismuthi subnit 20 grains Misturse cretse comp 4 drachms Aquae q. s. ad 2 ounces M. Sig.: Teaspoonful every two hours. Or:— R Tannalbin or tannigen. Sig.: 5 to 10 grains every three hours. 01006 3010 1 16 s. ad 30 Beoncho-pneumonia. R Sodium benzoate V^ drachm Liq. ammon. anisat 1 drachm Syr. prun. virgin 1 ounce Aquae q. s. ad 2 ounces M. Sig.: Teaspoonful every two hours. For child 5 years old. 2|0 4|0 3G|0 ad 6010 902 MISCELLANEOUS. Capillaby Bbonchitis. When expectoration is viscid: — IJ Ammon. carbonat 10 grains Syr. senega 4 drachms 16 Syr. prun. virg 6 drachms 24 Aquae camph q. s. ad 2 ounces q. s. ad 60 M. Sig. : Teaspoonf ul in water, every two hours. Acute Cataeehal Bbonchitis. IJ Ammon. muriat 15 grains 1 Ammon. bromid 20 grains 1 Syr. liquorit 6 drachms 24 Tinct. opii camph 2 drachms 8 Aquae q. s. ad 2 ounces q, s. ad 60 M. Sig.: Yo teaspoonful every two hours. Stimulating Expectobant. I^ Syr. senegse 20 drops Ammon. carbonat % drachm Tinct. opii camphorat 3 drachms Syr. tolutan 5 drachms Aquse q, s. ad 6 ounces M. Sig.: Teaspoonful in water every two or four hours. gtts. 20 2 12 20 q. s. ad 180 ' • Pleubisy. For cough with pain on breathing: — I^ Pulv. Doveri 10 grains 016 Pulv. ext. liquorit. 20 grains 13 Sacch. albi 30 grains 2|0 M. ft. chart, no. xx. Sig.: 1 powder every three hours. Pneumonia. Reduce fever with tepid baths or packs. Daily, attention to bowels with calomel or enema. IJs: Tinct. aconite, 1 drop every hour, until fever is reduced. Aid rest at night with: — IJ Codeine, Vio grain. Repeat in three hours if necessary. Or:— IJ Dover's powder, % to 1 grain. Repeat in three hours if necessary. PRESCRIPTIONS. 903 Erysipelas. Streptococcus vaccine, 50,000,000 to 100,000,000. Inject \>y hypodermic. Bactebial Vaccines. Vaccine treatment for erysipelas, pertussis, typhoid, and pneumonia, will be found on pages 450-454. Gastro-enteeitis. IJ Castor oil. Teaspoonful every two hours, for four doses. If diarrhea persists after flushing the colon and washing the stomach, give the following: — I^ Eudoxine. Sig. : 5 grains every three hours. The diet is most important. Persistent Vomiting. Lavage (stomach washing) with one tablespoonful of salt to a quart of warm water (100° F.). Then leave stomach rest at least six hours. Mouth- WASH. Pulv. acid, boric solution, 1 per cent. Stomatitis or Aphthae. R; Solut. kali permangan., 1 per cent. Sig. : Dilute with equal parts warm water. Wash three times a day. Enuresis. R Ext. rhus aromaticse fl 10 minims gtts. 10 Syrupi aromatici 20 minims gtts. 20 Aquse destillatse q. s. ad 1 drachm q. s. ad 4 Sig.: This amount to be given three times a day. Or: — R Liq. stryehninse hydrochloratis 45 minims gtts. 451 Liq. atropinae sulphatis 1^2 drachms 6J0 Syr. aurant q. s. ad 1 ounce q. s. ad 3010 Sig.: 5 drops at night. Increase gradually. For a child 14 years old. Younger children in proportion. 904 ]inSCELLANEOUS. Hookworm. R Eucalyptus oil 2 drops gtts. 2 Clilorofomi 1 drop gtt. 1 Castor oil 2 drachms 8 M. Sig. : One dose t. i. d. Eepeat treatment several days. Tapewoem. 5 Chloroform 10 drops gtts. 10 Oleores. filis mas 1% drachms 6 Syr. ginger q. s. ad 1 ounce q. s. ad 30 Nepheitis. IJ Potass, citrat 2^2 drachms 10 Est. buchu fl 2% drachms 10 Ext. uva ursi fl 1 drachm, 1 scruple 5 Syr. limonis 2 ounces 60 Aquse q. s. ad 4 ounces q. s. ad 120 M. Sig. : Tea spoonful every two to three hours. Pebtussis. IJ Phenacetine. Sig.: 2 to 5 grains every three hours, by day. ij^ Codeine. Sig.: Vs grain gradually increased to ^ grain, every two to three hours, at night, until cough lessens. In severe cases: — IJ Heroin. Sig.: V21 grain, given at night. Repeat in two hours. J.IEASI.ES. Pre-eruptive stage: — Hot bath or dry hot blanket pack. IJ Spiritus mindererus (freshly prepared). Sig. : 1 drachm, in water, every hour. When eruption appears: — Continue warmth and warm drinks. Strict attention to bowels. For cough (see I^ Acute Catarrhal Bronchitis), PRESCRIPTIONS. 905 Or:— IJ Ammon. bromid 45 grains Syr. liquorit 6 drachms Decoct. althfE q. s. ad 2 ounces Sig. : Teaspoonful every hour, until relieved. For a child 1 year old. 310 25|o q. s. ad 6010* Scarlet Feveb. To reduce fever: — IJ Tinct. aconiti 20 drops Spir. mindereri 2 ounces Syr. limonis 1 ounce M. Sig.: Teaspoonful every hour, until sweating is produced. For a child 5 to 12 yeafs old. Younger children, half the dose Itching: — R Calamine 1 drachm Ung. aq. rosse 1 ounce M. et ft. ungt. Sig.: Apply over body once or twice a day. Stimulant: — R Camphor 1 gramme Olive oil 10 grammes Sig. : Use hypodermically. gtts. 20 60 30 I Restoratives: — R Mist, ferri et ammonii acetatis, Glycerini aa 1 fl. ounce aa 30 Aquae q. s. ad 4 fl. ounces q. s. ad 120 M. Sig.: A teaspoonful or more, in water, every three hours. Or Basham's Mixture may be given: — R Tinct. ferri chloridi, Acidi acetici dil aa 1 fl. drachm aa 4 Liq. ammonii acetatis 6 fl. drachms 24 Aquae q. s, ad 6 fl. ounces q. s. ad 180 M. Sig.: Tablespoonful three times a day. For a child 6 years old. ScAELET Fever — Nephritis. (Diuretic.) R Acet-theocine. Sig.: 5 to 10 grains, every three hours. Vaginitis Following Scarlet Fever. R Solut. argyrol, 25 per cent. Sig.: Drop a few drops into vagina with medicine dropper, two or three timei? a da^. 906 MISCELLANEOUS. Simple Vaginitis. Iji Alum, powdered 1 ounce 301 Or: — IJ Zinc sulphate 1 ounce 30 1 Or:— IJ Borax 1 ounce 30 1 Sig. : A tablespoonful to a quart of water, to be used as a vaginal injection three or four times a day. Apply a sterile pad of cheese-cloth. A fresh pad to be applied after each irrigation. Tonic Aftee Exhaustive Disease, Such as Pneumonia oe SUMMEE DiAEEHEA. IJ Ferri pyrophos 1 drachm Quininse sulph % drachm Strych. sulph ^, grain Acid, phosph. dil 2 drachms Aquse q. s. ad 4 ounces M. Sig.: Teaspoonful three times a day. 4 2 015 8 q. s. ad 120 Tonic and Restoeative. I^ Ferri et quininse citrat % drachm 2 Syr. hypophos. comp 4 drachms 16 Aquse q. s. ad 2 ounces q. s. ad 60 M. Sig.: Teaspoonful after each meal. Tonic Dueing Choeea. IJ Liq. potass, arsenitis % drachm Ferri et ammon. citrat 1 drachm Aquse q. s. ad 2 ounces q. s. 2 4 ad 60 M. Sig.: Teaspoonful three times a day. Increase gradually. To Aboet Acute Tonsillitis. IJ Creosote 8 drops Tinct. myrrh 2 ounces Glycerini 2 ounces Aquse 4 ounces M. Sig.: Gargle every hour. Acute Tonsillitis. I^ Tinct. aconit. rad 1 ounce Sig.: I drop every hour for six doses. For a child 1 to 5 vears old. gtts, 8 60 60 120 3010 PRESCRIPTIONS. Milk Cbust. I^ Olive oil % ounce Castor oil % ounce Salicylic acid % drachm M. Sig. : Apply every six hours until the crusts loosen. 907 Eczema Rubbum. Salicylic-sulphur paste: — IJ Ac. salicyl. 15 grains Sulph. depur 1 drachm, 1 scruple Petrolati 6 drachms Zinci oxidi 2% drachms Amyli 2^4 drachms M. Sig. : Apply three times a day. Ichthyol ointment: — IJ Ammon. sulph. iehthyolat 1 drachm, 1 scruple Aq. dest 1 drachm, 1 scruple Adeps benzoat i^ ounce Adeps lanae 6 drachms M. Sig. : Apply three times a day. 1 5 25 10 10 Ebtsipelas and Cellulitis. R Magnesia sulphate 2 drachms Aquse 16 ounces M. Sig.: Apply as a lotion. 8|0 50010 BUBNS. R Picric acid ointment, 1 per cent. Sig.: Apply thickly and cover with strips of oiled silk, then steril gauze and bandage. EcZEilA. Cooling lotions: — R Pulv. calamini % drachm Pulv. zinci ox % drachm Glycerin! 15 grains Aq. calcis 1 ounce M. Sig.: Apply three times a day. 908 MISCELLANEOUS. Or:— IJ Phenol 20 drops Zinc, oxid 3 drachms Calamine 2 drachms Glycerini . 4 drachms Liq. plumbi subacet. dil 1 ounce Lime-water q. s. ad 6 ounces M. Sig. : Apply three times a day. To stop itching: — IJ Zinc oxide 2 drachms Amylum 2 drachms Naphthalan 1 ounce M. Sig.: Apply at night. Or Unna's Soft Zinc Paste: — a. 01. lini, Aq. calcis, Zinci ex., Cretse of each, equal parts. M. Sig. : Apply at night. gtts q. s. 20 12 8 16 30 ad 180 30 UbTICAEIA — ^HlVES. To stop itching: — IJ Resorein, Menthol, Phenol aa 15 grains Alcohol 7 ounces M. Sig.: Apply with cotton. aa 110 200 Scabies. IJ Balsam Peru 1 drachm Sulphur % drachm Betanaphthol 10 grains Petrolatum 1 ounce M. Sig.: Apply on affected areas. Repeat three successive nights. Hypodermic Medication. When immediate relief is required, hypodermic medication should be given. The rapid action of hypodermic medication is best shown in giving a dose of apomorphia hypodermically for the relief of spasmodic croup. CHAPTER XI. Remedies Most Frequently Administered: For hypodermic use the dose should be half that used by the mouth. For use hy rectum the dose should be twice that used by the mouth. Dose for Children. — Dr. Young's rule : Add 12 to the age, and divide the age by the result. Example. — For a child 2 years old, ^^^ = ^. The dose should be ^/t that for an adult. In giving powerful medicines and opium still smaller doses must be used for children. TABLE OF DOSES. Owing to the toxic effect, drugs marked "*" must be given with greater caution. Remedies. *Acid, benzoic boric camphoric (to check night-sweats) . . . gallic gallic (in albuminuria) hydrobromie, diluted hydrochloric, diluted *hydrocyanic, diluted nitric, diluted nitrohydrochloric, diluted . phosphoric, diluted salicylic sulphuric, aromatic sulphuric, diluted sulphurous tannic *Aconitina (white crystals) Aloes Aloinum Ammonii benzoas bromidum carbonas chloridum lodidum valerianas *Amyl nitris (inhaled or internally) Antimonii et potassii tartras (diaphoretic) et potassii tartras (emetic) oxysulphuret Antipyrin Apomorphine hydrochloride Argenti nitras *Arsenii iodidum *bromidum Fob Child Three Yeaes Old. 1 to 3 grains. 1 to 2 grains. 3 to 6 grains. 2 to 5 grains. 2 to 12 grains. 2 to 12 grains. 1 to 4 grains. 1 drop. 1 to 4 drops. 1 to 4 drops. 1 to 6 drops. 1 to 4 drops. 1 to 3 drops. 1 to 6 drops. 6 to 12 drops. 0.4 to 2 drops. Moo to 1^00 grain. 0.4 to 1 grain. 0.025 to 0.6 grain. 2 to 4 grains. 1 to 6 grains. 0.6 to 2 grains. 2 to 6 grains. 0.4 to 3 grains. 0.4 to 3 grains, 0.4 to 1 drop. 0.01 to 0.02 grain. 0.2 to 0.4 grain. 0.1 to 0.4 grain. 0.4 to 3 grains. Vio to % grain. 0.035 to 0.1 grain. 0.003 to 0.02 grain. 0.003 to 0.012 grain. (909) 910. MISCELLANEOUS. Remedies. *Atropinse sulphas *Auri et sodii cliloridum Bismuthi subnitras salieylas *Bi-omof ormum ( in whooping-cough, etc. ) Caffeine Calcii chloz'idum hydratum Calcii lacto-phosphas Camphora monobromata • Cerii oxalas Chinoidinum Chloral Chloralamidum (hypnotic) Chloroformum Chrysarobinum (eczema) Cinchonidina, and its salts Cocaina (locally, 14 psr cent, solution), internally Codeina - *Colchicine Confectio sennse *Creolin (locally, ,i^| to 2 per cent, solution) internally.. Creosotum Oroton-chloral Cupri acetas sulphas ( emetic ) *Digitalinuni *Digitalis *Duboisina, and salts *Elaterinum (U. S. P., 1880) Emetina, and salts (emetic) Ergota Ergotinum *Eserina, and its salts Ethyl chloride (local anaesthetic) Fel bovis purificatum Ferri arsenas bromidum carbonas saccharatus et ammonii citras et ammonii tartras et potassii tartras et strychninse citras hypophosphis iodidum saccharatum lactas pyrophosphas subcarbonas Ferri sulphas sulphas exsiccatus valerianas Ferrum dialys reductum Gaultheria, oil of Guaiacol (constituent of creosote) Guaiacol carbonas vel benzoas Homatropinse hydrobroraidum (mydriatic, locally, 0.2 per cent, to 4 per cent. ) Fob Child Three Years Old. 0.0015 to 0.006 grain. 0.006 to 0.025 grain. 1 to 12 grains. 1 to 4 grains. 1 to 2 drops. 0.2 to 1 grain. 1 to 4 grains. 1 to 2 grains. 0.6 to 2 grains. 0.4 to 1 grain. 0.2 to 2 grains. 0.6 to 6 grains. 0.6 to 4 grains. 3 to 12 grains. 0.2 to 6 drops. 0.035 to 0.6 grain. 1 to 6 grains. 0.012 to 0.1 grain. % to 14 grain. 0.002 to 0.004 grain. 12 to 24 grains. 0.1 to 1 drop. 0.1 drop, gradually in- creased. 0.2 to 1 grain. 0.025 to 0.1 grain. 0.012 to 0.05 grain. 0.003 to 0.006 grain. 0.025 to 0.4 grain. 0.0015 to 0.0033 grain. 0.0035 to 0.016 grain. 0.025 to 0.05 grain. 3 to 12 grains. 0.4 to 1.6 grain. 0.003 to 0.01 grain. 1 to 2 grains. 0.01 to 0.035 grain. 0.2 to 1 grain. 0.4 to 3 grains. 1 to 2 grains. 1 to 3 grains. 2 to 6 grains. 0.2 to 1 grain. 1 to 2 grains. 0.4 to 1 grain. 0.2 to 0.6 grain. 0.2 to 1 grain. 1 to 6 grains. 3 to 5 grains. 2 to 5 grains. 2 to 3 grains. 2 to 3 grains. 2 to 3 grains. 0.6 to 2 grains. 1 to 2 grains. 0.065 to 2 grains. TABLE OF DOSES. 911 Eemedies. locally, (25 Commencing doses to be increased cautiously *Hydrargyri chloridum conosivum *chloridum mite *Hydrargyri iodidum rubrum iodidum vir subsulphas flava (as emetic) HydrargjTum cum creta Hydrastine Hydrogenii dioxidum (10-volume solution) to 100 per cent.), antiseptic *Hyoscin8e hydrobromas *Hyoscyaminse sulphas Ichthyol (locally, 10 to 50 per cent.), internally Infusum digitalis lodoformum lodol lodum Ipecacuanha (expectorant) Ipecacuanha (emetic) Jalapa Liq. amnionii acetatis acidi arseniosi arsenii bromidi arseni et hydrargyri iodidi potassii arsenitis sodii arseniatis ferri chloridi .' .' ferri dialys potassii citratis Lithii benzoas bromidum carbonas citras salicylas Lupulinum Magnesii carbonas citras, gran sulphas Mangani oxidum niger Methylene blue with powdered nutmeg (malarial fevers Mistura chloroform! ferri et ammonii acetatis glycj'rrhizae composita potassii citras rhei et sodse Morphin and its salts *. . Morrhuol (derivative of codliver oil) Moschus Naphthol *jSritroglycerinum (trinitrin), % per cent, solution .... Oleoresina aspidii (filix mas) Opium ( 14 per cent, morphine) PhenocoU hydrochloride *Phosphorus *Pilocarpiua, and salts (cautiously) Piperazin Plumbi acetas Potassii acetas bicarbonas Potassii bromidum Foe Child Tu UKK Yeabs Old. 0.003 to 0.002 grain. 0.012 to 2 grains. 0.004 to 0.02 grain. 0.035 to 0.2 grain. 0.4 to 1 grain. 0.6 to 1.6 grains. 0.6 to 1 grain. 0.001 to 0.0035 grain. 0.001 to 0.003 grain. U.G to 1 grain. 15 to 30 drops. 0.2 to 1 grain. 0.035 to 0.1 grain. 0.02 to 0.05 grain. 0.035 to 0.2 grain. 3 to 6 grains. 3 to 6 grains. 15 to 30 drops. 0.2 to 1 drop. 2 to 5 drops. 2 to 6 drops. 15 to 30 drops. 1 to 4 grains. 1 to 4 grains. 0.4 to 2 grains. 1 to 4 grains. 1 to 6 grains. 1 to 6 grains. 3 to 12 grains. 5 to 20 grains. 2 to 6 grains. 0.2 to 1 gi'ain, 0.2 to 1 grain, 1 to 5 drops. 5 to 15 drops. 5 to 15 drops. 5 to 15 drops. 10 to 30 drops. Hoo to 1^5 grain. 10 to 30 drops. 0.4 to 3 grains. 0.4 to 1 grain. 1 to 2 drops. 1 to 3 gi'ains. 0.025 to 0.4 grain. 1.6 to 3 grains. 0.0015 to 0.004 grain. 0.003 to 0.001 grain. 3 grains (daily). 0.1 to 0.6 grain. 3 to 12 grains. 1.6 to 12 grains. 1.6 to 12 grains. 912 MISCELLANEOUS. Remedies. Potassii bitartras chloras cyanidum iodidum .nitras permanganas Pulvis antimopialis glycyrrhizse compositus ipeeacuanhse et opii jalapae compositus rhei compositus Kesina copaibse guaiaci jalapae podophylli seammonii Resorcin Rheum Saccharine ( substitute for sugar ) Salicinum Salipyrin (antipyretic, antineuralgic) .... Salol , Salophen ( antipyretic, antirheumatic ) . . . , Santoninum Senna " *Sodii arsenas benzoas boras ( in epilepsy ) , bromidum chloras hyposulphis iodidum phosphas salicylas *Spartein3e sulphas (cardiant and diuretic) Spiritus setheris nitrosi setheris compositus ammonise aromaticus camphorse chloroformi Strontii lactas vel bromidum vel iodidum *Strychnina, and salts Sulphonal (best in hot mint- water) Sulphur Syr. ferri bromidi ferri iodidi scillse compositus senegse sennse Terebene - Terpin hydrate (tonic expectorant) Theobrominse et sodii salicylas (diuretic) Thymol *Tinctura aconiti aloes asafoetidse belladonnse cannabis indicse capaici Foe Child Three Yeabs Old. 0.2 to 0.4 grain. 1.6 to 6 grains. 0.01 to 0.025 grain. 0.4 to 6 grains. 0.4 to 3 grains. 0.1 to 1 grain. 0.2 to 0.6 grain. 6 to 12 grains. 1 to 3 grains. 2 to 5 grains. 1 to 12 grains. 0.4 to 2 grains. 1 to 4 grains. 0.4 to 1 grain. 0.016 to 0.1 grain. 0.4 to 2 grains. 0.4 to 1 grain. 0.4 to 6 grains. 0.1 to 1 grain. 1 to 6 grains. 1.6 to 3 grains. 0.4 to 2 grains. 3 to 4 grains. 0.05 to 1 grain. 1.6 to 36 grainns. 0.003 to 0.02 grain. 1 to 3 grains. 1 to 6 grains. 1 to 6 grains. 0.4 to 1 grain. 1 to 4 grains. 0.4 to 6 grains. 0.4 to 24 grains. 1 to 6 grains. 0.012 to 0.8 grain. 3 to 24 drops. 3 to 24 drops. 3 to 12 drops. 1 to 6 drops. 3 to 12 drops. 3 to 12 grains. 0.003 to 0.016 grain. 1 to 4 grains. 1 to grains. 1 to 12 drops. 1 to 6 drops. 1 to 6 drops. 5 to 15 drops. 10 to 20 drops. 1 to 3 grains. 0.4 to 1 grain. 1 to 6 grains. 0.2 to 1 grain. 1 to 2 drops. 3 to 12 drops. 6 to 12 drops. 0.4 to 3 drops. 1 to 4 drops. 1.6 to 3 drops. TABLE OF DOSES. 913 Remedies. Tinotura cimiclfugae einchonae composita , colchici seminis conii •digitalis feiri chloridi gelscmii giiaiaci ammoniata hydrastis hyoscyami iodi compositus kino musk nucis vomicae *opii , opii camphorata stramonii strophanthi (eardiant and diuretic) .... Valerianae ammoniata veratri A'iridis *Trional (hypnotic) Trituratio elaterini (10 per cent.) Vinum antimonii (expectorant and alterative (emetici) colchici ergotse ipecacuanha; ( expectorant) (emetic) opii Zinci acetas bromidum iodidum oxidum phosphidum . .• sulphas ( emetic ) valerianas Fob Child 'J'liKKE Yeabs Old. 6 to 12 drops. li to 24 drops. 1 to 4 drops. 1 to 6 drops. O.G to 3 drops. 2 to 6 drops. 0.4 to 3 drops, t) to 12 drops. G to 24 drops. 1 to 6 drops. 1.4 to 3 drops. 3 to 24 drops. 3 to 12 drops. 1 to 3 drops. 0.4 to 3 drops. 1 to 48 drops. 1 to 3 drops. 0.2 to 2 drops. 2 to 24 drops. 0.6 to 2 drops. 3 to 12 grains. 0.025 to 0.2 grain. 1 to 5 drops. 6 to 15 drops. 1 to 3 drops. 1 to 5 drops. 1 to 3 drops. 5 to 15 drops. 1 to 2 drops. 0.1 to 0.4 grain. 0.1 to 1 grain. 0.1 to 0.6 grain. 0.2 to 1 grain. 0.02 to 0.035 grain. 3 to 6 grains. 0.1 to 1 grain. 68 INDEX. Abdomen, 72 in ascites, 358 in cretinism, 719 in dislocation of the hip, 863 in Henoch's purpura, 708 in intussusception, 285 in peritonitis, 354 in pseudo-Ieuksemic ansemia, 695 tapping the, 360 Abdominal band, 21 in gastroptosis, 234 in pertussis, 458 Abnormal growths, 842 Abnormalities, congenital, 57 of air passages, 60 Abortive pneumonia, 462 Abscess, complicating Pott's disease, 851 complicating vaccination, 644 in angina Ludovici, 216 in perinephritis, 374, 375 in pyelitis, 377 of brain, 804 of cervical region, 852 of inguinal region, 852 of liver, 347 of loin, 852 of spine, 852 of thoracic region, 852 alveolar, 215 cerebral, 804 hepatic, 347 caused by worms, 291 isclhio-rectal, 295 peritonsillar, 406, 522 resembling diphtheria, 522 retro-oesophageal, 217 retro-pharyngeal, 415 complicating scarlet , fever, 415 subphrenic, 351 Abscesses, in erysipelas, 659 in typhoid, 654 multiple, complicating cerebro-spinal meningitis, 784 renal, of urinary passages, 377 AcetonjEmia, 380 Acetonuria, 380 in diabetes mellitus, 394 Acid, carbolic, as disinfectant, 894 hydrochloric, in gastric contents, 66, 875 lactic, in gastric contents, 66, 875 Acidaemia, 384 Acidosis, 132, 235, 384 Acute milk infection, 256 Addison's disease, 732 Adenitis, acute, 712 chronic, 713 retro-pharyngeal lymph-, 416 tubercular, 714 Adenoid vegetations, 411 a point of entrance of tubercle bacilli, 485 causing deafness, 408 causing enuresis, 389 congenital, 59 face, 412 method of examining for, 412, 413 operation, 414 haemorrhage after, 415 Adherent prepuce, 363 Adhesia linguae, 59 Adhesions, in pleurisy, 436 in chronic empyema, 443 Administration of drugs, 895 Adrenal glands, diseases of, 732 Adulteration of milk, 119 (see also Milk Preservatives, 121) Ague (see also Malarial Fever), 662 Air passages, abnormalities of, 60 Airing out of doors, 21 Alalia idiopathica, 806 Albumin, concentrated preparations of, 194 in milk, effect of heat on, 153 in urine, 878 test for, 881 milk, 140 transformation of, by gastric juice, 67 water, 868 Albuminoids in cows' milk, 138 in human milk, 76 Albuminuria, 878 in malarial fever, 670 in measles, 588 in nephritis, 371, 879 lordotic, 381 orthostatic, 381 resulting from exercise, 24 transient, in scarlet fever, 614 Albimioscope, 872 Alcohol, content in liquid foods, 177 internally, 203 abuse of, 245 Almond milk, 868 Alveolar abscess, 215 arch, in adenoid vegetations, 411 Amaurotic family idiocy, 810 Amoebic dysentery, 251 (915) 916 INDEX. Amyloid degeneration, 879 of the liver, 349 Amylopsin ferment t€st, 226 Anapliylactic shock, 518 Anaphylaxis, 423, 517, 589 Anaemia, 69 1 associated with masturbation, 754 acquired, 691 congenital, 691 following diphtheria, 525 in Addison's disease, 732 infantum pseudo-leukfemica, 694 pernicious, 692 pretubercular, 493 pseudo-leukaemic, 694 secondary, 692 splenic, 691 Anaemic murmurs, 331 Anaesthesia, 890 intraspinal, 892 local, 892 partial, in multiple neuritis, 752 Anaesthetic, in adenoid operation, 414 in empyema, 442 in tonsillotomy, 409 chloroform, 890 ether, 891 ethyl chloride, 891 nitrous oxide, 890 Analyses of cows' milk, 114, 115 of woman's milk, 78, 80, 83 Anaphylaxis, 517 Anasarca, general, in leukaemia, 694 in nephritis complicating scarlet fever, 626 in post-scarlatinal nephritis, 617 in tuberculosis of the lung, 481 Angeioma, 57 Angina Ludovici, 216 pseudo-membranosa in scarlet fever. 608 scarlatina membranosa, 610 tonsillaris, 403 Ani, prolapsus, 296 Ankle, oedema of, in chlorosis, 696 Ankle-joint, diseases of, 865 in rachitis, 311 Anorexia, in acut€ tuberculosis, 493 in measles, 585 in meningitis, 787 in rheumatism, 699 in rubella, 578 Antibacterial action of the blood, 688 Anticolic nipple, 151 Antimeningitis serum, 791 Antipyretics, in broncho-pneumonia, 433 in cerebral pneumonia, 474 in influenza, 450 in scarlet fever, 619 in typhoid fever, 655 Antiscorbutic diet, 145 Antistreptococcus serum, in erysipelas, 659, 661 Antistreptococcus serum, in scarlet fever, 628 Antistreptococcus serum, in tubercular peritonitis, 358 Antitoxin anaphylaxis, 517 diphtheria, 534 in omphalitis, 35 eliminated by woman's milk, 82 in meningitis, 792 in tetanus, 759 in typhoid, 655 rashes, 515 streptococcus, in erysipelas, 659, 661 in sca.rlet fever, 626 Anus, absence of, 63 atresia of, 63 condylomata of, in syphilis, 676 congenital narrowing of, 63 iissure of, 294 Aorta, 331 area of murmur, 331 Aortic bruit, 332 cusps in diastolic murmur, 332 from aneurism, 332 systolic murmur, 332 valves, in diastolic murmurs, 331 Aphasia, complicating cerebral paralysis, 798 complicating diphtheria, 523 complicating pertussis, 451 complicating typhoid, 654 Aphonia, due to paralysis, 4 in hereditary ataxy, 767 spastica, intubation in, 554 Aphthae, Bednars, 208 Appendicitis, 278 diflferential diagnosis, from abscess of ovary, 281 from colic, 281 from hip-joint disease, 281 from intussusception, 281 treatment, 281 operation, interval, 282 catarrhal, 281 false (see also Pseudo-appendicitis), 282 gangrenous, 279 helminthic, 279 ulcerative, 279 Appendix, vermiform, location of, 73 Appetite, in gastroptosis, 232 abnormal, 231 loss of, 229 due to catarrh, 394 Arm in birth palsy, 44 Arthritis, 866 following empyema, 866 following measles, 866 following scarlet fever, 866 following traumatism, 866 Arthus j)henomenon, 518 Articular rheumatism, 700 Artificial feeding (see also Bottle or Hand Feeding), 150 Arrhythmia in myocarditis, 343 Ascaris lumbricoides, 290 Ascites, 358 treatment, 359 INDEX. 917 Ascites, troatincnt, tapping the ab- domen, 'MiO due to peritonitis, 359 Asphyxia, during intubation, 553 in diphtheria, 525 in pertussis, 457 in retro-pharyngeal abscess, 416 neonatorum, 45 Aspiration (see Lumbar Puncture), in ascites, 560 in encephalocele, 777 in hydrocephalus, 775 in nephritis, complicating scarlet fever, 621 of chest in pleurisy with effusion, 438 of pericardium, 341 Asthma, bronchial, 428 dyspeptic, 236 thymic, 713 Ataxia, hereditary, 766 Atelectasis pulmonum, complicating per- tussis, 457 diflferentiated from pneumonia, 472 in bronchitis, 426 in diphtheria, 544 in premature infants, 33 Athetosis in cerebral paralysis, 797 Atomizer, 392 oil, 418 steam, 419 Atony, general, in gastroplosis, 232 of intestine, '299 Atresia ani, 63 Atrophy, infantile, 321 urine in, 878 in acute myelitis, 764 in multiple neuritis, 752 in pseudohypertrophic paralysis, 802 Aura, of epilepsy, 761 of hysteria, 749 Auscultation, in asthma, 423 in bronchitis, 426 acute catarrhal, 423 capillary, 423 in emphysema, 423 in fluid or air in pleural sac, 423 in pleurisy, 423 subacute, 423 in pneumonia, 423 in tuberculosis, 424 of anterior fontanel, 733 Auto-intoxication, 285 Babcock's milk test, 133 Babinski reflex, 737, 786 in hereditary ataxia, 767 in tubercular meningitis, 782 Bacillary diphtheria of the colon, 252 Bacillus, of diphtheria, 502 of Eberth, in typhoid, 464 of influenza, 396 of Pfeiflfer, 395 Klebs-Loeffler, 502, 503 stain for, 889 pyocyaneus, in bronchitis, 425 Bacillus, tubercle, 486 stain for, in ^^putum, 888 typhoid, 646 Vincent's, in ulcero-membranoua ton- sillitis, 405 Back-knee in rachitis, 320 Backwardness, 3 differentiated from idiocy, 807 in speaking, 806 Bacteria, action of gastric juice on, fi^ action of saliva on, 66 in bronchitis, 425 in broncho-pneumonia, 430 in cows' milk, 77 in cystitis, 387 in empyema, 387 in erysipelas, 658 in follicular tonsillitis, 405 in measles, 584 in perinephritis, 374 in pertussis, 455 in vaginitis, 366 in woman's milk, 76 of intestines, 243 Bacterial vaccines, 450 Bacteriological memoranda, 888 Baginsky tonsillotome, 409 Baldness of occiput, in rickets, 311 in scurvy, 306 Baud, abdominal, 21 in gastroptosis, 234 in pertussis, 458 Banti's disease, 691 Barlow's disease, 301 Basedow's disease (see also Exophthal- mic Goiter), 731 Basham's mixture, 627 Basilar meningitis (see also Meningitis), 779 Bath, at birth, 18 in diphtheria, 533 in rheumatism, 703 in syphilis, 682 in typhoid, 655, 689 temperature of, 19 thermometer, 19 bichloride, in syphilis, 682 hot air, 621 hot and cold, in asphyxia neona- torum, 47 hot, as a diaphoretic, 620 oatmeal, 19 spray, in hysteria, 751 sulphur, in rheumatism, 703 tub, in typhoid, 655 Bednar's aphthce, 208 Bed-wetting, a symptom of phimosis, 363 caused bv presence of adenoids, 412 Beef- juice, '868 Bell's paralysis, 802 Benger's food, 191 Beriberi caused by lack of vitamines, 144 Bicarbonate of soda solution, 143 Bifid tongue, 214 918 INDEX. Bifid uvula, 215 Bile, 346 Bile-duets, congenital obliteration of, 37 Bilious attack (see also Dyspepsia), 219 Birth palsv, 43 Bladder, 3''78 extroversion of, 378 location of, 378 proper training of, 23 stone in, 386 washing, 386, 387 Bleeders (see also Hgemophilia), 709 Blepharitis, 824 Blindness following meningitis, 791 Blisters (see also Burns), 839 Blood, 683 antibacterial action of, 688 at birth, 683 circulation of, during foetal period, 325 in early life, 326 crisis, in pneumonia, 467 effect of antitoxin on, 536 erythroblasts, 684 examination of, 667 to prepare specimen, 651 in ansgmia, 691 in bronchitis, 685 in chlorosis, 696 in diphtheria, 508, 523 in fcA'er, 689 in gastro-intestinal diseases, 686 in hereditary syphilis, 685 in infectious diseases, 687 in malarial fever, 662 in meningitis, 787 in multiple neuritis, 752 in nephritis, 371 in nervous diseases, 686 in perinephritis, 375 in pneumonia, 467, 685 in rachitis, 686 in scarlet fever, 602, 622 in skin diseases, 686 ■ in typhoid, 651 in Winckel's disease, 41 inclusion bodies in, 647 letting, local ( see also Venesection ) , 897 . pathological conditions in disease, 687 reaction of pus, 686 serum treatment in scarlet fever, 628 test for, in urine, 886 Blood-vessels (see Thrombosis), dilatation of, in angeioma, 57 in hsemophilia, 709 in spinal paralysis, 768 in syphilis, 674 Bloody urine (see also Hsematuria), 382 in diphtheria, 513 in septic diphtheria, 524 Blue baby, 333 Boil (see also Furuncle), 835 Bone-marrow, in leukaemia, 693 Bones (see Fractures; also Joints). Bones, in hydrocephalus, 776 in rachitis, 310 in syphilis, 677 in tuberculosis, 677 Borborygmus, 273, 293 Bothriocephalus latus, 289 Bottle-brush, 151, 152 Bottle-feeding, 150 formulae, 160 rules for, 158 utensils required for, 150 Bottles, 'feeding, 150, 151 Bovine tuberculosis, 485, 493 Bowel movements (see Stools). Bowels, inflation of, in intussusception, 288 obstruction of (see also Intussuscep- tion), 284 proper training of, 23 Bow-legs, 3 in rachitis, 314, 320 Bradycardia, 330 in diphtheria, 514 in myocarditis, 343 Brain, 778 abscess of, 804 concussion of, 811 engorgement of, in cerebral pneu- monia, 475 in tubercular meningitis, 780 water on, 774 Breast-feeding, 84 dangers of suffocation during, 87 disturbances during, 88 schedule for, 84 suggestions for, 87 Breast-milk (see also Milk, Woman's), 74 Breast-pump, 80, 93, 94 Breasts, massage of, during lactation, 94 pear-shaped, best adapted for nursing, 106 Breath, in alveolar abscess, 216 in lithsemia, 709 in pulmonary gangrene, 435 in stomatitis gangrsenosa, 211 Breathing (see also Respirations), 424 Cheyne-Stokes, in meningitis, 783 in tubercular pneumonia, 478 in bronchial asthma, 428 in diphtheria, 426 in dry pleurisy, 437 in empyema, 440 in pleurisy with effusion, 438 in tubercvilous pneumonia, 478 labored, in retro-pharyngeal abscess, 416 Breck's feeder for premature babies, 31 Bright's disease (see also Nephritis), 370 urine in, 879 Bromide, administration of, per rectum, 896 of ethyl, as an anaesthetic, 891 INDEX. 919 Bronehi, diseases of, 423 in bronchitis, 425 in tubort'iilous pneumonia, 380 Bronchial asthma, 428 treatment, 429 catarrh, 425 glands, enlarged, 428 Bronchitis, 425 treatment, 427 complicating typhoid, 650 Broncho-pneumonia, 429 complicating diphtheria, 522 complicating measles, 592 complicating pertussis, 457 complicating variola, 642 differential diagnosis from atelectasis, 433 fibrous, 433 physical examination in, 432 pneumonia jacket, 431 predisposing causes, 430 tuberculous, 498 Broths, 870 Brudzinski's neck sign in meningitis, 786 Buhl's disease, 41 Bulgarian bacillus, 119, 265 milk, 174 Bulimia, 231 a symptom of hysteria, 231 Burns, 839 Buttermilk feeding, 173 how to prepare, 174 Butyric-acid test for syphilis, 673 Byrd method of resuscitation, 46 Caecum, 73 Caffeine, effect of, 202 "Caking" of breast, 94 Calcium salts, 141 Calculi, giving rise to bloody urine, 382 in bladder, 386 urethral, 386 vesical, 386 Calmette tuberculine test, 497 Calorie method of feeding, 158 Cancrum oris (see also Stomatitis Gangrsenosa ) , 210 Cane sugar, 137 Cantharidal collodion, 897 Capillaries in hferaophilia, 710 in malarial fever, 666 Caput succedaneum, 62 Carbohydrates, 135 Carbolic acid as a disinfectant, 909 Carcinoma, 845 Cardiac diseases, classification of, 330 paralysis, 527 in dysentery, 253 Carious "teeth, in rickets, 312, 313 possible point of entrance of tubercle bacilli, 485 Casein, 140 in cows' milk, 77 in woman's milk, 76, 86 Casein, in milk, 140 Casts in urine, in nephritis, 372 Catarrh, acute nasal, 391 treatment, 392 Catarrh, bronchial, 425 ^ duodenal, 276 Catarrh, follicular, 404 gastric, 394 in syphilis, 075 naso-pharyngeal, 394 with adenoid growths, 391 Catarrhal conjunctivitis, 819 croup, 417 epidemic fever, 395 jaundice, 228 nephritis, 614 pneumonia, 429 proctitis, 294 Cavities of the lung, 477, 479 Cellulitis, complicating vaccination, 644 of neck, in scarlet fever, 613 Centrifugal milk-testing machine, 133 Cephalhfematoma, 61 . spurious, 62 Cereal milk, 185 Cereals, 164 Cerebellum, 737 abscess of, 804 Cerebral abscess, 804 congestion, in pneumonia, 475 hcemorrhage, in pertussis, 457 hernia, 777 hypersemia, in insolation, 246 paralysis, 795 pneumonia, 464 thrombosis, complicating diphtheria, 524 Cerebrospinal fluid, 673. (See also Spinal fluid.) meningitis, 784 Cerebrum, 737 Certified milk in New York City, 118 Cestodes, 289 Chamomile injections, 274 Chatillon weight scale, 108 Chemical examination of cows' milk, 77 of gastric contents, 875 of urine, 877 of woman's milk. 78 Chest, in broncho-pneumonia, 592 in cerebral pneumonia, 448 in chronic pericarditis, 342 in empyema, 448 in pleurisy with effusion, 438 in rachitis, 312 in spasmodic laryngitis, 418 strapping of, in dry pleurisy, 437 in pleurisy with effusion, 439 Cheyne-Stokes respiration, in tubercular meningitis, 786 in tuberculous pneumonia, 478 Chicken-pox (see also Varicella), 633 Childhood, 1 Chills, in diphtheria, 512 in orchitis complicating mumps, 717 920 INDEX. Chills, in perinephritis, 375 Chloasma, 832 Chloral hydrate in convulsions, 741 Chloransemia, 695 Chloride of lime, as a disinfectant, 894 Chloroform, 890 in control of spasms, 741 Chlorosis, 695 blood in, 697 Chocolate and cocoa, 200 how to prepare, 868 Cholera infantum, 256 resembling typhoid, 652 Cholelithiasis, 348 Chorea, 744 causes, 744 symptoms, 746 treatment, 747 Chrostek's phenomena, 757 Circulation, changes in, at birth, 325 foetal, 325 Circumcision, 363 in treatment of masturbation, 755 operation for, 364 tuberculosis infection through, 480 Cirrhosis of the liver, 350 splenomegalic, 691 Cleft palate, 58 Clothing, 20 in summer, 20 in winter, 20 night, 21 Clitoridectomy, in masturbation, 755 Cocaine as an intra-spinal ansesthetic, 892 Cocoa, how to prepare, 200, 868 Coffee, 202 Cold, as an antipyretic, 434 in typhoid, 655 compresses, 434 ice collar, in tonsillitis, 403 pack, in chorea, 748 in pneumonia, 473 spray bath, in hysteria, 751 Colic, a symptom of worms, 290 in breast-fed babies, 274 intestinal, 273 Colicystitis, 385 Colitis (see also Ileo-colitis ) , 252 amffibic, 251, 255 diphtheritic, 252, 253 mucous, in syphilis, 675 Collapse, in diphtheria, 515 in dysentery, 253 pulmonary (see Atelectasis Pulmo- num). Colles's law, 673 Collodion, cantharidal, 897 iodoform, in tubercular meningitis, 783 salicylic, in mumps, 716 Colon, bacillus in bronchitis, 426 perinephritis, 436 course of, 73 dilatation of, 272 Colon, flushing, in intestinal colic, 275 irrigation of, in diarrhoea, 245 in dysentery, 266 in typhoid, 655 Colored race, mortality in, from tuber- culosis, 491 Colostrum, 74 Colostrum, corpuscles of, 74 proteins in, 104 Coma, in angina Ludovici, 216 in cerebral pneumonia, 464 in influenza, 398 in pachymeningitis, 792 in scarlet fever, 625 in tubercular meningitis, 783 to relieve, 475 Combustio (see also Burns), 839 Complement-deviation test in pertussis, 455 Composition, of cows' milk, 114 of woman's milk, compared with dif- ferent infant foods, 193 Concussion of the brain, 811 Condensed milk, 179 causing scurvy, 301 Condylomata, in syphilis, 676 Congenital (see also Foetal) abnormali- ties, 57 adenoids, 59 cysts of the kidney, 62 dislocation of the hip, 880 heart lesions, 333 idiocy, 807 malformations, 57 of the rectum, 63 obliteration of the bile-ducts, 37 sacral tumor, 62 stenosis of the larynx, 676 syphilis, 680, 681 Congestion of the liver, 347 Conjunctiva, infection of, 820 inflammation of, in acute nasal catarrh, 391 Conjunctivitis, acute catarrhal, 819 cleansing the eye in, 819 diphtheritic, 820 membranous, 820 phlyctenular, 826 Constipation, 266 causes, 267 sterilized milk feeding, 155 sugar feeding, 137 treatment, 269 diet, 270 alternating with diarrhoea, 229 in chlorosis, 696 in cretinism, 719 to correct, in bottle-fed infants, 130, 137 Convulsions, 739 treatment, 741 a symptom of worms, 291 during teething period, 741 epileptic, 760 in auto-intoxication, 285 INDEX. 921 Convulsions, in cerebral |)noumoniii, 404 in diphtheria, 515, 523 in dysentery, 253 in hydrocephalus, 776 in influenza, 396 in lithaemia, 709 in meningitis, 786 in pachymeningitis, 794 in pertussis, 457 in post-scarlatinal nephritis, 617 in scarlet fever, 605, 606 in typhoid, 649 lumbar puncture, 741 Ooprostasis, 299 Cord, umbilical, management of, 17 separation of, 1 Corpuscles of blood, 683 Coryza, 391 in measles, 585 in rubella, 578 in syphilis, 680 Cough, in acute tuberculosis, 493 in croup, 417 in dry pleurisy, 436 in pertussis, 456 in pleurisy with effusion, 438 in tuberculous pneumonia, 478 in variola, 642 croupy, 417, 512 night,' 421 reflex, 422 spasmodic, 422 useless, 422 whooping, 455 Coughs of reflex origin, 421 Counter-irritants, 435 Cows, breed of, best adapted for infant feeding, 114, 116 care of, 117 time and stage of milking, 115 Ayrshire, 116 Devon, 115 Durham or shorthorn, 115 Holstein-Friesian, 116 Cows' milk, albuminoids in, 138 care of, 117 curds in, 139 properties of, 77 Coxitis (see also Morbus Coxarius), 861 Cranio-tabes, a symptom in rickets, 312 Cranium (see Skull). Cream, 132, 146 for home modification, 146 how to procure, 147 condensed, 179 dipper, 147 gauge, 134 mixtures, 148 CredS's method of preventing ophthal- mia neonatorum, 821 ointment, in scarlet fever, 631 in tubercular meningitis, 783 Cretinism, 719 etiology, 719 Cretinism, prognosis and course, 730 symptoms, 719 treatment, 730 thyroid implantation, 731 Crisis, in pneumonia, 466, 407 blood, 467 Croup, catarrhal, 417 treatment, 418 emetics, 420 steam inhalations, 419 kettle, 420 spasmodic, 417 Croupous, enteritis, 252 oesophagitis, 217 proctitis, 295 stomatitis, 209 tonsillitis, 405 Crusta lacta, 829 Cry, as diagnostic aid, 13 from earache, 13 from hunger, 13 in cerebral disease, 13 in croup, 13 in marasmus, 13 in pneumonia, 13 in tubercular peritonitis, 13 Cryptorchidism, 365 Cupping, dry, 897 in bronchial asthma, 428 in dry pleurisy, 437 in hsematuria, 382 in influenza, 400 in meningitis, 791 in paralysis, 774 in pneumonia, lobar, 475 Curvature of the spine, 855 Cutaneous tuberculin reaction, 496 Cyanosis, in acute tuberculosis, 493 in bronchial asthma, 428 in broncho-pneumonia, 431 in diphtheria, 545 in hydropericardium, 343 in pulmonary tuberculosis, 481 of nails, in malarial fever, 670 oxygen in, 371 Curds, in cows' milk, 139 Cyclic vomiting, 235 Cyclops, 778 Cyst, congenital, of kidney, 62 Cystitis, 387 treatment, 389 Deafness, as a symptom, 408 caused by adenoids, 412 following measles, 595 following meningitis, 791 following scarlet fever, 620 with hypertrophy of tonsils, 408 Decomposition, 321 Decubitus, 569 Deficiency diseasciS, 298 Deformities, congenital, 57 in rachitis, 308 Degeneration, reaction of, 737 Delirium, in meningitis, 786 923 INDEX. Dentition, 5 before birth, 7 delayed, 7 difficult, 6 eruption of first teetb, 7 in cretinism, 719 in rachitis, 5 of first teeth, 7 of permanent teeth, 7 Depressed sternum, 61 Descensus ventriculi, 232 D'Espines sign in tuberculosis, 494 Desquamation, following antitoxin rash, 519 in measles, 588 in rubella, 580 in scarlet fever, 604, 607 in variola, 640 Development, mental, in cretinism, 719 in idiocy, 807 of body, 5 of infant, 1 of the various senses, 2, 3 Dextrin, 136 Diabetes insipidus, 383 Diabetes mellitus, 384 Diacetic acid test, 886 Diacetonuria, 380 Diagnostic points in auscultation, 423 breathing, 423 resonance, percussion, 423 vocal, 423 rhythm, 423 suggestions, 9 cry, 13 eye aphorisms, 12 gestures, 13 pulse-rate, 10 respiration, 11 sleep, 14 temperature, 1 1 throat, 13 tongue, 13 x-ray, 15 Diaphoretics, hot-air bath, 626 hot pack, 625 hot saline injections, 627 oiled-silk jacket, 477 Diaphyses, scur^'y, 66 Diarrhoea, 244 as a symptom of disease, 245 complicating measles, 596 in diphtheria, 515, 526 in malarial fever, 670 in syphilis, 675 in typhoid, 649, 653 fat, 241 nervous, 245 summer, 262 Diastase, 167 test for, 227 Diastatic enzyme, in human milk, 63 in intestinal contents, 82 in stool of nursling, 82 Diastolic murmurs, 331 Diazo reaction, in tuberculosis, 493 Diet- (see Feeding), antiscorbutic, 145 from 1 year to 15 months, 162 from 18 months to 3 years, 163 from 3 years to 10 years, 163 articles allowed, 164 articles forbidden, 165 in acute gastric catarrh, 222 in auto-intoxication, 285 in chlorosisi, 697 in constipation, 270 in diarrhoea, 246 in diphtheria, 539 in dysentery, 253 in gastritis, chronic, 229 in gastro-duodenitis, 228 in intestinal indigestion, 227, 363 in lithsemia, 709 in pellagra, 255 in pleurisy with effusion, 439 in pyelitis, 378 in rachitis, 230 See Vitamines, 144 in scarlet fever, 702 in scurvy, 302 See Vitamines, 144 in tonsillitis, 404 in tuberculosis, 497 in typhoid, 656 in ulcer of the stomach, 235 of a nursing mother, 94, 96 of a wet-nurse, 103 salt-free, 624 Dietary, 868 Diffuse cellulitis, in scarlet fever, 613 Digestive system, diseases of, 205 Dilatation of the colon, 272 Dilatation of the stomach, 230 in chronic gastritis, 228 Diphtheria, acute, 502 bacillus, 502, 503, 505 in bronchitis, 425 Klebs-Loeffler, 503 characteristics of, 504 growth on blood serum, 505 true and false, 506 bacteriology, 503 mixed infection, 538 mode of infection, 502, 504 chronic, 541 isolation in, 542 treatment, 577 complications, 523 anaphylaxis, 517, 556 measles, 596 omphalitis, 35, 512, 526 paralysis, 524, 540 scarlet fcA^er, 608, 628 course, 511, 528 diagnosis, 519 how to take a cultvire, 519 premembranous stage, 519, 520 differential diagnosis, 521 etiology, 502 INDEX. 923 Di|)litli('iia, oxti,il)ation, 572 follicular forms, 515 iiiiiiuinizatioii in, 5.'il intubation in, 542 isolation, 530 mild, 512 nasal, 513 pathology, 507 blood, "508 liaMuorrhagew, 508, 524 lesions, 507 lymph-nodes, 508 Diphtheria, pathology, membrane, 507 predisposing factors, 502 prognosis, 437 pro|)hylaxis, 529 pseudo or false, 500 mortality, 501 septic, 512 symptoms, 511 toxin, effect of, on nervous system of animals, 510 on heart, 511 tracheotomy, 574 treatment, 533 antitoxin, 539 dietetic, 538 hygienic, 524 medicinal, 539 Diphtheria antitoxin, 539 iiDiuunizing dose, 531 influence of, on mortality, 546 in treatment of* membranous oph- thalmia, 807 limitations of, 531 manner of administering, 534 rashes, 515 anaphylaxis, 517 desquamation following, 519 site of eruption, 517 Diphtheritic colitis, 251, 252 conjunctivitis, 821 dysentery, 252 oesophagitis, 217 omphalitis, 35, 512 paralysis, 526, 527 simulating anterior poliomyelitis, 527 rhinitis, 511 stomatitis, 209 Diphtheroid, 500 Diplegia, haemorrhage causing, 736 spastic, 795 Diplo-bacillus of Morax, 820 Diplococcus, Fraenkel, in broncho-pneu- monia, 430 in lobar pneumonia, 461 intracellularis, 787 pneumoniae, 430 in broncho-pneumonia, 430 in pleurisy with effusion, 430, 437 stain for, '889 Disease, diagnosis of, 10, 12 peculiarities of, 9 symptoms of, 9, 12 Disinfection, 894 in diphtheria, 528 in infectious diseases, 894 in scarlet fever, 023, 895 in typhoid, 656 in variola, 642 of sputa, 895 of urine and faeces, 895 of water closets, 895 Dislocation of the hip, congenital, 862 Displacement, of the heart, 842 of the liver, 348 of the spleen, 352 of tlie stoiiiach, 232, 234 Diverticulum, Meckel's, 37 Dobell's solution, 393 Drager pulmotor, 48 Drop foot in paralysis, 773 Dropsy (see also CEdema and Anasarca), of the feet, in leukaemia, 694 Drug eruptions, 617 resembling measles, 596 Drugs, administration of, 895 per rectum, 898 dosage of, 909 effect of, on woman's milk, 88 in treatment of constipation, 269 Dry cupping (see also Cupping), 897 Dry pleurisy, 436 Dry-tap in lumbar puncture, 790 Ductless glands, diseases of, 719 Ductus arteriosus Botalli, 334 closure of, 326 Duke's disease, 583 Duodenal bucket, 224 catarrh, 276 Dura mater, inflammation of, 794 Dysentery, 251 pathology, 251 symptoms, 253 treatment, 254 amoebic, 251 diphtheritic, 252 Dyspepsia, 168, 219 Dyspeptic, asthma, 236 Dyspnoea, in broncho-pneumonia, 434 in croup, 418 in dilatation of stomach, 231 in diseases of thymus, 691 in dry pleurisy, 437 in hydropericardium, 343 in lobar pneumonia, 475 in papilloniata, 846 in pulmonary tuberculosis, 481 in retro-pharyngeal abscess, 416 in toxic scarlet fever, 606 in tuberculous pneumonia, 478 oxygen in, 476 Dysiiria, 881 Ear, diseases of, 812 foreign bodies in, 818 syringe, 814 Earache, in diplitheria, 538 in scarlet fever, 628 934 INDEX. Ears, bleeding from, in diphtheria, 524 in diphtheria, 515, 523 in scarlet fever, 628 iniiammation of, in otitis, 812 running, in syphilis, 680 Eberth's typhoid bacillus, 646 Ecchymoses, in purpura, 705 in purpura hsemorrhagica, 706 in scurvy, 303 Eclampsia (see also Convulsions), 739 in epilepsy, 760 Ectogenous streptococcus infection, 658 Ectopia vesicae congenitalis, 378 Eczema, 827 associated with chronic gastritis, 229 bathing in, 828 in lithsemia, 709 intertrigo, 829 rubrum, 829 Effusion, in ascites, 359 in hydrocephalus, 774 in nephritis following scarlet fever, 626 in pericarditis, 340 in pertussis, 457 in pleurisy, 438 Eggs, nutritive value of, 199 Eiweiss milch, 140 Elbow-joint disease, 865 Electricity, in cerebral paralysis, 800 in chorea, 748 in constipation, 272 in enuresis, 390 Emaciation, in dilatation of the stom- ach, 231 in gastritis, 229 in hydrocephalus, 776 in myelitis, 764 in tuberculosis, 493 Embolism, in endocarditis, 338 in diphtheria, 524 Embolus, in endocarditis, 337 Emetics, in bronchitis, 427 in croup, 444 in dyspnoea or broncho-pneumonia, 434 in gastric catarrh, 220 Emphysema, complicating diphtheria, 544 complicating pertussis, 457 Empyema, 439 complicating diphtheria, 523 complicating measles, 595 James apparatus for expanding the lungs in, 443 of the mastoid antrum, complicating scarlet fever, 610 treatment, 443 Kenyon's syphon drainage, 442 surgical, 442 chronic, 443 tubercular, 444 Enanthem, in scarlatina sine angina, 608 in scarlet fever, 604 in measles, 586 Eneephalocele, 777 Enchondromata, 846 Endocarditis, 335 complicating chorea, 746 complicating diphtheria, 523 complicating rheumatism, 700 following scarlet fever, 624 following typhoid, 654 symptoms, 336 treatment, 338 malignant, 338 Enemata (see Rectal Irrigations), in chronic gastritis, 228 in constipation, 269 nutrient (see JRectal Feeding), oxgall, 228 Enteralgia, 273 Enteritis, croupous, 252 membranous, complicating diphtheria, 525 tuberculous, 486 Enuresis, 389 a symptom of faulty metabolism, 299 a symptom of lithsemia, 709 causes, 389 adenoids, 389, 412 tight prepuce, 389 in meningitis, 786 prognosis, 389 treatment, 389 diurna, 389 noctuma, 389 Enzymes, 145 Eosinophiles, in pneumonia, 687 in scarlet fever, 687 in skin diseases, 687 in syphilis, 687 Epidemic catarrhal fever, 395 cerebro-spinal meningitis, 784 hysteria, 750 Epilepsy, 760 aura in, 761 differential diagnosis, 762 from hysteria, 762 etiology, 760 following convulsions, 760 predisposing factors, 760 symptoms, 762 treatment, 763 grand mal form, 761 idiopathic, 760 petit mal form, 761 Epiphyses, in rachitis, 314, 315, 316 in syphilis, 681 Epiphysis, acute, 866 Epispadias, 365 Epistaxis, in haemophilia, 710 in measles, 598 in pertussis,' 455 in pulmonary tuberculosis, 481 in septic diphtheria, 513 in thrombosis of cerebral sinuses, 818 in toxic scarlet fever, 606 Epithelial desquamation of the tongue, 214 INDEX. 925 Erb's paralysis, 43, 774 Eructations, in chronic gastritis, 229 in gastroptosis, 232 Eruption, artificial, 20 drug, resembling measles, 596 following injection of diphtheria anti- toxin, 516 in chloasma, 878 in influenza, 397 in measles, 585, 893 in meningitis, 786 in poliomvelitis, 771 in rubella, 578 Eruption, in scabies, 841 in scarlet fever, 608 in stomatitis aphthosa, 206, 207 in syphilis, 676 in typhoid, 651 in vaccinia, 645 in varicella, 633 in variola, 639 Erysipelas, 658 blood in, 687 complications, 746 in the new-born, 55 treatment, 661 vaccine, 452, 660 migrans, 659 Erythema, 830 differentiated from syphilis, 676, 830 following injection of diphtheria anti- toxin, 516 on buttocks, 829 Erythroblasts, 684 Erythrocytes, 683 Eskay's albuminized food, 188 analysis of, 189 Estlander's operation in chronic em- pyema, 444 Ether as an anaesthetic, 891 Ethyl chloride, 891 Eucasin, 194 Eustachian tube, in adenoid vegeta- tions, 411 in otitis media, 812 inflammation of, in rhinitis, 299 Examination of heart, 326 of lungs, 423 of patient, 9 radiographic, 16 Exercise (see also Gymnastics), 23 in constipation, 271 in lithsemia, 709 Exophthalmia in thrombosis of cerebral sinuses, 818 Exophthalmic goiter, 731 treatment, 731 Exophthalmus, in exophthalmic goiter, 731 in hydrocephalus, 775 Expectorants, in l)roncho-pneumonia, 435 Expectoration ( see Sputum ) . in bronchitis, 426 in pulmonary tuberculosis, 481 in ulcer of stomach, 234 Exploratory puncture, in empyema, 440 in pleurisy with effusion, 438 points to be rioted in making, 440 Exstrophy of the bladder, 378 Extubation, 572 auto-,. 543 Eye, as a diagnostic aid, 12 diseases of, 819 in chlorosis, 696 in chorea, 745 in distinguishing the still-bom from the dead, 46 in exophthalmic goiter, 731 in gonorrhcpal infection, 3G8 in measles, 585, 595 in meningitis, 783 in nystagmus, 786 in stomatitis gangrsenosa, 210 prophylaxis and treatment of, in the new-born, 34 suffusion of, in rubella, 578 Eyelid, in blepharitis, 824 in hordeolum, 825 in purulent ophthalmia, 821 in trachoma, 824 method of everting, 825 proptosis of, in scurvy, 303 Face, cyanosis of, in broncho-pneumonia, 431 in adenoid vegetations, 411 in chlorosis, 696 in cretinism, 719, 720 in diphtheria, septic, 512 in nephritis, 372 in pertussis, 456 Facial paralysis, following mastoid op- eration, 802 in retro-pharyngeal abscess, 802 in the new-born, 802 Faecal vomiting, 286 Faeces (see Stools). Fainting (see Syncope). in leukaemia, 694 Fat, absorption of, 74 cream gauge for, 134 Feser's test, 134 Marchand's test, 134 in breast milk, 104 to decrease, 104 to increase, 104 in cows' milk, 132 excess of, 132 in stool, 132 Fatty degeneration of blood-vessels, 796 of newly born, 41 in pernicious anaemia, 692 growths, 846 heart, 330 liver, 349, 350 Faulty metabolism, 298 catarrhal tendencies, 299 lienteric stools, 298 nervous manifestations, 299 scybalous stools, 298 926 INDEX. Faulty treatment, 299 Feeble-mindedness (see also Idiocy and Imbecility), 806 Feeding (see Diet and Gavage). bottle or hand, 150 utensils required, 150 breast, 84 buttermilk, 173 caloric method of, 158 Casselberry method of, in intubation, 556, 557 cows' milk, 150 cream, 146 flour-ball, 166 from 1 year to 15 months, 107 goats' milk, 173 in atrophy and chronic gastritis, 229 in bronchitis, 427 in cleft palate, 58 in diphtheria, 538 in hypertrophic pyloric stenosis, 227 in intubated cases, 556 in myocarditis, 345 in pertussis, 459 in pneumonia, 477 interval of, 84, 86 malt soup, to make, 160 maternal, 85 mixed, 87 of premature infants, 30 rectal, 427, 539 Feeding bottles, 150 Femur in rachitis, 314 Ferment, lipolytic, 82 tests, 225 Fermentation, in chronic gastritis, 228 in auto-intoxication, 285 test in urine, 885 Ferments and their actions, 67 unorganized, 66 Feser's lactoscope, 134 Fever ( see also Temperature ) , 445 causes, 445 hay, 428 how to reduce, 474 hysterical, 447 in faulty metabolism, 299 in gastric catarrh, 223 in tonsillitis, 407 Fingers in cretinism, 719. First attempts at walking, 2 Fissure of the anus, 294 Fistula in alveolar abscess, 216 Flatfoot, 854 Flatulence, in gastro-duodenitis, 226 Flaxseed poultice, 896 Flexner anti-meningitis serum, 791 Flour-ball feeding, 166 Focal necrosis, 350 Foetal (see also Congenital) circulation, 325 ichthyosis, 50 typhoid, 647 Foetus, in syphilis, 672 Follicular formsi of diphtheria, 515 Follicular forms of tonsillitis, 404, 522 resembling diphtheria, 521 Fomentations, 896 Fontanel, 733 anterior, 733 in cretinism, 719 in hydrocephalus, 776 in rachitis, 308, 312 posterior, 733 premature closure of, 733 Food, dextrinized, 167 method of preparing, 167 intoxication, 255 Foods, infant, 182 patent, 181 composition of, compared with human milk, 193 Foot and mouth disease (see also Stoma- titis Aphthosa), 206 Foramen Magendie, in hydrocephalus, 736 ovale, closure of, 326 Foreign bodies in the ear, 818 in the larynx, 421 in the nose, 402 in' the oesophagus, 218 Formaldehyde in milk, 119 test for, 119 Formulae for bottle-fed infants, 161 Fourth disease, 583 Fractures, 43 . during labor, 43 green-stick, 43 in rachitis, 314 Fraenkel diplococcus, in lobar pneu- , monia, 461 Freckles, 834 Friedreich's disease (see also Hereditary Ataxy), 767 sign, in chronic pericarditis, 342 Fright, causing chorea, 745 causing convulsions, 739 Furuncle, 835 differential diagnosis from carbuncle, 835 in rachitis, 835 in syphilis, 676 vaccine treatment, 451, 835 Gall-bladder, congenital absence of, 37 Gall-stones, 348 Gangrene, 839 complicating erysipelas, 659 complicating pneumonia, 472 complicating typhoid, 654 of cheeks, 210 of genitals, 211 of mouth, 654 pulmonary, 482 superficial, 839 symmetrical, 841 traumatic, 840 Gastric catarrh, 219 contents, examination of, 875 fever, resembling typhoid, 654 INDEX. 927 Gastric juice, chemical constituents of, 65 influence of, on pathogenic germs, 66, 67 Gastritis, acute, 219 complicating diphtheria, 524 chronic, 228 treatment, 229 Gastrodiaphane for translumination of stomach, 231 Gastro-duodenitis, 228 Gastroenterostomy in spasm of the pylorus, 224, 226 Gastro-intestinal disturbance, causing asthmatic attacks, 428 haemorrhage, 41 tract, in syphilis, 675 Gastroptosis, 232 Gavage, apparatus for, 31 in cleft palate, 58 in intubated cases of diphtheria, 556 method of, in premature infants, 32 Gelatine food, 871 General hygiene of the infant, 17 Genital organs, diseases of, 361 in phimosis, 363 irritation in chronic cystitis, 387 Genu recurvatiun, 320 varum (see also Bowlegs), 320 Geographical tongue (see also Epithelial Desquamation ) , 214 Gerhardt's iron chloride reaction, 886 German measles, 577 Gestures as diagnostic aid, 13 Ginger poultice, 897 Gingivitis, 6 in scurvy. 303 Gland, thymus, 711, 712 thyroid, 719 Glands, adrenal, 732 bronchial, in broncho-pneumonia, 432 enlarged, causing bronchial asthma, 428 cervical, 299 causing torticollis, 705 in stomatitis gangrsenosa, 211 diseases of, 711 in adenitis, 712 in eczema, 827 in leuksemia, 693 in mumps, 716 in rubella, 578 in scarlet fever, 604, 628 in status lymphaticus, 711 peripheral, in acute tuberculosis, 493 submaxillary, in diphtheria, 512 in scarlet fever, 604 Glomerulo-nephritis, 370 Glossitis, 215 Glottis, oedema of, in erysipelas, 660 in scarlet fever, 631 in variola, 642 spasm of, causing cough, 421 Glucose in iirine, 884 Glycosuria, 383 Glycosuria, in .lialn-tes mellitus, 384 in pseudo-hyportrophic paralysis, 880 Goats' milk, 173 Goiter, exophthnlmic, 731 wet-nurse with, 98 Gonococcus, 367 in cystitis, 387 in gonorrheal vaginitis, 307 stain for, 889 vaccine, 452 Gram's solution, 889 Granular gastritis, 228 ophthalmia, 822 Granular ophthalmia from false or fol- licular granulations, 823 Granuloma, 35 Granulomata, 847 Graves's disease (see also Exophthalmic Goiter), 731 sign in bronchitis, 426 Grippe (see also Influenza), 395 Growing pains, 699, 701 Growth and height, 5 in diabetes insipidus, 383 Growths, malignant, 842 non-malignant, 842 Giiaiacum test for blood in urine, 886 Gums, bleeding, in purpura hsemor- rhagiea, 706 inflamed, 6 possible source of invasion of tubercle bacilli, 485 in scurvy, 303 in stomatitis gangrsenosa, 211 in toxic scarlet fever, 620 Gymnastics (see also Exercise), 23 in lateral curv-ature, 859 pulmonary, 498 in empyema, 443 in tuberculosis, 498 Habit-spasm, differential diagnosis from true chorea, 746 Hsematoma of the sterno-mastoid, 61 Hsematuria, 382 in cystitis, 387 in malarial fever, 670 in purpura haemorrhagica, 706 in pyelitis, 379 in scurvy, 302 in symmetrical gangrene, 841 Haemoglobin, at birth, 684 in diphtheria, 510 in rachitis, 684 Hsemoglobinuria, 382 in malarial fever, 676 in symmetrical gangrene, 841 in syphilis, 880 in Winckel's disease, 880 neonatorum, 40 paroxysmal, 382 Haemophilia, 709 Haemoptysis, in chronic tuberculosis, 481 in purpura haemorrhagica, 706 Haemorrhage, cerebral, in pertussis, 455 §^§ INDEX. Haemorrhage, follo^ving adenoid opera- tion, 415 following operation for peritonsillar abscess, 407 following tonsillotomy, 408 from bowels, 694 from genital tract, 382 from kidney, 382 from stomach, 694, 731 gastro-intestinal, 41 serum injections in, 42 in congenital obliteration of the bile duct, 38 in diphtheria, 513, 524 in leukaemia, 693 in pachymeningitis, 794 in syphilis, 765 in typhoid, 653 into subarachnoid space, 736 spontaneous, 39 subcutaneous, in scarlet fever, 506 in scurry, 303 umbilical. 40 Haemorrhagic diseases of the newly born, 39 Haemorrhoids, 298 Hair, 1 in cretinism, 719 Hand-feeding (see also Bottle-feeding), 150 Hands, disinfection of, 894 in cretinism, 720 Harelip, 58 nipple, 58 Hay fever, 428 resembling bronchial asthma, 428 Head, circumference of, at birth, 733 in hydrocephalus, 776 in rachitis, 308 nodding, in spasmus nutans, 743 retraction of, in cerebro-spinal menin- gitis, 786 shape of, 733, 734 supplementary, 62 sweating, 311 Headaches, 742 due to brain lesions, 743 to general systemic conditions, 742 to influenza, 396 to local origin, 742 in chlorosis, 696 in chronic gastritis, 229 in diabetes insipidus, 383 in lithaemia, 709 in tubercular meningitis, 783 reiiex, 742 sick (see also Migraine), 743 Heart and fcetal circulation, 325 Heart, 325 diseases of, 329 displacement of, 842 eflFect of exercise on, 24 examination of, 327 area of dullness, 328 location of apex beat, 326 Heart, fatty, 330 in chorea, 747 in diphtheria, 541 in gonorrhoeal infection, 368 in pertussis, 456 in rheumatism, 700 in scarlet fever, 617, 620 murmurs, 330 anaemic, 331 diastolic, 331 pericardial, 333 systolic, 330 venous, 332 palpitation of (see also Tachycardia), 330 position of, 327 primary tuberculosis of, 486 reflex symptoms of, 330 size of, "326 sounds and murmurs, 330 tension, 327 tricuspid insufficiency, 331 weight of, 326 Heat-stroke (see also Insolation), 246 Hehner's test for formaldehyde in milk, 120 Height, 5 Heliotherapy, 15, 498 Heller's test for blood in urine, 886 Hemichorea, 746 Hemicrania (see also Migraine), 743 Hemiplegia (see also Cerebral Paral- ysis), 795 complicating diphtheria, 523 haemorrhage into subarachnoid space causing, 736 Hemostatics in acute tuberculosis, 498 in internal haemorrhage, 42 Hepatic abscess, caused by worms, 290 Hereditary ataxy, 766 s}T)hilis, 680 Hernia, 361 differential diagnosis from hydro- cele, 362 in the new-born, 361 umbilical, 288 truss, 289 Herpes, circinatus, 837 tonsurans, 837 zoster, 831 Hiccough (see Singultus). Hinged bucket for extracting foreign bodies, 218 Hip, congenital dislocation of, 862 bilateral dislocation of, 863 unilateral dislocation of, 863 Hip- joint disease (see also Morbus Coxarius), 861 from perinephritis, 375 tubercular, 861 Hips, in lateral curvature of the spine, 855 Hirschsprung's disease, 272 Hives (see also Urticaria), 830 Hoarseness, in syphilis, 680 INDEX. 929 Hodgkin's disease, 716 Home modification of milk, 150 Hookworm disease, 293 Hordeolum, 825 ITorismascope, 882 Horlick's food, 185 lunch tablets, 164 malted milk, 184 Hot-air bath, 621 compresses or fomentations, 896 Hot and cold bath, in asphyxia neona- torum, 47 Human, blood serum, 39 milk (see Woman's Milk), diastatic enzyme in, 82 new reaction of, 82 properties of, 76 to preserve, 83 Humanized milk, 192 Hutchinson's teeth, 676 Hydrencephalocele (see also Meningo- cele), 777 Hydrencephaloid, 308 Hydrocele, 363 Hydrocephahis, 776 external, 776 foramen Magendie in, 736 internal, 776 intra-uterine, 777 spurious, 308 Hydrochloric acid, function of, in stom- ach, 66 in gastric contents, 875 test for formaldehyde in milk, 120 Hydropericardium, 343 Hygiene, of infant, 17 fresh air, 21 proper training, 23 of mouth, 17 nervous system, 23 stable, 126, 127 Hypersemia, cerebral, in insolation, 250 Hyperaesthesia, in acute myelitis, 764 in multiple neuritis, 752 Hypernephroma, 845 Hyperorexia (see also Biilimia), 232 in acute tuberculosis, 493 Hyperthyrea (see also Exophthalmic Goiter), 731 Hypertrophic pyloric stenosis, 226 gastro-enterostomy in, 227 tonsillitis, 405 treatment, 409 Hypertrophy of muscles, 802 of tongue, 214 of tonsils, 407 Hypodermic medication, 908, 909 in spasmodic laryngitis, 420 Hypodermoclysis, in scarlet fever, 626 in typhoid, 655 Hypospadias, 365 Hysteria, 749 differential diagnosis from epilepsy, 762 pathology, 749 Hysteria, tr<-:»tnif'nt, 750 epidemics of, 750 Hysterical fever, 450 Ice-bag, throat, 404, 407 coil, in meningitis, 78:5 Ice cream, 201 Ichthyosis, fa'tal, 50 Icterus, 346 complicating pseudo-leukajmic aiKC- mia, 695 complicating scarlet fever, 619 urine in, 878 neonatorum, 52 Idiocy, 806 congenital, 807 infantile amaurotic family, 810 Mongolian, 807 Ileo-colitis (see also Dysentery), 251 Imbecility, 806 Immunity conferred by woman's milk, 82 Immunization in diphtheria, 531 Imperforate rectum, 63 Imperial granuni, 187 Impetigo, 833 resembling varicella, 635 resembling variola, 641 Improper nutrition, 298 Inclusion bodies in blood of scarlet fever, 602 Incubators, 27, 33 Indican, in tubercvilosis, 493 test for, in urine, 884 Indicamiria, 289, 380 Indigestion, chronic intestinal, 276 Infancy and childhood, 1 Infant, foods, 182 mortalitv, 14 stools, 237 Infantile atrophy, 321 spinal paralysis, 76S Infarction, uric acid in kidneys, 878, 880 InfectioTis diseases, 445 table of, 448, 449 Inflamed gums, 6 source of invasion of tubercle ba- cilli, 485 Inflammation of the dura mater, 794 Inflammatory rheumatism (see also Eheumatism), 698 Inflation, of bowel, in intussusception, 288 of limgs, 47 of stomach, in gastroptosis, 233 Influenza, 395 bacteriology of, 395 complications of, 299 diagnosis, 397 eruption, 397 isolation, 400 symptoms, 396 treatment, 400 gastro-enteric type, 398 59 930 liSTDEX. Influenza, nervous type, 398 respiratory type, 398 Inhalations, in asthma, 429 in bronchitis, 427 in crouj), 419 Injections (see Eectal Injections), of horse serum, 33, 42 intrahiryngeal, 419 intravenous, 536 in erysipelas, 661 subcutaneous, in scarlet fever, 627, 632 Insolation, 246 differential diagnosis from menin- gitis, 246 Insomnia (see Restlessness at Night). from use of coffee, 202 in cretinism, 724 in gastroptosis, 232 in hysteria, 750 Intermittent fever (see also Malarial Fever), 662 Interstitial hepatitis, 350 Intertrigo eczema, 829 Intestinal colic, 273 hsemori'hage, 42, 650 indigestion, 273 chronic, 276 obstruction, from intussusception, 284 in constipation, 267 perforation, in typhoid, 649, 653 Intestines, 72 abnormalities of, 267 caecum, 73 course of colon, 73 sigmoid flexure, 73 transverse colon, 73 vermiform appendix, 73 absorption of fat in, 74 bacteria of, 243 formation of gas in, 74 haemorrhages from, 653, 731 perforation of, 753 Intoxication, food, 256 Intracranial injections, 792 Intraspinal aniiesthesia, 892 injections, 792 Intravenous injections, 536 in erysii5clas, 661 Intraventricular method of serum in- jections, 7SS Intubation, 542 false passage in, 553, 571 in aphonia spastica, 554 in cicatricial stenosis, 553 due to syphilis or trauinatism, 553 in deformities of larj-nx, 554 in diphtheria, 542 accidents during, 553 after-effects of, 563 effect of, in upper air passages, 5G0 false passage in, 571 feeding in, 556 Casselberry method, 556, 557 indications for, 544 Intubation, in diphtheria, method of, 547 mortality, 544 in papilloma of larynx, 554 Intubation instruments, 545 • specially constructed rubber tubes, 545, 554 Intussusception, 285 colic, 285 ileo-colic, 285 ileo or jejunal, 285 Invagination of bowel (see also Intus- susception), 284 Invertin, function of, 67, 135 lodophile reaction of blood, 686 Iritis, in meningitis, 786 Irrigation (see Rectal Irrigation). Irrigation, chamomile, in dysentery, 352 cold-water, in constipation, 269 in vaginitis, 618 nasal, 631 of bladder, 387 of colon, in typhoid, 629 saline, in diarrhoea, 245 Ischio-rectal abscess, 295 Isolation, in diphtheria, 529, 542 in influenza, 448 in measles, 596 in mumps, 718 in pertussis, 355 in scarlet fever, 623 in syphilis, 681 in varicella, 336 in variola, 642 Itching, in scabies, 841 in scarlet fever, 623 in variola, 642 Jacket, pneumonia, 434, 435 James's apparatus for expanding the lung, 443 Jaundice (see also Icterus), 52, 346 catarrhal, 228 Jaw, in alveolar abscess, 216 in angina Ludovici, 216 in tetanus, 758 necrosis of, in stomatitis gangreenosa, 211 upper, in syphilis, 676 Joints, diseases of, 848 in gonorrhoeal infection, 368 in haemophilia, 710 in meningitis, 786 in purpura rheumatica, 706 in rheumatism, 699 scrofulous, 486 Junket, 871 Just's food, 191 Keller's malt soup, 166, 870 Kenyon's sj^phon drainage in empyema, 442 Keratitis, in measles, 595 in meningitis, 786 Kernig's sign, 786 INDEX. 931 Kidney, falcnH in, 386 fonj^cnital cyst of, 62 .lilatation n'f, .377 (I i sea SOS of, 370 li.nnmorrliarro from, 382 inllaiMiiiation of, 371 in 7ic\v-born, 878 in p,ye]itis, 37 S in scarlet fever, 014, 620 position of, in infancy, 370 sacculation of, 377 Klcl)s-Ix)emer bacillus, .502, .503 in (liplitheritic omphalitis, 35 in measles, 502 in membranous conjunctivitis, 821 smear i)roparation, 505 stain for, 889 Knee, in morbus coxarius, 861 in rachitis, 316 Knee-jerk (see Patellar Reflexes). in multiple neuritis, 752 Knee-joint disease, 85 differential diagnosis from rheu- matism,. 864 in morbus coxarius, 861 in rachitis, 316 Knock-knee, in rachitis, 316 Koplik's sign in measles, 587 Kyphosis, 855 in Pott's disease, 848 in rachitis, 314 Lab ferment, 65 action of, on milk, 76, 77 Laboratory modification of milk (see also Percentage Feeding), 170 Lachrymal duct, inflammation of, in nasal catarrh, 391 Lactation, massage of breasts during, 94 Lactic acid, in buttermilk, 174 in gastric contents, 875 in stomach, 66 in urine, 174 Lactic acid bacillus, 174 Lactoscope, 134 Lactose, 1.36 La grippe (see also Lifluenza), 395 Lahmann's vegetable milk, 178 Laparotomy, in intestinal perforation, 653 " in intussusception, 288 in tuberculous peritonitis, 358, 360 Laryngeal spasm, 756 in bronchial asthma, 428 in rachitis, 312 in status lymphaticus, 711 recurring, 561 Laryngeal stenosis, congenital, 60 in diphtheria, 512, 537, 542 in retropiiaryngeal abscess, 416 intubation, in chronic, 554 specific, following intubation, 569 Laryngitis, complicating measles, 592 spasmodic, 417 Laryngitis, c|i;i;iM.i.i~ fioin di[)lilhcritic croup, 417 predisposing fiu-tois, 418 treatment, 419 Larynx, congenital steno^i- "'' 60 foreign bodies in, 420 granulomata of, 847 growths of (see also Papillomata ) , 846 in diphtheria, 512, 545 intubation in, 555 tolerance of, for intubation tube, 554 tracheotomy, in stenosis of, 574 Late speaking, 3 Lateral curvature of the spine, 855 Lavage (see Stomach-washing). Lecithin, 199 Leeches, application of, to relieve cere- bral congestions, 475 in convulsions, 741 in orchitis, complicating mumps, 717 in rheumatism, 702 Leffert's nasal syringe, .393 Lentigo, 834 Leptomeningitis (see also Pachymenin- gitis), 794 Leucocytosis, 684 in appendicitis, 281 in chorea, 687 in diphtheria, 508 in nervous diseases, 687 in pneumonia, 467 in rachitis, 686 in scariet fever, 604 Leucomain poisoning, 70S Leucoptenia in typhoid, 652 Leukaemia, 693 blood in, 693, 694 lymphatic form, 693 myelogenous form, 693 splenic form, 693 Lichen tropicus, 833 Liebermann phenol test for formalde- hyde in milk, 122 Lien mobilis, 352 Lime, saecharated solution of, 143 water, in modification of milk, 143 Lingual tonsil, in status lymphaticus, 711 Lipoma, 846 Lips, cyanosis of, in broncho-pneiunonia, 431 i^r adenoid vegetations, 411 in cretinism, 719 in septic diphtheria, 513 Liquor potassre test for pus in urine, 886 Lisping, 744 Lithffimia, 708 diet in, 709 urine in, 709 Lithuria (see also Lithsemia), 708 Liver, abscess of, 347 amyloid degeneration of (waxy), 349 cirrhosis of, 350, 691 descended, .349 932 INDEX. Liver, diseases of, 346 displacement of, 348, 349 in constipation, 26S fatty, 349 focal necrosis of, 350 functional disorders of, 348 in congenital obliteration of the bile- ducts, 37 in diplitheria, 59, 515 in faulty metabolism, 298 in gastro-duodenitis, 228 in leukemia, 693, 694 in malarial fever, 667 in pseudo-leuksemic angemia, 695 in scarlet fever, 619 in tuberculosis, 493 spots (see also Cliloasma), 832 ■weight of, 346 Lobar pneumonia, 460 Lobular pneumonia, 429 Local anaesthesia, 891 bv injection of sterile water, 892 blood letting, 897 remedies, 896 Lock-jaw (see also Tetanus), 758 LoefHer's bacillus, 504 Loefflund's malt soup, 160 Lordotic albuminuria, 381 Loss of speech due to paralysis, 4 Luetin reaction, 678 Lumbar puncture, 783, 789 amount of fluid to be -withdrawn, 790 needle required, 789 place for puncture, 789 dry-tap in, 790 in convulsions, 741 in hydrocephalus, 777 in meningitis, tubercular, 782 epidemic eerebro-spinal, 789 infantile spinal, 774 Lung, at term, 1 inflation of, 47 auscultation of, 423 cavities of, 479 compressed, 431 cut surface of, 479 gangrenous infiltration of, 211 in broncho-pneumonia, 432 in diphtheria, 610 in empyema, 440, 443 in lobar pneumonia, 460, 461 in tuberculosis, 424 in wandering pneumonia, 464 percussion of, 424 points in examination of, 423 transverse section of, 480 Lymphadenitis, retropharyngeal, 415 Lymphatic glands (Lymph Nodes), dis- eases of, 711 enlarged, causing torticollis, 705 in anajsthesia, 891 in diphtheria, 508 local, 512 in leukaemia, 693 Lymphatic glands, in mumps, 717 in pseudo-leuksemic anaemia, 695 in retro-oesophageal abscess, 217 in retro-pharyngeal abscess, 415 in tonsillitis, 405 in tuberculosis, 493 Lymphocytes, increase of, after second year, 684 in diphtheria, 687 in malaria, 687 in pneumonia, 687 in scarlet fever, 687 in typhoid, 687 MacEwen's percussion note, 733 Maerocephalus, in epilepsy, 760 Macrocytes, in syphilis, 685 Mackenzie tonsillotome, 409 Magendie foramen, in hydrocephalus, 736 Malarial fever, 662 blood in, 667 Plasmodia in, 663 symptoms, 670 treatment, 671 sestivo-autumnal, 665 double tertian, 662 quartan, 664 quotidian, 662 tertian, 662 Malformations of the rectum, 63 of the spinal cord, 766 Malignant, endocarditis, 338 growths, 842 in bladder, 387 ■ purpuric fever, 784 !Malt extract, in summer complaint, 167 soup, 166 to make, 160 [Malted milk, Horlick's, 184 ]\Ialtose, 67 Mammal a, infant food, 190 ]\rammary glands, 54, 79 Mannaberg's table of malarial parasites, 669 Marasmic thrombosis, 818 Marasmus, 321 Marehand's test for fat in milk, 134 Massage, method of performing, 272 in cerebral paralysis, 800 in constipation, 271 in spinal paralysis, 772 of breasts during lactation, 94 vibratory, 271 Mastitis neonatorum, 54 Mastoid disease, in otitis media, 815 operation for, 815 facial paralysis following, 817 Masturbation, 754 treatment, 755 ^Maternal feeding, 85 Matzoon (see also Zoolak), 198 Measles, 584 bacteriology, 584 complications, 591 INDEX. 933 Moaslcs, diagnosis, 590 from drug eruption, 596 from influenza, 596 from variola, 641 immunity, 595 incubation period, 580 mortality, 584 sequelae, tuberculosis, 486 symptoms, 585 desquamation, 588 enanthem, 585 eruption, 587, 588 treatment, 596 isolation, 596 German, 577 haemorrhagic form, 590 malignant form, 589 mild form, 589 relapsing form, 589 Meat juice, 200 Meckel's diverticulum, 37 Meconium, 237 Medication, points concerning, 895 hvpodermic, 908, 909 local, 896 rectal, 898 Megacolon, 272 Meig's food, 198 Melsena, 41 Mellin's food, 189 Membrane, in diphtheria, 502, 512 Membranous conjunctivitis, 821 Meningitis, cerebro-spinal, 784 bacteriology, 784 complicating diphtheria, 524 diagnosis, 787 etiology, 784 lumbar puncture in, 786 mortality, 785 pathology, 784 prognosis, 791 symptoms, 785 Brudzinski's neck sign, 786 Kernig's sign, 786 treatment, 791 serum, 792 tubercular, 779 bacteriology, 779 course, 781 diagnosis, 782 etiolog}', 779 lumbar puncture in, 783 pathology, 779 symptoms, 782 Babinski reflex, 783 tache cerebrale, 783 treatment, 783 jMeningocelo, 177 Meningococcus, 784 stain for, 889 Menstruation, effect of, on woman's milk, 75, 79, 99 in chlorosis, 696 praecox, 369 vicarious, 368 Mental faculties, 2 Mercury, administration of, to children, 211, 899 in treatment of sypliijls, 681 Mcteorismus (see also Intestinal Colic), 273 Microcephalus, craniectomy in. 800 fontanel in, 729, 776 in chronic hydrocephalus, 776 in epilepsy, 760 Micrococcus catarrhalis, 784, 787 in nasal catarrh, 391 Microcytes, in syphilis, 685 Micro-organisms (see Bacteria). Middle-ear abscess, causing abscess of brain, 804 Migraine, 743 Miliaria papulosa, 833 ruljra, 834 Miliary tuberculosis, 483 Milk, albumin, 140 Bulgarian, 174 cows', 114 addition of alkalies to, 143 adulteration of, 119 formaldehyde in, 120 albuminoids in, 138 analysis of, 114, 115 certified, in New York City, 118 composition of, 114 condensed, 179 diluents of, 149 eiweiss, 140 enzymes in, 145 fat, 132 home modification of, 150 idiosyncrasy, 169 infection, 256 pasteurization of, 156 predigested or peptonized, 873 protein in, 137 raw, 128, 129 saltsi in, 141 skimmed in feeding of premature in- fants, 33 starch in, 145 sterilization of, 152 changes caused by, 153 tuberculous infection through, 122, 131 imdiluted, as a food for infants, 131 variations of, 114 vitamines in, 145 ■woman's (see also Breast Milk), 75 analysis of, 78 comparative, 80, 83 apparatus for examination of, 79, 81 colostrum in, 74 comjx)sition of, 78 deterioration of, 104 examination of, microscopical, 81 enzymes, diastatic in, S2 fat in, to decrease, 104 to increase, 104 934 INDEX. ^lilk. "woman's, immunity confevi'ed b\'. 82, 483, 530 method of changing ingredients in, 104 to increase quantity of, 88, 96 to preserve, S3 proteins in, 104 reaccion of, 82 scanty, 87 specific gravity of, 79 specimen for examination, SO how to procure, 80 variations in, 101 Milk substitutes, cereal, 185 humanized, 192 Lahmann's vegetable, 178 mammala, 190 Milk-sugar or lactose, 136 Milk-test, Babcock's, 133 Mineral salts in milk, 141 Mixed feeding, 87, 107 additional foods during the nursing- period, 91 Mobius'sche kernschwund (see also Pleu- roplegia), 800 Modified small-pox (see also Varioloid), 642 Monarthritis, 368 in gonorrhoea! vaginitis, 368 Mongolian idiocy, 807 Monoplegia, 736 Morbilli (see also Measles), 584 Morbus coxarius, 861 ]\Iorbus maculosus Werlhofii, 706 Mortality, in cerebro-spinal meningitis. 784 in consumption, 492 in diphtheria, 503 in measles and complications, 590 in small-pox, 638 of babies raised in incubators, 28 Morton's fluid, 778 Mosite in diabetes insipidus, 383 Mosquera's beef meal. 195 beef jelly, 196 Motor function of the stomach, 876 Mouth breathing, a symptom of ade- noids, 411, 412 of enlarged tonsils, 408 Mouth, condylomata of, in syphilis, 676 diseases of, 205 haemorrhage from, in syphilis, 675 hygiene of, 17 in adenoid vegetations, 411 in angina Ludovici, 216 in Bednar's aphthse, 208 in stomatitis aphthosa, 207 in stomatitis catarrhalis, 206 in stomatitis mycosa, 208 Movable spleen, 352 IMucous membrane, conjunctival, in gas- tro-duodenitis, 228 of mouth, at birth, 65 in measles, 586 of pharynx, in scarlet fever, 608 ^Mucous membrane, of stomach, 65 in gastric catarrh, 219 of trachea and bronchi, in broncho- jmeumonia, 430 Mucus disease, 276 in stools, 242 Muguet (see also Stomatitis Mvcosa), 208 Multiple neuritis, 751 treatment, 753 Mumps, 716 complications, 717 diagnosis, 717 isolation, 718 period of incubation, 716 symptoms, 716 treatment, 717 Murmurs, 330 antemic, 331 cardiac, 328, 330 cerebral blowing, 333 ]\Iurmur5, diastolic, 331 pericardial, 332 systolic, 330 in chlorosis, 696 venous, 332 in chlorosis, 696 vesicular, in bronchial asthma, 428 Muscle education, 812 Muscles, atrophy of, in acute mvelitis. 764 in poliomyelitis, 770 transplantation of, 774 fatty infiltration of, in pseudo-hyper- trophie paralysis, 801 intestinal, 74 Avasting of, in scurvy, 306 Muscular atrophy, in acute myelitis, 764 in poliomyelitis, 770, 774 in pseudo-hvpertrophic paralvsis, 801 rheumatism, 703 spasms, in rachitis, 312 ]Mustard foot bath, 597 in convulsions, 741 plasters, 897 Myalgia, 703 Myelitis, acute, 764 chronic, 766 Myelocytes, 685 in diphtheria, 685 in leukaemia, 694 in pneumonia, 685 in svphilis, 685 Myocarditis, 343 complicating diphtheria, 523 treatment, 344 IMyxcedema (see also Cretinism^, 719 ^lyxoedematous idiocy, 719 Nrevus, 836 Nails, in secondary ansemia, 692 in syphilis, 675 Nasal "catarrh, 391 a symj)tom of measles, 390 INDEX. 935 Xasnl ontjirrli, a HViniitfun of svpliilis, 075 fausiiip otitis, IJOl (liplitlicria, 518 (loiicliinp, :!04, (527 syriiif^f, .'iD.'J Naso-phannRcal calarrli, 394 in sypliilis, 075 Kavel, dangers in handling, 35 management of, 17 Necrosis of liver, in malarial fever, GOO of jaw-bone, following stomatitis gangra'nosa, 211 Nock, in cretinism, 710 rigidity of, in typhoid, 050 stiff, in torticollis, 704 Neonatorum (see New-born Infant). haimoglol)inuria, 40 icterus, 52 urine in, 878 mastitis, 54 ophthalmia, 821 pemphigus, 50 sclerema, 53 Neo-salvarsan in treatment of noma, 214 in treatment of scarlet fever, 032 iilcero-mend)ranous tonsillitis, 400 Nephritis, acute, 370 as a coni])lieation, 372 blood in, 371 complicating diphtheria. 525 influenza, 399 urine in, 371, 372, 879 acute glomerulo-, 370 catarrhal, in scarlet fever, 614, 620 chronic interstitial, from increased urinarv pressure, 377 post-searlaiinal, 015, 620 secondary, 373 Nerve, pneumogastric, in dyspeptic asthma, 230 Nerves, in multiple neuritis, 751 vasomotor, causing asthmatic attacks, 428 Nervous impressions, effect of, on woman's milk, 88 Nervous system, diseases of, 733 hygiene of, 23 in typhoid, 050 Nestle's food, 183 analysis of, 184 Nettle rash (see also Urticaria), 830 Neuralgia, interstitial, 273 complicating variola, 042 Neuritis, multiple, 751 complicating influenza, 399 treatment, 753 peripheral, 751 New-born, abnormalities of, 57 acute fatty degeneration of, 41 asphyxia of, 45 bleeding in, 670 l^uhl's disease, 41 diphtheria in, 35 erysipelas in, 55 Newlxjrn, Irafdin- in, 43 hicmoglobinuria in. 40 hajmorrhage, ga-lro intestinal, in, 40 into adrenal gl.ui I-", 732 umbilical, 35, 40 ichthyosis of, 50 icterus of, 53 inflation of the lungs in, 4 7 malformations of, 57 mastitis in, 54 paralysis of, 43, 802 pemphigus in, 56 peritonitis in, 55. sclerema in, 53 syphilis in, 072 tuberculosis in, 55, 673 tvphoid in, 047 Night cough, 421 Night-sweats, in tuberculosis, 498 • Night-terrors (see also Pavor Noctur- nus), 753 Nipple, anticolic, 151, 153 harelip, 58 management of woman's, 92 sterilizer, 153 Nipple-shield, 93 Nitrous oxide and ether, 890 Nodding-spasm, 743 Nodes, lymph (see Lymph Nodes). Nodules, subcutaneous tendinous, in rheumatism, 700 tubercular, 779, 780 Noguchi's butvric-acid test for syphilis, 073 Noma (see also Stomatitis Gangraenosa), 210 in scarlet fever, 632 Nose, discharge from, in diphtheria, 512 diseases of, 391 foreign bodies in, 402 haemorrhage from, in exophthalmic goiter, 731 in syphilis, 675 in adenoid vegetations, 411 in cretinism, 719 picking of, 290 Nose-bleed (see also Epistaxis), in diphtheria, 524 in syphilis, 675 Novocaine as local anaesthetic, 892 Nurse (see also Wet-nurse), 22 Nurserv, furniture in, 22 light of, 22 location of, 21 method of heating, 22 ventilation, 21 Nursing (see also Feeding), 84 length of time for, 87 schedule for, 84 Nursing bottles, 150 care of, 151 Nutrient enemata (see Rectal Feeding). Nutrients and stimulants, 198 Nutrition, 65 936 INDEX. Xiitrition. impiopov. 298 Nutritional disturbance, 168 Nutritive tonics, chemical analysis of, 197 Nutritive value of eggs, 199 Nvlander's test for sugar in urine, SS5 Nystagmus, complicating spasmus nu- tans. 7J:3 in hereditary ataxy, 767 Oatmeal bath, 19 in eczema, 828 water, 869 Obliteration of the bile-duets, congeni- tal, 37 Obstetrical paralysis, 43 Obstipation, 299 ' 0'Dwyer"s method of intubation, 547 CEdema in angina Ludovici, 216 in erysipelas, 660 in variola. 624 of ankle, 696 of cheek, in stomatitis gangrjenosa, 211 of eyelids, in thrombosis of cerebral sinuses, 818 of feet, in myelitis, 765 of glottis, in scarlet fever, 631 of lars-nx, 617 of lips, in myelitis, 765 of pia mater, 617 of scalp, 818 CEsophagitis, acute, 217 chronic or diplitheritic, 217 (Esophagus, foreign bodies in, 218 Oigophony, 438, 440 Oil, enema, in acute peritonitis, 355 internally in chronic constipation, 269 Oiled-silk jacket (see also Pneumonia Jacket), 477 how to make, 435 Omphalitis, diphtheritic, 35, 512 septic, 36 Omphalomesenteric duct, 36 Onanism (see also ilasturbation), 754 Ophthalmia, granular, 822 neonatorum, 821 pneumococcus, 820 purulent, 821 Ophthalmo-tuberculin reaction, 496 Opisthotonos, hysterical, 749 in meningitis, 786 Orchitis, 366 in mumps, 717 Orthostatic albuminuria, 381 Osteitis, infectious, 866 of the femur, 864 of the tibia, 864 Osteoclasis in rachitis, 320 Osteomyelitis (see also Arthritis, Acute), 866 Osteotomy in rachitis, 320 Otitis, complicating diphtheria, 523 complicating influenza, 399 complicating measles, 594 complicating rhinitis, 391 Otitis, complicating scarlet fever, 610, 624 complicating typhoid, 654 complicating variola, 642 Otitis media, acute catarrhal, 812 symptoms, 813 treatment, 814 Oxygen, in dyspnoea and cyanosis, 476 in piilmonary stenosis, 334 in resuscitation, 48 Oxyuris vermicularis, 292 Ozsena, a sequela to scarlet fever, 622 Ozonic ether test for pus in urine, 886 Pachymeningitis, acute, 794 chronic, 794 hfcmorrhagic, 794 non-hoemorrhagic, 794 Pack, cold, 51S hot, 626 Palate, cleft, 58 in Bednar's aphthse, 208 in measles, 585 in purpura htemorrhagica, 706 in rubella, 578 paralysis of, in diphtheria, 526 Palpation of the liver, 346 of the spleen, 352 Palsy, Erb's (see also Paralysis), 774 acute spinal, from acute cerebral, 770 Paludal fever (see also Malarial Fever), 662 Pancreas, diseases of, 353 function of, 353 in syphilis, 675 position of, 353 Pancreatic juice, 65 Panopepton, 196 Panophthalmitis, in meningitis, 786 Papillomata, 847 Paracentesis, in otitis, 628 Paralysis, following pertussis, 457 in hereditary ataxA-, 767 in multiple neuritis, 752 in Pott's disease, 851 in thrombosis of cerebral sinuses, 818 of vocal cords, following intubation, 567 Bell's, 802 cerebral, 795 acquired after labor, 796 diagnosis, 797 differential, from infantile spinal, 799 occurring during labor, 796 of intra-uterine onset, 796 facial, 802 following mastoid operation, 817 retro-pharyngeal abscess, 817 in the new-born, 802 infantile spinal, 768 diagnosis, 770 from cerebral paralysis, 799 micro-organism causing, 768 INDEX. 937 I'arulyMiK. inrmit il<>, jdiMioIoffy, TOO Byni[)tomH, 770 fiicpanilytif, 770 trf(itrncnt,"772 rniiHcIc I'diication, 772 poHt (liplitlicTilif, r,2r», 540 fri'qiifncv of, 520 of l>luiii>M due to. 359 eom|»licatitiK i hentnatimn, 700 complicating t\pli<,ir|, fl54 chronic, 355 OlirinouH, 354 in I he new Inirn, fiS non tuhcrculoMM, 355 purulent, 354 McrouM, 354 tul»cr(MilouH, 350 Perilonsilhir ahnceuM, 400 rexenihlin^^ diphtheria, 522 Peril A'phlitin (nee also Ap()endieitiM) , ' 278 (uhen-uloiiH, 480 I'erniciouH aniemiii, 002 I'erHpira) ic)n (nee alw) Kweating), 12 PertUHMiH, 455 complement deviation U'nt, 450 comjdicaf ioiiM, 457 dia^nohiH, 450 «e«|ucl!i', XuhcrculowiH, 4H0 trciitment, 458 vaccine, 452 Pclechia, in liiemo|ihilia, 710 in |>ur]uira, 705 I'eycr'M p;itchcH, 72 in typhoid, 040 Ph:nyn;;cjil cat;irrli, (au»-iii;/; hpa>«modi<' cmup, 4 17 rh.iryn^itin, 415 in inttuen/.'!, 300 Pharynx, in local diphtheria, 512 in mycoMii, 208 in Kcarlet fever, 004 in Hcptic diphtheria, 512 in Klomalitis aphthoxa, 207 rhimosis, 303 rhlc;,'nionouH tonHilliiiH, 400 i'hloro;^lucin lent for formaldi-ln i|i. in milk, no IMilycfi-niilar ninrrhagic, 675 hereditary (see Inherited). inlieritedj 672 Colles's law, 673 contagion of, 673 intubation in. 554 luetin test, 678 modes of infection, 672 prognosis, 680 spirochsete pallida, 674 refringens, 674 stomatitis in, 682 symptoms, 674 Syphilis, symptoms, bones, 674 skin lesions, 676 teeth, 676, 679 transmission of, 680 treatment, 680 Wassermann reaction in, 678 Syphilitic stomatitis, 210, 682 teeth, 676, 679 Syringe, nasal, 393 Systolic murmurs, 330 Tache cerebrale in tubercular menin- gitis, 786 Tachycardia, 330 in diphtheria, 527 in exophthalmic goiter, 731 Talipes, congenital, with rachitis, 320 Tapeworms, 289 Tapping the abdomen in ascites, 360 Tea, 204 Teeth, eruption of, 7 grinding of, a symptom of worms, 290 hygiene of, 17 in adenoid vegetations, 411 in cretinism. 719 in rachitis, 312 in stomatitis gangrenosa, 208 in syphilis, 676, 679 Teething (see Dentition). Temperature (see also Fever), 11 effect of sugar feeding on, 137 how to reduce, 474 in distinguishing the still-torn from the dead, 46 variations in, 445 Tender nipples, 92 Tenesmus, in colicystitis, 386 944 INDEX. Tenesmus, in dysentery, 252 in intussusception, 285 in vesical calculi, 386 Tertian, intermittent fever, 662 double, 622 Testicles, in hydrocele, 363 in orchitis, complicating mumps, 717 tuberculosis of, 486 undescended, 365 Tetanic seizures in rachitis, 312 Tetanus, 758 Tetany (see also Spasmophilia), 756 Thermometer bath, 19 Thirst, excessive, in diabetes insipidus, 383 in diabetes mellitus, 385 in diarrhoea, 245 in gastric catarrh, 219 in gastro-duodenitis, 226 Thoracoplasty in chronic empyema, 444 Thorax, depression of, in rachitis, 312 . in empyema, 441 sarcoma of, 842 Threadworms, 292 Throat, as diagnostic aid, 13 diseases of, 291 ice-bag, 427 in diphtheria, 520 in rubella, 578 in scarlet fever, 604, 627 spray, 407 Thromboplastin in treatment of lisemor- rhages, 42, 415 Thrombosis, in diphtheria, 511, 524 in gangrene, 839 of pulmonary artery, 524 sinus, 818 Thrombokinase, deficiency of, causing haemorrhage, 40 Thrush (see also' Stomatitis Mycosa), 208 resembling diphtheria, 520 Thymic asthma, 713 Thymus, 711 diseases of, 712 primary tuberculosis of, 486 Thyroid, abnormality of, 732 desiccated extract of, in cretinism, 730 implantation of, 731 in exophthalmic goiter, 731 in leukaemia, 693 Thyroiditis, acute, 732 Tic, 745 Tinea tonsurans, 837 versicolor, 832 Tongue, as diagnostic aid, 13 bifid, 214 epithelial desquamation of, 214 hypertrophy of, 214 in chorea, 746 in cretinism, 719 in diphtheria, 512 in gastritis, 229 in glossitis, 215 Tongue, in measles, 585 in rubella, 578 in scarlet fever, 604 tubercular infection of, 486 Tongue-tie, 59 Tonics, restorative, 625 nutritive, 194 Tonsillaris, angina, 403 Tonsils, enlarged, 408 causing bronchial asthma, 428 indications for removal, 408 predisposing to laryngeal stenosis, 561 in diphtheria, 512 in leukaemia, 693 tuberculosis of, 410 Tonsillitis, 403 bacteriology, 403 sequelae, chorea, 746 rheumatism, 699 significance of, 404 treatment, 404 serum, 452 croupous, 405 follicular, 404, 522 hypertrophic, chronic, 407 phlegmonous, 406 ulcerative, 522 ulcero-membranous, 405 neO'Salvarsan in, 406 Tonsillotome, Baginsky, 409 Mackenzie, 409 Tonsillotomy, 409 bleeding following, ^ 408, 409 Torticollis, 704 treatment, 705 Toxaemia, in auto-intoxication, 285 in dysentery, 253 Toxicosis, 299 Toxin, diphtheria, effect of, on nervous system of animals, 510 in scarlet fever, 604, 606 Toxins ( see Poisons ) . causing convulsions, 739 elimination of, 538 Trachea, cannula, silver, 575 hard-rubber, 575 stenosis of, 546 Tracheotomy, in laryngeal stenosis, 574 operation, 575 after-treatment, 575 in syphilitic subglottic stenosis, 668 Trachoma, 807 Transfusion, 629 in haemorrhage of new-born, 42 Translumination of stomach, 231, 232 Traumatism, causing arthritis, 866 aphthae, 17 cerebral abscess, 804 epilepsy, 760 joint disease, 864 Tropon, 195 Trousseau's sign in tetany, 750 Truss, in umbilical hernia, 289 Trypsin ferment test, 226 INDEX. 945 Tubercle bacilli, disseminated by cows, 124 in tubercular perinephritis, 375 in the urine, 880 stain for, in sputum, 888 transmission of, 487 Tubercular, adenitis, 714 empyema, 444 hip-joint disease, 861 meningitis, 779 peritonitis, 357 Tuberculides, 49G Tuberculin, injections, 499 test for diagnosis, 300, 496 cutaneous reaction, 496 ophthalmo reaction, 497 Tuberculosis, following cerebral pneu- monia, 472 chlorosis, 696 empyema, 444 scrofulosis, 484 in the new-born, 55, 484 manifestations in bladder, 387 on skin, 406 modes of infection, 131, 485 of hip-joint, 861 of pericardium, 342 of tonsils, 410 predisposing causes, 486 acute, 483 bacteriologj', 486 D'Espine'si sign in, 494 diagnosis, 496 from faulty metabolism, 300 from syphilis, 678 Tuberculosis, acute, diagnosis, from typhoid, 495 sputum, 495' method of obtaining, 495 tuberculin reaction, 496 etiology, 483 pathological anatomy, 489 prognosis, 496 symptoms, 493 night sweats, 498 physical signs, 493 in nurslings, 494 resembling intermittent fever, 493 temperature, 493 treatment, 497 heliotherapy in, 498 bovine, 483 chronic pulmonary, 479 pathology, 479 symptoms, 481 treatment, 497 miliary ( see Acute ) . Tubercvilous adenitis, 714 ankle-joint, 865 broncho-pneumonia, 479 coxitis, 862 elbow-joint, 865 hip-joint, 861 infection, through milk, 122, 131, 483 knee-joint, 864 Tuberiiil.Mis nodules, 780 pneumonia, 477 wrist- joint, 865 Tumor of bladder, 387 of kidney, 379 sacral, 62 spindle-cell sarcoma, 842 spongy (see also Angeioma), 57 Tunica vaginalis, hydrocele of, 363 Turbinates, hypertrophied, causing bron- chial asthma, 428 Turpentine stupes, 896 Twitching, in chorea, 746 in meningitis, 782 Tympanites (see also Intestinal Colic), 273 a symptom of worms, 291 complicating typhoid, 654 in intussusception, 287 Typhoid fever, 646 bacteriology, 646 complications, 654 course, 654 diagnosis, 650 eruption, 651 etiology, 646 foetal and infantile, 647 internal haemorrhage, 653 intestinal perforation, 653 . leucopaenia in, 652 pathologj', 646 prognosis, 646 symptoms, 648 temperature, 649 treatment, 654 vaccine, 542 Uffelmann's test for lactic acid in stom- ach contents, 875 Ulcer, in scrofula, 681 in syphilis, 681 of stomach, 234, 696 of tonsil, 405 Ulcerations, aphthous, 206 due to intubation tube, 543 Ulcerative proctitis, 295 tonsillitis, 522 Ulcero-membranous tonsillitis, 405 resembling diphtheria, 520 Umbilical cord, 17 haemorrhage from, 42 in syphilis, 675 hernia, 288 polypus, 36 Umbilicus, bleeding from, 35, 39 in Meckel's diverticulum, 36 Uncinariasis, 293 Undescended testicle, 365 Unna's soft zinc paste, 828 Uraemia in post-scarlatinal nephritis, 617 Urea in diabetes insipidus, 383 Urethra in vaginitis, 368 Urethral calculi, 386 Urethritis, 366 I'ric acid, in blood, 708 60 946 INDEX. Urie acid, in iirine, 880 of new-born, 878 Uricacidsemia (see also Lithaemia), 705 Urine, 877 albumin in, 878 ammoniacal, 132 test for, 881 bloody, 382 diazo-reaction in, 883 in typhoid, 651, 653 disinfection of, 656, 894 fermentation test, 887 first, 877 in atrophy, 875 in auto-intoxication, 283 in colicystitis, 385 in cystitis, 387 in derangement of liver, 348 in diabetes insipidus, 383 in diabetes mellitus, 385 in diphtheria, 228, 515, 879 in epilepsy, 764 in gastro-duodenitis, 228 in icterus neonatorum, 878 in leviksemia, 880 in lithsemia, 708 in measles, 588 in nephritis, 372 in pneumonia, 467 in pj'elitis, 377 in scarlet fever, 604, 606 in septic diphtheria, 523, -526 in typhoid, 651, 653, 656 in tuberculosis, 493 in Winckel's disease, 41 incontinence of, in multiple neuritis, 752 in ectopia vesicae, 378 indican, test for, 884 method of collecting, 877 of breast-fed babies, 877 of new-born babies, 878 sodium chloride in, 878 specific gravity, 886 sugar in, 383 test for, 885 test for blood in, 885 test for diacetic acid, 886 test for pus, 886 urobilinogen reaction in, 238 Urino-pyknometer, 880 Urticaria, S30 Useless coughs. 422 Uvula, bifid, 215 enlarged, causing bronchial asthma, 428 inflamed, in spasmodic laryngitis, 417 in scarlet fever, 604 Vaccination, 644 Vaccines, bacterial, 450 autogenous, 451 stock, 451 in erysipelas, 452, 600 . in furunculosis, 451, 835 Vaccines, in pertussis, 452 in pneumonia, 454 in rabies, 451 in sinus thrombosis, 818 in streptococcus infections, 452 in tonsillitis, 452 in typhoid, 452 in vulvo-vaginitis, 451 Vaccinia, 645 Vagina, rectum terminating in, 64 Vaginitis, 366 catarrhal, 366 following scarlet fever, 617 gonorrhceal, 366 Varicella, 633 complicating erysipelas, 635 diagnosis, 633 from impetigo, 635 from variola, 634 pathology, 633 ■ treatment, 636 Variola, 638 complications, 642 desquamation, 640 diagnosis, differential, 641 eruption, 639 etiology, 638 isolation, 642 mode of infection, 639 mortality, 638 prognosis and course, 642 symptoms, 639 treatment, 642 Varioloid, 641 Vascular nsevus, 836 Vasomotor disturbance causing asth- matic attacks, - 428 Vegetable milk, Lahmann's, 178 Vein, transverse nasal, in adenoids, 412 umbilical,. 325 Veins, engorgement of, in insolation, 246 of abdomen, in ascites, 358 of scalp, in hydrocephalus, 775 in rachitis, 312 splenic, in malarial fever, 667 varicose, in chlorosis, 696 Velum palatinum, in diphtheria, 512 Venesection, 897 Venous murmurs, 332 Vermiform appendix, location of, 73 Vernix caseosa, 18 Verruca, 838 Vertebrae, in scoliosis, 857 Vertigo, a symptom of worms, 290 Vesical calculi, 386 Vicarious menstruation, 368 Vincent's bacillus, 406 Vitamines, 144 Vocal resonance, 424 Voice, husky, in papillomata, 846 in pleurisy with effusion, 438 in syphilis, 680 nasal, in diphtheria, 511, 526 with hypertrophy of tonsils, 408 INDEX. 947 Vomiting, ^1 chronic, 228 cyclic, 235 faecal, in intussusception, 281, 286 in dilat COLUMBIA UNIVERSITY LIBRARIES lllllllllllllillllllllllll IlliiPJIII III HI 0041073118