~K *^ "^ '^ . '^Js X^'^^ Ololumbia llniu^mtg ttt tIjF Qlitu 0f ^m fork (Haih^t nf pijgBirtauH anb ^urgputtH .^r.^..C....i=^..L)^.uLi^lh.e.v:. THE DISEASES OF CHILDEEN. BY THE SAME AUTHOR. HEADACHES: Their Causes, Nature, and Treatment. Third Edition. Revised and Enlarged. i2mo. Cloth. Price, $2.00. " Dr. Day brings to bear upon his subject a large amount of experience and medical knowledge, and makes many therapeutical suggestions of extreme value." — Lancet. " The rapidity with which this book has reached a third edition shows how well it has been appreciated by the profession." — Practitione7\ " It will always be a book of reference for the practitioner." — New York Medical youi'nal. "The extensive demand for a really good treatise on the subject is shown by the publication of the third edition of Dr. Day's work." — Edi7iburgh Aledical yottmal. THE DISEASES OF CHILDREN; FRiCTICiLAiHISIEMIlCffOM PRACTITIONERS AND STUDENTS. BY WILLIAM HENRY DAY, M.D., AUTHOR OF headaches; THEIR CAUSE, NATURE, AND TREATMENT, MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, PHYSICIAN TO THE SAMARITAN HOSPITAL FOR WOMEN AND CHILDREN. / SECOND EDITION. Rewritten and Much Enlarged PHILADELPHIA: PRESLEY BLAKISTON, No. IOI2 Walnut Street. I 88 I. 'J^ 33 TO MY COLLEAGUES, THE PHYSICIANS AND SURGEONS OF THE SAMARITAN HOSPITAL, S;^is ffiork is §«bical£iJ, WITH EVERY SENTIMENT OF RESPECT AND ESTEEM, BY THE AUTHOR, Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofchildrOOdayw PREFACE. This volume is the outcome of private and hospital practice, ex- tending over a lengthened period. My aim has been to make the work useful, and to rely on clinical experience rather than on theories ; which, even when proved, cannot always be brought to bear on points of practical interest. I entertain the hope that the following pages may prove useful both to the. student and to the practitioner. To assist the student, I have classified each disease and its varieties, after the method sanctioned by modern pathologists. To help the practitioner, I have carefully placed a descriptive heading before each chapter, to enable him to obtain readily the information he requires. In arranging the list of prescriptions, concentration has been my aim. Certain broad principles are kept in view, as regards dose and combination, but the details can be varied at the discretion of the practitioner, according to the peculiarities of each case as met with in practice. I have invariably prescribed remedies in safe doses. Some medicines will be taken by children in large proportions and a cure effected when small doses fail. Thus belladonna may cure incontinence of urine, and relieve whooping-cough, when its physi- ological effects are fully produced. Arsenic will cure chorea in large doses, whilst it will frequently fail in small doses. Opium re- quires to be given with caution. Calomel, iron, ipecacuanha, and free purgatives are well borne by children, while strychnia and prussic acid require care in exhibition. I have to thank my colleagues at the Samaritan Hospital for the opportunities they have given me of watching interesting cases Vlll PREFACE. under their care, and of giving me many valuable hints. I have especially to thank Mr. Alban Doran for the assistance he has ren- dered me in the chapters on Invagination and Intussusception, and on other questions of surgical interest. My warmest thanks are due to Dr. Milner Fothergill for much information and suggestion. I have laid myself under great obligation to the writers of stand- ard works, and if I have failed anywhere to acknowledge the debt, the omission has been purely accidental and unintentional. To the Transactions of the Royal Medical and Chirurgical Society, of the Pathological Society, and of the Clinical Society, as well as to the works of Jones and Sieveking and Wilks and Moxon, I am greatly indebted. lo Manchester Square; April, j88i. CONTENTS. CHAPTER I. PAGE Introductory Remarks, 17 CHAPTER II. Milk Diet and Hygiene, 26 CHAPTER III. Acute and Chronic Disease, 51 CHAPTER IV. Debility, 62 CHAPTER V. Dentition, 67 CHAPTER VL Marasmus or Atrophy, 73 CHAPTER VII. Fevers of Childhood, 7^ X CONTENTS. CHAPTER VIII. PAGE Typhoid Fever, 83 CHAPTER IX. Special Eruptive Fevers, ... 97 CHAPTER X. ^ MoRBiLLi OR Measles, loi CHAPTER XL Scarlet Fever or Scarlatina, 115 CHAPTER XII. Variola or Small-pox, 137 CHAPTER XIII. Diseases of the Mouth and Fauces, 148 CHAPTER XIV. Indigestion, 164 CHAPTER XV. DiARRHCEA, 174 CHAPTER XVI. Gastritis-^Mel.^na — Dysentery, 194 CHAPTER XVII. Constipation and Colic, 200 I CONTENTS. XI CHAPTER XVIIL PAGE Intestinal Obstruction, 207 CHAPTER XIX. Intussusception — Invagination, 210 CHAPTER XX. Diseases of the Liver, 225 CHAPTER XXI. Icterus or Jaundice, 231 CHAPTER XXII. Painless Enlargements of the Liver, 237 CHAPTER XXIII. Diseases of the Spleen, 242 CHAPTER XXIV. Diseases of the Kidneys and Urinary Organs, 248 CHAPTER XXIV {Continued-). Diseases of the Kidneys and Urinary Organs, 264 CHAPTER XXIV {Continued). Diseases of the Kidneys and Urinary Organs, 274 CHAPTER XXIV {Continued). Diseases of the Kidneys and Urinary Organs, 287 Xll CONTENTS. CHAPTER XXV. Diseases of the Peritoneum, 294 PAGE CHAPTER XXVI. Ascites, 299 CHAPTER XXVII. Intestinal Worms, .... . . 302 CHAPTER XXVIII. Diseases of the Nasal Cavities, 310 CHAPTER XXIX. Croup — Laryngo-tracheal Diphtheria of some Writers, . . 322 CHAPTER XXX. Diphtheria, 336 CHAPTER XXXI. Laryngismus stridulus, • • 357 CHAPTER XXXII. Pertussis or Whooping-cough, 366 CHAPTER XXXIII. Enlarged Bronchial and Mediastinal Glands, ^8^ CHAPTER XXXIV. Asthma, 393 CONTENTS. Xlll CHAPTER XXXV. PAGE Emphysema, 405 CHAPTER XXXVI. Bronchitis, 413 CHAPTER XXXVII. Pleurisy, 427 CHAPTER XXXVIII. Pneumonia, 448 CHAPTER XXXIX. Tuberculosis, . . '. 472 CHAPTER XL. Phthisis Pulmonalis or Pulmonary Consumption, 500 CHAPTER XLI. Diseases of the Heart, . 529 CHAPTER XLII. Diseases OF THE Brain, 557 CHAPTER XLIII. Epilepsy, 5S7 CHAPTER XLIV. Infantile Convulsions or Eclampsia, 606 XIV ' CONTENTS. CHAPTER XLIV {^Continued). r±G^ Congestion of the Brain, 6i8 CHAPTER XLV. Chorea or St. Vitus's Dance, 624 CHAPTER XLVI. Diseases of the Spinal Cord, 637 CHAPTER XLVII. Infantile Paralysis — Acute Anterior Polio-myelitis, . . . 647 CHAPTER XLVin. Rheumatism, 658 CHAPTER XLIX. Rickets or Rachitis, 669 CHAPTER L. Syphilis in Children, 684 CHAPTER LI. Anemia, . . . . ; 692 CHAPTER LII. Diseases of the Ear, 708 CHAPTER LIII. Diseases of the Skin, ^. 716 ERRATA AND ADDENDUM. On page 365, second line from bottom, for " Aquam ad Sj " read '' Aquam ad oiij." , , On page 379, second line from bottom, for "Aquam ad" read "aquse aa." On page 206, at bottom, add : Typhlitis and Perityphlitis.^ This disease consists in inflammation of the coats of the csecum, and of the tissues above and around it. It may occur without apparent cause, or follow diarrhoea or constipation. Blows on the abdomen, exposure to damp and cold, impacted faeces, or foreign bodies in the caecum may induce it. The symptoms are pain and tenderness over the right iliac fossa, colicky pains in the abdomen, vomiting, constipation or diarrhoea, and febrile disturbance. The patient lies on his back, or right side, with his legs drawn up to relax the abdominal muscles. The prognosis is generally favorable unless the disease leads to per- foration of the csecum and peritonitis. If abscess form, it may open into the bowel or externally through the abdominal wall, the chance of recovery being greater in the former than in the latter. The diagnosis consists in sudden localized pain and tenderness in the right iliac fossa, with more or less swelling, vomiting, and con- stipation. It may be mistaken for hip-disease* or ovaritis in young girls who have begun to menstruate, or to the passage of a renal calculus, t Treatment. — If pain and tenderness are acute, it will be advisable to apply three or four leeches over the csecum, followed by warm and light poultices. Opium to relieve pain in small doses by the mouth, or what is preferable, a few drops of laudanum thrown into the rectum. When the pain is relieved, enemata may be used, or even a mild laxative, if there is no vomiting, but the greatest care is necessary in the use of aperients. * Perityphlitis in Children, The American Journal of the Medical Sciences, by V. P. Gibney, M.D., 1881, p. 119. t See Chap. XXIV, p. 275. DISEASES OF CHILDREN. CHAPTER I. INTRODUCTORY REMARKS. The study of children's diseases — Their special characters and peculiarities — Manarjement during growth and development — Importance of attending to the constitutional rather than to the local state — Constitutional and hereditary disease. The diseases of clnldren have a claim to be considered separately and specially. It is before mental training has worked its influ- ence, and the body has undergone the wear and tear of adult life, that we are able to study disease in its most natural form. An opportunity is presented to us of seeing disease, as it were, unre- strained and free, running its course in a tender frame, keenly sensitive to exaltation and depression, without the complications and the thousand collateral circumstances which determine the form and character of the disease which is to assail it in subse- quent life. All practitioners of medicine will admit that the dis- eases of children should be regarded in a distinct light from like diseases of adults, where too frequently disease acts upon shattered organs and worn-out tissues. The remarkable peculiarities which disease assumes in children, the course it follows, and the rapid transition from a state of danger to recovery, make this study very important. Often obscure and difficult of detection, these diseases quickly attain force and intensity, and run on uncontrolled by any measures within our reach. It may be they have slumbered for a variable time in the system, occasioning little, if any disturbance to the general health that could be looked upon as positively foreboding evil to come; or it may be, from causes not readily discoverable, 2 18 DISEASES OF CHILDEElSr. tliej have a sudden and fierce origin. iJ^ow and then, after lasting weeks and months together, defying medicine and the highest medical skill, they take a turn in the right direction. Each stage of them is characterized by graver symptoms till a turning-point is reached, and then convalescence sets in slowly and steadily. A life of physical activity when the renovation of the tissues is most vigorously proceeding makes great calls on the digestive functions, and these again, for the maintenance of their integrity, depend on sleep and repose when weariness sets in. Excessive mental exertion interferes with the growth of the body. The two cannot be actively carried on with impunity at the same time ; the one is peculiar to childhood, the other comes naturally with the approach of maturity, and increases with the love of sedentary habits. When the organic processes are most active they are most easily upset, or hindered in their course, and in this respect alone they differ as much from similar functions in the adult as a thriving shrub does from a full-grown tree. The children of the present day are reared differently, taught differently, and fed differently from those of half a century ago, and, as a consequence, the power of disease is greatly modified by such changes. These are very important considerations, and must be borne in mind if we would successfully lay smooth this uneven field of medical inquiry, for I think fault maj^ often be ascribed to us in not adequately estimating the diflerence of power between similar diseases in the young child and the adult. It is necessary, then, that the diseases of early life receive a most attentive con- sideration, for if overlooked, or ill understood, the seeds of mis- chief are allowed to take deep root, and a degenerate maturity is encouraged. A large number of the children of the poor in Lon- don grow up to be tuberculous, and ultimately die of pulmonary phthisis, from disregard of their early illnesses on the part of their parents. Small children, imperfectly recovered from the eruptive . fevers, are allowed to run about in the streets almost before the rash has disappeared; and the lung affection, which so constantly attends measles, is permitted to go on without any treatment at all. Suppurating cervical glands, otorrhoea ending in cerebral dis- ease, dropsy, ophthalmia, etc., all follow in the rear of neglect and starvation. The functions of childhood are remarkable for change, development, and activity; the skin is sensitive to all external in- fluences, diarrhcea and vomiting are easily provoked, and the ner- INTRODUCTORY REMARKS. 19 vous system is very impressible. Ilence an amount of cold or heat which would uot affect a grown-up person would be fatal to a young child, for in proportion to the rapid changes which are going on there is a proportionate degree of risk. It is no easy task to adjust the balance and to keep it steadily equipoised. Disorder in one part is enough to disturb the whole machinery, and slight mischief having been set up in an unimportant part may rapidly extend its influence to another distant and vital part. We have much to learn then, during the period of growth, change, and development. In a great measure children must be managed according to the strength with which they enter into the world. Some are born weak and fragile, and require the most delicate attentions to rear them through this stage. If the same measures are adopted as with stronger children they would either die, or grow up miserably wretched or unhealthy. Ko astonish- ment can be awakened at this if we consider for a moment the life many mothers lead during the trying period of pregnancy. Late hours lead to fatigue, to excitement, and to stimulating and im- proper diet, which are sure means of causing them to bear an unhealthy offspring. In London and other large cities these re- marks are especially applicable. The calm quiet of country life, with regular and abstemious habits, alone conduces to a natural and tranquil state of mind and body. All this leads to sound and vigorous health in the mother, and as surely to health in the chil- dren she bears. M}^ colleague. Dr. Percy Boulton, has devoted much time and x attention to the subject of physical development in children. AYhat Professor Bowditch, of Boston, has done for Americans, Quetelet fur Belgians, and Charles Eoberts for English factory children. Dr. Boulton has done for well-to-do English children. The physical averages of factory children are as poor a standard of measurement as their mental averages are a criterion of brain capacity. It seems unnecessary to explain that syphilis, struma, and drink on the one hand ; bad food, clothing, housing, and premature exces- sive bodily labor on the other ; tend to stunt the growth of the working classes. An average of the weight and height of factory children is no standard for those more favorably situated in life. Dr. Boulton has arrived at the following very valuable conclu- sions : 20 DISEASES OF CHIEDEEN". " Health}' childreu grow at the following rate per annum — Slow growing, 2 inches a year Average, 2^ " " Fast growing, 3 " " A child that grows 2 inches a year will be a short adult, 2| inches a medium, and 3 inches a tall adult. Weight should increase regularly with height, and there is no more certain forerunner of disease or unhealthy development than discrepancy in the weight for height ratio. Growth should proceed regularly and evenly, not by fits and starts. Delicate children grow most irregularly. Illness in a great measure checks their development, during which time they lose ground that either is never made up, or only by a bound which sadly taxes the strength."* It is most important that we should have some standard to go by, and this is supplied us in the table of averages which Dr. Boulton has drawn up as the result of very numerous observations of his own amongst the children of healthy well-to-do people. He particularly mentions that his endeavor has been to exclude all dwarfs, giants, and evidently diseased and unhealthy children, which so seriousl}'' alter the averages of other observers, and be- lieves that he has thas prepared a scale which may be regarded as a standard for children brought up under favorable conditions. Table of Averages. Height. Wei ght. Height. Weight. Feet. Inches. Stone. lbs. Feet. Inches. Stone. lbs. 3 2 8 4 1 4 6^ 3 1 2 10 4 2 4 9 3 2 2 12 4 3 4 m 3 3 3 4 4 5 3 4 3 2 4 5 5 •)1 -2" 3 5 3 4 4 6 5 5 3 6 3 6 4 7 5 7^ 3 7 3 8 4 8 6 10 3 8 3 10 4 9 5 121 3 9 3 12 4 10 6 1 3 10 4 4 11 6 3^- 3 11 4 2 5 6 6 4 4 4 * Some Anthropometrical Observations, liarveian Society, March, 1880. INTRODUCTORY REMARKS. 21 The first year of infant life is especially perilous from defective nutrition and want of proper care.* We are assured of this from the fact that the mortalities so much greater among the children of the poor than among those of the rich ; in the manufacturing districts of the north, and in overcrowded dwellings, than in rural districts, where the mothers go to field work, and where three or four families are not compelled to reside in one small house. It is a mystery that children can be reared at all in some of our great cities and towns, on account of the impurity of the air they breathe, and the insanitary condition of the hovels they inhabit. Better accommodation must be provided for the poor if we would lessen the waste of infant life and the spread of zymotic diseases — a spread accelerated, no doubt, in these days by the rapid inter- course between one country and another. Those accustomed to children will observe signs and s^T-mptoms about them of great weight and significance, which would pass un- noticed by others not possessing this experience. They detect the coming storm, and avert it by simple and appropriate treatment ; and so a formidable disease may sometimes be annihilated by good judgment and forethought. There are few diseases occurring in later life that require so much sagacity to detect as the various disorders and ailments of young children, or so much discrimination, tact, and judgment in the successful management of them. I have elsewhere stated that constitutional symptoms always demand a large share of attention, and that we have often erred when we have trusted too exclusively to physical and local signs. At all ages and in both sexes, it is my belief that we are never likely to be so successful in controlling disease as when we mainly direct our treatment to the constitutional state.f This does not imply care- lessness of, or indifference to, physical signs. In children the con- stitutional state should never be forgotten, for many a sound practitioner has lost his little patient, whilst watching the pulse * It is stated on the authority of M. Kuborn, of Belgium, that the mortality for this period of life in the principal countries of Europe is as follows : " Out of 1000 children, there die in Sweden 153, in Denmark 136, in Scotland 156, in England 170, in Bel- gium 186, in Holland 211, in France 216, in Prussia 220, in Spain 226, in Switzerland 252, in Italy 254, in Austria 303, in Russia 311, and in Bavaria 372." — British Medical Journal, January 27th, 1877, p. 113. t Vide a paper by the author On the Relative Value of Symptoms in the Diag- nosis and Treatilient of Disease. Transactions of the St. And. Med. Grad. Associa- tion, vol. ii, p. 78, 1869. 22 DISEASES OF CHILDREN. closely and listening with care to the respiration, when he might have saved life by leaving these symptoms to take care of them- selves and looking to the general state as the sure index of danger. Neither the pulse, the skin, nor any light which auscultation and percussion afford, are such valuable signs of disease in children as they are in adults. Constitutional diseases are the consequences of impairment in the processes of nutrition and secretion. In children they are more frequently hereditary than acquired. A child is born with a predisposition to some particular disease, as tubercle, cancer, gout, etc. ; but if the life it leads is conducive to sound health, the morbid tendency may never show itself. And this may afford an explanation of a constitutional and hereditary disease skipping one generation and appearing in the next.* "When the general and constitutional signs of disease are well established, they are sometimes cut short with the same sudden- ness with which they attained their severity. But when the phys- ical signs of disease are also well developed, as in some cases of continued fever, bronchitis, and pneumonia, our prognosis becomes far more serious, and a tendency to sudden prostration, and even fatal collapse may steal on in a few hours. * "The health of an individual depends not merely upon existing, but also on ante- cedent causes. Part of his health is transmitted from his ancestors, and may be a mere survival of hygienic conditions which have been extirpated. Part of our health also depends upon the external conditions of our upbringing when young, and part also on the influence, physical and moral, to which we are exposed all through our lives. As there is no individual who can be said to have all his organic functions in the most perfect action, so there is no community that can be considered in a perfectly healthy state, for the general health depends upon all the movements of the private health of the individuals. The health of a nation, physiologically considered, stands closely in relation to that of an individual. The nutrition and health of an individual depend upon the well-adjusted balance of the supply and waste of the particles which compose the body. These particles of the body, all through the life of man, are incessantly dying, and are being replaced by new particles continually springing into life. Every organ is tluis undergoing, through its particles, a continued and rapid alternation of death and life. As the whole body is to one of these particles so is the whole body politic of a nation to the individuals of which it is composed. The death of an indi- vidual in a state is strictly analogous to the death of a particle in a single man, and the birth of an individual in a state is the analogue of the moulding of a new living particle into tlie body of a man. Wiien an individual becomes diseased, there is some want of balance between the waste and supply of his organs — or rather of the underly- ing protoplasm wiiich is incessantly changing from life to death. When the waste of the ultimate particles is greater than the power of restoration, disease attacks the indi- vidual." — Address of Dr. Lyon Playfair, On Sanitary Reform, delivered before the Social Science Congress at Glasgow, October 3d, 1874. INTRODUCTORY REMARKS. 23 "We cannot, in many complaints, so easily determine the extent and degree of local mischief in children as we can in adults ; and even where we are pretty certain, we shall find it an admirable rule to trust to the general condition of these young patients, rather than to rely on the uncertain knowledge which doubtful local signs often create in our minds. It is often quite impossible to depend upon the testimony of children as to the seat of pain or suffering, and the medical attendant requires to exercise very great dis- cretion and judgment before he draws any conclusion. Let the abdomen of a child be lightly pressed, and it will almost always, when interrogated, reply that it feels pain. Even the testimony of adults under such an examination may mislead us. In a case of fever it may be very important to be safe on this point, as I am satisfied I have seen leeches and counter-irritants applied when the local signs of pain or congestion, or inflammation have not existed.* The tumid and protuberant abdomen of a child is sometimes looked upon as an indication of disease, when it is in all respects healthy and natural. The contrast between the abdomen of a child and that of an adult is too well known to need comment here. Now, there are a few points respecting the management of chil- dren in health which if known are not acted upon, and the neglect of them is followed by serious after-consequences. Health is dependent in large measure upon points which may appear very trifling, but which nevertheless if overlooked, from their apparent insignificance, may grow into open dangers. Disease is early and easily implanted by the parents of children who set at defiance those natural laws upon the observance of which health and strength depend. A young child, like a young plant, requires suitable nourishment and judicious feeiling, and without in any way pandering to every fancied ailment, I would urge a * In the early part of my professional career I remember an old physician making pressure over the right iliac region of a fever patient whom he saw in consultation with me, and insisted that some lesion of the intestine was either present or threatening. The patient admitted that pressure hurt her, and accordingly the linimentum hydrar- gyri was ordered to be rubbed in night and morning over the supposed seat of mischief, and small doses of mercury and Dover's powder given by the mouth. I soon desisted from the use of mercury, but not before it had produced slight ptyalism. The progress of the case justified the opinion that the intestines had escaped the lesion to which they are so liable. I give this case in point, because delicacy of touch, the position of the patient when under examination, the weighing evidence from a set of symptoms rather than from one, are so essential in the diagnosis and treatment of disease. 24 DISEASES OF CHILDREN. constant scrutiny and watclifulness. Those children are the healthiest and strongest in every way who are allowed certain free- dom in their amusements and outdoor exercises. The overfond and timid parent shuts up her child in one temperature to protect him from cold and damp, and this often to the ruin of his general health, because it is impossible to provide against the variability of temperature in this climate. Very young children should be kept warm, and yet not strangled with tight clothing. Plenty of pure air is most essential for health. "When the weather is fine, they ought to be sent out in the air every day, and the windows of their nurseries and sleeping-rooms should be opened twice daily. In a climate like that of England, however, where we have seldom two days alike, great prudence is required before exposing children to any risk of cold, as the respiratory tract is so sensitive in early life. Cold alone will originate other evils; the mucous membrane of the stomach and bowels will also suffer, and delicate health becomes established, from which the child either sinks, or very slowly recovers. When infants are taken out of doors a nurse's arms are preferable to a perambulator, on account of the warmth she imparts to them. If we consider the way in which the children of the poor are brouo-ht up in the country, we may learn a lesson from it. When born of healthy parents, they endure with impunity the trying changes of our climate, and resist diseases to which their poorer brethren in large towns and overcrowded dwellings would quickly succumb.* In the middle and upper ranks of life children are often injudiciously fed ; their meals are increased in richness and frequency, when they should be of the plainest kind and moderate in quantity. When a child refuses food, my maxim is always to let it alone for a time. The appetite of a child is a good gauge of its powers of digestion, and if you force it to eat against its will the probabilities are that the food will disagree. In such cases the rule we ought to lay down for eating should be, "little and seldom," and not " little and often." The digestive organs require rest in * "Given tlie benefits of an outdoor life in a pure atmosphere, and tlie child of the country peasant will tlirive, and develop an abundance of blood and muscle, almost without meat at all. The children of the poorer classes in towns stand upon a very- different footing, and the struma and other diseases fostered in close alleys are often greatly aggravated by the effects of an insulBcient diet."— T^e Lancet. Editoi-'s Re- marks, April 20th, 1872, p. 550. INTEODUCTORY REMARKS. 25 common with the brain and the organs of locomotion ; and yet as soon as derangement of them sets in, the habit is too frequently followed of administering food and medicine, by which they are kept in a perpetual state of irritation. Some time ago I was called to see a young child in the country, whose friends were alarmed because of a refusal to swallow food. The pulse and temperature were normal, there was neither pain, headache, nor diarrhoea. In the absence of any tangible symptoms I suggested to the medical man in attendance that he might be content to leave the case alone. In a day or two the appetite returned, and the child recovered her usual spirits without the aid of medicine. Unless marked indications exist, I entirely disapprove of the pernicious practice of flying to tonics, alteratives, and aperients, as the case may be. Let the food be wholesome and nutritious, or the worst state of health may be engendered ; but medicines are foreign to the system, and should be avoided when possible, it being far better to trust to food than to physic. Convulsions, marasmus, abdominal and thoracic affections, are constantly to be ascribed to improper and insufficient food. Parents and nurses seem unmindful of the necessity for adapt- ing the diet to the age and strength of the child, by which they cause much unnecessary suffering, and frequently invite disease: Indigestion, that prevalent source of subsequent evil, is brought about in a great many cases by feeding young children with fari- naceous food and different kinds of biscuits, which undergo fer- mentation, and produce distressing flatulence and disorder of the' stomach and bowels. Such diet, in the absence of milk, is obvi- ously unfit for the purpose of growth and nutrition, indigestion sets in, and the child's hunger seems never appeased ; the liver is said not to act, medicine is given, and there is an aggravation of the evil. It loses flesh, and is crying and whining during the day, till the bowels start off, producing temporary ease. There is the same restlessness and discomfort at night. The extremities be- come wasted, and the skin hangs in loose folds ; the bowels are irregular, and the stools are vitiated ; sometimes there is consti- pation, and sometimes diarrhoea, and many children succumb be- fore they reach the age of one year, owing in a great many caseg to the manner in which they are fed. Each woman has her own method of feeding her child, and it cannot be denied that some children grow up, and thrive even, under any system that .the fancy or caprice of the mother may dictate. 26 DISEASES OF CHILDREN. CHAPTER II. MILK DIET AND HYGIENE. Composition of milk — Condensed milk, its properties and value — Use of milk in disease and constitutional weakness — Farinaceous foods — Dentition — Choice of a nurse — Constipa- tion — Scotch oatmeal — Stimulants — Air, exercise and sleep — Cold bathing — Aperient m.edicines, their uses and abuses — Preparations of iron — Antimony — Sedatives — Opium — Bromide of potassium — Hydrate of chloral — General conclusions. Milk contains all the necessary ingredients for the preservation of health, and at no period of life is it so valuable as during that of growth, when the functions of assimilation and digestion are most active. The rapid increase of growth in all the tissues, and the waste that also hourly goes on, demand that nourishment should be supplied at short intervals. "We thus introduce into the stomach a fluid which does not tax the tender membrane in its work of absorption, and rare are the instances in which it is not tolerated. The composition of milk is variable both in quantity and qual- ity, according to the animal which furnishes it and the state of that animal's health at the time. It varies according to the amount and quality of the food, the time at which it is drawn, and a number of other circumstances. For instance, pasture-fed cows yield an alkaline milk, whereas the milk of the stall-fed is more or less acid, and therefore less digestible for infants. The principal ingredients in milk are casein, sugar, fat, and salts. So long as the carnivora live on a purely animal diet no sugar can be detected in the milk, but when the diet is mixed, as it is in the human species and amongst difterent herbivorous animals, sugar rappears, and all the different ingredients undergo great variation. Woman's milk is rich in milk-sugar and fat, but poor in casein.* * "La Presse Medicale says that the researches of Dr. Condereau, of Paris, show ;that the milk of Esquimaux women contains a small proportion of salts, but is rich in sugar, and especially in fat, derived from the great amount of oily food which they consume to resist the cold in their native land." — Medical Press and Circular, Febru- ary a3th, 1878, p. 142. MILK DIET AXD HYGIEXE. 27 Mare's milk is poor in casein and fat, but extremely rich in milk- sugar. Ass's milk contains a much larger quantity of milk-sugar and salts than that of woman's, but more water and less casein and butter. Yernois and Becquerel estimate the casein of ass's milk at 35.65 per 1000, and the butter at 18.50 ; the casein in human milk at 39.24, and the butter at 34.61. After mare's milk, sheep's milk contains the most solids, then cow's, then goat's, then woman's. According to some authorities the casein is a combi- nation of albumen and potash. The great difference between albumen and casein consists in this, that the latter is not coagu- lated by heat, which precipitates the former. Casein is coagulated by acetic acid, which is not the case with albumen. Casein seems to have also the power of combining with the phosphates of lime and magnesia, and rendering them soluble. The saline matter of milk, which is nearly the same as that of the blood, is largest in cow's and goat's milk; it seldom exceeds one per cent., and in poor milk it may be considerably lower. Cows fed on beet-root and carrot augment the sugar ; the race of Alderneys are said to give more fat, and the long-horns more casein. In the' milk of the cow, goat, and sheep, the proportions of casein, butter, and sugar, are nearly the same, varying from three to five per cent. Milk, then, contains three classes of organic con- stituents ; the albuminous, the saccharine, and the oleaginous, with those mineral ingredients so necessary for the consolidation and development of the infant fabric. In the human female the saccharine and oleaginous elements are present in large amount, but they are affected by the kind of food which is taken and the amount of outdoor exercise. Exercise is said to favor the secre- tion of casein, and the cattle which feed in exposed situations, and have to take great muscular exercise to procure their food, as m Switzerland and some other mountainous and barren districts, yield only a small quantity of butter, but a larger proportion of cheese. The very opposite takes place, according to Carpenter, when the same cattle are stall-fed. Unless milk is perfectly fresh and reliable, it is very prone to undergo lactic acid fermentation, and thus, in becoming sour, a fungoid growth is developed which is highly detrimental to infan- tile assimilation. The milk so changed might not try the strong digestive powers of an adult, but for an infant or young child it would lay the foundation of delicacy, and invite those diseases 28 DISEASES OF CHILDREN. which are so ready to attack early life. We are too well ac- quainted with the cramp, spasm, and indigestion, which attack children who are brought up by hand, and who take their milk out of dirty bottles. The casein undergoes decomposition, and lactic acid is formed in large quantities. Pure cow's milk should, when placed in a tall narrow glass ves- sel, be opaque, and of a perfectly white color, having no deposit, and without any peculiar smell or taste. Boiling should not change its appearance. It ought to yield from six to twelve per cent, of cream by volume. This is hastened by adding water, and the cream should rise in from four to six hours. Its specific gravity varies from 1.026 to 1.035. Some authorities give from 1.028 to 1.032, and say that if it falls below 1.026 it indicates that the milk is poor, or that water has been added. The specific gravity is therefore a most important test of the quality of milk. But it must be remembered that a large quantity of cream will lower the specific gravity, which rises again when the cream is removed. Dr. Parkes says, " The average specific gravity of un- skimmed rnilk may be taken as at 1.030 at 60° Fahr., and the range is nearly 4° above and below the mean." In the adulteration of milk, water is most commonly used, and as I have just said, is to be detected by the specific gravity. Iodine detects the presence of starch, which, like gum and dex- trin, are added to give thickness. Annatto or turmeric is added for the sake of color. Chalk is added to give thickness and color, and to destroy acidity. Cream is adulterated with mag- nesia and arrowroot. Yolk of eggs is added both to cream and milk. When milk is boiled to preserve it, it may take up from the vessels that are used, lead, copper, or zinc. When examined by the microscope, milk is seen to consist of a number of round spherical bodies with dark margins floating in a trans2:)arent fluid. When the milk is fresh and healthy, the glob- ules are fairly uniform in size, they roll freely over each other, and do not collect together in masses. If they do become min- gled, and granular bodies of difterent sizes are seen, whilst a few globular bodies preserve their distinct isolation, it cannot be called good milk. Such a specimen of milk, known as colostrum, is found in the human female after parturition, and if it does not disappear on the fifth or sixth day, the milk must be considered unhealthy and unfit for the child. Of course we may find in it, MILK DIET AND HYGIENE. 29 pus, blood, epithelium in large amount, casts of lacteal tubes, eeeds, fungi, etc. The number of the globules determines the quality of the milk, and thev are more numerous in cow's than in human milk. The analysis of chemists differs so widely that in a work of this description it would be beyond the mark to give the results of their examination. The practical outcome of their investigations is enough for our purpose. It is beyond dispute that cow's milk is richer than human, and it must therefore be diluted in order to make it resemble the latter. Further, it contains less sugar, and accordingly a small amount should be added to make up for its deficient sweetness. When the milk is acid it presents just the same appearance as it does when treated with acetic acid, which causes the casein to coao;ulate. Seeing that the high price of ordinary pure milk may in time place it beyond the reach of the poorer classes, it is important to inquire whether some of the forms of "condensed milk" lately introduced may not be equally nutritious, and the milk be unaltered in its qualities, when deprived of the water it contains. These results have been accomplished hj Mr. Gail Borden, of ISTew York. He has invented a process for converting milk into a solid, which can be kept pure for a long period, and then by the addition of water be brought back again to its original flavor and consistency. About three-fourths of the water are removed, so that the milk is in a semi-liquid state, of the consistency of honey. Mr. Borden believes that neither "desiccated," powdered, nor "solidified" milk can be preserved for any length of time. They require hot ■ water to dissolve them, w- hilst the condensed milk prepared by Mr. Borden will dissolve at once in cold water. The condensed milk now known to the public has undergone no change except the removal of the water and the addition of sugar. One pound of the " condensed milk " is equivalent to three or four of the crude milk. It is roughly estimated that about eight million five hundred thousand pounds are manufactured annually in the eight or ten factories in the United States, or five hundred cases of four dozen one-pound cans daily. The Anglo-Swiss Condensed Milk Companj^ carried on in the commune of Cham, is conducted under the Borden process. It was the first to introduce condensed milk for family consumption, and 30 DISEASES OF CHILDREN. it has been followed by the Irisli Condensed Milk Company, at Mallow, near Cork, and the English Condensed Milk Company, at Aylesbury. The demand is already so great that neither company can meet it. According to Mr. Willard, "Dirty milk, milk foul with the drippings of the stable, cannot be condensed into a clean flavored product." To be so prepared it must be uniformly good. He pro- ceeds to make some interesting' observations on the causes that change milk into an unhealthy condition, and alludes to the well- known researches of Hallier and Pasteur, who consider that this change is brought about by the presence of living organisms in the atmosphere of germs from cesspools and putrid animal matter, that are absorbed by the milk, in which they grow and multiply. He alludes to the fungi theory, and quotes the words of Professor Caldwell on the deleterious eftects the microccocus, the cryptococ- cus, and the penicillium exert on milk, which is peculiarly suscepti- ble to emanations from decomposing and putrid matter. He points out that the germs floating about in the atmosphere, if inhaled by the cows, will infect the milk before it leaves the udder. He cites the statement of Mr. Foster, of Oneida, that cows inhaling emana- tions from putrid, decaying matter, yield milk unfit for making cheese. He mentions instances of the milk being tainted from cows passing through sloughs of decomposing vegetable matter. Particles of dirt adhering to the udder, and finally falling into the milk during milking, introduce germs which cause it to decom- pose and putrefy.* Perhaps the most important point is that no- ticed by Professor Low, of Cornell University. He observed in the hot weather a peculiar ropy appearance in the cream which had risen on the milk. Under a powerful microscope it was found to be filled with living organisms, and he traced this condition to the cows having slaked their thirst from a stagnant pool for lack of clear running water. This water was examined microscopi- cally, and found to contain the same class of organisms. The blood of the cows also yielded the same results. He then obtained a specimen of pure and good milk, and j)ut into it a drop of water from the stagnant pool, and in a short time an indefinite number * " Infusoria are sometimes found in milk, and fungi (oidiura lactis and penicillium) are so almost invariably if the milk has been kept." — Dr. Parke's Practical Hygiene, p. 244, 4th edition. For some most important observations on the changes in sour milk, see Professor Lister's Introductory Address, delivered at King's College, October, 1877. MILK DIET AND HYGIENE. 31 of these tiuy organisms became developed in the milk. The cows were hot and feverish, as indicated by the thermometer. These observations are highly interesting at the present time, when poi- soned milk has recently introduced severe epidemics of typhoid. The exact way in which this impurity of milk mentioned by Professor Low was brought about does not materially affect the question at issue. Whether it depends on M. Pasteur's vital or germ theory of fermentation, or on the physical theory which supports the view that communicable diseases are owing to or- ganic poisons neither independently reproductive nor indestructible, is of no moment. Whether the atmosphere contains living germs that induce putrefaction, or particles of dead organic matter which incite putrefaction, does not lessen the danger that milk consumers are exposed to.^ Few questions can be of more vital importance to the community at large, than that which estab- lishes the fact of the milk of the cows being rendered poisonous or injurious through the water they drink, or the food they eat. Very little difference appears to exist between the composition of the condensed milk of the English Company and that of the Anglo-Swiss Company. There is indeed a great resemblance be- tween them in every respect. Constituents of Condensed Milk. Water, .... Butter, .... Casein (including albumen), Sugar of milk, Cane sugar, Mineral matter, English Anglo-Swiss Company. Company. 26.1 to 29.0 25.3 to 27.1 9.2 to 19.7 9.1 to 10.4 11.4 to 12.8 10.9 to 13.0 13.1 to 14.3 14.0 to 14.7 35.3 to 38.1 361 to 39.0 2.1 to 2.4 2.0 to 2 4 Mr. Bartlett, in his paper on " Condensed Milk,"t from which I have borrowed this analysis, says that all the samples of con- densed milk are remarkable for their freshness, and that although some were open for a fortnight in damp and warm weather, no trace of milk fungus could be detected. The best dairy milk, ex- * See the Journal of the Koyal Agricultural Society of England, 1872, vol. xv, p.. 103, from which many of the foregoing observations are gathered. The American Milk Condensing Factories and Condensed Milk Manufactories, by X. A. Willard^ A.M., of Herkimer, New York. t Journal of Public Health, October 15th, 1873, p. 187. 32 DISEASES OF CHILDREN. posed for twelve or fifteen hours, became filled with myriads ot elongated bodies of fungus spores, from which the condensed milk is preserved, doubtless by the moderate but sufficient heat incident upon condensing. To sum up, — the chances of lactic acid fermentation are reduced in condensed milk, and this milk replaces human mother's milk better than that of the ordinary stall-fed cows of large towns, which is often, in addition to its natural unfitness for infant's food, weakened by admixture with water, and rendered unwholesome by adulteration. Several instances have been brought under my immediate observation. Some patients tell me that their children never throve until they gave them Swiss milk, and the same testimony is repeatedly given by hospital out-patients. Under its use the secretions are kept regular and in good order ; the unhealthy, slimy, and dark ofi:en- sive motions of 3'oung children are not nearly so common. I can- not say that there is anj^ real difterence in the nutritive or digestive properties of Aylesbury over Swiss milk, but the latter is consid- ered by some medical men to salt better than the former, and so far as mj' observations go, Swiss milk is the most widel}- known. Swiss milk contains rather less casein and rather more sugar, which may make it more digestible, and likely to keep longer. The great advantages of these condensed forms of milk are that they undergo few changes, and are unvarying in their qualities. They are par- ticularly adapted, too, for hot weather, when cow's milk readily undergoes putrefactive change, and causes sickness and diarrhoea. Cases are to be met with, however, in which cow's milk suits best, and after children have passed the age of three months they do not tbrive on the condensed forms of milk. This is partly to be explained on the ground that wben cow's milk is employed we dilute it with water, and add sugar for the first two or three months, but we gradually withdraw the sugar and give the milk undiluted. ^lan}^ families are in the habit of receiving their milk in deep jugs with narrow tops, and keeping it in small aud confined larders, where it is liable to be impregnated with the efiluvia of game, fish, etc. This odor has not the same chance of escape as when the milk is poured into shallow, broad vessels, where it can be kept -cooler with a large evaporating surface. Milk is an organic fluid quickly liable to putrefaction and fer- MILK DIET AND HYGIENE. 33 mentation, and to become tainted and undergo change of taste and odor when left in the vicinity of cheese, tainted meat, and some kinds of fruit. Poisons are conveyed through the medium of the atmosphere, or through water, and it is no longer a disputed ques- tion that milk may also be a disseminator of disease. It can ab- sorb deleterious effluvia, under the circumstances just alluded to, and become unfit for human consumption. When we remember how quickly, in hot weather, milk undergoes putrefaction and fer- mentation, losing its sweetness, and becoming rancid in the course of a few hours, we have the clearest proof that organic poisons may readily become absorbed by it Either by air or by water the poison of zymotic diseases is conveyed, and those persons engaged in milking, who have recently attended on the sick, may even propagate the disease by their hands or by their clothes. Our experience of the milk epidemic of typhoid fever, in 1873, opens our eyes still further on another point. The poison of cholera finding its way into w^ater, may be spread through milk in the same manner as typhoid ; and the atmosphere becoming con- taminated with the poison of scarlet fever and measles, may be absorbed by the milk. In short, it is not within the scope of imagi- nation to realize the manner or rapidity, with which the effluvia of contagious diseases may travel, charging the atmosphere with poison, and spreading death and desolation amidst the healthiest districts. The milk of diseased cows decomposes quickly, and instead of the round oil-globules, which are the only constituents of healthy milk, colostrum with granular masses, and a large amount of epithelium, are to be seen under the microscope. Casts of the lacteal tubes may also be sometimes detected. It must appear self-evident that few points can be of greater practical importance than to ascertain the chemical and microscopical characters of milk in all cases where sick children are living chiefly on it. I now come to consider, and that very briefly, what are the dis- eases in which milk is especially indicated as a medicine. As a diet we recognize its value, and assign to it the first position among all kinds of food. To bring up children healthy and strong milk in some one of the forms I have alluded to must be provided liberally. Constitutional weakness in children is greatly devel- oped by scanty and impure milk; hence we have great mortality before the age of one year is reached. In some of our large manu- 3 34 DISEASES OF CHTLDREX. facturing towns, as Manchester, Liverpool, Glasgow, etc., the mortality of infant life is appalling. The Registrar-General's return for the year 1871, shows that of 112,535 children born within the year, 19,301 died before they reached the age of one year. Regarding infant mortality, Dr. Carpenter, of Croydon, says that " ninety per cent, of the children which are put out to drj'^-nurse by wet-nurses, die after a few weeks of hand-feeding. This mor- tality is induced by the administration of imjDroper food. It is shown by the Registrar-General's statistics that more than 20,000 children, under one year of age, die in England every year from convulsions ; that is, one out of every 34 dies within the year, Tvhilst in Scotland one only in 370 dies from such a cause. The great difference between English and Scotch feeding among the poor is the cause of this variation ; the northern babies are not stuffed with farinaceous food before they are able to digest it ; Scotch mothers scarcely ever feed their babies with anything else than that provided by themselves in the first few months of their lives, and the result is, that convulsions as a cause of death, are comparatively rare in the first year."* We know that in some children, and even in adults, the diges- tive functions are so enfeebled that milk cannot be assimilated. The occasional aversion to milk is also well known, and the dislike to it cannot be overcome. I saw one child, six months old, who ■could digest about half a pint of milk daily, but if this quantity was increased severe sickness followed, and the attempt to give more with lime-Avater or plain water, or Dinneford's solution of magnesia, was of no avail. It w^as impossible to give it in any large quantity, and the diet was supplemented by veal broth, chicken broth, or weak beef tea. In some adults, severe discomfort, w-eight and indigestion, follow from the continued employment of milk, and it cannot be denied that ordinary cow's milk does tax or interfere with the digestive power in some cases if taken in any ■considerable quantity long together. It causes weight and heavi- ness and in some cases constipation, and where this is so, aversion or dislike is certain to ensue. Brandy, soda-water, lime-water, dill- water, etc., have been emplo^^ed to overcome this objection, and in a great many instances the addition has been successful, and the coagulation or curding in the stomach has been prevented. * Some of the Causes which produce Infant Mortality and Constitutional Weak- ness, by Alfred Carpenter, M.D., Public Health Journal, June, 1873. MILK DIET AND HYGIENE. 35 In all those diseases that are of a consumptive or wasting character, and where emaciation is going on, milk is extremely valuable, suitable to the digestive organs, containing all desirable elements for the repair of the body, and best compensating for its waste. In cases of extreme debility and marasmus, chronic dyspepsia, carcinoma and ulceration of the stomach, gastrodynia, etc., milk is our sheet anchor ; solid food cannot be tolerated by the digestive organs, and if we had not a remedy like milk, our patients would literally die of starvation. I can call to mind one severe case of gastric pain (neuralgia of the stomach) in which milk was the only food taken for upwards of four 3'ears ; nothing but a rigid adherence to this simple diet procured the patient ease, and gave him rest at night, instead of the agonizing suffering which he had endured for years. This patient had long ridiculed the idea of living on milk ; indeed, it is only in confirmed states of ill health that patients can be brought to understand that milk is possessed of extremely nutritive qualities, and is sufficient to maintain life. As life advances, and more especially towards its decline, when the tissues are undergoing degeneration, and the eliminating func- tions are becoming impaired (as in structural degeneration of the kidney), milk may temporarily arrest or lessen the activity of these changes and prolong existence. The skim-milk treatment of diabetes is fresh in our recollection, and whatever doubt may be thrown on its virtues as a therapeutic agent, there can be none as regards its nutritive and non-irritating properties. In acute diseases of the febrile class, and nervous diseases gene- rally, milk is a powerful restorative. In the diarrhoea of enteric fever and some other profuse discharges, heemorrhages and loss of blood, and great lactation, we have in milk a valuable remed}^ By increasing the general nutrition it has the effect of diminish- ing the discharges from the mucous surfaces. Among children of well-to-do parents, and in the higher ranks of life, I have repeatedly seen the advantage of giving them a good supply of milk morning and evening, before going to bed and on getting up. The appetite has improved, and each meal has been relished and digested through" the milk, which has acted like a tonic. These facts are, however, known to all of us, and similar instances occur in our practice every day. This brings me to say that milk is constantly underrated by 36 DISEASES OF CHILDREN. parents and mothers, and credit is given to certain patented "corn-flours" to which they are not entitled. We may lay it down as a golden rule that unless food is easy of digestion it fails to be nutritive. Many of the forms of food advertised for chil- dren are said to contain a large percentage of earthy phosphates, and to be singularly rich in nitrogenous or plastic materials. They may be of service where milk is also freely supplied, but without it they are of questionable value, as they contain a large proportion of starch, which young infants are incapable of digesting. The salivarj'- and pancreatic glands do not reach their functional development until the infant has attained the age of eight or nine months ; and as starch requires to be acted upon by their secretions before it becomes converted into a soluble sugar, it follows that all farinaceous foods are incapable of digestion, and therefore worse than useless before that age is reached. The true function of the saliva is to convert starch into glucose or sugar, and unless it is so acted on by the salivary or pancreatic secre- tions, it either passes through the bowels unchanged or undergoes lactic acid fermentation, producing flatulence and spasm by the quantities of intestinal gases which are generated as a consequence.* Experiments have been conducted to prove that the saliva of an infant four or five months old has no action on insufliciently cooked arrowroot, sago, tapioca, and the so-termed "corn-flours," but the salivary secretion of an adult has considerable trans- forming power. Still chemists are of opinion that they are not suitable for any age.f In very young children milk is the only nourishment required, so nicely adjusted are its component parts, but until we can con- * Some Experiments on the Digestibility of Starch by Infants, Journal of Public Health, August, 1872, p. 111. t See Chap. XIV, On Indigestion. It is important to allude to this fact of salivary secretion in infantile life, "For the first few months it appears that no saliva at all is secreted ; and it is true under natural circumstances, from the character of the food, and the absence of masticatory organs, that it is not required."^Pavy, On Food and Dietetics, 1875, p. 527. "Tlie digestion of starch is accomplished by the saliva and pancreatic juice, both of which are rich in diastase. Diastase also exists abundantly in the liver, and in smaller quantities in the intestinal -juice, in the blood, the urine, and apparently in all the intestinal juices. Diastase from all these diverse sources appears to act substan- tially in the same manner on starch, changing it by a progressive hydrolysis into sugar and dextrin." — L/iimleian Lectures on the Digestive Ferments, by W. Boberts, M.D., F.R.S., April, 1880. MILK DIET AND HYGIENE. 37 vince mothers and nurses that a child can grow and thrive on it, we must expect the substitution or admixture of other foods. Sometimes we are told the milk does not agree, and on inquiry we find that either the nurse or the mother, if suckling, is out of health, and the milk as a consequence is defective and ill-suited to nourish and sustain the child.* Every mother should know the importance of weaning her child at seven or eight months, because suckling beyond this time is likely to damage the health of both. If the mother can nurse her child so much the better. If deli- cate she should not suckle during the night, as it will disturb her rest and exhaust her. When, however, the mother's milk is scanty, she should not attempt to nourish the child entirely, but give warm milk and water out of a bottle. If she cannot suckle it, it should have equal parts of milk and water, and it is a good plan to boil it before putting it into the bottle. Let it be sweet- ened with half a teaspoonful of sugar, and see that the tube and bottle are well rinsed out, and kept perfectly clean. It is a bad plan to overfeed a child at one time ; the sixth part of a pint of milk is enough for a meal, if the child is under a month old. If the milk disagrees, a tablespoonful of lime-water, or sometimes the same quantity of dill-water, may be advantageously added to each bottleful. Regular feeding is of great importance ; till the child is two months old, once in two hours will be often enough, and afterwards once in three hours ; of course if the child is very delicate, it may require to be fed oftener, but it is an error to put it to the breast every time it cries. * Much of the milk brought from the country is impure. Many children perish the first year of their existence from failure of the digestive organs to support them, and when brought up by hand or underfed they are prone to die of bronchitis, diar- rhoea, whooping-cough, etc. As to farinaceous diet, much may be urged for and against it; it may cause cliildren to look plump and fat, but if too long continued the blood becomes thin and anajmic, and exhaustion, and even fatal syncope, are not unfrequently met witli in these children. At the present day, however, farinaceous foods, as corn-flours, arrowroot, etc., are underrated, if not altogether condemned, by many persons as unfit for nutrition. Liebig and some other chemists advocate this view, which led to the employment of too nitro- genous a diet, and so an opposite error crept in. Facts must speak for themselves, and it cannot be denied that we see some yoitng children whose flesh-forming power ap- pears to be due to the nutrition of starchy food. Abundant instances of the kind are to be met with among the rural population of England. It is a point deserving con- sideration wliether a too exclusively animal diet may not sow the seeds in early life of a uric acid diathesis, and develop gout and Briglit's disease with advancing years. 38 DISEASES OF CHILDREN. In treating the ailments of suckling children, we ought to ex- amine the milk of a wet-nurse very closely, for any error in diet on her part, or any indiscretion in drinking, will be certain to be felt by the child she is bringing up ; mere emotion, anger, or dis- appointment will influence the lacteal secretion. Attacks of cramp, spasm, flatulence, emaciation, and diarrhoea in young chil- dren can constantly be traced to dj'spepsia brought on by the milk, or the mental condition of the nurse, and all the medicines we may prescribe will prove but palliatives so long as this state of things is suffered to go on. In selecting a wet-nurse it is very important that she should be in good health and spirits, and free from con- stitutional taint. She should be fully grown, and as a rule, not less than twenty-two years of age. Leucorrhoea is an objection, and any evidences of strumous disease, as scars in the neck; then the most rigid inquiry should be instituted as to whether she be free even from the suspicion of syphilitic disease. The evidence of syphilis is somewhat difficult to find in the absence of any active manifestations, but it is always well to search for maculfe and ul- ceration about the fauces. A few cases in illustration of these remarks may be here quoted. Case 1. — A lady consulted me in February, 1868, about her infant which Avas five months old. It was not thriving to her satisfaction, the skin and muscles being lax and flabby, the bowels frequently relaxed, and the motions sometimes consisting almost wholly of mucus, with an occasional streak of blood. There was also a good deal of redness and excoriation around the anus {Intertrigo). The nur.-e who suckled the child seemed a fairly healthy woman, but a microscopic examination at once showed that the milk was very deficient in the number of oil-globules, and therefore unfit for the purposes of nutrition. I recommended asses' milk to be given alone, as digestion was weak and cows' milk did not agree. The child gradually improved from that time, the bowels becoming regular and the motions healthy.* Case 2. — An infant, seven months old, was subject to occasional * The milk of the ass often suits witli the delicate digestion of an adult; it is richer in sugar and soluble salts, and contains less nitrogenous matter and fat than cow's milk. Though it is therefore adapted in particular cases to some infants from the facility with which it is digested, its composition is not rich enough for a strong and thriving child. For further information on this point see Dr. Pavy, On Food and Dietetics, 2d edition, 1875, pp. 185-529. MILK DIET AND HYGIENE. 39 attacks of vomiting, cramp, and flatulence. The motions were never two days alike, sometimes being hard and pebbly and light- colored, at other times loose and frequent. The child was always uneasy after food, unless an attack of diarrhoea or vomit- ing came on, when it usually became quiet or fell asleep. The child was fed on cow's milk, sweetened and diluted with water, and biscuits were generally added. It is quite clear that this method of feeding did not agree with it, indigestion being a marked feature of the child's sufferings. It was found that the milk was not good, and in addition to the biscuits which disa- greed, and increased the amount of flatulence, the child was fed at irregular hours, and the stomach loaded. New and good milk was now procured, and a small quantity of dill-water was added, all biscuit food and farinaceous articles being solemnly forbidden. The child almost immediately began to improve, and at the end of two months had grown plump and strong without a sign of discomfort. Case 3. — A lady requested me, in April, 1868, to visit her child, who was then six months old. The child was fat and plump, and always inclined for food, which he took greedily. When he was not eating he fell asleep. The only complaint made was that the bowels were habitually confined, and that in consequence, aperient medicines had to be constantly resorted to. The motions were very hard and pale, the child often crying when straining to empty his bowels. It was evident to me that the child was overfed, and I persuaded with some difliculty that he should be restricted to milk-and-water. In the shape of medicine nothing was ordered except a two-ounce enema of soap and water to be thrown into the bowel early every morning, and pressure to be applied at the anal aperture, that it might be retained a little time. ' This was enough to act as a gentle stimulus to the liver, and to regulate the bowels, without any other mode of treatment. Here was a child of sound and vigorous constitution, that would have thriven. on that upon which another child would have starved, and when this simple regulation of diet was enforced, no further remedies were required. Instances of this kind are repeatedly met with where constipa- tion is the chief symptom. The child's bowels act once in two or three days, whilst the appetite is good, and the condition is in every other respect healthy. The motions are deficient in moist-- 40 DISEASES OF CHILDREN. lire, and painful to pass tbroiigli the anus, which becomes red and tender. The little suflf'erer screams in its straining efforts to evac- uate the impacted mass. This nursery trouble may set in soon after birth, and add to the risk of teething. The liver in these cases does not act well, and the small intestines fail to furnish their due amount of secretion, and the rest of the intestinal tube becomes sluggishlj- passive in propelling its contents. Overfeed- ing causes this troublesome constipation as often as underfeeding induces diarrhoea and exhaustion. But the cause is not always ascertainable. In some cases I have been inclined to regard it as constitutional. It occurs occasionally where the mother's milk is healthy, and microscopically faultless. The mother may be weak and languid, notwithstanding the good character of her milk, and if her health is not attended to the milk will become impoverished, and the child suffer in other ways. -Mere constipation in the child is no evidence that the milk is at fault, but when given too frequently and abundantly it de- ranges the hepatic functions. In these cases of otherwise healthy children a saline aperient given at bedtime, and repeated early in the morning is a good remedy.* After a few doses the bowels begin to act more regularly, and the motions become soft. In alternation with the mixture the soap enema is an excellent rem- edy. As the nurse sits with the child in her lap before a fire, friction with the hand for a short time, morning and evening, over the abdomen acts as a capital stimulant to sluggish bowels. We now and then meet with another class of cases in which the mo- tions are moist and of proper color, but considerably larger and firmer in consistence than we expect to find in infants of five or six months old. The bowels will not act without an enema or an aperient of some kind, and parents become alarmed if this goes on, as it often will in spite of any treatment, till dentition sets in. When there is no mechanical obstacle, as hernia, imperforate rec- * Formula 1 : R. Magnes. sulph., .^j Tinct. rliei, 5s-<. Vel syr. rliei, . . . . . . . . . ,^ss. Vel syr. zingib., Si.j Tinct. cinnam. comp., .o.j Aquam anethi ad, Si.j. — M. One to two teaspoonfuls to be taken at bedtime and in the early morning, I'or a child five or six months old. MILK DIET AND HYGIEXE. 41 turn, or invagination, the fault may in most instances be attributed to the food. If the general health of the child should keep good, no harm will follow from this form of constipation. The aperient must be varied from time to time, and the enema used in change Avith it. When simple remedies fail, a teaspoonful of the decbct. aloes comp., or a grain or two of scammony or jalap, or even an occasional mercurial will rouse the torpid liver and inactive vis- cera, and promote the passage of bile and mucus. It sometimes happens that immediately a tooth penetrates the gum the symp- toms improve and the constipation departs. In other cases the constipation is troublesome, and an enema has to be given every third or fourth day till the child can run about and take exercise. Milk mixed with bread, as children grow older, is very excel- lent. For my own part, I have much faith in the familiar expres- sion, "Bread is the statf of life;" and if we want to know its nourishing properties we have only to look at our village popula- tion. Many healthy chiklreu from the age of three months thrive on this diet, and grow up strong and healthy. Scotch oatmeal is another valuable article of diet ; it is very nutritious, and regu- lates the action of the bowels better than an3'thing else with which I am acquainted. It should be mixed with milk, and may be given to children from the age of one year. Of course, differences of situation necessitate differences of treat- ment, and children of delicate parents, living in a vitiated atmos- phere require a special diet. At seven months old the child may have milk, to which Eobb's biscuits or Liebig's food may be added, or well-baked bread. The child should have plenty of warm milk in addition. At ten months old it should have weak broth or beef tea. When a year and a half old it may have pounded meat, with a little gravy, or meat cut up very line. Much will depend upon the natural strength and constitution of the child ; but solid animal food should not be given till it is two years old. Hospital patients have repeatedly told me that milk alone would not satisfy the hunger of their children, and before bottles came into fashion I have often seen strong and health}' children, at four or live months old, being fed with milk thickened with bread; whereas, among the verj^ poor in rural districts, gruel has in many instances been the only article of diet. A delicate child would break down under this system of feeding, but in those who are thriving and breathing pure air it has no prejudicial effects. Whether the 42 DISEASES OF CHILDREN. child be strong or delicate, milk should be the chief article of diet till the age of two years; and the continuance of debility should be an indication to persevere with the milk pure and alone. It is a popular error among mothers that milk must soon give place to solid food, and yet those whose practice lies among children wnll often observe a child at eight or nine years of age, with a good appetite, eating meat three times a day, grow thin, pallid, and languid. These children have delicate digestions, the tongue is indented at the sides, the back coated with a whitish fur, and there are superficial abrasions of the mucous membrane, all indi- cating extreme feebleness of digestive power, amounting to slow starvation.* Place such a child on a diet of milk and he begins to thrive at once; his tongue gradually improves, his bowels are regular, and he gains flesh and strength with surprising rapidity. If you can induce the parents of such a child to give him a basin- ful of milk-and-bread for breakfast instead of tea, and let him have well-minced mutton or chicken once a day, and cod-liver oil, he will throw ofi' his delicacy, and the rest will have enabled his digestive organs to gain strength. When children have cut their incisor teeth they are liable to feverish discomfort and restlessness; they alarm the nurse and the mother by starting in sleep and exhibiting a spasmodic movement of the lips and eyelids. If we examine the mouth in such cases we shall generally observe that the gums are red and tender, and although other teeth are not appearing nor distending the gum, they are probably at no great distance. It is always well to punc- ture this inflamed gum with a lancet, and to give a freely acting purge. If the child is strong enough, let it contain a grain of calomel, for, much abused as this drug is, and told as we are on evidence that seems conclusive, that it does not increase the secre- tion of bile, I know not where to find any purgative or alterative medicine that acts so efliciently in many of the diseases of early life. Let it be given on an empty stomach, and do not deny the child if old enough, a drink of cold water, or of toast-and-water. This is, however, at best a critical period with children, requiring much care and watchfulness on onr part. The nervous system is easily affected, and the digestive functions are readily upset, which would be less likely later on. The extreme frequency of convul- * See Cliap. XVI, On Indigestion. MILK DIET AND HYGIENE. 43 sions in early life should always be borne in mind whenever the system is out of order, and the medical attendant should never lose sight of the liability to them in young children, however well a case of illness maj^ be progressing. The balance between health and disease is so delicately adjusted in early life, that a very slight disturbing cause will incline it to one side or the other. Health and disease hold close relationship, and we are often perplexed to know where one ends and the other begins. Where medicines are necessary, it is very important that they should be prescribed in as agreeable a form as possible, A medical man will often get much credit by ordering his medicines pleasant to the taste; and there are very few drugs really neces- sary for children which cannot be given in a pleasant form. Some practitioners there are, however, who seem never to have con- sidered this matter, and as a consequence, many of their medi- cines are thrown aside by the mother or the nurse, who, ralher than hear the shrieks of the child, gives up the effort to adminis- ter them. I think a certain degree of tact and judgment is required in prescribing for young children. The habit of giving j'oung children wine and beer is a verj'' bad one; their digestive organs require no stimulants to aid the pro- cess of digestion, as is the case in after-life, when the stomach loses its tone and becomes enfeebled, and where a glass of wine is necessary before the patient can either fanc}^ or digest his food. Some of the strongest and healthiest children I have ever seen have been those whose diet has been the plainest, and where stimulants, cheese, and pastry have been ranked with objectionable nursery drugs, as gray powder, cordial mixtures, and teething powders. In illness, and especially in acute disease, where time is valuable, stimulants may be demanded ; and in my own experience, I have several times known young children recover from acute diseases in consequence of their administration. The following is a typi- cal case: Case 4. — A healthy child, ten weeks old, was sutiering from troublesome catarrh, in February, 1870. Tbe child was restless and could not suck comfortably, owing to the obstructed state of the nostrils. Bronchitis, confined to the upper tubes, ensued, and alarming prostration set in. The cough was very harassing from the accumulation of phlegm, and there was great flatulence and irregularity of the bowels. The mother, at my request, reluctantly 44 DISEASES OF CHILDREN. consented to give up suckling. The child was fed on ass's milk, of which he took two pints in the twenty-four hours, mixed with four small teaspoonfuls of brandy. He was also fed with a little beef tea three or four times a day, with a few drops of brandy. This last soon appeared to irritate the bowels, and was, therefore, discontinued. In the shape of medicine, he took half a grain of carbonate of ammonia in s^-rup of tolu and water every four hours. The temperature of the room was kept at 70°, and, what I have found of great value in the pulmonary affections of young children, the chest was covered, back and front, with cotton-wool ; and this was allowed to remain on during the critical state of the child's illness. Bej'ond attention to cleanliness, the child's clothes were not removed during the illness. This is a great point to look to in dangerous disease. The fatigue and exhaustion that result from frequently dressing and undressing a young child are not considered, and the repose and rest, which are valuable aids to treatment, are altogether overlooked. The temperature ran as high as in genuine fever, but on administering suitable food and medicine it fell, and the child rapidly improved. I have known this high temperature cause much alarm among medical men ; but it must not deceive us, especialh" with children, who, from mere gastric disturbance, will, in the course of a few hours, become burning hot. There is nothing more important than air and exercise for chil- dren * When shut up in the house they become fractious and irritable, losing their color and appetite, and becoming very way- ward and difficult to manage. The natural disposition of a child maj^ be greatl}^ determined by being habitually shut up in a room, and deprived of proper air and exercise. In the house it soon tires of its amusements, but when carried in the open air fresh objects continually meet its eye and engage its attention ; digestion is im- proved and healthy sleep promoted. Children who live in London and other large cities exhibit in a most remarkable degree the salutary effects of country air, and, when they have been kept from * "Life and health walk hand in hand. Health is nothing but integrity of life; disejise is nothing but an offence and abbreviation of it. Gymnastic exercises will not under all circumstances be successful, but, eceteris paribus, it will be in creating fine men Exercise, whether pleasing or not pleasing, is equally advantageous. The same degree of perspiration, the same muscular action, is produced; the same results of sound repose, strength, and health necessarily follow." — Physical Education, Mac- niillan, pp. 3-17 and 303, Se])teraber, 1873, No. 165, MILK DIET AND HYGIENE. 45 falling into ill health b}^ the tenderest and most judicious care, they revive under the influence of change with a rapidity that is trul}^ astonishing. In densely populated places foul and impure gases are breathed into the system, and carried into the blood, which only the pure oxj'gen of the country can remove. If eating a heavy meal on going to bed, or indulging in tea and coffee after a good dinner, tend in some adults to cause sleepless- ness, melancholy dreams, throbbing headache, and cardiac pulsa- tion, sending children to bed exhausted and with empty stomachs will also equally cause discomfort. Such children dream, and are restless in their uneasy sleep ; they toss the clothes off, and are peevish and tired when they are roused to dress and get up in the morning. If jaded by long walks and the strain of school, inter- rupted digestion is indicated by fatigue, and they are sent to bed too exhausted to obtain refreshing sleep. Children should have a light meal half an hour before retiring to bed ; a sandwich or a slice of bread and butter will in most cases suffice to satisfy the craving stomach and allay the fainting empty feel. If food, how- ever nutritious, is given them at this time, when they are too ex- hausted, and the nervous force which should have been reserved for the stomach has been expended in active locomotion, we only aggravate the evil. The feeble stomach as much resents the pres- ence of food as the weak eye resents the light. Let us bear in mind that a child requires more sleep than a grown-up person, because tissue change is much more energetic, and the organs de- mand more rest for their repair and growth. The digestive system, too, requires the frequent administration of suitable food, that the absorbent process, with its varied chemical changes, may be actively carried on. Cold-bathing is another aid to health, and the sooner this is be- gun the better. It is the foundation of much subsequent good health. With a good circulation there is nothing more calculated to keep the skin in a healthy state ; for on it depends to a very great extent the regularity of every function in the child. When early practiced, children will grow up to revel in the luxury of cold water, coming out of it with a skin at first mottled like the slate-gray lines that permeate hard soap ; and subsequently under friction, gradually becoming red, as the blood passes more quickly through the capillaries. The tonicity of these vessels is increased, and that relaxation and debility which render them helpless to 46 DISEASES OF CHILDEEX. contract on exposure, is in a great measure guarded against. AVhen the latter condition exists, children are very liable to cold and affections of the respiratory organs. A cool, elastic, and firm skin is an indication of health, and often by it alone the medical attendant is able to decide on the state of his little patient. Daily intercourse with disease can alone teach us bow to pre- scribe. Aperient medicines should be delayed as long as possible, but if they must be resorted to they should be of the simplest kind ; and whenever I can, I always endeavor to avoid bulky pow- ders. Frequently they are not properly mixed, and as often they are not swallowed, and so we are disappointed in our cases. The aromatic syrup of senna is not difficult to administer, and the syrup of rhubarb is enough to move the bowels of young chil- dren, regularly and efficiently, if continued a little time, and there be no necessity for promptitude in our measures. Honey or treacle spread on bread is a favorite laxative with some persons. The syrup of roses maj^ be given with an equal quantity of castor oil, and there are few children who will not take it. Infants of a few weeks or months old will suck readily a teaspoonful of a mixture made with castor oil, white sugar, and carbonate of magnesia, with two minims of oil of dill to the ounce (Form. 23). It is a good combination where there is costiveness and painful flatulence. Diuneford's solution of magnesia is a safe and useful antacid and aperient for young children, dispelling flat- ulence, and gently stimulating the peristaltic action of the bowels. An equal quantity of syrup of rhubarb may sometimes be advan- tageouslj^ combined with it. In feverish states, with constipation, young children will take a mixture containing a grain or two of nitrate of potash with a few grains of sulphate of magnesia, when s-weetened (Form. 8). In hot and excited states of the system we may order with most excellent eflect, a purgative and alterative lozenge composed of one grain of calomel and two grains each of scammony and jalap. It is well to order it to be given the last thing at night, as it then empties the bowels fully and eflect ually early in the morning. It causes copious and full evacuations, freely unloading the liver and small intestines ; and in cases of feverish excitement, it has acted in my hands like a charm* How frequently do we see the ill eflects of aperient medicines, * See Chap. XVII, On Constipation, where this Bubject is more fully considered. MILK DIET AND HYGIENE. 47 adopted and had recourse to on any accession of real or fancied ailment. If the medicine employed is simply of a laxative char- acter, and the child is in even tolerably fair health, the mere evac- uation of the intestinal contents can do no harm, and the child is none the worse if not the better for the experiment. But many are not satisfied with this mild class of remedies, and thej^ select some cathartic purge which throws the intestines into violent com- motion, unduly stimulating and exciting the mucous follicles, and irritating the whole intestinal tube. The stomach, liver, and pan- creas, are disturbed in their quiet functions, and the furred tongue is a sign of weakness and temporarily deranged stomach, from the unnecessary employment of medicine. Such medicines are enough to enfeeble and suspend digestive power, and to create as much disturbance as a mass of indigestible matter in its passage from the stomach through the bowels. Children are often brought to us, looking pale and languid, with a dark areola under the eyes and a furred tongue. We ascertain, perhaps, that the trustworthy nurse considers them bilious, and gives them gray powder once or twice a week. They have very little appetite; the bowels do not act for want of power ;*'they complain of being tired and are glad to go to bed. These are the cases which run into ansemia ; enlarged glands spring up about the neck, and if there happen to be a strumous taint, we get ab- dominal or pulmonary disease. The syrup of the hypophosphite of iron, with or without quinine, is very valuable, and Parrish's chemical food (Syr. Ferri Phosph. co.) will efiect, in such cases of pure debility, a marked improvement in the health and appear- ance of children. The syrup of the iodide of iron, in cases of anaemia with a disposition to swollen cervical glands, is a well- known but overrated remedy. I am very doubtful if it possesses any real value. We may employ it in many cases of chronic cough and debility, with or without a few drops of ipecacuanha wine; where we have any reason to suspect a tubercular origin we may give it very early. The Vinum Ferri is a slightly astringent prep- aration. We may sometimes prescribe with good effect a steel powder, consisting of one grain of sulphate of iron and three grains of sugar. Children take it with a relish, either in water, sherry, or ginger wine. It is a cheap tonic, and is very available for hos- pital patients. A most excellent preparation is reduced iron (Fer- rum Redactum) ; it is a valuable remedy in ansemia, chorea, and 48 DISEASES OF CHILDREN. general debility. A grain or two may be given on bread-and-but- ter twice or three times a day. It has the advantage of being tasteless, and a very small dose is required. Then there is the iron lozenge (Troch. Ferri lledacti), which no child will refuse to take. Each lozenge contains one grain of reduced iron, mixed with relined sugar and gum acacia ; one may be taken after each meal. It is not advisable, as a rule, to prescribe for children prepa- rations of iron with quinine, as the bitter being objected to, the medicine runs the risk of not being regularly administered. Iron, too, is much more valuable as a tonic than quinine; it is less stimulating, is a good blood restorer, and strengthens and invigo- rates the nervous and circulating systems, on which the regular per- formance of all the bodily functions depends. These forms of iron regulate the bowels by the gentle stimulus they impart to the muscular fibre of the intestines, and the alteration they effect in the constituents of the blood. Dissatisfaction is sometimes felt at the apparent inertness of these agents, but this often arises from their being discontinued too soon, or not given regularly. We labor under great disadvantage in all chronic forms of illness, as the necessity to give medicines according to the rules laid down by the medical attendant does not seem of sufiicient importance, and where cases are tedious and protracted, friends and nurses are apt to grow negligent and indifferent. In acute forms of disease they are more regularly given, and hence they often obtain a credit which is not their due. Antimony is a medicine seldom required in the ailments of young children. It is so depressing that unless the disease is urgent, as in croup, and a few other diseases, we may dispense with it and choose ipecacuanha, which is not so lowering, frequently as effective, and much more manageable. Emetics are often required for infants and young children, who vomit readily, the act being accomplished without the straining and distress which are experienced in adults, because the stomach is not so conical in form as in later life, but is more elongated, and resembles rather a dilatation of the intestines. Emetics should be withheld from children with head aftections; in peritonitis or acute abdominal diseases, or where tliere is great debility ; but in the early stage of many disorders, as in croup, they promote the free action of the skin, and at a later stage favor the expulsion of false MILK DIET AXD HYGIENE. 49 membrane from the trachea. In whooping-cough, pneumonia, bronchitis, and the early stages of the exanthemata, emetics are of great utility in reducing the force and fulness of the pulse, in lowering the tension of the vascular system, and in promoting secretion. The thick and tenacious secretion which clings to the glottis in whooping-cough becomes thinner and more easily detached by their action, w^hilst the hypergemia of the bronchial mucous membrane is lessened. Emetics are serviceable during the invasion of acute tonsillitis; in some forms of acute indigestion and dyspepsia they are also useful by exciting the liver to freer action, and removing morbid secretions from the stomach. An emetic repeated twice or three times a day, followed by a little warm water to insure its complete effect, is preferable to one large dose. Sedatives are remedies not to be recklessly employed in the dis- eases of young children. The sooner ignorant minds are made aware of the dangers they incur in giving these medicines without medical advice, the more chance is there of rearing strong and healthy children. The influence of the profession should be brought to bear upon the indiscriminate sale of soothing or teeth- ing powders, and the public should be cautioned against them. Under the prevalent and frequently erroneous notion that children are suffering from their teeth, a poor woman, to keep her child quiet, or to get a night's rest herself, gives it a teething powder to send it to sleep.* Where there is great excitement of the nervous and vascular systems sedatives are sometimes employed with great advantage, llyoscyamus, hydrocyanic acid, and the compound tincture of camphor are so important to us that we should Hud it difficult to get on without them. Tincture of opium, however, * "In November, 1874, four children died at Komford after taking 'teething powders,' and death was preceded in all of them by stu]ior, drowsiness, and insensi- bility. These dangerous symptoms set in soon after the powders were given, and were clearly due to an overdose of opium. Dover's powder appears to have been the form in which opium was administered." — British Medical Journal, Nov. 14th, 1874, p. 622. "In 1846 I also was distressed to find the use of opiates among children very preva- lent in manufacturing districts. In this case the motive was not criminal, for the practice had arisen in ignorance of its bad effects. But it was not difficult to trace a large amount of direct and indirect mortality to this pernicious custom. Among childi'en the administration of opiates, under the names of quieters and soothers, is nearly as destructive to health as the excessive use of alcoholic stimulants among adults. The craving for both arises from those depressing physical causes of disease which abound in cities." — Dr. Lyon Playfair, On Sanitary Reform, Social Science Congress, Glasgow, Oct. 3d, 1874.^ 4 50 DISEASES OF CHILDRElSr. requires to be given with the utmost caution. In administering tincture of opium by the mouth it is well to observe the rule of giving the sixth or fourth of a drop to an infant under three months, and to repeat it as occasion may require; half a drop for a child of six months, and a full drop for a year, adding a drop for every year of the child's age. I once prescribed six minims in an ounce and a half of demulcent mixture for a child fourteen weeks old, one teaspoonful to be given three times a day. This was enough to make it so sleepy and heavy, that the mother said she could not keep it awake. When roused, it opened its eyes, and then fell off to sleep again. Instead of having six motions during the day, it had three. Fortunately we can often get on without the internal exhibition of laudanum, which is a remedy we regard as certainly dangerous to young children if incautiously given. A child will, however, take a dose of calomel with far greater impunity than an adult, and be infinitely less likely to run any risk from salivation. Bromide of potassium, and hydrate of chloral, are now recognized to be of great value in the treatment of children's diseases. To sum rp these points, it is to be observed that I have laid stress — 1. On the peculiar forms which disease assumes in childhood, as distinguished from the forms of the same disease prevalent in adults ; 2. On the rapidity with which functional sometimes passes into organic mischief, during the period of bodily and mental development ; so that no ailment should be con- sidered too trivial to receive attention ; 3. On the great importance of looking to constitutional symp- toms rather than to local derangements, because the primary disturbance may be of greater moment than the secondary eflects ; 4. On the necessity of looking to diet, and adapting the quality and quantity of the food to the age and natural strength of the child ; 6. On the importance of selecting medicines, when medicine is absolutely demanded, from that class which will sup- port the bodily powers and assist in maintaining each function as nearly as possible at a normal standard. 9 ACUTE AXD CHRONIC DISEASE. 51 It is my object in the following pages to carry out these general principles, and to show how they are to be adapted to particular diseases, and what exceptional treatment each disease seems to warrant. CHAPTER III. ACUTE ASB CHRONIC DISEASE. Importance of distinguishing between acute and chronic disease — Acute diseases brief in their duration — Chronic diseases sloic in their progress — Illustrations of both forms — Collapse — Asphyxia — Hcemorrhage. Treatmext of Acute Disease : To endeavor to prevent its passing into the chronic form — Use of alcohol — Emetics — Purgatives — Inhalations. Treatment of Chronic Disease : To be guided by its duration, and the character of the constitution, whether strumous, syphilitic, or cachectic — Im- portance of rest and fostering physical growth — Country residence — Sea air. Diseases may be advantageously divided into two great classes, the acute and the chronic. Although we recognize a connection between them and an interdependence, there exists, notwithstand- ing, a wide difference. The importance of defining the line of demarcation cannot be over estimated. Between the duration of acute and chronic disease there is another distinction. An acute disease like haemorrhage or cholera may terminate in a few days or hours, whilst a chronic disorder, as asthma or rheumatism, may continue through the greater part of life. An acute disease is, so to speak, an emergency, and immediate measures are neces- sary to meet it. Chronic disease being, by its very definition, slow in its progress, gives us time to consider ; during which time emergencies may arise of a character generally but not always to be described as subacute. The management of the acute is com- paratively simple, the management of the chronic is often a com- plex affair. There is the treatment both of the chronic condition and the difterent intercurrent maladies which arise in its course. Since these secondary maladies are often more prominent than the chronic morbid mischief which underlies them, the primary state may be overlooked. The character of the disease itself gives the main lines by which we must travel, and which may be fairly clear ; but when secondary complications arise, they furnish con- tingencies -which tax to the utmost alike our acquired knowledge and our individual skill. 'This involves the true comprehension, 62 DISEASES OF CHILDREN. not only of the acute miscliief, but also of the chronic condition which lies beneath and influences it. An apparently simple inflammation of a joint in a healthy child becomes a wonderfully diflierent condition in a child who is naturally strumous ; so that the state of constitution has to be recognized in every child, whether its ailment be acute or chronic. Indeed, constitutional debility and the strumous and syphilitic diatheses are practically chronic diseases. The manner in which they influence complica- tions is only too well known ; and the fatal result of a simple acute affection, not in itself severe, may be entirely due to some chronic morbid condition underlying it. The terms acute and chronic are, after all, somewhat arbitrary. They seem to imply two sets of diseases perfectly distinct, and having no exact relation the one with the other ; but in reality there are intermediate stages or degrees of disease which these two terms do not include. Subacute is a term used to signify the duration of disease when it is neither actually acute nor chronic, but something between the two — a relic of the acute affection, with a duration shorter than the chronic. Indeed, acute and chronic are terms used as much to convey an idea of the duration of the morbid affection as of its intensity. Diseases called by either name, may belong essentially to the same great family. Acute pneumonia may become chronic pneumonia, acute pericarditis chronic pericarditis, acute rheumatism chronic rheumatism, and acute nephritis may terminate in the chronic form with albuminuria. Many other illustrations might be fur- nished. "In a general way, we call diseases that spring up in the system suddenly, or in a brief space of time, or that are rapid in developing their characteristic phenomena, or are of short dura- tion, acute ; and those which have the reverse characteristics of slowness of increasing, mildness of manifestation, and longness of duration, chronic. These distinctions, however, are obviously not . of an essential or fundamental kind, as they have reference not to the nature of the phenomena so much as to the mode of their manifestation and their degree. Indeed, nearly all the diseases termed acute present themselves in the chronic form; so that we may almost say that we have two marked varieties under every individual nominal diseace, namely, an acute and a chronic variety."* * Nature and Art in the Cure of Disease, by Sir John Forbes, 1857, p. 62. ACUTE AND CHRONIC DISEASE. 53 Some loml diseases are essentially of a chronic character, as the "usual forms of hip joint disease and mesenteric disease; the cir- culation is depressed and low, and changes proceed slowly ; whilst in many constitutional diseases, as fevers, inliammations, etc., the tendency is, to produce lesions and such changes in the secreting functions of organs that they become temporarily or permanently deranged, and health does not return till the natural secretions are once again restored, and the parts involved have resumed their normal state. The term acute may be applied to a class of affections which are largely inflammatory or zymotic, including the whole list of febrile and eruptive diseases. The condition may also arise from severe shock as after surgical operations, and the patient may actually sink in consequence, or it may be caused by exposure to great heat or cold, or sudden and severe prostration, as in bronchitis during winter ; or in the severe gastric disturbance caused by the pres- ence of indigestible food in the stomach. First, as regards pyretic affections. The rapidity with which the rise of temperature comes on is in itself instructive. "Where the evidences of any acute specific disease are wanting, and there are no obvious lesions to account for the rise of temperature, the practitioner is apt to assume that he has got a case of typhoid fever to deal with. The oncome of typhoid, however, is usually insidious, and a period of prostration precedes the pyrexia. But it is so in some other diseases. It is so in nearly all diseases marked by a period of incubation, though not in all ; for a child may be exposed to the infection of scarlet fever, and feel quite well till a sudden rise of temperature comes on. Thus, I have known a child convalescent from pneumonia with a normal tem- perature at 9 A.M., get a rise of four degrees at 1 p.m., and forth- with symptoms of scarlet fever to be developed, passing regularly through each succeeding stage. The premonitory symptoms of typhoid fever are not sufficiently well marked to enable us always to foretell what is in store for us. The absence of one symptom alone may be embarrassing, because it renders incomplete the chain of evidence we require to establish our diagnosis — there is a missing link. We have often to wait for some days, say eight or ten, till fever-spots have appeared, or there is such a combina- tion of symptoms, as elevation of temperature, quick pulse, diar- rhcea, and tympanites, which leave no doubt as to the nature of 54 DISEASES OF CHILDEEX. the case. "Whereas, on the other hand, acute indigestion is essen- tiall}^ a very acute disease ; the rise of temperature, of pulse and respiration, being exceedingly rapid in young subjects. This very rapidity in itself should put the practitioner on his guard ; such rapid rise in temperature, pulse, and respiration, is very rarely seen except in catarrhal conditions attacking children of highly nervous temperament. In these children the different nervous centres are highly mobile and unstable, and great perturbations are readily excited by slight provoking causes. To this subject we will refer further on. The same holds good of rapid variations in the pulse. A very rapid pulse quickly produced is suggestive rather of a fright or start than of any actual lesion. What has been said of the temperature and pulse holds good of the respira- tion, but a great inequality between the two is of ill omen, a rapid pulse with slow respiration denoting a grave condition. I may here observe that children in- whom the neurosal temperament is highly marked are exceedingly liable to disturbances in their health, and to fluctuations in temperature. I may quote one in- stance among many. A child is excitable, nervous, and weak ; one of those restless children that are never still. It contracts a Blight catarrh, and the only physical sign of the mischief is a little alteration in the breathing; but dulness is nowhere to be detected. A ny agitation excites cough of a spasmodic or irritable character, and sleep is restless and disturbed. The pulse is quick, the respiration hurried, the countenance is placid ; the tempera- ture in the evening runs up to 103° or more, and falls in the morn- ing, perhaps for a few days, to 101° or 100°, and then resumes its normal state. If the child so attacked was not of this neurosal constitution, slight catarrh would not send up the temperature in this way, or manifestly affect the constitution. I have known several instances of this in rickety and feeble children who have Been allowed to get into an exhausted condition. In such children the temperature may be persistently high for days together ; the pulse 160, and respirations 60 to 80. Yet there have been no physical signs to account for it, no cough, no vomiting, no stupor. General tuberculosis is sometimes at the root of this condition, but in other cases the health gradually improves and the symp- toms pass off.* * "The physician is liable to be misled by placing too much reliance on the phe- nomena of temperature. They are not infrequently interfered with by complications ACUTE AND CHRONIC DISEASE. 65 We have other instances of acute diseases in children, as severe pain from abdominal trouble, colic, gravel, etc., — a degree of pain which may even produce shock and unconsciousness. Acute headache is very ominous in a young child, and may be the commencement of meningitis or convulsions, or precede pneu- monia, or some eruptive disease. Collapse is an acute condition brought about by the loss of blood or violent exertion, by intense mental excitement, by overpowering heat, by acute diarrhoea, by the excessive use of stimulants, and by the continuance of bronchitis or pneumonia, which has so affected the nervous centres and the cardiac ganglia as to almost paralyze them, and to inferfere or even arrest the normal changes in the lungs. In the latter condition I have known the cerebral circula- tion so damaged as to lead to convulsions and death. When a large quantity of blood is lost by hpemorrhage, the heart is almost paralyzed in its movements from the withdrawal of its normal stimulus, and it can only propel, at each contraction, a small portion of blood — not enough to sustain the vital functions. Asphyxia, again, may be classed as an acute condition ; it is a common mode of death in many diseases, as in lai^yvgismus stridulus, croup, and in hronchopneumonia, in which pus and mucus may till up the small branches of the air tubes and cells, so that the respiration fails and the heart ceases to beat. In the latter condition we have recourse to poulticing, and the free administration of stimulants to raise the faltering circulation. It may also be induced by drinking boiling water from a kettle, or from getting a bead or button into the trachea. Again, in haemorrhage, which may be active or due to acute disease, when arising from the rupture of an artery as in the lung,. and accidental events. As an illustration, a young girl had passed through typhoid fever, convalescence being declared in connection with other symptoms, by the laws of thermometry belonging to the decline of fever or defervescence in this disease. Sud- denly hysterical symptoms were manifested, and the temperature rose to 105°. The physician, a man of learning and larger experience, was naturally alarmed. In a few hours, however, the temperature declined, and recovery took place without further impediment. The expressive comment made by the physician was, ' This is not the- first time I have been fooled by temperature ! ' With regard to the information fur- nished by the thermometer, as well as other diagnostic symptoms, it is to be borne in mind that there are exceptions to rules which are generally applicable." — Austiit: Flint. The temperature may be raised, like the respiration or the pulse, by excite- ment or nervousness, especially in delicate girls or young children of mobile temper- ament. 56 DISEASES OP CHILDREN. the quality of the blood evacuated and the symptoms induced are quite different from the passive form of haemorrhage, which some- times takes place from the stomach and bowels, or from the kidneys where the blood has become thin and disorganized by some poison, as that of typhoid fever : it is a state allied to congestion in its early stages, when the smaller vessels become large and rupture through long-standing debility, or some impediment to the pulmo- nary circulation in consequence of heart disease. For the manage- ment of this active form of haemorrhage, saline aperients, low diet, tartarated antimony, and the most absolute rest are needed ; whilst in passive haemorrhage we should have recourse to the mineral acids? tannic or gallic acid, or even astringent forms of iron. Treatment of Acute Disease. — The chief point is to arrest it as quickly as possible, so that it may not run into a chronic form ; and this may often be attained when the case comes under treat- ment early, and the constitution is sound. Hence we may sometimes cut short acute diseases in the young when we cannot do so in the old, because in the latter, there is not only the constitutional debility belonging to advancing age, but tissue-change also. The remedies we employ are as a rule (at least at an early stage) antiphlogistic and eliminative, such as venesection, and the use of calomel and antimony. In the violent pain of acute disease, as enteritis or colic, larger doses of opium are borne than are safe under ofher circumstances. But they should be reduced or withheld entirely as soon as the pain ceases. To approach a young child in acute disease is a difficult matter, and requires much care and tact, unless it is so ill that its sensi- bilities are blunted, and it takes no notice of anything that is going on. To examine it, to feel the pulse, to listen to the chest, or to look into the throat, are wellnigh impossible in some cases, and the information so gained is at such a cost that it is scarcely worth possessing. The fretfulness and peevishness of some children is most trying to contend with in severe cases. The children put themselves in such a temper by obstinate refusal to take medicine, that in cases where coercion has to be used, it is as a rule better to abandon the medicine, at least for a time. With regard to the use of alcohol in acute disease, perhaps there is no one point of greater importance than this. Many acute affections in young children may be conducted safely through each ;Btage without any necessity for its administration. If there is ACUTE AND CHRONIC DISEASE. 57 cerebral exhaustion through failing circulation, it may have the effect of stimulating the cerebral cells, in fact, of sending more blood to the brain, and thus tranquillizing the system and promoting sleep. If, however, there is great exhaustion, and the stomach is irritable, and cannot retain food, gas is often generated and disten- sion takes place, which interferes with cardiac movement. Now, alcohol Tinder some circumstances is clearly indicated, as when there is great excitability and restlessness, high temperature, rapid pulse and respiration. Here a full dose of alcohol will often pro- duce the most beneficial effect. It is as useful here as the chronic use of it in imperfect nutrition is to be deprecated. In the treatment of acute disease we ought not to traverse but to follow Nature's processes. A great deal may, however, be done to expedite the different stages of the malady. In acute indiges- tion, for instance, w^here the child vomits and subsequently is purged, the attack usually wears off quickly. Where these pro- cesses are not spontaneously instituted, we can usually do much good by administering an emetic, with a grain or two of calomel, followed in two or three hours by several grains of jalap or scam- mony, according to the age and strength of the child. Also in acute catarrh, a dose of ipecacuanha wine with a few drops of antimonial wine will often shorten the whole attack; not only as to* the first stage of vascular turgeseence and dryness of the bronchial lining membrane, but also that of the secondarj'' stage of free secretion and expectoration, especially if the measures appropriate to that stage are then resorted to. These measures are stimulant expectorants and tonics. Probably inhalations of steam, simple or medicated, will tend to shorten both stages. In diarrhoea, due to irritant material in the bowel which the system is itself attempting to remove, but without success, a few grains of rhubarb by its first action as a purgative Avill effectually dis- lodge the irritant matter ; while its secondary action as an astring- ent tends to prevent any persisting diarrhoea so set up. Chronic disease may take on an acute form ; it may assume acute manifestations, and it should be our aim, if possible, to pre- vent this. The tendency of this condition is to produce slow degenerative changes, and death from failure of the vital powers.' In chronic affections after scarlet fever and nephritis, acute symp- toms may spring up indicating pericarditis or pleurisy. Bron- chitis, again, of an acute and sometimes of a subacute character, 58 DISEASES OF CHILDREN. frequently comes on in the strumous or syphilitic diathesis. Strumous children are liable to suiter from acute suppuration of their cervical glands, or mischief in their joints, or affections of their bones. It is often set up by an acute malady, or by a period of insufficient food. In congenital syphilis, condylomata or syph- ilides may be excited by some intercurrent cause, notably vaccina- tion, or even shock. Both in syphilis and struma we may have acute periods of anaemia and malnutrition. Under these circum- stances, if the child be exposed to the poison of specific disease it vv^ill most likely have it in a very severe form of an asthenic type- Or a family of children v^nth congenital taint may be at the sea- side when two or three days of severe cold may be experienced ; one child of the number has bronchitis or pneumonia, to which it may succumb, whilst the other children are unaffected by the changes of temperature. Acute disease is very common at an early period of life ; thus infants are often carried off by convulsions when there exists any derangement of the alimentary canal through feeble digestion, or improper food. " Defective nutrition in the early stages of life, iu the nursery, unrecognized by those who have the management of children, is the probable explanation of one of the problems of practice. Healthy parents, still young, constitutionally well en- dowed, living under favorable social circumstances, not unfrequently have children who, although apparently healthy at first, sicken and die of phthisis and of other diseases as they grow up."^ General debility or uniform depression of the bodily powers, is a chronic disease under which acute disease may be readily ex- cited. In this chronic state we have, as it were, to steer a defec- tive ship through a tempestuous sea, in which it may be wrecked, unless great skill and judgment are exercised in its management. Chronic disease is exceedingly fatal in more than one way, for either imperfect nutrition of tissues having begun, the disease goes on without the prospect of repair for an indefinite period, and during this time an acute disorder is very likely to be awakened ; or if not, nutrition gradually fails, and death takes place sooner or later from exhaustion. After death, pathological changes present themselves, which show that they must have so impaired the vital processes as to render the constitution very prone to fall before the assault of any acute disorder. * Nutrition in Ilealtli and Disease, by J. 11. Bennett, M.D., 187G, p. 227. ACUTE AND CHRONIC DISEASE. 59 Acute disease, then, is very apt to supervene on chronic. "When the great glandnlar organs of the body are impaired, and the liver or kidneys are diseased, and the elimination of morbid prod- ucts is interfered with, there is in the one case the absorption of biliary elements into the blood, and in the other the retention of urinary ingredients which may deprive the patient of life, gradu- ually or rapidly. The effects of deficient or improper food in inviting chronic disease among children is well known, and the evidence is over- whelming on the point. The careful feeding of children is more important than their education, for if this is neglected the mental organization must suffer. If the body is not properly nourished, the brain circulation is weakened, and the intellectual powers become feeble and imperfectly developed ; they do not acquire the vio'or of the robust child whose digestive functions have received attention, and plenty of good food has been given at proper inter- vals during the day ; robust children grow and thrive better, they accomplish their school-work better, and they obtain more re- freshing sleep. I have repeatedly seen children who are languid, weakly, and irritable, with such a history as the following: The last meal of tea and bread-and-butter is given about five or six o'clock, they retire to bed an hour or two later, and get no other nourishment till breakfast next morning. The consequence is, that in three hours after the last meal they are drawing on their reserve, the stomach is empty, and they are so exhausted that they begin the following day quite unable to perform its duties properly. Physical and intellectual strain are both ill-borne at such times. Deficient animal food for growing children, especially boys who follow athletic sports, is a fearful mistake ; a farinaceous diet will not supply its place. Too long fasting at any age produces ex- haustion, irritable brain, and enfeebled digestion ; the appetite be- comes impaired, and when food is taken, it is repugnant and dis- tasteful. Malnutrition having been established, anaemia, general debility, tuberculosis, phthisis, etc., are gradually and certainly induced. Delicate boj-s often refuse to eat the fat of butcher's meat, de- claring that they would rather take cod-liver oil. Now cod-liver oil is not attractive to the palate, but these children can digest it 60 DISEASES OF CHILDEE^T. when they are unequal to the assimilation of the other animal fats. Treatment of Chronic Disease. — This is altogether different from that of the acute form. The method is to be watchful ; the sen- tinel has to give notice of an attack, rather than to invite it. The position is one of defence. If our treatment is to be success- ful we must be guided to a very great extent by the character and duration of the disease, as well as the constitution of the patient and his hereditary or acquired tendencies. In the strumous dia- thesis we want more iron, more lime, and more fat. In syphilis we essentially want mercury. In cachectic conditions this remedy should be combined with iron, cod-liver oil, and good food. In both cases pure country air and the seaside are important. In a nervous diathesis, quiet, avoidance of excitement, and little school- work, are indicated. In a bilious child the great point is to look to the digestive organs — not to allow more food to be taken than can be digested, or a bilious seizure is certain, and consequent de- pression, which renders the child susceptible to all external influ- ences. Some remedies seem to bring diseases quickly to an end, notably in chronic disease ; they arrest it, and prevent the next stage of tissue change. In this way we can cure ague by quinine and ar- senic ; certain skin afiections, as itch, by sulphur ; and sj^philis by mercury ; but the same principle does not hold good in the acute diseases, which terminate of themselves in recovery. Thus we do not actually cure typhoid fever or the exanthemata ; we can watch the different stages of the special malady, and sometimes even prevent complications, or render them milder ; but we do not ac- tually cure the disease. By not losing sight of this great principle we may often modify and render milder a disease which might otherwise be virulent and fatal. How important it is that in many chronic affections the child should sleep thoroughly so as to get plenty of rest, the value of which cannot be overestimated. "The value of rest and placidity in fostering the generation of that highly organized animal tissue which forms so large a portion of our staple food is well known to the stockkeeper and grazier. A homely illustration may be found in the fact, that in infancy the child who sleeps much mostly thrives ; and mutatis mutandis, the observation is equally true, that the wakeful, restless child, seldom displays the evidence of ACUTE AND CHRONIC DISEASE. 61 active nutrition ; and, doubtless, all will admit that in infancy de- velopment is in its highest state of activity, and that the healthy infant passes the greater portion of its life in a state of rest and sleep. Growth — the renewal of some parts, and the fresh devel- opment of others, seems thus to claim as its helpmates sleep and rest."* A good physical development is the first thing to be aimed at. The quick, bright, intelligent, but slight town child, the delight of its parents and their friends, does not possess the potentialities of the strong, bulky, slow-witted, often loutish-looking child, we see in the country. The one is eating its cake, is living its life, the other is storing up force. Slow, apparently indeed dilatory, comes the intellectual development of the typical country child ; but its potentialities are far beyond those of the other child. In "Westmoreland this fact of slow developjment is recognized in the saying that "Westmoreland lads have no sense till they are twenty-one." There is a direct antagonism between mental precocity and physical growth. ^Yith these facts before us it is quite clear that where we have bright, quick town children, with a defective phj'sique, a small thorax, and a flat abdomen, it becomes emi- nently desirable to develop a totally different condition. Xo mat- ter at what cost to their immediate prospects these children should be sent into the country to grow into healthy animals. The more marked the characteristics of town birth, the more necessary is it to adopt such a plan. If permanent life in the country for several years is not attainable, a month in spring, and two or better three months in autumn, should be spent in the country. The duller, the quieter, the less exciting the country residence the better for strumous children. For very delicate children, it may be advis- able for the spring months to select a warm and comparatively low-lying sea-residence. In the autumn, however, it is well to choose a place where the air is bracing, if by the seaside, where there are downs ; in the country, where there are hills. The more nearly the life then led approaches that of the ordinary country child the better. After a substantial breakfast the children should be sent out for a walk ; if at the seaside, where they must take a bath, this walk should not be too Ions;, so as not to exhaust * On Pain and the Therapeutic Influence of Mechanical and Physiological Eest, etc., by J. Hilton, F.R.S., The Lancet, 1860, vol. ii, p. 103. 62 DISEASES OF CHILDREN. them before takins; it. A child should never take a bath in the sea in a condition at all approaching exhaustion. If an inland residence is preferred, the walk may be made longer, provided it does not go to the length of fatigue and loss of appetite. The midday meal should be substantial, and there is no objection to a sleep after it, especially if the child feels drowsy. A prejudice prevails against sleeping in the day, which is by some persons car- ried to extremes. The intention is that the child shall eat, sleep, and grow. If such treatment of town children were more thor- oughly carried out, we should hear less of imperfect physiques, of an early breakdown after much precociousness ; and town chil- dren would, so treated, approach more closely to those reared in the country. Precocity is eminently undesirable, and, if possible, to be avoided. We must, too, never overlook the fact, that acute and chronic disease with their complications, depend upon a variety of influ- ences and associations. The anatomical relations may guide func- tional complications, and even determine lesions of structure. The scrofulous, the rheumatic, and the anaemic states, severallj^ influ- ence the liability of certain organs to suft'er in different ways, be- cause the state of the secretions, the degree of vascularity, and the morbid changes of the blood, dispose to diseased action. Vital resistance is as great in the strong as it is defective in the delicate. CHAPTER IV. DEBILITY. Definition — Symptoms and treatment — Liability to lead to organic disease. Under the head of debility in children, or constitutional de- pression, I shall enumerate a group of symptoms which is very commonly met with, especially among the out-patients of our hospitals. It is a condition sometimes the forerunner of disease, and then the signs which characterize this altered health are lost in the disease which springs up. I think I am justified in attributing importance to this condition,, under the title or designation of DEBiyXY. 63 debility ; for promptly recognized, it assists us to attach significance and weight to the earliest indications of a departure from the normal standard of health. By debility, I mean functional impairment, atony, weakness, or preternatural slowness in the performance or working of the vital processes, leading, when neglected or overlooked, to debility (and it may be to structural change) in one or more of the great central organs of life or tissues of the body. This may be considered by some as involving an unnecessary addition to our medical nomen- clature; but debility or weakness, as commonly employed, is used to indicate symptoms attendant on various diseases, and has no isolated and individual recognition that seems to me commensurate Avith its importance. The loss of blood, or free purgation, or deficient food, or any causes that reduce the vital powers of the j)atieut, will induce debility in a simple and uncomplicated form — a deviation from that equalized condition of all the bodily and mental functions we term health. As the constitution tardily recovers from the shock it has sustained the functions of the vital organs are sluggishly carried on, and if repair is not uniform in all of them, the balance is dis- turbed, and after some hesitancy disease breaks out where Ave least expected it. In our earh^ contact with some forms of illness we are unable to make any other diagnosis than that of debility. When symptoms referable to one organ more than to another become apparent, we leave a general plan of treatment for that which is determined of the prevailing symptoms. When it has reached this stage or change, the debility I am attempting to describe has no longer an independent existence. I claim for this a separate and special classification among the ailments of children, where debility is observed in its purest and unmasked form, before degenerative lesions are conmion, as in after life, to account for failing strength, increasing debility, and structural alteration. There are very well-defined symptoms belonging to this state, alike in many instances, and varying in extent and character in others, the debility being a marked feature of the complaint throughout. There is powerlessness and lassitude of the whole system ; every function may be said to have received a shock ; a temporary pause in the uniform working of the bodily functions has taken place. The child does not usually complain of anything, Gl DISEASES OF CHILDREN. but hangs and droops about, and ceases to take an interest in bis amusements. The vivacity of childhood has departed ; in some cases he has a shy and timid look, is afraid of your approach, and cries without provocation. In most cases there is neither discomfort nor pain ; the bowels are said to be regular, but the evacuations are scanty from the small amount of food that is taken. On inquiry we shall generally find that the bowels act sometimes every day, and sometimes once in two or three days. Among private patients, where there is no difficulty in testing the statement, I have been led to regard the latter period as the most common. The tongue is clean and moist, it may be pallid, but indicates no active dis- turbance. Very frequently there is a film on the tongue of a thin silvery whiteness, or the coating is thicker and yellowish, but the front of the tongue is nev^er involved, the tip and sides showing a natural hue. Sometimes it presents a smooth and dusky aspect, as we might expect in a languid state of the circulation. The pulse is weak, small, and usually slow ; sometimes it is rather accelerated, but this is owing to the agitation and nervous excitement so readily induced by the examination. The thermometer indicates no elevation in temperature. On the other hand the skin often feels very cool, and the mother tells j^ou that her child does not take sufficient exercise to keep him warm. He is often noticed to be lying across a chair or sofa in a passive state of indifference, dropping off into a calm, quiet, and prolonged sleep. It is the quiet sleep of fatigue, and not the restless sleep of exhaustion. If awakened he readily falls off to sleep again, and is glad to go to bed early, when the same drowsy sleep returns and lasts till morning. In April, 1869, a lady brought to me her little girl, four years of age, who was a very intelligent and pleasing child. I was left to find out her ailment as w^ell as I could, her mother saying " she really did not know what was the matter with her, but she was certain she was not well." When a year old the child suffered from palpitation, and two years afterwards she had whooping- cough. She appeared well till eight weeks before I saw her, since which time she had been ailing in health. She was said to be " very languid, constantly yawning, and wishing to go to bed early in the day." Her face flushed on being asked a question, and when a stethoscope was applied to her chest she burst into a fit of tears, which her mother said was not natural to her; the tongue DEBILITY. 65 was furred at the back, and the urine was rather high-colored ; the lower eyelids were dark, and the expression languid, but no complaint whatever was made of pain ; the bowels were rather confined. I advised that the child should be tempted to take nourishment frequently, milk and eggs being given in the way that were most agreeable to her. She was not to suffer fatigue from running about, but to be driven in an open carriage when the weather was fine, or to be wheeled about the garden. Ape- rient medicine was strictly forbidden. Thirty minims of the Syr. Ferri Phosp. Comp. in two teaspoonfuls of water were ordered three times a day. Improvement soon set in, and on the 12th of May she had nearly recovered her usual activity, the appetite had returned, the tongue was quite clean, and the bowels acted regu- larly every day. A careful physical examination in these cases reveals nothing important about the chest or abdomen. The two most common attendant symptoms are headache and pain at the epigastrium, both being signs of debility in the brain and stomach respectively. So far as we can learn, the headache seems to be a heavy oppres- sive weight across the centre of the forehead, and it is very per- sistent, giving the child a dull and painful appearance. In many of these cases the aspect is desponding and inanimate, and the cheerful expression of childhood has vanished ; the eyes are heavy and have a hollow look, but there is nothing approaching intoler- ance of light, nor squinting, as we observe in threatening cerebral disease, though it is not to be forgotten that the brain may be in- volved if these symptoms are allowed to go on without treatment. The pain in the stomach is of the same dull aching character, rather discomfort than actual pain, and is limited to the root of the ensiform cartilage or its immediate vicinity. It is the uneasi- ness of slight gastralgia, or the gnawing sensation we have all experienced when the stomach is empty, and we are waiting for a meal to appease it. There may be aching of the limbs, muscular fatigue, and pain in the course of the spine. The sj' mpathetic system shares in the general constitutional de- pression, and is reduced below its normal standard. The appetite required to insure the perfect digestion and assimilation of food and nourishment is impaired, and the emotions are susceptible and. heightened to a degree which readily excites disturbance of both. 5 66 DISEASES OF CHILDREN. mind and body. The face may change from the pallor it exhibits in repose, to frequent blushing, and there may be palpitation of the heart, all induced by slight correction- or fatigue, or the over- taxhig of the digestive functions even with the ordinary diet of health, when half paralyzed by fear or emotional excitement. There is no very striking symptom which indicates this derange- ment in the health. It is to the totality of them we must look for a diagnosis. This must be arrived at by a careful process of exclusion. The indications of the disease are negative, and it is the failure in the discovery of any specific cause for the debility which indicates its pure and uncomplicated character. There is nothing, so to speak, that is apparent or tangible, and hence it is that a depraved state of health creeps on unnoticed, and is not discovered till some very prominent symptom arrests attention. There is no cardiac affection. Such cases as these make us cautious in giving an opinion. In the absence of any discoverable disease, we are doubtful whether this unaccountable debility may not be the harbinger of mischief to start up hereafter. Disease may be hidden, to come forth by and by. In the diseases of adult life, a cause is often discovered. iVot so in the cases I am describing ; the debility is uncomplicated, and it must be seen and treated before it has merged into actual disease. These cases usually terminate well if promptly and skilfully treated, but a continuance of this condition may lead to pro- tracted disease, and subsequently to death. For example, deficient nervous power, as shown by headache, may lead to cerebral ex- haustion, and to coma and convulsions, in the same manner that congestion and inflammation of the brain may terminate. These are opposite states of the system, leading to the same consequences, but requiring a different mode of management. The weak and enfeebled stomach of young children, causing instant rejection of food by vomiting, is often checked by a simple tonic, and sympathy is so strong with the cerebral functions, that when the stomach has recovered its power, the brain is lulled into quietude. If it did not so yield to treatment, the symptoms would pass on and implicate the brain in the manner just de- scribed. To equalize all the forces of the body is the surest method • of maintaining its efficient working. It is the loss in either that .invites disease. DENTITION. 67 When the debility has weakened the digestive and nervous functions, and induced loss of appetite, muscular pains, deficient and high-colored urine, and torpid bowels, a plan of treatment the opposite of that which is stimulating and generous, may suf- fice to bring about a return of strength and animated feeling. These cases of pure and simple debility, when neglected, cause chorea, epilepsy, convulsions, paralysis, etc., and finally lead to those changes in the blood which originate aneemia, tuberculosis, and every form of diathesis that lowers health and provokes disease. CHAPTER Y. DENTITION. Symptoms : In healthy children there is often an absence of suffering — In the rickety and delicate, abdominal or cerebral disease may spring up — Temporary and permanent teeth — Order of their appearance — Diarrhoea — Convulsions — Eczematous affections of the skin. Causes of Difficult Dentition : The rickety constitution — Vaccination. Treatment : Depends upon the strength and constitution — The strong and vigorous to be treated differently from the fesble and rickety — Aperients — Carminatives, bromide and iodide of potassium, hydrate of chloral — Lancing the gums — Care in diet. Dentition is a subject which requires careful consideration, for it is important that we should form definite ideas concerning the part it plays in affecting the health and exciting convulsive and other diseases. Whilst the dangers of dentition have undoubt- edly been exaggerated by some authorities, and the friends of the child are apt to become anxious during this period, there is, it must be remembered, a real degree of risk in certain tempera- ments. Every thoughtful practitioner ought to be on the watch for indications of disease, which the process of teething is capable of exciting. In perfectly healthy children the teeth appear one by one in regular succession with little or scarcely any suffering ; in other instances, as in the rickety, their advent is contemporaneous with the commencement of delicate health ; and in another class they are the harbingers of abdominal or cerebral mischief. The evolu- tion of the teeth tests the vigor of the child, and the more tardy and lingering the process, the less is its strength and vitality. 68 DISEASES OF CHILDREN. The teeth begin to appear in healthy children between the seventh and eighth month, and the process is completed between the twenty-fourth and thirtieth month.* The two middle or central incisors in the lower jaw first appear ; then in the coarse of a week or two the two middle incisors in the upper jaw ; next come in another month or six weeks the two lateral incisors in the upper jaw, followed by the two lateral incisors in the lower jaw. Then about the twelfth or fourteenth month the first four molars appear, generally those of the lower jaw first ; but they do not follow any definite order in their appearance. After the lapse of another three or four months the four canine teeth suc- ceed, and between the twentieth and thirtieth month the four posterior molars pierce the gum, thus completing the number of twenty-four teeth. These are called temporary teeth. The jper- manent teeth are thirtj^-two in number, and they make their appearance as the former are shed. The permanent teeth belong to that important period of child- hood — the second dentition. These teeth begin to appear between the seventh and eighth year, and at this time there are forty- eight, twenty deciduous, or perfectly developed teeth, and twenty- eight permanent teeth in various stages of development. The evolution of the first true molars is, according to Mr. Saunders, an evidence that the child has attained the age of seven years. The following table is of assistance : Central incisors developed at 8 years. Lateral incisors " 9 " First bicuspid '' 10 " Second bicuspid " 11 " Canines " 12 to 12^- vears. Second molarsf " 12^ to 14 " * " If a child pass over the ninth month without teeth, you should carefully inquire for the cause. It may be that an acute illness has retarded dentition. It may be (but this is very rare), that there is some condition of the gum which interferes witli the advance of the teeth. It may be (and this is infinitely the most common cause of late dentition) that the child Ls rickety ; fail not then, when called to a child in whom tlie teeth are late in appearing, to look if it be rickety, for, if you do fail lo look for rickets, you will most likely attribute to the iriitation of teething symptoms wiiich are the consequence of the rickety diathesis — the late dentition in rickets being in itself merely a .symptom of the general disorder. TJie rickety deformities may be very trifling, and yet the teeth considerably retarded in their development." — Lectures on Rickets, by Sir William Jenner, Bart., M.D. Medical Times and Gazette, vol. i, p. 334. f Carpenter's Physiology, 8th edit., p. 1106. DENTITION. 69 Symptoms. — The symptoms and disorders that accompany the first dentition vary in different cases. A perfectly healthy child may not suffer in the least degree, one tooth appearing after another without causing any local or general disturbance ; but, in many instances the excitement is considerable ; the mouth is hot and swollen ; the cheeks are flushed ; the child is fretful and sleepless ; it resents the slightest interference ; the appetite fails; thirst is present, and often sickness and diarrhoea as well. One of the earliest sj^mptoms attending dentition is an increase in the activity of the salivary glands, and saliva is seen to be con- stantly drivelling from the mouth ; but this moisture may be present for some weeks before the teeth appear. In some cases the constitutional disturbance is even greater than that which I have described ; the mouth is hot and dry ; aphthous ulceration is seen on the gums and inside of the cheeks ; the tongue is thickly coated, and the child can no longer suck. Convulsions and spas- modic movements are very common in teething children. Fre- quent contractions of the muscles of the eyes, the lids of which are only partially closed, and the eyes turping upwards beneath the upper eyelids, so that the white sclerotic is ouly seen, give a terrified expression, and is alarming to the parents. Rolling of the head, twitching of the facial muscles and of the limbs, flexion of the toes and fingers, and a peculiar smile are often observable at such a time. In this state of excitement almost any sympa- thetic disorder may spring up, as bronchitis, convulsions, menin- gitis, diarrhoea, and eczematous and erythematous affections of the skin. Some of these affections are quickly fatal, and others tedious and difiicult of cure. In rickety children dentition is delayed. They are feeble in constitution, the appetite is capri- cious, sleep is disturbed, and the bowels are relaxed. During dentition, children are very liable to diarrhoea, the mucous membrane of the bowels is irritable and sensitive, and if the food given is not easy of digestion, or if the weather be cold, it is easily induced. What share teething exerts in causing diar- rhoea it is impossible to say ; but there is a close connection exist- ing between these states When diarrhoea is present we do not hastily attempt to check it if the teeth are piercing the gums, and the mouth is uneasy : still, if the drain continues or is excessive the child becomes exhausted, and the possibility of convulsions must not be overlooked. 70 DISEASES OF CHILDREN. Diarrhoea may be in some measure due to enfeebled digestion caused by pain and restlessness, and general disorder of the system. Billard attributed it to an increased development of the intestinal follicles and glands, which is noticed at the period, of dentition.* A 3'ear of delicate health may elapse before a tooth is seen, and then one may slowly appear without causing pain. Convulsions in a case under my care preceded the appearance of each tooth. Children who suffer from difficult dentition will be often ob- served to roll the head from side to side, and to raise the hand to it, or put the fingers in the mouth. Sickness and febrile disturb- ance are noticeable ; the child becomes languid and wastes, the muscles are flabby and the joints relaxed, the motions are often- sive, and dark, green, or slimy. Slight ulcerations of the mouth are common, the child is peevish and irritable, it experiences pain on taking food, and does not obtain sound sleep. In some rickety children during dentition, sickness and vomit- ing are the chief symptoms, and the child is drowsy and inclined to sleep at any time during the day. If the head is hot, and the veins distended about the scalp, the pulse quick, and the temper- ature runs up to 101° or 102°, we may with reason dread the su- pervention of convulsions or meningitis. Convulsions in several children of the same family are often to be met with. In one in- stance a mother had lost three children from convulsions during dentition ; the fourth child was the subject of laryngismus strid- ulus, and at two years old it had only seven teeth. Laryngismus stridulus frequently attends dentition in rickety children, the seizure passing off as the teeth appear, and the general condition improves. Eruptions on the face and scalp have been usually at- tributed to dentition — the "tooth-rash" of vulgar talk. The causes of difficult and delayed dentition are an acute dis- ease, the rickety constitution, struma, marasmus, and tuberculo- sis. All these disorders retard the development of the teeth, by lowering the general health. In some cases we may trace the failure of health from the time of vaccination when it is perfornied at the third or fourth month ; this in many instances seriously interferes with the development of the teeth, and disposes to reflex nervous irritation. The mortality under the age of two years has been variously * On the Dangers of Dentition, by J. Finlayson,'M.D., Obstetrical Journal, 1873-74, p. 591. DENTITION. 71 estimated bj different writers, some ascribing half the deaths, others a third, and others again, a sixth, as due to difficult denti- tion. The treatment of dentition will depend upon the general symp- toms that are present, and the constitution of the patient. The practitioner must exercise his own judgment as to the treatment he will adopt, and not blindly attach himself to any routine plan. The strong and vigorous child who is feverish and thirsty, with a hot and tender gum, a full pulse, and constipated bowels, will de- mand quite a different mode of management from a puny and rickety child whose teeth are delayed. In strong children a grain of calomel with two or three grains of rhubarb will be required to clear the bowels. A saline mixture, as the citrate of potash, should be given to abate the pyrexia, and if the child is excited and sleepless, a few drops of tincture of henbane may be added, or a draught at bedtime containing hydrate of chloral and bro- mide of potassium, should be given. The child's head should be kept cool, and whatever determines to cerebral congestion should if possible be prevented. "Affusions of the head with cold water, performed every hour or two, are, it is true, a not very tender, and by parents not much admired, remedy ; it is, however, very useful against all convulsions in children, and therefore against those oc- curring during dentition."* In the rickety, a mild aperient is occasionally required, such as bicarbonate of soda and rhubarb, to regulate the bowels, and to correct the secretions. A teaspoonful of castor oil may be advis- able now and then, and if the bowels are over active, a grain of Dover's powder at bedtime is often of great service. If there is- vomiting and flatulence some carminative will be necessary. A mixture containing hydrocyanic acid with solution of magnesia and sal volatile often answers exceedingly well.f In cases where- there is much restlessness and disturbance of the nervous system, * Vogel, Diseases of Children, 1874, p. 106. f Formula 2 : R. Acid. Hydrocy. Dil., ^ss.. Spt. Amra. Arom., ........ Ttjjij Syrupi, njjxx Liquor. Magn. Carb., 3j. — M".. To be taken every four hours. 72 DISEASES OF CHILDREN. bromide and iodide of potassium with sal volatile will often abate sickness, and relieve head-sjmiptoms if present.* The gum-lancet is occasionally required. If the tooth is nearly through, but still hidden, and the gum is red and tightly stretched over the tooth, then a proper incision will give much ease, and the slight bleeding will relieve the capillary vessels. It is both mis- chievous and cruel to have recourse to the practice if dentition is going on naturally. This practice of lancing the gums is a very old one. It appears inconsistent with the state of medicine in the present day to suppose that puncturing the gums would be so frequently resorted to if it had no advantages. " May not some diseases be rendered milder, and their favorable termination more certain or probable by measures calculated to relieve the turges- cence of the gums ? If so, those who totally disregard the state of the gums, are not less in error than those who use the gum- lancet when it is not required. "f The cases where incision is re- quired are probably few, but there are undoubtedly some which do benefit by the operation, and where convulsions have been pre- vented by having recourse to it. When the gum has yielded to the advancing tooth a child often experiences instant relief and comfort. So far from causing the infant pain, I have repeatedly lanced the gum without the child evincing the slightest indication of feeling pain from it, but of obtaining speedy relief. I have never seen haemorrhage or ulceration of the gums follow, and in properly selected cases it certainly has its advantages. Finally, care in diet is of the greatest importance whilst a child is teething. Improper food will easily bring on acute indigestion and febrile exciten^ent, demanding the use of salines and aperients till the system is again tranquil. * Formula 3 : R. Potass. Bromid., gr. ij Potass. lodidi, gr. i Spt. Amm. Arom., "JJij Synipi, ")Jxx Aquam ad ......... . SJ- — ^i- To be taken every four hours. For children a year old. •f Diseases of Children, by J. Lewis Smith, M-D., 18G9, p. 307. MARASMUS OR ATROPHY. 73 CHAPTER VI. MARASMUS OR ATROPHY. Nature and definition of— Deficient food the most common cause — Mortality amonr/ infants — In treatment the primary object is to remove the cause — Care in feeding — Cod-liver oil—Raw meat juice — Digestive ferments — Liquor Pepticus and Liquor Pancreaticvs — Saline essences of pepsin and pancreatin — Acid glycerin of pepsin — Artificial digestion. Atrophy consists in the decrease of size of a tissue, or of the whole body, with consequent impairment of function. It is the opposite state to that known as hypertrophy. When adipose tissue atrophies, the fat-cells diminish in size, owing to the gradual loss of their contents, and emaciation results. The elementary con- stituents of any other tissue, or organ, or set of organs may become similarly affected, and so produce diminution in size, and a pro- portionate impairment of function. It is not the same process as degeneration, although degeneration is always sooner or later accompanied by atrophy. Degeneration consists in the deteriora- tion of the qualify of a tissue, and does not (at all events at first) necessarily imply diminution in its size. On the contrary, the size may be temporarily increased, as, for instance, in fatty degeneration of the liver. Atrophy is a common disease among infants and young children, as the out-patient practice of any London hospital amply testifies. It has its origin in defective nutrition, and is rather to be regarded as a state of extreme debility.and lowered vitality than as a specific and independent affection. " Experience has taught us that patients often die without offering, in the post-mortem examination, the slightest modifica- tion in the anatomical condition of their organs. In the course of our physiological experiments, we often see dogs arrived at the very last stage of emaciation, although the appetite continues unimpaired till the last moment. They sink from sheer exhaustion, while the lacteal s are gorged with chyle; and, when opened, their bodies offer no trace whatever of pathological alteration."* Causes. — Whatever interferes with the nutrition of an organ is followed by its atrophy. If the food given to an infant be un- * LectiD'e on Experimental Pathology, by Claude M. I'ernard, Medical Times and Gazette, 1860, vol. i, p. 209. 74 DISEASES OF CHILDREN. wholesome- or deficient, the digestive organs are sooner or later deranged, and the processes of assimilation are disturbed. The nutritive changes in growing tissues are far more active than in the mature; consequently any interference with the nutrition of an infant is followed by far more rapid and serious consequences than in the case of an adult. It has been pointed out by Dr. Murchison that emaciation may arise from functional derangement of the liver, as when the bile is impeded in its passage into the bowel, and the assimilation of fatty and albuminous matters is interfered with, or from deraiigement of the glycogenetic function of the liver.* It may also arise from stricture or obliteration of the thoracic duct; by which means the chyle elaborated by the mesenteric glands fails to reach the general circulation. Atrophy is also caused by whatever occasions any great waste of nutritive material. Thus, prolonged hfemorrhages, long-continued suppuration, excessive vomiting and diarrhoea, by depriving the body of large quantities of nutritive matter, lead to general atrophic changes. As to some other causes of atrophy, the most frequent are any circumstances that bring about defective nutrition in infants and very young children. A child may have been born healthy, but the mother is suddenly unable to suckle it, and from that moment it ceases to thrive. 'No artificial food can efliectuallj^ take the place of the mother's milk, the child wastes and becomes emaciated, diarrhoea and vomiting ensue, and it dies exhausted. In another class of cases the child is incessantly sick, and life is frequently arrested by an attack of convulsions. Hundreds of infants die annually in London and other large cities because the food given to them is either unwholesome, indigestible, or insufiicient, their digestive organs are too feeble to assimilate it, or the mother is working hard, and in delicate health at the same time, and so has not sufiieient breast-milk to nourish her infant. We continually see pale and feeljle women bringing up their children by the breast when a year old, and they tell us with some surprise that since their milk diminished the children have not thriven. The blood, in these cases, gets into a thoroughly impoverished state, and the mammarj' glands can no longer secrete milk sufiieient in quantity, or good in quality. * Croonian Lectures on Functional Derangements of the Liver, The Lancet, 1874, vol. i, p. 4G7. MARASMUS OR ATROPHY. 75 It has been pointed ont that food ricli in starchy products is a common cause of atrophy in young children when given to them before the salivary and pancreatic glands have reached their full development. Before the seventh or eighth month the starch is not converted into glucose or sugar, and hence one cause of indi- gestion and defective nutrition.* The mortality among infants brought up by hand is enormous.f The deaths during the first two months are four times the number during the third month.]: Where infants are imperfectly fed, nutrition takes a wrong direction, and if they do not flag or die earl}-, then some morbid deposit in the shape of tubercle may be infiltrated into the difterent organs, or some inflammatory afl:ec- tion set up. Sometimes young children, without any ascertained cause, sud- denly become fretful and irritable, and lose flesh and strength ; the face grows pale, and the body-heat diminishes ; in these cases they sleep badly, there is uneasiness in the bowels ; the motions are dark and offensive, and death gradually follows. " In chronic atrophy the last traces of adipose tissue disappear from the face ; the integument everywhere becomes loose and cor- rugated, and, in addition, various contractions of the muscles take place, as a result of cerebral irritation, especially that of the frontal, next of the corrugator supercilii, and the levator al?e nasi et labii superioris muscles, by which the face acquires a senile ap- pearance, and, on account of which, the French Psediatricars, in a very ungallant manner, call it a Yoltairean face."§ * See Chapter II. t "In England, out of 100 children born ; while for the whole period of one year 15.2 per cent, children will die tlie first month, 1.7 the next, and so on. In France, out of a million births, 29,121 die in the first week, 22,128 in the second, and 22,236 in the sixteen days following." — On Infant Feeding, by C. H. F. Routh, M.D., ISTfi, p. 64. X "According to the English Life-Table, of 1,000,000 cliildren born, 149,493 die before they reach the age of one year ; and of these 149,493 deaths, 46,503, or nearly a third, die during the first month of life. The annual rate of mortality per 1000 among infants, according to this Englisli Life-Table, is equal to 571.3 in the first month of life ; declining, however, to 91.6 per 1000 in the eleventh month. The annual rate among infants aged one month and under one year does not exceed 114.6 per 1000; whereas among infants from birth to one year of age it is equal to 165.6. It is evident that in dealing with tlie mortality among infants during the first year of life it is necessary to take account of the age in months at insurance, for the rate of mortality among infants aged six months is but one-fiftli of the rate whicli prevails during the first month of life." — Infant Insurance and Mortality, Brit. Med. Journal, vol. i, 1S75, p. 785. 2 Vogel, Diseases of Children, 1874, p. 15. 76 DISEASES OF CHILDREN. In the treatment of 3farasmus and Atrophy we must seek to remove whatever influences appear to have induced the disorder. If the mother has not milk enough to support her infant, a wet- nurse shoukl be procured, or it must be brought up by hand, and every care ought to be bestowed on feeding, according to the age and digestive capabilities of the child. Into this question I have already entered.* Cod-liver oil may be given to young infants after food in these cases, with the greatest advantage ; it will have the eft'ect of improving the appetite, promoting sleep, correcting the secretions, and increasing weight. When it does good, sick- ness is not induced ; indeed, I have seen many infants cease to be sick on taking the oil. Half a teaspoonful of steel wine may be added to the oil in suitable cases. If cod-liver oil cannot be borne an equal quantity of glycerin may be given with good results. It is usually taken with relish. Inunction of cod-liver oil is also of service. Haw in eat juice in some cases of atrophy and wasting proves highly nutritious and digestible. The directions for pre- paring it are given in another place.f Cases will sometimes occur in which the digestive functions are completely in abeyance. All foods are rejected by the stomach or passed undigested by the bowel. In such cases as these, as indeed, in all where the alimentary tract is in a high degree of irritation, the principle of physiological rest will be found to be of great value. We must give the digestive organs as little to do as possible; as they cannot perform their functions effectually, we must relieve them of this, by introducing arti- ficially digested food, and thus reduce their work to that of mere absorption. This can be eftected by "peptonizing " the food before it is given. There are several valuable preparations of the digestive ferments in the market, while many are practically inert. Amongst the most effective may be mentioned Benger's prepara- tions, the " Liquor Pepticus " and " Liquor Pancreaticus ;" Savory and Moore's two saline essences of Pepsin and Pancreatin, Bullock's Acid Glj^cerin of Pepsin (which, on account of its sweetness, is readily taken by children), and others. The strength of these preparations is very similar. Dr. W. Roberts has called attention to this subject in his Lunileian Lectures on the Digestive Ferments. He says: "Any extract of pancreas may be used for * See Chapter II. f See Chap. XV, On Diarrlioea. MARASMUS OR ATROPHY. 77 the preparation of artificially digested food, but the most suitable are those prepared with dilute spirit or chloroform-water. The extract sent out by Mr. Beuger, uuder the name of ' Liquor Pan- creaticus,' is an almost faultless pharmaceutical preparation. It is made by extracting perfectly fresh and finely chopped pancreas, with four times its weight of dilute spirit. By some ingenious devices, Mr. Benger has succeeded in overcoming the mechanical difficulties of the manufacture, and has produced an extract w^hich possesses the diastatic and proteolytic properties of the pancreas in a highly concentrated degree. It is a nearly colorless solution, with ver\' little taste or smell beyond that of the spirit used to preserve it."* The following are Dr. Roberts's methods of arti- ficially digesting milk and milk-gruel: '"■a. Peptoxized Milk. — Fresh milk is diluted with water in the proportion of three parts of milk to one part of water. A pint of this mixture is heated to boiling, and then poured into a covered jug. When it has cooled down to about 140° Fahr., three tea- spoonfuls (foiij) of the Liquor Pancreaticus, and twenty grains (about half a small teaspoouful) of bicarbonate of soda (in solution) are mixed therewith. The jug is then placed under a 'cosey ' in a warm situation for one hour. At the end of this time the product is again boiled for a couple of minutes. It can then be used like ordinary milk. " b. Peptonized Milk-Gruel. — Half a pint of well-boiled gruel is added, while still boiling hot, to half a pint of cold milk in a covered jug. The mixture will have a temperature of about 125" Fahr. The Liquor Pancreaticus and the bicarbonate of soda are then added in the same proportion as in the preceding process {a). The jug is placed under a 'cosey' and kept warm for an hour and a half. The contents are then boiled for a couple of minutes, and the product is ready for use. By this second method the use of the thermometer is dispensed with." In cases of great debility and exhaustion it may become neces- sary to feed the child per rectum. The following is Dr. Roberts's plan of preparing nutritive enemata: "A nutritive enema should be prepared in the usual way — of milk, or of milk with beef tea or eggs, or of milk-gruel. * Lumleian Lectures, On the Digestive Ferments, by W. Eoberts, M.D., F.E.S., The Lancet, April, 1880, to which the reader is recommended to refer for further par- ticulars. 78 DISEASES OF CHILDREN. To half a pint of the warm enema a tablespoonful of the Liquor Pancreaticus, and thirty grains of bicarbonate of soda should be added. The enema can then be administered at once." Two ounces is quite sufficient at one time, for if more be used it ma}^ not be retained. CHAPTER VII. FEVERS OF CHILDHOOD. Definition of fever — Its causes and symptoms — Action of the fever-poison on the blood and nervous system — Termination by critical change or crisis — General management of fevers, prophylactic and curative — Simple febricida — Febris ephemera — Febris continua sim- plex — Its definition, causes, symptoms, and treatment. The term fever is employed to signify an accelerated state of the circulation, with thirst, loss of appetite, elevation of temper- ature, prostration of the mental and bodily powers, and derange- ment in the secreting functions. These changes are the conse- quences of external causes, which the system is unable to resist. The causes may be sudden or slow, powerful or mild ; they may temporarily impede its actions, and eventuate in a speedy restora- tion to health ; or they may induce a combination of phenomena which destroy the life of the patient. All diseases which exhibit febrile symptoms at their commence- ment must have a close resemblance to one another, and do not then admit of a diagnosis, which is easy at a later period, when the development of particular symptoms enables us to fix the exact nature of the affection, and in many instances to trace its origin. Different individuals are variously afiected according to peculiar circumstances, and the state of the general health at the time of attack. Thus exposure to cold and moisture in one per- son produces only a feeling of malaise and general constitutional disturbance ; it docs not fix upon any particular organ, and ter- minates without complication. In another person, as the general disease advances, there is a determination of the complaint to some organ ; or in a third person tlie local disease may proceed as rapidly or even more so than the general disorder ; and this is exemplified in some cases of pneumonia occurring in young and FEVEES OF CHILDHOOD. 79 vigorous subjects. Then there is a class of cases in which the local disorder precedes the constitutional, and the inflammatory sj'mptoms increase and become more developed, whilst the symp- tomatic fever and general derangement follow later. Increased heat and accelerated circulation 'constitute fever, and without them the patient cannot be said to labor under it. In the early stages they may be absent, as during the period of de- pression and lassitude, when the vital energies are prostrate, and before the system has shown any reaction. But quickly come re- markable changes and manifestations, as uneasiness, restlessness, shivering, coldness along the spine, involuntary tremors, rigors or convulsions, and exacerbations. And to these succeed lesions of the organic functions, in disturbed respiration, circulation, diges- tion, and nutrition ; the attitude is altered, the expression changed, and the intellectual powers enfeebled or destroyed. The symptoms are owing to changes in the quality and constituents of the blood, which becomes altered in color and consistence, the serum in- creased, and the crassamentum thickened or loosened. Then fol- low changes in the quality and amount of the secretions ; they become putrid and offensive to the tissues in which they are in contact, and lead to local inflammations and changes of structure. The fever-poison enters the blood and paralyzes the nervous sys- tem — it afiects all the solids and fluids of the body, and tends to the disturbance of its several functions. It is well that we should bear in mind the liability of the mildest form of fever to change its characters and become developed into a dangerous type at some period of its progress ; and hence it is that very mild cases of typhoid (remittent) pass oif in a few days, whilst in others they become severe, protracted, and even fatal. From constitutional infirmity or improper diet, alarming symptoms may arise at any period of the fever, or if the blood is surcharged with the con- taminating elements of tissue metamorphosis, which the excretory channels cannot eliminate, coma or delirium may set in unexpect- edly and destroy the patient's life. Thus it becomes a trite maxim, which observation daily indorses, that " where there is fever there is danger." All fevers have a tendency to terminate by critical change or crisis, as it has been termed, if the vital powers are not too much exhausted. This is seen in ague and some idiopathic fevers, in 80 DISEASES OF CHILDREX. which a free sweating, or evacuation from the bowels, is followed by favorable symptoms. In the management of fevers in general there are prophylactic and curative measures to be borne in mind. If the causes which produced the fever can be ascertained they should be removed, and the patient placed under the most favorable hygienic conditions. Such measures should be resorted to as support the constitutional powers and encourage the due performance of the different func- tions of the body. Excess of food, by inducing vascular plethora and general excitement, will predispose to fever, whilst moderate exertion of the mind and body, and the inculcation of habits which neither overexcite nor depress, will enable the child of delicate physical organization to resist the infectious effluvia or other epi- demic influences which strike down the robust and strong. In districts where the soil is low and heavy, and there are many trees, children should not be exposed to the night or morning air on an empty stomach, and if it can be managed their apartments should be at the top of the house. In the autumn season of the year an occasional dose of quinine and a mild aperient will be advisable in unhealthy localities. In short, a due regulation of the digestive and secreting functions should be observed, and all causes that morally or physically depress the system should be carefully avoided. When the impression of fever has been made, its full development may sometimes be prevented by a careful diet, rest in bed, laxative medicines, and cooling drinks ; by the employment of a warm bath, or determining the blood to the external surface. Although these measures ma}' not arrest the fever, they will con- trol the premonitory stage, and render the subsequent disease milder and shorter in its duration. We shall treat of the serious complications that arise in the course of the specific fevers under their respective heads. Simple febricula^ or feverishness, is the term I would employ to express a slight degree of febrile action. It may be classed as a mild grade of inflammatory or continued fever terminating in twenty-four hours, or lasting over a few days. The aft'ection is not jjeculiar to children and may occur to adults. The mildest variety is generally caused b}' fatigue and exposure to the sun in hot weather, or by prolonged mental excitement, or by continuous study in close rooms. I have met with several instances of this kind and almost invariably in the summer season of the year. FEVERS OF CHILDHOOD. 81 when the weather has suddenly changed, and Ijecome hot and re- laxing. In May, 1877, three children, aged respectively five, seven, and eight years, were brought to me in the Out-patient De- partment of the Samaritan Hospital on the same day, with tem- peratures vaFying from 101.6° to lOi.i'" (rectum). May 14th. — The youngest child had the highest temperature. She had been ailing for a week, refused food, and was extremely thirsty and fretful ; there was a shrill croupy cough, and the hands and body were very hot ; pulse 140, respirations 50 per minute ; the tongue was whitish and moist, and one or both cheeks flushed both morn- ing and evening ; there was no diarrhoea, and the urine was clear. I thought the case very like typhoid fever, or acute tuberculosis; rather the latter affection. I ordered half a grain of quinine in a powder with sugar night and morning, and a mixture of citrate of potash and bromide of potassium three times a day. On the 17th she was no better, refusing beef tea and scarcely taking any milk; there was constant cough and the bowels were inclined to be loose. The temperature in the rectum was 104.2°, pulse 140, respirations 50. On admission as an in-patient two days later (19th), although no change had been made in the treatment, the temperature at 8 p.m. was 98.2°, and it never exceeded 98.6^ dur- ing the month she remained in the hospital. On a careful exami- nation of the thorax some slight mucous rales were detected when the child coughed or cried, but there was no dulness anywhere. The urine was cloudy and contained phosphates in abundance. A mixture of phosphoric acid and quinine was prescribed, and a w^eek later the child was running aboat the ward, eating an ordinary diet, and left the institution on the 16th of June quite Avell. In the absence of local or specific disease, we must classify these cases as "simple febricula" or "pyrexia." This fever is also the consequence of local irritation and tem- porary obstruction to the digestive functions. If the source of irritation resides in the stomach from an undigested meal, au> emetic gets rid of the offending mass, and subdues the fever at once. If digestion has advanced to the stage of imperfect chyli>- fication, the separation of nutritive elements does not properly take place, and absorption of well-selected elements does not ensue ; whilst there is retained in the intestinal canal matters^ which also become sources of irritation till an active aperient, washes them out of the system. Hence the rapidity with whichj 6 82 DISEASES OF CHILDREN. this simple variety of fever departs, leaving behind it no ill effects. Worms in the intestinal canal, excessive secretion of bile, indul- gence in stimulants may induce it. However simple the fever may be, it is marked by a coexistence of symptoms, and is not characterized by any single one. It depends on a variety of exciting causes, and is not specific, nor does it present anj^thing of a definite character like those cases of fever arising from conta- gion, in which there is a change in the healthy proportion of the constituents of the blood. During the period of the first denti- tion the infant is liable to pyrexia, which passes off with the ap- pearance of the tooth through the distended gum ; or it may have convulsions, which may depart quickly or return from time to time, and even end fatally if the process is slow, and the con- stitution is intolerant of the irritation through excitability of the nervous system. When the fever arises from the various causes which excite gastric or intestinal disorder, it may be called symp- tomatic fever, for there is neither shivering, brown tongue, nor active cerebral disturbance, which belong to the exanthematous fevers. Still caution is necessary, as severe fevers often set in with very mild symptoms. It is doubtful whether such cases ever lead to a fatal termination. The temperature from slight sources of irritation in these cases may rise to 105° Fahr. in the evening (as high as is common in typhoid fever) and fall to the normal point next morning. In fact, a high temperature in children is often a delusive indication when not viewed in connection with other symptoms.* In this symptomatic fever (for I still cling to the term in the short variety of the afl'ection) the lassitude and general weakness are slight, because the nervous centres are not severely depressed, whereas in the specific fevers they are sometimes involved to a great extent, and the cerebral functions are destroj^ed or seriously in- * " Cases of ephemeral fever, without any very serious foundation (bedeutungnvolle Begrundung), are particularly cliaracteristic of the period of childhood. Therefore, in children's diseases, even when we find a very high temperature, we must be very ■ careful in drawing conclusions from the first (or a single) observation. At tiiis age also more or less high temperatures may occur at stages (Punkten) in the course of a • disease, in which we generally find very moderate or normal temperatures in the adult. And even in convalescence, especially after muscular exertions, very considerable ele- ^vations of temperature are sometimes met with in children." — Wunderlich, On Medical '.Thermometry, New Syd. Soc, 1871, p. 208. TYPHOID FEYEE. 83 volved, as when effusion takes place, or the concentration of the special poison partially or completely paralyzes them. Treatment. — This consists in the tirst instance in giving cooling drinks, and, in the shape of nutriment, nothing beyond milk and seltzer water. A few^ alterative doses of gray powder and rhu- barb, or a brisk purge, wnll bring down the temperature and soon set matters right. Sometimes an emetic acts like a charm. The cause has only to be removed, and, if not long in operation, the child is quickly restored to its usual health. There is no serious congestion or irritation of any particular organ, and consequent I}'' the depurating functions are only temporarily impaired. As soon as the fever begins to decline (or before, if there is much moisture on the skin) quinine given three times a day will be found of great service. In those cases where there is a febrile paroxysm morn- ing and evening, I am in the habit of giving quinine before it is expected to come on, and when it is fully developed I recommend a simple saline mixture, cooling drinks, and cold sponging. Where there is much cerebral excitement it is well to give the quinine in hydrobromic acid. CHAPTER YIII. TYPHOID FEVER. Definition and variotis meanings — Infantile remittent fever and typhoid fever synonymous terms — Symptoms, cmirse, and progress — Complications and sequelce of typhoid fever — Treatment — Diagnosis of typhoid fever from meningitis — Acute tuberculosis— Symptoins dependent on the severity of the fever poison — Epistaxis — Scematuria. Typhoid or enteric fever is distinguished by the prevalence of gastric and intestinal symptoms. It has received the name of in- testinal fever, pythogenic fever, and muco-enteritis. Most German writers call it abdominal typhus (typhus abdominalis). In ad- dition to these terms, there is the well-known name of infantile remittent fever. I must disavow at once any belief in infantile remittent fever as caused by a separate and distinct poison, or that the disease differs in its nature or causes from that of typhoid. I can conceive few greater blunders in practical medicine than to consider this a 84 DISEASES OF CHILDRElSr. separate and distinct affection, not following the sanie course as tj'phoid fever, and not leading to the same complications. To me it seems, however, that there is a condition to which this term may he applied without causing confusion ; it should be limited to the Ttiildest cases, which usually run a quick course, and do not de- velop into the severe and unmistakable typhoid. The term may be vague and ill -defined, but it conveys to the minds of many persons a form of mild fever arising from miasmatic influence like typhoid, and attended witli much gastro-intestinal disturbance. In these milder cases we have no characteristic rash, and the short duration of the fever in some children does not allow of its being classed under the name of a specific disease. The pyrexia is due to a depraved condition of the alimentary canal, of long or short duration, and when this is corrected the disease quickly departs. To such cases as these the term typhoid fever could not with propriety be well applied. I would not, however, mix it up with simple febrile disorder, nor with fever symptomatic of worms, dentition, and visceral derange- ment, which pass away as quickly as these conditions are remedied ;* but it is something more chronic and intractable, lasting only a few da^^s in some instances, whilst in others it has the duration and all the attendant complications of the genuine typhoid state. To these milder forms, caused by the imbibition of a small dose of fever poison, I wish especially to draw attention. If we will ac- cept the term with this understanding it cannot mislead us. In the nomenclature of diseases, drawn up by the Royal College of Physicians of London in 1869, infantile remittent fever is rightly mentioned as synonymous with enteric fever, and among most medical men 1 presume its close relationship to this fever is now settled. Writers in France, Germany, and Italy acknowledge the same classification. They speak of infantile remittent fever in children as being the same as typhoid fever in the adult, but inas- much as they give it this name they certainly recognize some dis- tinctive feature. We hear members of our profession, especially country practitioners, speaking of remittent fever in children as a distinct disease, and I have found the prejudice so great, and the belief so strong, that it has not been possible to convince them of the identity of the two affections. My main object will be to show * Vide Febris Ephemera. TYPHOID FEVEE. 85 that this remittent fever, in its severe forms, is intimately con- nected with the course and complications of typhoid fever. Ty])hoid fever frequently sets in insidiously, initiated by chilliness or slight rigors, frequent and soft pulse ; then ensue febrile symp- toms and thirst, with diarrhoea and abdominal tenderness; to this succeed tympanites and gurgling in the right iliac fossa. The skin becomes hot, and there is occasional sweating. From the seventh to the fourteenth day an eruption of rose-colored spots appears over the abdomen, there is headache and prostration, followed by stupor and delirium. After death there is discovered disease of the agminate and solitary glands of the ileum, and enlargement of the mesenteric glands. When death takes place early, the morbid changes are chiefly found in the small intestines, spleen, mesenteric glands, and bronchial raucous membrane. The heart may contain coagula, and its muscular substance be soft and pale, with or with- out incipient molecular decay.* The spleen is generally enlarged in the first or second week, but returns to its normal size by the third or fourth week. Whether we call this disease in children typhoid, or remittent fever, it comes on very gradually in some cases, and sets in with severity in others. It follows a course in children similar to that in adults. In the mild form the child is off his appetite and out of sorts for some days ; he complains of thirst, is fretful and irri- table, and ceases to be cheerful or to take pleasure in his usual amusements; his nights are disturbed and unrefreshing; the bowels are confined, and the motions dark and unhealthy, so as to need aperient medicine, or they may be loose and offensive from the onset. Then succeeds heat of surface, followed by perspira- tion and a lowering of temperature. During the first week the abdomen may be natural in shape, and free from tenderness ; but there soon follows some amount of tympanites, and pain over one or both iliac regions, when pressure is applied with the hancl. In the evening there is a febrile exacerbation, with accelerated pulse and breathing, the lips become dry, and the tongue is coated on the dorsum with a whitish-yellow fur. There may be two exacer- bations in the twenty-four hours, but commonly there is only one. It is from the recurrence of these exacerbations that the term "remittent" is derived. During the night the child becomes * Yogel on Diseases of Children, p. 177. 86 DISEASES OF CHII.DREIS'. more restless and disturbed; he is wandering and talkative, and the cerebral functions may be sufficiently disturbed to produce delirium ; in the morning he looks pale and exhausted, but im- proves during the day till evening returns, when he is again fever- ish and drowsy, and this may happen for several successive nights. Sometimes there is a morning exacerbation (about 10 or 11 a.m.), and this has scarcely subsided before the evening paroxysm sets in. He now loses flesh rapidly, and is dull and indifferent to all that goes on around him. During the second week, but seldom before the tenth day, fever-spots make their appearance on the abdomen, though they are frequently altogether absent or few in number. The eruption is of a light-rose color, scarcely elevated above the surface, disappearing on pressure and quickly reappearing when the pressure is removed. All the symptoms increase in severity, and the pulse may reach 140 to 160 ; the tongue is more heavily furred, or brownish in the centre, red at the tip and edges and contracted; the urine is scanty and high-colored, but sometimes it is clear throughout the fever, and alkaline without the slightest turbidity ; diarrhoea is continuous, and the motions are of a yellow- ochre color, and of a thin pea-soup consistence. In exceptionally severe cases blood and mucus may be present, and when so they indicate more than usual ulceration. About the beginning of the third week, in favorable cases, the symptoms begin to decline and a general amelioration takes place; the bowels act more regularly and become more natural, thirst diminishes, and the pulse loses its frequency, the tongue is more moist and clean, and the evening paroxysm diminishes. The child resumes a more cheerful and healthy appearance, but he is left weak and emaciated. When the disease sets in with great severity from the onset, it is accom- panied by headache and vomiting, the child rolls his head to and fro on the pillow, and is only half conscious when roused to answer a question, or awakened out of sleep Many of the symptoms are similar to those just descpbed, except that they are proportionately more severe, especially the evening exacerbations of the fever. There is difficulty in forming a diagnosis at the beginning of the illness, as the vomiting and cerebral symptoms may lead to the inference that the brain is the organ primarily at fault. The drowsiness is sometimes extreme, and when there is the additional symptom of constipation we may be reasonably mistaken in fixing the true seat of mischief. But soon the vomiting ceases, and by TYPHOID FEVEE. 87 the second or third day the peculiar heavy aspect of fever is recog- nized, and the child sinks into a state of stupor or indifference. The skin becomes hot and dry, and the temperature runs up to 103° or even to 105°. When it reaches the latter height at an early stage of the illness we may generally rest satisfied that the symptoms are not attributable to meningitis. Fever-spots may now he looked for, but their presence does not seem to bear any relation to the mildness or severity of the fever, and they are sometimes absent altogether. The pulse is always frequent, and if it con- tinues so is to be regarded as an important symptom. In some children, whose nervous irritability is more marked, it will exceed 140, and remain so as long as the fever and temperature continue high. It may run up to 180 and be too rapid to be counted. " An intermittent pulse seldom occurs in children, and I do not remem- ber to have ever met with a dicrotic pulse in children under ten years of age."'^ This remark requires some qualification. An ir- regularly intermittent pulse is common in the neurosal affections of children when there is no valvular disease of the heart. About this time (second week) there' is often hacking cough and hurried respiration. There is constantly to be recognized some rhonchus or coarse crepitation over the jjosterior surface of the luno;s, even if auscultation reveals nothino; in front. If the disease has lasted long we shall almost invariably detect these signs, or even crepitant rhonchus with a low degree of pneumonia. If the abdomen has been hitherto soft and free from tenderness, a sense of discomfort and pain is complained of at this stage, and there is tympanites with gurgling, and the bowels act five or six times in the twenty-four hours ; the tongue is more thickly coated, and there is a red streak in the centre, and in the course of the next few days it is glazed, smooth, and red, whilst the gums are dry. During the second week the stupor becomes more profound, or active delirium appears, and the child is noisy at night and attempts-, to get out of bed ; he is unconscious of all that goes on around^ him, and the evacuations are passed involuntarily. Epistaxis ia- not uncommon. In a few cases the bladder becomes distended and the urine dribbles away. On examination it may be found albuminous. There may be even convulsions and noisy delirium^ but the insensibility is not so profound as that generally met witk in brain affections, and the morbid stupor of fever is characteristic. * Vogel, On Diseases of Children, 1874, p. 180. 88 DISEASES OF CHILDREN. In fever we do not as a rule witness the strabismus and irregu- larity of the pupils, nor the screwing up of the eyelids as in cere- bral disease. The child may be noticed to pick his lips and nose, and make them bleed, and there may be subsultus. By this time there is great emaciation, and the child is so reduced that it seems beyond the hope of recover3\* By the seventeenth day, or the close of the third week, some signs of amendment in returning intelligence are observed, and the pulse becomes less frequent, whilst the tongue begins to be moist, and the sordes disappear. If no improvement sets in the vital powers become more and more depressed, the typhoid condition increases, and the child sinks from exhaustion. This is most likely to happen about the fourteenth or fifteenth day, but it may be protracted to the fourth or fifth week, or, indeed, indefinitely prolonged, according to the complica- tions that are present in each particular case. When death takes place during the first week of the fever it is generally due to cere- bral disturbance or some other serious complication, as epistaxis or intestinal haemorrhage. The latter condition is rare in children. Of the sequelfe of typhoid fever in children we may mention diarrhoea, inflammation of the parotid gland, and tuberculosis. Dr. Clifl:brd Albutt has pointed out that the mesenteric glands are often so injured by typhoid fever that nutrition is very much impaired; and it is under these circumstances that tuberculosis is apt to show itself, whilst the period of convalescence renders the constitution liable to measles, scarlatina, and whooping-cough. The mortality is only 5 to 10 per cent.f In proportion to the severity of the fever convalescence is rapid or slow. In severe typhoid there is great emaciation and muscu- lar prostration, lasting many weeks, and the child is greatly re- duced in flesh and strength, but bedsores are seldom seen. Meigs and Pepper say that typhoid fever may attack children * " Wliether the musciilar wasting in fever is the cause of an increased temperature, or tlie increased temperature melts down the muscular structures, may not be positively affirmed, but there exists no doubt as to the fact. After a severe pyretic affection, the muscles of the limbs are often wasted to an extent quite surprising when compared to the adij)Ose layers. The lax and shrunken Jiand betokens the diminution in the bulk of the interossei and otJier muscles. In liectic fever the muscles seem sometimes to have almost entirely disappeared at death, tlie patient being, as it is called, ' only skin and bone.'" — Dr. Miliier l^^otliergill, "On tlie Typlund Condition," Edinburijh Jledical Journnl, September, 1873. f Meigs and Pepper, Diseases of Children, 1874, p 832. TYPHOID FEVER. 89 luider two years of age, or as early as the eighteenth or twentieth month, but it must be acknowledged that the disease is rare under five years of age. A ease is recorded by Dr. Dunbar Walker, seen in consultation with Dr. West, of "enteric fever in a child fifteen mouths old,"* and Dr. AViltshire also mentions having seen, with Dr. Walters, of Reigate, "a well-marked example in an infant aged six months."! The morbid appearances when the disease ends fatally are chiefly seen at the lower end of the ileum, the most entensive mischief being found near the ileo-C£ecal valve, where there is shown a ten- dency to destruction of the mucous membrane, and ulceration or even sloughing, or perforation of the peritoneal coat. The glands of Peyer's patches take on the appearance of vesicles or pustules, and subsequently they burst and produce an ulcer, with oval or irregular outline, havino; thin and undermined edges. The ileum is the chosen seat of these ulcers, but they may be seen scattered through all parts of the intestine, large as w^ell as small. It is common to meet with enlaro-ement and softening of the mesenteric glands, and in severe and rare instances they may take on suppu- ration. Treatment. — During the gradual approach of the disease, when there is thirst and loss of appetite, the child must not be tempted to take food which it cannot digest. Thirst should be relieved by small draughts of cold water, or toast and water, about a table- spoonful at a time, and. a simple saline mixture of citrate of pot- ash, or a mixture of nitrate of potash with a few grains of sulphate of magnesia, if the bowels are confined (Form. 8). For the first few daj'S scarcely anything but cold water is required. If the secretions are dark and offensive, an alterative powder of hydrar- gyrum cum creta with a few grains of rhubarb will be necessarj^ or the syrup of senna and rhubarb, or even castor oil, should there be discomfort or pain in the abdomen. When there is tenderness of the abdomen, a warm poultice is comforting ; and if there is pain Dr. West recommends a few leeches, which I have never found necessary, and I should try other means before resorting to them. The excitement and restlessness at night may be greatly relieved to the advantage of the patient by bromide of potassium alone, or in combination with hydrate of chloral. They have proved of such value in my hands in all cases of wakefulness from * Brit. Med. Journal, vol. i, 1879, p. 347. f Ibid., vol. i, 1879, p. 427. 90 DISEASES OF CHILDREN'. , . nervous exhaustion that I recognize them as valuable calmatives in fever. Dr. West speaks highly of a combination of tartar emetic and opium. "A draught containing five minims of lauda- num, and a quarter or a third of a grain of tartar emetic, will be a suitable anodyne for a child of five years old, and may be re- peated night after night with almost magical efl'ect."* One drop of laudanum, or something less, for each year of the child's age, in restlessness and excitement, will often induce refreshing sleep ; and it may be repeated, should circumstances appear to demand it, without giving rise to any bad effects. If there be much heat of scalp and the vessels are full about the temples, and the con- junctivae injected ; if the delirium is wild and the excitement fierce, then we ought certainly to shave the head, and apply four or six leeches. These symptoms often succumb to the local abstraction of blood, and life has thus in many cases been saved. The head symptoms that occasionally supervene in an advanced stage of the disease are very ominous, and require counter-irritation ; they are often attended with squinting, and there is some amount of ob- scure meningitis with eftusion, which may ultimately terminate in acute hydrocephalus. The temperature of the room should not exceed 65°, and all unnecessary articles of furniture and luxury should be removed; the clothing should be light, the head shaved or the hair cut short, and the head elevated on the pillow. During the second week, when the vital powers require support, milk, beef tea, and chicken broth will be needed ; and, if there is diarrhoea, milk, arrowroot, and rice-water, flavored with cinnamon, must be substituted for animal broths. Milk is apt to be overrated in fever, for where the bowels are loose and irritable, and the stom- ach weak, as we expect to find it in the first week or two of the fever, the milk is too heavy to be digested, and the curd, acting as an irritant when the fluid portion is absorbed, provokes diar- rhoea, and even keeps it up if present. It should therefore be di- luted with seltzer water, or lime-water, and in many cases it may be replaced by beef tea, or, what is better, barley-water, beef tea being apt to induce and keep up purging. When diarrhoea is troublesome, a grain or two of Dover's powder at bedtime, or a starch enema with a few drops of opium, or bismuth will check the irritation. A grain of acetate of lead with acetic acid every * West on Diseases of Children, 1859, p. 392. TYPHOID FEVER. 91 three or four hours is sometimes of service (Form. 29). A mixture containing rhatany root* is an excellent remedy after each evacu- ation, and the child may be allowed a little port wine in arrow- root. Stimulants are not often required under ten years of age if the child can digest sufficient nourishment, but cases occasionally occur where life has been saved by a free exhibition of them. A teaspoonful of brandy every three or four hours in water or thin arrowroot will restore the tone of the nervous system, and sup- port the faltering circulation. Alcohol proves serviceable by dilating the cutaneous capillaries, and encouraging perspiration. In the shape of medicine, a few drops of dilute hydrochloric acid with spirit of chloroform, as in the case of adults, will be usefult if there is no abdominal pain or discomfort ; and in low febrile conditions, where there is no diarrhcea, quinine with phos- phoric acid is an excellent measure.* Diagnosis. — The cerebral complications of typhoid fever in children are most important. § Like the bowels and the lungs, the brain is liable to be attacked in the course of typhoid fever, and young patients more than those of mature years, are very prone to be carried off by cerebral complications. The febrile process once established creates disturbance and excitement in the nervous * Formula 4 : R. Tinct. kramerife, . ^iij "Kxx S-ss. 5iv.— M. Liquor opii sed., .... Spt. chloroform, .... Syr. zingiberis, ..... Aquam ad ..... A dessertspoonful after each action of the bowels. For children from five to eight years of age. t Formula 5 : R. Acid, hydrochl. dil., . . . . . . . "JJxl Spt. chloroform, ........ "Xxx Syr. rosfe, . . . . . . . . . 5ss. Aquam ad ........ . §iv. — M. A dessertspoonful every four hours. I- or children from five to eight years of age. X Formula 6 : R. Quinise sulph., ........ gr. iv Acid, phosph. dil., ........ ^j Syrupi, . . . . . . . . . ^ss. Aquam ad ........ . .fiv. — M. A dessertspoonful three or four times a day. For children from five to eight years of age. § See the abstract of a paper on this subject read before the Harveian Society by the author. Brit. Med. Jour., Feb. 14th, 1S75, p. 122. 92 DISEASES OF CHILDREN. system at a time when its active growth and rapid development are ill calculated to bear this extra strain. If simple inflamma- tion of the brain comes on now and then in healthy children, I think it may occur during the progress of typhoid fever in rare and exceptional cases. The blood is changed, the nervous system is excited or depressed at one stage or another, and the functions of assimilation are perverted or destroyed, and efiete matters from the decomposed tissues are not properly eliminated from the system. Setting aside the injurious etfect which the circulation of poisoned blood at an elevated temperature must have on the nervous centres, there seems no satisfactory reason why the cere- bral changes should be restricted to congestion of the vessels, or simple vascularity of the membranes. Xow, it should be fully understood, and experience confirms the truth of the statement, that vascularity of the cerebral mem- branes is by no means infrequent in persons dying from typhoid, w^iere the brain has escaped altogether during the progress of the disease. If the lungs are involved, as they frequently are in typhoid, and there is any amount of pneumonia, or interference with the pulmonary circulation ; if the heart grows feeble, from increasing exhaustion of the j^atient, and its cavities become in any way oppressed, then congestion of the brain orit^ membranes will he frequently found after death ; the cause has been mechan- ical, and we may term the condition one of " passive congestion." Ko relation can be established between the cerebral symptoms and the amount of vascularity which the membranes of the brain reveal. If we judge from the character of the delirium, or the convulsions, and the general insensibility of the patient, that these symptoms indicate excessive congestion or inflammatory action, we shall be deceived, and errors of diagnosis wnll certainly lead us into errors of practice. The diagnostic symptoms of meningitis and typhoid fever are plainly drawn in our textbooks ; but those who have seen much of the cerebral and abdominal diseases of young children must admit the frequent difficulties that beset their path. The worst cases of all for diagnosis are those in which a strumous child is seized with tubercular disease in the abdomen with diarrha3a and other intestinal symptoms ; there is nothing to call attention to the brain till coma or convulsion sets in. Still, the ai:)proach of meningitis is slower and more insidious ; it is less severe than TYPHOID FEYEE. 93 typhoid fever, and at an early stage very rarely presents tlie high temperature of the latter atfectiou, which is a diagnostic sign of great value. We cannot, therefore, invariably separate typhoid fever in young children, characterized by a distinctly remittent type, from cere- bral meningitis, especially when the child is under live years of age. The symptoms of one disease or the other must predominate before we can decide with which we are dealing. Usually the bowels are constipated in the cerebral disorder, and vomiting comes on without cause, whether the stomach contains food or not ; the belly is normal or retracted, the pulse less frequent, and liable to irregularity in force and frequency. Above all, the tem- perature in meningitis is generally elevated towards the decline of the complaint, and only runs high at an early period in excep- tional cases. The ophthalmoscope is another aid to diagnosis iu obscure cases.* If the symptoms are mixed together in various degrees, and there is irritation of the digestive organs, and cerebral congestion or inflammation, then, if with severe diarrhoea there are thin, ochrey, and slimy stools, heat of skin, loss of appetite, thirst, and flushed countenance, we say this is a case of fever ; but if there supervene in a few days uneasy gestures, strabismus, loss of con- sciousness, picking of the lips and nose, retching or vomiting, then we infer that the brain has been attacked in course of the fever, and the symptoms are the result of exhaustion or overexcitement. Our diagnosis must mainly rest on the order in which these symptoms have occurred. We must not dwell too much on the fever process, and set down the vomiting and carebral symptoms to gastric disturbance, whilst the brain has been slowly and im- perceptibly going wrong, and is, perhaps, the chief source of trouble. If the physician is called to see the case early, and an exact account of the mode of invasion has been furnished, his judgment will seldom lead him wrong, if he carefully weighs the evidence on both sides, and notes the absence or prevalence of fever in the same house. Acute phthisis or tuberculosis may be mistaken for typhoid fever. A quick pulse, hurried respiration, circumscribed flushing * See Chap. XLII, " Diseases of the Brain — Simple Meningitis and Tubercular Meningitis." 94 DISEASES OF CHIT.DREK. of the cheeks, emaciation, delirium, mucous rales iu the chest, and high temperature are common to both aftectious.* In some adults suffering from tj^phoid fever we witness the evening flush on the cheek with great regularity and persistence. In other cases, with all the symptoms precisely similar, the face is pallid, and without the faintish blush. This points to a recurrence of the febrile condition with greater force, and often indicates, as the disease advances, serious local changes, either in the intestines, thorax, or brain. So far it is" a symptom of grave import when it recurs at a late period of the fever. The periodical flushing is not peculiar to fever as fever. It belongs to the nervous system, and may ensue from many causes. The nervous system is highly hn- pressible in children, and their diseases have a great tendency to remission. Witness the flushing of the face and heat of head in some of the cerebral afiiections of young subjects, coming and going like an attack of ague. Or, again, in dentition, nothing is more common than for the child to wake up restless, with hot head and flushed cheeks. Common gastric disturbance will cause the same symptoms, which vanish with an active purge. Fever affects the nervous system through the poisoned state of the blood, and the depression, the reaction, and the subsidence all depend upon it. We know that this is the true explanation of the dangerous con- gestions and inflammation of the liver, lungs, or brain, that are liable to occur in the progress of fever, adding to our difficulties, and taking us out of the prescribed course to meet such serious complications by local depletion, diuretics, stimulants, and so forth. May we not fairly come to the conclusion that there are degrees, nay, even varieties of fever originating from a common cause, and that, whilst it is the exception to meet with a case where there is any difficulty in recognizing the variety before us, we sometimes see cases in which the symptoms are not sufficiently defined to enable us to say what form of fever we have to deal with. Thus, the remittent character of the disease is very well marked in some cases, but to this are added symptoms which some authors have enumerated as belonging to a distinct afl:ection they call gastric fever, and subsequently symptoms which we regard as belonging to typhoid fever. It appears certain that infantile remittent fever, * See Chap.s. XXXIX, XL, " Oa Tuberculosis," and "On Plitliisis Pulmoualis." TYPHOID FEVER. 95 well developed, embraces both tbese types, or ratlier that identical symptoms frequently supervene. There is, however, a caprice in fever which should put us on our guard. The fever-poison, assailing the system for weeks, works such changes in the blood and tissues of the body, that we can never be certain we have landed a case of fever in safety, so long as there is much departure from the standard of general health. Some of the worst cases of epistaxis, hsematuria, and bleeding from the bowels have occurred when patients have be- come convalescent from fever, with clean tongue, regular pulse, and ffood digestion. If we have reason to think that the tone and quality of the blood have suffered much, either from the fever itself or the remedies employed to reduce it, we should as early as possible begin such treatment as shall gradually replace the solid constituents that have been destroyed. The haemorrhages are not altogether confirmatory of the typhoid character of the disease. Any causes that tend to bring about an impoverished condition of the blood may produce the complication. In scurvy and pur- pura, and fevers of a low type (in all of which serious haemorrhage may occur), the changes in the chemical composition of the blood are nearly identical. Intestinal haemorrhage occurs in typhoid fever without ulceration ; it is met with in cases described by some writers under the vague head of gastric fever. Sometimes, though rarely, a patient succumbs to haemorrhage in typhus also, and it would seem that the fever-poison — whether typhus or typhoid^ but more especially the latter, and in the more severe remittent forms which merge into the continued type — leads to the same issue. In one case you will find rose-colored maculae on the chest and abdomen, and the tongue red and papillas elongated. There is no tenderness of the belly and no diarrhcEa. In another case the fever is of a very low type, partly from the severity of the poison, and partly from the age and constitution of the patient. The teeth are dry, the tongue is covered with sordes, but there is no diarrhcea. On inspection after death ulceration is found in the lower part of the ileum. We meet with another case in which there is a plentiful eruption of rose-colored spots, but there is no diarrhoea ; on the contrary, there is constipation, and the bowels are diflicult to move. In another case there are fever-spots and severe headache. In another, delirium at night, severe bowel ir- ritation, and rose-colored spots. These cases, and they are not 96 DISEASES OF CHILDREN. infrequent, tend to show that the symptoms are not always alike. We cannot say that a case of fever is not typhoid because there exists no diarrhoea, and we cannot predict that there exists no ul- ceration because there is constipation. We are accustomed to think that if the bowels are quiet in fever the patient has a good chance of doing well, that the intestinal canal is at all events free from any lesion ; but what I think is a surer sign of the mucous membrane being healthy is a normal state of the evacuations, without the offensive odor th-at is present whenever there is ulcer- ation. How^ever well cases may be progressing the general health is liable to break down unexpectedly by further contamination of the blood, and the entry into the veins of infectious particles from the ulcerated glands in the intestines. Mere quietude of the bowels is not, as I have just said, any proof that the glands have escaped. Perfect uniformity in the order of symptoms does not occur ; diseased action is not uniform. It would be neither a safe nor a scientific hypothesis to lay down the rule that all diseases possess a uniform phalanx of symptoms. This is modified and in- fluenced by a variety of circumstances. There is a simple form of fever, and a severe form of fever. Both, so far as our present knowledge goes, are intimately allied, but one is transient and slight, and the other is severe and dangerous. To go a step further in the same direction, it would appear that the cases described under the head of gastric fever and typhoid fever are one and the same in their nature, progress, and termina- tion. The stomach may be more involved at one time than at another, as evidenced by the prominent papillce of the tongue, and the gastric disturbance and vomiting, but it is the same fever not- withstanding. Let it also be borne in mind that constitutional power varies as much as it influences the course of a disease. Vitality is stronger and resistance is greater in some persons than in others. The de- gree of local change discovered after death is often slighter than is proved to have been present in cases that have recovered. Be- cause some diseases end fatally, we are not necessarily to flnd tangible evidence of the cause of death on dissection. To some constitutional idiosyncrasy — apart from organic change or the effect of specific poison on the blood and nervous system — we must often ascribe the tendency to sink; so we must also regard as a SPECIAL ERUPTIVE FEVERS. 07 mystery that tenacity of life which remains, when all hope of saving it has apparently passed away. CHAPTER IX. SPECIAL ERUPTIVE FEVERS. Their dassif cation and general sxjmptoms — Vaccinia — Varicella — Character of the eruption — Diagnosis from small-pox — Treatment. The special eruptive fevers of childhood are vaccinia, or cow- pox; varicella, or chicken-pox; variola, or small-pox; rubeola, or measles ; scarlatina, or scarlet fever. They are all due to the reception of a poison into the system, which, after a variable pe- riod, sets up tolerably uniform constitutional symptoms. There are shivering and rigors, or even convulsions, cold along the spine, loss of appetite, headache, languor, and disturbed sleep ; then re- action comes on, followed by fever, heat of skin, and the specific eruption. These are the chief symptoms which mark the onset of the exanthemata. They often prevail as epidemics, and these present very opposite characters in the degree of vascular action and the power of resistance. Though some epidemics are mild, they are as a rule more severe than those of sporadic occurrence, and the severity of the attacks and their complications depend on age and constitution ; upon hygienic conditions, and the season of the year. If the health is lowered by previous illness they attain greater force, and the mode of early treatment may determine the result. They pursue a determined course, and active interference is sometimes more injurious than when the unaided powers of nature are left alone, for in this way it is possible to invite various affections more dangerous than the original malady. The exan- themata generally attack persons only once in life, and that at an early period. Scarlet fever is the most likely of these diseases to happen a second time, and it is the occasional accompaniment of measles. Small-pox and measles may also be united in the same individual ; and a severe attack of whooping-cough may set in be- fore the latter has departed. Vaccinia, Cow-pox, or Vaccination. — The virus of cow-pox when introduced into the system produces a specific disease, only modi- 7 98 DISEASES OF CHILDREN. fied by its passage through the cow, or one of the lower animals. Vaccination so induced is protective against variola or small-pox. Cow-pox is a vesicular disease, occurring chiefly on the teats and udders of cows ; it is natural to them, and as a disease of spon- taneous origin, occurs almost exclusively to the milch cow, and follows a uniform and definite course. About the fourth day of invasion a few red and tender pustules appear on the teats and udder, which change into vesicles, and pass through the same stages as in man. From the friction used in milking, the vesicles burst, and the lymph which exudes sets up similar sores on the milker's hands, and in this way the disease is conveyed to other animals in the dairy who were previously well and healthy. After successful vaccination there is nothing certain to be observed till the third day, when a small red nodule is noticed ; on the fifth day an oval or circular vesicle is seen, depressed in the centre, and containing a little lynmh. There may be as many spots as punctures a day or two before, but in many cases we cannot say they are due to the virus. On the eighth day the vesicle is increased and threatens to burst, the centre is depressed, and there is a large quantity of transparent fluid. The vesicle is at its highest state of perfection ; the skin for some distance around it is inflamed of a rosy hue, and the subjacent areolar tissue is hard, tender, and painful. The child is fretful and feverish, and his nights restless and disturbed. On the tenth or the eleventh day the areola has extended, and the greater part of the arm may be erj'^thematous. If the vesicle has not been opened it now bursts, and the centre dries into a hard dark scab, and falls ofl:' about the twenty-first day, leaving a deep circular depression or cicatrix, with several pits or dots, having a whitish or more pearly look than the rest of the arm. In children who are young and of full habit an eruption of roseola sometimes takes place on the body and extremities, having a papular or vesicular appearance; it occurs about the ninth or tenth day, and lasts about a week. Vaccination does not follow the same course in all cases, the vesicle being developed earlier in some cases than in others, and instances of retarded cow-pox are sometimes met with, particularly when dry lymph is employed. When the health is good, children should be vaccinated early, but when they are delicate it should be postponed till they are stronger. " It is enough to state that one fourth of the deaths of small-pox in England occurs under the age of one year. SPECIAL ERUPTIVE FEVERS. 99 Of 20,590 deaths from small-pox which occurred in England in the six years 1856-61, 5000 were in children under one year of age."* There is no exact rule to go by as to the time of taking the lymph, as the vesicle varies in its progress to perfection, but it should not be taken later than the eighth day ; sometimes it is ripe on the fifth or sixth day, and this happens when the arm has become inflamed from the moment of inserting the vaccine. In vaccinating children some precautions are necessary to be observed. No child who is out of health, or has recently had scar- latina or measles, or has a chronic skin eruption, should be vac- cinated. If boils or a pustular eruption follow vaccination they will demand alterative medicine, tonics, and good air. These sequelae are occasionally intractable, and the ulceration on the arm may prove most rebellious to treatment. I have often witnessed the inflammation so great as to require the constant application of lead lotion under oil-silk, or warm fomentations. Wasting of the deltoid, and paralysis of the arm, followed vaccination in a case I saw in 1873. Sloughing and protracted ulceration of the shoulder ensued in the case of a child, four months old, brought to me in June, 1880. "A case of fatal pypemia after vaccination " is recorded. f I am not an advocate for vaccinating children before the third month, but it is done by some medical men as early as the sixth week. I^prefer vaccination from arm to arm, but where this cannot be done the vesicle should be punctured with a lancet, and the lymph collected in an open capillary tube, drawn up by capillary attraction. One end of the tube must be placed within the vesicle, taking care to avoid contact with the blood or pus. When it is full, the ends of the tube are to be closed by holding them in the flame of a spirit-lamp or candle. In deciding upon the spot for vaccination, the arm just below the shoulder is usually selected, and there is no better, for the part is hidden by the dress of women whether high or low dresses are fashionable. If there should be a growing naevus, or other ugly mark on the skin, it may be selected as a fitting spot for the opera- tion, and in many cases it lessens the disfia^urement, or destroys it altogether. Varicella or Chicken-pox. — This disease has also received the * Vaccination, by Dr. Seaton, Keynolds's System of Medicine, vol. i, p. 4S9. t See The Lancet, 1860, vol. ii, p. 263. 100 DISEASES OF CHILDREN". name of swine-pox or bastard-pox. It is botli contagious and infec- tious, and tlie eruption consists of small vesicles about the size of a hemp-seed, which never become pustular. It was formerly con- founded with small-pox, just as small -pox and measles were mixed np together and not recognized as distinct diseases. It is a disease of childhood and has never been known to occur a second time. The period of incubation lasts from ten to twelve days according to Dr. Murchison and Dr. Squire. Some authorities make it longer.* There is slight febrile disturbance, and the disease ends without any ill consequences, in the course of four or five days. The child is poorly and off his appetite; there is lassitude and flying pains about the limbs, and the sleep is disturbed. Small red pimples appear, which change into vesicles containing a thin transparent fluid, or slightly turbid serum. On the third day they mature and burst, and dry up on the fifth without leaving any mark as in variola, or having an inflammatory areola. The eruption comes out irregularly, and new vesicles may be seen just making their ajDpearance as the old crop are fading away. It is first observed on the body and back, then extends to the face and scalp, and lastly is seen scattered over the extremities. When the vesicles are pricked they collapse, and there is no swelling or distinct elevation of the skin. Children of all ages are liable to the complaint, but it is not so common after the seventh year. It cannot be communicated by inoculation; it is no protection against small-pox, and vaccination has no power to prevent the disease. The diagnosis from modified small-pox rests on the fact that the eruption of varicella is most marked on the back, the face often entirely escaping, and that owing to the eruption coming out in an irregular manner, all stages may be met with at the same place on the same day, whereas in small-pox the rash is either all papular, vesicular, or pustular. The treatment required is confinement to bed, a light fluid diet, and a saline and antimonial aperient. If any of the vesicles are umbilicated, and likely to leave a scar on the face, they may be touched with collodion. For any subsequent weakness that re- mains during convalescence, a little quinine or the syrup of the iodide of iron will be found necessary. * See Clin. Trans., 1878, p. 240, Observations on the Period of Incubation of Scarlet Fever, and of some other Diseases, by Charles Murchison, M.D. MORBILLI OR MEASLES. 101 CHAPTER X. MORBILLI OR MEASLES.* Varieties of Measles: 1. MorhiUl mitiores — 2. Morhilli (jraviores — 3. Morbill sinei catarrho — Symptoms of each form — Character of the eruption — Its lingering nature in some cases. Mortality, Causes, and Complications : Not always attributable to unhealthy localities — Frequency of bronchitis and pneumonia — Rapidity ivith which the lung becomes hepatized in some cases — Intestinal irritation and diarrhosa — False croup —Congestion of the brain — Pharyngitis and aphthous ulceration of the mouth — Swelling of the cervical glands — Case in illustration. SEQUELiE : Oancrum oris— Strumous ophthalmia and ulceration of the cornea — Otorrhoea — Suppuration of the cervical glands — Chronic diarrhoea — Phthisis. Treatment : Importance of maintaining a warm temperature and good ventilation in the sick-room— Utility of cupping where pulmonary engorgement and cerebral congestion are present — Value of stimulants in the typhoid stage of the disease — Bidimia. Ileasles is a more prevalent, but a less dangerous disease than scarlet fever, and the greatest proportion of children that fall vic- tims to it are under the age of five years. In scarlet fever the same rule as to age applies, though not to the same extent. Although measles is essentially a disease of early life, it may occur ahiiost at any age, and few persons at one time or another escape it, whilst scarlet fever frequently spares people altogether. The period of incubation is much longer than in scarlatina, and extends from ten to fourteen days, during which time the patient is apparently quite well. The eruption generally appears on the fourth day of the fever. In my own famil}'-, three children, who were laid up with it at the same time, exhibited a short febrile stage, the eruption appearing on the second and third days of the fever, and cases are unquestionably to be met with where the catarrhal symptoms and the eruption are coincident. f * "Measles and scarlet fever were long regarded as varieties of small-pox. Measles was first distinguished from variola by Abu Dschafar, and other Arabian physicians in the twelfth century ; but measles and scarlet fever continued to be looked upon as one disease, which was designated ' morbilli.' An Italian physician, Philip Ingrassias, of Palermo, in the middle of the sixteenth century, first described scarlet fever, which he called ' rossalia,' as distinct from morbilli or measles." — Clinical Lectures on Medi- cine, by Dr. Murchison. A Case of Rotheln, or German Measles, Lancet, October 29th, 1870, page 595. f Some degree of confusion and even error are apt to arise in calculating the dura- tion of the incubation period, some authorities reckoning from the time the poison is received into the system, and the first appearance of symptoms, whilst others calculate from the same period, till the eruption shows itself. If the former metliod of calculation is adopted it will reduce the incubation period to ten or eleven days. See Clin. 102 DISEASES OF CHILDEEN". Three varieties of measles are described : 1 . Morhilli mitiores. 2. Morbilli graviores. 3. llorbilli sine catarrho. 1. llorbilli. — The disease sets in with symptoms resembling the approach of a severe cold, or with a convulsive seizure. These are pallor, loss of appetite, and shivering ; tlie child is languid and heavy, and lolls where it can ; headache, drowsiness, and restless sleep, with wandering and screaming at night, are noticeable warn- ings. These symptoms are so severe in some children that it is difficult to prevent them from falling out of bed. About the third, or more frequently the fourth day after these premonitory signs, the eruption appears. At first it is not unlike fleabites, and may be seen on the forehead, face, thorax, and neck ; in one case under my care the eruption in the first instance seized the left cheek and neck, and twelve hours elapsed before the eruption appeared on any other part of the body ; there is scarcelj^ any on the arras and legs at the beginning, but in the coarse of twenty-four hours it extends to the trunk and extremities, and may be noticed on the back of the hands, the papules being darker, smaller, and less coherent. The eyes are suft'used and watery, and the conjunctivae injected in most cases ; but this is not necessarily so, and the eyes in the worst forms may have a dull look and be free from irritation ; or the lids may stick together, and the eyes remain closed during the activity of the eruptive stage. The mucous membrane of the nose and fauces is congested, and there is frequent sneezing ; the cervical glands are felt to be enlarged. The skin is hot, and the tempera- ture may run up to 104° or 105°, but in ordinary cases it will rarely be found to exceed 102° ; the pulse may range from 140 to 160, while the respiration is hurried and short. The bowels ar© generally costive, though there may be diarrhoea, and the urine is turbid and contains urates ; the tongue is covered with a thick creamy fur, which shows points of redness as it is removed, and the whole may become red and moist by the eighth or tenth day from the commencement of the symptoms. Pharyngitis, pain in swallowing, thirst, and loss of voice are frequently present, and the irritation extending into the lungs causes loss of sleep and Trans., 1878, p. 238, Observations on the Period of Incubation of Scarlet Fever, and of some other Diseases, by Charles Murciiison, M.D. MORBILLI OR MEASLES. 103 restlessness.* Remissions and exacerbations are comnaon, as in some other diseases of children. Vomiting is occasionally present at the commencement of the disease, but it is far less frequent than in scarlet fever, and is not so generally confined to the early stages. In one case, however, a child fourteen months old vomited thirty times a day, and before the eruption appeared I dreaded some cerebral affection. "Vomiting occurred during the first stage, sometimes almost as late as the eruptive period, in thirteen, and was absent in twenty-three cases, of which I have preserved records."f The little patients may bring up bile from the violence of the retching, and epistaxis from the fulness of the nasal vessels is not unfrequently met with. There may be no thoracic compli- cation in the shape of cough or bronchitis for the first two or three daj's of the eruption, but when it becomes more marked and de- veloped, and is raised above the skin in blotches, the cough, is in- cessant and irritating, and both small and large crepitation are heard throughout the chest. I have noticed the upper lobes of both lungs frequently attacked, and where the lower w^ere not the first to show signs of mischief, and that, too, in cases which were not tuberculous. This is owing to the extension of the inflamma- tion down the larynx and trachea to the bronchi. When the eruption is at its height, and the bowels are free, the pulse usually begins to fall in frequency, and the temperature declines, but the symptoms do not generally decrease on the appearance of the eruption ; they often increase, and the breathing becomes acceler- ated and embarrassed. On the seventh day of the fever the erup- tion begins to fade, and by the tenth day the child may be down- stairs and well, having scarcely any cough, or in any way com- plaining. In some cases there is only occasional loose cough, without any physical signs. The eruption, too, is variable. On the morning of the third day of the fever it may be copious on the face, and the papulae may be distinct and elevated above the * A delicate boy, aged six years, came under my care in March, 1877, and on the fourth day of the fever the temperature was 104.8°, pulse 176, respirations 28 ; and on the seventh day, when the eruption could scarcely be defined, the temperature reached 105°, pulse 200 running, respirations 60 ; there were extensive r41es through the front and back of tlie chest, yet the urine was copious, clear, acid, specific gravity 1022, and at no time of the illness did it throw down the slightest deposit, or deviate from health. As an instance of rapid recovery and convalescence, this little bo}^, who was near death on the 28th of March, and in a critical state for a week after, was running about the wai-d with scarcely any trace of catarrh on the 11th of April. t On Diseases of Children, by Lewis Smith, M D., Philadelphia, 1869, p. 461. 104 DISEASES OF CPIILDREN. surface ; by the evening the eruption may run together, and as- sume a large vermilion patch on the cheek. The constitutional symptoms run high, with considerable fever, thirst, and w^andering ; next day the eruption may assume a more purple hue, to be again followed by increasing brightness of color. Sometimes it is con- fluent, resembling scarlet fever, and the spots are dark and purplish from rupture of the capillaries, and remain for a length of time, and do not disappear on pressure. Sometimes the rash begins to fade as early as the fifth or sixth day, and from above downwards in the order in which it has first appeared. During the next two or three days the cuticle desquamates in furfuraceous scales. About this time diarrhoea is not uncommon, and if the weather is cold and great precautions are not observed, capillary bronchitis or pneumonia may supervene. If on the seventh day of the fever there is an increase of temperature, and the pulse and respiration are also more frequent, we may reasonably take alarm, because the symptoms have become aggravated at. a time when they ought to be better. In such cases I have known the eruption copious and dusky, with the features swelled, and the lips dry ; in a recent case under my care there was albumen in the urine from renal congestion, wandering at night, and diftused bronchitis. 2. MorbiUi Graviores — Malignant Measles. — The symptoms here are more severe from the first ; the eruption comes out irregularly, lasts longer, and has a dark-claret hue, which has received the name of black measles. It is slightly raised above the skin, and has the appearance of petechi?e. Some authorities do not consider this a distinct species, holding that the darker color of the eruption is due to imperfect decarbonization of the blood from pulmonary complication. The disease beginning as morbilli mitiores may pass into this grave variety. The constitutional symptoms are of a typhoid character, the pulse is frequent and small, the aspect heavy and bloated ; the tongue is dry and glazed in the centre, and sordes collect on the teeth ; the motions are dark and putrid, or there is severe diarrhoea. The lungs are early involved in capillary bron- chitis or pneumonia, and death takes place in many instances by asphyxia or coma. There is dry and constant cough, and the child is drowsy and indifierent. Kfiles are heard over the posterior sur- face of the lungs, and air enters them imperfectly. I have known them so loud, and the mucus so great in the tubes, as to give rise to physical signs bearing a close resemblance to the gurgling of a MOEBILLI OR MEASLES. 105 cavity, and yet in a week after the whole lung has been resonant, while scarcely a trace of bronchial irritation remains. The blood in these cases is dark and fluid, and the tibriu and solid parts are deficient. 3. 31orUlli sine Catarrlio. — This is by some regarded as merely a mild form of measles without the occurrence of pulmonary symp- toms; just as there are also cases in which the eruption fails to come out, and which, with all the other symptoms marked, must be classed as irregular forms of measles. The fact is, however, many cases of so-called morbilli sine catarrho are really cases of rotheln, or nothing more than varieties of erythema. The mortality of measles is estimated at 1.15 per cent., but the fluctuation is considerable from year to year. It is essentially a disease of early life, for it seldom recurs, and, unlike scarlet fever, the deaths appear to be greatest between one aud two years of age. After the age of five years the mortality undergoes great diminu- tion. The returns of the Registrar-General give the greatest number of deaths before the completion of the first year ; the ab- solute mortality is greatest among male children, but as more boys are born than girls the proportional death-rate is almost equal in both sexes. CoAises. — The disease is due to a specific poison, and it may be inoculated by the blood of a person sufl^'ering from it, or the secre- tion from the nose and air-passages.* The poison is more powerful in some epidemics than in others, which is perhaps due to atmos- pheric changes ; those in the winter months are proverbially more severe than those in the summer mouths, from the liability to more pulmonary mischief. The cause of death among the poor is in many instances pneumonia, brought on by want and exposure, and inattention to temperature. An epidemic does not always seize upon unhealthy localities where dirt and destitution abound, or where the water-supply is deficient, but where unrestrained inter- course is permitted to take place between healthy and diseased children, t * Drs. Braidwood and Yacher, of Birkenliead, have found that glycerin bj-eathed on by a patient sufl'ering from measles during any of the eruptive days, exhibited numerous spherical sparkling bodies, like those found in vaccine, but larger, and others elongated, with sharp cut ends sparkling and colorless. Such particles were not found in glycerin breathed on by healthy children, nor even by those suffering from scarlatina or typhus. Trans. Path. Soc, vol. xxis, p. 422. t Outbreak of Measles, Brit. Med. Journal, Dec 1st, 1SG7, p. 574. 106 DISEASES OF CHILDREN. Of the complications of measles, the chief are bronchitis and pneumonia, and these most frequently commence in the iirst stage of the disease when the eruption is at its height ; or when the patient has sufiered exposure to cold; or in its decline, even when the most assiduous precautions have been followed. When it does arise during the first four or live days of the fever, the rash often disappears, and the pulmonary symptoms proceed to a fatal termi- nation. The lung speedily runs into hepatization, and there may be scarcel}^ any cough to direct our attention to it. Wherever there is any thoracic mischief the chest should be examined at each visit, for the slight bronchitis which almost invariably ac- companies measles may creep down into the air-passages, and ex- tend to the smaller bronchial tubes and the vesicular tissue of the lungs. The occasional absence of cough and dyspnoea should not mislead us, when we remember how nmch the thoracic organs may be involved with little disturbance of their functions. But broncho-pneumonia implicating the minute structure of the lungs will soon cause acceleration of the pulse, and produce some lividity of the features. When these s^-mptoms are present it would be inexcusable to overlook the physical examination of the chest. Another complication of measles during its progress is an attack of colitis, in which the motions contain mucus and blood, accom- panied hy pain and drawing up of the extremities. The solitary glands are inflamed and tumefied, a condition which may run on to superficial or deepseated ulceration, and the child may perish from diarrhoea and exhaustion. If it occurs after the eruptive stage in the decline of the complaint, it is more difficult to arrest, and may cause death after some weeks. Thus the same tendency to irritation of the pulmonary mucous membrane is apt to extend itself to the intestinal canal, and if, from constitutional weakness, the child's strength is greatly reduced by a slow and imperfect re- covery, then phthisis may supervene after many weeks or months. Croup is another disease which occurs as a complication of measles. A case is recorded b}^ Mr. Royes Bell, of a boy, seven years of age, in which there occurred on the second day of erup- tion a cronpy cough. The paroxysms of suffocation became so frequent that tracheotomy was performed, but the child died of ulceration of the trachea fifteen days after.* From my own obser- vation I should say that inflammatory croup or catarrhal laryngitis * Case of Measles complicated with Croup, the Lancet, vol. i, 1879, p. 295. MORBILLI OR MEASLES. 107 was not uncommon. It is characterized by soreness of the larynx, and a loud, shrill, ringing cough. The child may cough up a little thin phlegm, but no false membrane is ever formed as in membra- nous laryrigitis. The aspect is never so distressed or anxious, nor is the voice so subdued, or the cough so hoarse. If diphtheria is epidemic when measles prevails it is a frequent complication, and even without this complication the mucous membrane of the mouth and pharynx sometimes takes on an aphthous and ulcerated con- dition about the eighth day, when the decline of measles is ordi- narily looked for.* * On tlie 17th of April, 1877, at 10 o'clock a.m., I saw, with Dr. Cleveland, of Maida Vale, a male child, eighteen months old, who, on the seventh day of measles, was seized Avitli swelling of the cervical glands on both sides so as to obliterate the ramus of the jaw. I saw him on the eighth day, when the temperature was 102.4°, the pulse 128, respiration tranquil ; the mucous membrane of the cheeks and lips, the sides of the tongue, pharynx, and tonsils, were covered with a yellowish fibrinous exudation, which was firmly adherent to the mucous membrane in some places, but easily separated in others. The child could swallow and speak distinctly, but there was irritation in Oie larynx and a little mucus in the upper bronchial tubes as revealed by auscultation. A spray of carbolic acid was used (1 in 50) with the effect of dislodging a considerable quantity of mucus from the air-tubes, which gave great relief (see Chapter XI, "On Scarlet Fever"). At 9 p.m. he was intelligent and clear, the glands were less swollen, the throat was less oppressed, and the breathing easier, but the temperature was 104.8° ; the pulse small and running 180, respirations 50; the face was flushed, the tongue dry- ish; he was disposed to sleep, and could swallow well. On the 18th, 10 a.m., the temperature was 104°. He had been restless and uneasy all night; there was much discharge from the mouth and nostrils. On the 19th, 10 a.m., temperature 102°. His general appearance was better, and his bowels had acted very freely from the mixture of chlorate of potash, quinine, and dilute hydrochloric acid ordered on the preceding day. At 3.15 p.m. temperature 102° ; was cheerful and observant, refused beef tea, but took milk without much forcing. 10 p.m., temperature 103°, pulse slightly better, discharge from mouth and nose less; the spray had been used twice; glands on right' side of face .less swollen. 20th, 10 A.M., temperature 100.8°. He appeared wonderfully better, sitting up in bed and looking bright, but in the evening he was more feverish, and the temperature was 101.2°. 21st, 10 A.M., temperature 101°. Less cheerful, being listless and indifferent ; there was great difficulty in getting him to take nourishment. Brandy and milk given every three hours. The swelling and inflammation in the throat had increased, but the dis- charge was less, pulse running and rather feeble. 10 p.m., temperature 103°, pulse still feeble and quiet; seemed sluggish when left alone and violently irritable when disturbed to have food given him ; some soreness in swallowing, but took milk without much pressing. 22d, temperature 101.8°. Looked brighter, and glanced about quickly; had taken a pint of milk during the night, and thirty drops of brandy every three hours; the pulse was feeble and he was much inclined for sleep. At another consultation (3 p.m.) the temperatui-e had reached 103.3°, pulse 128, feeble, respiration quiet, the tongue was 108 DISEASES OF CHILDEEN. In tliree or four instances in my own experience, congestion of the brain and effusion into the ventricles and base of the brain carried the children off. Among the sequelce are cancrum oris, and a severe and trouble- some form of strumous ophthalmia, leading in many cases to ulceration of the cornese and permanent damage of the organs of vision. Otorrhoea is another common affection, so is suppuration of the cervical glands ; chronic diarrhoea, phthisis, croup and en- largement of the mesenteric glands are also among the consequences of the disease. When whooping-cough follows, it has probably been contracted beforehand. Except in the malignant form, measles may be considered a favorable disease if the febrile symptoms are moderate, and the partially covered with a creamy exudation at the sides, inside of cheeks and lips, and there was a small, irregular, dirty ulcer below the inferior incisor teeth ; the pharynx was red and swollen, and an attempt at examination dislodged from the air-passages a good deal of muco-purulent secretion ; the nasal passages were also discharging a watery, glairy secretion, but in no way offensive; the urine was clear and non-albumi- nous. As there had been some purging from the chlorate of potash and quinine mix- ture, Dr. Cleveland gave five minims of tincture of the perchloride of iron in a little syrup of orange-peel every four hours ; a poultice was applied to the throat. 23d, 10 A.M., temperature 101.3°. The mouth was less swollen; he swallowed well and drank milk freely. At 10 p.m. the temperature rose to 103.4°, the glands and throat were more swollen, and he M'as restless and averse to nourishment. 24th, 10 A.M., temperature 101.4°, pulse 136, respirations 40. The lungs were clear and resonant throughout, and there was neither difficulty in swallowing nor embarrass- ment in respiration ; a large white aphthous patch covered the hollow of the hard palate and the tongue ; the neck was much swollen, but no sign of suppuration. The iron and chlorate of potash mixture was resumed. 10 p.m., temperature 102°. General appearance dull and feeble; would take nothing but milk with a little brandy in it. 25th, 10 a.m., temperature 100.8°. Throat much less swollen, and general appear- ance brighter; was interested in his playthings, and talked a little; discharge from nose less, but slimy saliva was discharged from the mouth. Had taken a quart of milk and two eggs, and occasionally half a teaspoonful of brandy in twenty-four hours. 27th, 10 A.M., temperature 99.8°. Nasal discharge had ceased ; the mouth was much cleaner, and the secretion diminished ; cervical glands much reduced in size, but the pliaryngeal redness continued. 10 p.m., temperature 101° ; pulse good ; sleeps well. 29th, 10 A.M., temperature 99.4°. Had wonderfully improved, and sat up for a short time near the fire ; glands again smaller in size, and no difficulty whatever in swallow- ing. Has complained for two days of tenderness about the wrist of right arm, and to- day both arms seem affected with rheumatism. May 2d. Had had pains in the parts last alluded to, but he ran about the room, and was removed to his mother's home, some two miles distant; temperature 99°. May 12th. No complaint of pain now; the ulcer on the inside of the lower lip had not liealed, but the glands of the neck were natural, and he was in every respect con- valescent. MORBILLI OR :MEASLES. 109 eruption comes oat well. ]S"ot\Yithstanding the activity of the eruption, it is to be viewed with apprehension if the skin is hot and dry, and the respiration hurried. If the fever increases after the appearance of the rash, and the pulse becomes quick and small, the patient's condition is alarming ; and if pneumonia or whooping- cough, or constant diarrhcea be present, the danger is proportion- ately greater. Treatment. — The temperature of the room should not be less than 70°, and all draughts should be carefully excluded. In mild cases it is only necessary to confine the patient to bed, and to maintain warmth and a gentle action of the bowels. For the first three or four days the diet should consist of gruel, milk and water, thin beef tea, or chicken broth. Barley-water flavored with lemon, linseed tea, and the inhalation of steam will be grateful to the sore and inflamed mucous membrane. If the febrile symptoms are considerable, a diaphoretic mixture* with a little antimonial wine every four hours, or a saline aperient,t will be necessary to encourage the action of the skin and bowels. Sometimes a warm bath, if the skin is dry, to promote perspiration, will be found serviceable. When symptoms of exhaustion are threatening, the carbonate of ammonia, with a little spirit of nitrous ether, may be given, and alcoholic stimulants, if they seem to be demanded, such as brandy or sherry beaten up with Qgg; and raw-beef juice has proved useful in cases that at one period of the illness ap- peared hopeless. If the cough is very troublesome, and the patient can obtain no rest at night, a little ipecacuanha wine with morphia, or the compound tincture of camphor may be prescribed when the lungs are not overloaded with mucus (Form. 77). Hydrate of chloral, with syrup of tolu, or these combined with, bromide of * Formula 7 : R. Liquor, amm. acet., ........ gj Vin. antim., ......... "^xl Syr. tolutani, giij Aquam ad ^^iv. — M. A tablespocnful every four hours. For a child five or six years old. f Formula 8 : R. Magnes. sulph., . . . . . . . . . gr. xl Potass, nitrat., ......... ^ss. Syr. limonum, vel syr. tolut., ...... ^iij Aquam ad ......... 3iv. — M. A tablespoonful every four hours. For a child five or six years old. 110 DISEASES OP CHILDREN. potassium, will allay excitability and promote sleep, whilst a warm batli is soothing and hastens the process of desquamation. When the pulmonary symptoms are severe, and there is drowsi- ness, blood should not be taken from the arm, but cupping between the scapulae may be resorted to if the pulse is small, jBrm, and hard, and the rash well out. After this the air will enter the lungs more freely, and the duskiness of the eruption will be ex- changed for a more general redness. In the malignant form of the disease, where there is a typhoid condition, the strength must be supported from the first, and eggs, beef tea, milk, coffee, etc., must be regularly given. Brandy or wine should be mixed with an egg or milk, and given, notwithstanding any delirium that may be present. If the breathing is hurried, or there is dulness or crepitation in the lungs, and especially if there is any difficulty in expectoration, carbonate of ammonia, spirit of chloroform, and senega will be necessary (Form. 69, 70). If the eruption is dusky, or disappears too suddenly, and there is any oppression in breath- ing, mustard poultices should be' applied to the chest, the feet plunged into warm water, and wine and difi:usible stimulants freely given. When the child begins to recover, and during convalescence, it cannot be too much insisted on that all chance of cold should be carefully avoided, as neglect of this rule may, by weakening the general health, invite some of the troublesome sequelse we have alluded to, and among them tuberculosis ; for measles seems to have the power of especially rousing into activity the various forms of scrofulous disease. Warm clothing and flannel worn next the skin are most important, and sea-bathing and cold spong- ing are very valuable, if used in proportion to the strength and constitution of the child. When measles has been severe, and has reduced the general strength by causing some degree of subacute pneumonia, or chronic intestinal disorder, it is sometimes followed by a voracious appe- tite, and a sensation of hunger approaching to bulimia. This is also noticeable as a sequel to some other diseases of children where digestion is imperfectly performed, and the absorption of the chyle does not ensue owing to disease of the mesenteric glands. If, be- cause of this insatiable appetite, food is injudiciously given, the digestive organs are never rested, but grow weaker and weaker, whilst the body slowly wastes. In these cases the complexion is ROTHELN, OR GERMAN MEASLES. Ill wan and pale, and nothing does any real good. The tongue is commonly covered with a light fur in the centre, and the papillae are prominent, the epithelium peels oft' in places, and it presents a sore and ragged appearance. These children swallow their food as soon as it is in their mouths, and thus overtax the feeble mu- cous membrane. The rational treatment consists in restraining the child's consumption of food, and giving at first an exclusively milk diet, and, later on, beef tea, eggs, etc. Medicinally, a few 'grains of chlorate of potash, with dilute hydrochloric acid, will be useful.* Quinine, steel wine, and, above all, cod-liver oil will be found of the greatest service during convalescence. ROTHELN, OR GERMAN MEASLES (RUBEOLA NOTHA). Us'uaUy a mild affection, resembling common measles— Premonitory fever seldom exceeds twenty-four hours — Eruption brighter than in measles, less diffused than in scarlatina — Cervical glands slightly enlarged — Symptoms and treatment. JRotheln, or German measles (scarlatina morhillosa — hybrid mea- sles).i'\ is reckoned as a mild aftection, and frequently fails to come under the notice of the great bulk of the profession. It is still, however, of importance, and possesses a few special peculiarities with which we ought to be acquainted. Formerly some observers regarded the disease as a modification of measles and scarlatina. I am disposed to think that doubtful cases of erythema or urti- caria are sometimes mistaken for measles or scarlatina ; for it is certain that in practice we encounter cases of febrile excitement in young children attended with an obscure rash which it is im- possible to classify under any recognized exanthem. It is probable * Formula 9 : R. Potass, chlorat., gr. xx Acid, hydrochl. dil., rr^xl Syr. hemidesmi, . §S3. Aqiiam ad ^iv. — M. A tablespoonful three times a day. For a child five years old. t It is clear that the name of " hybrid measles " or " hybrid scarlatina " is both ob- jectionable and confusing, because it is calculated to lead the observer to suppose that the disease is a modified form of measles or scarlatina, or in other words a combina- tion of the two disorders. Copland (Med. Diet., p. 652) speaks of rotlieln under the head of rose-rash, and terms it red-rash, or fiilse measles. The leading features appear to be the absence of catarrhal symptoms, the slight amount of fever, and the enlargement of the cervical glands. 112 DISEASES OF CHILDREN. that Vogel,* under the title of rothehi, describes the same disease as the one under consideration, though he says the duration of the eruption, which is considered the most characteristic symp- tom, Lasts only one, or at most two days, whereas Murchison and Liveing say that it continues four days. These writers both speak of the occasional presence of catarrh, whilst the German author notifies its uniform absence. But probably different epidemics vary a little in their symptoms, as we find is the case with com- mon measles. The disease presents some symptoms allied to, but many unlike, the common form of measles. The eruption is said to partake of the character both of measles and scarlatina, yet it is now regarded as specific and distinct from both. The swelling of the throat and tonsils, and the white coated tongue, followed by redness and enlargement of the papillee, resembles scarlatina ; while the ca- tarrh and congestion of the air-passages liken it to measles. But it is less severe than either of these fevers. In severe cases the complaint is ushered in with shivering and febrile disturbance, headache, pains in the limbs, sore throat, red- ness of the pharynx and tonsils, and in some instances nausea, and even vomiting. In addition to these sjmiptoms, the respiratory organs are sometimes slightly affected, and there is catarrh, short cough, sneezing, and coryza. There is not this complete set of symptoms in all cases, but some are usually present. The remark- able feature of the aft'ection is, that the premonitory fever, instead of lasting three or four days as in common measles, seldom con- * " The exanthema differs in no respect from that of morbilli ; small round spots of the size of lentils cover the entire body, occasioning, in most instances, a consider- able amount of itching. At some places these spots stand so closely together that they coalesce and form irregular figures. They also rise somewhat above the level of the normal integument, and tiie finger, in lightly passing over them, perceives an unequal hare ness. The eruption, however, differs very much from measles in respect of its duration. It completely disappears by the end of the first, or, at the longest, by the end of the second day, and the desquamation tliat succeeds it is very insignificant, barely notice- able. Tlie same is true of the catarrhal symptoms. Although, along with an in- tense erui)tion of the exanthema on the face, the eyelids swell up, and the conjunc- tivae are somewhat injected, still bronchial catarrh is uniformly absent, which, in mor- billi, on the contrary, is a pathognomonic, never-failing symptom. Scarcely any pre- cursory stage wa.s noticeable in most of onr cases, and the indistinct febrile plienomena disappeared so completely after tlie first day, with the fading of the exanthema which soon followed, that by the tliird day it was totall.v im))ossible to keep the ciiildren in bed, and they quickly recovered without the first sequelae." — Diseases of Children, 1874, p. 495. EOTHELN, OR GERMAN MEASLES. 113 tinues more than twentj'-four hours, when the rash makes its appearance, and hence, if this he true, we have a means of diag- nosis which is distinct and valuable. The eruption first ap[)ear3 on the thorax and arms, but often on the face and neck ; it is characterized hy small, red, elevated patches, or distinct and minute round papules. They sometimes coalesce and run together, forming large and irregular patches, and when the patches unite, the body becomes universally red, and the eruption resembles that of scarlet fever, being brighter than that seen in measles. When the rash disappears the skin may desquamate in branny scales, so we cannot attach much im- portance to desquamation as a diagnostic feature. "The eruption is copious in a direct ratio to the severity of the general sj-mp- toms."" With the appearance of the eruption the throat affection is apt to increase, and the swelling in rare instances becomes so great that the patient is unahle to swallow. The cervical glands, too, become inflamed and enlarged. f "The protracted duration of the eruption is certainly one of the characteristics of the malady, though no doubt a more or less variable one, and of little or no value as a means of early diagnosis. In the case under my care in the hospital the eruption lasted from five to seven days, a longer time than is usual either in measles or scarlet fever.":}: It appears to me that not much reliance can he placed upon the dura- tion of the eruption, or to the extent of the desquamation, as in one case of ordinary measles under my care in April, 1877, the skin was desquamating at the end of a month, the eruption though faded was distinct at the fourteenth day, and after washing, it was quite bright on the extremities, neck, and shoulders. Another very important feature of rotheln is that it never pro- duces measles or scarlatina in others, so that, from this point of view, it is entitled to be regarded as a distinct and independent * Case of Rotheln or German Measles, by Dr.Murchison, Lancet, Oct. 29th, 1870, p. 595, t In the cases described by Dr. Julius Pollock, the cervical glands were a good deal enlarged, the tonsils swollen and red, and where the rash faded a mottling of the skin remained, in most cases for several days. The period of incubation varied from 6 to 8 or 14 to 16 days. — Lancet, May 12tli, 1877, p. 681. Dr. Squire gives the period of in- cubation from 14 to 21 days. Mr. Parker Douglas says that the glands beliind the sterno-mastoid were afiected in his cases, that coryza is not invariable, and that a mot- tling of the skin is left which persists for a few days. — Lancet, May 26th, 1877, p. 784. X On Rotheln, or German Measles, by R. Liveing, M.D., Lancet, March 14th, 1874. See also Diagnosis of Skin Diseases, p. 44. 114 DISEASES OF CHILDREN. disease. It has a tendency to propagate itself, and epidemics of it have been recorded, but it is doubtful whether the disease is so contagious as the other exanthemata. It affords, moreover, no protection against the two diseases to which it bears a close resem- blance, for some children who have suffered from it previously, and others subsequently, had both scarlatina and measles ; and those suffering from it have not, in a single instance, communi- cated either of these latter diseases to others. The disease, though highly contagious, appears to be more epi- demic than measles or scarlatina, and is a milder affection than either. One attack is protective against a recurrence of the disease, but not against a subsequent attack of common measles. The idea has been started that rotheln is common measles modi- fied by a previous attack, but the fact that rotheln frequently pre- cedes measles is conclusive against this view. Albuminuria and dropsy are rare complications ; these dis- eases may result from the temporary renal congestion of ordinary measles, but their absence distinguishes them from the sequelse of scarlatina. I would again repeat that the typQ of the disease varies with the particular epidemic; a fact which is too apt to be lost sight of; and which explains the slight differences in the descriptions of authors. The treatment consists in confinement to bed, a febrifuge mixture to encourage diaphoresis (Form. 7, 12), and, if catarrhal symptoms arise, demulcent and sedative remedies (Form. 65, QQ^ 74) as the case may appear to demand them. SCAELET FEVER OR SCAKLATIXA. 115 CHAPTER XL SCARLET FEVER OR SCARLAimA.* Vakieties of the Fever and theik Classification : ] . Scarlatina simplex — The premonitory or incubation stage — 2. The stage of eruption— S. The stage of decline and desquamation. 2. Scarlatina Anginosa : Character of the throat affection and its relation to the eruptive stage — Increased severity of the constitutional symptoms — State of the tongue, pulse a7id temperature — Alteration in the cardiac sounds. 3. Scaklatina Maligna : State of throat and tonsils — Constitutional symptoms of an adynamic type. 4. Scarlatina sine Eruptione : Absence of the specific eruption and mildness of the symptoms — Tendency to anasarca and dropsy. Pathology: Relation to enteric fever — Coexistence of the two diseases — Dr. Klein's researches on the minute anatomy of scarlet fever. Causes and Consequences : Predisposing and exciting causes — • Pathology and morbid appearances — Mortality — Sequelce of scarlet fever — Liability to finasarca and acute desquamative nephritis — Congestive or uremic headache. Treat- ment AND General Management of the different varieties : Aconite and its mode of action — Liquor ammonice — Sponging the body in high temperature — De- lirium and coma — Scarlatincd dropsy — Effusion into the serous cavities — Treatment of the throat affection — Preventive measures. Scarlet fever, or scarlatina, may be defined as a contagions and infectious fever, attended with a scarlet rash on the bodj, and with inflammation of the throat and fauces. Three varieties are described : 1. Scarlatina simjylex. 2. l:^carlatina anginosa. 3. Scarlatina maligna. Scarlatina has three well-defined stages : 1. The premonitory or incubation stage. 2. The stage of eruption. 3. The stage of de- cline and desquamation. 1. TJie incubation stage lasts from the day of infection till the commencement of the febrile symptoms, and is usually short. It may extend from three to five, or even eight days. In some in- stances the period may continue only a few hours. f There is no * " The term ' Scarlatina ' is said to have been the vernacular name for the disease on the shores of the Levant, and was first adopted in a medical work by Prosper Mar- tianus, another Italian physician, who, about the middle of the sixteenth century, also described the disease as distinct from morbilli. Epidemics of scarlet fever were first described in this country by Sydenham in 1676, and about the same time in Scotland by Sir Eobert Sibbald, pliysician to Charles II, and in the middle of last century by Fothergill and Huxham." — Clinical Lectures on Medicine, by Dr. Murchison, Case of Eotheln or German Measles. — The Lancet, Oct. 29th, 1870, p. 595. t Of 75 cases collected by Dr. Murchison, the latent period was less than twenty- four hours in some, and in none did it exceed six days. — Clin. Trans., 1878, p. 257. 116 DISEASES OF CHILDREN. exact rule to go hx as to the duration of this stage : one child will resist infection for a longer period than another, or the infection, ■u'ill be slower in disturbing the constitution. Some children are more susceptible than others; and the character of the epidemic may differ in severity. A child may be feeling out of sorts for daj-s, languid, depressed, and " off his appetite ," but the illness excites no apprehension if scarlet fever be not prevalent at the time. "When chilliness, thirst, quick pulse, and increased tempera- ture of the skin succeed, the parents become anxious. Diagnosis is even now impossible, but if there is nausea or vomiting, and the tonsils and fauces are inflamed during the prevalence of an epi- demic, we can scarcely mistake the character of the fever. As the case progresses the breath becomes intensely hot, the skin pungent and burning ; and, to^^'ards the evening, or during the night, the cerebral functions may be so disturbed as to lead to convulsions or delirium. At this stage the characteristic eruption will appear, and it is seldom delayed beyond twenty-four hours. 2. 7he eruptive stage is marked hy small red points upon the face and neck, which extend to the trunk and limbs, especially the inside of the thighs, and the flexures of the joints. In the course of twelve, or at most twenty-four hours, the eruption assumes a general erythematous appearance, and the little patient becomes as red as a " boiled lobster." The rash, however, is often variable in severity, and mixed in its character, so that a young practitioner might be excused for overlooking the nature of the case, when distinct large or small red spots are disseminated over the white normal surface of the body. TV^hen the spots are small, scat- tered, and dusky, there is ground for alarm. When there is a well-developed eruption it relieves the internal organs from exces- sive oppression by the fever-poison. The eruption is brightest in healthy and strong children, whereas in the feeble it is limited, and the spots approach a claret hue. The eruption of scarlatina, as well as the constitutional symptoms, attain their height b}^ the second day ; the eruption begins to decline on the fourth, or at the latest on the fifth day, when the throat becomes easier, and tran- quil sleep returns. The throat of scarlatina is never so painful as it is in severe tonsillitis, where the swelled tonsils almost occlude the pharynx from tumefaction and threatening suppuration.* The tongue is * The diagnosis of thethroat affection is considered in Chapter XXX, On Diphtheria, SCARLET FEVER OR SCARLATINA. 117 very characteristic in most cases, but, like the eruption, does not invariably assume the same appearance. When the eruption is brightest and inflammatory fever runs high, the dorsum and centre are covered with a white creamy fur, and the elongated papillne project through the deposit, giving the tongue the appearance of a white strawberr3^ The temperature frequently runs up to 105° or 106°, and some of the worst, and even fatal cases in children, have not exceeded it. It has, however, been known to exceed 112° in fatal cases. The fever and the rash appear to hold a close re- lation to one another, and they subside simultaneously, leaving the patient weak and languid. In the decline of the disease, the urine frequently contains albumen, and the child is pale and thin. About the third week after ajDparent and complete recovery from mild scarlet fever, anasarca and albuminuria may set in. 3. The stage of desquamation. — The skin begins to peel where the eruption first made its appearance, and if it has been copious, the old epidermis may exfoliate in large scales, or come away from the fingers like a glove; the process is a very slow one, and if pre- cautionary steps are not taken may extend over many weeks. The mucous membrane also participates in this process, by the escape of phlegm from the fauces, and epithelium from the renal passages. The motions at this period are also putrid and ofiensive, and in- dicate the profound eftect of the fever poison on the two chief ex- cretory channels. 1. Scarlatina Simplex. — The disease begins with the usual symptoms of fever: thirst, quick pulse, hot skin, headache, pain in the back and limbs, restlessuess and disturbed sleep. On the second day of the fever, a bright -red scarlet effiorescence appears, having many red points, which are not elevated above the surface of the body. In some parts these small points run together, and cause the redness to be general ; whereas in other parts they do not coalesce. The eruption is first seen on the face, neck, and ab- domen, and especially over the thorax and bends of the joints. On exposing the back and loins it may be often seen most distinctly. The eruption disappears on pressure, and returns at once when it is removed. About the fifth day the rash declines, and by the eighth it fades and disappears. The cuticle begins to peel and separate about the fifth day from the parts first affected, and this process may continue for many weeks. The hands and trunk may be seen to throw off" small or large scales ; and, whilst it lasts, 118 DISEASES OF CHILDREN. there is great irritation and itcliing of the skin. At the commence- ment of the disease, before there is any rash on the body, or the throat is sore, there is pain and difficulty in swallowing. On look- ing into the throat the tonsils are noticed to be swelled and in- flamed, and lymph may be seen adherent to them ; there is diffused redness of the soft palate ; the uvula is also red and elongated, and the pharynx inflamed. The tongue is covered with a thick white fur, and the jDapillse may be seen through it. Sometimes in the course of two days the fur disappears, and leaves the tongue of a strawberry hue, or it is red and strawberry-looking from the first. The appearance of the rash is not attended by any subsidence of the fever, the skin being hot and burning, and the temperature elevated, with wandering and delirium at night ; there is probably no disease in which the temperature runs so high. Vomiting is a common and earlj" symptom. I have constantly observed it before the rash, and in this way anticipated the disease. The pulse is frequent, full, and compressible, and ranges from 120 to 140 in a minute. The urine is scanty and high-colored, containing urates at an early stage, and commonly albumen later on. During the fever the amount of urea and uric acid excreted by the urine is increased, while that of the chlorides is decreased.* The rash does not always appear on the second day ; it may be delayed in some cases till the third or fourth day, or commence on the first day of the fever. In the mildest cases there is little else noticeable than a general erythema of the skin ; there is no pain in swallow- ing, nor inflammation of the tonsils or pharynx, or, at any rate, the reddening of the throat is so slight that it may well escape attention. The eruption comes out and continues the usual period, followed by desquamation. 2. Scarlatina Anginosa. — Here the throat is more severely af- fected, and the submaxillary glands are frequently enlarged and tender, so that the patient has pain on opening his mouth or in swallowing ; the tonsils are covered with a fibrinous or sloughing exudation; one tonsil maybe more aft'ecled than the other, or neither may be implicated in this way. On the first day of the fever, before the rash appears, I have seen the right tonsil exca- vated by a deep, ragged, ashy-looking ulcer, and the tongue loaded with a creamy fur at the back. I have also noticed a similar * Clinical Essays, History of Scarlet Fever. — Dr. Kichardson, Asclejjiad, vol. i, p. 114. SCARLET FEVER OR SCART.AIINA. 119 ulcer on the fifth day of eruption, and general inflammation of the pharynx and uvula, whilst the fur is cleaning off the tongue. Mucus collects about the fauces and throat, causing troublesome hawking and spitting, as well as heavy breathing, and the inflam- mation extends to the nose or runs along the Eustachian tube to the ear. In one case the whole external ear assumed an erysipel- atous redness, and there was much deafness. The patient recov- ered without any otorrhoja, and with unimpaired hearing. As in the former variety, the eruption comes out on the second day of the fever, when the throat usually becomes easier ; the eruption may appear first on the arms and chest, for the reason probably, that protected parts are least likely to be chilled. The rest of the throat may now be swelled, and the left tonsil may present two or three small ashy sloughs, like the right. The pulse may reach 120 or 140, and the respiration become accelerated. The urine at this stage is turbid, often high-colored, and contains a large quantity of lateritious sediment. In some cases the swelling of the throat increases, and the voice becomes husky and weak, though the pulse may have fallen in frequency. On the third day of the fever the eyelids may be swelled, and the conjunctivpe so inflamed that the patient cannot open the eyes; it leads sometimes to ophthalmia tarsi, and repeated small abscesses in the lids. By the fifth day the extension of the sloughing may have ceased, though fresh portions of grayish slough may fix on the uvula, and on any sound part of the tonsils. The skin now becomes cooler, and the tem- perature falls, the pufiiness of the face subsides, and the tongue cleans. The cutaneous irritation at this stage is extreme, and in some cases prevents the patient from obtaining any rest or sleep. Severe febrile symptoms may arise in less than twenty-four hours after infection. In 1869 I was summoned to a young person who the night previous was in good health, and walked and drove out. At my visit, at 9.30 p.m., I found her with high fever, hot and burning skin, great thirst, and loaded tongue ; pulse 120, very weak, tremor in the legs, and prostration of strength. Both ton- sils and uvula were much swollen and inflamed, and on the right tonsil was a patch of yellowish-looking lymph. There was pain, and difficulty in deglutition, but no hoarseness or enlargement of the glands in the neck. She had been very sick in the early part of the day, and brought up clear bile. The following day the face was much flushed, and a copious eruption of scarlet fever came out 120 DISEASES OF CHILDREN. on the chest, abdomen, shoulders, and loins ; the skin was hot and perspiring ; temperature in axilla 104° ; in mouth 105° ; pulse 120, firmer and fuller. She could speak more distinctly, though the swelling of the throat was greater, and the lymph on the tonsils was increased. She was in all respects more comfortable since the eruption had appeared, and sickness had entirely subsided. For the next two days the patient remained in the same condition, when the throat became easier, and she could speak with ease and clearness. From this time recovery was rapid, and the convales- cence uninterrupted. In some cases this variety of scarlet fever is attended with more severe constitutional symptoms than those I have enumerated ; sleep is disturbed, and exhaustion sets in early ; the pulse is fre- quent and feeble, the secretion of urine nearly suppressed,* and effusion takes place into one or more of the chief cavities of the body. Scarlatina 3Ialigna (Cynanche Maligna of Cullen). — This is the most alarming variety of all. The disease concentrates its viru- lence on the throat and tonsils, where dark, offensive exudations form, with deep ashy-looking ulcers and sloughs. The pharynx uvula, and part of the hard palate are sometimes seen covered with a gangrenous deposit, and a bright-red line of demarcation is visi- .ble. Similar ulceration may also be seen on the inside of the cheeks in severe cases ; the nostrils also become inflamed, and furnish a thin, irritating discharge, which inflames and excoriates the lip. The salivary glands are also inflamed and swollen. The fever at an early stage of the disease assumes an adynamic type, and the constitutional depression is severe. There is wandering and drow- * I saw in consultation a little boy, in 1878, who on the fifth day of the eruption passed only two teaspoonfuls of urine in twenty-four hours, containing a considerable quantity of bile pigment and a trace of albumen, so that there was ample proof of very defective elimination. The patient was weak, restless, and wandered at night ; the throat was severely affected, and there was a difficulty in getting him to take nourish- ment. A poultice was applied to the loins, and next day a free secretion of urine took place, in which neither bile nor albumen could be detected. Mr. Nauglitin, of Baker Street, informs me that lie attended a cbild, aged six years, in 1875, who did not pass urine for seven days, and she was delirious tlie whole time. The suppression came on ten days after the eruption had disa{)peared, and it seemed traceable to eating heartily of indigestible food. There was no vomiting. The first urine passed after this long interval wa.s about a teaspoonful, and approached the color of ink. As the quantity increased the color became normal, and the patient experienced no subsequent incon- SCARLET FEVER OR SCAELATIXA. 121 siness, or great irritability and restlessness ; the pulse is feeble and rapid, or irregular; tbe tongue drj, brown, and chapped, and sordes may be seen on the lips, teeth, and gums. The temperature runs high ; in a fatal case under ray care it reached lOS"^. Some- times the patient dies before the abortive eruption comes out. There is no uniformity in, the time of its appearance or in its char- acters; it is often dark and in irregular patches, or it may be pale and bright at first, and then change soon to a claret hue, some spots being larger than others, and there are also observed in some cases petechife, which prove that the blood is much changed. The disease in many cases proves fatal on the third or fourth day. How far this variety differs from the others in its real nature is still an undetermined question. Is not the disease the same in all cases, — a distinct fever, brought about by a specific poison, but from constitutional predisposition, locality, physical conditions, or extreme susceptibility of the organism, assuming a mild or a severe form ? Epidemics vary in their severity, and produce varieties of type, but a number of collateral circumstances must be ranged side by side, before we can admit any essential difiference in the nature of the disease. There is a form of latent scarlet fever {scarlatina sine eruptione) which is of so mild a character that the disease is not suspected till the general health show^s signs of failure. I have seen chil- dren on various occasions sufierino- from anaemia and general de- bility, with or without albuminuria, who have had some desqua- mation of the skin without the specific eruption. In one case, a little girl, who w^as said to have escaped the disease when her brother was laid up with it, came under my treatment for symp- toms of general debility. Her urine was scanty and non-albumi- nous, and there w- as not any sign of anasarca, but I could not avoid associating her state with the probability of infection. She may have had some sore throat and feverish disturbance, but they were not noticed by the mother, though her skin w^as rather harsh, and the epidermis inclined to peel at the tips of the fingers. Cases of anasarca occasionally come under our notice which have had their origin in the poison of scarlet fever without any eruption. The absence of eruption, and the slightness of the illness, have caused the child's state to be overlooked, and the necessary pre- cautions for avoiding cold and exposure have not been taken. These patients are capable of communicating the disease to others. 122 DISEASES OF CHILDEEN. As reojards tlie pathology of the disease, I may here give the views of Dr. John Harley,* who describes scarlatina as essentially a disease of the lymphatic system. How far these views may be correct appears to me one of those perplexing questions which further observations only can determine. Dr. Harley gives the post-mortem appearances in twenty-eight fatal cases, and the morbid changes described appear in many of them to resemble the first stage of enteric fever. The glands of Peyer (glandules agminatfe) were purple, swollen, and vividly injected, and the mucous membrane of the snlall intestine was of a pale or bright rose color. The solitary glands were also prominent, and of a yellowish color, " so that the lower third of the ileum appears as if sprinkled with grains of sago" — presenting eminences like hempseeds. This appearance, which French writers call "Psoren- terie," was observed in most of the cases. The solitary glands or follicles of the large intestine were also swollen and purple, and the caecum, where they exist in the greatest number, is sometimes severely congested and inflamed. The spleen in some of the cases was greatly enlarged, and as firm as liver, the mesenteric glands were likewise turgid, and enlarged to the size of a pigeon's egg, and the mesentery has been found converted into a thickened lobulated mass, resembling a bag of large or small marbles. The right cavities of the heart were often distended with blood, and contained colorless clots of entangled fibrin, adherent to the chordae tendinese, and continuing through the auriculo-ventricular opening. These wormlike clots extended into the pulmonary artery, the superior cava, and larger vessels of the neck, as far as the cranial cavity. Branches may also be sent into the lungs, from which they may be withdrawn eight or nine inches long. The same may be seen in some cases of surgical pyrexia where a clot is forming in the heart. Oppression and severe pain in the cardiac region, orthopnoea, a rapid and feeble pulse with an alteration in the heart's sounds, indicate that a deposit is taking place. The left side of the heart in the twenty -eight cases alluded to was generally found empty and contracted ; there was onlj'- one case in which a fibrinous clot was found in each cavit}^ — in this case there was a fibrinous clot on both sides. The tendency, ac- cording to Dr. Richardson, is to the formation of clot in the right * Med.-Chir. Trans., vol. Iv, p. 103. The Pathology of Scarlatina. SCARLET FEVER OR SCARLATINA. 123 cavities, and from what we learn in some other diseases where the temperature is unusually high, it is what we should expect. The lungs were deeply congested in some of the twenty-eight cases, and points of ecch3miosis were seen on their pleural surface, and" also in the parietal pericardium. Pericarditis and pleuro- pneumonia are occasionally present. Ileemorrhage from the bowels was the cause of death in one case, and scarcely any part of the mucous membrane was healthy; there was bright-red villous exu- dation, and the thin vascular membrane came away exposing the bowel, which was blotched and spotted with ecchymosis. General inflammation of the mesenteric glands and those of the pleura are constantly observed, and profuse diarrhoea with light slimy stools as we observe in tj'phoid fever, are features of clinical interest. Out of the twenty-eight cases, more or less albuminoid or fatty degeneration of the kidneys existed in six. Most of the patients died from the third to the sixth day, but kidney change occurred in no case before the fifteenth day. The bile was found normal only in five cases out of twenty; in the remaining fifteen it was much deranged ; the specific gravity was low (1014) in thirteen cases, and the solid matter less than a third of the normal amount ; the biliary acids were deficient, but the coloring matter was never absent. The minute pathological anatomy of scarlatina, according to the most recent researches of Klein, consists mainly of changes in the kidneys, liver, spleen, and Ijmiphatic glands of the throat. In the kidnej'S there is a proliferation of epithelium cells, and changes in the walls of the bloodvessels. Later on, there is a development of round cells which constitutes a true interstitial nephritis, due to an embolic process. In the liver there is also a growth of round cells and thickening of the walls of the bloodvessels, with an in- filtration of the interlobular and intralobular connective tissue. In the cervical glands, there is inflammatory swelling and multi- plication of the lymphatic nuclei, and in places, large giant cells containing several nuclei. There is also a hj^aline thickening of the arterioles.* During the last few years many writers have noted the associa- tion of scarlet fever with enteric fever, or one has so rapidly followed the other, that they have been naturally regarded as holding some relation to one another. The cases recorded by Dr. * Trans. Path. Soc, vol. xxviii, p. 430. 124 DISEASES OF CHILDREN. Harley show that scarlatina coexisted with enteric fever in a few of them, and that rose spots were distinguished on the abdomen and chest, when there was a general scarlet rash on the body. Papules were also seen distinctly on the pallid skin after the scar- let blush had faded away. The account given leaves little room for doubt. Diarrhoea is common to both diseases in their decline, and the evacuations are alike in character. The tongue in typhoid fever often presents a red angry appearance with enlarged papillae, as we observe in scarlet fever. We have much evidence to show that mixed cases do exist, and that the two morbid conditions cannot be separated in a few instances where the febrile process is prolonged. The fact of diarrhoea being present in the latter stages of the disease is fully explained by the state of the intes- tinal glands, and we must, I think, agree with Dr. Harley that this morbid change is one of the strongest proofs that a patholog- ical relationship does exist between the two diseases, which acci- dental intercurrence fails to explain. "Whatever the resemblance of the pathological states may be, in some cases, such as Dr. Harley relates, the two diseases in their local and general signs present on the whole a striking contrast. Jf a child goes on well for the first week or ten days of scarlet fever he commonly gets over the attack, but in typhoid fever the disease is lingering and slow, and this security cannot in most cases be felt till some weeks have elapsed. There are crises and relapses which expose the child to danger till convalescence is permanently established. The violence of this short fever is not 80 alarming as in some others, and cannot be speedily cut short. It is less alarming in scarlet fever than in almost any other com- plaint. "Delirium," says Dr. Gairdner, "is apt to subside of itself, and may be safely neglected; it will disappear as soon as the crisis is fully established." He quotes the opinion of Heberden, who also entertained the view that there " was no disease in which the patient was more apt to be delirious, and with less danger, than in scarlatina."* Such remedies as, antimony and opium are out of the question, and shaving the head to meet the delirium would only be necessary in exceptional cases. When delirium arises the little patients should be carefully watched and tended, but excessive interference is bad practice, and does an infinity of harm. * Clinical Medicine, by Dr. Gairdner, 1862, p. 193. SCARLET FEVER OR SCARLATINA. 125 Causes. — These are due to the influence of a Sfiecific and highly contagious poison. The poison retains its power for a considerable length of time, and the clothes worn by patients suffering from it, as well as carpets, curtains, etc., absorb it. There can be no doubt whatever that medical men sometimes convey it from patient to patient, and so carry it to their own families. Infec- tion is as great at the beginning as during the time of desquama- tion, but it is worthy of notice, that some persons are more susceptible to infection than others, and that a severe disease though apt to produce its like, may also result from a mild one. Children at the breast are rarely affected by scarlet fever, but such eases are recorded ; the disease is more prone to occur about the second and third year, though there is very little difference up to five years of age, and after this period the deaths undergo a remarkable diminution, but nothing like that observed in measles. Then with regard to the proportion of deaths in the two sexes : more males are said to die under the age of ten, and after ten more females ; but as the population in any given district may vary considerably between the two sexes the distinction is not easily recognizable. As to the influence of meteorological conditions most writers agree that the disease is most prevalent in the antunm, and lea-st in the spring ; next follow the summer months, and lastly the winter. The average annual mortality in England alone from this ter- rible scourge is estimated at from 20,000 to 22,000. It is greater in towns and cities than in rural districts, and stands highest on the list of communicable diseases. Then follow whooping-cough, measles, and small-pox in the order I have placed them. Although scarlet fever rarely happens a second time, numerous well-authen- ticated cases are placed on record. When it does happen that a child is seized witha recurrence of the disorder, it is exceptional, and so mild in its nature and progress that it never proves fatal. Concerning the recurrence of scarlet fever many examples are to be found. A case occurred in the London Fever Hospital under the care of Dr. Broadbent, where the patient had a second attack after being convalescent from a first attack, and whilst the skin was still desquamating.* A similar case of recurrence, two months after the first attack, * British Medical Journal, April 1st, 1876, p. 411. 126 DISEASES OF CHILDEEN". came under the care of Mr. Elkington at the Birmingham and Midland Hospital for Sick Children.* The child, 3 J years of age, was admitted on JS'ovember 22d, 1875, suffering from a large ab- scess in the left thigh. There was a history of scarlatinal eruption and sore throat six weeks previously, and the patient was still desquamating. The temperature on admission was 101:°. On the 23d the abscess was opened antlseptically, and two ounces of thick creamy pus were evacuated. A drainage-tube was inserted, and for the next eleven days all went well, the temperature keeping normal and the abscess closing quickly. On December 5th the patient had headache, sore throat, and vomited several times ; temperature 105°. A rash, resembling scarlatina, was visible on the chest, arms, and neck, and there was great congestion of the throat and tonsils. On the 6th the rash was fully developed over the whole body, accompanied by intense thirst and restlessness. Morning temperature 103°, evening nearly 106°, with delirium. From this time the progress was favorable, the rash fading, and the skin desquamating like an ordinary case of scarlatina. On the 13th the temperature was normal. There are no more obstinate and troublesome sequelae from any of the diseases of childhood than those which follow scarlet fever. Otorrhoea and deafness, enlarged glands in the neck, ophthalmia, oz£ena, eruptions of the scalp, acute rheumatism, and chorea are the diseases commonly met with. Hypertrophy of the tonsils and persistent ansemia are frequent consequences. However slight the symptoms may be, troublesome sequelae are apt to ensue, and this is the more likely to happen if the patient quits the sick-room too soon, or the health has been delicate before the attack. In 1862 I attended a girl, seven years of age, who was seized with the most severe tyj^e of the disease, in which the glands of the neck were greatly implicated, and the delirium was so fierce and continuous that her life was despaired of. She made a tedious recovery through having an abscess on the right side of the neck, which pointed over the mastoid process, and led to exfoliation of the temporal bone. Otorrhoea continued more or less, and pieces of bone came away. Twelve years elapsed before the local trouble was cured and the wound healed, but now the hearing is perfect and the health re-established after years of extreme medical care and nursing, which only the wealthy and affluent could procure. * British Medical Journal, April 1st, 1876, p. 411. SCAELET FEVER OR SCARLATINA. 127 My experience leads nie to think that tuberculosis can be more frequently traced to scarlet fever than is generally supposed. Of all the sequelpe anasarca is the most common, — an infiltration of serous fluid into the subcutaneous areolar tissue, — which is prone to occur in some parts more than in others. If, during the period of desquamation, the patient is exposed to cold from incautiously venturing out too soon, and a chill is received, the escape of the fever-poison, instead of taking place through the skin, is directed to the kidneys, and this sets up irritation and acute desquamative nephritis. It does not induce this in all, as I have on several occa- sions seen puffiness of the lower eyelids at the end of three weeks, and swelling of the glands in the neck, whilst desquamation was going on without albuminuria. With the kidney affection there is headache, pain in the loins, sickness and diarrhoea, and a large quantity of albumen in the urine, which may be clear when first passed, or turbid and loaded with urates. It may vary from day to day, and sometimes contain a considerable quantity of cayenne- pepper-looking crystals of uric acid ; but the albumen may remam undiminished, particularly if animal food is indulged in, or there is any other error in diet. Effusion into the pleural, pericardial, and abdominal cavities is common, and the temperature is apt to run high.* All these symptoms may improve without any dimi- nution in the quantity of albumen. f A serious consequence of scarlatina is the headache of ursemia, which I have elsewhere fully considered.:}: At the end of three or four years, and long after every trace of dropsy has disappeared, the child so manifestly declines in health and spirits that the at- tention of parents is at last awakened to his altered condition. He is unable to pursue his studies at home or to continue at school, and he has no inclination to join in the pleasures of his playmates. * Vide Chap. XXIV, On Acute Desquamative Nephritis, and (Edema of Lungs, Chap. XXVIII. f "The percentage of kidney complications in scarlet fever varies from five to seven- teen. Frerichs has described a rare form of dropsy without any disease of the kidneys occurring after scarlet fever, which he believes to be due to paralysis of the cutaneous nerves by exposure to cold during desquamation, and I have lately seen one such case, where repeated examination of the urine revealed no change, whilst there was very acute dropsy of the skin, without any effusion into cavities, which lasted twelve days." — Steiner on Diseases of Children, by Lawson Tait, p. 341. X Headaches, their Nature, Causes, and Treatment, by W. H. Day, M.D., 3d edit. Toxemic Headache, chap. ix. 128 ■ DISEASES OF CHILDREN". A severe and continuous frontal headache ensues, and the child loses his vivacity and interest in everything. The veins are full about the head and lips, in some cases, and there is a set color on the cheeks. The urine is scanty and contains albumen, with renal casts and eiDitheliura; it varies greatly in some cases, the deposit thrown down some days being very considerable, and at other times barely perceptible. Indulgence in animal food is prone to cause renal congestion in these cases, with an aggravation of the head s^miptoms, and there is associated with it sometimes dilata- tion and hypertrophy of the left ventricle, increased tension in the pulse, perceptible to the finger, but more accurately estimated by a sphygmographic tracing. For the treatment of this complica- tion the reader is referred to the chapter on albuminuria. Treatment — The treatment of mild cases consists in confinement to bed, a mild aperient, and cooling drinks. Rest in bed and judi- cious nursing will carry most children safely through the attack. With regard to purgatives and active reruedies, they have less influence over this disease than some other febrile affections, and the pulse will continue quick, and the temperature high in spite of them. If the bowels are costive and the stomach loaded, an active purgative may be necessary. I give preference to purga- tive remedies, especially at the onset of the disease. But at the commencement of the disease, and in its early stages, if it is at all severe, the chief indication is to promote a free action of the skin till the child is bedewed with perspiration. If this could be ob- tained, it would be the best remedy at our command, by favoring the excretion of the morbid poison before it had time to damage any internal organ, and produce those changes in the blood which sometimes lead to fibrinous deposition in the heart. A hot-air bath ma}" be speedily constructed, as in croup, and it should be so arranged that the child's face is exposed to the pure air, which should circulate freely through the room. In hot weather, during the rising of the fever, free ventilation of the sick apartment is not apt to induce cold, but when desquamation has set in there is great susceptibilit}-. I am here constrained to point out the value of the action of aconite in reducing fever and inflammation, from the influence it exerts in bringing down the temperature and lessening blood pres- sure. From what we know of its power in subduing fever in some cases of surgical pyrexia it is unquestionably a remedy of great SCARLET FEVER OR SCARLATINA. 129 value, and if we consider the tendency which the blood has to coagulate in its passage through the central organ of the circula- tion, it might be advantageously resorted to in the early stages of this disease. It brings down the pulse, and promotes a free action of the skin, and encourages the loss of heat by evaporation. In some cases it reduces fever and inflammation, as in tonsillitis, without promoting perspiration. I fully agree with Dr. Fother- gill, that the specitic action of aconite is exerted on the vascular system, by paralj'zing the vasomotor nerves and lessening the con- tractility of the vessels. If then it has the power of dilating the vessels, and by drawing the blood towards them diminishing the tension in an inflamed part, it ought to be employed where this condition is present. All who have given the remedy a fair trial in catarrh, sore throat, and inflammation of the tonsils, will be willing to admit, that it converts with marvellous rapidity, a dry and burning skin into one that is moist and sweating, and in this way it relieves the restlessness and constitutional disturbance. Aconite is of most service and can be more advantageouslj^ em- ployed when the pulse is hard, and the action of the heart strong and violent. My own experience of the action of aconite is, that it lessens the frequenc}^ and increases the fulness of the pulse ; it reduces the hardness and incompressibility. Half a minim in a teaspoonful of water for a child should be given every hour, but should the pulse become weak or irregular, or there be any sign of weakness or prostration, it ought to be discontinued. The indi- cation for givi)]g aconite is elevation of temperature, for where it is present there is fever or inflammation ; when the temperature is normal or nearly so, it should not be employed, but when it shows indications of rising, and the pulse though not more fre- quent becomes more resisting, it may be prescribed. Durina: scarlet fever, or after it, when kidney complication has arisen, aconite may be given, for if it does not shorten the fever it soothes the nervous system, and by promoting free perspiration controls the inflammation that attends it, and moderates the throat aft'ec- tion.* When the throat is dusk}^ and much swollen, and the * It is doubtful whether aconite will shorten the fever of acute specific diseases, as scarlet fever, measles, etc., but it has a beneficial influence in these diseases, soothing the nervous system, and favoring sleep, by inducing free perspiration. Whether this remedy can lessen the severity of the fever, or diminish the duration of the acute specific diseases, is doubtful ; but there is no doubt it can control and subdue the inflammatory 9 130 DISEASES OF CHILDREN. symptoms assume a typhoid character, aconite would be too de- pressing, and the local disorder is best treated by the application of nitrate of silver or the diluted tincture of the perchloride of iron. Internally, the iron and chlorate of potash mixture recommended in diphtheria will be found invaluable. (Form. 54.) Some years ago Dr. Richardson advocated the value of liquor ammonia, from its power in holding the fibrin of the blood in solation, and keeping it in a fluid state. A few drops of the Liquor Ammonife in water, with or without the addition of the Liquor Ammonise Acetatis, is the form he recommends to be given. Both these remedies tend to eliminate carbonic acid by the breath and skin, but they require caution in their administration, lest the free ammonia interfere with oxygenation, and break up or damage the red corpuscles of the blood. In Scarlatina anginosa, if there is reason to think the digestive organs are loaded, and the tongue is heavily furred, an emetic should be given at the onset. A grain or two of calomel and an active aperient may be ventured upon, if the pulse is full and strong, and the inflammatory fever runs high. Milk and soda water to drink frequentlj^, ice to suck, beef tea and chicken broth will be demanded. Warm linseed poultices, or even two or three leeches, to the throat will be advisable, if there is swelling about the jaws, or pain in swallowing. Eflervescing medicines, such as carbonate of ammonia and lemon-juice, are refreshing and agree- able to take. Sponging the body with vinegar and tepid water (one in four), or iced water, if the temperature runs high, should be practiced three or four times a day. I prefer this milder practice to cold efl:usions, or cold wet packing, which, so far as my experience goes, are only to be adopted in exceptional cases. The treatment by cold water has proved curative in this variety of scarlet fever when cerebral symptoms are present, and coma threatens ; no other remedy except cold having the power to reduce the hyperpyrexia, as in those cases of rheumatism, where a dangerous rise of tem- perature takes place.* This plan should be adopted when all other affections which often accompany them, and wliich, by their severity, may endanger life. Thus aconite will moderate, but neitlicr prevent nor shorten the course of the inflammation of the throat in scarlet fever, and the catarrh and bronchitis in measles, and in this indirect manner lessen the height of the fever. — Dr. Ringer's Handbook of Therapeutics, 4th edition. Aconite, p. 435. * See Chap. XLIII, " On Acute Rheumatism." SCARLET FEVER OR SCARLATINA. 131 remedies fail, and the skin is extremely hot, the pulse full, and there is drowsiness, convulsions, or delirium. It is better to im- merse the patient in tepid water tirst, and gradually cool it by the addition of ice. The etfects of the bath on the temperature should be carefully w^atched, the patient not being kept in it for more than ten minutes at one time. If there is delirium and a tendency to coma, the scalp may be shaved, and cold lotions applied to the head. In this form of the disease, depression soon sets in, and port wine, beef tea, champagne, and soda-water will be required. For the throat affection, if the patient is old enough to manage it, a gargle of chlorate of potash and dilute hydrochloric acid will correct the unhealthy exudation that hangs about the throat, but in the case of very young children this cannot be used, and then mopping out the fauces with a solution of nitrate of silver (gr. x to the 5J) twice a day will be effectual in most mild cases, or a weak solution of chlorinated soda may be substituted. The inhalation of the steam of hot water as long as the throat is sore, is a safe and excellent practice, and according to Dr. Gaird- ner, supersedes almost all other local applications.* The inhalers used for this purpose, however useful and easy of application for adults, are somewhat alarming and difficult for very young chil- dren. The steam-draft inhaler brought before the notice of the Medical Society of London, by Dr. R. J. Lee, is well adapted in these cases. f When the exudation is of an ashy color and inclined to extend, the solution of perchloride of iron, applied ou a sponge with for- ceps, will exert an excellent effect. It should be used night and morning at least, and after two or three applications, the throat will assume a more healthy appearance, and the fetor of the breath w^ill diminish. In very young children, it is necessary to apply the solution lightly, and to limit its application to the diseased surface, for if any roughness is employed, and great care is not taken, the healthy parts are irritated, and the soreness and inflam- mation increased. The diluted solution for children is generally strong enough ;:j: but this may be left to the discretion of the * Clinical Medicine, Scarlet and Enteric Fever, p. 196. f Medical Society Proceedings, vol. iv, p. 201. X Formula 10 : R. Liq. Ferri Perchlor., §j Glycerini. Aquse, aa . . . ^ss. — M. Fiat solutio. 132 DISEASES OF CHILDREN. practitioner, as where tlie throat is dark and much implicated, I should not hesitate to employ the pure solution (Liq. Ferri Per- chlor., B. P.). In cases, however, where the jaws are stiff from the swelling, or the child resists obstinatelj^, or is exhausted, it is perhaps better to desist from local interference with the throat. If a case of this difficult}^ presents itself, the carbolic acid spray is one of the best applications. When foul secretions collect about the fauces, and cannot be thrown off by any eflbrts of the little patient, the spray ought to be employed. It both cleanses and disinfects. As it is of the utmost importance that the patient should breathe as pure an atmosphere as possible, it is evident that if the air becomes con- taminated before it reaches the lungs (as it will do if the throat is covered Avith decomposing secretions) the child's life is placed in still greater jeopardy. The vulcanite spray producer, as sold by surgical instrument makers, is of great service in all inflammatory or irritative aiiections of the throat, larynx, and bronchi. It is easy of application, and causes neither pain nor inconvenience. The vulcanite end must be introduced between the teeth and above the tongue, because a young child will not open its mouth when bid. Then with gentle pressure on the hand-ball, a steady and uniform stream of carbolic spray can be kept up and maintained, if compression is made about once in every second. It acts directly on the diseased tissues, and gradually penetrates deeper than any gargle or other similar mode of application ; causing neither pain nor irritation to the inflamed and sensitive throat. I give prefer- ence to carbolic acid, but other medicinal agents ma}^ be used. In cases of throat affection due to the exanthemata, I have seen excellent effects follow the use of the spray vaporizer — the respira- tion and the power of swallowing rapidly improving, and patches of slough and exudation expectorated. In young children I have on several occasions known life saved by it, and it is a remedy to be held in remembrance. Three or four inhalations may be used in the space of twenty-four hours, and the strengtii of the liquid may vary from one in twenty to one in forty. For fear of fatiguing the child, each application should not exceed three or four minutes. Soon after its use, I have known a child, previously on the verge of coma and breathing rapidly, wake up lively, and from that time improve, till a repetition of the same application was de- manded by a relapse of the sj^mptoms. SCAELET FEVER OR SCARLATINA. 133 Meigs and Pepper recommend a decoction of stronjr green tea and alum, or sage tea and alum, or lime-water, or honey of roses and borax.* Sir T. Watson a solution of chloride of soda.f Dr. "West one part of hydrochloric acid to six parts of honey, by means of a dossil of lint or a camel's-hair brush, two or three times a day.:]: For the coryza, any of the astringent washes used for the throat, or a solution of nitrate of silver — gr, j or gr. ij to 5j of water, thrown up the nostrils every four hours.§ In Scaiintina maligna the treatment must be of a supporting character from the first, and ammonia, bark, iron, || port wine, and brandy are required to be given freely. There is here a tendency to failure of the heart's action, either from debility and exhaustion, or from fibrinous deposit in its cavities. Sir Thomas Watson recommends in scarlet fever a chlorine drink, now well known to the profession. It is composed of eight grains of chlorate of potash, one drachm of hydrochloric acid, and one pint of water. A child ten years of age may have it rather more diluted, and take half the quantity during the da3^ The chlorine possesses disinfecting properties, and the solution renders the foul secretions which collect upon the fauces less noxious and hurtful, and the tongue becomes clean and moist. ®[[ Or the following mix- ture may be used : Put an ounce of chlorate of potash and the juice of two moderate-sized lemons into an ordinary wine bottle, and fill up with Avater. A wineglassful may be given, or taken, two or three times a day by the patient and by those in attendance. For the dropsy that follows scarlatina, warmth and a milk diet are to be adopted. An occasional aperient of compound jalap powder in the morning, and small doses of tincture of digitalis with acetate of potash during the day should be given, if the urine is scanty and high-colored, or contains any blood. If there is pain in the loins, a vapor-bath or a poultice, applied every night * Diseases of Children, 1874, p. 754. t Principles and Practice of Medicine, vol. ii, p. 909, 4th edit. X Diseases of Infancy and Childhood, p. 732. § Ibid. II Formula 11: R. Amm. carb., ......... gr. viij Tinct. cinch, corap., ^ij Syr. aurant., . ^iij Aqnam ad ......... . ^^iv. — M. A dessert or tablespoonful every four hours. For a child four or five years old. T[ Principles and Practice of Medicine, 4th edit., vol. ii, p. 910. 134 DISEASES OF CHILDREX. should be emploj-ed."^ When the urine is clear, though albumin- ous, and the febrile symptoms have departed, the tincture of per- chloride of iron (Form. 53) should be given, and if the child loses flesh, and there is no sickness or diarrhoea, cod-liver oil will be a useful adjunct. For the efl'usions that are liable to occur in the pleural or pericardial cavit}^, diuretics and tonics are to be em- ployed, and all those remedies which encourage the action of the excretory organs, and improve the qualitj' of the blood at the same time. When an attack of scarlet fever and its consequences have passed awa}^, the patient should wear flannel next the skin^ and go to the seaside for change of air. Flowever well a child may be going on, after a severe case, a mouth or six weeks ought to elapse before it goes out of doors, and even then the weather should be considered. For many months after an attack of scarlet fever, and it may even be for an indefinite time, there will be observed in some cases, especially those marked b}^ ansemia, a faint and persistent trace of albumen, with no other morbid change in the urine, as tube casts or renal epithelium. This condition awakens some anxiety, though it may continue for twentj^ years without any manifest impairment of the general health. When anemia is present, I strongl}^ advocate the steady use of the tincture of the perchloride of iron, and in some instances, where renal congestion is easily provoked, the addition of gr. -^^ of perchloride of mercury three times a day. AYhen the diet is carefully regulated and cold avoided, perfect recovery may take place, but there will be no chance of this, unless stimulants are prohibited, and milk and white fish take the place of meat. Xow, as to some precautionary measures in arresting the spread of this disorder. Isolation of the patients suffering from scarlet fever is one of the chief circumstances to be borne in mind in order to prevent its extension. The apartment in which the sick person * See Chap. XXIV, "On Acute Desquamative Nephritis." In the Practitioner fur August, 1876, Dr. de Havilland Hall has recorded an interesting case of acute desquam- ative nephritis following scarlet fever, in which the patient, a boy nine years of age, passed no water for fifty hours after admission, and from his mother's account very little had been passed previously. Tlie entire absence of any of the symptoms of uraemia in tlie case was attributed in part to the fact that all articles of nourishment, except a little milk and a free supply of water, were withheld. The only medicinal treatment was a dose of Pulv. Jalapas Co. and a drachm of bitartrate of potash as a drink. SCARLET FEVER OR SCARLATINA. 135 is confined should be well ventilated, and curtains, carpets, and all unnecessary articles of furniture should be removed. The bed linen and that worn by the patient should be changed daily, and placed at once into a deep common hip bath, under water, so that the desquamating epidermis may be less likely to propagate infec- tion. I recommeiid a weak solution of carbolic acid to be thrown into the bath, and two or three saucers containing it to be put in the sick-room and various parts of the house. I also insist on the importance of adding disinfectants to the evacuations, and getting rid of them directly. With these precautions I have often known the disease not to spread. Infection persists so long as there is the least trace of desquamation, and to insure safety, isolation should be enforced for at least a week after the last particle of exfoliated cuticle has been detached. Dr. Wm. Budd's* directions for limiting the spread of the disease are well known to the professsion His paper is so full of interest, and his directions so eminently practical, that I shall quote the chief precautions which he enforces. 1. The room is to be dismantled of all needless woollens or other draperies, which might possibly serve to harbor the poison. 2. A basin charged with chloride or carbolate of lime, or some other convenient disinfectant, is to be kept constantly on the bed, for the patient to spit into. 3. A large vessel, containing water impregnated with chlorides or with Condy's fluid, should always stand in the room, for the reception of all bed and body linen immediately on its removal from the person of the patient. 4. Pocket handkerchiefs are proscribed, and small pieces of rag are used instead for wiping the mouth, and nose. Each piece after being once used is to be immediately burnt. 5. As the hands of nurses of necessity become frequently soiled by the specific excreta, a good supply of towels, and two basins, one containing water with Condy's fluid or chlorides, and another plain soap and water, are always to be at hand, for the immediate removal of the taint. 6. All glasses, cups, or other vessels, used by or about the patients, are to be scrupulously cleaned before being used by others. * Scarlet Fever and its Prevention, Brit. Med. Joiirn., 1869, vol. i, p. 23. 136 DISEASES OF CHILDEEX. 7. The discharges from the bowels and kidnejs are to be received, 071 their very issue from the body, into vessels charged with disinfectants. Dr. Bndd considers that by these means the infectious power of the germs is destroj-ed as they emanate from the skin, the surface of which is so extensive, that the poison escaping b}'' it is far greater than that which is cast off by all the other surfaces of the body combined. An impalpable powder armed with the subtle poison of scarlet fever, floats in the atmosphere and conveys infec- tion to an}^ person who may be within the sphere of its influence. To prevent the escape of these particles from the body and carrying the poison far and near, Dr. Budd strongly advises anointing the body and scalp with olive oil impregnated with camphor twice a day. As soon as the skin begins to peel (and this is sometimes as early as the fourth daj^) the oiling should be commenced, and con- tinued till the patient is well enough to take a warm bath, when the whole body and head should be well scrubbed with disinfect- ing soap (Calvert's or McDoughall's). The baths are to be repeated every other day until four have been taken, when, if the patient has new clothes, and there is no throat or kidney complication, he may return without risk to his family in a week or ten days. After this the sick-room should be well fumigated, and the bedding or curtains exposed to a high temperature (240° or 250°), which is said effectually to destroy the power of the specific poison. The principles advocated by Dr. Budd apply to all contagious fevers, as small-pox, measles, typhus, etc., and the method employed has proved so successful in his hands, that, during a period of twenty years, he had not known the disease to spread beyond the sick-room. " Hanging rags steeped in disinfectant solution about the room is not to be commended, but a sheet moistened with a strong solu- tion of chloralum, carbolic acid, or Condy's fluid, and suspended outside the door of the room, is very necessary to complete the isolation of the patient. . . . Care must also be taken in using different disinfectants that they do not counteract each other ; for example, carbolic acid decomposes Condy's fluid."* The prophylactic powers of belladonna, which have been vaunted for preventing an attack of scarlatina, are so fanciful that I do not attach importance to the statements that have been made iu favor of it. * Handbook of Uygiene, by Dr. Wilson, second edition, 1873, p. 304. VARIOLA OR SMALL-POX. 137 CHAPTER XIT. VARIOLA OR SMALL-POX. Theee principal, Vabieties generai>ly described: 1. Variola discreia or dis- tinct small-pox — 2. Variola confluens or conjlueni small-pox — 3. Variola hcemorrhagica. 1. Variola discreta has three distinct stages — (1) The stage of incubation — (2) The stage of eruption — (3) The stage of desquamation. 2. Variola confluens ushered in with more severe constitutional symptoms, and. irregularity in the appearance of the rash — Contents of the pustules and occasional implication of the cellular tissue beneath — Danger of the secondary fever and affection of the throat and salivary glands. 3. Vari- ola hcemorrhagica or black .small-pox, met with during the prevaltnre of a severe epidemic — Varioloid or modified small-pox; its symptoms and general character. Causes: Small-pox due to a specifie poison' from a person infected, with it, and communicable by iuocxdation. Prognosis and Complications : Mortality and morbid appearances found after death. Treatment : Importance of keeping the apartments cool and well ventilated — Value of disinfectants — U-'ic of emetics and purgatives in the ea>iy .stages — Remedies for the relief of itching and local irritation — Management of restlessness and delirium — Local inflammation and collection of matter — Applications to the throat and fauces — -Frequency of boils — Diarrhoea — Prevention of pitting — Ophthalmia. Small-pox is a highly contagious febrile disease, following a definite and uniform course, which after a latent period passes through the stages of pimple, vesicle, pustule, and scab. Since the introduction of vaccination this disease has become compara- tively rare ; and if this preventive measure is efficiently carried out there is every reason to hope that it will gradually become ex- terminated. In this country it is compulsory to vaccinate by the third month, and as very young children are especially subject to the disease, and it spreads with alarming force, the law cannot be too stringently observed where the health is good. Older persons who have been successfully vaccinated are in a great degree exempt from the disorder, and they may enjoy immunity from it if revac- cinated when growth is completed, or VN'hen an epidemic prevails. When a person who is unprotected by vaccination is exposed to the contagion of small-pox, he may contract the most malignant form, according to the state of his health and the type of the dis- ease that prevails. Three varieties of small-pox are usually de- scribed : 1. Variola discreia, or distinct small-pox. 2. Variola confluens, or confluent small-pox. 3. Variola haimorrhagica. 1. Variola discreta, or the milder type, has three stages like 138 DISEASES OF CHILDREN. other exantliematoLis affections. (1.) The stage of incubation. (2.) The stage of eruption. (3.) The stage of desquamation. 1. The Stage of Incubation. — Fourteen clays usually elapse between the time when the poison is received into the system and the aj3pearance of the eruption.* Two days preceding the eruption the constitutional symptoms are marked by a rigOr, severe head- ache, loss of appetite, and thirst, but they are sometimes over- looked, and in a few instances I have seen children brought for an opinion about the characier of a small-pox eruption wdiich covered the face, and caused but little derangement in the general health. There is usually the history of a day's malaise before the spots appear, and where a child is seen during this doubtful period, there is always such rise of temperature as warrants rest in bed, and a cautious diagnosis. Generally some symptoms of gastric disorder precede the outbreak of the exanthem, as a thick-coated tongue, vomiting, and irregularity of the bowels ; pain in the back and loins, constantly observed in adults, cannot be ascertained in young children, as if the question is put they are certain to com- plain of it. At this time the accompanying febrile excitement is always shown by tlie clinical thermometer. Then disturbances ensue in the nervous and vascular system ; the skin feels hot and pungent, and there is headache and restlessness — headache is a constant and severe sj-mptom. Sometimes there is delirium or convulsions, and a torpid or even comatose condition, from which it is not easy to rouse the child. The pulse is quick and full, 120 to 140, and towards evening the febrile exacerbations become greater, and the temperature rises to 101° or 105°, the eyes are suffused and heavy, and then tlie eruption makes its appearance, which occurs earlier in severe than in mild cases. Sometimes a roseolous rash precedes the characteristic eruption, which has received the name of " roseola variolosa," and then it may be im- possible to diagnose it from measles. The eruption first shows itself on the face, in the form of small red elevated papules resembling measles. Soon an elevation takes * In three cases mentioned by Dr. Murcliison, the incubation-period, dating from . the time the poison entered tlie system till the first symptoms appeared, was thirteen daj's in two cases, and eleven days in one case, so that tlie latent period is subject to variation, as it is in all of the infections diseases. Of eighteen cases, the shortest incubation-period was five days in one case, eleven days in five cases, and thirteen days in one case. — Observations on the Period of Incubation of Scarlet Fever, and of some othen Diseases, Clin. Trans., 1878, p. 238. VARIOLA OR SMALL-POX. 139 place in the centre hy the development of a small tubercle, and by the second day, it attains the size of a pin's head, and imparts a feeling of small shot to the finger. On the third day, it is as large as a lentil and extends over the rest of the face and neck, to the shoulders, trunk, and extremities. The eruption is darker and most abundant where the parts are exposed or uncovered, and on protected parts, as the body or feet, it is of a light rose color. About the fifth day, a small vesicle containing a clear fluid forms on the top of each pimple — it is tense, like a small blister, but soon becomes depressed in the centre, with an inflamed areola or base surrounding the elevated pimple. All the points, or papules, do not pass through the same process of change, as some of them never reach the stage of maturation, but pass away in the course of a few" days, especially on the legs and feet. The excitement and inflammatory fever now quickly subside, the pulse is reduced in frequency, the secretions become more natural, and the cerebral disturbance passes off. On or about the sixth day, there is sore- ness and swelling of the throat with difficulty in swallowing, and the rash and small circular white spots may be seen on the fauces. This does not occur in all cases. The throat is sometimes free, though the attack is a severe one. The face and eyelids swell, so that the features of the patient are no longer to be recognized. On or about the eighth day, the central depression disappears, and the contents of the vesicles become purulent, the redness of the areola is more extensive, and the face more swelled and bloated.^ In cases that pursue a satisfactory course, a brown spot forms in the centre of the pustule, which attains its full size by the ninth day, the areola around the base becomes less inflamed, and the pufliness of the features disajjpears. At the same time the face and hands begin to swell. The pustules now rupture and the escape of their contents dry up into scabs, which fall off in the course of four or five days, beneath which the skin is of a pur- * "Each well-formed pustule, when carefully dissected, will be seen to consist of two compartments, the upper one being the larger. These compartments are both filled with pus, and communicate with each other at the marginal borders. This septum is a layer of false membrane, deposited in the derma at an early stage of the disease, which, by removing the surface-layer of the pustule, is brought into view, presenting a bright red or purple color, and is highly infecting. Eut the mature surface is multiloc- ular, and when a transverse section is made, presents an appearance that has been compared to a severed orange.'' — Vogel, Diseases of Children, 1874, p. 499. Tra'nsla- tor's remarks. 140 DISEASES OF CHILDREN. plisli color, whicli lasts for a considerable length of time. The bursting and desiccation of the pustules begin first on the face, and gradually pass downwards to the trunk and extremities. Scratching the surface prevents children from giving the pustules a chance of drying up without bursting. The swelling of the hands and feet passes off, and the patient is convalescent by the seventeenth or eighteenth day. If the case is a severe one, and the child has not been vaccinated, a permanent depression or scar is left in the skin marking the situation of each pustule. This becomes covered with a new epidermis, and the cicatrices appear very marked in children, but as they grow older, the skin being thin and elastic, the depressions are not so apparent. About the eighth daj", when the vesicle has become pustular, a secondary or suppurative fever appears ; the face is more swelled and inflamed, the pulse is quick and weak, the tongue inclined to drj'ness, and the temperature considerably elevated. The urine is scanty and high-colored* and the bowels consti- pated, so that the little patient becomes restless, or even delirious at night ; the surface itches to such an extent that the child scratches and tears open the pustules unless the greatest precau- tions are taken. 2. Variola Conflaens or Confluent Sniall-'pox. — This variety of the disease is more severe than that just described. It sets in with more severe rigors, with fever, headache, and delirium. The secondary fever is also of a tj'phoid character, and there may be coma and jactitation. The rash does not appear with the regu- larity of the milder affection ; a red erythematous blush appears on the skin, and on the second day, small red points may be seen, and the pustules are not distinct but run together and are flat. They often contain a thin, brownish, ichorous discharge, instead of puru- lent matter. The cellular tissue beneath maj^ be involved in severe inflammation and slouo-hino-, and the swelliuo; of the face and salivation begin earlj^ in the disease. The secondary fever is much more dangerous than in the first form, and quickly assumes a * Tlie urinary secretion in tlie eruptive and suppurative stages may contain traces of allMimen, which indeed is common to tlicse periods in some otiier of the exanthe- mata. Becquerel states that it is normal during desquamation, but in the putrid form of the disease "it is decomposed and ammoniacul," and ma.y sometimes contain blood. But tliis is simply due to the hsematuria, which we have seen to be common when the poison is of a very malignant character, arid is part of the same condition which pro- duces ecchymoses of the conjunctivae and petechise on the skin. YAEIOLA OR S.MALL-POX. 141 typhoid character. The eruption is dark and livid, and petechi{« are common, as well as hremorrhages from the mucous surface of the bowels or bladder. The exhaustion increases, and the patient perhaps dies convulsed, or in a state of coma. In cases of recovery" the cicatrices are deeper, and the deformity greater. In one case of extreme severity that came under my care some years ago, the outline of the nose was completely effaced, and the eyelids infil- trated with serum and covered with pustules. The fauces, mouth, and nose were similarly affected, and the tongue was so swelled that it could not be retained within the mouth. The neck and cervical glands were swollen, and viscid saliva was constantly pouring out of the mouth. This distressing condition had only lasted a few hours, when, in making an ineffectual attempt to swallow^ a little fluid that had been put into the mouth, the patient was seized with suffocative symptoms, and died instantly. 3. There is yet another variety termed Variola hcemorrh.agica or black small-pox, which is occasionally met "with in severe epi- demics. Bright red petechiae occur upon the skin about the size of a pin's head coincident with the appearance of the papules, which become darker and of a purple hue on the third or fourth day of the disease, when a spot of purpura or of haemorrhage occupies the pustule. White pustules may be seen on the fauces and palate. Htemorrhage from the mucous surface of the vagina, bowels, and urinary passages (h?ematuria) distinguish the disease. The mind is collected, and death occurs on the third or fourth day of the disease. Congestion of the chief internal organs is seen in the lungs, mesenteric glands, and spleen, and ecchymoses, like the petechia on the skin, are scattered over the intestines. Soft clots are found in the right side of the heart, while the left is empty. These cases are rare, but they occur in every severe epidemic, and when once seen cannot readily be mistaken, though they may be overlooked, in consequence of death happening before the rash is well developed. Varioloid or modified small-pox is the term used when the disease happens a second time, or the patient has been protected by vacci- nation. The fever lasts only a day or two, and the eruption ap- pears in the morning, the general health being slightly deranged the day before. A few scattered pimples appear on the forehead, face, and nose ; some of them become vesicles, and others shrivel up, whilst on different parts of the body they present various 142 DISEASES OF CHILDEEl!f. stages of imperfect development. The rapid fall of temperature on the second or third day as the rash appears, distinguishes it from typhus and from measles. Unless the rash is extensive there is no secondary fever. The cause of small-pox is due to a specific poison from a person laboring under the disease, or from clothes left ofi'by the sick and worn by the health3^ It is conveyed b}'- the atmosphere and is caught from vehicles in which diseased persons have ridden. It may be communicated by inoculation or by the scabs from the sick. " Most likely it is communicable from the moment when the initiatory fever begins. It may be given by the breath of the patient before the eruption has appeared on the surface of the body. It continues infectious so long as any of the dry scabs re- sulting from the original eruption remain adherent to the body ; a single breathing of the air where it is, is enough to give the dis- ease. The dead body for several days after death, has been known to communicate the disease, and in all probability it would pro- duce the disease for some months afterwards."* Small-pox seldom attacks the same person a second time, not one per cent, being liable to a recurrence of it. The disease may attack the foetus in utero. As to the prognosis of the disease, it is favorable in the vac- cinated, if three or four good vaccination-marks remain, if the disease is mild and distinct, and if the children are strong and health3^ It is unfavorable if vaccination have never been per- formed, or if there be only one or two faint marks of a single vac- cination ; if the symptoms assume a confluent form, and the pus- tules are dark and flattened. A sudden disappearance of the rash, with prostration of the strength, and a rapid feeble pulse, are indications of danger ; and where they are present the typhoid state continues, and leads to death by syncope, convulsions, or coma. Inflammatory affections of the brain, pneumonia, and sup- puration of some of tlie viscera, are among the modes of fatal termination. Death most commonly occurs in small-pox after the primary fever, and seldom before the twelfth day — the most frequent com- plications are meningitis, and aft'ections of the thoracic organs, severe diarrhrca, and lesions of the intestinal canal, and, according to Vogel, gangrene of the mouth is sometimes present.f * Keynolds's System of Medicine, vol. i, 2d edit., p. 242. f Diseases of Children, p. 491. VARIOLA OR SMALL-POX. 143 The mortality from tins disease increases with age; "while it is very fatal at the extremes of life.* Much will depend upon the age and constitution of the child, and whether it has been pre- viously vaccinated or not. Where it is neglected, the child gets a severe attack, and, if it recovers, bears through life the most dis- figuring cicatrices. In the case of a mother and child, who came under my notice some years ago, the former, who was protected bj^ vacciiiation, had only a few small spots on her face, and made no complaint of her health bej^ond slight lassitude and disordered digestion ; whilst the latter, who was four months old, and suckled by the mother, had her face covered with the eruption, and the body and limbs were also much involved. The child recovered, but to this day the face is frightfully pitted by the numerous cica- trices. Of the morbid appearances found in those who have died of small-pox, evidences of inflammation are met with in the intestinal canal, the bronchial tubes, and various parts of the brain, in con- sequence of a deteriorated state of the blood, which is found liquid, dark, and uncoagulated. Universal congestion of the internal organs is also present, and the liver, spleen, and kidneys contain a ffreat deal of blood. The brain and membranes are cons-ested, and the sinuses full of blood. Pustules or false membrane may be seen in the mouth, tongue, fauces, and pharynx, and throughout the oesophagus to the rectum, beneath which the membrane is infiaraed and vascular. Evidence of inflammation in the interior of the heart and pericardium is also to be noted, and a change in the nmscalar structure leading to granular or fatty degeneration. Treatment. — There is no disease in which it is more necessary to keep the apartment cool and ventilated. In the winter season of the year there should be a fire in the room, and the windows opened from time to time, and so managed that the patient may not be exposed to draughts of cold air. In the summer, when the weather is hot or sultry, the windows should be opened at the top, and curtains and carpets be removed. Disinfectants, in the shape of carbolic acid, Condy's fluid, or chloride of lime, should be placed in saucers and put in the room and passages of the house. All these important precautions ought to be strenuously enforced. Before the eruption makes its appearance the treatment should * " According to Dr. Marson, patients of all ages die at tlie rate of 50 per cent, in the confluent, and 8 per cent, in the semi-confluent, and 4 per cent, in the discrete variety." — Hooper's Fhysician^s Vade Mecum. Dr. Guy and Dr. Harley. Article, Variola, p. 305. 144 DISEASES OP CHILDREN". be directed to moderate the fever aud subdue the nervous excite- ment. To attain this object an emetic may be given, followed by a mixture of sulphate of magnesia with nitrate of potash (Form. 8), or infusion of senna, to control the fever and open the bowels freely. If the child is strong and there is constipation a grain or tW'O of calomel, followed by a draught of sulphate of magnesia and senna, should be ordered. In mild cases a dose of castor oil, or a draught of rhubarb and magnesia, will be sufficient to .clear the bowels of an}^ irritant matters. If the disease happens in hot weather, and there is much thirst and soreness of the throat in sw^allowing, weak tea and milk with toast will be sufficient nourishment for a day or two, and grapes, strawberries, and iced lemonade may be taken freely. Raspberry vinegar is an excellent drink and relished by all patients. During the period of eruption aud maturation the measures to be employed are much the same; and, if there is restlessness and irritation of the skin, it is a good plan to use a warm bath, to which oatrneal or carbonate of soda is added. If itching and irri- tation of the face are severe it shoukl be smeared over with olive oil, or olive oil to which carbolic acid (1 in 40) is added, or glj^c- erin, or zinc ointment. Pork lard melted in a saucer and applied to the face allays irritation in a remarkable manner. If the strength appears deficient it must be supported by suitable nourishment, as beef tea, chicken broth, and so forth. When the fever subsides a stimulating diaphoretic may be giveu.* If the child is restless at night bromide of potassium or hydrate of chloral at bedtime should be employed, for if the patient cannot obtain sleep he will become exhausted and the restlessness will increase. Opiates, however, must be used wnth great caution. For the delirium which arises in the course of small-pox, care should be observed in noticing whether it is due to a plethoric state, with a full pulse and active * Formula 12: R. Liquor aram. acet., ^ss. Spt. aether, nitr., ........ 3j Syr. rosse, . . giij Aquam ad ,^iv. — M. A tablespoouful every four hours. For children five years of age. Formula 13 : R. Amm. carb., gr. viij Liquor amm. acet., Syr. aurant., aa ....... . ^ss. Aquam ad ........ . 5iv. — M. A tablespoonful every four hours. For cliildren five years of age. VARIOLA OR SMALL-POX. 145 cerebral excitement, or whether the child is weakly and delicate, and the pulse quick and running, so that each beat is not appre- ciably distinct. In the former case cokl sponging or ice to the head may be required ; in the latter case stimulants and nourish- ment, with quinine if the temperature be high, are the only reme- dies to subdue it. Local inflammation must be treated on general principles. "Where collections of matter form, whether in the cellular tissue or under the scalp, they should be opened early to prevent their spreading, and cavities may be washed out with carbolic acid lo- tion (1 in 40) or nitrate of silver (gr. x to the 5J). The discharge from the pustules in severe cases is very irritating and causes much discomfort. To meet this the linen cannot be too frequently changed, and oxide of zinc and starch in equal proportions, or calamine powder and oxide of zinc, or flour, or some of the toilet powders in use, may be dusted over the body from a common dredger. For the vomiting, which sometimes occurs, iced water or prussic acid is useful ; and if the child is old enough an effer- vescent mixture, and a poultice to the epigastrium. If the throat is much swollen two or three leeches may be applied, and after- wards a i^oultice. Mopping out the throat with a weak solution of nitrate of silver, or the infusion of roses with sulphuric acid, is also to be recommended. Boils frequently result from small-pox, and they are tedious to heal. The discharge exhausts the patient and prolongs his con- valescence. When this complication has arisen quinine and bark will be required to support the strength. The mineral acids with tincture of gentian often ansvver well, and the wounds should be dressed with some stimulating ointment. If sloughing takes place a carrot or a linseed poultice should be applied, and the free use of carbolic acid or Condy's fluid should not be omitted. When the eruptive fever has passed away, and there are languor and clammy skin, the mineral acids with bark or calumba will be serviceable.* When the strength begins to fail tonics and stimu- * Formula 14: R. Acid, nitric, dil., Acid, liydrochl. dil., ha, . . . . . . . ^ss. Tinct. cinch, co., vel tinct. calunibse, .... giij Syrupi, 3ss. Aquara ad ........ . ^iv. — M. A tablespoonful three times a day. For children five years of age. 10 146 DISEASES OF CHILDEEX. lants will be needed. Quinine and ammonia are the best, and wine and brand}^ according to the exigencies of the case. In the hsemorrhagic variety of the affection, the free use of stimu- lants, and supporting measures of all kinds are demanded. In the shape of medicine some styptic preparations of iron, as the tincture of the perchloride, should be given to restrain the haemorrhage. When diarrhoea is excessive it should be checked by krameria,* small doses of laudanum, or the Pulvis Cretse c. Opio.f The prevention of pitting is no insignificant part of the treat- ment. The parts affected, jiarticularly the face, should be protected from the air, and the lymph let out from the distended vesicles by a needle, and absorbed by cotton-wool. The top of each pustule is to be lifted up, and a thin point of nitrate of silver applied to the base. The remedj^ to be successful should be applied on the second or third day of eruption, and, though it causes some pain, it soon passes off, and diminishes the swelling and tumefaction of the pustules, and prevents cicatrices. Of the application of mer- curial ointment to prevent pitting, Rilliet and Barthez state, that it was successful even in cases of confluent small-pox, and that when applied on the first or second day it prevented the develop- ment of the eruption, and caused an abortion of the pustules. To protect the skin, collodion may be applied, or, still better, the flexible collodion made of collodion, castor oil and Canada balsam. The plan adopted at the Small-pox Hospital is as follows: " Wait until the pustules have discharged, and the discharge has begun to dry, then put on some of the best olive oil, or a mixture of one-third glj'cerin and two-thirds of rose-water. Some of this may be applied once or twice a day, for a few days, until the scabs begin to loosen. Cold cream and oxide of zinc, or olive oil and lime-water, form good applications ; or if the discharge is * Formula 15 : R. Tinct. kramerise, 3y Tinct. opii, "JJxij Spt. chloroform., '"Kxvj Syr. zingib., ^iij Aquam ad ^iv. — M. A taljleppoonl'ul after each action of the bowels. For children five years of age. f Formula IG : Be. Pnlv creta? c. opio, • 9u Tinct. catechu, 3'j Aqnam menth. pip. ad §ij. — M. Two teaspoonfuls after each action of the bowels. For children fis^e years of age. VARIOLA OR SMALL-POX. 147 thin and excoriating, calamine mixed with olive oil. The patient should be warned not to allow the scabs to dry and remain some time on the nose and other parts of the face, particularly on the forehead and near the end of the nose. AYhen this takes place, the dry scabs themselves leave deep marks in the skin, worse than the eruption of small-pox itself. The pain of removing the dry scabs is sometimes considerable, and the patient can hardly be prevailed to take them off, or allow others to do so. In common the pits from the eruption are not deep at first, just after the patient has got well, and we ma^^ deceive ourselves by thinking our efforts to prevent disfiguration have been attended with considerable success. The disease leaves a peculiar brown stain on the skin at first, which soon wears oflf, but the pitting is more perceptible a twelvemonth or so after the patient has got well.*" If ophthalmia is severe two or three leeches to the temples may be necessary, and in milder cases a solution of nitrate of silver (gr. j to gr. iv to the oj). When the eyelids are swollen and cedematous, and the lips stick together by a tenacious secretion, they should be bathed frequently with warm water and a little Ung. Cetacei, or diluted yellow oxide of mercury ointment (Hyd. Oxy. Flava gr. viij, Vaseline oj) applied to the edges of the eyelids night and morning. When ulcerations of the cornefe ensue, it has been recommended to touch them with a sharp point of nitrate of silver, or a collyrium of sulphate of zinc and opium may be used.f Meigs and Pepper speak highly of a collyrium of borax and sul- phate of zinc.:{; * Small-pox, by J. F. Marson, Reynolds's System of Medicine, 3d edit., vol. i, p. 252. t Formula 17 : U. Zinci sulph., . . . . .■* gr- ij Vini opii, n^xx Aqiiam rosae ad • SJ • — M. Fiat collyrium. X Formula 18: R . Sodse biborat., gr. xij Zinci sulph., gr. j Aquae camph., gj Aquam destill. ad , 5j. — M. Fiat collyrium. 148 DISEASES OF CHILDEEN. CHAPTER XIII. DISEASES OF THE MOUTH AI^D FAUCES. Stomatitis and its Vaeieties: Stomatitis simplex, or simple inflamraation of the mouth — Symptoms— Causes and treatment — Stomatitis follicularis ( Vesicular stomatitis — Aphthous stomatitis) — Symptoms — Causes and treatment — Stomatitis fungosa — Aph- thce — Le Muguet — Thrush or white mouth — Diffuse inflammation of the mouth — Symptoms and treatment — Value of chlorate of potash — Ulcerative stomatitis — Char- acter of the ulceration — Local and constitutional causes— Treatment — Chlorate of potash — Bark — Iron — Cod-liver oil — Local application of nitrate of silver — Hydro- chloric acid — Gangrenous stomatitis — Gangrene of the mouth — Canerum oris — Symptoms — Pathology and treatment — Caustics — Chlorate of potash — Wine — Mercu- rial salivation^ Rare in children — Treatment — Gingivitis— Acute tonsillitis— Hyper- trophy of the tonsils — Simple pharyngitis — Reti'o-pharyngeal abscess — Cynanche parotidea, or mumps. INFLAMMATION of the moiith is a troublesome and painful disease in infants and 3'oung children. Although extremely common during the period of dentition, it may occur at almost any age. In one variety the iuHammation does not extend through the mucous membrane, or, at the worst, it produces a number of ♦small, circular, irritable ulcers, with a red margin surrounding a depressed centre, whilst in another the ulceration involves the gums and the mucous membrane more deeply, and in a third, swelling and gangrene attack the cheek, and destroy the life of the sufferer. Stomatitis simjjiex, or inflammation of the mouth, is a mild aftection, causing trifling constitutional disturbance, and, except under neglect, rarely leading to ulceration. It is common among the infants and suckling children of the poor during the first year of life, involving a portion, or sometimes nearly the whole mucous membrane of the mouth, particularly if the food is taken through bottles and the hygienic conditions are bad. It is rare among the children of the upper classes, unless the nipples of the nurse are sore, or the milk is faulty. In the out-patient depart- ment of our hospitals it is very frequent. In its mildest form it is an erythema, but occasionally minute vesicles are seen on the aftected membrane, and the lips swell with an herpetic eruption upon them. Sometimes the salivary glands are very active, and saliva dribljles from the mouth. The sjmiptoms are heat and dry- ness of the mouth, restlessness and feverishness, flatulence and diarrha-a ; the mucous membrane presents patches of redness DISEASES OF THE MOUTH AND FAUCES. 149 raised above the surrounding surface, which are seen on the inside of the cheeks and the angles of the mouth ; they may also be observed on the hard palate and gnms, having a yellowish patch of lymph in the centre, with a red^margin. The causes are gastro-intestinal disorder and uncleanliness, and eating indigestible or irritating articles of food. It is seen in scarlatina and measles, or during dentition, when the gums are irritated by the pressure of teeth, and then the disease is local instead of general. In these cases the gums are often red and spongy, and bleed on being touched. The disorder usually yields to a regulated diet, a dose of castor oil, or a powder of rhubarb and carbonate of soda. If it does not improve under this treatment, a mixture containing a little mag- nesia, or the Liq. Magn. Carb. will be useful. Lime-water should be added to the milk, and the mouth cleansed after each meal with a piece of soft rag dipped in warm water. If the gums are swollen and distended by the teeth, they should be lanced. Occasionally the disorder is kept up till the nurse is changed, and the method of feeding is altered. In one well-marked and obstinate case which came under my notice, the mouth did not take on a healthy appearance till feeding with a spoon was substituted for the bottle and the nurse. I Stomatitis follicularis [vesicular stomatitis — aphthous stomatitis) is common with children during the first dentition. Large and distinct pearl-like vesicles of a round and elevated form resem- bling herpes, take place on the inside of the cheeks, lips, sides of the tongue, and more rarely on the gums. When they rupture, a little glairy fluid is discharged, leaving a round and superficial ulcer with a red margin and a yellowish-gray base. The complaint arises from inflammation of the mucous follicles, symptomatic of some intestinal disorder and acidity of the primce vife. It occurs during teething, or after whooping-cough or measles, in fact, it may follow any exhausting complaint. There are several of these ulcers which do not usually run together, except the disorder is severe; and although most frequent on the mucous membrane of the cheek, they are sometimes noticeable on the tonsils and soft palate. Symptoms. — ^^The constitutional disturbance is slight, and there is nothing to notice beyond trifling feverishness, loss of appetite, thirst, and irritability ; sometimes there is not even this assemblage 150 DISEASES OF CHILDREN. of symptoms, and the chief feature is pain with soreness of the mouth, which prevents the child from taking nourishment. The complaint is of common occurrence in delicate children, and is without danger. The ulcers pass away under treatment in the course of a few days, but are prone to recur from time to time, as in adults when the digestive functions are deranged. It is im- portant to bear in mind that the disease does not always follow the same mild course. After the bursting of the vesicles the superficial ulceration that remains may be coated with a similar exudation to that which occurs in thrush, and to be even associated with the formation of false membrane, as in diphtheria. Such cases some- times follow severe attacks of measles. Treatment. — An alterative dose of gray powder, soda, and rhu- barb is useful, and tonics — bark, with a few grains of chlorate of potash — will bring about a cure. If the mouth is very painful, and prevents the child from taking food or sucking, a weak solu- tion of nitrate of silver may be brushed over the excoriated parts daily, or they may be touched with a piece of alum ; a lotion con- sisting of one ounce of glycerin of borax to five ounces of water is also a simple and useful application. Stomatitis Fmigosa — AphtJue { Underwood and Deioees) — Le lluguet {French) — Thrush or White Mouth — Diffuse Inflammation of the Mouth. — -Tliis complaint is met with at all ages, but it is most com- mon in infants and young children, as the result of improper or artificial feeding. The mouth is hot and dry, and the salivary secretion is diminished. Small white conical patches form on the inside of the cheeks, angles of the mouth, and sides of the tongue. After two or three days these elevated patches present a curdy or soft cheesy exudation of false membrane, and may be seen on the pharynx, tonsils, or hard palate, and if removed the surface bleeds until it is covered by fresh exudation. The patches assume a gray- ish ragged appearance, leaving an unbroken smooth surface, or a superficial excoriation, which increases the difficulty of swallowing and sucking. The disease may extend into the oesophagus or the air-passages, and cause cough and expectoration, which reduces the child's strength, and may end in exhaustion and inanition. It is most frequent in infants of two or three months old. The con- stitutional symptoms are gastric disorder and diarrhoea, with all the symptoms of muco-enteritis; the motions are greenish, mixed with curdy masses of milk, and in this way- the disease extends DISEASES OF THE MOUTH AND FAUCES. 151 through the whole alimentary tract. The amis is often red and excoriated from the acrid nature of the howel discharges, and there is erythema of the buttocks and perinseuni of the child, and if of the male sex, the scrotum is sore, excoriated, and inflamed. Febrile excitement is not uncommon, and the pulse is accelerated. It occurs in delicate children who are badly fed and clothed, and is looked upon as a serious sign ; but it is simply the local indica- tion of a feeble constitutional condition. It comes and goes, and when seen as the accompaniment of acute or long-standing chronic disease, is of evil augury. The exudation has been seen in the stomach in Peyer's patches, and in the CEecum. " Under the microscope the curdy exudation of thrush has been found to consist of thickened epithelium cells, mingled with numerous minute cryptogamic sporules or seeds, from the midst of clusters of which, long threadlike, jointed, and branching plants arise, intertwining with one another. It was discovered by Berg, of Stockholm, and Grubz, of Vienna, at the same time, and has been named the Oidium albicans.''*- Like the former variety, it is chiefly met with among the chil- dren of the poor, and those brought up by hand or suckled too long. The predisposing causes are attributable to general or local dis- ease, but the exciting cause is owing to a parasitic fungus, as we have just seen in the mucous membrane. This vegetation is proba- bly derived from some mouldy article of diet, which may spread and be conveyed to the nurse's nipple, and from the latter to the child's mouth. Treatment. — In most cases a dose of castor oil and a proper regu- lation of the diet will be all that is needed ; but in every case I would recommend the chlorate of potash, which is a specific ; and a few grains administered three times a day will have a marvellous effect in curing the disorder. The mouth should be washed out after each meal, and a local application of the glj^cerin of borax be employed ; or the affected part may be brushed over with a solution of nitrate of silver (gr. v ad fsj). Sir William Jenuer recommends a solution of sulphite of soda (5j ad f.^j), from the destructive influence which the sulphurous acid has on the fungus. Ulcerative Stomatitis [Ulcero-membranous stomatitis., Rilliet and Barthez) is a mild and frequent disorder, but in no way dangerous * Reynolds's System of Medicine, Art. Thrush, vol. iii, p. 8. 152 DISEASES OF CHILDREN. to life. It is more frequent in hospital tlian in private practice. It would seem to be an aggravated form of the membranous affec- tion, which either advances to ulceration, or in milder cases is absorbed without proceeding any further. The affected mem- brane in the first instance is white or dirty gray, or black, and the surrounding membrane swollen and inflamed. The plastic exudation is thick, and is more or less adherent to the tissue "beneath, and, if raised, exposes a superficial bleeding ulcer. Even when the exudation is gently removed blood oozes from the ex- posed surface. The affection is seen to occupy the inside of the cheek, and to extend to the gums of the front teeth, which are swollen and sjDongy, bleeding on the slightest touch, and, by their retraction, causing the teeth to become loose in their sockets. The cheek and lips in contact with the affected parts likewise become the seat of irregular ulceration, which may prove very obstinate, or degenerate into a more severe form. In mild and favorable cases, the ulcers being superficial rapidly diminish in size and heal quickl}^, the saliva becomes less in quantity, and the gums take on a healthy appearance. But in some cases the ulcers destroy the gum, and extend deeplj^ and are very intractable to treatment. They may involve the whole mucous membrane of the mouth, running together and extending to the hard palate ; and when the disease is so general, the submaxillary glands are hard, swollen, and pain- ful. The breath is offensive, and the salivary secretion is increased. The subjects of this complaint are delicate children, who have been badly fed and cared for. It is common between the ages of five and ten years, and it often prevails as an epidemic. The scrofulous children of the poor are frequent victims, particularly if their health has been further reduced by eruptive diseases or pneumonia, or if they possess bad teeth. In one case under my care there was an obstinate irregular ulcer on the gum, which had receded from a carious tooth, and it resisted all remedies till the decayed stump was removed, when it took on healthy action. There is generally some febrile disturbance, which continues for a day or two. In the case of a female child, nine months old, who was shown to me in May, 1877, by Dr. Wynn Williams, the ulceration occupied the inside of the lower lip in three distinct patches, the largest being the size of a threepenny piece. The ulceration was not deep nor surrounded by induration of the mucous membrane, which DISEASES OF THE MOUTH AND FAUCES. 153 presented no variation from the tint of health. There sprang up from the base of the ulcerated surface long whitish points, like the fungoid excrescences of an open wart. When first seen by Dr. Williams the affected part presented a pealike hard body, feeling like a wart. The child was suffering from bronchopneumonia, chiefly of the right lung, of one week's duration, and the lip be- came affected on the third day of the attack. The face was pallid, and the lips dusky and separated, the respiration was short and p.hallow, 60 per minute; the morning temperature 103°, the pulse 112; in the evening the temperature reached 104.2°, and the pulse 120. There was no ulceration in any other part of the mouth, nor any aphthous exudation. When the exanthematous fevers have altered the qualit}'- of the blood, or a young child is struck down by some acute disease with a high temperature, the mucous membranes are prone to sufier, and especially the mouth. Treatment. — This consists in attention to the general health ; the diet should be regulated and the digestive functions attended to. In the shape of medicine the chlorate of potash is a specific here, as in other varieties of ulceration of the mouth in children. A grain three or four times a day in water for a child a year old, and one additional grain for every year of the child's age up to ten grains will be a suitable dose. A drop or two of the dilute hydrochloric acid, and the addition of the tincture of cinchona, or the ammonio-citrate of iron will soon bring about a cure in ordi- nary cases. Cod-liver oil, quinine, and the syrup of the iodide of iron will be useful. If the ulceration is obstinate, the application of a solution of nitrate of silver to the ulcer, or the hydrochloric acid is desirable. I have often known the gums to take on healthy action at once after an application of nitrate of silver (gr. v ad 5j), and to be well in a week when chlorate of potash has been given at the same time. As in the sore throat of scarlatina, brush- ing over the affected part with the tincture of iron and glycerin is a good application. Gangrenous Stomatitis {Cancrum oris). — This is a serious and rare* constitutional affection, attacking children whose blood is * " I have only seven times had the opportunity of witnessing it ; but so fatal, that in six out of these seven cases the patients died. The larger experience of other ob- servers shows an equally unfavorable result, since 20 out of 21 cases that came under the notice of MM. Killiet and Barthez had a fatal termination, and a recent French 154 DISEASES OF CHILDRElvr. deranged, and is a far more important disease than any of the varieties we have hitherto considered. It may follow the eruptive fevers (particularly measles), typhoid fever, and tuberculosis. " In by far the majority of cases it succeeds to some acute illness, by which the health of the child has been greatly undermined. The disease of all others which seems most to predispose to this affec- tion is measles. Of ninety-eight cases collected by M. Tourdes, in forty-one, or nearly half the cases, it followed measles. In nine, it followed intermittent fever ; in nine, typhoid ; in seven, it is put down as due to calomel ; in six, it followed pertussis ; in five, scarlet fever; in five, enteritis; and the remaining followed various dis- eases. Again, of forty-six cases collected by MM. Boulez and Caillault, in thirty-eight it followed attacks of measles."* Most authorities agree that the disease is most often seen between two and five years, but it may occur to any children up to twelve or thirteen. Like the former disease, it is more frequent in hospital than in private practice. The disease is regarded by most ob- servers as beginning in the mucous membrane .of the mouth, with the formation of thick yellow patches of membrane, which termi- nate in ulceration. A hard swelling also forms, surrounded by a tense infiltration of the cellular tissue of the cheek. The symp- toms begin with fetor of the breath, and a discharge of saliva ; the inside of the cheek is tense, hard, red, and shining, and it is usually limited to one side. In the centre is a bright-red spot, and the mouth is opened with difficulty. An irregular excavated ulcer forms, which is covered with an ashy loose slough. The teeth become loose, and occasionally drop out, whilst the alveoli are laid bare, and sometimes become necrosed. As the disease advances, the swelling of the cheek increases, an(i the central spot becomes a gangrenous eschar or slough, and blackened shreds of tissue are cast off". The disease is usually limited to one side of the mouth. Treatment. — The only reliable means of cure consists in the ap- plication of strong hydrochloric acid, or nitric acid, and it is obvious that if such a remedy is to be of service, it must be active writer (Tourdes, Du Noma, etc., 4to, Tli&se de Strasbourg, 1848) wlio has collected from different sources 239 cases, which did not all occur in children, states that 176 of the number, or 75 per qent., terminated fatally." — Wesfs Diseases of Infancy and Child- hood, 4tli edition, p. 532. * Keynolds's System of Medicine, Art. Gangrenous Stomatitis, vol. iii, p. 17. DISEASES OF THE MOUTH AND FAUCES. 155 and applied tliorouglily whilst the patient is under the influence of chloroform. It may be necessary to repeat the application from time to time, and the mouth must be washed frequently with Condy's fluid, or a weak solution of chloride of soda. If the cheek is tender on the outside, a poultice or fomentation will be advis- able. Castor oil, chlorate of potash, iron, etc., will be needed (Form. 9, 10). Mercurial Salivation. — Merciirj-, when injudiciously^ administered, may produce ulceration of the gums, loss of teeth, fetor of the breath, and salivation, leading to the various forms of stomatitis and gangrene of the mouth ; but such cases are very rare, and we look for the influence of the drug in the greenish stools of infants, rather than in the excessive action of the salivary glands.* In addition to these symptoms there may be swelling of the sub- maxillary glands and superficial ulceration upon the gums, which may extend to the cheeks and tongue, giving rise to an ulcerous or gangrenous form of stomatitis. The constitution sympathizes in the irritative febrile disturbance, and weeks may elapse before the afi:ected parts resume a healthy state. Children so afl:'ected lose flesh and strength, and are peevish and irritable. They are dis- inclined to take nourishment if the mouth is sore and painful, and that which is swallowed is imperfectly assimilated from the quan- tity of altered saliva which finds its way into the stomach. '•Nearly 30,000 children of all ages have come ander my care during my connection with the Children's Infirmary and the Chil- dren's Hospital, and I have administered mercury to any of them who seemed to require it, but hardly ever saw salivation follow its employment before the completion of the first dentition ; and never observed that medicine, at any age, produced any afl:ection of the mouth sufliciently serious to cause me a moment's anxiety."t When given in a single or moderate dose it would appear to be eliminated by all the secretions, and not a trace can be detected in any organs or tissues. When, however, it is continued recklessly or intentionally for days together, the power of elimination gradu- * In some cases of ptyalism, the parotid and salivary glands are said to be swelled and hypersemic, and the fluid dribbling from the months of cliildren may reach many ounces in twenty-four hours. In adults it has been estimated in severe cases at seven or eight pounds. " Lehniann and other observers have found it at iirst more mucous, cloudy, of greater spej:ific gravity, and richer in solid constituents (young and old epi- thelial cells) than normal saliva." — JSfiemeyer^s Practical Medicine, vol. i, p. 443. t West's Diseases of Infancy and Childhood, 4th edition, p. 539. 156 DISEASES OF CHILDREN. ally fails, and it accuninlates in the body, lessening the amount of fibrin in the blood, and increasing the activity of all the glandular organs. " The chief channel of escape seems to be the kidnej'S, but it is very certain that, at least in some cases, the drug is freely excreted by the salivary glands as well as by the intestines."* Chlorate of potash and sulphate of magnesia are both useful remedies, the former acting upon the mucous membrane of the mouth, and the latter stimulating the action of the bowels. For the soreness of the mouth, a solution of nitrate of silver (gr. v ad fi^j) should be applied twice a day, and every time after taking food, which should consist chiefly of milk; the parts affected should be gently wiped with a piece of soft rag dipped in the lotion of borax before mentioned. The employment of sedatives may be required to allay pain and procure sleep. Gingivitis — Inflammation of the Gums — Disorders Accom-panying Dentition. — Dentition in most healthy children is attended with redness, heat, and swelling of the gums, whichare also tender, and there is dryness of the mouth in some cases, but often a free flow of saliva. There is pain in suckling, when the child attempts to grasp the nipple, which it speedily releases, and cries, and is fret- ful. When children are strong and full of flesh there is consider- able disturbance of the system, and the cutting of each tooth is attended with heat and flushing of the face, sleeplessness, and fever. Cerebral disturbance, and even inflammation or convul- sions, are occasionally observed ; skin diseases and eruptions about the scalp are common. In rickety children dentition is retarded, and there is no derangement worthy of notice. Some children pass through dentition with little, if any, constitutional disturbance, one tooth after another appearing in regular succession, without pain or irritation of any kind. But it is not so in every case ; there are many instances in which dentition is painful, and every new tooth either provokes a short attack of inflammatory fever, diarrhoea, salivation, or even a convulsion. The gums are red, hot, and swollen, and the child is perpetually putting the fingers in the mouth, and is unable to suck and grasp the nipple ; aphthous ulceration takes place, the child is feverish, cannot sleep, and is extremel}^ restless and fretful ; sometimes laryngismus or inflam- mation of the air-passages (bronchitis or pneumonia) springs up, * Treatise on Therapeutics, by H. C. Wood, M.D., 1876, p. 368. DISEASES OF THE MOUTH AND FAUCES. 157 or cutaneous eruptions, as lichen or strophulus. In some children the fretfuluess and disturbed sleep are very trying to the parents, and not without anxiety to the medical attendant ; the child grows pale and fractious, though the gums have been lanced and the teeth are appearing. It sleeps for a short time, then wakes up flushed and excited, and cannot rest again. The child is un- easy, and puts the fingers to the mouth, cries at any sudden noise, and will not leave the nurse's arms. The nervous excitability is great, and unless the child gets rest, it grows pallid and exhaust- ed, refusing food, and often vomiting the little that is taken, the hands and head are hot, the pulse is quick, and the temperature elevated. Treatment. — In ordinary cases a simple aperient, and rubbing the gums to and fro with a piece of w^hite sugar will suffice ; but if the gum is tense and painful, and the tooth distends it, a free incision will give immediate relief. The lancet should be made to incise the gum in the direction of the alveolar process, although a second and shorter transverse incision is sometimes advisable. If the child is strong, a grain of calomel, and a saline niixture (Form. 8) will be necessary to open the bowels and remove any intestinal disturbance. If in spite of the gums being freely incised, and the mouth moist, the nervous irritation and sleeplessness continue, and the nurse and attendants are worn out with the restlessness of the child, sleep must be procured, and the nervous irritation allayed. For this purpose, a mixture of bromide of potassium and hydrate of chloral is advisable at bedtime, and it should be repeated if tranquil sleep does not ensue, while the bromide may be given during the day. Tonsillitis — Cynanche Tonsillaris — Quinsy — Causes — Symptoms — Treatment.^ — This disease sets in with rigors and febrile symp- toms, pain in the head, limbs, and back, to which succeed heat and dryness in the throat. Any attempt at swallowing is extremely painful, and the patient feels as though there was a lump in the throat. The voice is thick and guttural, and the tongue is covered with a creamy fur. The pharjnix presents a deep reddish tint, and one tonsil is noticed to be more swollen than the other, the disease being usually limited to one side; a patch of lymph is seen coating the aifected tonsil, and the act of swallowing causes * The diagnosis from the throat affection of diphtheria and scarlet fever is considered in their respective chapters. 158 DISEASES OF CHILDREX. a darting pain through the ear on the affected side, and throbbing; there is a free discharge of saliva, and liquids return through the nose. The neck below the ramus of the jaw is tender and swollen in some cases, and as the complaint progresses the inflammatory fever increases, till the stage of suppuration is reached, which or- dinarily happens in Ave or six days. The disease may end in reso- lution, the inflammation and infiltration of the afi:ected tissues gradually subsiding, or it may go on to suppuration, leaving a deep, ragged, excavated ulcer, or it may terminate in chronic in- flammation and enlargement. When suppuration takes place there is fluctuation, but the tonsil maj^ be infiltrated with blood and serum, and the palate be much swollen without the formation of any pus. Delicate children are occasionally liable to the complaint from cold and exposure to draughts of air when the body is heated, as when coming out of a hot and close room * Treatment. — If there is much tenderness below the jaws, and the little patient feels pain in separating them, two or three leeches will be useful, and a poultice applied afterwards. At an early period, before any matter has formed, a few punctures with a bistoury guarded with a piece of lint will relieve the tension, and drain the infiltrated tissues; the mouth must be continually washed out with warm water. At an early period, if there is much febrile excitement, a diaphoretic containing antimony (Form. 7) or aconite should be given. In some inflammatory affections of the throat in children, as in tonsillitis and general pharyngitis, half a minim of the tincture of aconite may be given to a child in a teaspoonful of water every hour, or even half hour, with great advantage. But its effects must be watched lest it should depress the circulation too much, or render the pulse unsteady. The remedy will generally convert the dry and hot skin into a sweating one, and control the febrile excitement and restlessness ; the pulse loses its hardness, and falls in frequency, the temperature is reduced, and relief follows in a short time. The tonsils become less swollen and congested, and * Of 1000 cases of tonsillitis treated by Dr. Morell Mackenzie at the Hospital for Diseases of the Throat, there were only 3G oases from 10 to 15 years of age, and 184 from 15 to 20. The most common period is between 20 and 30; after 25 there is a remarkable fall. Young ciiildren are very little subject to the disease, and before the age of five it is seldom seen (Diseases of llie Throat and Nose, ISSO, p. 49). DISEASES or THE MOUTH AND FAUCES. 159 the mucous membrane of the throat more moist and natural. "If caught at the commencement, a quinsy or sore throat rarelj'' fails to succumb in twentj'-four to forty-eight hours."* Guaiacum is another remedy which has long enjoyed a great repute in the treatment of this affection. Dr. Morel! Mackenzie thinks it far superior to aconite. It may be given in the form of powder, four or five grains in a little jam, every six hours, or the Trochisci Guaiaci of the Throat HosjDital Pharmacopoeia may be ordered. f A grain or two of calomel to stir up the functions of the liver will abate the headache. The patient must be fed with milk and soda-water, tea, lemonade, and thin water arrowroot, the tartrate of potash drink to keep the bowels free, and beef tea to support the strength. Tonsillitis is soon succeeded by prostration, and quinine and other tonics may be called for at an early stage of the aftection. Hypertrophy of the tonsils may follow acute tonsillitis, but more commonly it is seen in delicate children who are anasmic, rickety, or strumous, or afflicted with a syphilitic taint. The disease begins as a chronic affection during the first two or three years of life.:|: The tonsils project in the middle line of the fauces, narrowing the aperture, and interfering with swallowing and speaking. Children so afiected sleep heavily at night, with the mouth open, and are restless. They are liable to catarrhal attacks and deafness. If they are young, and the tonsils do not meet, local treatment by nitrate of silver and perchloride of iron may keep the disease in check. As the age advances, and the general health improves, the enlargement under treatment subsides, but in too many cases excision of a portion of the enlarged glands must be resorted to. Cup-shaped depressions in the lower part of the chest-wall are frequently observed in children suffering from enlarged tonsils, when they nearly meet, and narrow the entrance for the admission of air to the lungs. These depressions, due to imperfect expansion of the lungs, disappear after excision of the tonsils, by permitting a freer entrance of air to the imperfectly * Handbook of Therapeutics, by S. Ringer, M.D., 8th edit., p. 441. For fuller infor- mation on the action of aconite, see Chap. XI, On Scarlatina. t A Manual of Diseases of the Throat and Nose, vol. i, p. 57, 1880. X Of 1000 cases, Dr. Morell Mackenzie met with 265 under the age of 10 years, and of these 84 occurred from 1 to 5, and 181 from 5 to 10 (op. cit., p 61). 160 DISEASES OF CHILDEEX. expanded vesicles.* The -well-known pigeon-breast sometimes arises from chronic enlargement of the tonsils. Simple 'pharyngitis, or inflammatory sore throat, is an affection of the tonsils, soft palate, and pharynx, unaccompanied by ulcera- tion or exudation, and is common among children during cold and changeable weather. It is either a simple idiopathic affection, or it occurs as the accompaniment of measles, scarlet fever, bronchitis, pneumonia, croup, and laryngitis. It is much oftener a secondary than a primary disease. The mucous membrane of the parts just alluded to is swollen and slightly red, and a mucous or sero-puru- lent secretion is seen upon them, particularly the back of the pharynx, which has a red, roughened, and granular appearance. The mucous membrane in the secondary affection is often dnsky and purple, and the tonsils are more swollen than when the com- plaint is idiopathic, and arises from cold and exposure, or from swallowing boiling liquids. Symptoms. — The complaint begins with disturbed sleep and restlessness ; there is febrile excitement, as heat of skin, flushed face, headache, thirst, tenderness over the pharynx, and diflnculty in swallowing. The appetite is gone, and the child refuses to take food. The pulse and respiration may be increased in frequency, and the temperature reach 100° or more. In very young children there is often croupy cough and bronchial irritation. In one case under my care the tracheal irritation was certainly secondary to the pharyngeal aftec'tion, and it travelled down into the bronchi and produced suftbcative bronchitis and death. The disease is not dangerous in itself, but from the complications to which it may give rise. The treatment consists in applying a piece of linen rag (twice folded) dipped in tepid water to the throat under a piece of oiled silk. If this does not give comfort, and there should be swelling and irritation of the cervical glands, a warm linseed poultice is the best application. In young children I have occasionally mopped out the phar^nix twice a day with a solution of nitrate of silver (gr. V ad f,5J), and seen great advantage follow it when the disease has not invaded the trachea. In recent and acute cases, the tem- perature of the apartment should be warm, and the atmosphere moist. Milk and water, weak tea, and mucilaginous drinks should * Two Observations on Children, by Norman Moore, M.D., St. Bartholomew's Hos- pital Reports, 1874, vol. x, \). 130. DISEASES OF THE MOUTH AND FAUCES. 161 be given as a diet. A refrigerant and saline aperient is usually needed (Form. 8), and diaphoretics and mild sedatives of various kinds are useful (Forms. 7, 12, 7(3) to calm excitement, subdue irri- tation, and determine to the skin. Retropharyngeal abscess consists in the formation of matter be- tween the vertebral column and the posterior wall of the pharynx ; it is most frequent in infancy and early life. Children of a stru- mous or tubercular constitution are most liable to the complaint, and caries of the cervical vertebros, or inflammation of the sub- mucous areolar tissue may provoke the disease. "The cause is mentioned in twenty cases of the primary form, collated by Dr. Allin, as follows: Exposure to cold, ten cases; lodgment of bone in pharynx, eight cases ; blow with a fencing foil, one case. In the last case, the button of a fencing foil passed through the right nostril into the pharynx."* Sometimes no cause can be ascertained. Many writers describe the disease as secondary when it follows the eruptive fevers, as measles and scarlatina, the inflammatory state of the pharynx involving the cellular tissue beneath, and leading to suppuration. It is then regarded as of idiopathic origin. "When thus occurring, it is similar, both as regards cause and nature, to lumbar abscess. In a few recorded cases the abscess has been a sequel to erysipelas." (Lewis Smith.) It has also been traced to inflammation of the lymphatic glands, between the pharynx and vertebrae. (Fleming.) Symptoms. — The disease generally sets in with fever and restless- ness, furred tongue, heat of mouth, difl&culty in deglutition, and the impossibility of assuming a recumbent posture. There is also in some cases a stifl:hess of the neck, and pain in moving the head. As the complaint advances the respiration becomes labored, and food cannot be swallowed without pain. Occasionally there is croupy cough. The early symptoms in a strumous-looking child, two years of age, which came under the care of Dr. Oxley, at the Liverpool Infirmary for Children, were stifltness of the neck, labored breathing, and a croupy sound on inspiration, but the little patient was able to swallow and cry. Eleven days afterwards a firm elastic swelling nearly filled up the throat. This was punc- * Diseases of Children, by Lewis Smith, M.D., 1869, p. 319. 11 162 DISEASES OF CHILDREN. tured with a bistoury, aud a large quantity of pus evacuated. The child recovered.* The abscess can generally be detected on obtaining a view of the pharynx and fauces, wdien it is seen to push forward the posterior wall of the pharynx against the velum palati, or, if lower down, obstructing the larynx and involving the respiration. The pus may even extend downwards into the pleural cavity, and excite danger- ous mischief within the w^alls of the thorax. When dyspnoea threatens there is danger of suffocation, and coughing or swallowing increases the paroxysms; the head is thrown back and the patient sits upright, with the tongue pro- truding from the mouth; the pulse is frequent and small, the aspect is livid, and death occurs from apncea. In some rare in- stances the abscess has burst and deluged the trachea and bron- chi, causing death by suffocation. In the case of a child three years of age, recorded by Dr. C. Elliot, of the Bristol Children's Hospital, slowly increasing dys- phagia was the leading feature, followed by convulsions and death. ISTothino- could be detected on examination but some redness of the fauces and slio;ht enlarajement of the tonsils. There was no dyspnoea. Beef tea and brandy w^ere introduced into the stomach through a gum elastic catheter. After death " an abscess contain- ing about two ounces of pus was found situated in the upper and . posterior wall of the pharynx." There was no disease of the bone, and the larynx, and tonsils were healthy. f Diagnosis. — The disease may be mistaken for croup, but the peculiar cough of the latter should distinguish it, and the insidi- ous manner in which retropharyngeal abscess creeps on ; it is much slower in its development, and the respiration is not in- volved till a late period. The complaint is quicker in its progress when it follows the exanthemata than when it arises from disease of the spine. Treatment. — When the abscess is detected it should be opened with a bistoury, in the median line, without delay, and the finger will sometimes detect fluctuation when an inspection of the fauces fails to discover anything wrong. For a day or two after the puncture the tumor should be occasionally pressed with the finger to squeeze out any accumulation of matter, and if the case goes * Brit. Med. Journal, 1874, vol. ii, p. 371. t II)., 1879, veil, i, p. 663. DISEASES OF THE MOUTH AND FAUCES. 163 on well recovery will take place in two or three weeks. If the abscess is detected early and opened the majority of the cases will recover, but if due to disease of the spinal column they are gener- ally^ fatal. After puncture, cod-liver oil, the sj^rup of iodide of iron, quinine, nourishing diet, and pure air wnll complete the cure. Cynanche parotidea — parotitis or mumps — is a contagious and common disease in children, often occurring as an epidemic in schools, or other places where a large number of young persons are living under the same roof. Sporadic cases are occasionally met with, and boys are far more frequently attacked than girls. The disease consists in inflammation of one or both parotid glands, sometimes, however, attacking one side of the face only, and ter- minating in resolution ; the testicles of boys, and the breasts and ovaries of girls, occasionally sympathize in the swelling, especially when the afi'ection begins to decline. Ordinary mumps is usually excited by exposure to cold, and runs its course in four or five days. When one member of a family suffers the others also be- come affected, though some authorities (with whom I cannot agree) assert that the complaint is not infectious. When the blood is contaminated by typhus, and some other fevers, inflammation of the parotid may terminate in suppuration. According to Virchow the disease commences in the gland ducts rather than in the interstitial tissue of the parotid. W^hen it arises from simple catarrh, the tendency to suppuration is much less than when it originates in catarrhal inflammation of the gland ducts. The symptoms are febrile disturbance and headache ; there is stiffness and pain in opening the jaws, and swelling takes place between the cheek and the ear, extending down the neck along the ramus of the jaw to the submaxillary gland. The face is sometimes flushed and the child is very restless, and even wanders at night. Treatraent. — If there is much swelling two or three leeches may be necessary, and a poultice applied afterwards, but warm fomen- tations and a piece of flannel carried under the chin usually suflice to bring about a cure. A saline and cooling aperient is desirable to relieve the feverish symptoms and open the bowels. The diet should be exclusively fluid, consisting of milk, thin arrowroot, tea, etc. If the gland remains enlarged after the acute symptoms have subsided it leads to no bad consequences, and disappears in the course of time. 164 DISEASES OF CHILDREN. CHAPTER XIY. INDIGESTION. State of the digestive orgaxs in infancy and childhood : Influence of den- tition on the digestive process — Chymification — Chylification — Absorption — Defecation — Sympathetic disturbance in other organs — Digestion of different principles of food, starch, sugar, and fat — Sugar ivHl not replace fat — Nitrogenous elements of food — Influence of weaning on digestion — Emotioned indigestion — Solid meat not required till molar teeth appear. Symptoms : Symptoms of the different varieties of indigestion — Yomiting — Pain — Intestinal irritation —Eczematous eruptions — Anorexia — Vitiated appetite — Bulimia — Pyrosis. Causes: Atrophy — General debility or inherited weak- ness — Improper or deficient feeding — Excess of animal food-. Treatment : Alkalies — Calumba — Bark — Mineral acids — Nux vomica — Citrate of iron and quinine. The functions of the digestive system in infancy differ in a remarkable desfree from those of adult life when the orsrans con- cerued have reached a higher state of development. The calls for nourishment to meet the changes that are perpetually going on in the child are frequent, and too much care and importance cannot be devoted to this early period, when the stomach is so constantly occupied in preparing the food that is introduced into it for ab- sorption and nutrition. Children may be compared to small birds whose circulation and respiration are very rapid, while the machinery of life is in active motion ; in fact they live fast. These tiny creatures are contin- ually pecking up food to compensate for the incessant waste in their physical economy. But the balance between waste and repair is soon overcome in favor of the former, and small birds are short lived. In children, owing to the further development of the organs, the process of repair is in excess of waste and leads to growth. Indigestion is most common in infaucv, and decreases with growth and the completion of the first dentition, when the stomach in health}^ children becomes capable of bearing a mixed diet. The digestive organs in early life will only assimilate the simplest diet, and any deviation from it will be followed by dis- comfort, and symptoms which make up the sum total of indiges- tion. In the predental period of infancy the food reaches the stomach almost as soon as it is introduced in the mouth without mastica- tion. When once it is in contact with the gastric mucous mem- INDIGESTION. 165 brane, a secretion is poured out ; and the two combining form a substance called chyme, and the process is termed chymijieaiion. The next step consists in the action of the muscular coat of the stomach walls, forcing the fluid mass through the pyloric orifice into the duodenum, where mixing and becoming incorporated with the biliary and pancreatic secretions it is transformed into a creamlike substance termed chyle^ and this process is called chyli- jicaiion. The villi which are scattered over the surface of the small intestine absorb the nutritive elements, and convey them into the lacteals, and so into the circulation through the recep- taculum chyli. Those portions of the food which are useless, or resist absorption, are conveyed along the remaining tract of intes- tine and finally thrown out of the body as excrementitious matter, and this process is termed defeoation. In a state of health these processes are carried on without our consciousness, and a sense of comfort and satisfaction only is felt. Where digestion is imper- fectly performed*, either from defective health, or from the quality of the food that has been taken, then indigestion results, and the symptoms that ensue are oppression, pain, weight, and distension. The food is either rejected by vomiting, delayed in the stomach, or passed on into the bowels, causing diarrhoea, or some other form of irritation in these viscera. "We have here to consider what happens in infants and very young children in these cases. There is deranged action in the stomach itself, an alteration in the character of the secretion, and irregular or unhealthy muscular action. But indigestion once established does not limit the resulting disturbance to the stomach itself; it involves by sympathy other and distant organs, and there is not an important viscus in the w'hole body that does not share in the general derangement, so much so, that it frequently distracts our attention from the stomach, and deludes us into looking at the sympathetic disturbance as the primary evil. In children, as in adults, the stomach may have lost its vigor and tone, and therefore be incompetent to fulfil its functions ; but in the vast number of instances indigestion originates from the quality and quantity of food that is introduced into it. The mucous membrane is readily irritated, and resists the oflfence, just as any other organ of the body becomes irritated by some abnor- mal stimulation, and finally fails under the excitement, even 166 DISEASES OF CHILDREN. though there may he no discoverahle alteration or gross structural change. Hence, then, it is proverbial in early life that the stomach being delicate and susceptible to any disturbance, we should be most careful to select a proper diet, to consider the quality of food that is supplied, to measure the capabilities of the digestive system, and to deal with theni accordingly. We have no need to pursue more than cursorily the question of mastication, because it is the digestion of infancy we are now mainly concerned with, and yet it is necessary to allude to tbe development of the teeth. There are two sets of teeth, the deciduous and the permanent. In infancy there is a period of several months before any teeth are developed, and when therefore the function of mastication is not required. In the early months of life there is no secretion of saliva. (Pavy). The mother provides the necessi- ties of living in the form of milk, which her child consumes till growth and development fit it for an independent existence. Ey the time when the mother should wean her child at seven or eight months, the teeth begin to appear, and by the end of the first year in healthy children there are usually as many as twelve. There is no longer need for a fluid diet exclusively, but among the lower classes, prolonged lactation to diminish the risk of repeated preg- nancies, is carried far beyond the limits of health in the mother or her offspring. Chiklren of fifteen or sixteen months old may often be seen clinging to the breast for their only sustenance in the out-patient department of our hospitals. When the child is once permitted to sustain itself another diffi- culty is presented. In many instances it is either provided with food which is improper, or it devours it too hastily, and so the troubles of indigestion are established. Food imperfectly masti- cated resists the solvent action of the gastric juice, and irritation of the digestive organs arises. Regarding the process of insalivation, the secretions of the parotid and submaxillary glands are poured into the mouth, as well as that of the lingual and other smaller glands. Parotid saliva, in man at least, is water}', and acts as a solvent; submaxillary saliva is more viscid, and contains more of the active principle, ptyalin, w^hich converts starch into glucose or grape-sugar. Digestion of Starch. — Starch is a non-nitrogenous principle, entering largely into the composition of some foods. Whilst it INDIGESTION. 167 remains in this condition it resists absorption till tlie digestive system exerts its influence upon it. The first conversion is into dextrin, which mnch resembles starch, and then into sugar, Avhich is easily absorbed. The action of the saliva converts starch into sugar when the process of mastication is properly carried on. As the food passes out of the stomach, the secretion of the pancreas and the fflands linino; the mucous membrane of the intestines exert their action upon the remaining starch, and further trans- formation into sugar takes place, and the bloodvessels convey the latter into the circulation, whilst the unchanged starch- granules mix with the evacuations and are carried out of the system. Starch is not naturally a part of the food of very young infants when the digestive functions are imperfectly developed. Sugar is the form that suits them.* Digestion of Sugar. — This is principallj^ the cane sugar which exists as a juice in many plants. It is so readily soluble that the digestive functions are in no degree taxed when it enters the stomach, by which it is readily absorbed into the circulation, undergoing a change into grape-sugar. In some forms of dyspepsia, and especially in that of children, lactic, butyric, and other acids may be present as secondary products, arising either by their respective fermentations from articles of food, or from decomposition of their alkaline or other salts; and the tendency is immensely increased by saccharine articles of diet. The envelopes of the fat-cells are dissolved by the gastric juice, and their contents set free These run into droplets, and are passed on into the small intestines, where they are acted upon by the bile, and the pancreatic secretion. By the agency of these the greater part of the fat is emulsified, and therefore rendered capable of absorption ; partly split up into fatty acids and glycerin, and partly saponified. The absorption of fat appears to be of a physical rather than of a chemical nature. State of Digestion at the Time of Weaning. — In even healthy children this seldom takes place without causing some disturbance in the constitution, and the symptoms that arise are generally those that indicate disorder in the functions of digestion. The change of food when the mother ceases to suckle her child is fraught with risk for some time, the child is fretful and sleepless, has flatulence, * See Chap. II, p. 36, where this subject is more fully considered. 168 DISEASES OF CHILDREN. diarrlioea, or vomiting, and forthwith it declines, looks pinched and careworn, has a weak cry, and the skin shrivels from the absorption of the subcataneons fat, redness about the arras and thighs is observed, and the changed aspect is remarkable. JSTot that this abnormal condition ensues in all cases, for many healthy infants bear the change without manifesting either local or constitutional disturbance. Indigestion is constantly associated with wasting in children ; when they are so suffering, the food that is swallowed is at once rejected ; they lose color and'streugth, the muscles waste, and the limbs become attenuated. The child refuses the breast or takes it greedily ; then begins to whine and cry, and can obtain no ease till the milk is rejected, because the digestive powers are unable to assimilate it. In addition to these sj-mptoms others arise, as heat about the mouth, with pain and acid eructations ; the motions are often slimy, offensive, and of a dark-greenish hue, or they are pebbly, and there is constipation. When the child is fed on milk or has a wet-nurse the motions may be pale and almost like the milk that is swallowed, which passes through the bowels un- changed ; or the motions are variable in character (diarrhoea alter- nating with constipation), being loose and thin at one time, and sticky and clay-colored at another, with green spots like bits of spinach among them. Vomiting^ so frequently present in these cases, is a reflex action of the nervous system, and is a common symptom of indigestion, or irritability of the stomach in infancy and childhood. It is also symptomatic of disease of the brain, of the lungs, of the various exanthemata, and diarrhoea depending on poisoned blood. It is a symptom that invariably excites alarm when it arises without any discoverable cause, and cannot be attributed to overfeeding or mechanical irritation. It usually happens that the milk does not agree, either from fatigue, indiscretion in diet, or bad health in the nurse ; what is swallowed soon causes flatulence and pain till it is finally rejected as a curd from the stomach, and the child at once seizes the breast again till the same symptoms recur, or after some discomfort it passes through the stomach and creates intes- tinal irritation and diarrhoea. The same is likely to ensue when the milk is healthy, but the child has been allowed to go too long without food, or is fiitigued from heat or overexcitement. If, from any of these circumstances, vomiting ensues, it is important INDIGESTION. 169 to allow the stomach rest, and whilst its tone is lost, to give a tea- spoonful of cold water or barley-water, till the sickness has passed off. When the symptoms do not yield to these measures, and the child is otherwise in good health, a mild mercurial and milk and lime-water given by a teaspoon will generally aftbrd relief. It may at the same time be advisable to prescribe small doses of hydro- cyanic acid in a solution of magnesia, and to apply a mustard poultice to the epigastrium, Durino; the continuance of this state of thino-s the child is weakly, and an erythematous rash may appear on the buttocks, or eczema on the face and scalp. I have seen this appear and dis- appear according to the severity of the indigestion, and in one case it was so bad that the ej-elids became oedematous from the swell- ing and the features distorted. Anorexia is a common symptom in dyspepsia, and when it is present children will struggle to the utmost rather than swallow one particle of food. Vitiated appetite is sometimes seen in chil- dren. In one case under my care, a girl suflfering from anasarca and albuminuria, devoured the most loathsome things possible, and required careful watcliing to prevent her from so doing. JBulimia is seen amono; children sufferino; from worms in the in- testinal canal or mesenteric disease. It is also very common in cases of chronic hydrocephalus, and is by no means rare during convalescence from measles and some otlier acute diseases.* Then there is a form of dyspepsia not uncommon, especially in boys.f The tongue loses its epithelium and is superficial!}' ulcer- ated. Children thus affected bolt their food and have ravenous aj^petites. They lose flesh and do not thrive ; they are pallid and delicate-looking, and if the condition is allowed to go on it may pass into mesenteric disease. In some cases dj-spepsia and intestinal irritation are brought on by giving young children too much animal food, which they swal- low without suflficientlj' masticating it. After a time, in addition to epigastric pain, tenesmus and bearing down ensue, the child wishing to go to the closet every minute ; the motions are lump}", thick, and brown, with jellylike clots of blood on them, and there are faintness and nausea before the bowels act. This form of in- digestion may, if the symptoms are not attended to, pass, into dys- * See Chapter X. f See Chapter II. 170 DISEASES OF CHILDREN. enteric diarrhoea, and the child may die of mesenteric disease and phthisis. Pyrosis is sometimes seen in children of eiglit or nine years of age, demanding the same line of treatment as in the adult. The causes of indigestion in infants arise in nineteen cases out of twenty from defective power on the part of the stomach to assimi- late and digest the food that is supplied, or to the food not being always of the most digestible quality, I remember a lady who had live children, and all of them reached the age of one year without any illness or drawback. All the five children were wet- nursed. The sixth child was born at the full term, and in every respect was strong and vigorous. A healthy wet-nurse was pro- cured whose milk presented microscopically^ no deviation from the healthy standard, she w'as twenty-five years old, and all her func- tions were regular. The child at the ao;e of two months had an erythematous eruption of the face and scalp, attended with great itching and much redness. Small vesicles and prominent elevated points soon appeared over the inflamed parts, and finally ran into one another, causing excoriation and superficial ulceration of the surface. The tongue was clean and without aphthae, the surface of the body healthy, and there were seldom less than three or four motions in the twenty-four hours, of a bright-3'ellow color. The child occasionally brought up a curdlike mass of milk, almost as soon as swallowed, and the uneasiness evinced by a whining cry, and the incessant drawing up of the extremities, would often mo- mentarily cease, after lasting many hours, by the expulsion of wind from the stomach, or by the action of the bowels. This was clearly owing to indigestion, and imperfect assimilation of the milk taken ; either it w^as too rich, or the stomach too feeble to exert the neces- sary changes, or the mucous membrane secreted an undue amount of acid, and caused fermentation in the food products. Barley- water, substituted for a time, would arrest sickness and spasms, and so would isinglass and water, and then the child would return again to the nurse's milk for a few days without any inconvenience. Jjut after a time the same inconvenience would return, and then it was finally determined to discard tlie nurse, and try the eft'ect of cows' milk with an equal quantity of water, and one tablespoonful of lime-water to the bottle. A third of a bottleful was allowed at each feeding at intervals of two hours. Immediately the change of diet was instituted, a remarkable improvement set in, the erup- INDIGESTION. 171 tion began to fade, and the child was brisk and lively. But after a few more days had elapsed the same colicicy pains and flatulence returned, the child was pale and pinched, and the motions became acrid, offensive, white, and sticky.* It was obvious that the liver was not pouring out its proper biliary secretion, and to meet this, a powder containing a grain of gray jDOwder, two grains of rhu- barb, and half a grain of cinnamon powder, was given every night, whilst a carminative mixture of bicarbonate of potash, sal vola- tile, and dill-water was given at intervals during the day. About twenty drops of brandy were added to each bottle of milk. An improvement soon set in, the motions assumed a more healthy character, and the child became bright, the features filled out, it slept, and enjoyed the food, which now caused scarcely any flatu- lence or discomfort. A still further manifestation of improvement w^as shown in the decline of the eczematous eruption, once so per- sistent and troublesome, but now fading with the child's better nutrition, and only giving evidence of its latency by occasionally showing itself when the digestive functions were temporarily dis- turbed. The alimentary canal is extremely sensitive in early life, and a mother learns from experience that if she is careless in keeping her own digestion in proper order she is sure to derange that of her oflTspring. After the seventh or eighth month, when the teeth begin to appear, the child wall need some solid article of food, and it fs then that biscuits and some farinaceous articles of diet may be given with the milk, later on a little beef tea or gravy, but not meat, till the second year. The irritation caused by the coming molar teeth induces the child to make masticatory efibrts, and this excites the action of the salivary glands. The other causes of indigestion are an impure atmosphere and confined rooms, especially if several children occupy the same apartment. Hot sultry weather will frequently induce the com- plaint, and children reared in towns and cities are more frequent sufi:erers than those brought up in the country. Artificial feeding is probably the most frequent cause, especially that by the bottle, from the liability of the contents to turn sour and disorder the digestion. All children so suflering should be fed with a tea- spoon. Older children experience indigestion from eating unwholesome * See Chap. XV, On Diarrhoea. 172 DISEASES OF CHILDREN. food, as sweets and raisins, cherries, etc, wliicli, undergoing only partial change, cause pain and intestinal irritation. They are often feverish and drowsy, have headache, and are disinclined to move; they hring up what is swallowed, and complain of pain over the epigastrium. Their nights are restless, and the nervous system is so upset that a convulsion may follow. The neglect or continuance of the disease may lead to aphthous ulceration of the mouth, diarrhcea, or eclampsia. Treatment. — In addition to the hints and suggestions already thrown out in this chapter, concerning food and judicious feeding, there are other matters to be recollected. Three conditions appear to be necessary to ward off indigestion in an infant, and when they exist, it is remarkable how slight is the stomach derange- ment. These conditions are: 1. The child to be healthy born ; 2. The mother to be healthy, if she supports her own child; 3. The cow's milk used to be pure, from the same cow, and to be properly diluted. The cause in operation requires to be diligently sought for, and a careful inquiry should be made into the circumstances of each individual case in order to remove it. It sometimes happens that an emetic will get rid of the offending material at once. Care in nursing and proper feeding will often cure the disorder. The fixed alkalies of lirae and magnesia may be added to the milk. If there is acidity, an occasional powder of soda and rhubarb is of service, and a grain or two of mercury and chalk may be added when the biliary secretion is deficient. It is a good plan to give alkalies when there are free acids generated in the stomach; a grain or two of bicarbotiate of potash with sal volatile will pre- vent the coagulation of the milk and the formation of a curd. Dandelion and calumba may be added if the stomach has lost its tone and the liver is inactive.* Alkalies ought not to be continued for too long a period, and the circumstance that curd is vomited by no means implies that there * Formula 19: R. Sodffi bicarb., gr. xij Spt. amra. arom. "^.tij Syr. rhei, ve] sncci taraxaci, giij Tinct. cahinilia;, . . . . . . . • 5J Aqiiam anetlii ad . siss. — M. 3ij ter die. For children a year old. INDIGESTION. 173 is acid in the stomach, hecanse the gastric juice may be insufficient and the stomach weak. In that case the mineral acids are suit- able to the youngest child, the hydrochloric or nitric acid, or both combined.* If there is sickness and debility, with scanty secretion from the liver, hydrocyanic acid in combination with nitric acid may be given. f Bark and nux vomica are also useful in some cases. t Indigestion in children sometimes assumes an exceedingly acute form. From being comparatively well, a child becomes suddenly ill, restless, and feverish ; its circulation and respiration are excited, and its temperature runs up to 103°, or even higher ; the mother thinks the child has caught cold, or is commencing some feverish attack, but the suddenness and character of the seizure render this view unlikely. This suddenness is the great charac- teristic of acute indigestion, and at once points to the real cause, and relieves the anxiety. In such cases it is well to give an emetic of ipecacuanha, with a little antimonial powder and calomel. The child vomits, is at once somewhat better, and if its bowels are opened subsequentlj^, in a few hours the alarming symptoms dis- appear. The quickness of the decline corresponds to the acute- ness of the attack. In chronic indigestion change of air is very serviceable, and one wet-nurse may have to be changed after another ; calumba, bark, and nitric acid are useful in these cases. In older children, * Formula 20 : R. Acid. nit. dil., nj^xij Acid, hydroch. dil., . fijjxxiv Tinct. calumbse, ........ gj Syr. aurant, . . . . . . . . . ^ij Aquam ad ........ . ^ij. — M. 5j ter die. For children a year old. t Formula 21 : , B- Acid, hydrocyan. dil., ^^\) Acid, nitric, dil., t^xx Syrupi, ^ij Aquam ad ^iss. — M. 3j ter die. For children a year old. t Formula 22 : R. Tinct. cinch, co., 5iss. Tinct. nucis vom., ^xij Syrupi .i^ij Aquam ad giss. — M. 3j ter die. For children a year old. 174 DISEASES OF CHILDREIS". the citrate of iron and quinine is a valuable remedy if there is ansemia. Dr. Lauder Brunton advocates for children with defective digestion, stale bread cut very thin, and the butter well rubbed into it, in preference to bread cut thick, with a thick layer of butter, commonly seen in the nursery. In doing- this the fat becomes finely subdivided, resembling the condition found in milk. CHAPTER XV. DIARRHGEA. Varieties — 1. Simple diarrhcea {catarrhal diarrhcea) — 2. Bilious diarrhoea — 3. Chol- eraic diarrhoea {cholera infantum) — 4. Congestive or inflammatory diarrhoia {chronic muco-enteritis, mucous diarrhoea, entero-colitis) — Thermic diarrhoea — 5. Lientery {lienteric diarrhosa) — 6. Dysenteric diarrhxa — Symptoms of the different forms — Green stools, their causes and significance — Clay-colored pasty stools — Chronic diarrhea — The result of persistent simple diarrhcea, or the other varieties — Causes of diarrhma — Dentition — Oversuckling — Impure air and water — Filth and orer- crowding — Irritating food — Sour milk — Cold — Diispepsia — Congestion of the liver — Artificial feeding — Sometimes a complication of rickets, whooping-cough, and measles — Treatment of simple diarrhoea— Castor oil — Dover'' s powder — Bismuth — Ipecacuanha — Astringents— Warmth — Rest — Stimulants in cases of exhaustion — Rhubarb — Treat- ment of the choleraic, and^ remaining acute forms of diarrhoia — Treatment of chronic diarrhoea — Raw meat juice — Extract of malt — Acetate of lead — Gallic acid — Logwood — Catechu — Kramer ia — Sulphuric acid — Syrup of red gum — Extract of Bael — Sul- phate of copper and opium — Astringent enemata — Change of air — Prolajjsus ani — Its causes and treatment. Diarrhcea is produced by many conditions, and among children is more often a salutary than a diseased process. It is of common occurrence when a septic poison is generated from the decomposi- tion of vegetable matter, or the atmosphere is charged with miasmatic effluvia. After absor^^tion through the lungs into the blood, the intestinal raucous membrane becomes irritated and excited, in virtue of an inherent disposition on the part of the economy to eliminate these noxious agents.* We meet with it again, when water containing organic impuri- ties, obtained from the vicinity of graveyards and stagnant pools, is used for drinking purposes. When contaminated with fetid * See Lectures on the Infective Processes of Disease, by J. Burdon Sanderson, M.D., LL.D., F.R.S., December, 1877. DIARRHCEA. 175 gases, fermentative dyspepsia arises, and the bowels show signs of a disorder, varying from simple irritation to choleraic purging, cramps, and loss of body heat.* As a healthy process, a sharp attack of diarrhoea proves its own cure, irritant and offensive matter being thus got rid of by the bowels, when the stomach cannot assimilate the food that is taken. We aid these efforts when nature fails to complete the cure hj administering such remedies as remove any morbid mate- rials from the system. Diarrhoea is common enough in infants when too much milk is swallowed, or when rich or sour milk, instead of being thrown up by vomiting, passes on into the intestines, and creates irritation there. Exposure while dressing, insufficient clothing, the use of too cold water in washing, and the neglect of cleanliness, will all induce excessive peristaltic action of the bowels. Statistics clearly prove that there arc few diseases in infancy and early life of greater frequenc}^ or danger than diarrhoea ; it will often set in from slight or unascertainable causes, and decide the fate of a young child in a few hours. The delicacy of the stomach and intestines in infancy renders this one of the com- monest ailments. If the supply of food is not of the simplest kind, and given in small quantities to suit the tender age of the child, the process of digestion and absorption will be deranged, and the local disturbance thus initiated will convey the irritation to some other organ, and expose the life of the child to consider- able peril. Diarrhoea in children may be conveniently grouped into the forms enumerated at the commencement of this chapter. This is, however, at best, but an arbitrary division, for simple diarrhoea may pass into any of the other varieties, if the irritation lasts long enough to excite suthcient disturbance in the mucous membrane ; and it is often impossible to separate them in practice. * The diminution in the minjber of deaths from infantile diarrhoja during the last seven years is mainly attributable to improved sanitary legislation, and is far less de- pendent on temperature and other atmospheric conditions than is generally supposed. Indeed, the returns of the Registrar-General for 1877 show that the mortality of infants from this cause v?as, during the third or Michaelmas quarter, not much more than half the average of the seven preceding summer quarters. The poor, in receiving higher wages, are enabled to live in better houses, and to obtain a superior quality of food. This change in their social position will most likely induce them to exercise greater vigilance than formerly, and will awaken them to the danger of any unliealthy in- fluences that may spring up around them. 176 DISEASES OF CHILDREN. 1. Simple Diarrhcea {Catarrhal d'mvvhcea,). — In this variety there is an excess of natural action, the evacuations are copious, rehixed and frequent, and the child, if an infant, is soon exhausted in con- sequence. The attack may at first be painless, and as there is a loss of consistence in the motions they are squirted out with spas- modic effort. The evacuations are fecal, and if at first greenish, they become yellow as the symptoms subside and improvement sets in.* The early symptoms of simple diarrhoea are hardly notice- able if the discharges are moderate, but there soon follow genea^al discomfort and peevishness, the child is disturbed in its sleep, and, perhaps, becomes languid and paler than usual. The tongue may be slightlj' coated, and there is usually some thirst and diminished appetite. AY hen the attack is acute there is sickness, thirst, and dryness of the mouth ; the strength is reduced, and in a few hours the child may be much weakened. The little patient becomes sunken about the eyes, the features are sharpened and even col- lapsed, and the fontanelles are depressed ; there is sometimes febrile disturbance with cough and bronchial irritation ; the abdomen may be swollen and tender from flatulence, or concave and empty. If the diarrhrea goes on actively for a day or two, flesh and strength are rapidly lost, the muscles feel soft and flabby, the pulse becomes quick and feeble, and life is placed in imminent danger. The change in the character of the evacuations consists in their being thinner and more copious, though they seldom lose their feculent appearance, except in very severe cases, or where the disease is obstinate. In these cases the motions soon become offensive after escape from the body, and may be even greenish and slimy. When the diarrhoea is sharp and continuous it sometimes in- duces so much relaxation of the sphincter as to cause prolapsus ani. The anatomical changes in the lining membrane of the intestinal tract consist in congestion of the vessels, which disappears after death. There would seem to be no pathological changes in the simple form of the complaint, even if it proceed to a fatal termi- nation. * "The normal form of the infantile faeces in the first year is pappy; the color is yellowish, like that of the yolk of egg : the smell is feebly acid, never putrid, and only in children who are fed upon a meat diet repulsively pungent, as in the adult ; in later years they are no longer to be distinguished fi-om the adult." — Vor/el, Diseases of Chil- dren, 1874, p. 135. DIAREHOEA. 177 2. Bilious diarrhea may be witnessed in some children who eat inordinately of animal food, and live too well for the wants of the system. Impure milk, like impure w^ater, is capable of giving rise to this form of diarrhcea, and in severe cases the symptoms may become dj^senteric* A large quantity of bile is secreted by the liver and poured out into the intestines, which it irritates. The disease is most common in hot weather, and of course far more frequent in tropical climates, when the liver is apt to be congested from diminished respiratory action. It arises from an excessive secretion of bile, which stimulates the bowels to frequent action, the motions being copious, loose, and of a dark-yellow or green color; the urine is scanty and high-colored, and may contain traces of bile also. The secretion of bile may be enough to pro- voke fever, unless it finds its way freely out of the system. 3. Choleraic diarrhcea (cholera infantum — gastro- intestinal catarrh — Rilliet and Barthez) is most common in infants, and in those who are early weaned or badly fed. The disease usually follows a rapid and fatal course. Its frequency is much greater in cities than in country districts, and in summer and autumn, than at other seasons of the year. " It is so frequent during the period of first dentition, that some writers consider dentition a cause." (Lewis Smith.) It is in my experience far more fre- quently due to atmospheric influences and errors of diet. It usually commences with simple or inflammatory diarrhoea, the child loses its appetite and is fretful, then it is seized w^th purg- mg, and occasionally wnth .vomiting, attended with prostration, pallor, and sjanptoms of sinking. Violent retching sometimes coexist with choleraic diarrhoea, and the disease may set in very suddenly, and rapidly proceed to a fatal termination. The tongue is slightly coated or clean, smooth, and dry, and the pulse quick and small. As the disease progresses the respiration becomes oppressed, the urinary secretion is suspended, and the surface of the body is cold, damp, and sometimes livid. The discharges at first are thin and fecal, or frothy, with mucus or altered bile ; but *■ An epidemic of diarrhoea, traceable to one special milk supply, is described by Dr. Philpot as having occurred at Upper Norwood in September, 1877. The attack was ushered in with rigors, pains in the limbs, and pyrexia. The bowel discharges were " of an offensive bilious character, going on to mucus, and, in some instances, bloody stools, with tenesmus." There was no fatal case, and the disease yielded to treatment in a few days. — Medical Ezaminer, Jan. 10th, 1878, p. 29. 12 178 DISEASES OF CHILDEEX. in the course of a few hours tliere are no traces of a biliary secre- tion whatever, the evacuations being copious, frequent, and like rice-water or oatmeal gruel, from containing shreds of intestinal epithelium. It is the excessive discharges of colorless fluid which distinguish this form of diarrhoea from any other. So great is the quantity that one evacuation will saturate the napkins of the child, and completely soak through the bed linen, as though they had been kept under water for hours. When the stools are pale and fluid there is no odor belonging to them ; but if they are in any degree feculent, and yellowish or greenish, then they are ex- tremely fetid and oflensive, and, notwithstanding the utmost cleanliness, the odor is at once perceptible on entering the sick- apartment. At first there are evidences of pain and griping sensations in the stomach and bowels ; the hands and extremities are cold, the face pinched, and the eyes hollow. There is usually a craving thirst, and fluids are no sooner swallowed than they are brought up again ; all appetite is gone, and sleep is broken and unrefresh- ing. If the disease does not soon yield to remedies, the child passes into a state of coma and dies. If the disorder lapses into a chronic form, the evacuations may assume a dark-greenish and putrid character ; the belly becomes tumid or tympanitic, and the tongue is covered with aphthfe. The disease may end fatally in a few hours or extend over some weeks. Cases apparently hopeless some- times recover. The liver has been observed to be enlarged in this affection by several writers, but the most constant anatomical change would appear to be enlargement or softening of Peyer's patches, with an erythematous or inflammatory condition of the lining mucous membrane. The following is an example illustrating these several points : A female infant, ten months old, was seen by me on July 10th, 1868, at 8 A.M., having slept onlj^ two hours during the night, and not at all the day before. It had been taken out in the air, and the want of sleep attributed to being left in the sun. The bowels acted three times before 3 o'clock on the preceding day, and again at 3 A.M. next morning ; the last motion was very watery, but fecal. On my visit the child was cold, pinched, and collapsed, eyes languid and set, lips very blue. The child was at once placed in a warm bath, and twenty drops of brandy given in some arrow- DIARRHCEA. 179 root, which she greedily sucked. The circulation almost at once returned in the skin and lips, and she was then taken out and put into a blanket ; but gradually the arterial hue deserted the lips, the surface of the body was pale and contracted, and she became livid as before. She was again placed in the bath, and precisely similar symptoms resulted, the color returning, and the child as- suming a brighter asj^ect. When removed from the bath she as quickly as before became blue and collapsed, but to a somewhat less extent. A mixture of aromatic spirit of ammonia and spirit of chloroform was given, and a mustard poultice applied along the spine. At 11 a.m. the child had rallied, and there had been a col- orless watery motion without a tinge of bile. The medicine and beef tea were given alternately every hour. At 1 p.m. dilute sul- phuric acid with spirit of chloroform was prescribed every second hour, and at 5 p.m. the child had rallied, though there had been three similar rice-colored watery motions, after which more decided collapse set in, and the child expired with a slight convulsive seizure at 7.45 P.M. 'No post-mortem was allowed. 4. Congestive Inflammatory or Mucous Diarrhoea — Enter o-colitis — 3Iuco- enteritis. — In this variety there is a considerable degree of inflammatory action, quickness of pulse, and constitutional disturbance. The evacuations contain a large quantity of thin mucus, which afterwards becomes thicker and approaches the color of pus. The motions are neither frequent nor excessive ; they are usually variable in color, sometimes being greenish and offensive like chopped spinach, and at other times yellow and mixed with mucus.* Straining in going to stool is a common and distressing symptom, and more or less blood is intimately mixed with the mucus or fecal matter. Among the causes of this form of diarrhoea may be enumerated damp and cold, and transitions of weather, but errors in diet would appear to be a fertile source of its origin. If the nurse's milk is too rich, or in any way unhealthy, it is very likely to set up diar- rhoea in any form. It may be a sequel to choleraic diarrhoea, the * " Dr. Graves regards this green matter as a secretion from the mucous membrane of tlie small intestines, and not bile. Drs. Simon and Golding Bird (Medical Gazette, Sept., 1845) consider it owing to blood which has nndergone a chemical change." — Quoted from Churchill's Diseases of Children, 1848, p. 533. Ballard held that it was the mucus of the gastro-intestinal canal acted upon by the gastric juice, and indicating insufficient or improper food. It is often the sign that weaning should be instituted, the mother's milk no longer being a sufficient food. 180 DISEASES OF CHILDEEX. bowels remaining irritable, and producing chronic inflammatory changes in the mucous membrane, so leading to gradual death by exhaustion. I quite agree with Meigs and Pepper, who consider that whether diarrhoea is caused by improper food, summer heat, dentition, or epidemic influences, the complaint, if it becomes chronic, is apt to terminate in this disease.* It is not unfrequently met with in children in the outdoor department of our hospitals, and I have long been of the opinion that the complaint is traceable in them to exposure to heat or cold. The cases we ordinarily meet with during the summer are of this character, and hence its fre- quency among the children of the poor, who are at the same time badly fed and reared in an unhealthy atmosphere. The cutting of the teeth may exert an influence in causing diarrhoea, as it does in setting up irritation in the brain and other organs. It is common between the ages of six months and two years, when the first dentition is completed.! The disease may be acute or chronic. In the first form the symptoms are active from the first, inflammatory products passing oti' from the intestines, and the disease seldom lasting more than a week or ten days. The chronic form of the disorder may con- tinue for weeks or months ; there is a gradual loss of flesh and strength, and the bowels are perpetually acting. The morbid appearances are a thickening or inflammation of the intestinal mucous membrane, which becomes red or of a darkish- graj^ hue, with the evidence of ulceration or enlargement of the glandular follicles lining the colon and small intestine. Muco-enteritis ma}' follow an attack of measles, pneumonia, whooping-cough, or typhoid fever. It is prone to attack feeble and delicate children of strumous constitution. The abuse of aperient medicines may induce a simple diarrhoea which passes into this form, and weaning, or the change of a nurse is another cause. The morbid anatomy of the aflection shows disease of both the large and small intestines. In the large intestine, the sig- moid flexure and descending colon are chiefly aflected ; in the small intestine the lower part of the ileum. In the acute stage, * Diseases of Children, otli edition, 1874, p. 3S4. t "The greatest prevalence of diarrhcea coincides exactly with that time whilst the process of dentition is going on most actively, and that exactly half of all cases of diarrhoea occurred in children between the ages of six months and two years." — West, on tbi Discuses of Infancy and Childhood, 1859, p. 587. DIAERHGEA. 181 the mucous membrane of the intestine is increased in vascularity and softened. Thermic diarrhoea is the form met with in summer and espe- ciall}'' in hot climates. It has been well described by Dr. C. G. Comegys and Dr. H. C. Wood. It may be designated " thermic or heat diarrhoea." "Any one who has seen," says Dr. Wood, " as I have this summer, the child on whom drugs had ceased to act, and who was seemingly doomed to die, relieved in twelve hours by enforced cold bathing, every three or four hours, will grant to Dr. Comegys the credit of having introduced one of the most life-saving improvements in modern infantile therapeutics. The sudden sweet sleep, replacing, after the bath, the fretful nights and days of unrest, is a thing never to be forgotten when once seen, and the arrest of diarrhoea is certainly no less remark- able."* " We are summoned, in short, very often to see a child with a hot skin (temperature 102^°-105°), rapid pulse (130-150) and breathing (30-40), with frequent purging of semifluid, greenish, watery, fecal, and half-digested matters; the mouth and tongue are dry, the thirst is intense, but the water given to appease it is quickly thrown off, the eyes are staring, pupils contracted, insomnia, rolling the head, and uttering distressing cries, due to the headache from hyperpemia of the cerebral vessels and the un- appeased thirst." The bath is first at the summer temperature of 75°, the feet and legs are first gradaally immersed, and then water is poured over the chest and abdomen till the whole body is under water. Colder water (65°) is then poured in a continuous stream over the upper part of the head, and this is kept up for fifteen minutes. When the child is removed from the bath it is wrapped in a woollen shawl, and placed in bed with additional covering. It falls asleep, the skin is cool, the pulse and respiration fall in frequency, and the temperature is at or below the normal standard. If the symptoms return the bath may be resumed three or four times a day. The internal treatment consists in giving beef tea, milk, and lime-water ; " one grain of quinine and a half to a tea- spoonful of whiskey every three hours for a child eight to sixteen months look formidable, but they will be borne admirably." * Sunstroke or Thermic Fever, by Dr. H. C. Wood, Philadelphia Medical Times, A.ugust 5th, 1876, p. 542. 182 DISEASES OF CHILDREN. Witli tlie departure of the fever, bismutli and pepsin are given to restrain diarrhoea and assist digestion."^' 5. Lienteric Diarrhoea. — This form of diarrhoea, known as lientery, is characterized by the passage of undigested food through the bowels ; it is very commonly seen in artificially reared children, especially among those who are subject to mesen- teric disease. Food which they cannot assimilate passes through them. Meat, or bad milk, or vegetables, on which the gastric juice has no action, pass through the stomach, setting up irrita- tion in the bowels. The food undergoes scarcely any change in its passage through the long and tortuous length of the alimen- tary canal. Shortly after eating the child experiences discomfort, and passes the meat, which has just been previously taken, with- out the secretion of the stomach having exerted a solvent action upon it. It is probable that the stomach is feeble and primarily at fault in so rapidlj^ dislodging its contents. The child's appetite is greedy and never satisfied ; there is great debility and loss of flesh, because the food is not absorbed, and there is thirst and general irritability. Dyf^enleric DiarrlvEa. — When the discharge of mucus from the bowels is excessive, and is attended with a considerable quantity of blood also, and there is no fever, we may recognize this form. It is not exactly one of acute or chronic dysentery, but of great congestion of the intestinal vessels, leading to their rupture. There are feculent discharges, with tenesmus, pain in the body, and wasting, and the child loses flesh rapidly. Dysentery may be described as a severe form of muco-enteritis, with more pain than is felt in diarrhoea. Chronic Diarrhea. — This form may be, and often is, the conse- quence of the acute forms passing into it by slow degrees, or it may follow cold and overfteding, the use of sour milk, or the milk of a w^et-nurse which is in all respects apparently healthy. The continued discharges from the bowels gradually reduce the strength and impair the powers of nutrition. A chronic state of irritation or catarrh is induced, and the longer it lasts the more diflicult will it be to control. In this form of the disease the mo- tions are variable, sometimes being copious and at other times quite * Cool Batliing in tlie Treatment of Inflammatory Bowel Affections during the Summer, by C. G. Comegys, M.D., Pluladelphia Medical Times, July 17th, 1875, p- 605. DIAEEHCEA. 183 thin and slimy, with gelatinous masses of mucus streaked Avith blood. As we have seen in the disease known as '•'•Ikniery^'' any undigested food in the motions is significant of feeble digestive power and impaired nutrition ; the milk or other articles of diet pass through the stomach rapidly, and in many cases there is a deficiency of bile. Causes of Diarrhcea. — In most cases diarrhoea is the consequence of improper feeding. A very common cause is the habit of giving young children farinaceous or biscuit food instead of milk, especi- ally if the child is delicate or rickety. The stomach is easily deranged, and the unhealthy products of digestion entering the intestinal canal excite irritation till they are eliminated. So far, it is a salatarj'' process, and the diarrhcea may soon pass off. Since the use of feeding-bottles has become general, diarrhoea is easily provoked if they are not properly cleansed and rinsed out. When this precaution is neglected, any fresh milk that may be put in turns sour and acid. It may be induced by unhealthy nurses whose milk is deranged through privation or anxiety, or when they are suftering from leucorrhoea. Impure water, bad air, filth and overcrowding, are also to be enumerated among the chief causes of the com. plaint. Exposure to cold or heat, and biliary de- rangement may all lead to the disorder. Very troublesome diar- rhoea may sometimes be witnessed in children at the time of weaning. The child has probably become badly nourished from the mother suckling it till it is a year old, and then the change of diet to corn flour, mashed potatoes, bread and butter, and even a little meat, will cause relaxation of the bowels, restlessness, and thirst ; five or six motions will escape during the day, slimy and containing spots of blood. Only a change of diet can set matters right. Diarrhoea is sometimes noticed in connection with rickets, and it very frequently follows whooping-cough and measles. Troublesome diarrhoea may be kept up by the indiscriminate use of aperient medicines. Treatment. — This will depend upon the cause, which should be- if possible ascertained. But whatever may be the origin, and whatever the variety or stage of the disorder, the diet will require' immediate and careful attention. ISTothing can be done towards, eftecting a cure till the age and constitution of the child are con- sidered, and it should be particularly noticed whether it has- \ 184 DISEASES OP CHILDREN. . become suddenly or gradually ill ; this question is of immense importance in the plan of treatment to be pursued. If the child has no teeth, corn-flour, and farinaceous food of all kinds must be forbidden, and milk in some shape be relied upon. If the child is an infant, and artificially reared, a tablespoonful or two of lime- water should be mixed with each bottle of milk, and this will aid the digestion of it and prevent it turning sour. If there is much sickness, it may be necessary to apply a small mustard poultice to the pit of the stomach, to suspend the milk for a time, and to give barley-water in its place, and a teaspoonful of cold water occasionally. Too much stress cannot be laid on the importance of feeding, and of selecting the purest milk. When every pre- caution has been taken with .the bottle, in the way of cleanliness, I have known the diarrhosa continue, or the bowels to remain quiet one day and the discharges to be healthy, and jet griping pain, exhausting diarrhoea, and sickness to follow next day. The bottle is abandoned in consequence, and the child is fed with diluted cow's milk in a teaspoon, and forthwith the diarrhoea ceases. In some cases Swiss milk has occssionally succeeded better than cow's milk, and that when one wet-nurse after another has failed.* The simple form of diarrhoea is consequent upon irritation of the lining membrane of the bowels in the majority of cases, and therefore it is not prudent to hastily check it, as it is an effort on the part of nature to expel offending matters from the system ; if after a time the diarrhoea continues, a morbid action of the mucous membrane is kept wp, which demands remedies to control it. If it appears to arise from irritation in the stomach or bowels, a, teaspoonful of_ castor oil, or a few grains of soda and rhubarb, will soon arrest the symptoms and the child will feel no further trouble. In that variety of diarrhoea where there is straining with mucus, or mucus with blood, a paste of castor oilf and magnesia, with a carminative will be very useful. If there is * See Chapter II. t Formula 23: B. 01. ricini, 5ss. Magnes. carb., gij Sacchari, . ......... ^iij 01. anisi, "Jlij.— M. A teaspooful for a dose. (An infant may take a dose occasionally.) For children from six io twelve months old. DIAREHCEA. 185 griping pain, and the diarrhoea is profuse, the addition of half a minim of laudanum will be serviceable.* Castor oil possesses mild and unirritating qualities, and promotes the escape of fluid secre- tions from the intestinal canal without pain or discomfort. This being accomplished, its subsequent action is said to be astringent, so that at the commencement it is probably the safest and best eliminator of morbid secretions which excite the irritation of the bowel. When the diarrhoea is acute and recent, soothing and unirri- tating diet is especially to be recommended, rice-water flavored with cinnamon, or barley-water, so that the intestines may have all possible rest. Sago, tapioca, corn-flour, arrowroot, and chicken broth, are all ai;ticles of diet to be borne in mind. In older chil- dren, where the diarrhoea appears to depend on congestion of the mucous membrane, a combination of gray powder and Dover's powder will be useful for a few nights, with bismuth mixture during the day.f I have seen excellent results from this plan of treatment in out-patient practice, even when the children have not been confined to the house. The treatment of summer diar- rhoea has already been considered. The treatment of diarrhea, particularly in teething children, is apt to be looked at with a one-sided .view, — the quickest way to stop the diarrhoea. This is a fatal mistake. If the child is of full habit with florid face and greedy with its food, it is not a good plan to hastily cheek the diarrhoea, but we should simply moderate the alvine losses by some alkaline mixture ; and if there are any teeth pressing against the gums, the latter should be * Formula 24 : R. 01. ricini, §ss. T. opii, "jjvj Mucilag., 3ij Syr. zingib., ^iij Aquam anethi ad ,^iss. — M. One teaspoonful to be given occasionally. For children from six to twelve months old. t Formula 25 : R. Sodae bicarb., gr. xij Liq. bismuth., 3'j Mucilag., 3ij Syr. zingib., . . . . . . . . , .^ss. Liq. magnes. carb., ........ .^iv. — M. A dessertspoonful three times a day. For a child two years old. 186 DISEASES OF CHILD REX. scarified or well incised. Very often the general disturbance and intestinal disorder yield at once to these remedies. Speaking of the diarrhoea arising from improper food or teething, Dr. Pavy writes: " I am in the habit of giving, and with the most satisfactory result, a little ipecacuanha with a bitter and a saline. My prescrip- tion consists of a few minims of the vinura ipecacuanha, twenty minims or so of the tincture of calumba, and one or two or three drachms of the Mistura Saliua of the Guj^'s Pharmacopoeia, which is made by saturating a solution of carbonate of potash, containing twenty grains of the carbonate, to each liuid ounce of water, with lemon-juice. Conjoined with this a couple of grains of gray powder are sometimes given as an alterative everj' morning ; or sometimes a powder consisting of a quarter or half a grain of calomel, two grains of the dried carbonate of soda, and five grains of the aromatic powder of chalk."* The formula, recommended by Dr. West, containing small doses of vinum ipecacuanh^e and liquor potass^e, is also very useful f As a rule, astringents are objectionable at an esLvly stage of diarrhoea, which may continue in spite of them unless other pre- cautions are taken. If tbe motions contain mucus and are slimy, and there is an}- escape of blood, or redness about the anus, chalk mixture, catechu, acids, or bismuth, will be of no service ; but in their stead the remedies we have already pointed out, especially the castor oil paste and alkalies, with an alterative or sedative, as the case may appear to warrant. The diet is primarilj^ at fault in these cases, undigested food having passed into the bowels, and having excited over-activity of their functions. Warmth and the most complete rest, with a dose of castoi* oil, is the most appropriate treatment, and a grain of Dover's powder with a grain of gra^^ powder maj- be necessary. Xow and then a quarter of a grain of calomel will be found of use in children who are old enough and strong enough to bear it. Among hospital patients, a large number of cases of diarrhoea are traceable to oversuckling, and suckling by mothers in delicate health, or harassed hy anxiety. The return of the catamenia or even menorrhagia is no hindrance to the habit. If such children are removed from the breast, and cows' milk is given diluted with water, previously warmed and sweetened, the diarrhoea will gener- * Digestion and its Disorders, 18G7, p. 199. t Oj>. cit., p. 524. DIAEEHCEA. 187 ally subside. AVlien milk appears to keep up the diarrhoea, barley- water, or cold water thickened with isinglass will be necessary, or thin water arrowroot. Sometimes a powder containing two or three grains of rhubarb and carbonate of soda will neutralize the acidity which has resulted from the fermentative products of di- gestion and soon arrest the disorder.* In some cases where a child is strong, and where there is no ab- dominal pain, the motions containing mucus or blood, a mixture of sulphate of magnesia, tincture of rhubarb and peppermint- water may bia prescribed with advantage. f As to stim.iilants, if there is much exhaustion a few drops of brandy (and there is no better stimulant) in weak arrowroot or milk are advisable, and if there is much sickness, a mustard poul- tice to the epigastrium. A teaspoon ful of cold or iced water will often allay the sickness. Wine whey (one part of wine to three of boiled milk) is useful where the child is exhausted, and life may sometimes be saved by it. • In the treatment of bilious diarrhosa, alkalies, especially soda salts, should be given to relieve acidity, with one or two minims of laudanum, if there be much pain. An occasional mild mer- curial is also serviceable. Treatment of Cholera Infantum. — In the whole catalogue of in- fantile disorders there is no disease requiring greater vigilance and care. Any error of judgment is speedily fatal. The child should be confined to a spacious airy room, and the utmost quie- tude observed. When the bowel discharges are profuse and watery, and the child's strength is good, a dose of castor oil or rhubarb may be advisable, because the choleraic poison, or other otlending * Formula 26 : R. Pulv. rhei, Sodse bicarb., aa ....... . gr. xij Spt. anim. aroni., . . .• n^xx Syr. zingib., ^iij Aqiiam menth. pip. ad giss. — M. A teaspoonful every four hours. For children a year old. f Formula 27 : B. Magn. sulph., ^j Tinct. rhei, 3j Vel syr. rhei, ^^ij Tinct. quinice, . . . . . . . . . ,^ss. A*quani. menth. pip. ad ^iss. — M. A teaspoonful every four hours. For children a year old. 188 DISEASES OF CHILDREN. materials, will keep np the intestinal discharges, as long as thej remain pent up in the system. Elimination through the bowels, consistent with the strength of the child, is therefore a rational mode of treatment. After this, it is well to moderate the drain, if the child's strength fails, b}' krameria, or one or two drops of laudanum (Form. 15), and the treatment continued, or modified, according to circum- stances. If looseness of the bowels goes on unchecked, it becomes a diseased and not a carative process. When there is vomiting, I have given prussic acid' in combina- tion with a drop or two of laudanum, or the solution of muriate of morphia; but too frequently nothing has arrested the sickness. It is in these cases that dilute sulphuric acid has been recom- mended (Form. 34). The fact of vomiting ought not to discourage a plentiful supply of cold water, in very small quantities at a time, or toast-water to alleviate the thirst. If indeed the retching is distressing and urgent, a drink of tepid water, by facilitating the escape of morbid secretions from the stomach, is a rational plan to try. In this way the vomiting and purging may be arrested in many cases that appear almost hopeless. As long as there are offensive matters in the bowels, it must be our endeavor to get rid of them, as their retention in the body in- creases the mischief, and therefore opium and its 2:)reparations should be given with great caution. When the disease has passed into the stage of collapse, there is an impediment to the circulation through the lungs, and the reme- dies for exhaustion, as stimulants and opiates, generally fail to aftbrd relief. The body must be kept warm with flannel or the warm bath, cramps relieved by friction, and a few minims of sal volatile or chloric ether administered. If it is considered advisable to employ a warm bath to encourage reaction, the temperature should not exceed 95° Fahr. ; the child should not be suddenly immersed, but a blanket should be laid over it, and then the child being also well protected with flannel, can be gradually let down into the water without causing any alarm. Dr. George Johnson attributes the collapse in cholera to spasm of the arterioles of the pulmonary artery from an alteration in the blood, but this does not appear to me quite a satisfactory expla- nation of the phenomena, when we remember there are conditions allied to this form of collapse in which the blood cannot be said to DIAEEHCEA. 189 have undergone a poisoned state, or tlie lungs to be specially im- plicated. On the other hand, some drugs in poisonous doses, and some animal and vegetable substances have exerted such an irri- tating action on the stomach and intestines as to produce symp- toms resembling cholera collapse.* The calibre of the vessels may be influenced by the sympathetic nerve throughout the alimen- tary canal, and paralysis of the vasomotor nerves would produce dilatation and relaxation of the vessels, the child being thus bled as it were into its own veins, and watery discharges are the con- sequence. When reaction is established, a few drops of brandy are useful, chicken broth, milk, and the mineral acids are serviceable. Calomel is scarcel}^ to be thought of in these cases, for fear of increasing the general depression. If it is ever advisable it should be confined to the early stage where the motions are fecal, and never had recourse to where the discharges are watery and serous, for fear of increasing the gastro-intestinal irritation. Wie- meyer seems, however, to have used it successfully, and Dr. Lewis Smith has seen advantage follow a fractional part night and morn- ing with opium and astringents. " For cholera infantum, if seen early, give a hypodermic injection of morphia of suitable dose, to be followed up with small doses of calomel and camphor in sugar of milk, until biliary dejections are seen." (Comegys.) This seems to me, however, a very hazardous measure. In the treatment of dysenteric diarrhoea, Dr. de Havilland Hall advises one or two grains of ipecacuanha three times a day, and though sickness may at first be produced, tolerance is soon estab- lished, f Treatment of Chronic Diarrhosa. — If the diarrhcea occurs in an infant it should, if suckling, be limited to the breast, and no other food be given whatever, unless circumstances of a grave character should arise, and then it may be necessary to suspend nursing for a time, and give barley-water, thin veal broth, etc. Then, too, the milk of one nurse will keep up diarrhoea, when that of another will be easily digested ; and it will not unfrequeutly be found that one nurse after another will fail to supply suitable nourishment to the child, till we have to fall back upon plain milk and water. If this * On some Analogies of Cholera, etc., Med.-Chir, Trans., 1868, vol. ii, p. 1, by W. Sedgwick, M.K.C.S.E. f St. Barth. Hosp. Repts., vol. xi, p. 273. 190 DISEASES OF CHILDREN. does not succeed, condensed milk sboiild be tried, as I have pre- viously mentioned. The microscope may detect nothing wrong in the milk of the nurse, and yet it may cause the most violent irritation. Where milk disagrees to such an extent as this, it is obvious that some other means must be adopted for a time to sup- port the child. For children who ha-ve reached five or six months old, veal broth, or weak beef tea, or raw meat juice, may be tried, if the milk appears to keep up irritation. As the child grows older it will be able to digest better, and then the discretion of the practitioner must be used, and the diet varied according to cir- cumstances. As long as the stools are unhealthy, or pasty, all farinaceous food must be given with caution, as it will frequently pass through the stomach undigested. Too much importance cannot be attached to the food. It is of the highest consideration that it should be pure, nutritious, and unirritating. Where there is defective nutrition the child will gradually waste, and the more exhausted it becomes, the more difficult will it be to overcome the diarrhosa, which is prone to go on in spite of all the pharmaceutical remedies in vogue. Hence it is that raw meat juice sometimes answers so well in these cases. It may be made of beef, or mutton.* * " Take a quarter of a pound of the best rump steak, gravy meat, or reddish buttock meat ; cut it in very minute piece*, so as to make the finest jaossible mince of it, as fine as cut up spinach. Tiiis is best done by a sausage machine, then add water to the brim. If there be time to wait, this water may be cold ; if not, it should be lukewarm, oi-, at least, not exceeding a temperature of 120° Fahr. Stir up frequently with a spoon. At the end of two or three hours the supernatant water will have the color of dark claret^ The meat at the bottom will have become as white as fish. Strain through a coarse sieve. Drink the juice cold — about a claretglassful three times a day." — On Infant Feeding, by C. H. F. Routh, M.D., 3d edit., p. 335. ''Take one pound of fresh beef, free from fat, chop it up fine, and pour over it eight ounces of soft water, add live or .six dro{,)s of hydrochloric acid and fifty or sixty grains of common salt, stir it well, and leave it for three hours in a cold place. Then pass the fluid through a hair sieve, pressing the meat slightly, and adding gradually towards the end of the straining about two more ounces of water. The liquid thus obtained is of a red color, possessing the taste of soup. It should be taken cold, a teacupful at a time. If preferred warm, it must not be put on the fire, but heated in a covered vessel placed in hot water Should it be undesirable for the patient to take the acid, this soup may be made by mei'ely soaking the minced beef in distilled water." — Handbook of Therapcutlrs, by S. Ringer, ]\1.D., 4th edit., p. 610. "A piece of the lean of mutton should be minced, poimded to a pulp, and all fibrous threads carefully removed. To insure its fine division and complete separation from indigestible fibre, it is useful to have it rubbed through a sieve. The pulp, duly mixed with breadcrumbs and salt, may be given in a daily quantity of from one to three ouncGF, according to the age of the child. This is particularly called for when the DIAREHCEA. 191 With reorard to drno's, it should be remembered that there is a great tendency to acidity of the secretions ; excess of acid in the stomach retards the digestive power, excites fermentation, and causes flatulence, pain, and irritation, so that the child is never easy, and can obtain no rest.* Potash, by neutralizing the acidity, arrests the fermentative process, and it may be given with dill, aniseed, or cinnamon-water, three or four times a day after feed- ing. If the stools are thin a mixture of bismuth and potash, or soda may be given (Form. 25). As long as the motions are acrid and offensive one of these remedies should be prescribed. Some- times a grain of ITyd. c. Creta may be most advantageously added to a powder of soda and rhubarb. Ipecacuanha in doses of a quarter of a grain, with the castor oil mixture and laudanum (Form. 24), is an excellent remedy, particularly in the dysenteric variety. Creasote has been employed successfully where the mo- tions are frothy and fetid. A chronic diarrhoea is cured or kept in check by gallic acid or acetate of lead, recommended by Dr. "West (Form. 28, 29). f Some of the following mixtures containing motions contain a large proportion of unaltered food. Under this invaluable remedy the state of the bowels and of the general health often improves at once and together. Occasionally, in chronic diarrhoea, I have seen benefit from the extract of malt." — On Infantile Diarrhoza, by W. H. Dickinson, M.D., Medical Times and Gazette, September, 1872, p. 256. * See Chapter XIV, "On Indigestion." f Formula 28 : R. Acid, gallic, ......... gr. viij Tinct. cinnam., . . . . . . . . • .oj Tinct. opii, ......... "J^iv Syrupi, 3ij Aquje cinnamomi, . . . . . . . • 3^' Aquam ad ......... 5ij. — M. Two teaspoonfuls everv four hours. Formula 29 : R. Plumbi acetat, . . . . . . . . . gr. vj Aceti, nj^xx Tinct. opii, ......... "Xviij Mucilag. acacise, oij Syr. zingib., oj Aquam ad ......... 51,). — M. Two teaspoonfuls every six hours. Formula 30 : R. Tinct. opii, "jjyj Tinct. card, co., ........ .5.) Syrupi, , . . gij Decoct, hffimatoxyli ad ...... . o'°^- — •^^• A teaspoonful every four hours. 192 DISEASES OF CHILDREJST. logwood (Form. 30), cateclin, and chalk (Form. 31), krameria (Form. 32), nitric acid (Form. 33), or sulphuric acid (Form. 34), with bark or chloric ether, may all prove useful in turn. Sulphuric acid, however, whether combined with an aromatic or sedative has Formula 31 : R. Tinct. catechu Syr. zingib., ...... Mist, cretse ad ..... • A teaspoonful every four hours. Formula 32 : R. Tinct. kramerise, ..... Tinct. opii, ...... Spt. chloroform., ..... I'ulv. acacise, ...... Aquam ad . . . A teaspoonful every four hours. Formula 33 : R. Acid, nitric, dil., Tinct. camph. co., Spt. chloroform., Syr. zingib., Decoct, htematoxyli ad A teaspoonful every four hours. Formula 34 : Bi. Acid, sulph. dil., . Spt. chloroform., ........ Syrupi, .......... Aquam ad ......... A teaspoonful every four hours. Formula 35 : R. Acid, nitric, dil., , . . Syr. gummi rubr., ........ Spt. chloroform., ........ Decoct, hsematoxyli ad ...... . A teaspoonful every four hours. These prescriptions are suitable for children of a yea.r old. Formula 36 : R. Ext. belse liquid, Syr. gummi rubr., ........ Tinct. camph. co., ........ Syr. zingib., ......... Aquam ad ......... A teaspoonful three or four times a day. For children six years Formula 37 : R. Cupri sulph., ......... Liq. opii sed., . Spt. chloroform., ........ Aquam cinnamomi ad ...... . Two teaspoonfuls three times a day. For cliildren six years of 3J 5iss. — M. 3'i wjjxx 3ss. Siss.— M. "Kxxiv 5i "Kxij giss.— M. 3ss. giss.— M. w)Jxx nijxx giss.— M. 31J Jiss. — M. of age. 'i^xxiv 5iij.-M. DIAERHCEA. 193 not answered my expectations, and I have been so frequently dis- appointed with it that I now seldom employ it. The syrup of red gum, combined with nitric acid and logwood (Form. 35), or with the extract of bael, are all useful (Form. 36). A dose of castor- oil paste (Form. 23) may be needed to remove irritant matter from the bowels, and especially in those cases where exposure to cold has chilled the surface and increased the cono-estion of the internal organs. Sulphate of copper is another remedy to be employed with opium, and a few drops of spirit of chloroform in special cases (Form. 37). In very obstinate cases enemata of starch and opium may be necessary. I found no remedies administered by the mouth check the alvine discharges so effectuallv as one used nio-ht and mornino- in a case depending on mesenteric disease. In very obstinate cases Trousseau employs an enema of one grain of nitrate of silver dis- solved in an ounce of w^ater. In the dysenteric diarrhoea of chil- dren, Dr. Ringer speaks favorably of salicylic acid used as an in- jection (1 to 300).* This chronic diarrhoea indicates a relaxed state of the system generally and loss of tone, A tonic regime is consequently re- quired, and frequently gives relief when other remedies have failed. Thus, change of air, by altering the surrounding circumstances, is often of incalculable benefit. Removal to the seaside, or some dry and healthy locality, will accomplish more than any drugs when the case has assumed a chronic character and the bowels are irregular in their action. Cold baths in the morning, or if the little patient be very feeble, baths with the chill taken off, with friction and shampooing, tend to brace up the relaxed tissues. Benefit is frequently obtained from the use of cod-liver oil, steel wine, malt extract, and other remedies of a similar invigorating character. Every case of diarrhoea demands care, from its liability under neglect to lead to the severe forms we have described, or to originate mischief in the brain, or tubercle, or marasmus, as the general strength becomes more and more reduced. Prolajjsus Ani.' — In cases of long-continued diarrhoea the sphinc- ter ani loses its contractility, and the surrounding parts become relaxed. When the diarrhoea is cured the local irritation ceases, * Handbook of Therapeutics, 8th edition, p. 599. 13 194 DISEASES OF CHILDREN. and the child's bowels may act once or twice daily without any protrusion of the rectum. The treatment consists in sponging the relaxed parts with cold water, and if there is tenesmus an opiate enema after the bowels act will be of service. Another plan is to wash away all fecal matter from the gut, and then apply a strong solution of alum before it is returned. When the gut remains protruded, apart from any action of the bowels, gentle pressure with the finger dipped in oil will cause it to return. Cold water enemata every morning are serviceable in this state of re- laxation. I have found great benefit from the use of sulphate of iron and infusion of quassia as a valuable astringent enema,* and the decoction of tormentilla has also been recommended. Where the prolapsus ani is not the result of diarrhoea, but is rather a chronic condition, it is well to hold the child in the hands whilst the bowels are being relieved, as, by so doing, the gut will rarely be forced down. If, on the other hand, the child is placed where its feet can reach the ground, it will make such powerful expul- sive efforts as will commonly cause protrusion. Another plan is to keep the little patient lying on its back whilst the motions are passed. A compress and bandage may be worn during the day to prevent descent. CHAPTER XYI. GASTRITIS — MEL^NA — DYSENTERY. Gastritis : Symptoms — Causes and treatment. Softening of the Stomach : Nature and causes. H^ematemesis and Mel^na : Causes^Symptoms and treatment. Dysentery : Symptoms — Causes — Pathology and treatment. Gastritis is of rare occurrence in children, and the symptoms are too obscure to enable us to diagnose the disease with any approach to certainty. Catarrh of the gastric mucous membrane {gastritis mucosa) has been referred to active hypercemia ; it occurs in the case of drunkards, as well as in chronic heart disease and pulmonary phthisis. The anatomical changes in this state are a * Formula 38 : R. Ferri sulphat., 3J Inf. quassise, o^iij' — M. Fiat enema. A fourth part to be used every morning. GASTRITIS. 1 95 dark-reddish slate-gray discoloration of the mucous membrane, spots of ecchymosis, and a general hypertrophy of the parietes of the stomach.* The disease niay be induced by irritating articles of food, and by swallowing corrosive acrid substances, or from any causes which excite indigestion or flatulence. The stomach may exhibit the evidence of gastric catarrh after death in those chil- dren who, during life, have had no symptoms of the disease, nor even disturbance of digestion. The symptoms are distension and pain at the epigastrium, increased on pressure, vomiting of a glairy mucus or greenish secretion, and constant retching after food. If the disease goes on the child becomes thin and emaciated ; there is thirst, and the tongue is covered with a thick white fur ; the pulse is frequent and small in acute cases, and there is constipation alternating with diarrhoea ; but a subacute form of gastritis may be present, giving rise to no more symptoms than are ordinarily to be met with in irritative dyspepsia. If this continues the nutrition of the child sutFers, and it loses flesh and strength. The treatment consists in giving cold water and sedatives after a careful regulation of the diet. Whilst pain and sickness con- tinue, milk in small quantities at a time is the best form of nour- ishment, and it may be necessary to add a little lime-water to assist digestion. For the relief of the profuse gastric secretion, Vogelf recommends half a grain of nitrate of silver in three ounces of water as a mixture, of which two teaspoonfuls may be given to children from one to two years of age. For older children he gives a sixth of a grain of nitrate of silver. But gastritis, of a subacute character, demands that bland and non-irritating food should be taken, cold or iced water to allay thirst, and bicarbonate of potash and hydrocyanic acid as a seda- tive to the mucous membrane. If there is much irritability of the stomach, a grain of calomel, with a few grains of tragacanth powder, divided into six parts, and given in the space of twenty- four hours, will be a serviceable remedy. Poultices may be ap- plied to the epigastrium if the pain does not yield to the remedies mentioned, and enemata are preferable to purgatives. In cases of gastritis produced traumatically the best treatment probably is that of opium and bismuth. * Rokitansky, Path. Anat., vol. ii, p. 257. t Diseases of Children, 1874, p. 141. 196 DISEASES OF CHILDREN. Softening of the Stomach. — It is most important not to mistake the appearance found in the stomach after death, from the action of the gastric juice, with those that result from disease, or the introduction of irritating substances. The experiments of Hunter showed that the gastric juice after death was capable of discolor- ing the coats of the stomach, more especially in those persons who had died suddenly. As many individuals were quite well up to the time of death, he believed that these changes were caused by the action of the gastric juice after life was extinct. In some instances, the process is limited to the mucous mem- brane, which is softer than usual, and breaks down under slight pressure of the finger ; in other instances, the morbid change is greater, and it extends through all the coats, by means of a soft irregular ulcer, the contents of the stomach escaping into the peri- toneal cavity. The diseased process most frequently attacks the fundus of the organ, where the fluids gravitate, and the bloodves- sels ramifj'ing over the coats of the stomach are dark and con- gested, producing a condition resembling chronic inflammation. Adherent to the interior membrane may be seen an opaque or brownish tenacious mucus, which is easily removed on pouring over it a slight stream of water. The disease appears to be not uncommon in infancy and early life, when gastric disorder is so frequent, but I am not able to refer to any symptoms, either in my own experience, or that of others, which would enable us to say during life, that softening of the stomach would be found after death. Softening of the intestines has also been mentioned by writers on medicine, the mucous membrane becoming softened or destroyed down to the peritoneal investment. HcEinatemesis and Meloena Vera. — Infants of a few days old Bufter occasionally from vomiting or purging of blood, sometimes from both. " It is essentially a disease of the early days of life, generally occuring between the first and sixth day."* Dr. Rahn Escher considers that the hasmorrhage is greatest within the first t went}' -four hours of life, usually ceases on the second day, but may continue to the fifth, or even later. ■Causes. — In man}' cases it is impossible to find out the source of the hferaorrhage. Various opinions have been oftered as to the cause of this rare and obscure condition. The disease would ap- * Diseases of Infancy and Childhood, by T. H. Tanner, M.D., p. 116. SOFTENING OF THE STOMACH. 197 pear to depend cljiei3y on the physiological changes which take place at birth, when respiration becomes established, and the lungs, liver, spleen, and intestines are liable to become congested through an increase of pressure on the venous system ; hence one reason, probably, why convulsions are frequent after birth in delicate chil- dren. Tedious labor and the pressure of instruments are mentioned as factors in the production of the hfemorrhage. Some cases are on record which show a hereditary tendency to bleed in the parents.* Of twenty-two cases recorded by Rilliet and Barthez, twelve recovered. These were probably cases of pressure of the child's head during tedious labor, and congestion of the venous system from a difficulty in establishing respiration at birth. f " Taking the cases altogether, the mortality is about 60 per cent." (Groom.) Pathology. — Some authorities consider the haemorrhage as a crisis of the plethoric condition, and such cases would appear to be by no means uncommon in the newly born, there being general cong-estion of the inteo-uments and chief internal organs. Cases are recorded which show that it is sometimes due to blood cha^nge, as in purpura h?emorrhagica. Bouchut quotes from Billard (p. 497) the case of an infant, five days old, whose trunk, limbs, and arms were covered with violet petechise, and the yellowish spaces between them (from the slight jaundice which was present) gave the surface " a tiger-like aspect." After death, dark blood was found in the intestines and stomach, the spleen had ruptured from over-engorgement, and the heart was full of blood ; the cellular tissues contained large ecchymoses, as did the kidneys and bladder ; the pleurae presented petechite, and the brain was congested. After death, in ordinary cases, the internal organs have been found exsanguine, but healthy. Spiegelberg and Landau report cases in which abscesses were found in the duodenum, arising from, embolism. Cases of this kind never recover.:]: The symjptoms are prostration of the strength, pallor, rapidl breathing, inability to suck, small pulse, and occasionally convul- sions. Cases W'hich survive the shock may end in diarrhoea, hydrocephalus, or mesenteric disease. * Melfena Neonatorum, by J. Halliday Crooni, M.B., Med. Times and Gazette, Oct. 23d, 1880, p. 480. f Traite Clinique et Pratiqxie des Maladies des Enfans, Paris, vol. ii, 18-53. :j: Melfena Neonatorum, by J. Halliday Groom, M.B., Med. Times and Gazette, Oct.. 23d, 1880, p. 480. 198 DISEASES OF CHILDREN. Blood drawn from the nipple in suckling {spurious hcBmatemesis) must not be mistaken for true hsematemesis. Treatment. — This is unsatisfactory and uncertain ; little, if any- thing, can be done. Astringent enemata with cold water where the haemorrhage from the bowels is bright and active, or even cold applications to the abdomen, may be suitable in some cases. When faintness and exhaustion threaten, ammonia, ether, etc., will be required. Dysentery. — Young children are sometimes seized with this disorder, but it is very rare, and it is not improbable that intestinal haemorrhage has been mistaken for it. When the stools are slimy and contain mucus, there is afi alteration in the intestinal mucous membrane, and, if it lasts, more or less blood may be mixed with them. In some chronic cases the evacuations are little more than lumps of blood and mucus, dark in some instances, and pink or bright red in others. In aggravated cases, the bowel discharges are so altered that they become oifensive, and of a slate-gray hue from containing portions of mucous membrane which have sloughed, and there is a discharge of pus, indicating the presence of ulceration. Dysentery may begin as a primary disease, or commence as simple diarrhoea, and depend upon the same causes ; the inflammatory form of diarrhoea [eniero-colitis] is closely con- nected with it. The symptoms resemble those of entero-colitis, but are more severe ; they usually begin with violent sickness and vomiting, when the disease is acute, accompanied with shivering and pallor. The motions at the onset may be copious, and for the first few days of a bilious character, then they become more scanty and slimy, with glairy mucus resembling white of egg, and mixed with blood. Sometimes pure blood escapes, but generally it is mixed with the fecal matter, which now and then escapes in lumps, causing griping pain in the abdomen, tenesmus, cramps in the thighs, and difficulty in micturition. There are abdominal pain and tenderness in the course of the colon, and frequently around the navel. Fever is seldom present unless the disease lasts some time, when the skin becomes harsh and hot, and the pulse frequent. When the disease assumes a chronic form, the child becomes emaciated, and the bowel discharges are mixed with pus and ■blood ; there are pieces of lymph in the motions, which are very dysejSitery. 199 acrid and offensive. The cliild is restless, and cannot sleep at night from pain and tenderness ; there is gradual loss of flesh, prostration of strength, constant thirst, nausea, and disinclination for food. " Of thirty-six cases, the termination of which we have recorded, four proved fatal." (Meigs and Pepper.) The com- plaint may terminate in peritonitis and ascites, in mesenteric disease and hectic fever, or in a sudden fit of convulsions. When the disease is progressing towards recovery, the evacuations become less frequent, and blood no longer appears in them ; the child ceases to be feverish, and rests at night, whilst the appetite returns. Causes. — The disease is more frequent in hot summer weather, when unripe fruit is eaten, and bowel disorders are common. Improper feeding, defective ventilation, scanty clothing, impure water, and exposure to cold and damp, are all capable of origin- ating the disease. The influence of malaria, too, is to be reckoned as a cause, as well as the exanthemata, particularly measles and variola (Meigs and Pepper), and diseased intestine from typhoid. Pathology. — -In the acute stage of the disorder, the morbid changes are to be seen in the large intestine and rectum, as in entero-colitis. It resembles this disease, except that the changes in the rectum and colon are greater, and it often exists in an endemic and epidermic form. In some cases the small intestines are involved ; the mucous membrane is swollen, soft, and reddened in patches or throughout its entire length. In some places it may assume a dark or gangrenous appearance. The follicles are enlarged. In the more advanced or chronic stage, small round specks of ulceration form, which finally run together, and produce a ragged uneven appearance, varying in extent and depth. The mesenteric glands may be natural, or slightly enlarged and red. In long-standing cases the ulcers become contracted, and surrounded by hardened tissue. Treatment. — When the disease is recent, and sets in with acute symptoms, a warm bath is of great service, followed by poultices to the abdomen. The most absolute rest and warmth are de- manded, and, if there is no vomiting, the castor-oil paste (Form. 23), with a drop or two of laudanum, will be necessary to adminis- ter in order to clear the bowels of any scybalee (Form. 24). If there be tenesmus and straining, an opiate clyster will give great relief. In some form or other opium is the most valuable remedy 200 DISEASES OF CHIL.DEEN. we possess in this complaint, as it controls the action of the bowels, allays pain, and procures sleep. Acetate of lead, catechu, kra- meria, sulphate of copper (Form. 29, 31, 32, 37), will at once come to our aid in turn^ when the bowels continue obstinately irritable. When calomel is employed, it should be given in very small doses at an early stage, in combination with opium or Dover's powder, but its use requires extreme caution. jS^itrate of silver has been recommended, in combination with a few drops of opium, given in some suitable vehicle, like mucilage or syrup. The eighth of a grain may be given to a child two years old every three or four hours. As regards diet, if an infant, it should be kept to the breast, and no other form of food given. Older children may have barley- water, sago, tapioca, rice-water, etc., as mentioned under the treat- ment of chronic diarrhcea. CHAPTER XYIL CONSTIPATION AND COLIC. Causes op CoxsTlPATioif : General dehility — Diet — Deficiency of gastric, hepatic and intestinal secretions — Torpor of intestines from atony nf their muscular fibres — A fre- quent accompaniment of cerebral disease — Hernia and intussusception. Treatmext : Regulation of diet — Laxatives — Aperients — I^itrohydrochlorie acid and taraxacum — Belladonna — Strychnia — Enemata. Causes of Colic : Diet — Poisonous or irritat- ing substances — Flatulence — Presence ofseybalm in intestines. SYMPTOirs AND Diag- nosis FROM Peritonitis: Treatment: Castor oil and opium — Use of enemoia — Hot poultices — Belladonna — Hydrate of chloral and bromide of potassium. Constipation is one of the commonest disorders of early life. When it occurs in infants it is a source of much trouble to the mother, who is sorely tried with the difficulty, because the child cannot thrive without a frequent action of the bowels. The younger a child is the oftener should the bowels act. In inftxnts they are moved throe or four times a day ; and in children over one year there are generally two evacuations daily. Among children artificially reared, constipation is a frequent ailment, particularly if they are feeble. There is deficiency of in- testinal secretion, so th^t by the time the motions reach the large intestine and rectum they are extremely hard and pebbly, and the CONSTIPATION AND COLIC. 201 child cries and undergoes painful straining to evacuate the hard- ened masses. Eest is not obtainable at night from flatulence, the belly becomes swollen, the legs are spasmodically drawn up, and then stretched out again. If this state of things is suffered to go on, the child may have a convulsion, or die worn out with pain and exhaustion. An accumulation of gas in the intestines may occur in these cases, especially where the secretion of bile is scanty, and those articles of diet are indulged in which cause fer- mentation. When the amount of mucus is sparingly secreted, the muscular fibre fails to propel the contents of the bowel, and hence constipation is common in such cases. The color of the faeces depends upon the admixture of bile, and the motions may be brown, green, or almost black, or like clay. When bile is deficient, the motions are pale ; ordinarily they are of a gingerbread hue. " The consistency of the f^ces also varies considerably ; they are liquid w-hen the serous exhalation of the mucous membrane is excessive ; semifluid when the secretion is muco-gelatinous, or they are mixed with the secretion of the shape of grumous particles. The feculent matter found above the various intestinal strictures presents a ];>eculiar frothy appear- ance."* Constipation, too, in older children is sometimes caused by starch compounds, as rice, arrowroot, tea, astringent and tonic mixtures. And, according to my experience, it often originates in the neglect of parents to inculcate the habit of getting the bowels to act at stated hours. Constipation is also a frequent accompaniment of cerebral disease, as meningitis, hydrocephalus? marasmus, in consequence of a loss of tone in the muscular fibre of the intestinal coats. Constipation is likewise observable in children with sluggish livers, who are not otherwise ill. The complexion is sallow and the appetite capricious, the motions are pale and contain scarcely a trace of bile. The tongue is coated, the urine scanty and high- colored, and headaclie and lassitude are also common. These symjDtoms often arise from overfeeding and eating greedily. I have elsewhere alluded to constipation as the consequence of hernia, intussusception, and intestinal obstruction. f Imperforate anus is another cause. The symptoms generally met with in constipation are distension * Eokitansky, Path. Anatomy, vol. ii, p. 110, Syd. Soc, 1849. t See Chap. XVIII-XIX. 202 DISEASES OF CHILDEEX. of the abdomen from tympanites ; the bowels having lost their contractile power, expand and push up the liver, stomach, and spleen, thus interfering w^ith the descent of the diaphragm. In these cases the abdomen after a time becomes painfal, and the child is restless, the tongue is furred, the mouth hot, and there is sometimes vomiting. In many simple and uncomplicated cases, the symptoms are not so marked, the abdomen is more or less tense, and there are scanty dry evacuations, heaviness of manner, loss of appetite and thirst. Habitual constipation may cause convulsions in young children. Whilst constipation is most common in delicate children, espe- cially if brought up by hand, it is of frequent occurrence in strong children who are so reared ; and heiice I am inclined to credit injudicious feeding as a cause. I have over and over again seen the strongest and best-developed children so attacked ; they are plump, bright, and healthy-looking, tbe only ailment being a painful straining in emptying the bowels. Now, in these cases, although the skin is of a normal hue, and the conjunctivae of pearly brightness, deficient biliary secretion is the essential cause of the evil ; and until the liver pours out more bile, there is no proba- bility of relief. When the liver has been stirred up by a mer- curial purgative, the bowels have become regulated, and a recurrence of the evil has only happened with food, improper in quantity or quality. Treatment. — No remedies will be of any use till we have ascer- tained the cause ; and the first step to take under any circum- stances will be a proper regulation of the diet. To prescribe drugs till this is inquired into will be a fruitless proceeding. Milk ought to enter largely into the dietary of young children, and weak animal broths in place of mucilaginous and starchy foods, with a liberal allowance of cold water. If the child is old enough, Scotch oatmeal with milk once a day is an excellent remedy to keep the bowels open. The oatmeal and treacle biscuits made by Scotch confectioners and bakers, or the so-called "Yorkshire parkin," is a famous aperient food for children. These biscuits may be procured of Macalpiue & Co., 287 Oxford Street. Prunes and senna are also serviceable, and if in season, a few grapes or a baked apple maj'' be allowed. In infants and children of a few months old, the castor-oil paste is a safe aperient (Form. 23), re- lieving the flatulence and exciting the action of the bowels. The CONSTIPATION AND COLIC. 203 syrup of rhubarb is another good remecl.y, and manna is a safe and mild laxative which infants take readily.* Manna may also be given in the form of paste with a little cream of tartar.f A sup- positorj^ of common yellow soap introduced into the rectum at night will sometimes cause the bowels to act naturally in the early morning. A child delicate from birth suffered from constipation, passing motions resembling clay marbles in color and shape ; it was never easy day or night. All treatment failed to give relief till at six months old, malt extract, mixed with milk, was tried, and in a very short time the motions became natural and the bowels regular. In older children I. have known treacle and bread insure a daily and regular action of the bowels. :{; In some strong children where febrile disturbance and heat of surface attend constipation, a few grains of sulphate of magnesia with cinnamon, which dis- guises the taste, will answer extremely weJl,§ or (Form. 8), regu- latino; the dose accordino; to the age of the child. If the com- plexion is sallow, the urine turbid, or if the motions indicate a deficiency of bile, a little gray powder w^ith rhubarb and bicarbo- nate of soda may be given with advantage for a few nights, and a citrate of potash mixture during the day. In some cases, if the belly is tumid and the hepatic secretion habitually defective, small doses of the perchloride of mercury may be ordered with tincture of cinchona and taraxacum. I have also seen excellent effects follow the administration of nitrohydrochloric acid with taraxa- * Formula 39 : R. Mannpe opt., gij Aquse anethi, ......... 5J. — M. A teaspoonful once in two or three hours till the bowels act. For children from four to six months old. f Formula 40 : R. Potass, bitart., gss. Mannse, o^"- Aquam anethi ad ........ ^iss. — M. About gr. X or gr. xv for a dose, to be .repeated occasionally. For children from four to six months old. X See Chapter II. § Formula 41 : R. Magnes. sulph., . 3j Syr. rhei, ^ss. Tinct. cinnam. co., 3ss. Liq. magnes. carb. ad . . . . . . . 3iss. — M. One or two teaspoonfuls occasionally. For children from four to six months old. 204 DISEASES OF CHLLDEEX. cum* where the liver is sluggish, and the child is torpid and pale, and needs a tonic and alterative at the same time. The Pulv. Gljcjrrhizge Co. (Ger.), which contains sulphur is an admirable aperient for children, and is not disagreeable to take. Lastlv, there are cases repeatedly met with where it should be our object to give as little aperient medicine as possible by the mouth, because the constipation depends on a laxity of the intes- tinal fibre. A judicious combination of belladonna and strychnia is to be recommended in obstinate constipation, but if in spite of these remedies and diet, the bowels remain persistently costive, a two-ounce enema of warm soap and water will rouse them to activitv, and render soluble the fecal masses which are lodged in the descending bowel and rectum. This may be used for infants and children of any age. In every case of obstinate constipation, the finger well oiled, or an elastic tube should be passed up the bowel to ascertain if any hernia or mechanical obstruction exists for if it does, all treatment by the mouth will be unavailing until it is removed. Experience, however, teaches us the danger of too active inter- ference in cases of constipation, unless urgent symptoms are present ; the bowels may be torpid for days or weeks together in exceptional cases, without danger to life.f * Formula 42 : R. Acid, nitric dil., "Xxvj Acid, hvdrochl. dil., Succi taraxaci, Svrupi, Aquam ad 3ss. 3SS. .^iv.— M. A dessertspoonful three times a day. For a child three or four years old. t Mr. .John Gay has recorded a case of obstinate constipation in a boy aged seven, of healthy appearance, who was admitted into the Koyal Free Hospital, in July, 1853. Four years previously he had an attack of typhus fever, accompanied with pain and tenderness. On recovery his bowels were torpid, and purgatives and enemata were needed to procure evacuations from them. '•' Daring the three months prior to his admission, nothing whatever pa.*sed from his bowels." Neither his health nor appetite suffered, and he had only been sick on one or two occasions in consequence of taking unwholesome food. The umbilical measurement increased to forty-nine inches without material inconvenience to the respiratory organs. Along the left side of the body was a prominent swelling, corresponding to an enlarged descending colon. One remedy after another failed to dislodge any fecal matter, and at la.st a speculum was introduced into the rectum, and the sphincter dilated ; then the tube of an enema syringe was passed high up into the bowel, and a stream of warm water kept constantly playing for half an hour upon the contents till they were dissolved. These repeated operations brought CONSTIPATION AND COLIC. 206 Colic is a common complaint in young children. It consists in painful contraction of the intestinal coats, and is caused by the accumulation of hard fecal matter in the bowels, or some irritant food, or substance lodged in the intestines. Slight attacks in infants are not uncommon from excessive acidity in the stomach, forming: milk into a hard indigestible curd. In children it is frequently induced by eating unripe gooseberries or other indi- gestible fruit, and drinking large quantities of cold water when the stomach is empty and the body heated. Worms in the bowels, internal strangulation, or obstruction are severally capable of causing the disorder. Colic often accompanies diarrhoea in young children. Exposure to cold is another cause, and so is bathing in too cold water. The sj/mptoms are sudden twisting pain in the abdomen, gener- ally in the direction of the transverse colon, and coming on in par- oxysms. The child draws up the legs and bends the body forwards to relax the abdominal muscles. There is generally flatulence, but the suft'ering may be intense, without any distension whatever, and with even retraction of the umbilicus. When the gas which is naturally formed in the stomach and intestines is not expelled by the anus, then the delicate muscular structure of these organs yields, and the abdominal wall becomes distended and tense. In typhoid fever and some other affections in v^'hich the ganglionic system is severely implicated, there is a drumlike distension of the intestines (meteorism) accompanied with quick shallow breathing, and increased action of the heart. The abdomen is not equally distended ; it may be conical along the centre, and the small in- testines be more involved than the colon in certain cases. I believe that in the latter class, fecal matter or undigested food is the chief cause of the pain. In addition to the sjanptoms just enumerated, the child shrieks out with pain, the angles of the mouth are drawn down, and the face is pitiable. Syncope and even convulsions may happen in severe cases. The disease is to be distinguished from peritonitis by the sud- denness of the pain, and the freedom from suffering between the paroxysms; by the quietude of the pulse, the. absence of fever, and the relief obtained from pressure. Most practitioners must away hard and fecal matter, like hard cinders, and soon reduced the size of the abdomen to that of twenty-six inclies in circumference. — Path. Trans., vol. v, p. 174; also Holmes's System of Surgery, loc. cit. 20G DISEASES OF CHILDREN. have observed children when pale with agonj, throw themselves across a chair to obtain the relief which that pressure affords. Treatment. — If the case is one of simple colic, and we consider the pain to be due to muscular contraction, it will be advisable to keep the bowels quiet till the pain is relieved. To attain this end, flannel wrung out of warm water should be applied to the abdo- men, or repeated poultices. I have found a mixture of carbonate of magnesia and spirit of chloroform with peppermint-water very serviceable, particularly if the bowels are distended. When the pain is mitigated, and we think it is desirable to act upon the bowels, a dose of castor oil with tincture of opium and two or three minims of spirit of chloroform will be indicated. In infants at the breast troubled with colic, it is often well to give the mother or nurse some carbonate of magnesia ; in other cases, where the milk is too firmly curdled by excessive acidit}^ in the stomach, and who "possett"* a portion of this curdled milk, cajeput oil with potash is useful. f A copious injection of warm water with a little oil will often produce speedy relief. When colic seems to arise from indigestible matter in the stomach, an emetic of ipecacuanha may be given. If there are symptoms of obstruction, they must be dealt with in accordance with the instructions under that heading ;| enemata may be tried, and if these fail, the little patient must be kept under the influence of opium and belladonna. The latter drug is said to be verj' serviceable in the colic of children. § Hydrate of chloral and bromide of potassium are also useful, by relieving spasm and inducing sleep. * This is a provincialism for which we have ho equivalent in ordinary English ; it means when a portion of the milk curdled by the stomach is ejected by the mouth. I Formula 43 : B. Potass, bicarb., gr. viij 01. cajeputi, "Xviij • Aquae anethi, oj- — ■^^• A teaspoonful three times a day. X See Chap. XVII. I Handbook of Therapeutics, by S. Einger, M.D., 4th edit., p. 502. INTESTINAL OBSTRUCTION. 207 CHAPTER XYIII. INTESTINAL OBSTRUCTION. Causes : Intussusception — Fecal accumulation and foreign bodies — Hernia — Malformation of rectum and anus — Diverticda and congenital strictures — Clinical records of these affections — Diagnosis of rarer forms of obstruction. Treatment : Reduction of any hernial protrusion — Abdomincd section to disengage the bowel — Enemata. By obstruction of the bowels is to be understood an interrup- tion to their functions, arising either from causes acting from without, as in hernia or volvulus; from within, as in fecal accu- mulation; or directly implicating the walls of the intestine, as in stricture. Intussusception is the most frequent cause of acute obstruction in childhood.* Next to this, hernia is not uncommon in children as a cause of obstruction, but the protruded intestine does not often become strangulated before adolescence. In obscure cases of obstruction, before resorting to extreme measures, it is advisable that a surgeon should examine the abdomen in the regions where hernia may occur. Mr. Howard Marsh tabulates forty-seven cases of stranofu- lated hernia in children, giving as full details as he could glean from the original records of each case. This valuable table accompanies a paper in which the author discusses the subject at length. f In cases of obstruction in new-born infants the practitioner may find that he can pass his little finger into the anus. That being the case he must still bear in mind that the rectum may be im- perforate some distance above the anal aperture. The most puzzling forms of acute obstruction that are met with in childhood are those due to certain congenital malformations of the intestinal canal. From time to time such cases come under the notice of the physician. In children and adults no trace can be found, as a rule, of the fetal omphalo-mesenteric duct. But it sometimes remains as a diverticulum from the ileum.:}: Close to this abnormal outgrowth * See Chap. XIX. f Eeports Illustrating the Surgery of Childhood, St. Bartholomew's Hospital Re- ports, vol. X. X For the anatomy of this condition, see Struthers, On Diverticula from the Small Intestine, Edin. Med. and Surg. Journal, 185^. * 208 DISEASES OP CHILDREN. tlie intestine itself is often very narrow, not from any morbid deposit in or outside its coats, nor yet from ulceration and cicatri- zation, but purely from ill-development. An interestino; case is recorded of "intestinal obstruction caused by a hernia through the mesentery of a Meckel's diverticulum, which had retained its attachment to the umbilicus." The patient, a boy seven years of age, was seized with severe pain at the um- bilicus, relieved by the sitting posture. He had occasionally suf- fered from attacks of pain. Vomiting set in on the third day, and continued with varying severity throughout the illness, but it was never fecal. The urine was scanty, and of high specific gravity. Paroxysms of pain occurred from time to time, and enemata brought away fecal masses. The pain abated on the fifth day, but on. the following, increased distension of the belly took place, and he died. After death, commencing peritonitis was discovered, and " about two feet of the lower part of the ileum were found hano-ing in a collapsed condition on each side of a cordlike loop. This loop was formed in the mesentery of a well-developed diver- ticulum, the upper end of which was attached to the umbilicus by an impervious cord half an inch long, the diverticulum itself being four inches in length. The gut, where it passed through the loop, ^^ as constricted and pale, but a small projecting portion at the origin of the diverticulum was of a deep purple color."* Two cases of fatal obstruction, one in a girl of thirteen, are recorded by Dr. Southey, from congenital constriction of the gut, at the point of departure of diverticula, the remains of the omphalo-uiesenteric duct.f Yery frequently the diverticulum itself is the cause of mischiev- ous or fatal complications. It may adhere to some part of the abdominal wall, and drag the intestine to such an extent as to completely obstruct it. This occurred in a child of ten, in Dr. Wilk's experience.:]: Sometimes the diverticulum becomes ad- herent by a band of lymph to the mesentery, forming a loop in which a knuckle of intestine may become strangulated ; this has been observed in a child aged four.§ In other cases the diverticu- lum may become filled with foreign bodies, or undigested food, * Clin. Soc, Oct. 22d, 1880. f Trans. Clin. Soc, vol. v, pp. 159-163. X Trans. Path. Soc, vol. xvi. ? Holmes's System of Surgery, vol. iv, Art. Diseases of the Intestines, by George Pollock, Esq., p. 610. . INTESTINAL OBSTRUCTION. 209 and fatal obstruction with perforation of the morbid outgrowth may ensue, as in a specimen exhibited before the Pathological Society.* Diverticula may become perforated in typhoid fever.f A displaced appendix vermiformis may become united to the bowel, forming a band, and ultimately causing obstruction. Mr. Pollock, in his article on diseases of the intestines, in Holmes's System of Surgery, after enumerating the signs of intus- susception, then proceeds to describe the symptoms of these rarer forms now under our consideration. " In all internal strangulations by bands, etc., the s^nnptoms are generally very acute ; the pain is sudden, sharp, even agonizing occasionally^; vomiting sets in early, and is usually incessant; the distension may not be as great as in the more slowly operating causes of obstruction, since little food can be taken, but still the small intestine becomes much loaded ; there is generally great tenderness on pressure, for usually peritonitis is not long absent ; there is early evidence of grave constitutional damage, for the portion of intestine, tightly bound down or encircled at the Rtrictured part, soon thickens and inflames, or may blacken and mortify." As for chronic obstruction, the physician should be on his guard in watching all disorders in which it .may take place. It often accompanies intractable tubercular disease of the peritoneum in ill-fed children. Treatment. — If a hernia exists and can be discovered, it should be reduced, and after this an enema of oil or gruel should be employed. If the symptoms point to internal strangulation, and a diagnosis can be established, the abdomen should be opened that the constricted intestine may be set free. If any abdominal swell- ing points to fecal accumulation in the csecum, or large intestine, enemata of castor oil and poultices to the abdon^en should be used, and it may be necessary sometimes to remove the hardened masses from the rectum with a scoop. In some cases of abdominal ob- struction attended with inflammatory symiptoras, it may be neces- sary to employ a few leeches to the abdomen,, and. give full doses of opium and belladonna.:}: * Trans. Path. Soc, vol. xxiii. t The Lancet, November 10th, 1877. X See Chapter XVII, On Constipation and Colic. 14 210 DISEASES OF CHILDREN. A case is recorded where a child three days after birth had passed no motion. As the linger could only be introduced an inch within the rectum, the case was looked upon as one of imperforate anus, and an operation was performed. Two days later, the child died from peritonitis. A post-mortem examination showed that the obstruction was due to a volvulus situated two feet above the ileo-cEecal valve.* CHAPTER XIX. IXTUSSUSCEPTIOX — INVAGIXATIG^^. Meaning and Definition: Two, forms described — 1. Simple intussusception, slight or spasmodic — Case in illustration — 2. Severe or inflammatory forms. Anatomical Appearances — Cattses : Diarrhoea the commonest cause — Constipation — Blows upon the abdomen or sudden jerks on the body — Weight of a tumor dragging dov.m part of intestine. Symptoms : Course and terminations — Persistent vomiting frequently present — Tenesmus and bloody mvLCUs. Diagnosis: From local enteritis — Internal strangulation — Simple colic — Vomiting — Amount of urinary secretion as a means of diagnosis— Impacted faeces — Typhlitis, etc. Treatment : Enemata — Inflation — Dangers of purgatives — Gastrotomy. IxvAGiisrATiox belongs particularly to infancy and early life, and is one of those disorders that demands prompt and judicious treat- ment. Fortunately its frequency bears no relation to its invariable painfulness and danger. This malady essentially consists in the passage or inversion of one portion of intestine into another, just in the same way as one tube may be slipped into another, or, what is a better illustration, the end of a glove-finger or stocking pushed within the upper portion. The effect of this invagination is not primarily strangulation, or arrest of the circulation, but ob struction to the passage of the intestinal contents. Sir Thomas Watson observes, however, that " the containe^i^ portion of intes- tine is liable to be nipped and strangulated by the coutalnm^ por- tion, and all the peril of hernia results, with much less chance of relief by art. This state of things is called intussusception."t Intussusception may be divided into: 1. Simple, slight, or spasmodic cases, where the invaginated intestine has not been * Brit. Med. Journ., vol. i, 1880, p. 7.38. f Principles and Practice of Physic, 1857, vol. i, p. 40. INTUSSUSCEPTION — INVAGINATION. 211 sufficiently irritated to become inflamed. 2. Severe cases, where the involved portion has inflamed or sloughed. The first variety is unattended by inflammation, and may be considered mainly due to spasm. A good example of this will be described presently. Slight intussusceptions have been found in the bodies of children who have had no symptoms of such displace- ment during life, and who have died from other forms of disease. Invagination of the small intestine is not uufrequently found at the autopsies of children who have died during the period of den- tition, or from diarrhoea, without any symptoms of intussuscep- tion.* Billard has seen it in cases of constipation, and Lewis Smith in infants who had had subacute or chronic entero-colitis.f " It is the result of an unequal irritability of the intestine, and the consequent irregularity of its movements, and it is, therefore, frequent in diseases characterized by torpor of the cerebro-spinal system, and in the mortal agony proceeding from them ; whereas it rarely or never occurs in diseases accompanied by, or ending with, abdominal paralysis, such as cholera, typhus, general peri- tonitis, etc.":j: The intussusception in some cases is slight enough to make it probable that no trace of inflammation or even congestion is present. The invaginated mass is usually from half an inch to two inches in length, and, as a rule, this accident is multiple. There may be ten or more distinct intussusceptions at distances of a few inches from each other. In the museum of the College of Surgeons there is a specimen of a portion of the small intestine of a child four j-ears of age, in which three intussusceptions are to be seen all close to one another.§ An intussusception involves three layers of intestine. The in- nermost consists of the invaginated upper portion of intestine ; its mucous layer is internal and the peritoneal external. The middle or inverted portion also belongs to the invaginated segment, and is reflected below from the lower limit of the inner layer, and above is continuous with the upper margin of the outer layer. From its inversion the mucous membrane lies external to its peri- * Meigs and Pepper, Diseases of Children, art. vi, Intussusception, p. 463. t Lewis Smith on Diseases of Children, Philadelphia, 1869, p. 419. X Roliitansky, Path. Anatomy, 1849, vol. ii, p. 54, translated by E. H. Sieveking, M.D. I No. 1365, Pathological series. 212 DISEASES OF CHILDEEX. toneal coat. The outer layer consists entirely of that portion of intestine into which the former two have intruded themselves. Above it is reflected upon the middle layer, with which, in fact, it is there continuous. Its mucous surface is innermost, facing tliat of the middle layer, " The inverted portion is invariably the one that sutfers most ; the inflammation of the entering tube is less considerable, and it is characteristic that, even when the inflam- mation of the volvulus runs high, its mucous membrane remains pale ; the sheath of the volvulus also is but slightly affected in small intussusceptions, with the exception of the peritonitis at the point where it enters."* "The vessels of the portion of intestine thus incarcerated become engorged and render the obstruction complete ; the whole of the folds involved become swollen and deeply congested ; blood is extra vasated into the substance of the mucous membrane as well as into the mesentery ; in a short time both the serous and mucous surfaces become inflamed and the efi"usion of lymph takes place ; the opposed serous surfaces become adherent, and also, to a less degree, the mucous surfaces; bloody serum and mucus are eftused into the canal, and this discharged per rectum is very diagnostic of intussusception. "f The following I consider to have been a typical case of the spasmodic variety, unattended by peritonitis, or actual constric- tion, and terminating in complete recovery. E. S , set. 2 years and 9 months, was first seen by me on January 4th, 1875, at 10 a.m., having been in good health the previous day. She was an intelligent and precocious child. I found her in bed, very flushed and excited, skin hot, but sweating. Temp. 103°, pulse 160, respirations quick and shallow. . She lay with her legs extended, and bore pressure over the abdomen with the hand without complaining. The belly was rather tympanitic, and the bowels constipated ; they had acted scantily on both the two previous days ; there was thirst, but no vomiting. The child was allowed to drink a little milk and iced water at intervals to allay thirst. The abdomen was fomented, and half a grain of calomel ordered every four hours, together with citrate of potash. January 5th (10 a.m.). — The child had been sick once, and the bowels not having acted, her mother used a simple enema of warm water, which returned as injected. She cried out occasionally with * Rokitansky, Path. Anatomy, p. 57. •j- On Diseases of the Alimentary Canal, by S. O. Habershon, M.D., 1857, p. 316. INTUSSUSCEPTION — INVAGINATION, 213 pain, but no distension or tumor can be felt. Has taken two powders, and kept both down. The sixth of a grain of calomel, with one grain of Dover's powder, was ordered every four hours. (7 P.M.). Dozing, and no return of sickness. Having passed no urine, a gum elastic catheter was introduced, and six ounces of clear urine drawn off. 6th — A good deal of tenderness over stomach and neighborhood of nmbilicus, but no vomiting. Eight ounces of warm soap and water were thrown up the bowels, which brought away a little feculent matter. A carminative mixture of rhubarb, aromatic spirit of ammonia, and peppermint-water were substituted, and ordered every four hours in place of the powders. 7th (10 a.m.). — The bowels not having acted, and there being no certainty of obstruction, I gave a lozenge of scammony and gr. ^ of calomel, which had the eftect of causing considerable pain and uneasiness, without producing any evacuation. The child again could not pass urine, and on that account a catheter was intro- duced into the bladder, and seven ounces of clear acid urine drawn off. The finger inserted into the rectum was unstained by fecal matter. I now determined to keep the bowels at perfect rest, and ordered the following mixture : R. T. belladonnpe, ttjJvj Spt. chloroform, ^vij Acid, hj'drocy. dil , fi^vj Syriipi, ......... ,5ss. Aquam ad ^iss. — M. 3ij every four hours. (3.30 P.M.). The child was disposed to be drowsy, and the mus- cular system was much relaxed; great tympanites over stomach, and above line of umbilicus, but nothing marked over either iliac fossa; lips rather dry, and tongue creamy; has kept down milk and water and beef tea during the day. Urine again drawn off, less in quantity and deeper in color, sp. gr. 1020, reaction acid, faint cloud on heat, and nitric acid. (8 p.m.) Mr. Stephens, of Hoddesden, and Dr. Habershon, joined me in consultation. We considered the symptoms due to intussusception, though no cause could be ascertained beyond a sudden change to a more luxurious and mixed diet than the child was accustomed to at home. Rest- lessness and refusal of the bowels to act (notwithstanding the remedies tried) were the chief symptoms. Three grains of the 214 DISEASES OF CHILDEEN. bicarbonate of soda were added to each dose of the mixture. Four ounces of urine drawn off. A copious warm soap-and- water enema was thrown into the rectum, and three or four small scjbalre came away, which could not be detected in the morning. Dr. Habershou thought the belladonna had brought them down. He considered that a portion of the ileum had slipped into the ccecum ; but my first impression was, from the twisting umbili- cal pain, and the absence of any lump or dulness in either iliac region, that the displacement (if any really existed) took place between the lower j^ortion of the jejunum and the upper part of the ileum. The paralysis of the bladder must have arisen from sympathetic irritation. 8th (10 A.M.). — iSo action of the bowels or sickness ; has passed a little urine. At the upper constricted part of the rectum (left sacro-iliac symphysis) I felt something hard protruding through it for about an inch, and between the rectum and bladder at its upper part was an elastic fulness, which I considered to be a distended convolution of small intestine. An O'Beirne's tube, well oiled, was passed up gradually into the descending colon without meet- ing with any resistance. An enema of sixteen ounces of warm soap-and-water, with two ounces of infusion of rhubarb, was then injected, and it speedily returned as thrown up. Shortly after this, a repetition of the enema brought down a mass of feculent matter four inches in length ; and by continuing to wash out the rectum, the fulness much diminished behind the bladder. A warm poul- tice was applied to the abdomen, and the belladonna mixture continued. (10 p.m.) jN^o further action of the bowels ; rectum empty. 9th. — In uneasy sleep, waking up at intervals in pain and dis- comfort ; the tympanites was less over the stomach, and the margins of the ribs could be distinctly seen over the hypochon- dria ; i^ain referred to hypogastrium, but no tumor could be felt ; has passed a little urine ; injection repeated, followed by the escape of a few small scybaUie. Pulv. Ipecac. Co. gr. iss. to be given every four hours, if in pain. 10th. — A few scybalous masses came away after an injection of warm w'ater. 11th. — Rectum empty. Half an ounce of warm linseed oil thrown into the rectum. Has passed water three times since yesterday. INTUSSUSCEPTION — INVAGINATION. 215 12th. — During the latter part of yesterday there were three scanty actions of the bowels, with considerable pain for three or four hours. Twelve ounces of warm soap-and-water were injected, which returned untinged Avith fiBces, An ounce of warm linseed oil was therefore thrown into the bowel. 13th. — The abdomen was more tympanitic, and painful at the lower part. She passed water freely, and there was tenesmus, but no motion ; pulse 112, weak and thready. I thought this increase of pain and swelling might be owing to the bowel, after recovery from the invagination, again slipping down into its old position. A few drops of brandy ordered in a little thin arrowroot every three hours. 14th. — A very slight oozing of fecal matter. 15th. — Bowels moved slightly three times. 16th. — From 10.30 till 12.30 last night she was most uncom- fortable, after which she passed a dark-green liquid motion. At 2 A.M., one copious but less dark motion, at 3 a.m., one of a bright- yellow color, all being attended with pain of a griping twisting character; at 11 a.m. there was a rather lumpy action of the bowels ; at 8.30, 11.30, and 12 p.m. a liquid motion, so that it w^as evident from the quantity that had passed, there must have been accumulation beyond the immediate reach of enemata. 17th. — A soft motion was passed this morning, when the child shrieked out with more pain than she had felt before, and clasped her mother ; the pain was referred to the umbilicus, but only a slight degree of tympanites could be detected in this situation. Though this escape of fecal matter might have been sufficient to irritate the bowels and produce pain, it was possible that a portion of intestine had become iuvaginated or twisted from time to time, or the pain was due to the bowels being thrown into commotion, causing irregular contraction or spasm, by their freer action. Two grains of the Pulv. Ipecac. Co., and the sixth of a grain of calomel, were ordered every two hours if in pain. 18th. — Had seven hours' sleep. Took two powders. 19th. — BoAvels open four times. 20th. — Bowels acted twice — a good night. 21st. — Bowels moved twice. Went to her home in the country. April 10th. — Mr. Stephens reported that the journey home threw the child back a month, and enemata were required every third day, in order to act on the bowels. There were tenderness and 216 DISEASES OF CHILDREN. tympanites, and only small scybalous motions were evacuated. For a long time after her return home the temporal fossae were greatly sunken, and the skin was like vellum from the absorption of fat. January, 1876. — For some three months past the child had been quite well. In this case the degree of constriction was too slight to entirely prevent the passage of the intestinal contents, and the chief danger lay in death from exhaustion rather than from obstruction. The normal vermicular movement of the intestines in these slight cases has the effect of restoring the invaginated gut to its proper place, when rest and aj^propriate measures are adopted. The second variety of intussusception is that which chiefly con- cerns us, by producing very positive and umistakable symptoms, in addition, in some cases, to a defined abdominial tumor, and the partial protrusion of the invaginated intestine (sausage-like in shape) into the rectum, within reach of the surgeon's finger. A mass of coagula may be mistaken for an intussusception, as in a case recorded hy Mr. Morris, in the twentj^-eighth volume of the Path. Soc. Irans., where an intussusception of the ileum ac- tually existed, but this did not involve the large intestine, which was full of clots. In genuine intussusception, it is the upper segment of the bowel that is almost invariably forced into the lower Brinton doubted whether the contrary can ever occur. Ascending intussusception,* however, is spoken of by some writers.! Handfield Jones and Herbert Page describe a case where both varieties coexisted, and " the extremities of the two intussusceptions overlapped each other.":j: The proportion of frequency with respect to age goes to show, that of twelve specimens in children noted in the Museum of the College of Surgeons, two were aged respectively four years, one a year old, and none of the remainder exceeded ten months. The proportions of frequency in the different parts of the canal * In the Museum of tlie College of Surgeons is a specimen of a cat's intestine, willi an ascending or retrograde intussusception close to one of the ordinary variety. t Meigs and Pepper, p. 4G3. X A Case of Intussusception in whicli Abdominial Section was performed, Med. -Cliir. Trans., vol. Ixi. INTUSSUSCEPTIOX — INVAGIXATIOX. 217 which are liable to this displacement are as follows, according to Brintou :* Ileum and csecum into large intestine, 56 per cent. "Half the large class of ileo-cfecal intussusceptions are infants under seven years of age, many but a few months old." " Small intestine invaginated into a lower part of small intes- tine, 32 per cent." Colon intussuscepted into itself, 12 per cent. (According to E.okitansk}'-, however, "Intussusceptions occur with equal fre- quency in the colon and small intestine.") " The rectum scarcely ever forms more than the outer layer of an intussusception which has descended into it from above." Brinton believes that the sloughing-off of an intussusception is not complete on an average before the eighth day, and the liber- ated bowel is not expelled till two days later ; " and as the intus- susception, where primarily fatal, mostly kills in about five days and a half, we may fairly conjecture that the casting loose of the invagination is sometimes only prevented by the death of the pa- tient." (Brinton.) The average duration of the cases directly fatal, appears to be the same in the different varieties, five days and a half. Anatomical Appearances. — There are numerous specimens of in- tussusception at the Museum of the College of Surgeons, showing the direction which the displaced intestine takes. In nearly all cases from the human subject, it is of the descending variety, or in a direction downwards. In infants, the lower end of the ileum suffers most frequently. This is ow'ing partly to the looseness of the attachment of the caecum in the right iliac fossa, and the imperfect development of its muscular coat in early life, which allows the ileum to slip through the valve. Causes. — Intussusception in very young children may arise from many disorders of the alimentary canal, especially diarrhoea ; in- deed, this is a common cause in infants ; even in older children, diarrhcea, muco-enteritis, and dysenteric discharges are capable of originating the complaint. In a large number of cases it cannot be denied that derangement of the functions of the intestinal viscera precedes the displacement, and since it happens so fre- * Intestinal Obstruction, by Wm. Brinton, M.D., F.E.S., edited by T. Buzzard, M.D. 218 DISEASES OF CHILDREN. qnentl}^ to j'oung children, it may be accepted as a certainty, that irregular contraction of these viscera from the ingesta is a common cause of the disorder. " The cause of this abnormal involution appears to be sudden and spasmodic contraction of a portion of in- testine, impelled, onwards into a portion less contracted or alto- gether flaccid. It occurs at all periods of life, but perhaps is more frequent in youth and infancy."* Of 52 Qases tabulated by Dr. Lewis Smith, the health was re- corded before the invagination in 34 ; of these 34, the previous health was good in 17, and deranged in 17 ; the previous health in most of the 17 consisted of diarrhoea or dysentery, or diarrhoea alternating with constipation ; others had threadworms, obscure abdominal pains, nausea, and vomiting. One child had symptoms of invagination at ten weeks old, which passed off.f The male sex is most liable to the complaint, and of 34 cases, 23 were boys. (Lewis Smith.) The liability of young children to the disorder is in a great measure due to the delicate structure of the walls of the intestines, which are imperfectly developed in infancy, and to unsteadiness in their movements. It is not proved that intussusception is due to congenital laxity of the mesoccTecum or mesocolon. Among the exciting causes, blows and contusions of the abdo- men have produced diarrhoea and constipation, followed by in- vagination ; violent fits of screaming, and straining at stool have induced the complaint. Tossing the child up in the arms suddenly with a jerk, and then bringing it quicklj^ to the ground, may cause intussusception. (Rilliet and Barthez.) The simple form of intussusception is usually situated in the small intestines, and very rarely in the colon ; m the more aggra- vated form the ileum is general!}' invaginated into the colon. The latter is, as Brinton has shown, the most frequent. The bowels may act as many as four or five times a day, and the child die notwithstanding, and after death the invaginated intes- tine may be from one to two feet long. The bowels may remain pervious for weeks, and then death ensue. Sy)apioms. — These vary in severity according to the age of the child and the cause which may have produced it, but griping par- * Haberslion, op. cit., p. 318. t Lewis Smith, op. cit., 1869, p. 420. INTUSSUSCEPTION — INVAGINATION. 219 oxysmal pain, pallor, faintness, and constipation, are common in most cases, increasing after a few days when enteritis is estab- lished. At first, as in the case of simple invagination related, pressure is borne by the hand, and the little patient may have com- fortable snatches of sleep ; but if the invagination continues, the symptoms assume a more aggravated form, and inflammation, marked by great abdominal pain, vomiting, and tenesmus, arises in the displaced portion of intestine. If the child is very young, convulsions may supervene,^" and even if this complication does not arise, the child soon loses flesh, the face is pinched and hag- gard, and the eyes dark and sunken. Vomiting is a frequent symp- tom, and cases are rare where it is not present ; at first the con- tents of the stomach are simply rejected, and afterwards the ejecta are grass-green, and ultimately become stercoraceous, as in the well-known vomiting in cases of strangulated hernia. After a day or two, the bowels generally cease to act, and a few more scanty evacuations will not in these cases prove that the bowels are not obstructed, for the excrementitious matters may issue from below the seat of obstruction. These scanty motions are generally tinged with blood, including much mucus, and are very characteristic. But as Mr. Marsh has pithily remarked in regard to the case of a young child in his own experience, "intussusception, even though it involves a considerable length of intestine, does not necessarily produce any symptoms beyond those that commonly attend slight catarrhal enteritis. The development of symptoms depends upon the degree of constriction. In this respect an intussusception is like a hernia, which may be ' down ' without being strangulated or even obstructed. And to say that vomiting, constipation, and the discharge of blood and niucus or serum from the bowel are the symptoms of invagination is inexact, in the same sense, in which it would be to say that vomiting and constipation are symp- toms of hernia. "f A solid cylindrical tumor may generally be detected by careful examination. It is most frequently found in the right iliac or hypogastric regions, sometimes it can be felt by passing the finger * Dr. Habershon records a case of intussusception where convulsions and insensi- bility followed constipation, vomiting, and pain in the abdomen, in a boy six years of age. Notwithstanding that he passed the cfecum, together with the vermiform process and ascending colon, in a motion, he completely recovered. — Op. cit., p. 337. t A Case in which Abdominal Section was performed for Intussusception, St. Earth. Hosp. Eep., vol. xii. 220 DISEASES OF CHILDREN. up the rectum, but it may be obscured by tympanites due to the enteritis which it produces. When it can no longer be distin- guished after having once been detected, it may have shifted, but more frequently it has sloughed off. Diagnosis. — In endeavoring to form a right conclusion as to the cause of the symptoms of obstruction, we must not hastily infer that they arise from intussusception. " I admitted into St. George's Hospital, some years ago, a little child who had many of the sj-mptoms of intussusception, — obstinate constipation, straining to go to stool, occasional vomiting, and, it was said, a bloody dis- charge from the anus occasionally ; and in whom there was also to be felt a kind of oblong tumor, somewhat tender to the touch, at one part of the abdomen. All this rather pointed to intussus- ception, but the course of the disease convinced me that the cause of the obstruction was really (as I believe it \eYj often is) limited peritonitis, producing adhesion or impaction of neighboring coils of intestine."* It may be impossible to distinguish the vomiting, feeble pulse, tympanites, and worn look from local enteritis or in- ternal strangulation, but when mucus and blood are passed per anum, it greatly assists the diagnosis. " The sudden onset of the pain, and its subsidence, becoming aggravated in paroxysms, is an indication of this form of obstrnction."f The symptoms often commence insidiously, and are so puzzling that the ripest judg- ment may be deceived. It may be mistaken for enteritis, but the historj'- should come to our assistance, the temperature and febrile excitement are not so great, and the colicky pain is more parox- ysmal and severe. " In contrast to simple colic the spasm is more regular in its recurrence, there is less sensation of twisting and grinding, and more of a continued paroxysm, caused by the violent and energetic action of the muscular fibre to overcome the ob- struction ; the large coils of intestine may sometimes be felt rolling and turning over in the abdomen during its continuance.":]: " The movements and throes of intestinal obstruction, added to the pain and intense constitutional reaction of enteritis, form, in the earlier stages of intussusception, a concurrence of sjnnptoms 60 characteristic of this state as often hardly to require the detec- tion of the swelling produced by the invaginated bowel." (Brinton ) * IIolmeK's Surgical Treatment of Children's Diseases, 1868, p. 509. t Ilabershon, op. cit., p. 318. X Medical Diagnosis, by Dr. Barclay, ISoO, p. 4(30. INTUSSUSCEPTIOIS^ — INVAGINATION. 221 Let it also be borne in mind that in forming a diagnosis we should recollect that hardened and impacted feeces, typhlitis, haemorrhage, dysentery, peritonitis, and cholera infantum may all be mistaken for the condition we are describing ; and that the symptoms belonging to each of these states must be carefully ob- served and compared, for the diagnosis is not unattended with difficulty. When the obstruction is high up in the intestinal tube the urinary secretion is more scanty than when it is situated lower down; but this symptom cannot be much relied on. "Still less reliance is to be placed on the allegation that vomiting comes on earlier, and is more distressing when the obstruction is high up. . . . . "We incline to believe the cause of the obstruction to be invagination if a little bloody mucus be passed by stool, if a sudden pain were felt before vomiting had been experienced, and when constipation had not been known to exist."* Intussusception may end fatally in a few days, or terminate in recovery in three weeks. In infants the disease is ahiiost invari- ably fatal. Intussusception of tbe small intestine is readily distinguished from the ileo cfecal and colic forms. Small intestine alone involved. Ileo-CEecal form and colic form. 1. Little or no tenesmus. 1. Much tenesmus. 2. Much hfemorrhage by stool and vomit. 2. Simple blood-staining of motions. 3. Symptoms of obstruction very early. 3. Obstruction late or absent. 4. Tumor small and movable. 4. Tumor large, more fixed, easy to feel. 5. Invagination not felt per rectum. 6. Invngination often detected per rectum. Sloughing and expulsion of the intussusception is most frequent when the small intestine alone is involved. Recovery too is far more frequent in that variety than in ileo-ctecal or colic intussus- ceptions. Treatment. — This is medical^ mechanical., and operative. Tlie symptoms in many cases at the onset are too obscure to indicate with anything approaching certainty the lesion w^e have to en- counter. Mucous discharges from the bowel, vomiting, tenesmus, and the escape of blood are not conclusive signs. Even diarrhoea and intestinal derangement, which more properly belong to an irritated rather than to a displaced intestine, may be present in cases of intussusception. * Barclay, op. cit., p. 463. 222 DISEASES OF CHILDREN. Whenever sj-mptoms of obstruction of the bowels present them- selves in a young child, Ave should not overlook the possibility of intussusception. ^Vhen the seizure is sudden, and displacement is considered no longer doubtful, we may adopt remedies with some chance of success. If there be a tumor in the abdomen with localized tenderness, two or three leeches may be applied over the spot. If there be no sickness at the beginning, and constipation be the chief feature of the complaint, a dose of castor oil may be neces- sary, and warm-water enemata ; but if these should fail to move the bowels it is no longer advisable to continue them, but to sub- stitute in their places remedies of a soothing and sedative charac- ter. The intestines may be kept at rest by opium in small and repeated doses, and fomentations to the abdomen may be used, or a warm bath. The opium will often alia}' the distressing sickness which is present, and iced water, ice to suck, or hj'drocyanic acid will all be useful. Sometimes a small mustard poultice to the pit of the stomach will stop the sickness. The chief aim of the medical treatment consists in the most absolute repose and the simplest diet, that the intestines may be kept free from commotion, and bulky matters, the refuse of diges- tion, may not enter them. Under this plan the bowels have, after many days, often gradually righted themselves. The mechanical treatment consists in the forcible injection of copious enemata of warm water, soap-aud-water, or thin gruel. This simple measure is often successful, for where the intussus- ception takes place between the ileum and crecum (as it frequently does), the fluid may pai^s beyond the valve into the ileum, and overcome the resistance. Another plan is to pour warm water through a funnel at a varying height, according to the force required. A piece of india-rubber tubing, about two yards long, is attached by one extremity to the funnel, and by the other to a tube, which is inserted into the rectum. I have recorded a very interesting case, successfully treated in this manner.* Inflation by means of air has been used successfully since the time of Hii^pocrates, and it is doubtful whether, in these modern times, it is practiced as often as it ought to be ; for when it has * Intestinal Obstruction in a Child : Treatment by Belladonna and Gradual Injec- tion of Warm Water poured into the Rectum tlirough a Funnel and India-rubber Tub- ing; Recovery. By W. li. Day, M.D., Brit. Med. Journ., May 31st, 1879. INTUSSUSCEPTION — INA^AGINATION. 223 been employed in children, many cases are recorded where the resistance has been overcome. A pair of ordinary bellows may be used, the nozzle introduced into the rectum, and the inflation proceeded vi'ith till the obstruction yields. The surgical treatment consists in performing the operation of gastrotomy, when all other measures have proved unavailing. The circumstances of each particular case must be carefully weighed — the urgency of the symptoms, and the strength of the patient ; the probability of inflamniation, and the prospect of alighting on the seat of mischief. From what we have learned of late years respect- ing the tolerance of the peritoneum to local injury, and with what impunity it may be liandled without exciting inflammation, there is reason to think that the lives of many children might have been saved if the operation had not been too long delayed. Many writers, however, are of opinion that this treatment is attended with too much risk to justify the step, because there is diificulty in ascertaining the seat of obstruction, and even if found, the operation is attended with extreme danger. If a tumor can be felt in the left iliac fossa, where the intussusception frequently is located, there is a fair chance of localizing the constriction, and the operator has not to search at all parts of the intestinal tube. Besides, the distance to which enemata travel may aid the diag- nosis. It seems certain that if the operation holds out any chance of success, it should not be delayed over three or four days when the symptoms are severe ; because the invaginated bowel may inflame and contract adhesions with the surrounding parts. " Only three cases collected by Haven, in which gastrotomy was per- formed, terminated favorably."* The two following are examples of gastrotomy, one fatal, and one successful. Case 1. — Mr. Hutchinson has described an interesting case of a child six months old on whom he operated. The child was under the care of Dr. Madge, and had been ill four days when he saw it, with painful straining and the passage of bloody mucus. " The invaginated part could be easily felt in the left flank by manipula- tion through the abdominal wall, and also by the finger introduced into the rectum." (An infant sister died a year previously of the same lesion.) The intussusception had begun in the csecum, and at the post-mortem next day there was universal peritonitis, and * Meigs and Pepper, op. cit , p. 477. 224 DISEASES OF CHILDEEX. tbe cfficum was attacbed by a long mesentery. Mr. Hutchinson considered that the caecum had been loose congenitally.* Case 2. — Mr. Iloward Marsbf has described an interesting and successful case of gastrotomj. The child (a male infant seven months old) was seized, fourteen days before he saw him, with diarrhoea, sickness, and occasional grijijing pains in the abdomen. The case was considered by the medical attendants, Dr. Miller and Dr. Barnes, of Eye, in Suffolk, to be due to catarrhal enteritis, and natural evacuations followed small doses of castor oil emul- sion. In two or three days griping and sickness returned, and there were in addition tenesmus and a quantity of slimy mucus mixed with blood. The child remained in much the same condi- tion till twelve hours before the consultation (April 11th, 1875), when the pain and tenesmus were violent, and he became pale and restless. On examination a firm cylindrical and sausage-shaped tumor was felt in the abdomen, " extending from the umbilicus to the left iliac fossa," and two inches of the bowel protruded from the anus, with the ileo-caecal valve at the extremity. In- sufflation and warm-water enemata failed to reduce the invagina- tion. The child was placed under chloroform, and the abdomen having been opened, the entering portion of the gut was carefully pulled out, when it was found that the invaginated intestine "included at least half the colon, and an equal portion of the small intestine." After the operation small doses of laudanum were given, and the child drank freely of milk and water. The sickness ceased at on e and two days after the operation a fecu- lent motion was passed. The wound had nearly healed eighty- four hours after the operation, and a few days later the child recovered. Nine months after the child was in good health. This case is one which testifies to the importance of an operation when the sj'mptoms are severe ; and shows that the possibility of strangulation or inflammation being present, should not prevent the operation, when the case holds out no other hope of success. In cases which appear most formidable before the operation, the in- vagination having been restored, improvement may at once set in, proving that the circulation through the bowel has not been interfered with. * Med.-Chir. Trans., vol. lix*, 1876, p. 100, Abdominal Section for Intussusception into Colon. t Ibid., p. 81, A Cane in vvhicli Abdominal Section was successfully performed for Intussusception in an Infant seven months old. DISEASES OF THE LIVEE. 225 CHAPTER XX. DISEASES OF THE LIVER. Congestion of the Livek: Nature — Causes — Si/mptoms and treatment. Adhesive Inflammation of the Livek — Hepatitis — Intekstitial Hepatitis— Hob- nailed Liver — Cirrhosis — Chronic Atrophy: Symptoms — Causes— Diagnosis — Morbid anatomy— Treatment. Syphilitic Disease of the Liver— Albu- minoid Enlargement. Congestion of the liver is not unfrequent in children. It is manifested by constipated bowels and clay-colored evacuations ; the appetite is poor, the complexion sallow, and the tongue coated ; the conjunctivae have a yellowish tint, and the urine is high- colored and turbid on standing. There is a sense of weight and fulness about the region of the liver, and its edge may sometimes be felt below the ribs on the right side. This is a state of active congestion. It should be remarked that in making an examination of the liver we shall find it proportionately larger in early life than in adult life, and that what would be considered an enlarged area of hepatic dulness in the latter would not necessarily be so in the former. " In the adult the average weight of the liver is one-fortieth that of the entire body, whereas previous to puberty it may be as much as one-thirtieth or even one-twentieth."* The liver varies in health as to size, and there is more blood in it at one time than at another. " For instance, the amount of blood in the liver and its size are greatly influenced by diet, both being temporarily increased after a meal, and particularly when the food has been too large in quantity, or has contained an excess of fatty, sac- charine, or alcoholic ingredients. "f The pathology or nature of the change consists in a uniform enlargement of the liver, which is also darker in color, from con- taining more blood than it does normally. The congestion may affect chiefly the hepatic or portal vein ; the lobules have in the first case a light border, and in the second a dark border. The congestion, therefore, is spoken of as intralobular and interlobular. The causes are overfeeding and inattention to the rules of * Lectures on Diseases of the Liver, by Dr. Murchison, 1877, p. 7. t Ibid., p. 131. 15 226 DISEASES OF CHILDEEX. health. Rich and stimulating food in large quantities, especially if children are confined indoors, and do not get sufficient exer- cise ; or cold after a heavy meal ma}" induce it. Organic disease of the valves of the heart, as mitral regurgitation, and more or less distension of the right cavities, will, b}- inducing a mechani- cal obstacle to the return of blood through the veins, set n^) passive congestion. Under these circumstances the liver is habitually congested, and it grows larger, at least for a time. " The pressure exerted by the constantly distended hepatic veins causes atrophy of the central portions of the lobules, and induces a form of granular liver, ditferent from true cirrhosis, where the atrophy commences at the circumference of the lobules."* An enlarged liver may sometimes occur in connection with chronic disease of the lungs. In two cases of emphysema of the lungs, in children under ray care, the liver was enlarged in both ; it may be present in ascites, and sometimes produces it ; it occurs in mesenteric disease, and in rickety suljjeots, where the head is large, the teeth decayed, and the limbs small. The symptoms are a dragging pain or tightness below the right ribs, but, as some children will bear pressure without complaining, the physical signs denoting enlargement of the liver are mostly to be relied on for diagnosis. In a large number of cases pain is altogether absent. There is now and then some degree of jaun- dice present, but this is more often seen in adults than in children; the liver may be felt an inch below the ribs, and the motions may be deficient in bile when the skin is perfectly clear. Simple con- gestion of the liver, therefore, in children is not usually attended with jaundice. The urine is scanty, and on standing ma}'- throw down copious urates, though it is sometimes perfectly clear and natural. The general signs are headache, nausea, loss of appetite, furred tongue, flatulence, and even vomiting. There may be diarrhoea and irritation of the bowels, languor and drowsiness. The liver may remain large after jaundice for a long time, and pain of a dragging character ensue, with dyspeptic symptoms, headache, and lassitude. As the circulation is relieved and the turgid capillaries are unloaded, the jaundiced hue, which is not necessarily present, passes oft'. Treatment. — We must first aim at the removal of the cause. When congestion of the liver happens to young children from * Lectures on Diseases of tlie Liver, by Dr. Murcliison, 1877, p. 132. DISEASES OF THE LIVEE. 227 overfefeding and inattention to the rules of health, care and atten- tion to diet will soon cure the complaint. In the shape of medi- cine a mild mercurial, followed by a saline aperient, will excite a watery discharge from the mucous membrane of the bowels, and brii]g away some bilious motions. A warm bath at bedtime for a few nights is an admirable remedy, and if there is pain or weight over the region of the liver, a hot poultice will be beneficial. The perchloride of mercury with tincture of bark is often useful, and the nitrohydrochloric acid and taraxacum (Form. 42) where there is debility and dislike to food. When the congestion is due to disease of the thoracic viscera an occasional calomel purge, fol- lowed by a saline aperient is equally available, and the diet will require to be regulated. A small dose of calomel stimulates the upper bowel and duodenum, and drives the bile along the' intes- tines. Small doses of ipecacuanha are also useful by increasing the action of the liver and skin. When children are sleepless and irritable, bromide of potassium is useful if the liver is congested, and the urine high-colored and scanty. In similar cases, the chloride of ammonium, w^hich acts on the skin and kidneys, is an excellent remedy, though rather too nauseous for children. Later on, w^hen the urine is clear, and there is debility, the syrup of the iodide of iron, nux vomica, or arsenic, are suitable remedies. Adhesive Inflammation of the Liver. — The liver may be enlarged from interstitial hepatitis or adhesive inflammation, and attain a large size, stretching above to the nipple, and below to the navel. In an early stage it has been known to extend to the pubes, and the spleen to be enlarged at the same time. In cirrhosis the liver is at first increased in size in consequence of an infiltration of small round cells into the areolar tissue of the portal canals, and the increase of the organ depends upon the extent of the cell proliferation. After a time, as this cellular tissue fibrillates and contracts, the liver diminishes in size, the portal veins are compressed, and the passage of blood is impeded ; the vascularity of the liver is lessened, indeed some of the branches of the portal vein are entirely obliterated, hence atrophy and shrinking of portions of the liver. The small gall-ducts undergo compression in the same way as the branches of the portal vein. Wilks and Moxon consider that in many cases there is no proof of 228 DISEASES OF CHILDREN. lymph being thrown out as in active inflammation, and that the whole change is chronic* An interesting case of cirrhosis in a child is recorded by Dr. Arthur Fox,t accompanied with jaundice, heematemesis, and coma. After death the liver was found unusuall}^ large, the capsule thick- ened, and the surface finely granular. " The glands in the portal fissure were much enlarged and deeply pigmented. The spleen was enormously gorged with blood and somewhat friable." The kidneys were congested but otherwise normal. The intense jaun- dice was attributed to the pressure of the enlarged glands on the bile-duct. There was no history of hereditary syphilis, but his mother had been a chronic drinker for years. Dr. Fox considers that cirrhosis in children may be one of the consequences of alco- holic heredity, though it may occur independent of it as a grave general disease. Dr. Murchison relates a case of interstitial hepatitis in a child twelve years of age, coming on from a chill, and ending in cirrhotic contraction and death. The disease set in slowly, followed by severe abdominal pain and deep jaundice. The liver extended nearl}^ to the pubes, and the spleen was enlarged. Death was preceded by diarrhoea, with haemorrhage, offensive breath, rapid pulse, fever, delirium, irregular breathing, and coma. A post- mortem examination revealed a small rounded liver (16 ounces\ the tissue being firm and the surface irregular and puckered ; capsule thickened ; spleen enlarged.:}: Causes. — Spirit drinking is the most common cause of cirrhosis in the adult. When taken up by the bloodvessels of the stomach, alcohol is at once conveyed to the liver. Murchison relates a case in a boy, nine years of age, who drank "a good deal of wine and water between meals." Paracentesis was twice performed. He died from prostration and collapse, After death the liver was found tough and hob-nailed, and weighed 21| ounces. § A torpid and sluggish liver, hereditary syphilis, cold and chills, and the want of regular exercise have given rise to the disease in children. According to Dr. Budd, the small miliary tubercles found in * Pathological Anatomy, 1875, p. 447. f "Case of cirriiOKis in a boy aged eleven years; jaundice of nearly tliree years' duration."— jBnl Med. Journ., Dec. 21st, 1878, p. 913. X Lecture on Diseases of the Liver, by Dr. Murchison, 1877, p. 632. ^ Op. cit., p. 302. DISEASES OF THE LIVER. 229 the liver of persons dying of phthisis never cause adhesive inflam- mation of the organ, which, as he sajs, is remarkable, seeing the tendency they have to set up inflammation in the ditfereut tissues of the lung." Diagnosis. — This is not very easy in children who exceptionally indulge in alcohol. A sallow hue of the skin, or even jaundice; thirst, dry tongue, furred or reddish ; scanty and high-colored urine ; costive bowels, with a defi.ciency of bile in the motions ; pain in the hepatic region, and tenderness on pressure are to be looked for. Ascites is often present to a considerable degree. There is sometimes epistaxis, or hfemorrhage from the bowels. Morbid Anatomy. — The liver is much reduced in size, and of a yellowish color, resembling beeswax. Fibrous tissue of a tough character is diffused through the organ and around the vessels. As it contracts, the parenchyma is squeezed into a coarse nodular appearance ; the capsule is thickened ; the walls of the portal vein are also thickened, and its calibre is diminished. The hepatic cells are destroyed, or in a state of fatty degeneration. Treatment. — Diet is important. It should consist of milk, eggs, white fish, farinaceous food, and poultry. At an early stage, wdien the liver is congested and tender, the application of two or three leeches may be necessary, or a linseed poultice frequentl}'^ renewed. Small doses of hyd. c. creta with rhubarb are serviceable, and a saline aperient to unload the portal circulation, and keep the bowels freely open, will relieve the symptoms greatly. If there is loss of appetite the compound infusion of gentian, taraxacum, and dilute nitric acid may be given. When ascites threatens, diuretics, such as the acetate of potash in decoction of broom, should be tried, and if they fail, hydragogue purgatives, as the compound jalap powder, are indicated. When ascites is present to a degree which embarrasses the respiration and causes pain, recourse must be had to paracentesis. If there is a syphilitic history, mercury and iodide of potassium may be demanded. Syphilitic diseases of the liver is another form of hepatic enlarge- ment. The lesions of this organ seen in hereditary syphilis usually consist in hardening and hypertrophy, so that it creaks as the knife passes through it. "On a uniform yellowish ground a more or less close layer of small white opaque grains is seen, having the appearance of grains of semola, with some delicate arborescences * Diseases of the Liver, 1852, p. 129. 230 DISEASES OF CHILDREN. formed of empty bloodvessels. On pressure no blood is forced out, but only a slightly yellow serum, which is derived from the albu- men."* The change may be limited to the right or the left lobe of the liver. The capillary vessels are obliterated, and the dimen- sions of the larger vessels reduced. The microscope shows the morbid appearances to be due to the presence of a fibro-plastic material. These changes may be developed during intrauterine life. The symptoms are not very definite ; there may be vomit- ing, diarrhoea, or constipation, but never any jaundice. Death takes place early. Fatal peritonitis, it has been said, may be the consequence of the hepatitis being followed bj^ the extension of inflammation from the peritoneal covering of the liver. There is a case recorded by Dr. Goodhart,f in which the liver and spleen were very large in an infant two months old. The evi- dence of congenital syphilis was doubtful, but a care was effected by one grain of gray powder, given night and morning, followed by the syrup of the iodide of iron. Frerichs speaks of three forms of syphilitic disease of the liver : 1. Simple interstitial hepatitis ; 2. Hepatitis gummosa ; 3. Waxy, amyloid or lardaceous degeneration of the liver. All three forms may be found in the same liver, or may exist independently.:]: There is albuminoid enlargement of the liver, in which albumin- ous matter is infiltrated through the organ. It is commonly met with in rickety children. The organ is paler, harder, and more elastic than natural, and the connective tissue around the portal vessels is increased. A similar state of the liver is found in con- genital syphilis. ( Wilks and Moxon.) * Diday on Infantile Syphilis, New Syd. Soc, 1859, p. 92. t Enlargement of the liver and spleen ; the hepatic swelling quickly subsiding under medical treatment. — Brit. Med. Journ., vol. ii, 1878, p. 438. X Diseases of the Liver, New Syd. Soc. Trans., 1861, vol. ii, p. 152. ICTERUS OR JAUNDICE. 231 CHAPTER XXL ICTEKUS OR JAUNDICE. Definition and Symptoms: Causes — Cold and bad atmosphere — The entrance of bile into the blood from distension of the bile-ducts, and retention of bile within the liver — Fecal accumulation pressing on the liver — Treatment : Icterus neonatorum — • Acute Yellow Atrophy of the Liver. By the term jaundice we imderstatid a yellowish color of the in- tegument, caused, bj the entrance of bile into the blood ; this, with yellow conjunctivae and urine, and the whitish or pipeclay appearance of the fseces, distinguish it from every other disease. The sym'ptoms of jaundice in children often commence with sick- ness and vomiting of food ; there may be severe frontal headache, languor, and lassitude ; the child can make no exertion to do any- thing ; there is loss of appetite, and sometimes pain over the re- gion of the liver, though this may be absent even when the organ is considerablj' enlarged. Pain, indeed, is a rare symptom in the jaundice of children, and when present in the jaundice of adults, it probably indicates distension of the bile-ducts from the passage of a gall-stone. The surface of the body and conj unctivse generally assuiiie a yellow appearance, and the extremities are sometimes much more affected than the back. The temperature is normal, and the pulse slow, except there is acute pain over the liver from the amount of congestion present, and then there is dryness of the skin and febrile disturbance. The urine is generally of a dark Madeira color, from the ad- mixture of bile, and it stains linen yellow. Casts of the urinary tubules have been observed in it. In very severe cases the sweat and saliva are also yellow, and objects appear yellow to the eye. The bowels are usually constipated, and the motions pale like pipe- clay. Sometimes there is diarrhoea, and the stools are colorless, if the bile-duct is completely obstructed. In cases where the consti- tution is bad, petechise may appear on the skin, and there may even be haemorrhage from the mucous surfaces. According to Wickham Legg, the tint of jaundice has been observed by several authorities in the mouth before it has been apparent elsewhere.* Causes. — Jaundice results in infants and very young children * St. Bart. Hosp. Eept., vol. xiii, p. 12. 232 DISEASES OF CHILDREN. from a bad atmosphere and cold, so that the skin and organs of respiration do not perfectly perform their functions. The disease is most common in the feeble and delicate. As the skin takes on its proper functions, and cold is guarded against, the jaundice dis- appears in a few dnjs, provided nothing is given in the shape of food except breast-milk. A grain of Tlyd. c. Greta, followed by a dose of castor oil or some other laxative, complete the treatment. Jaundice may, however, arise from enlargement and inflamma- tion of the liver or umbilical veins, or from obstruction or inflam- mation of the bile-ducts, or even absence of the gall-bladder. It has been attributed to spasmodic closure of the ducts, but whether this can produce it or not, we know that the essential or true cause is a retention of the Ijile within the liver, and the transuda- tion of the bi'e through the capillaries and bile-ducts into the cir- culating blood. Jaundice may arise from congestion of the liver ; the secretion of bile is diminished because the sorsred state of the bloodvessels presses upon the gall-ducts, and does not allow the bile to pass freely through them. " In young persons, and in per. sons in whom the liver is healthy and its capsule thin, it will necessarily enlarge much more for a given force of distension than in persons in opposite circumstances."* The liver is enlarged and of a deep-red color in the central parts, whilst the margins are pale. Jaundice in older children, as in adults, is most common in sum- mer and autumn, and in some cases is accompanied with dlarrhfjea. Nausea and sickness, headache, loss of appetite, drowsiness, and restless nights are common symptoms. I attended a severe case of jaundice in a young lad some years ago, which came on after ex- citement and running some distance immediately after a heavy meal. Jaundice has arisen from round Avorms entering the orifice of the bile-duct and causing biliary colic, vomiting, and all the sj'mp- torns of gall-stones f A similar case is also on record.:]; Dr. Budd mentions the fact that several cases of jaundice, in quick succes- sion, have come to his knowledge in children of the same family, or in several persons living in the same locality. He attributes it to some poison (probably miasm) which arrests the secretion of the * Budd on tlie Liver, 1852, p. 50. f Miircliison, op. cit., p. 345. J Brit. Med. Journ., vol. ii, 1878, p. 877. ICTEEUS OR JAUNDICE. 233 liver owing to some change in the blood.* Probably the liver was imperfectly developed. Some persons have small livers, just as others have small hearts. The diagnosis from cerebral disease consists in the absence of febrile disturbance — no heat of head or intolerance of light — the vomiting is less, and the pulse is slow rather than frequent. There is often tenderness over the region of the liver, the motions are pale, and the urine high-colored. The treatment of jaundice is that of biliary congestion. If there is pain or great tenderness over the liver a leech or two may be applied there or at the anus, followed by a warm linseed poultice. Two grains of Hyd. c. Creta, or even a grain of calomel should be given at bedtinie to a child seven or eight years old, followed by sulphate of magnesia during the day, or the nitromuriatic acid mixture, with taraxacum (Form. 42). It is important to keep the bowels open and to give a farinaceous diet chiefly. Milk in soda- water is nutritious and refreshing. If there is thirst, barley-^vater, with a little cream of tartar in it, will be useful. Bicarbonate of soda and tartaric acid given in full doses whilst eflfervescing will relieve sickness and keep up a gentle action of the bowels. If the liver remains sluggish and painful, a lotion of nitric acid applied at bedtime under oiled silk is a good application. It causes red- ness and tingling of the skin, and when this happens it should be omitted till the erythema has passed away before it is reapplied. f Emetics repeated daily are in favor with some practitioners, es- pecially when the jaundice is due to catarrh of the bile-ducts. Icterus neonatorum is not a disease of the liver, as its name seems to impl}^, but is merely caused by the changes in the color of the skin during the first few days of life. In infants after birth the skin is much congested ; this gradually declines till a rosy tint is reached in the course of a few days. It sometimes happens in children otherwise well, that the skin, after the first two or three days of life, assumes a yellowish-orange tint, which popularly goes by the name of jaundice, the urine and motions being in all re- spects natural. The complaint is caused by the blood in the skin * Diseases of the Liver, 1852, p. 273. f Formula 44 : B:- Acid. nit. dil., 5j Aquam rosse ad . . 5xx Fiat Lotio. 234 DISEASES OF CHILD REX. changing into a yellowisli tint before tlie normal color is reached. The conjunctivae in these cases remain clear, and the urine con- tains no trace of bile-pigment. The disorder is, therefore, in most cases, a mere cutaneous discoloration. This simple form of icterus has been shown to be frequently due to deficient oxygenation of the blood, but " icterus neonatorum " may also represent a very grave condition, viz., obstruction of the bile-duct* from congenital stricture, or from inspissated bile, or the jaundice may have a py<"emic origin from phlebitis of the umbilical vein, as Dr. Murchison has shown (op. cit., p. 347). A male infant, seven weeks' old, was sent to me by Mr. Butler, of Guildford, on April 8th, 1879, suftering from severe jaundice. On the third day after birth, he became very yellow, but took Swiss milk well, and was also suckled by a wet-nurse. The child was well nourished, and had not wasted, though the mother said he seemed less plump than at birth. The color of the integument was of a deep yellow on the face and thorax, and of a lighter hue below the nmbilicus, scrotum, and buttocks. The conjunctivae presented a yellowish-green tint, varying from time to time in intensity. Both the liver and spleen were enlarged. There was a good deal of tympanites, but the child could retain his food ; there was no vomiting, the faeces were relaxed, and although nearly always clay colored, a trace of bile had been seen in the motions ; the urine was of a pale-saffron color. The history of the case favored the supposition that the jaundice might be caused by absence, obstruction, or malformation of the gall-bladder or bile- ducts. He was ordered to be fed on milk and lime-water, and as the diagnosis could at best be only doubtful, a powder containing a grain of Hydr. cum Greta and bicarbonate of soda, was ordered, occasionally at bedtime, and a mixture containing the solution of carbonate of magnesia and taraxacum during the day. Mr. Butler informed me, six months later, that the child had died, and a post-mortem examination had been made by Mr. Bisshopp, of Tunbridge Wells, on August 23d, 1879. A good deal * Mr. Glaister has described a most interesting case of fatal ^'icterus neowitorum," ■where the common bile-duct was found to be constricted, " a few lines from its duodenal insertion," and the left hepatic duct "seemed to split up into fibrous threads." The mother had borne seven cliildren before, six of whom had sliown similar symptoms, four out of tliese six cases ending fatally. Both parents were troubled with frequent liepatic symptoms. — Lancet, vol. i, 1879, pp. 293, 330. ICTERUS OR JAUNDICE. - 235 of ascitic fluid was found in the abdominal cavity of a deep-yellow color, wliicli appeared due, not to any inflammation of the peri- toneum itself, but to the dense, hard, contracted state of the liver, from chronic inflammatory changes, which had obstructed the hepatic circulation precisely in the manner seen in cirrhosis. The gall-bladder contained a glairy white fluid, but no bile. The hepatic, cystic, and common bile-ducts were all absent. The ana- tomical malformation had caused the incurable jaundice, the chronic inflammation of the liver and dropsy, and finally the general wasting and death. Acute yellow atrophy of the liver {suppressed secretion of bile — fatal Jaundice) has been met with in 3'oung subjects, but it is very rare in children. "Out of 25,700 cases admitted into the London Fever Hospital in nine years, there was only one case of this disease."* It is supposed to consist in inflammation of the organ, which leads to suppression of bile, and degeneration of structure. In this curious disease the liver quickly undergoes degeneration, after a few daj's of indisposition, and hepatic derangement. The premonitory symptoms are nausea, furred tongue, diarrha3a, or constipation, slight pyrexia ; there may be rheumatic pains and cardiac distress. Jaundice is alwaj- s present, but bile is to be seen in the stools, and there is no obstruction in the bile-ducts. The severe symptoms are owing to biliary suppression, and the accu- mulation of bile products in the blood. The skin becomes hot and dry, the pulse quick, vomiting of cofltee-grounds matters follows, with haemorrhage from the bowels. Sometimes there is epistaxis, and the bowels are constipated ; the urine is of a dark-brown color, like porter, and contains bile, tyrosin, leucin, etc. As the disease proceeds, delirium and coma (sometimes convulsions) come on, the motions are dark from the presence of blood, the skin is of a deeper jaundice hue, and petechial spots of ecchymosis occur in diflerent parts of the body. In the case of a boy, aged seventeen, described by the late Mr. Harry Leach, there had been " slight icterus for fourteen days, pain across the epigastrium, anorexia, and frequent vomiting." These symptoms were followed by stupor, debility, intense jaundice, pain over the liver, which was enlarged, cofi:ee-grounds vomiting, convulsions, frantic delirium, loud screaming, and death. The pulse was weak and irregular, the respiration slow, the heart * Murchison, op. cit., p. 257. 236 DISEASES OF CHILDEEX. thumping. The ho\yel5 were constipated, the urine (which was of the color of porter/ required to be drawn off with a catheter. It contained tyrosin, a Large quautitj' of urea, phosphates, and chlo- rides, but no albumen. The sp. gr. was 1035. A post-mortem examination revealed congestion of both lungs ; the spleen weighed 4f oz., both kidneys lOi^ oz., and were granular and fatty; the liver weighed 31| oz. — it was soft, pale, and Habby ; the inferior aspect was of a dark-greenish hue from the accumulation of bile in the independent portions. The biliary vesicle and ducts were empty and shrunken. The portal vein was free.* This form of jaundice, ending in coma, occurred to four mem- bers of the same family ; in the case of two of them, being brothers of the respective ages of 11 and 13 years, it terminated fatally.f Causes. — Syphilis, and irregular habits in youth, predispose to the disease. According to Freriehs, hypersemia and diffuse in- flammation of the liver are excitino; causes. Diagnosis. — The disease resembles yellow fever, but is to be distinguished from it by the shrinking of the liver, and the pres- ence of leucin in the urine. Morbid Anatomy. — -The liver is shrunk and shrivelled, and the division into lobules is not discernible ; it may shrink to one-half its size in the course of a week or ten days, " it is soft and flabby, and of a light-yellow color, or brownish-yellow, or crimson orange, or some kindred tint.";}; It may be enlarged at an early stage, but this is of short dura- tion, and is soon followed by a dimii;ution in its bulk. The hepatic cells disappear, leaving only granular matter and oil, the biliarj^ ducts are pervious, the gall-bladder is empty, the spleen is congested and enlarged. Treatment. — This is almost hopeless. At an early stage cupping or leeching over the liver may be of service ; an emetic, followed by a full dose of calomel, appear to be the remedies which in a few cases have been attended by recovery. Dr. Budd reconmicnds sulphate and carbonate of magnesia, with small doses of sal volatile. * Brit. Med. Jour., 1878, vol. ii, p. 877. t Budd, op. cit., p. 2G9. X Ibid., p. 270. PAINLESS ENLAllGEMENTS OF THE LIVER. 237 CHAPTER XXII. PAINLESS ENLARGEMENTS OF THE LIVER. Hydatids of the Liver : Pathology — Symptoms — Causes — Diagnosis — Termination and Treatment. Lardaceoub ok. Amyloid Disease. Fatty Livek. Simple Hypertkophy' of Liver. Hydatid tumors of the liver, most common during the middle period of life, are rarely found in childhood or old age. I have seen a large hydatid cyst extending downwards to the umbilicus, and across to the splenic region, in a girl eight years of age ; and cases are recorded of its occurrence in children considerably younger. A membranous sac or cyst forms in the liver, containing a color- 'less limpid fluid like water. In the fluid a variable number of cysts or bladders facephalocysts) are found, varying in size "from a millet-seed to a goose's egg." Hundreds or even thousands of these acephalocysts may be detected in a single parent cyst, to the walls of which the scolices of the echinococcus adhere. The sac or cyst is formed by the tissue of the liver, and is of variable thick- ness, being thicker in tumors of old than of recent standing. Hydatid tumors grow very slowly, and are generally painless, at least when of small size, and they are rarely accompanied by dropsy or jaundice. This latter symptom will depend upon whether the common bile-duct undergoes compression from being sur- rounded by enlarged lymphatic glands, or is otherwise obstructed by some swelling of the liver, when there may be continued or remittent jaundice.* A case is also recorded by Dr. Gayley, in Avhich a patient had repeated attacks of hepatic pain with jaun- dice. The hydatids came away per anum, and the health remained good.f Hydatid tumors may be large enough to fill the greater part of the abdominal cavity, or to reach upwards into the chest nearly to the clavicle ; they may not exceed the size of an orange, and when deeply seated they may escape observation altogether.^ When they can be felt they are perfectly smooth, and they have an elastic or fluctuating feel. Occasionally the so-called hydatid fremitus may be felt. If several cysts exist, the surface of the liver may be irregular or lobulated. * Path. Trans., vol. xxv, p. 156. f Path. Soc, Oct. 20th, 1874.. X Diseases of the Liver, by C. Murchison, M.D., 1877, p. 55. 238 DISEASES OF CHILDEEX. Ascites is au occasional consequence of pressure and interfer- ence with the circulation through the liver, but a case is on record where the portal fissure was much pressed upon without producing this result.* In some cases there is oedema of the lower limbs from pressure on the vena cava, and albumen has been detected in the urine from the tumor compressing the renal vein. In very exceptional instances, secondary hydatid cysts have been found in the spleen and kidnej-. Causes. — The adult tssnia ecchinococcus inhabits the intestines of the dog ; the ova are voided in the fseces of the animal, and being swallowed with the food and drink, find their way to the liver, lung, or some other organ, and there become encysted. Diagnosis. — When a tumor occupying the region of the liver is smooth and globular, and there is fluctuation with an absence of pain, fever, and jaundice, and the general health moreover remains good, we should .suspect the existence of echinococci. The possibility of abscess or ovarian cyst, and especially pleuritic effusion, should be remembered, but these conditions could scarcely be confounded with a hydatid C3'st,if care be taken before coming to a conclusion. Termination. — The contents of a hydatid tumor maj' ultimately dry up, and the sac become obliterated, or it may burst spontane- ously through the walls of the abdomen, or into the bronchi, intestine, or stomach, and the patient recover. The cyst may suppurate and induce pyasmia and gangrenous abscess of the liver, or it may burst into the pleura and produce fatal empyema. f When it bursts into the lung, the patient spits up a hydatid from time to time, and as the disease proceeds and the orifice in the pulmonary tissue becomes larger, several hydatids may be coughed up at one time. The symptoms attending this pulmonarj' com- plication are frequent straining cough, constant expectoration of a sanguineous or purulent character, and a disgusting taste in the mouth from the admixture of bile.| The most dangerous conse- quence is the liability of the sac under gradual growth and dis- tension to ulcerate and rupture into the peritoneum, and there set up fatal inflammation. The tumor, too, may continue to increase in size, causing such compression of the hepatic structure, and * Clin. Trans., 1878, p. 236. t Miirchison, op. cit., p. 120-123. t Budd, op. cit., p. 4-44. PAI^•LESS ENLARGEMENTS OF THE LIVER. 239 disturbing the functions of adjacent organs by its growth, till it wears the child out by pain and exhaustion. Treatment. — Up to the present time, drugs have proved useless. "When the tumor is large, it should be tapped with a fine explora- tory trocar, or aspirator, and the fluid drawn off. The with- drawal of a small quantity of fluid by the hypodermic syringe, as a means of diagnosis, has been sometimes followed by complete atro})hy of the cyst. The cases most likely to end in cure are those which have a thin cyst-wall, and where the vesicles are few in nundjer, or the acephalocyst is solitary. Several successful cases are related by Budd,* and Dr. Murchisonf gives a table of eighty cases in which a cure followed the operation of puncture. Moreover, inflammation and suppuration may be set up iu the sac by puncture, and recovery even then may ensue ; or the hyda- tid may slowly exhaust the patient's strength, as we sometimes see in opening a large chronic abscess. Even the simple process of puncture is not free from danger, as there is a risk of the irri- tating fluid escaping into the abdominal cavity and provoking inflammation. Several fatal cases are recorded from puncture, death occurring in a few hours, faintness, rigors, vomiting of bilious matter, pain in the abdomen, and coldness of the extremi- ties preceding death. Sometimes peritonitis has ensued, followed by a slow recover3^:{: A case is related by Mr. Bryant, where agonizing pain, lividity, unconsciousness, and sudden death fol- lowed the tapping of a hydatid cyst, and the result of the post- mortem examination seemed to show that the portal vein had been transfixed by the trocar, and that the hydatid fluid, being sucked into it, acted as a fatal poison.^ Injections into the cyst have been tried, those containing iodine or carbolic acid being generally selected. Iodide of potassium given internally, and iodine ointment rubbed in over the enlarged liver, have severally been employed without success. Lardaceous or amyloid disease of the liver — scrofidous enlargement of the liver (Budd) — is a disease which belongs to the weak and cachectic. In this peculiar degeneration of the liver, waxy and fatty matter is infiltrated throughout it, and in many instances a * Budd, op. cit., p. 448. t Miirchison, Clinical Lectures on Diseases of the Liver, 1877, p. 77. X Frericlis on Diseases of the Liver, New Syd. See, vol. ii, p. 251. ? Clin. Trans., 1878, p. 236. 240 DISEASES OF CHILDREN". similar extension of the disorder can be traced into the different tissues, as the lymphatic glands, bloodvessels, spleen, and renal organs. Pathology. — The liver is greatly enlarged and thickened ; it may be some\vhat paler than usual from a deficiency of blood, or at other times scarcely altered from its normal appearance. In some cases it presents a white appearance on section, and the lobules are either obliterated altogether, or they are scarcely to be dis- tinguished. This " waxy " or albuminous matter never becomes hard, or shows any tendency to contract like lymph, which is the product of inflammation ; it is destitute of cells or organization. The surface of the liver is smooth, wliite and glistening, even when the disease is of long standing. " These circumstances," saj'S Dr. Budd,* " explain the fact that the foreign matter, though large in araou'ut, does not much impede either the passage of the blood through the liver or the escape of the bile through the ducts." The lobules become of a faint reddish color and enlarged, the gland structure is uniform and smooth, and on section resembles " smoked salmon." This peculiar deposit may occur in isolated portions of the liver, or it may be scattered throughout the entire organ. It is first deposited within the lobules, and between the secreting cells, which are diminished in number. A similar con- dition of the spleen often accompanies this degeneration. Micro- scopically oil-globules can be seen in abundance when the fatty matter is examined, but the great increase in the size of the liver is owing to the infiltration of this peculiar morbid matter stretching the capsule and obliterating the appearance of the lobules. "It first atifects the minute vessels, especially the arteries, and extends to the capillaries, afterwards invading the proper elements of the texture implicated. "f Syphilis and scrofulous disease of the bones, especially when accompanied by chronic suppuration, are its usual casual relations. Caries of long standing appears to be a common cause. " Out of eighty-three cases of lardaceous dis- ease, seventy-three were in connection with either suppuration or syphilis, leaving bat ten cases which were not ostensibly accounted for by these agents.":]; The general symptoms are those indicative of anaemia, gradual * Diseases of Liver, 1852, p. 318. t Pathological Anatomy, by Wilks and Moxon, 1875, p. 640. % Discussion on Lardaceous Disease, Path. Soc., March 18ih, 1879. PAINLESS ENLARGEMENTS OF THE LlVEr.. 241 wasting and cachexia. It comes on so slowly that if it were not for the increased size of the abdomen, no notice would Ije taken of it ; there is occasional yellowishness of the conjunctiva and a little tenderness over the liver. After a time there is languor and loss of appetite, gastro-intestinal derangement, and sometimes vomiting and diarrhoea, with pale stools. Fever of an irregular type is common, attended with cough, dyspnoea, and quick pulse; the urine is often of low specific gravity from the presence of albumen, which is a consequence of the kidnej'S ]iartici[)ating in the waxy degeneration, and the drain of albumen may be so great as to destroy life. The presence of waxy casts in the urine is a guide to diagnosis. In addition to these symptoms we frequently meet with enlarge- ment of the submaxillary and cervical glands. The disease may terminate in peritonitis, pneumonia, or tubercular disease of the lungs ; but more frequently it ends in exhaustion, ascites, or general anasarca. In a case mentioned by Portal of a boy, aged 8, who died from the disease, the bronchial and mesenteric glands were found enlarged, " and filled with a substance like plaster," and a slice of the liver exposed to heat became hardened like albumen* In another case, related by Abercrombie, of a boy, aged 11 years, there was found after death, extensive disease of the mesenteric glands, the lungs were tuberculous, and there was a chain of enlarged glands extending from the bifurcation of the trachea to the diaphragm ; some contained pus, others were of cartilaginous hardness, whilst in some there were calcareous particles.f There is little to be hoped from treatment beyond attention to the general health, warm clothing, nourishing diet, chloride of ammonium, preparations of iron, cod-liver oil, and pure air. "When there is disease of the joints the surgeon's aid may be required, and if the complaint has a syphilitic origin, it will demand special remedies. Dr. Budd gives as his experience that he has met with more than one instance where recovery took place, the peculiar morbid matter passing oft* with the bile, or becoming absorbed. Fatty Liver. — This form of enlarged liver arises from the accumu- lation of oil within its substance. The organ increases uniformly * Budd on the Liver, 1852, p. 304. f Ibid., p. 305. 16 242 DISEASES OF CHILDREN. in size in every direction ; it is smootli on its surface, of doughy consistence, and on examination, after deatli, it is found to be pale in color. No matter how severe the disease may be, the secretion of bile is not interfered with, therefore jaundice, in uncomplicated cases, does not occur ; the superficial veins of the abdomen ave not enlarged, and there is no ascites. Symptoms. — These are ansemia and debility, languor, lassitude, flatulence, irregular bowels, and depression of spirits. The skin is bloodless, and has a sallow or waxy appearance, resembling fine polished ivory, or a common wax model. Most of the constitu- tional symptoms are " often due for the most part to fatty degener- ation of other organs, and more especially of the heart."* The spleen is rarely enlarged, and the complaint appears to arise chiefly in connection with phthisis, or some other wasting disorder. Treatment. — This consists in attention to the digestive organs by alkalies, vegetable bitters, and aperients. The waters of Ems, Vichy, and Schwalbach are to be recommended. AVhen an?emia is the leading feature, the preparations of iron, especially the ferri et ammonite citras will be found serviceable. The treatment, how- ever, resolves itself into that which the primary aftection requires. A simple hypertrophy of the liver has occasionally been met with in diabetes. CHAPTER XXIII. DISEASES OP THE SPLEEN. Symptoms: Pain in left hypochondrium — Cough — Dyspnoea — Salloumess of complexion — Increased size of the abdomen — May lead to cirrhosis and enlarged superficial veins over abdomen. Pathology — Causes: Ague — Typhoid fever — Diseases of liver — 06- structive disease of the heart — Emphysema of the lungs — Tuberctdosis — Syphilis — Ance- mia. Diagnosis: Oenerally easy on account of thinness of abdominal walls — Not to be mistaken for enlarged liver, kidney, or mesenteric glands. Treatment; Attention to the general health — Fomentations — Poultices and leeches in the acute stage — Mild mercurials in syphilitic cases — Quinine and arsenic if traceable to ague — Chalybeates in anaemia. Affections of the spleen in children have been in my own per- sonal experience almost exclusively confined to the lower classes, and even among them they are not of frequent occurrence. f " We ^" Dise.xses of the Liver, by C. Miirchison, M.D., 1877, p. 49. t " 00 cases of deatli returned as due to spleen diseases in England, among male sub- jects, wliicii occurred in 1877, only 9 were under five years of age ; and of 07 females, DISEASES OF THE SPLEEN. 243 sometimes meet with splenic disease in children in this country, and more especially in dispensarj^ and hospital practice, where poor and insufficient food, bad ventilation, and humid houses have ex- erted a predisposing eifect."* They may be described as those of enlargement and hj^'pertrophy, arising chiefly from congestion and inflammation. The elastic structure of the spleen renders it susceptible of dis- tension from slight causes, and hence any afl:ection of the liver or arrested skin action may increase its bulk. If these disorders con- tinue, the spleen fails after a time to propel the blood onward, and, from such arrest, permanent congestion and enlargement fol- low ; and sometimes inflammation and abscess. There is no organ so variable in size and consistence as the spleen. "It is much smaller in elderly than in young people — indeed, it may waste away in old age to a pale relic of not more than two or three drachms in weight. "f In amyloid or lardaceous degeneration, the Malpighian cor- puscles may alone be afiected. The spleen is enlarged, and its density is increased. On section, clear waxlike little bodies, of variable size, having the appearance of boiled sago, are to be seen in the.-e corpuscles, hence the disease is known as the " sago spleen," which is frequently seen in those children who die of phthisis. There is another variety of the amyloid spleen in which the pulp is chiefly involved. It appears to be an advanced condition of the former afiection, the disease extending from the corpuscles to the pulpy parenchyma.:}: The general symptoms are not well marked, but if the spleen has attained any considerable size, there is usually some amount of pain or tenderness, or distension in the left hypochondriac region, or over the epigastrium, extending through to the back; and there may be cough or dyspnoea on lying down ; but these are only occasional symptoms. The child is sallow and pale ; the tongue is bloodless and clean ; the pulse is weak and frequent, and only 12 were under five years of age. Under fifteen years of age it is extremely rare. In London, in the year 1877, of 8 cases of death in males, 3 were under five years of age ; and of 10 cases of females, 2 were under five years of age." — Fortieth Annual Re- port of the Registrar-Oeneral, pp. 152-158. * Reynolds's System of Medidine, vol. v, p. 178, article. Diseases of the Spleen, by J. E. Warden, M.D., F.R.C.P. t Pathological Anatomy, by Wilks and Moxon, 1875, p. 473. X Pathology and Morbid Anatomy, by T. H. Green, M.D., 1871, p. 69. 244 DISEASES OF CHILDREN. tliere is loss of flesh and strengtli. The nrine often contains urates, and the motions are offensive, deficient in bile, or they are loose and contain mucus. Sometimes they are constipated. In some cases there is scarcelj^ any inconvenience bej'ond that caused by the increased size of the abdomen from the splenic tumor, the appetite and digestion being excellent. In two cases that came under my notice, although the tumor reached below the umbilicus in one case, and nearly filled the abdomen in the other, there were no noticeable symptoms beyond the inconvenience of a bulky mass in the abdomen. The complexion was sallow in both cases, but there was no headache, no fever, no pain in the side, or shoulder, which is often mentioned by writers.* In other instances pain is com- plained of on pressure over the splenic region ; the child lies on the left side with its knees drawn up, and is restless and sleepless at night. As splenic disease progresses, and the blood becomes more impoverished, an anaemic bruit may be heard over the base of the heart. There may be swelling of the abdomen terminating in ascites ; but this is very rare, owing to the thick capsule of the spleen not admitting of the exudation of any fluid, as happens in some affections of the liver and intestines. The spleen, being out of the way of the portal circulation, has no direct tendency to cause ascites ; but when there is cirrhosis, or any mechanical im- pediment to the venous circulation in the liver, the spleen may become enlarged. When the spleen has attained a very large size, the superficial veins become distended, in consequence of an inter- ference with the circulation through the deeper abdominal vessels. In very long-standing cases of splenic disease, the patient becomes anaemic, from a deficiency of red corpuscles in the blood, and an excess of the white. In one disease of the spleen there is an excess of white corpuscles in the blood (leukpemia) over the red, just as there is in disease of the lymphatic glands, and there is associated with it at the same time a new growth of lymphatic tissue in the spleen. Hence the tendency to pallor, to 03dema of the limbs, to * " The shoulder-tip pain and the nerve tenderness in these diseases are owing, as I believe they are in liver diseases, to an extension of irritation or inflammation from the diseased organ along its pneumogastric twigs to the trunk of the par vagiira. In a case in which the morbid state of the spleen has been intense, and continued for a time, this irritation or inflammation passes up the trunk of the nerve to the base, and even to the origin of the par vagum, and tiie two divisions of the spinal accessory, giving rise to pains tliere, and other distin-bances." — On the Symmetry of the Pancreas and Spleen, by D. Emljleton, M.D., Brit. Med. Journ., vol. ii, 1874, p. 371. DISEASES OF THE SPLEEX. 245 haemorrhage from the gums or nasal passages, as the consequence of these changes in the circulatino- blood. Under a continuance of these symptoms the child sinks from exhaustion, or death is often due to diarrhoea. Pathology, — As we are unacquainted with the functions of the spleen, we are in doubt concerning the theory of the morbid changes to which it is liable. Its turgidity, probably, depends upon some relaxation of the vessels and tissues of which it is com- posed, as well as to a nerve paresis. The fact of the spleen having been removed from the body without impairing the rest of the functions would go far to substantiate the view that it has no inlluence upon the secretions of the stomach or pancreas. Still, Michael Foster writes as follows : " After a meal the spleen in- creases in size, reaching- its maximum about iive hours after the taking of food ; it remains swollen for some time, and then re- turns to its normal bulk."* " It is a point of considerable interest that the spleen, the lym- phatic glands, and Pe^'cr's patches all suffer involution at the same period of life — about fifty. At that time the spleen grows smaller, the Ijmiphatic glands waste, and Peyer's patches smooth down and lose their peculiar structure ; and that is about the period of life at which the diseases, and especially tj'phoid fever, in which these three parts are involved, cease to be common. "t Some interesting observations are mentioned by Swedenborg.:]: Causes. — Enlargement of the spleen is frequently due to ague, and hence mostly prevails in marshy districts along with inter- mittent fever. Louis, Murchison, Warburton Begbie, and many other observers have noticed it diseased in tj^phoid fever. Disease of the liver, as cirrhosis, or whatever obstructs the circulation of the spleen, maj^ increase its bulk. "It is often greatly enlarged in European children who are resident in the tropics."§ This is most likely a state of mere hyperaemia, but long-continued congestion ultimately leads to enlargement and induration. Obstructive dis- ease of the heart, emphj-sema of the lungs, by causing dilatation of the right cavities of the heart, and acute tuberculosis may in- * A Textbook of Physiology, 1878, p. 346. f Clinical Lectures on the Diagnosis of Extra-pelvic Tumors of the Abdomen, by Sir W. Jenner, Bart., M.D., Brit. Med. Jour., 1869, vol. i, p. 113. X On the Functions of the Spleen, ibid., \). 403. ^ Reynolds's System of Medicine, article, Diseases of the Spleen, by J. E. Wardell, M.D., F.E.C.P., vol. V, p. 141. / 246 DISEASES OF CHILDEEX. diice congestion of the spleen. In the latter affection I have seen a few caseous deposits of considerable size both in this organ and the liver, when the lungs have been studded with similar tubercles and the diaphragm honeycombed.* An enlarged spleen, associated with rickets, came under my care in April, 1880, in the case of a child a year old, the spleen reaching to the ilium below, and on its inner border to the umbilicus. Althousrh mechanical conges- tion may be one cause of the hypertrophy, it more frequently arises from some morbid condition of the blood, from endocarditis, giving rise to infarctions,-}- from syphilis,:}: from fevers,§ from anaemia, II but in many instances it undergoes enlargement without assignable cause. On section it is soft, vascular, and of a dark-red color. A healthy woman and her husband had six children, three of whom had disease of the spleen. One child, a boy, was noticed to have a large spleen when fifteen months old, and he lived to be nine years and a half old. Epistaxis began at the age of five years, and continued to recur periodically about once a month. A second child (whom I saw in August, 1880), ten years of age, bled from the nose in the same way, and quite as profusely. "f A third child, a girl one year old, had an enlarged spleen, extending to the ilium and umbilicus. It had only been detected five weeks. All these children were ravenous for food. The spleen has also been found hypertrophied in some cases of leucocyth?emia {splenic leucocythce- mia), and in this afiection it attains a great size. Dr. Taylor has recorded the case of a boy, twelve years of age, who died from this disease, and whose spleen was found to weigh 51 ounces.** Diagnosis. — As the abdominal wall in children is not covered with much fat, and the muscles are thin, the diagnosis of enlarged spleen is far easier in them than in adults. Some care, however, * " Tubercle occurs, for the most part, in the spleen only in acute universal tubercu- losis ; it occurs more frequently in children than in adults, in the proportion of 40 to 13. It appears both in the form of gray granulations, yellow miliary tubercles, or yellowish cheesy masses, of the size of a pea and above." — Jones and Sieveking's Path. Anat., by Payne, 1875, p. 657. f Vide Chap. LI, On Ulcerative Endocarditis. X Vide Chap. L, On Syphilis. ? Vide Chap. VII, On Fevers. II Vide Chap. LI, On Annemia. ^ "In nearly all affections of the spleen nasal haemorrhage is a common symptom, and among ancient physicians, and to tliis day among the people, repeated bleeding of the nose, especially if from tlie left nostril, is taken for an almost pathognomonic symptom of such disease." — Nievieyer's Textbook of Practical Medicine, 1875, vol. i, p. 293. ** Path. Trans., vol. xxv, p. 253. DISEASES OF THE SPLEEN. 247 is necessary not to mistake for an enlarged spleen an abdominal tumor caused by enlargement of the kidney or liver, or by disease of the mesenteric glands. In forming an opinion of tumors in this situation, it is well to glance at the anatomical position of the spleen. It lies hidden in the left hypochondrium under cover of the ribs, between them and the stomach. When healthy it cannot be felt through the abdominal parieles; if it can it is diseased. Moreover, it is influenced by the respiratory movements. An enlarged spleen may extend inwards to the epigastrium and umbilicus. In some children it reaches down to the spine of the ilium. The tumor is smooth, elastic, and firm, and, being situated just beneath the integument, its shape and firmness can generally be well ascertained. In cases of difficult diagnosis the history of asfue would be of much assistance. Sir W. Jenner has seen a tumor, supposed to be fecal, which turned out to be "a big spleen, and the child was purged for it till it had bloody stools."* Tu- mors which are due to enlargement of the kidney do not cause any projection posteriorly ; the expansion takes place in the direc- tion in which they meet with the least resistance, and that is always in front, f Treatment — The general health will. require careful attention to maintain it at the best possible standard. In this we must be guided according to the circumstances and surroundings of each individual case, the strength of the child, the stage at which the disease has arrived, and the complications it may have produced. If inflammatory symptoms are present, and there is any degree of acute pain, thirst, dyspnoea, etc., poultices and fomentations, and even two or three leeches, applied over the affected part, may be necessary to reduce congestion of the gland. If the skin is hot and dry, and there is any degree of fever, saline aperients (Form. 8-41) to unload the bowels and drain the portal system will be needed. When all acute symptoms have departed, the use of iodine externall}^, in the shape of ointment (Ung. lodi.), and the iodide of potassium internally may be demanded. Very frequently a cachectic state of the system exists, arising from ague, syphilis, or rickets, and these conditions must be met by suitable remedies, such as arsenic, mild mercurials, quinine, etc., continued for a long * Clinical Lectures on the Diagnosis of Extra-pelvic Tumors of the Abdoruen, Brit. Med. Journ., 1869, vol. ii, p. 43. f See Chap. XXIV, Hydronephrosis. 248 DISEASES OF CHILDEEX. time. ]Mr. Tyson, of Folkestone, has recorded a " Case of Syphi- litic Enlarged Spleen in a Child." At two years of age, the spleen reached to the crest of the ilium, and nearly to the umbilicus. A grain of gray powder was given night and morning, and one grain of iodide of potassium with ten minims of the sj'rup of iodide of iron, three times a day. In three months the spleen was smaller, and two months later it only extended an inch below the maro;in of the ribs. The remedies were given for about a year, when the spleen was imperceptible, and the child's health excellent.* In a large number of cases, an8smia is so marked, and the consti- tution so reduced, that the patients lose Hesh, and gradually sink away exhausted. Chalybeates are of course indicated. CHAPTER XXIY. DISEASES OF THE KID>:ETS AXD URI^TARY ORGAXS. Theories of the urinary secretion — Remarks on the urine — Congestion of the kidneys (active and passive) — Temporary and intermittent albuminuria — Treatment of congestion. AcrxE Desquamative Nephritis : Local and constitutional symptoms — State of urine and appearances under the microscope — Scarlet fever the most frequent cause. Pathology: Morbid anatomy. Progi^osiS: Case of acute desquamative nephritis from cold and exposure, terminating in chronic albuminuria. Treatment : Value of small doses of perchloride of mercury and perchloride of iron in the congestive stage. TnE renal affections of children are less frequent than manj^ of the ailments to which early life is liable, but there hangs about them an obscurity which, in a physiological point of view, is per- plexing, and in a clinical one, difficult to reconcile with our knowl- edge of disease, and of the active functions which the kidneys possess when health is continuously maintained. In order to understand the disorders to which the kidney is liable, it is well to glance at the renal apparatus in health, and to see how the ditlerent structures are concerned in the elimination of morlud elements from the blood. Beale and Johnson say the water is first eliminated from the blood, and the urine salts are gradually added as the water pa.sses * Tlie Lancet, 1880, vol. ii, p. 653. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 249 down the tubules. Ludwig, Brunton, and others, entertain the view that the water of the blood, holding the different salts in solution, is first squeezed out in a very diluted form, and that the absorption of water goes on through the epithelial lining of the tubules, the urine thus becoming more concentrated as it passes down the tubules. The former assert that the function of the epithelial cells of the tubules is to excrete urine salts, while the latter assert that their true function is to absorb w^ater. There are two facts which stand in a very significant relation to these views : one, that after copious draughts of water the epithe- lial cells do not exert themselves in absorbing water freely, and so the urine is copious and of low specific gravity, while during thirst the epithelial cells absorb w^ater more a'ctively, and the urine is scanty and contains excess of salts. The other fact is that in cirrhosis of the kidney, where the tubules are denuded of epithe- lium, the urine is copious and of low specific gravity. The importance of this subject practically, is the question as to whether the urine, when first squeezed into the glomeruli, is albu- ndnous or not. According to the view of Ludwig and others, it is primarily albuminous in a faint degree, and the albumen is reab- sorbed along with much of the water by the epithelial cells of the tubules. According to the other view, albumen is thrown out along with the urine salts in disease of the urinary tubules. The question has not yet been settled, but the view of Ludwig seems more feasible, and consistent with the known fact, that albumen appears in the urine when the tubules are diseased. On the assumption that the epithelial cells normally reabsorb albumen as well as water, w^e can readily understand how, in cer- tain conditions, albumen is present in the urine. When the tubules are the subject of inflammation, they lose their power to reabsorb albumen, consequently albuminuria is constantly found in tuljular nephritis, as we see commonly after scarlet fever. AVe can there- fore understand how temporary derangement of the epithelial lining of the tubules may he followed by the appearance of albumen in the water. Such a condition may exist without the kidneys being necessarily organically diseased. In cases of albuminuria, then, the question arises, whether the passage of albumen in the water is due to conditions of temporary derangement, or to struc- tural disease of the kidneys. Li the treatment of sick children, a constant observation of the 250 DISEASES OF CHILDREX. urine is as important as in the management of disease in adult life. At all ages morbid conditions affect the secretion of the kidneys, and childhood is no exception to this rule. Even when not on the sick-bed, the insidious effects of errors of diet, and other bad habits, are first shown in alterations of the amount of daily excre- tion of urine, and in changes in its constituents. Intemperance, the chief vice of man, directly affects the kidne3's, so that the reveller longs to make water after a banquet. Gluttony, and the preference for rich, rather than wholesome food, are the com- monest failings in childhood. Hence the turbid urine passed by children subject to gastric and intestinal irritation through over- indulgence in sweets and pastry. Ignorance of the evil effects of draughts of cold air, and wet feet, renders children liable to catar- rhal affections, which produce changes in the urine. For some obscure reason, calculus is not rare among boys in the humbler ranks of society, possibly because their skin and lungs are hardened against chill, whilst during customary exposure to cold their kidneys become congested; on the other hand, children of gentle breeding, have often weaker lungs, but through efficient clothing they are less liable to contraction of the bloodvessels of the skin, and to consequent increased pressure on the kidneys. Lastly, it is in childhood that reflex and emotional influences act so strongly on the renal secretion. The phenomena of enuresis, and of loss of control over the bladder, from the very fear of that accident, are almost peculiar to childhood in civilized lands, where the adult, even among the lowliest, learns self-control, or through experience, adopts precautions. An antiquated, coarse expres- sion, common to most countries, shows that in former less refined states of society the involuntary escape of urine, as the result of fear, was not rare in adults. It is physiologically most interest- ing to observe, on the other hand, the great delicacy of even very young well-bred children in this country with regard to micturi- tion. A gentleman taking his little girl out for a walk, is often astonished to find that when the child shows sj'mptoms of desire to pass water she cannot be persuaded to do so in the 0[)en air, and indeed feels much hurt at any attempt at persuasion of a kind which previously she has only heard from her nurse or mother. An infant is often assisted in micturition by being hummed to, or coaxed, a practice very similar to the method em- DISEASES OF THE KIDNEYS AND UEINAEY ORGANS. 2^1 ployed by a rider when he desires his horse to stale at a moment convenient to himself. Since very slight disturbances produce feverishness in childhood, and since high temperature involves the excretion of concentrated urine, that fluid will almost always be found to be ahove the normal specific gravity in a children's ward, its acid reaction is likewise well marked under these circumstances. In fever among children, the thick and almost milky urine, turbid when passed, not merely turbid when cool, is highly characteristic. The turbidity is dis- solved but slowly on boiling in a test-tube, for it is due to the urate of soda, insoluble in cold, and only Sjiaringly soluble in hot water. In many febrile diseases, however, children pass clear urine, which on cooling throws down the well-known deposit so readily redissolved on boiling in a test-tube. In this deposit the more soluble urate of ammonia predominates. The urine of a child sufiering from acute scarlatinal nephritis is very rich in morbid products. It is smoky, or almost brothlike, from the presence of altered blood, and throws down a deposit rich in epithelial casts, and in the beautiful light-yellow rhomboidal crystals of uric acid. Such urine must be carefully examined day after day, and its gradual return to a normal condition will be a valuable guide to the treatment of the case. Phosphates are often found in the urine of nervous and sick children, and in such cases the fluid may be copious and below the normal specific gravity ; oxalates may also be found in pale abundantly excreted urine. Mucus is frequently deposited in the urine of children suffering from paraplegia, from spina-bifida, or from local causes, such as calculus, and is an unfavorable symptom, since it may denote seri- ous changes in the genito-urinary tract ; the presence of pus is due to the same causes as in adults. In cases of enuresis the condition of the urine must be carefully examined ; when a morbid salt is discovered the administration of a drug which counteracts its for- mation often cures the patient, as the presence of such a salt in the bladder may alone cause the complaint. That attention which is now paid to the urine in adults when ill has not extended as far as it should do to the examination of urine in children. With the exception of the albuminuria of scarlet fever the profession as a body knows little of these modifications of the urine produced by disease in children. There seems to ex- ist a widespread impression that changes in this secretion are only 252 DISEASES OF CHILDREN. important in adult and advanced life, an impression which, to my mind, is erroneous and ill-founded. In the present state of our knowledge we are not able to draw any satisfactory inferences from the specific gravity of the urine in children. I found that in 242 cases admitted into the Samar- itan Hospital under my care, the highest specific gravity reached, was 1034, in four cases. 1. Epileptoid seizures; 2. Congestive headache ; 3. Tuberculosis ; 4. Catarrh. In all these four cases the urine was pale, scanty, and very acid. The lowest specific gravity was 1006, in a boy six years of age, on the fifth day of typhoid fever, when it became pale, clear, and alkaline. After taking small doses of hydrochloric acid for five days, the reaction became acid, and the specific gravitj^ reached 1018. The urine was never turbid, nor threw down a deposit, notwithstanding that the temperature reached 103.6°. In states of debility, and in some cases of mitral disease, the specific gravity fell to 1010. The average specific gravity of the whole 242 eases was 1023, and instances of this were furnished in anaemia, debility, pleurodj'uia, rickets, phthisis and headache. In only 32 was the specific gravity under 1020 ; 57 had a specific gravity of 1030, or over. In 38 there w^ere phosphates. In none was sugar found. In three cases only were there large "cayenne pepper crystals," and these were in: 1. A case of tuberculosis, where the urine w^as highly acid, pale, and scanty. 2, Lobular pneumonia. 3. Chronic albuminuria. A girl sufiering from chronic mitral disease became very nervous, and afterwards her urine threw down a o-reat deal of uric acid. There was only one case of chronic albuminuria in the whole 242 cases, and this occurred in a strumous girl, nine years of age. The specific gravity varied from 1016 to 1020, and the microscope showed irregular-sided granular casts, some uric acid, epithelial cells, and broken-down blood-corpuscles. Congestion of the kidneys is one of the most important disorders to which these organs are liable. It is a common attendant on many ailments of children, passing away with the recovery of the patient, and leaving neither inconvenience nor structural change behind it. In measles and scarlatina, as well as in many inflammatory dis- eases, there is a determination of blood to the internal organs, and active congestion of the kidneys is of frequent occurrence. In measles it is often slight; it is notably more marked in some cases DIFEASES OF THE KIDNEYS AXD URIXAEY ORGANS. 253 of scarlet fever, and there is a considerable amount of blood with casts of the uriniferous tubes and epithelial cells, so that the urine is albuniinons. This is a point I shall more particularly consider when I come to speak of a state of congestion of the kidney, brought on, not by the scarlatinal poison, but by exposure, bad living, impure air, and the strumous habit. The passive form of congestion, as in adults, is most common in mitral regui-gitation, and other valvular diseases of the heart; in emphysema, pneumonic conditions, pleuritic eifusion, or disease of the liver, pressing on the vena cava. This form of venous con- gestion is owing to an impediment through the systemic veins. The i^assage of blood through the kidney is slow, and congestion takes place, the urine is scanty and high-colored or turbid, and more or less impregnated with albumen. In obstructive disease of the heart, the fulness of the venous system distends the renal veins, and the Malpighian capillaries becoming engorged, a transu- dation of serum takes place through their walls, rendering the urine albuminous. When the walls of the capillaries are ruptured from this overdistension, blood is mixed with the urine, and blood casts are visible. The first efi'ect of passive congestion is to cause enlargement of the gland, and ultimately contraction and atrophy, the surface of the kidney becoming uneven, and finely granular as the wasting process goes on. (Johnson.) The treatment consists in relieving the circulation by hydragogue cathartics, absolute rest, and tapping of the chest or abdomen, if there is a lar2;e accumulation of fiuid, and it cannot be o:ot rid of in anj^ other way. Experimental research has long demonstrated the fact, that a ligature placed round the renal vein, obstructing the return of blood, causes the kidney to increase in volume, and the urine to contain albumen, casts of the uriniferous tubes, and renal epithe- lium. Hence the liability, in inflammatory disorders, and checked cutaneous action, for the kidneys to become congested, like other organs, and so to create a disturbance in the intricate and nicely adapted circulation through the Malpighian tufts, and plexus of capillaries, which surround the uriniferous tubes. Some cases of intermittent albaminuria are due to congestion of the renal vessels, or to loss of tone in them. An interesting case of this kind is alluded to by Dr. Morley Rooke, of Cheltenham. 254 DISEASES OF CHILDREIf. There were no renal products under the microscope, the albumen disappearing with rest, but returning when the patient assumed a vertical position.* In children, as in adults, the injudicious use of mercury may produce temporary albuminuria, either by setting up some blood change, or inflammatory condition of the renal structures. It passes away when the remedy is discontinued. Other irritants or substances, which find their way out of the system by the kidneys chiefly, as lead and alcohol, have the same effect. Acute Desquamative Nephritis. — The disease follows the same course and presents similar sj^mptoms in children to adults. The symptoms are those of general febrile action with a temperature which may reach 104,t with quick throbbing pulse, thirst, head- ache, and loss of appetite. There is pain in the loins and legs, and in a few days the face is pale and shrunken, the eyelids are pufty, so that the eyes cannot be seen, general anasarca or dropsy sets in early, and the hands and lower limbs are oedematous ; eiiusion into the pleural sacs, pericardium, or abdomen, are common, and pneumonia is occasionally present. At first the urine is scanty or almost entirely suppressed ; it is dark from the presence of blood, and contains a thick sediment. If there is pain across the loins, or deepseated tenderness on pressure, more or less blood will often be seen, or detected under the microscope, with tube-casts, and renal epithelium. The patient is, restless and talkative in sleep, and if the urine does not increase in quantitj^, the poisoned elements in the blood will sometimes lead to convulsions, delirium, or coma. Convulsions are, however, infrequent in the albuminu- ria of children. As the disease progresses, and congestion of the kidneys diminishes, the urine becomes pale and increased in quantity, and the anasarca gradually disappears. Notwithstand- * Brit. Med. Jonrn., Manchester Meeting, Aug., 1877. See Clironic Desquamative Neplirilis, p. 264. " Under ordinary circumstances albuminous bodies do not diffuse through animal membranes, but it has been shown by Bernard, Pavy, Stockvis, and others, that albumen of eggs will pass out through the kidneys, while the albumen of blood does not do so under similar conditions" (Dr. Lauder Brunton). — Practitioner, June, 1877, p. 427. t This high temperature appears to be unusual. Dr. Dickinson mentions that he ha.s no thermometric record, at the outset of this disease, of more than a few points above 100°. When uncomplicated, lie has known the temperature to range for many weeks between 97.5° and 99.5°. — Diseases of the Kidney, part 2, Albuminuria, 1877, p. 278. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 255 ino- this, the albumen may be equally great in amount, and any error in diet, or cold, will renew the renal congestion and hsema- turia. The microscopical appearances of the urine show epithelial casts of the uriniferous tubes. In these casts are to be seen blood- corpuscles and renal gland cells, besides small and large hyaline casts, but these are often indistinct, and cannot be seen for weeks together, even when there is a large amount of albumen. The large hyaline casts may be absent altogether (Johnson). As the disease goes on, oily casts and cells are detected in the tube-casts, indicating that the secreting cells of the kidney are undergoing fatty change.* The causes of this affection in childhood, are most frequently due to scarlatina and to suppressed action of the skin following exposure to wet and cold. When the rash of scarlet fever is out, or the skin is desquamating, cutaneous action is checked by cold, and a morbid process is set up in the kidney. The circulation being impeded, the urinary constituents accumulate in the blood and lead to dropsical effusions. It is generally admitted that the more severe the throat affection the less likely are the kidneys to become affected ; but it must be borne in mind that when the throat is very sore the patient is treated with more care, and is not so likely to be exposed to cold, which would cause or aggra- vate kidney disease. , Scarlatinal dropsy is most frequent from the tenth to the fourteenth day, but it may be delayed much later. In two cases under my care, about the same time, the symptoms came on in one case at the end of the fifth week, and in the other case at the seventh week. Nephritis in children has also been observed in connection with pneumonia, rheumatic fever, small-pox, typhoid fever, chronic dyspepsia, and the consumption of indigestible food. Next to scarlatina, diphtheria and measles are the most common causes. Scarlatina then is the most frequent cause of acute nephritis, the kidneys being irritated as they assist in the removal of morbid products from the blood. This unhealthy stimulation throws upon these organs work to which they are unaccustomed, and as a con- sequence they become congested, and the tubes choked up with * For farther information on this subject the reader is referred to Dr. George John- son's Lectures on Bright's Disease, 1873 ; Dr. Roberts on Urinary and Renal Diseases, 1877 ; and Dr. Dickinson on Diseases of tlie Kidney, part 2, Albuminuria, 1S77. 256 DISEASES OF CHILDREN'. exudation. If, at the same time, the patient is exposed to wet and cold during the shedding of the cuticle, symptoms of acute renal disturbance are set up and dropsy follows. Dr. Dickinson writes : " That at the Children's Hospital where children are treated up to twelve, a series of 103 cases of albuminuria connected apparently with renal inflammation, gave 75 where the disorder was traced to scarlatina, 3 to measles, 1 to erysipelas, 1 to acute rheumatism, and 1 in which it came on in the course of eczema ; 5 from cold, and 17 from uncertain causes made up the tale."* Boys are more liable to scarlatinal dropsy than girls, just as adult males are more prone to kidney disease than females. The greatest frequenc}^ in children is between the ages of live and fifteen. " There are two periods which are especially amenable to the disease. The scarlatinal form is most common under ten years of age ; the form which results from cold is especially apt to occur between twenty and thirty.'^f The association of tuberculosis with this disease is extremely uncommon. Pathology. — In consequence of suppressed skin action the kid- neys become congested through having to take on increased func- tional activity, whereby the organs become congested and swollen. Hyperplasia of the epithelial cells in the tubules then takes place, and these cells are incapable of separating the solid urinary constituents, which, remaining in the blood, give rise to the well- known symptoms already described. Hence. effusion takes place in the various tissues and serous sacs of the body. The blood undergoes changes, in becoming poor and thin, faUing in specific gravity, whilst albumen and blood appear in the urine from dila- tation and rupture of the renal capillaries. For some time urea is eliminated by the vomiting and diarrhoea that ensue ; but when these functions fail, the gradual accumulation of excrementitious urinary compounds in the blood occasions convulsions or coma. Morbid Anatomy. — If death takes place during the acute stage the kidneys are found congested and enlarged ; they are of a dark- red or chocolate color, the cortex is mottled with spots of anremia and is ecchymosed, and the medullary cones are dark and con- gested. The uriniferous tubes are crowded with epithelial cells and blood, the walls of the capillaries are thickened, and conges- tion of the pelvis of the kidneys, ureters, and bladder is found in * Diseases of tlie Kidney, by Dr. Dickinson, part 2, Albuminuria, p. 321. f lb., part 2, Albmninuria, p. 2G8. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 257 addition to effusion into the serous sacs. After a variable period the kidneys in some cases undergo degeneration (chro^iic desquam- ative nephritis). Prognosis. — When the secretion of urine is free and there is not much blood or albumen mixed with it, the prognosis is favorable, and many cases due to scarlatina or measles completely recover; but if the albumen is in excess and the urine is deficient in quan- tity, or the child is of a strumous constitution, the prognosis is bad. The subjoined case is a good example of acute desquamative nephritis, terminating in permanent albuminuria and chronic change of structure. E. S , pet. 9|, a fast-growing, strumous-looking girl, was ad- mitted into the Samaritan Hospital under my care on June 15th, 1875, suffering from acute desquamative nephritis and anasarca. The parents stated she had never had scarlet fever, nor had the disease prevailed in the house or neighborhood. The case seemed due to cold and exposure. On admission, the eyes were almost obscured from oedema of the lids ; the arms, legs, and thighs were tense from subcutaneous infiltration, and there was free fluid in the peritoneum. There was slight effusion into the left pleural sac (about a quarter of a pint) ; the first sound of the heart was a little prolonged, and louder than usual, but the valves were healthy. Temperature 100.1°, pulse 120, respiration 32. The mother said that she noticed her daughter's face swollen in December, 1874, ])ut she had attended school regularly till a month before admis- sion. The urine was high-colored and turbid ; reaction, acid; sp. gr. 1010; it was thick and clotty on boiling, and the addition of nitric acid rendered the whole an albuminous curdlike mass, adherent to the test-tube. June 16th. — There was much more oedema of the feet and legs, and the temperature was 102-2°. The urine was thick, scanty, and dark-colored ; only twelve ounces were passed in twenty- four hours (although she drank freely of cold water), sp. gr. 1030; on the application of heat, the urine coagulated in large and divided clots. The addition of nitric acid converted it into a thick, soapy mass, which admitted of the tube being inverted, wliile only a little fluid escaped. Under the microscope, there was not a trace of blood-corpuscle, urinary cast, or epithelial cell, which is unusual with this albuminous condition of the urine. 17 258 DISEASES OF CHILDREN. She was ordered a mixture of tincture of digitalis with acetate of potash, aud compound jalap powder occasionally. 19th. — The temperature had risen to 104°, and the pulse to 140 ; the anasarca had much increased, and there was great stupor and drowsiness. A third of the urine was albuminous, and on standing all night looked like barm. The microscope now showed large epithelial cells, probably from the straight portion of the tubes, and numerous blood-corpuscles, some of them altered and shrunken ; a few epithelial cells from the convoluted portion of the kidneys, and two short and small granular casts. There was now acute nephritis, with a limited degree of desquamation. Three days later, forty-four ounces of pale urine were passed in twentj'-four hours. A few hyaline-looking casts, large and small, with here and there a renal gland cell, were seen under the micro- scope. Bark and hydrochloric acid were now substituted for the previous mixture. At the end of another week, seventy-five ounces of similar urine, with a low specific gravity, were passed in twenty-four hours. The tincture of the perchloride of iron was given in ten-minim doses three times a day. During the remainder of her stay in the hospital she passed above the average amount of nrine, as the healthy functions of the kidneys were in slow process of restoration. On the 24th of July she left the hospital feeling quite well, and presenting no trace of dropsy. The presence of albumen was doubtful. On October 9th of the same year, the patient was readmitted with symptoms of acute desquamative nephritis. There was much anasarca of the face and limbs, which increased for a few days after admission into the hospital. The urine was highly albuminous, and clotted like cream on the sides of the test-tube. The deposit contained granular casts, indicating the desquamation of cells already morbid; moreover, numerous cayenne pepper crystals of uric acid were found, proving imperfect elaboration of the nitrogenous principles in the blood, from reduced functional activitj' of other organs. In November she caught cold, and had an attack of acute renal congestion, followed by a large quantity of bloody urine, of a bright claret-color. At the close of the month, the urine was still dark, containing blood-corpuscles, broken irregular granular casts, and some fresh renal cells. For the first time I detected DISEASES OF THE KIDNEYS AND UEINARY ORGANS. 259 increased impulse of heart, and intensification of aortic second sound. The J^ of a grain of perchloride of mercury was added to each dose of the mixture. There was a slight reduplication of the first sound over the interventricular septum, and the apex beat was lower by half an inch. JaTiuary 11th, 1876. — A careful examination of the heart re- vealed the following condition. The second sound was intensified to a certain extent over the aorta, and to a greater extent over the pulmonary artery in the second left intercostal space. There was occasional doubling of the second sound over the conus arteri- osus ; there was no doubling of the first sound anywhere ; cooing inspiration was audible over the upper lobes in front, but not behind. Apex beat in fourth interspace, and impulse extended to outer side of nipple. The pulse did not present the feeling of tension, and when the finger was lightly applied to the radial artery it felt the stroke and collapse. Sphygmographic tracings showed moderate tension ; greatest sweep at about 150° to 200° ; systolic rise was not anywhere greatly prolonged. 27th. — At her mother's request, the patient left the hospital, her general health was good, and all dropsy had disappeared. The urine was clear and acid, sp. gr. 1020; it contained only a trace of albumen. This favorable change was attributable to the per- chloride of mercury, which she had continued regularl}^ n-p to this time. June 11th, 1877. — She was perfectly well in health, and had re- mained so ever since January, 1876. She had never any headache, sickness, or diarrhoea, and her mother considered her as well as at any time of her life. She was fed on oatmeal porridge and milk every morning, and had meat three times a week. Analysis of Urine. — Clear bright yellow, with mucous cloud; sp. gr. 1024 ; faintly acid reaction. Became very milky with heat, and the cloud was partially cleared with eft'ervescence by the ad- dition of a few drops of nitric acid (phosphates). Albumen a sixth part. The microscope showed ordinary squamous epithelium, and a quantity of hyaline tube-casts, but they were very indistinct. The high specific gravity is unusual with such albuminous urine.* * There are several points in which this case is both suggestive and instructive, showing as it does, in a very striking manner, that the presence of a large amount of albumen in the urine is not incompatible with active growth of the body, and a good 2G0 DISEASES OF CHILDREN. As a rule, children recover more frequently from the dropsy of scarlatina and other febrile diseases, than from that which is due to cold and constitutional causes. Usually the disease terminates in six months, but it may assume a chronic form, and be indefi- nitely protracted; the interstitial tissue of the kidneys increases, and contraction ensues. Of 50 fatal cases under the age of sixteen, 28 died from diseases of the respiratory organs, including pneu- monia, pleurisy, bronchitis, and empyema. Of the remaining 22 cases, death was caused by uremic convulsions in 8, by pleuritic effusion in 5, by vomiting in 3, b}' peritonitis in 4, by pericarditis in 1, and by sloughing of the scrotum in 1. (Dickinson.) !Now as to the general management of these cases. When the primary cause of the disease can be ascertained, we may do much in mitigation, or cure of the symptoms, by directing careful atten- tion to all those points which bear upon the original malady. If the albumen be due to pressure from morbid growths, or to an en- larged liver, we know the best plan to adopt in mitigation of the evil; and if the thoracic organs are unhealthj^, they may induce renal changes through obstruction to the circulation. AVe may excite the action of the skin by the warm bath, and by diapho- retics ; we may relieve the portal circulation by efficient purgation, and thus we can indefi^nitely prolong life if there is no hope of saving it. But all drugs and therapeutic agents are secondary to state of health. When such cases as these occasionally come under close observation, and opportunities are afforded of studying their course and progress, we may reasonably commit ourselves to the assertion, that whenever a large amount of albumen is daily separated from the blood for many months, it must indicate pathological changes in the renal organs of a chronic and incurable nature. It is remarkable, and very exceptional, that tlie retained urinary excreta should cease to give rise to any constitutional symptoms when there was no vicarious discharge from the stomach or bowels going on, to wash out the impurities from the .system. There was no flatulence, dyspepsia, or any complaint whatever, and the slender ankles, healthy features, and the hue of the countenance indicated a return to health, though the patient was living in a poor home, without much care or attention to diet In this case we may explain the coexistence of albuminuria with good general health on the hypothesis, that a mild subacute inflammation of one, or even both kidneys, was at one time going on. Such a condition is not incompatible with an almost perfect functional activity of the kidneys in other respects, and may be compared with clironic Ciitarrh of tlie mucous membrane of tlie nose and bronclii, where inflammatory prod- ucts are discharged for years. But the fact must not be overlooked, in this and similar cases, that continued congestion, whether it be inflammatory or otherwise, ultimately tends to modif}' the nutrition of the kidney, and to alter the glandular structures, so that in time it leads to atrophy and contraction of the organ. DISEASES OF THE KIDXEYS AND URINARY ORGANS. 261 diet, for the closest relation exists betwixt the solids and fluids taken in as food, and the condition of the urinaiy secretion. Treatment of Acute Desquamative Nephritis. — The patient should be kept in bed, and the temperature of the apartment maintained between 65^ and 70°, but well ventilated, and free from currents of cold air. In all cases, and particularly where the secretion of urine is scanty, diluent drinks should be taken freely, and the diet be very scanty. For children, milk is the only nourishment neces- sary, as it does not irritate the kidney. If the milk disagrees, or the patient tires of it after a time, or if it deranges digestion, or causes constipation, a little veal broth or mutton broth must be substituted, and barley-water, sago, or arrowroot are useful, but in every case the patient must soon return to a mik diet. Alcoholic stimulants should be prohibited. To reduce the inflammation, cupping, or leeches to the loins may be necessary, if the child is strong and full of blood ; but if there is much haemorrhage from the kidney the patient may be too weakened, and aperients and diaphoretics will be safer. A diapho- retic mixture containing antimony, or a solution of acetate of am- monia, will determine action in the skin, and relieve any dropsical eft'usion that may be present. It is important to unload the bowels well, and for this purpose, a purge occasionally of compound jalap powder, will relieve arterial tension if present, and rouse the kid- neys to freer action. A fair allowance of fluid should be taken to wash out the tubes, and to prevent their obstruction. In this way the congestion of the gland is relieved, and there is a better chance for all the constituents of the urine to escape. " Of all diuretics water is the best " (Dickinson), and it may be taken to the extent of two or three pints daily. The bitartrate of potash drink, flavored with lemon and sweetened with sugar, is very agreeable ; whilst it helps to clear the renal channels of morbid secretions, it keeps the bowels free, and also assists in relieving the contamina- tion of the blood. A mixture of citrate of potash and tincture of digitalis increases the quantity of urine, and, so far as my experience goes, has no tendency to aggravate renal congestion. It is a favorite remedy with me when the secretion is scanty and high-colored, or contains blood, although Dr. Dickinson is of opinion that digitalis, by add- ing to the force of the heart, may increase the discharge of blood. 262 DISEASES OF CHILDEEN. In the form of infusion, digitalis is a good diuretic, and one or two drachms may be taken three times a day. In the early stage of the acute affection, warm baths, or the hot vapor-bath, may be used with great advantage, and they are par- ticularly suitable for children, if the action of the skin is defective, and there are any signs of cerebral oppression. The sweating that ensues brings immense relief to the system, unloading the capil- lary circulation, and lessening the distension of the renal vessels. The baths may be employed evevy night on going to bed, for the first few nights, and then less frequently. The temperature may vary from 98° to lOO-", and the child may be immersed from 10 to 15 minutes. Dr. George Johnson speaks highly of a wet sheet and blanket bath. "A sheet is wrung out of warm water, and the patient, either naked or covered only by a shirt, is enveloped in the wet sheet up to the neck. Then three or four dry blankets are closely folded over the wet sheet. He may remain thus packed from two to four or six hours, or even longer. Recently, a boy in the hospital with acute renal disease and almost complete sup- pression of urine, consequent on scarlet fever, was kept packed in- cessantly for four days without serious discomfort, and with great relief from very distressing and alarming symptoms. When he left the hospital all traces of his malady had disappeared.'"* If head symptoms in the character of convulsions or coma super- vene, we may generally attribute them to a poisoned state of the blood (ursemiaj, or to an ansemic state of the brain through some source of exhaustion, as protracted vomiting or diarrhcea. Yet it is remarkable that son:ie severe cases of nephritis in children, with an enormous escape of albumen from the system, are not accom- panied by headache, or cerebral symptoms of any kind. If they are present, and the head is hot or painful, cold lotions may be applied, or a mustard poultice to the nape of the neck will be serviceable. Bromide of potassium or chloral may be needed to calm the cerebral irritation, and a free action on the bowels and kidneys must be kept up, so that the morbid products may be gradually eliminated from the circulation.! * Lectures on Briglit's Disease, 1S73, p. 133. t " I offer for your practical guidance this rule of treatment : wlien such symptoms as headache, delirium, convulsions, or coma are the results of uraemia, give purgatives freely; and if the renal disease be acute, and therefore probably curable, your treat- ment will often be completely successful. On the other hand, wlien you have reason DISEASES OF THE KIDNEYS AND URINARY ORGANS. 263 Inflammatory complications, as pleurisy, pericarditis, bronchitis, and peritonitis, must be treated on general principles, always re- membering that the kidney disorder is the cause of the evil. Diaphoretics and local applications, with careful regulation of the diet, are the remedies to be relied upon. When the acute stage has passed, and there is passive conges- tion of the kidney, our treatment must undergo considerable change. Of all remedies, none are equal to small doses of per- chloride of mercury, combined with the tincture of perchloride of iron, when every trace of blood has disappeared from the urine, and there is sufficient albumen to justify the opinion that renal congestion is present. I have known epithelial and fibrinous casts to be facilitated in their escape from the convoluted tubules of the kidney, when these remedies have been continued for weeks, and the amount of albumen to undergo a marvellous diminution. When the evidences of general debilit}^ and anaemia are most prominent, the perchloride of mercury should be withdrawn, and the iron given alone. In some cases, the vinum' ferri, or the acetate of iron, may be ordered according to the discretion of the practitioner, and if there is a deficiency of renal secretion, the bitartrate or the acetate of potash may be added. to believe that the like brain-s^'mptoms are consequent on cerebral haemorrhage, or embolism, or thrombosis, be very cautious in the use of purgatives, which may greatly increase the patient's distress and exhaustion, while they can do little to improve his condition. In inflammatory afl^ections of the brain and its membranes, purgatives are often useful, but less frequently and strikingly so than when cerebral symptoms are the result of uraemia." — Lectures on Bright'' s Disease, by G. Johnson, M.D., F.R. S., 1873, p. 136. 264 DISEASES OF CHILDREN". CHAPTER XXiy {continued). DISEASES OF THE KIDNEYS AND URINARY ORGANS. Chronic Desquamative Kephritis: Sometimes follows an acute attack after scarlet fever or exposure to cold — 3fai/ be associated with (1) the large white kidney ; (2) the red granular kidney — Symptoms of the disease ivith the large white kidney — Character of the wine — Albumen occasionally absent in confirmed cases — Conclusions to be drawn from a microscopic examination of the urine — Small red granular kidney rare in early life — Symptoms and morbid appearances — -Cardio-vascular changes — Lardaceous or wary kidney — Nature and causes — State of the urine in — Treatment of chronic Bright'' s disease in the different varieties of the affection. Chronic desquamative nephritis is a very rare disease in chil- dren ; it may be the consequence of an acute attack after scarlet fever, or exposure to cold, but in by far the greater number of in- stances it creeps on slowly, and belongs to adult life. The course it follows and the symptoms it presents in children, are in all re- spects like the same disease in the adult. If the acute stage does not pass away completely, and any inflammation remains behind, the urinary tubules become plugged with a fibrinous or exudative material, which interrupts the circulation through the gland, and by favoring a state of habitual congestion, renders the chances of recovery less promising. After an attack of acute Bright's disease (acute desquamative nephritis), when the constitutional symptoms have improved, and the urine remains persistently albuminous, the patient is exposed to a return of the disorder from cold, or errors in diet, renew^ing renal congestion, and paving the way for incurable degeneration. This chronic form of disease may be associated with (1) the large white kidney ; (2) the red gramdar kidney. It appears that we may have disease of the kidnej's commencing in (1) the epithelial lining of the tubules; (2) m the fibrous tissue; (3) in the bloodvessels. The symptoms and morl)id appearances are characteristic of each varietj^ to a great extent, and ought to be carefully studied in their clinical history and pathological bear- ings. When the urinary tubules are inflamed and irritated by the passage of a specific poison through them, as in scarlet fever, they take on an excess of cell growth, and, as exudation proceeds from the congested vessels, the kidney increases in volume, and becomes large and smooth. The capsule peels oft' readily {large white kidney). If the disease is not arrested, or cured, the morbid altera- DISEASES OF THE KIDNEYS AND URINARY ORGANS. 265 tions continue, and the miscliief extends to the intertubular strnc- ture, at the same time the growth of tibruid tissue begins, which may end in contraction and granulation. The kidneys are reduced in size to one-half, especially in the cortical part, and the surface instead of being smooth is irregular and granulated. They are firm and fibrous, and the capsule thickened and adherent. The depressions and granulations are produced by the contraction of the fibrous tissue between the tubes {gramdar kidney — cirrhosis of the kidney). The large white kidney is the sequel of an acute attack of nephritis, particularly after scarlet fever, or exposure to cold. The dropsy and oedema, if present during any time of the acute affec- tion, pass off more or less completely, leaving the state of the urine to tell the mischief that has been inflicted upon the renal organs. The albuminuria may continue for months, or even years, before symptoms of degeneration ensue ; or, indeed, at a time when the general health is in no way deranged. This, however, will greatly depend on the amount of albumen in the urine ; if there is only a mere cloudiness or opalescence in the secretion, the health may be unimpaired, and the patient perform the usual duties of life with- out suflering any inconvenience, but a copious precipitate cannot continue very long without the liability of a return of dropsy and inflammatory complications. The disease sometimes commences as a chronic disorder. The general symptoms of chronic disease with a large white kidney when pronounced, are a pale and pasty face, and dropsy. There is loss of appetite and nausea, and the bowels and stomach are easily deranged, diarrhoea and vomiting being ver}'- common. In the case of a girl under my care in 1876, the profuse albuminuria was attended on three or four occasions with severe epistaxis, preceded hj frontal headache. Troublesome cough, from conges- tion of the lungs and bronchial irritation, often prove extremely inveterate, whilst pericarditis, and serous efi'usion into one or both pleural sacs is not uncommon. Cerebral symptoms from ursemia, and haemorrhages and extravasations of blood, more especially belong to the granular form of the complaint. The urine is generally pale and of normal specific gravity ; as the disease proceeds, a microscopical examination detects granular and hyaline casts. The variability in the amount of albumen in the urine from time to time is just one of those circumstances 266 DISEASES OF CHILDEEJiT. which requires especial notice and attention. The patient, to whom I have alluded, presented a good example of this when the chronic stage was established. There were days when the albu- men was so small in quantity that the urine revealed on careful examination a mere trace, and I had my doubts whether it was present at all; but when the urine was allowed to stand a few hours, after carefully employing the usual tests, its presence could invariably be verified. I can only connect this temporary decrease of albumen to some mysterious process of digestion.* In many cases of albuminuria the albumen is present in the urine chiefly, indeed, in many cases solely, during the period of digestion ; just as in some cases of diabetes the sugar is found in the urine mainly, and sometimes only, during digestion.! A case of albuminuria is described in an infant seven weeks old. It was born healthy, but soon after birth suffered from constant vomiting. There was no history of scarlatina or measles, and no evidence of disease in the thorax or abdomen ; indeed, the child lay listlessl}^ in any position in which it was placed, and appar- ently suft'ered no pain whatever. The urine was "almost like pure water, and containing suflicient albumen to make a deposit of some height in the test-tube." Emaciation followed, and death took place at the end of a month. As the kidneys only presented some spots of congestion, the ease was considered as one of albu- minuria from imperfect digestion and assimilation of the albumi- nous constituents of the food.:}; In other cases albumen is never present in the urine except after severe exercise. The question maj', however, be asked : Is albumen in such a case as this ever entirely absent from the urine? Dr. Roberts relates the case of a girl, ?et. 8, who came under his care in April, 1864. She had general anasarca after scarlet fever four months previously. There was excessive pallor, shortness of breath, and a puffy, pasty face. The urine was scanty and high-colored, but not a trace of albumen or tube-cast could be found. She died four weeks after admission. On a post-mortem examination, "the kidneys were good examples of the 'smooth, white' Bright's kidney." They were slightly en- * Temporary albuminuria may arise from indigestible articles of food, as some kinds of diec-se, shellfish, crabs, cockles, mussels, etc. Nervous excitement and mental emo- tion will also give rise to it. — Dr. Basham, On Dropsy, 186G, p. 306. t See the remarks on Intermittent Albuminuria, p. 253. X "Albuminuria in a child seven weeks old," by G. F. Helm, B.A., F.R.C.S. ; Lan- cet, Jan. 18th, 1868, p. 8o. DISEASES or THE KIDNEYS AND URINARY ORGANS. 267 larged, and the capsule peeled off readily. The surface was de- pressed here and there, and atro[»hy had commenced.* There are some points worth considering here in reference to the microscopical character of the urine. In the earliest stages it is scarcely altered, being, as we have before mentioned, of normal color and specific gravity, but more or less albuminous. When death occurs before fatty casts and cells are detected, the kidneys are in the first stage of degeneration {large white smooth). When small hyaline and oily casts and cells appear in the urine, there is a process of atrophy {fatty degeneration). When granular and large hyaline casts appear, there is a further contraction of the kidney, or the disease is in the third stage {granular degeneration). After death the kidneys are found : 1. Large, white, and smooth. 2. The same appearance, with yellowish opaque specks on the sur- face (granular fat kidney), or large white kidney, with fatty de- generation. 3. Atrophy of the cortical portion, with an uneven granular surface (Johnson). The small red granidar kidney so far belongs to advancing years as to be hardly worth noticing under the diseases of early life. It is a chronic and insidious disease from the comrnencement, and although associated with the gouty diathesis more particularly, no cause can be assigned in a lars-e number of cases. It holds no relationship to tubercle whatever. Dr. Dickinson has seen the disease in a girl of 5. He mentions another case of a girl under the late Dr. Hillier who died at the age of 10, and one under Dr. Ogle, at St. George's Hospital, of a boy, who died at 11, "with granular degeneration traceable to scarlatina." Dr. Dickinson had two fatal cases under his own care at the respective ages of 12 and 14.t The disease has succeeded to scarlatina contracted many years previously. A case is related by Barthels:}; of a girl who at 10 years of age had ague, measles, and scarlet fever, but no dropsy. At 18, after being in good health for eight years, she became aft'ected with albuminuric retinitis ; there was albumen, with small hyaline casts in the urine, and hypertrophy of the left ventricle. Maddenino; headache and obstinate vomitins^ succeeded to dimin- ished urinary secretion. She became completely blind, and h xd * On Urinary and Renal Diseases, p. 408. f Part 2, Alburninnria, p. 376. X Cyclopaedia of the Practice of Medicine, by Dr. H. von Ziemssen, Diseases of the Kidney, vol. xv, p. 429. 268 DISEASES OF CHILDREN". five convulsions of an epileptic character in one day. To these symptoms succeeded twitchings of the muscles, profuse diarrhoea, and death from exhaustion. After death the kidneys were found atrophied, and the surfoce mottled and covered with shallow de- pressions; the substance of the organs was tough; renal arteries large ; there was purulent peritonitis and ulceration of the mucous membrane at the lower end of the ileum; the brain was pale and firm; the left ventricle of the heart was hypertrophied. The kidney in this disease is much reduced in weight, the sur- face is rough and irregular, and the capsule so thickened that it cannot be torn off the surface beneath without removing some of the tissue. Some of the urinary tubules are denuded of epithelium, and others contain fibrinous deposit. The urine, in granular dis- ease of the kidney, contains a small quantity of albumen, and is copious and of low specific gravity ; epithelial, granular, and hya- line casts are found under the microscope. Dropsy is almost certainlj^ absent, but there may be transient puffiness of the eyes and ankles. We often find d_yspnoea on exer- tion from osdema of the pulmonary tissue or cardiac change ; and in these cases the face is sallow rather than white. With these changes the heart becomes hypertrophied, and the arteries thickened. Simple cardiac hypertrophy is a common ac- corapanimeut o^ granular disease of the kidney ; the morbid matters, not readily passing through the capillaries, raise the blood pressure in the arteries, and, an obstruction thus being created in the blood flow, the left ventricle hj'pertrophies. For a long time there may be no signs present except accentuation of the aortic second sound or reduplication, but not necessarily any murmur, unless the valves are diseased. Atheromatous change has been found in the mitral valve and aorta, associated with granular fibrosis of the kidney at the age of six.* The muscular coat of the small arteries under- goes thickening, and even degenerative changes. The sphygmo- graph affords ample evidence of this in the characteristic tracing, and the finger placed on the pulse detects tension and hardness. This increased effort on the part of the heart and systemic arteries, causes both to become h^-pertrophied. As the heart increases in power the vessels lose their elasticity and become brittle, whilst the force with which the blood is driven through their channels, frequentlj' leads to rupture and extravasations. The researches of * Dickinson, op. cit., p. 412. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 2G9 Sir William Gull and Dr. Sutton are in the direction of proving, that the view advanced by Dr. Johnson is unsupported by their experiments and investigations ; they consider that blood charged with urinary excreta does not satisfactorily explain the cause of hypertrophy of the heart, and the arterial changes in the muscu- lar coat of the smaller vessels. This change in the minute arteries is due to the formation of a " hyaline-fibroid " substance in the in- tertubular parts of the kidney, '-and that, in fact, the muscular coat is often variously atrophied." The cardio-vascular changes are not consecutive to the renal mischief; they may be independent of it, and the contracted granular kidney forms only part of a general morbid condition. These observers admit the frequent association between hypertrophy of the heart and renal degenera- tion, but at the same time they consider that this is no proof of any relation between them of cause and effect. The large white kidney, the granular contracted kidney, and the lardaceous kid- ney have been found when the heart was free from hypertrophy. For further information on the subject I refer the reader to the paper of Sir William Gull and Dr. Sutton.* The next form is that known as the lardaceous or waxy kidney. It has also received the name of amyloid kidney. A waxlike material is found infiltrating the kidney, commencing in the mus- cular coat of the minute arteries ; this imparts to the kidney a smooth and anaemic look. When the disease is far advanced, the gland loses all its smoothness, and becomes shrunken, uneven, and puckered. On incising the surface, the natural structure is seen to be much wasted, the cortex is bloodless, and the cones red, whilst the whole organ is much more tough and hard. This dis- ease is secondary and constitutional, not local. It consists pri- marily in a change in the composition of the blood, and secondarily in the walls of the arteries, as well as all the organs of the body which they supply. f The striking peculiarity of the morbid deposit is a deep brown- reddish color, which it assumes on the addition of a weak solution of iodine. The causes of the disease are chronic suppuration from caries or * Med.-Chir. Trans., vol. Iv, 1872, Chronic Bright's Disease with Contracted Kidney (Arterio-capillary Fibrosis). t See Chapter XX, On Diseases of the Liver, — Lardaceous or Amyloid Disease of the Liver. 270 DISEASES OF CHILDREN. necrosis of bones, scrofulous abscesses, phthisis, chronic bedsores, S3"philis, etc. The disease is essentially chronic and most common in males. It is most frequent between 20 and 80. Dr. Dickinson has seen it in a child of 5, and he alludes to the case of a boy 2} years old, under Dr. Gee, who died from chronic abscesses in the thigh and P3'femia.* The disease is recognized during life b}^ a worn and cachectic look ; by the copious secretion of albuminous urine ; and by the presence of oedema and dropsy. The urine is abundant in the early stages, but as the complaint advances it becomes scanty, very albuminous, and of high specific gravity. " Cells resembling those of pus are occasional!}' found, either separate or aggregated round a cast. The tube-casts are usually hyaline, and do not yield a brown coloration with iodine. Epithelial casts are also some- times seen."t Thej- are sometimes granular, or they contain fatty epithelium (Green). Treatment of Chronic Bright' s Disease. — To aim at a cure or to give relief in this formidable complaint, we must bear in mind the course of the malady and its tendency towards a fatal termination ; for in so doing we know what symptoms to expect, and how best to avert or relieve them when they threaten. The cause having been ascertained, we may learn how to approach the disease in its milder forms with some chance of success. Is it the sequel of an acute attack, or a chronic insidious disease from the first ? Is the constitution fairly good, or the health broken down ? For on the issue of these questions our opinion may be in a great measure guided. In one case the tendenc}' of the renal changes will be to cause cerebral trouble in the form of chronic headache, confusion of ideas, and convulsions or coma; in another case infiammatory complications of the serous cavities ; in a third anasarca or dropsy ; in a fourth derangement of the stomach and bowels is the chief evidence of the poisoned blood ; in a fifth the changes fall chiefly on the sj'stemic vessels, and the left ventricle of the heart, pro- ducing for a time no other indication of failing health than stupor and inactivity, nausea and capricious appetite, or occasional epis- taxis or heematuria. If the chronic disease has succeeded to the acute variety of the affection, as after scarlet fever or exposure to cold, great care is * Dickinson, part 2, Albuminuria, 1877, p. 491. f On Urinary and Renal Dise;ises, by Dr. Roberts, 1876, p. 491. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 271 required not to submit the patient to changes of temperature, or to an irregular diet, as acute renal congestion is rekindled on slight provocation. If there is chronic disease of any bone or joint, and the albuminuria appears to be dependent on these affections, then the source of such irritation should be removed if possible before the patient's strength is worn out, and the renal degen- eration is too ftir advanced. If there is local pain to any extent across the loins the patient should be put to bed and a linseed poultice applied. If the urine is turbid and contains renal blood-casts, it is advisable to make the child lie on the abdomen to lessen the renal congestion, and to give diluents and fluid diet. In one case immediate relief followed the adoption of this simple method of treatment. When the patient is well enough to be out of doors he should be warmly clothed with flannel next the skin, and the greatest care be taken to avoid cold. A residence at the seaside is to be recommended, and moderate exercise may be taken if the disease is not so far advanced as to prevent it. All treatment will be futile without the most rigid attention to diet, and this should consist chiefly of milk, or milk and water, if there is much albumen in the urine, and renal congestion is present to any extent. Animal food should be prohibited under these circumstances, for if indulged in it will increase arterial ten- sion, and derange the digestive functions. This is not borne out by the experience of some writers, who consider that animal food should be given as soon as the stomach will bear it. " It is a most remarkable fact that the albumen in the urine decreases by the use of animal food, and increases again under a vegetahle diet."* But this testimony is quite at variance with my experience, as the case of E. S , related at p. 257, very strikingly proves. All stimulants should be prohibited, as they are apt to produce deleterious consequences. Children do not require them in health, and there is no disorder in which they would prove more injurious. If anffimia is a leading feature of the complaint, the liquor ferri perchloridi is a good haematic, and a safe diuretic at the same time. When the urine is deficient in quantity, and there is any anasarca from renal inadequacy, the efficacy of the tincture of the per- chloride is well spoken of in combination with the liquor ammonite * Basham, On Dropsy, 1866, p. 217. 272 DISEASES OF CHILDREIS". acetatis. " It is as an aramonio-chloride kept in solution by acetic acid that its beneficial influence becomes most apparent. It is a very simple preparation ; a few drops of the tincture, according to the age of the patient, are added to a drachm of the liquor am- monice acetatis, previously acidulated with acetic acid."* Another writer on this subject also testifies to the same eflfect. "I have frequently combined with each dose of the perchloride of iron ten grains of the hydrochlorate of ammonia; and I believe that this ammonio-chloride of iron is a useful'preparation."'f' If there is any renal congestion, the addition of small doses of perchloride of mercury to the liquor ferri perchloridi, as previously referred to under the acute aflection, will be advisable. The syrup of the iodide of iron, the syrup of the phosphate of iron, or steel wine, in combination with cod-liver oil, are useful preparations in strumous subjects, and may be taken advantageouslj^ for weeks together. However important it may be to improve the quality of the blood in chronic Bright's disease by the exhibition of ferru- ginous preparations, they cause in many instances so much head- ache and constipation, that they cannot be given alone for any length of time ; if the headache is dependent on congestion rather than on anemia, they must be set aside for other remedies. The bowels ought to act once every day at least. Sometimes the mineral acids — phosphoric, nitric, or hydrochloric — are useful where the loss of albumen is excessive, and there is atonic dyspepsia. Gallic acid seems to be ineffectual in lessening the drain of albumen. Dr. Lauder Brunton found that strychnia in doses of gr. oVth stopped the albumen in a case of chronic and intermittent albumi- nuria, but caused sickness and headache ; in the same case pan- creatic enmlsion stopped it at first, but afterwards it became worse than ever; quinine and sulphuric acid doubled the quantity in twenty-four hours. But the same authority speaks in the highest terms of arsenic, which acts " upon the secreting structures of the kidney . . . and a2:)pears also to possess a special affinity for epithelial structures." He gave Liq. Fowleri Ti^iij at mealtimes and the albumen disappeared, reappearing when the arsenic was discontinued, and again arresting the albumen when the remedy was resumed. The case in question was supposed by Dr. Brunton to * Basham, On Dropsy, 1866, p. 218. t Lectures on Briglit's Disease, by G. Johnson, M.D., 1S73, p. 138. DISEASES OP THE KIDNEYS AND URINARY ORGANS. 273 be clue to " imperfect digestion of albuminous substances, which were absorbed from the intestine, and excreted in the urine in much the same way as wliite of egg would have been if the person had swallowed several raw eggs at once."* For any dropsical condition that may exist, a dose of the com- pound jalap powder, witli a little bitartrate of potash, is a good and quickly acting aperient, which may be given once or twice a week in a little tea or plain water, early in the morning, but even this aperient must be employed with due consideration to the gen- eral strength. If anasarcous effusion is great, it may be necessary to puncture the extremities. The ordinary practice is to make one or two punctures through the subcutaneous tissue on the dorsum of the foot or calf of the leg, from half an inch to an inch in length, and then to wrap the limb in hot moist ilannel. I have repeatedly made a small puncture either on the dorsum of the foot or over one or both ankles, and then wrapped the limb in dry flannel, changing it as often as it becomes very wet. I have never seen any local irritation or erysipelas follow this plan, though the drain of fluid in some cases has been enormous. Dr. Southey has re- corded the notes of a case of parenchj'matous nephritis, in which tlie anasarca was combated by drainage-tubes and small silver canulas. The advantages claimed were, that one puncture in each limb was suflficient, and that sores and erysipelas were not so likely to ensue ; the canula could be kept in the same opening without inconvenience for forty-eight hours, and when the instru- ment was withdrawn the orifice closed at once. Above all the patient is kept dry. Several pints of dropsical effusion may thus be safely and painlessly drained away in the course of one day.f Dr. Southey found the same plan equally advantagfeous in drawing away pleuritic effusions | Diuretics are sometimes serviceable to assist in the removal of dropsical effusions. In some forms of the disease diuresis is pro- fuse enough to contraindicate their use. They are infinitely less valuable than purgatives, which relieve the portal circulation and intestinal veins, by inducing watery secretion from the bowels. I have a great preference for digitalis, with acetate or citrate of potash, when an alkali is not objectionable. * Arsenic in Albuminuria, Practitioner, June, 1877, p. 432. t Clin. Trans., vol. x, 1877. t Ibid., vol. xii, 1879. 18 274 DISEASES OF CHILDREN. BroncTiial and dyspeptic symptoms require uo special considera- tion ; they must be treated according to the circumstances of each particular case, remembering tliat the strength of the patient is to be carefully husbanded, and that mercury and antimony, if occa- sionally required, are seldom necessary. If ursemic symptoms threaten, the action of the skin and kid- neys must be encouraged. The poisoned and watery state of the blood will seldom admit of venesection or any kind of depletion. An occasional warm bath is an excellent diaphoretic, by pro- moting the action of the skin, and increasing the secretion of urine at the same time. The skin becomes supple under its use, and a general amelioration in the patient's condition takes place. I have known headache relieved when the temperature of the bath has not exceeded 98°, but if much higher, and there is no free sweat- ing, headache, capillary engorgement of the face, and other dis- tressing symptoms may ensue. Finally, we may repeat that warm clothing, thick boots, care against cold, especially in the evenings, and a seaside residence ought to be rigidly enforced. CHAPTER 'X^IY {continued). DISEASES OF THE KIDNEYS AND URINARY ORGAN^. Dysueia — Eenal Concretions and Calculi — Lithiasis— Symptoms of Stone IN THE Kidney and Bladder — Oxaluria — Hematuria — Tubercle of the Kidney — Cancer of the Kidney — Hydronephrosis — Incontinence of Urine — Diabetes mellitus — Diabetes insipidus — Acute Cystitis — Causes — Symptoms and treatment. Dysuria — Renal Concretions and Calculi. — Calculous disorders are very common in early life, from the liability of the digestive functions when deranged to cause irritation in the urinary passages. The imperfect assimilation of the nitrogenous principles of food checks their downward metamorphosis to urea, so that a quantity of intermediate products are formed ; these products are either insoluble, or, at least, irritating to the geni to-urinary organs. Liihiasis is recognized by pain and weight about the loins, and ^difficulty in voiding urine, which is scanty and high-colored; it •becomes turbid on cooling, and has a strong sickly odor. The DISEASEvS OF THE KIDNEYS AND UEIXAEY ORGANS. 275 commonest form of gravel consists of urate of ammonia, or free uric acid, which falls to the bottom of the vessel on standing like brickdust. The digestive functions are deranged, the tongue being furred, the appetite excessive, and the bowels costive. The child is restless and feverish at night, and loses energy and activity. The white or pink tinge of the urates depends upon the amount of coloring matter in the urine. " In young children the ' milky urine,' which alarms motliers, is due to a deposit of peculiarly white urates."*t The pink or brickdust deposit, only visible after the urine has cooled, and readily dissolved by heat, consists of the amorphous urate of ammonia colored with purpurin. The milky sediment, which exists as a deposit before the urine has cooled, is formed of the crystals of urate of soda. When a careful section of the kidneys is made, yellowish or brownish striee may be seen running towards the base of the pyramids. This appears to be a post-mortem change arising from the precipitation of the urates into the uriniferous tubes.:): When it occurs during life it may prove the commencement of those changes which lead to gravel or calculus, blocking up the urinif- erous tubes, and finally causing them to become impervious, or the concretions escape into the pelvis of the kidney, where they may be seen in large numbers after death. The symptoms of stone in the kidney, or of the descent of a calculus from the kidney to the bladder, are less marked in chil- dren than in adults. There is febrile disturbance, and pain and difficulty in passing water, with localized pain and tenderness over one loin. In severe cases, there is faintness and vomiting, and the skin is bedewed with a clammy sweat. Uric acid calculi have been seen in the pelvis of the kidney of an infant. The occurrence of colic in children of three or four years old is often attended with uric acid gravel (West).§ It must always be borne * Guide to the Examination of the Urine, by Dr. Wickham Legg, 2d edition, 1872, p. 48. t " In the urine of children it is veTy frequently met with in the form of small spherical globules very like the crystals of carbonate of lime from horses' ui'ine ; and these sometimes occur in the adult." — Urine and Urinary Deposits, by Dr. Beale, 1861, p. 275. X "In infants dying within forty-eight hours of their birth, such striae are almost invariably found (Virchow); they have also been found in still-born infants, which have never respired (Hoogeweg and Martin)." — On Urinary and Renal Diseases, by Dr. Koberts, 3d edition, 1876, p. 477. I " Dr. Debout d'Estrees gives an account of a child at Contrexeville, born of gouty 276 DISEASES OF CHILDREX. in mind that it is most difficult to elicit symptoms of localized pain in children. The treatment of dysuria and uric acid gravely when severe, con- sists in the eniploj'ment of warm baths at bedtime, which relieve the pain of micturition and encourage diaphoresis. If there is reason to think from the local and recurrent pain that a concre- tion has formed in the kidney, hot poultices to the loins will be advisable. The bowels must be kept fully open, and for this pur- pose there is nothing better than a full dose of castor oil. After this a mixture of liquor potassse and tincture of hyoscyamus will lessen the acidity of the urine, and promote its free discharge. The diet should be sparing and unstimulating, and should consist of milk and water, barley-water, and thin arrowroot. Xo animal food should be given whatever till the urine has assumed a healthy state, and pain and irritation have passed away. The waters of Carlsbad and Vichy are very useful. In children, calculi and wnnary sediments usually consist of urates, hence tlie alkaline carbonates are verj^ serviceable, and they may be persevered with to great advantage. Children who have had rheumatism sometimes suiffer from uric acid in the urine, and in such cases the diathesis will require careful atten- tion. When a s-tone has formed, the child must be handed over to the surgeon. The symjjtoms of stone in the bladder in children are the same as in the adu,lt — frequent desire to pass water, which is voided with, painful efiorts, and is sometimes mixed with blood ; occasional stoppage of the stream, and a sore and elongated pre- puce from the- child's hands being constantly applied to it. Pro- lapsus ani, accompanied with marked dysuria, is often the first symptom of calculuas in children. Calculi, though frequent in boys, are very rarely found in female children. Hence, when morbid vesical symptoms occur in little girls, the probability of the? presence of a stone in the bladder must not be overlooked on account of its rarity. In the autumn parents, which had real nephritic fits at a fortnight old. The mother, a young woman, twenty-.six years old, who had been suffering from uric gravel for four years, had, during her pregnancy, three fits of nephritic colic ; nevertheless, the child was born in due time and in good condition, but a fortnight after its birth it had real nephritic fits, vomiting, writhing, and complaining chiefly when the loins were touched. The fits ended by the emission of rather thick sand. TJiey returned every six weeks." — A Few Words on the Causes of Gravel, Practitioner, June, 1877. DISEASES OF THE KIDNEYS AND URINABY ORGANS. 277 of 1877 a girl, nine years of age, came under my care in the Samaritan Hospital. Her mother stated that she had been sub- ject since birth to incontinence of urine, and for more than six months before admission she suflered from dysuria, with constant desire to pass water. On the day of admission the labia were swollen, and the clitoris was large and tender. A few excres- cences, neither vascular nor painful, existed around the meatus urinarius. The urine contained a trace of albumen, and there was a scanty deposit of pus-cells. Suspecting the presence of a calculus, I asked my colleague, Mr. Alban Doran, to sound the patient under chloroform. He discovered a large stone, and two days later removed it through the urethra, which he enlarged by means of the dilator, invented by the late Professor Simon, of Heidelberg. The stone weighed 2.V drachms, and consisted of a nucleus of uric acid, coated with oxalate of lime. The patient was enabled to retain her urine and to pass it at will the follow- ing day. She made a good and rapid recovery. Within a month after this patient was discharged, a delicate girl of ten was admitted, also suffering from incontinence of urine and occasional dysuria. There was a distinct history of calculus in the family, her maternal uncle having been operated on for stone when a youth. A sound was introduced into the bladder under chloroform, but no calculus could be detected. The mucous membrane of the bladder was rough at one or two points. The ino-uinal and the whole line of iliac and lumbar glands were much enlarged, but the abdominal walls were flattened, and none of the solid viscera had increased in size. On examining her urine two da^'s after the sounding it presented manj^ of the qualities it did on admission ; it was very acid, and deposited a large amount of mucus. Under the microscope, a great number of crystals of oxalate of lime were detected. She recovered completely under rest and antistrumous remedies. Dr. W. Eoberts* and others have s^iown that although oxalaria is most frequent in nervous and debilitated young people, it is not accompanied with definite symptoms, since in many cases it may exist to such an extent as to produce the characteristic mulberry calculus, without any constitutional symptoms, until the stone has mechanically caused vesical irritation. Hcematuria or haemorrhage from the kidneys in children may be * Uriiia.17 and Eenal Diseases, 1876. 278 DISEASES OF CHILDEEX. met with in tuberculosis, scarlatina, purpura, and some other dis- eases in Avhich the blood has undergone changes in its composition. A case of acute hsematuria is recorded in a girl of nine, in which sudden hferaorrhage followed the disappearance of severe pustular eczema on the face and body, of two years' duration * I have given details of a very interestiug case of '' Paroxysmal or inter- mittent heematuria in a young child, following supposed injury. "f The treatment must be in accordance with the disease which has originated the s^-mptoms. Gallic acid in iive-grain doses, three times a day, will be found beneficial, and if there is anpemia, the tincture of the perchloride of iron is a good styptic and diuretic at the same time. Quinine may be sometimes prescribed with advantage. If there is any evidences of renal congestion, rest in bed and a milk diet will be necessary. Tubercle of the kidney is seen in cases of general tuberculosis, one kidney being generally afl:ected. The organ is increased in size, and converted into a soft, cheesy, yellow mass. Anj^ treatment is unsatisfactory. Cancer of the kidney is a rare disease, and when present, is of the medullary character. :J: I have had no experience of the affection, but authors describe the symptoms as beginning with pain in the region of the kidney, frequent micturition, and the presence of blood and albumen in the urine. It is extremely doubtful whether cancer-cells have been seen in the urine. " The most important symptom is a generally uneven, nodulated, immovable tumor, sometimes as large as a child's head, reaching from the false ribs to the crest of the ilium, and inwards to the vertebral colunm, and occupying a considerable part of the abdominal cavity." (Steiner.j§ The children become cachectic and sallow, and finally die exhausted. Mr. Spencer Wells has recorded a most interesting case of soft cancer of the right kidney in a girl only four years of age. " The diagnosis in this case was made without much difii- culty, although the urine was quite normal. The growth was extremely rapid, hardly six months from its commencement to its fatal terminatiou, when the diseased mass weighed between 16 * Brit.'Med. Journ., 1878, vol. ii, p. 877. f TJie Lancet, vol. ii, 1880, p. 336. % "In the Children's Hospital at Prague in 100,000 cases it was only seen four times." — Steiner on Diseases of Children, by Lawson Tait, 187-4, p. 279. ^ " In 16 children its average weight was 81 lbs. ; the smallest was 1 lb. 9 oz., and the largest 31 lbs." — On Uriiw.ry and Reno.1 Diseases, by Dr. "W. Huberts, 1876, p. 523. DISEASES OF THE KIDNEYS AND URIXARY ORGANS. 279 and 17 lbs. The tumor occupied the whole of the right side of the abdomen, bulging backwards in the right loin. It was uniformly elastic, but no fluctuation could be detected. The intestines were pushed downwards, and to the left side. The rapid growth, and the absence of fluctuation, were, of course, strongly against the opinion that the tumor was ovarian ; while the rarity of ovarian disease in young children, and the comparative frequency of renal encephaloid, led to a diagnosis which was confirmed by a puncture with a fine exploring needle. A few drops of reddish serum were obtained, containing nucleated cells of various size and shape. I sent the child home, with a note to Dr. Williamson, of ISTantwich, expressing my opinion that the tumor was a mass of soft cancer,- and that the right kidney was the most probable seat of the dis- ease. This proved to be correct. Dr. Williamson sent me the specimen, and I exhibited it at the Pathological Society in Decem- ber, 1862.* The whole kidney was infiltrated with encephaloid. Although so enormously enlarged, the shape of a normal kidney was distinctly preserved. Its surface was soft and elastic, in some spots giving a sense of deepseated fluctuation, but no cyst was found, nor were there any marks of suppuration or haemorrhage. Coils of small intestine adhered to its inner and under surface. The ureter was completely occluded by the pressure of the tumor. The left kidney was quite healthy. Thus the normal condition of the urine was explained. The diseased kidney added nothing to the contents of the bladder, and the healthy kidney supplied only normal urine."t Hydronephrosis — Dropsy of the Kidney. — This disorder is caused by an obstruction to the escape of urine from the kidney. The pelvis of the kidney becomes dilated into a pouch or bag, and the renal substance atrophied or absorbed. Sometimes it is divided into smaller compartments or cavities. The tumor may attain enor- mous dimensions, and fill the abdomen as a soft fluctuating mass. In women it has been mistaken for an ovarian cyst, and tapped under that impression. One or both kidneys may be afl:ected.:{: "Of 52 cases collected by me the hydronephrosis was confined to one kidney in 32 instances, and afi:ected both (double hydrone- phrosis) in 20 cases. When the hydronephrosis was single the * Trans. Path. Soc, vol. xiv, p. 179. t Diseases of the Ovaries, 1872, p. 203. X See Chap. XXVI. 280 DISEASES or CHILDREN. right side was more frequently aifected than tlie left (19 right and 13 leftj.''^*" Of these 52 cases "there existed congenital malforma- tion in 20 cases, affecting the kidneys, the ureter, and the renal artery In 13 out of the 20 congenital cases the hydrone- phrosis was double, that is, it affected both kidneys. Two of these perished still-born, one lived six hours, one thirty, and one thirty- six, whilst one died twenty days, and another between three and four months, after birth."t The contents of these cysts consists of watery urine, uric acid, and the earthy salts, but blood, pus, and epithelium may be also present. Death may occur suddenlj'- from uremia. In some cases of congenital hydronephrosis urea is absent. A very interesting case is recorded by Mr. Henrj' Morris to prove that urine is freely secreted during intrauterine life, and that a considerable quantity which the bladder and ureters cannot hold is passed into the sac of the amnion, in which the child floats. Urea appears to be in very small proportion (5 in lOOOj.J Hydronephrosis is found to be caused by the impaction of a stone or calculus in the ureter, which causes inflammation and contrac- tion ; an imperforate urethra is another cause. A pelvic growth, by compressing the ureter, may prevent the escape of the urine, lu some obscure cases no mechanical cause can be ascertained to account for the condition. The symptoms depend on the size of the tumor and the pressure it exerts on surrounding organs. ' The usual situation of the tumor is in the lumbar region, extending forward to the umbilicus and downwards to the iliac region. The tumor is soft and fluctuating ; it is sometimes felt distinctly lobulated, and if of large size there is dyspnoea, and the child cannot lie down without difliculty. The colon generally lies in front of the tumor, "There is one peculiarity which is pathognomonic when present, namely, the sudden diminution or disappearance of the swelling coincidently with the sudden discharge of a large quantity of urine. This sign is not always available, but it is sufiiciently frequently met with to give it an important diagnostic value. "§ When the symptoms arise from the impaction of a calculus, * Renal and Urinary Diseases, by Dr. Roberts, 3d edit., 1876, p. 487. t Ibid., p. 490. X Case of Congenital Hydronephrogis, Royal Med.-Cliir. See., May 13th, 1876. g On Urinary and Renal Diseases, by Dr. Roberts, 1876, p. 497. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 281 attacks of nephritic colic and vomiting are not uncommon, with pus and even blood in the urine. If both kidneys are affected, then the elimination of urea is imperfect, and symptoms of urfemia may be looked for. Should the disease be caused by a renal cal- culus it may be dislodged, and, the sac emptying itself, the symp- toms pass away, the sac shrivelling up and causing no further trouble. Peritonitis, septicaemia, or suppuration in the tumor, fol- lowed by hectic, may ensue. Impaired health and chronic tuber- culosis have also followed. Treatment. — A milk and flaid diet is preferable to much animal food, as it is important to keep the urine free and to avoid the accumulation of fecal matter in the bowels. When there is con- stipation a warm-water enema, or a mild non-irritating aperient, will be called for. In the case of a little girl under Dr. Roberts's care, friction and shampooing the tumor resulted in the escape of a large quantity of urine, and the swelling subsided. Other eases are recorded where the tumor has suddenly disappeared after a profuse discharge of urine through the ureter and bladder. If this does not occur, and the patient's rest is broken from pain and want of sleep, tapping may be had recourse to as a means of temporary relief. In October, 1879, a girl seven years of age was admitted under my care into the Dorset Street Branch of the Samaritan Hospital suffering from abdominal tumor, which had been known to exist since she was two years old. The case was seen by my colleagues and variously diagnosed as hj'datid, ovarian, and renal. Mr. Knowsley Thornton, holding the latter opinion, advised and performed exploratory and antiseptic tapping, and drew off six and a half pints of slightly albuminous urine. The cyst refilled, and, the diagnosis being now certain, Mr. Thornton removed the cyst by laparotomy on January 2d, 1880, securing the renal vessels with fine earbolized silk, and using all details of Lister's method. Some congestion of the other kidney, with h^ema- turia, followed the operation, but passed off in a few hours, and the child recovered rapidly, and four months afterwards was in jDcrfect health. The cyst was shown as a fresh specimen at the Pathological Society, January 6th, the child at a meeting of the Royal Medical and Chirurgical Society, March 9th, 1880, when nephrectomy was under discussion, and full details have been pub- lished by Mr. Thornton jointly with myself.* * The Lancet, vol. i, 1880, p. 870. 282 DISEASES OF CHILDREN. Enuresis (incontinence of urine). — This common disease in chil- dren is generally difficult to cure, and the closest investigation frequently fails to discover the true cause. It is met with in the progress of disease of the bladder and brain, and from deficient power in the tone of the bladder and sphincter, in weakly and strumous subjects, " We can sometimes trace the affection to spinal irritation ; and the worst case of the disease I ever saw was in a girl affected with diseased spine."* It may originate from gastro-intestinal disorder, ascarides in the rectum, and an excess of uric acid in the urine. When these sources of irritation are removed the patient gets well. But incontinence of urine, among children in too many instances, appears to arise from no mechan- ical or inflammatory condition of the bladder or kidney, and from no unhealthy state of the urine. We know that the child wets the bed, but neither the parents nor the physician can always assign any reason for it. A long prepuce would seem to be a fre- quent cause. A very obstinate case under my care, which had resisted all drugs, was cured on its removal. Children who are put to bed without emptjnng the bladder, often wet the bed at night, and when the habit is once established, it is difficult to overcome. In some children the absence of control over the blad- der occurs only at night, and in others during the daytime also ; in some cases there is almost a constant dribbling, and the child is wet and excoriated, v^'hilst in other cases the desire to pass water is very frequent, and he cannot hold it for a moment when once the desire to pass it has commenced. Boys suffer far more frequently than girls. It may be again urged that the condition of the urine may increase its irritating qualities, especially acid conditions. In such cases, a comparatively small quantity of urine in the bladder may excite reflexly the relaxation of the sphincters. Incontinence of urine commonly depends upon an abnormal con- dition of the bladder centres situated in the lumbar portion of the cord. In normal micturition, the sensation of fulness in the bladder is received by the centre in the cord, until it excites an efl:erent impulse to the sphincter, which relaxes and permits the contents of the bladder to escape. In early infancy this does not excite consciousness ; then the micturition is involuntarj^, and purely * Plolmes's Surgical Treatment of Children's Diseases, 1868, p. 581. DIPEASES OF THE KIDNEYS AXD URIXAEY ORGANS. 283 reflex. About the period of the completion of the first dentition, or even earlier, a child ordinarily becomes conscious of the call to void urine, and intimates the desire to its nurse. The relations of the call to consciousness have become established. These relations never become lost again ordinarily, except in very advanced life, or in disease of the spinal cord. Under other circumstances the relations of this call to consciousness do not become perfectly established. In the majority of cases of nocturnal incontinence, during the period of wakefulness, the little patient is conscious of the call, but during sleep the reflex action goes on without excit- ing consciousness. 'In more aggravated cases the call does not excite the attention, and the incontinence occurs during the wak- ing state, as well as during sleep. Prognosis. — This is hopeful, for as the child grows older he gains strength. Incontinence of urine usually ceases at puberty, when the spinal centres become perfectly developed. The disease is never fatal. Treatment. — From what has been written concerning the causes of enuresis, the treatment will have to be adopted accordingly. The patient should lie on a hard bed, and strict attention be paid to hygienic rules. As bedtime approaches, the quantity of fluid should be limited, and two or three hours after falling asleep the child should be awakened to pass water, and the same thing should be repeated during the night, that the bladder may not get too full. lie should be prevented from lying on his back, and for this purpose a handkerchief tied round the waist, with a knot over the spine. If the urine is high-colored and there are urates, it must be put into a healthy state, but if it is clear and throws down no deposit, the extract of belladonna (gr. \ to gr. J) three times a day is a drug we ought to employ. "It appears generally admitted that of all specilic means the administration of belladonna is the most eflfectual, and such is certainly my experience. I begin with |^th of a grain of the extract three times a day, or a smaller quantity in very young children, and gradually increase the quantity until the fauces and the pupil become affected. If the enuresis is not ma- terially relieved by the time tlie fauces become dry and the pupil enlarged, I leave oflF the drug ; but if there is a material improve- ment, a few days' perseverance will usually cure the disease for a time. I believe that it is liable to recur, as I have seen several 284 DISEASES OF CHrLDREN". cases of relapse. Thej are, however, under the immediate control of the drug, and are, therefore, of no very serious consequence."* In belladonna poisoning there is paralytic retention of urine, con- sequently in these cases of hyperfesthesia of the bladder centres belladonna is useful. t In those cases where no abnormal source of irritation can be discovered it is well to give belladonna. In many cases this drug will effect a cure, but it should be given in full doses, and all 3'oung creatures, including human beings, bear com- paratively larger doses of this agent than are required in the case of adults. " I have been obliged to give as much as 5iss. or even 5ij of the tincture before success was attained.":]: In many cases it is well to add bromide of potassium to the belladonna. If the condition seems to depend on debility, the tincture of the perchloride of iron, with or without strychnia, will be found of service — five minims in a little water three times a da}^ has often proved of great benefit in my hands. The mineral acids, too, are sometimes serviceable. Cold sponging to the loins and lower part of the back in the early morning are useful measures, and in very obstinate cases a blister to the sacrum. " Another local applica- tion, which is very energetic, and in obstinate cases ought certainly to be employed, is the cauterization of the neck of the bladder. Either the stick-caustic should be used, or a solution of ten grains or even more to the ounce. I prefer the former. But it is a very painful application and not free from danger, and should never be employed till after the failure of general treatment."! I have ap- plied to the urethra, a solution of nitrate of silver (9j ad oj), with very encouraging results. The patient, a nervous timid girl, ten years of age, had suft'ered from incontinence of urine from birth, and the treatment hitherto employed had been unsuccessful. The incontinence took place during the night, as well as the day, and the mother said " her child's clothes were alwaj's wet." I used a small uterine sound, and twisted round the top of it a piece of cotton-wool, well saturated with the solution. This was passed along the urethra to the neck of the bladder, and then quickly withdrawn. The application caused no pain at the time, nor any subsequent inconvenience. At the end of a week, the patient had * Holmes, op. cit., p. 585. t A Treatise on Tlierapentics, by II. C. Wood, M.D., 1876, p. 232. X A Guide to Therapeutics, by R. Farquharson, M.D., 1877, p 223. § Holmes, op. cit., p. 584. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 285 only wetted the bed once ; at the termination of a fortnight, twice ; and on both these occasions the incontinence was nocturnah I should state that as the urine was high-coloi-ed and rather acid, I prescribed a mixture of belladonna and bicarbonate of potash, but the good effects were, I believe, largely attributable to the caus- tic application, as the child had been under the care of several medical men, who had, no doubt, eniplo^-ed the usual remedies. In some cases of imperfect development of the cerebro-spinal system, this incontinence of urine is best treated by strychnia, a well-known stimulant to the spinal centres ; in other cases there is a hyperfesthesia of the bladder centres in the cord, and then a sedative like bromide of potassium is indicated ; in some cases, other different sensations than these of a full bladder are received by this centre, and under what may be called a misconception, the efferent impulse is sent off" to the sphincter to relax, and the con- tents of the bladder escape. In such case, careful search for every possible source of such irritation must be instituted, and, if pos- sible, be found and removed. Without that, all treatment is futile. According to Dr. Herbert Tibbits, incontinence of urine in children has yielded to faradization after every other sort of treat- ment had failed. " One sponge should be applied over the symphy- sis pubis, and the other to the sacrum and perinseum alternately."* Sometimes enuresis arises from a long prepuce, and when this is the case there is nothing to do but to remove it. A boy, aged six years, came under my care in 1871, suffering from incontinence, which was perpetually troubling him during the day, but not at night. The prepuce was very long, and the child perpetually put his hands to it, which kept up the irritation. The tincture of the perchloride of iron was given without relief. Hydrate of chloral, in five-grain doses every night at bedtime, caused temporary im- provement, but he soon grew w^orse than ever. Large doses of belladonna kept the disease in check for three weeks, and then the symptoms returned with their former severity. The removal of the prepuce completely cured him. A chronic case of incontinence of urine is recorded by Mr. Teevan, in which a perfect cure was brought about by an opera- tion.! ^ boy, 12 years of age, had suffered from nocturnal incon- * A Handbook of Medical and Surgical Elecrticitv, 1877, p. 215. f Practitioner, October 1st, 1876. 286 DISEASES OF CHILDREN. tinence from birth, and all medical treatment, iucliiding iron and belladonna, had been unavailing. On the 11th of February, 1876, when Mr, Teevan saw him first, the urethral orifice was "not much bigger than a pin-hole," and there was, in addition, "a small blind internal fistula situated just above the sphincter." The sphincter was divided, and the floor of the meatus externus incised. Six weeks afterwards the cure was complete and permanent. Acute cystitis is sometimes met with in children either from injury, or the irritation of stone in the bladder. It is also said to arise from cold, and to occur during the course of febrile affections. The mucous membrane of the bladder is injected and swollen, and pours out considerable secretion. In the chronic form, mucus and pus are freely poured out. The sj^mptoms are straining in passing w^ater, followed b}" a few drops sometimes mixed with blood ; pain over the pubis and weight in the perinseum. In a ease of simple acute cj-stitis which came under my notice in Xovember, 1876, the desire to pass urine was frequent, and very painful. The patient was a girl ten years of age, and no cause could be dis- covered to produce it. There was no indication of stone or other mechanical cause. The urine was neveralbuminous, but frequently high-colored and turbid, and this was the onl}'' explanation that could be offered. Under the influence of rest in bed, and a milk diet, with a mixture of citrate of potash, the symptoms passed off in about a fortnight, the urine never becoming ammouiacal or alkaline. Treatment. — This consists in confinement to bed, and the em- ployment of warm hip-baths at bedtime, if micturition is frequent and painful. A linseed-meal poultice should be employed over the loins, or lower part of the abdomen, if there is much pain. A demulcent mixture of mucilage and liquor potasste, with or with- out opium,* is useful to allay pain and irritation which the acid urine excites. In some cases, tincture of belladonna with citrate of potash is even more eflicacious. As a mild and efficient purga- tive there is nothing better than castor oil. The diet must be simple and no stimulants of anjj- kind should be given. ]\Iilk and * Formula 45 : R. Liquor, potass., 5J Liquor, opii sed., llp^'iij Mucilag., 5SS. Mist, caniph. ad .^iv. — M. A tablespoonful every four hours for a child of eight or ten years old. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 287 water, or milk in soda-water, are the best forms of nourishment. If milk is strongly objected to, then weak veal or chicken broth, and barley-water must be substituted. In this respect, the diet and treatment generally are closely akin to that recommended for the uric acid diathesis. CHAPTER XXIV {continued). DISEASES OF THE KIDNEYS AND URINARY ORGANS. Diabetes: Varieties of . 1. Diabetes mellitus : Sj/mptoms — Causes — Tests for sugar in the urine — Patholor/y— Prognosis — Treatment. 2. Diabetes insipidus, or Sim- ple Diuresis: Symptoms — Causes — Pathology — Treatment. Diabetes mellitus is recognized by a large increase in the urinary secretion, owing to the presence of sugar. The complaint is not frequent in adults, and in children it is exceedingly rare, particularly under five years of age. It is not alluded to by Tan- ner, or Meigs and Pepper, Vogel, or Lewis Smith. Dr. West mentions one case as having come under his observation, in a little girl three and a half 3^ears of age, whose brother at two years, and whose sister at two and a half years, died of the same disease.* Out of a total of nearly 7C0 cases. Dr. Prout only saw one instance in a child of five, and about a dozen cases between eight and twenty years of age, four of whom were females. f Dr. W. Rob- erts met with it in a boy of three years, and he mentions the singular fact that as many as ten deaths from diabetes under the age of one year are recorded in the Registrar-General's Report for 1851-1860.5: Symptoms. — These are gradual in their onset, the disease being generally of some weeks', or even mouths' duration before it is dis- covered. Failing strength and gradual loss of flesh, notwithstand- ing an excessive appetite, excite suspicion that the patient is going wrong. Then the frequent calls to pass urine in immoderate quantities, and the insatiable thirst soon clear up the nature of the malady. It is worthy of notice that there may be urgent thirst before the renal secretion is increased. The urine is of a light * West, on the Diseases of Infancy and Childhood, 1859, p. 655. t Prout, on Stomach and Renal Diseases, 1848, 5th edit., p. 36. X On Urinary and Renal Diseases, 1876, p. 221. 288 DISEASES OF CHILDREX. straw-color, and has the odor of new-mown hay ; it is more or less saccharine in taste, and of high specific gravity, reaching 1030 to 1050, or even 1060. In this respect it differs from albuminous urine, and that of diabetes insipidus. It should, however, be borne in mind that the specific gravity of saccharine urine may be low. Prout mentions a case where it was as low as 1010,* and Dr. W. Eoberts says it may sink to 1015. f There appears to be an an- tagonism between diabetes and gout, the latter ceasing on the sujDervention of the former in adults.;}: As the complaint advances, the symptoms increase in severity, the thirst becomes greater, and the appetite is excessive ; the patient rapidly loses flesh and strength ; the skin is dry and harsh ; the tongue clean and flabb3',or red and aphthous ; digestion is de- ranged,, and pain or sinking at the stomach is often present, with more or less flatulence, or even vomiting ; the bowels are consti- pated and the mind is dej^ressed. In some cases there is sweating at this stage, and even attacks of diarrhoea. Inflammatory com- plications of the pleura and peritoneum may supervene, and later on symptoms of pulmonary phthisis, with diarrhoea and hectic. Phthisis is the most frequent termination according to Prout. The urine now diminishes in quantit}^ the legs become oedematous, and death usually occurs from exhaustion. In some cases death takes place from coma. Causes. — The disease appears to prevail chiefly in families that are phthisical or epileptic. Dr. W. Roberts alludes to a family of eight children who all became diabetic, though the parents were healthy ,§ and instances are mentioned in which it has appeared through the third and fourth generations. The excitins; causes are probably exposure to cold and damp, drinking large quantities of fluid when the bodj^ is heated, excessive use of saccharine articles of food, febrile diseases, and mental emotion. " Glycosuria has been repeatedly observed in cases of pneumonia, whooping-cough, and phthisis, which lead to deficient oxygenation of the blood."|| Some disturbance in digestion and assimilation apj^ears capable of originating it; the kidneys take an excessive action followed by the usual symptoms. * Front, on Stomach and Renal Diseases, 1848, 5th edit., p. 25. f On Urinary and Kenal Diseases, 1876, p. 226. X Lectures on Diseases of the Liver, by C. Murcliison, M.D., 1877, p. 559. § Op. cit., p. 223. II Lectures on Diseases of the Liver, by C. Murchison, M.D., 1877, p. 558. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 289 Diabetes is sometimes of traumatic origin, following injury to the brain or spinal cord. The chief tests for sugar in the urine are three: 1. The Copper Test (Trommer's test). — Put some of the suspected urine in a test-tube, to which add a drop or two of a solution of sulphate of copper. Liquor potass?e to the extent of half the volume of urine is then added, and the mixture boiled. If sugar is present, a reddish deposit of the suboxide of copper is thrown down. When there is no sugar, the precipitate consists of black oxide of copper. Fehling^s solution is a more delicate test than the preceding. Boil a small quantity of the solution in a test-tube, and then add a few drops of urine. If there is much sugar present, a yellowish- brown precipitate of oxide of copper will be thrown down. When no change results from boiling an equal quantity of urine and the solution, there is no sugar present. Pellets containing the constit- uents of the cupric test, introduced by Dr. Pavy, are convenient, and form both a simple and reliable test. 2. Moore's Test. — An equal quantity of urine is to be boiled with liquor potasses in a test-tube, when, if sugar be present, the mix- ture will assume a dark-brown brandy-color. There is some objec- tion to this test, as the same proceeding slightly darkens healthy urine. "Again, all high-colored urines of high density become darker when boiled with liquor potassfe, although free from sugar, and albuminous urines, even when not high-colored, darken sen- sibly under the same treatment."* 3. The Fermentation Test. — A little German yeast is to be put into a test-tube, and then filled to the top with the suspected urine. The tube is now to be inverted in a dish or saucer, and put in a warm place, or in a temperature of 80°. The urine begins to fer- ment, and carbonic acid gas is seen collecting at the top of the tube, and if there is a large quantity of sugar, all the urine is driven out before it. According to Dr. Roberts, this is a less sensitive method of sugar-testing than Moore's plan.f Another plan is to take two glasses of urine ; to one, add Ger- man yeast, and put both aside in a warm place for twenty-four hours ; then take the specific gravity of each ; the dift'erence will indicate the number of grains per ounce. * On Urinary and Eenal Diseases, by W. Koberts, M.D., 1876, p. 183. t Op. cit., p. 183. 19 290 DISEASES OF CHILDBEN. Pathology. — Claude Bernard, in 1848, stated that sugar was secreted by the liver in health, and that if the eighth pair of nerves were irritated at their origin in the fourth ventricle, an abnormal quantity of sugar is produced in the liver. The sugar so formed was supposed to be carried to the heart by the hepatic veins and vena cava, thence it was conducted to the lungs by the pulmonary arteries, and combustion taking place, the sugar was consumed. Further researches have tended to show that it is glycogen, not sugar, that is formed in the liver ; but glycogen is a product so readily converted into sugar, that as far as the pathology of diabetes is concerned, the distinction is not impor- tant. When the sugar formed in the process of digestion is in excess of the capacity of the liver to dehydrate into glycogen, then it appears in the urine. Or in cases where oxj^genation is defective, and the sugar found in the liver and muscles is consequently not burnt off, then also it appears in the urine. We therefore get glycosuria as the consequence of derangement of the digestive act, or in diseases where the blood is imperfectly oxygenized. Fur- .ther, " whatever quickens the circulation of the blood through the liver, particularly in the hepatic arteries, favors the conversion of glycogen into sug'ar, possibly by increasing the amount of albu- minoid ferment ; and, accordingly, whatever paralyzes the vaso- motor nerves of the hepatic vessels, either directly or indirectly, dilates these vessels, produces an increased flow of blood through them, and so leads to diabetes."* Prognosis. — This is very unfavorable, the disease being fatal in the greater number of cases, and the younger the child the greater is the fatality. The duration of the disease is variable. It usu- ally lasts from one to three years. " I saw a case, a child of three years, who died in three weeks. Becquerel mentions the case of a boy of nine years who died in six days."! If sugar persists in the urine when the patient is restricted to a purely animal diet, it is of evil omen. Treatment. — This, in children, is based on the treatment found useful in diabetes in adults ; it mainly consists in regulating the diet, so as to prevent the accumulation of sugar in the blood, for on this depends the excessive thirst, the inordinate appetite, and * Lectures on Diseases of the Liver, by C. Murchison, M.D., 1877, p. 558. t Dr. W. Roberts on Urinary and Renal Diseases, 1876, p. 281. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 291 the emaciation. All food, therefore, containing sugar, or articles convertible into it, should be avoided, espjecially bread and pota- toes, rice, tapioca, and arrowroot — indeed, all matters rich in starch. Some vegetables, as turnips, cabbage, broccoli, carrots, parsnips, peas, asparagus, and seakale, must be avoided. Endive, watercress, lettuce, and celery, may be taken. Sweet fruits, as apples, pears, oranges, and currants, fresh or preserved, are dele- terious. Animal food is chiefly to be relied on ; bacon and ham, fish of every kind, butcher's meat, poultry, game, and broths and soups are permissible. Eggs dressed in any form, cheese, butter, cream — indeed, every form of fat may be taken. Bran cakes, made after the formula of Dr. Camplin, are very serviceable. They are entirely free from starch, consisting of bran, eggs, butter, and milk. Gluten bread and biscuits, prepared by Van Abbott, Princes Street, London, and similar bread of other well-known firms, is to be recommended. There are also almond rusks and biscuits, introduced by Dr. Pavy, and made by Mr. Blatchley, Oxford Street. These may be taken in change with other suit- able forms of diet. Dr. A. S. Doukin relates the case of a girl ten years of age, who was successfully treated by the skim-milk method. The urine ranged from 1040 to 1045. There was great thirst, excessive ap- petite, polyuria, and great loss of flesh. A restricted meat diet, iron, and Dover's powder at night failed to do good, but when the patient was placed on a skim-milk diet the specific gravity of the urine fell to 1016 within a week, and on the thirteenth day of the treatment it fell to 1012, and not a trace of sugar could be detected. In little more than six weeks she had gained five pounds in weight. " This case, and others I have treated, convince me that diabetes is curable in childhood and early life, when the disease is recog- nized earl}^ and the constitution good. On the other hand I have found, contrary to what has been asserted by certain writers, that the disease is quite intractable, especially when considerably ad- vanced, in subjects at or beyond the middle period of life."* Glycerin should take the place of sugar, and in combination with dilute phosphoric acid it allays thirst. Tea and coftee with- out suo;ar are suitable. The patient should drink enough water, and no more than to allay thirst, and lemon-juice may be added to it. * Clinical Transactions, vol. ix, p. 39. 292 DISEASES OF CHILDREN. Exercise in the open air, short of fatigue, is important. Drugs have little or no influence over the disease, the only means that hold out any hope of cure being great care in diet. In the experience of many physicians, opium, however, is a remedy which, when given in large doses, reduces the quantity of urine. It seems to have the power of diminishing the appetite and thirst, and of inducing sleep and allaying irritability. Some physicians have a preference for codeia ; it is equally effective and less constipating. Alkalies, arsenic, bromide of potassium, lactic acid, and peroxide of hydrogen are all useless. A powder of bicarbonate of soda and rhubarb, or castor oil, by correcting the secretions and reliev- ing constipation, will be advisable from time to time. Iron may possibly retard the progress of the disease for a period where the patient is ansemic, and there are no better forms for administration than the ferri et ammonite citras, the tincture of the perchloride, or the solution of dialyzed iron. Cod-liver oil^ too, is useful to support the strength. The clothing requires to be warm, and flannel should be worn next the skin. A residence at the seaside, or even sea-bathing will be advantageous in some cases. The best foreign watering-places are Carlsbad and Vichy. Finally, all those hygienic measures ought to be carried out which naturally suggest themselves where the kidnej^s are doing excessive work. Diabetes insipidus is characterized by great thirst and excessive discharge of pure limpid urine of low specific gravity (1003 to 1007), containing neither sugar nor albumen. In a table of seventy cases given by Dr. W. Roberts, seven occurred in infancy, and fif- teen from five to ten years. In two or three of the cases the dis- ease existed at birth.* As in diabetes mellitus, the complaint would seem sometimes de- pendent on gastric and intestinal disturbance, but in a large pro- portion of cases no cause can be ascertained. Exposure to cold, by checking the action of the skin, and throwing more work upon the kidneys, has originated the complaint ; drinking large draughts of cold water, violent muscular exertion, cerebral tubercle, febrile diseases, blows and falls, syphilis and hereditarj^ influences appear to be among the most frequent causes. The exact cause has been attributed to some change in the renal capillaries, which allows of * On Urinary and Kenal Diseases, 1876, p. 198. DISEASES OF THE KIDNEYS AND URINARY ORGANS. 293 an increased quantity of watery fluid being separated from the blood, just as happens in a hysterical paroxysm. Dr. Handfield Jones considers that the Malpighian capillaries are more affected than those of the tubular plexus.* Some authorities consider the disease neurotic. Symptoms.— These may be gradual, the disease having lasted from infancy to maturity in some cases, or it may come on quite suddenly. " In two cases the symptoms commenced immediately after violent muscular efltbrt. One was a boy of twelve, who strained himself in pushing a cart-wheel sunk in the mud."t The urine is colorless, and containing a very small proportion of solid constituents, having a specific gravity nearly as low as water itself, 1003 to 1007 ; it is of acid reaction, but quickly becomes neutral or alkaline, and undergoes decomposition. The skin is generally harsh and dry, and the thirst intense, arising no doubt from the greater quantity of urine passed than in saccharine dia- betes The general health is often wonderfully preserved, not- withstanding that the disease may have existed from an early period of life. Dr. W, Roberts mentions the fact of a boy of ten years of age under his care, being well nourished and in good health, though he passed fifteen pints of urine dailj'' for several months.:}: In most instances, however, symptoms resembling those met with in diabetes mellitus are present ; there is loss of flesh, thirst, voracious appetite, heat and drjaiess of the skin, pains in the limbs and loins, and irritability of temper. The disease is of uncertain duration, and generally terminates in phthisis or cere- bral disease. Pathology. — After death the kidneys have been found degener- ated and containing very small abscesses. The base of the brain has revealed miliary tubercles in a few cases. "The pathology of diabetes insipidus appears to be somewhat similar to that of diabetes mellitus, only that the renal vessels are dilated instead of the hepatic ones."§ Treatment. — Valerian in large doses is well spoken of by Trous- seau and Handfield Jones. In a boy, ten years of age, under the care of Dr. W. Roberts, the valerianate of zinc in gradually in- * On Functional Nervous Disorders, 1870, p. 790. t Eoberts, op. cit., p. 200. J Op. cit., p. 204. ? Diabetes Insipidus, by Lauder Brunton, M.D., Keynolds's System of Medicine, vol. V, p. 430. 294 DISEASES OF CHLLDEEST. creasing doses, up to twent}' grains daily, reduced the urine from fifteen to five pints a day, and greatly diminished the thirst.* Camphor, iron, ergot, and galvanism have been tried with varj^- ing success. Mercury and iodide of potassium have been found serviceable where the disease is of syphilitic origin. The disease, however, can scarcely be considered amenable to treatment. Xo remedy has been known to cure it, and it has usually a fatal ter- mination. A normal appetite, and the absence of organic compli- cation, may be looked upon as favorable signs. CHAPTER XXY. DISEASES OF THE PERITONEUM. ActjTE Peritonitis: Symptoms — Causes — Morhid appearances — Diagnosis and prog- nosis — Treatment. Chronic Peritonitis: Causes and treatment. Tuberculae Peritonitis (Tabes mesenterica) : Symptoms — Causes— Consequences — Morbid appearances — Diagnosis and treatment Enlargement of the Abdomen. Acute peritois'Itis is a very rare disease in children, the mucous membranes being much more prone to inflammation than the serous in the young. AYhen it is present the symptoms resemble thdse observed in the adult. In the new-born infant, peritonitis is more common than in later childhood, and syphilis appears to be a frequent cause of it at that early period. There ma,}^ be con- stitutional evidence in the hoarse voice and copper-colored erup- tion over the body. Eilliet and Barthez met with a dozen cases of acute peritonitis. " M. Thore found that acute peritonitis ex- isted in about six per cent, of all the infants who died at the Hospice des Enfans trouves."t Peritonitis, which is rarely a primary disease, may commence rather suddenly with rigors and shivering ; more frequently it comes on gradually in the course of some other disease, with pain in some part of the abdomen, as about the umbilicus or hypogas- trium, and from thence it spreads over the whole abdominal region. The slightest pressure is intolerable, not even the weight of the bedclothes can be borne ; the child lies on his back with his knees * Op. cit., p. 215. t Diseases of Children, Dr. Churchill, 1858, p. 592. DISEASES OP THE PERITONEUM. 295 drawn np, to relax the muscles of the abdomen. The face wears an anxious and painful expression, the lips are compressed, and the nostrils active ; the breathing is short and thoracic, for as the diaphragm descends on full inspiration, the abdominal pain is in- creased, but the epigastrium may rapidly rise and fall at the same time. In such cases I have known the respirations to reach 80 per minute. The bowels may be constipated or relaxed, and the urme scanty and high-colored. Occasionally the bladder is para- lyzed, and the urine has to be drawn off. The tongue is clean, or it has a whitish fur upon it, which soon becomes dry. There is thirst and loss of appetite. The disease may drag on for some days, during which the skin becomes moist and damp, the pulse feeble and fluttering, and there is vomiting of cofiiee-colored fluid, besides gaseous distension of the abdomen, torpor of the mental faculties, and death by asthenia is often the result. Sometimes the disease is more limited and circumscribed ; it does not extend over the whole abdomen, and yields to the remedies employed. Causes. — Peritonitis may arise from cold, wet, fatigue, and bad living. A, fatal ease is recorded by Mr. Jeaftreson, of JSTevvcastle- oii-Tj-ne, of a girl fifteen years of age, from perforation of the rectum with a walking-stick, which her uncle was holding between his legs whilst she was jumping on his knee. A rent was dis- covered in the anterior wall of the rectum, through which the finger could be passed into the peritoneal cavity. Peritonitis ensued, and death took place within forty-eight hours* It some- times occurs as a sequel to scarlatina. Dr. Burney Yeo has related an instructive case of " infective peritonitis " in a boy twelve years of age, complicating an attack of whooping-cough, and terminating fatally. There was pneu- monic infiltration of the left lung and fluid in the left pleural sac. He quotes from Ziemssen's Cyclopcedia to the eftect, that pus may pass from the pleural cavity through the diaphragm into the peri- toneum, and there set up fatal peritonitis.f Several cases have come under my notice in which septicaemia in women, springing from operations involving the peritoneum, has extended to the pericardium and pleural cavities. Peritonitis has followed inflamxmation of the csecum, from the impaction of a foreign body in the vermiform appendix. The * Brit, Med. Journ., 1874, vol, ii, p. 403. t Ibid., December 7tb, 1878, p. 827, 29G . DISEASES OF CHILDPwEX. disease may terminate iu twenty-four hours, or last four or five weeks. It may also follow injuries or operations on the abdomen, as tapping. The morbid changes detected after death, are the effusion of lymph over the peritoneal surface and amongst the intestines ; the vessels of the peritoneum and abdominal wall are injected ; and there is clear or lemon-tinted serum in the peritoneal cavity, or even a thick or thin muco-purulent matter. The spleen and liver may be coated with lymph. - In a case related by Dr. West, of a boy, nine 3-ears of age, a pint of pus was found in the right pleura, the inflammation having extended from the abdomen to the thorax.* This is not an uncommon coincidence. The diagnosis from colic has been already given, f but we may repeat that in peritonitis the constitutional symptoms are more severe, the pain is increased on pressure, it is not paroxysmal, and the pulse soon becomes quick and feeble. As the disease assumes a more chronic form, crepitation can often be felt by the hand, when it is laid on the abdomen above the effused lymph. The prognosis is grave, unless the inflammation is limited in ex- tent and moderate in decree. Treatment. — Where the patient is strong enough, a few leeches should be applied to the abdomen, and it may be even necessary to repeat them. This requires to be carried out effectually if the case be seen early, and the child is able to bear depletion well. It offers the best chance of relief. Then warm light poultices are very comforting, and they should be frequently renewed. Small doses of calomel, combined with opium or Dover's powder, are also serviceable to allay pain and abate inflammation. Opium is in- valuable in peritonitis, and should be given freely. If the bowels are constipated for any length of time, warm-water enemata, and an elastic tube passed up the anus to favor the escape of gas will be advisable. The diet should consist of milk-and-water, thin ar- rowroot, or weak beef tea, according to the state of the stomach and the strength of tbe patient. When peritonitis succeeds scarlet fever the symptoms are less acute, but, owing to the defective elimination of urine by the kid- neys, dropsy is very apt to arise. Chronic feriionilis may be the sequel of an acute attack, or it * Diseases of Infancy and Cli'ldhood, 4tli edit., p. 618. f See Chap. XVII, On Constipation and Colic. DISEASES OF THE PERITONEUM. • 297 may arise from the irritation of tubercles in the peritoneum of strumous subjects. The symptoms are abdominal pain and tender- ness, with more or less swelling ; sometimes crepitation can be felt from the efiusion of Ij-mph between the folds of the intestines. If this does not cause fatal obstruction the case may recover, but w^jere the complaint is due to the irritation of tubercle, the mesen- teric glands are apt to become involved, febrile disturbance comes on in the evening, food is vomited, and death takes place from phthisis or exhaustion. The treatment consists in supporting the general strength by nu- tritious and easily digestible food, such as milk, raw eggs, cod-liver oil, or malt extract. A blister to the abdomen is sometimes of service. Tabes mesenterica is a chronic tubercular disease of the mesenteric glands, and is sometimes associated with tubercular peritonitis. Enlargement of the abdomen is the first symptom which attracts notice, and there may be some amount of fluid in the peritoneal cavity. A child may be quite well and strong till he is seized with whooping-cough, or one of the exanthemata, and from that period the disease commences. He gradually loses flesh and strength, and if he has been accustomed to run about he now ceases to do so ; he complains of being tired, and wishes to be nursed by his mother. The complaint sometimes commences with looseness of the bowels, the motions being thin and yeastlike, containing mucus or even streaks of blood. Then the abdomen begins to swell, and is tender on pressure, colicky pains are common, and the child will lie on his back in bed with his legs drawn up. He often cries out with pain, and the face is pinched and drawn. On examination, the liver may sometimes be felt below the ribs, and the spleen also. As the case goes on, the abdomen becomes irregular in shape, and in some cases crepitus can be detected when the hand is passed lightly over it, from the efi"usion of semi-organized lymph. As the disease advances, an irregular nodular mass may be felt about the umbilicus, or to one side of it. This is frequentl}^ found to consist of omentum, mesentery, and intestines glued together, and among this mass there are enlarged mesenteric glands, sometimes the size of a filbert. As the disease goes on, some degree of ascites is present, and the lumbar regions are dull on percussion. Emacia- tion sets in, there is constant vomiting and diarrhoea, the pulse be- comes quick and small, the temperature rises in the evening, and 298 DISEASES OF CHILDREN. the child dies exhausted or in convulsions. The disease ma}'- ter- minate by bronchia] phthisis, puhxionarj consumption, or tubercu- lar meningitis. Disease of the mesenteric glands may lead to intestinal occlusion. In the case of a boy, four years of age, who came under my care at the Samaritan Hospital in 1878,* there was considerable distension of the abdomen, and symptoms of obstruction a few days before death, which was preceded by coffee-grounds vomiting, convulsions, and unconsciousness. After- death, the intestines and omentum w^ere found glued together in a large mass, and adherent to the peritoneum at the umbilicus and brim of the pelvis. The diagnosis is generally not difficult; the liver is often healthy, and as the disease advances the belly becomes irregular over its surface, and more painful than in ascites. There is often a fluctu- ation in the temperature, and the signs of tubercular mischief in other organs as the complaint advances. The treatment consists in maintaining the general strength and meeting the chief symptoms as they arise, but it is very unsatis- factory. If there is any amount of peritonitis, opium in some shape or other must be given, and linseed poultices be applied to the abdomen to relieve the pain and tenderness. When diarrhoea is very active, a little chalk mixture with catechu or krameria (Form. 31, 32) will be necessary, and the diet must consist of rice, milk, and arrowroot. The treatment is much the same as should be employed in chronic diarrhoea. When the bowels are quiet the syrup of the iodide of iron and cod-liver oil, if the stomach will retain it, should be prescribed. I have found painting the abdo- men night and morning with a weak tincture of iodine (1 in 7) useful, and then applying a flannel bandage. I prefer this to rub- bing any kind of ointment into the abdomen. When the child is well enough to be moved, change of air to the seaside will be ad- visable. Enlargement of tlie abdomen\s very commonly observed in delicate children who are rickety or of a strumous habit of bodj', but I have seen it in fairly developed children who. are otherwise healthy. The parents observe that the abdomen is disproportionately large to the rest of the body, and that it becomes very much so after food. In many cases the increased size is chiefly due to flatus in the intestines, to constipation, and improper feeding. The abdomi- * Lancet, Aug. 10th, 1878, p. 185. ASCITES. 299 nal walls yield and become overstretched ; the abdomen is soft, pressure gives no pain, and no tumor can be felt. This condition is sometimes seen with congestion of the liver, and with that con- dition known as '' pot bell}'." I have noticed it not rarely in deli- cate children after an acute illness, as whooping-cough or measles. In children brought up by hand, with delayed dentition, it is not uncommon. It arises chiefly from the accumulation of gas in the intestines; a clear tympanitic note is heard all over the abdomen, especially in the left hypochondriura, and in both flanks. The epigastrium is prominent, either from undue distension of the stomach, or of the transverse colon behind it. " The little child's abdomen is large because its abdominal ar^d intestinal muscles are weak, its pelvis is shallow and small, its diaphragm flat, and its liver and spleen large, and because much flatus is formed in its small intestines, especially during the digestive process."* Enlargement of the abdomen, when seen in connection with tubercular peritonitis, causes pain on pressure ; the abdomen is irregular in outline, partly from the enlarged viscera beneath or from semi-organized lymph ; the bowels are often very loose, and the belly painful ; the face is pinched, and the child rapidly loses flesh. The liver may remain very large without any impairment of the general health, a condition we sometimes see in connection with the strumous diathesis and freneral cachexia. CHAPTER XXVI. ASCITES. Causes — Nature — Sijmjjtoms — Diagnosis — Treatment — Iron — Saline aperients — Copaiba — Paracentesis. Disease of the liver, by obstructing the portal circulation, is the most common cause of ascites in children, but it may arise also from great enlargement of the spleen, from chronic peritonitis, and from tabes mesenterica. The enlarged glands in the latter disease cause friction and irritation of the peritoneum, and so lead "" On Extra-pelvic Tumors of tlie Abdomen, by Sir W. Jenner, Bart., M.D., Brit. Med. Journ., Jan. 2d, 1869, p. 2. 300 DISEASES OF CHILDREN. to serous effusion into the cavity. It has been supposed to arise from the pressure of enlarged lymphatic glands on the portal vein near the liver.* It appears to me that cachexia and anaemia are not uncommon causes of this form of dropsy. In the absence of any history of acute illness, and if organic disease is not present, it seems a reasonable inference that a loss of tone in the perito- neum or lymphatics may favor the secretion of serum into the peritoneal cavity. I have published a case in illustration of this view.f Symptoms. — The abdomen is more or less prominent in propor- tion to the amount of fluid present. If the distension is great the diaphragm is pushed upwards, and there may be some dulness on percussion and defective expansion in the lower lobes of the lungs. Over the seat of effusion the percussion-note is dull, chiefly heard in the flanks, and more in one flank than in the other wlien the patient turns on his side. Along the anterior surface of the abdo- men the percussion-note is clear, and this varies according to the amount of air which the intestines contain ; the higher they float the more tympanitic is the note. The constitutional symptoms are a gradual decline in the general health; the skin is dry; the bowels are usually constipated ; the urine is scanty, acid, and high- colored, from the presence of urates, which may be whitish instead of pink ; there is often thirst and a voracious appetite. As the abdominal distension increases, the superficial veins become en- larged and tortuous ; the child is thin and wasted, the features are pinched, and the nights restless and wakeful. As the disease advances the emaciation increases, a hectic flush appears on the cheeks at night, the pulse becomes rapid and feeble, respiration is accelerated, and death takes place from exhaustion. The diagnosis mainly rests on the primary and uniform swelling in the abdomen, without any oedema of the legs, and the absence of swelling in the upper parts of the body, the presence of disease in the liver, and the high-colored, scanty, and non-albuminous urine. As ovarian cysts have been met with in children, this fact should be borne in mind in all cases of doubtful diagnosis. Hydatid cysts of the liver, hydronephrosis, enlarged spleen, and mesenteric glands must also be taken into consideration, and the conditions * Brit. Med. Journ., Nov. 20th, 1875. t Ascites in a Young Child ; Treatment by Paracentesis and Copaiba ; Eecovery, by W. n. Day, M.D., Clin. Trans., 1877, p. 164. ASCITES. 301 belonging to each carefully investigated. The chief points of diagnosis in the case of ovarian tumors, as distinguished from ascites, are to be found in Mr. Spencer Wells's work.* Treatment. — This to a great extent depends upon the cause. If there is disease of the heart, lungs, or kidneys, these affections must receive appropriate treatment; but usually, however, the mischief is seated in the liver, which we must endeavor to over- come. Whatever may be the cause which has induced the disease, the bowels should be kept freely open, and for this purpose the compound jalap powder, given early every morning, is a good remedy to drain off the fluid. When the urine is scanty and high- colored, digitalis and citrate of potash will relieve the congestion of the kidneys and act as a brisk diuretic. ' Then the syrup of the iodide of iron is a good tonic, or the tincture of the perchloride of iron may be given. Ascites has over and over again yielded to tonics, and they ought to have a steady and ftiir trial where the effusion appears to be independent of any organic lesion. f If these remedies fail, as they frequently will do, copaiba is an excellent remedy, according to some authorities, acting as a diu- retic and carrying off much fluid by the bowels. In the case just alluded to, I believe its action was that of a general tonic and not that of a diuretic. It does not disagree with digestion or appe- tite. Other cases of ascites are recorded which have yielded to the use of copaiba. Dr. Liveing's two cases of improvement seemed due to its action as a diuretic, but it should be held in mind that the urine was albuminous in both, and remained so when the patients left the hospital, although the dropsy had en- tirely disappeared. There was chronic (Bright 's) disease in one, and a soft systolic bruit at the cardiac apex in the other, so that the relief at best was only temporary.:}: When all drugs have proved unavailing, and the increasing pressure causes pain and discomfort, paracentesis must be had recourse to, and the operation should be performed before the abdomen is too much distended. The tonic treatment and the copaiba may be again employed after the tapping, and a perma- nent cure may follow the operation in some cases when it has * Diseases of the Ovaries, 1872, p. 125. f Case of Ascites treated successfully with Tonics, by J. S. Bristowe, M.D., Clin. Trans., 1869, p. 12. X Cases of Ascites treated with Copaiba, Clin. Trans., 1870, p. 30. 302 DISEASES OF CHILDREN. been twice performed. Sucli cases seem generally due to liver disorder, or to debility and ansemia. CHAPTER XXVIT. INTESTINAL WORMS. Varieties of — OxYURis VERMrcuLARi^, or Ascaris Ver^iiculaeis — Ascarides (Threadworm) — Ascaris lumbricoides (Round-worm) : Symptoms — Causes — Treatment. Trichocephalus dispar (Long Threadworm) — T^nia or Tape- worm : Treatment. The presence of worms in the intestinal canal is one of the com- monest troubles of childhood. Worms produce in some cases an amount of constitutional disturbance and local irritation which the best observers may be pardoned if they attribute to specific disease. It is with the two nematodes, Oxyuris and Ascaris^ that we have generally to deal in childhood. The Oxyuris vermiculcuis, or threadworm, has its headquarters in the csecum, but frequently descends to the lower part of the large intestine or rectum. AVorms infest children, whether living in country districts or in the con- fined dwellings of houses and cities ; but their presence is not neces- sarily incompatible with previously good health. They are not uncommon in strumous subjects, or in children laboring under chronic disease, in whom the digestive and assimilative functions are at fault — where there is subacute inflammation of the intes- tinal glands (muco-enteritisj. They are often spoken of as " ascar- ides," since Linnseus placed their species under the genus Ascaris. But the term is confusing, as they have long been classified under a separate genus, Oxyuris, and must not be confounded with the long worm Ascaris lumbricoides. In a mass of Oxyuri, or threadworms, the majority are females, and aj)pear like little moving pieces of thread, about a quarter of an inch long, with a pointed tail. The males are shorter, and keep the anal end of their body more or less coiled up. The eggs are commonly introduced by the habit which children have of biting their nails. They are hatched in the stomach, the larvae under- INTESTINAL WORMS. 303 going their subsequent growth and metamorphosis within the alimentary canaL Symptoms. — The appearance of the parasite in the motions is of course the only pathognomonic sign ; as it almost exclusively inhabits the large intestine, it is very rarely vomited like the true Ascaris,^ though the constitutional symptoms are the same in both affections. But the presence of threadworms in the bowels excites symptoms of reflex irritation, by which they may be suspected before they are seen. Itching of the nose and anus is the most frequent feature of this kind. At night the irritation becomes so great that sleep may be prevented, and in any case the child is certain to indulge in the dirty habit of continually touching the anus. The finger nails often excoriate the skin around that orifice, leaving marks once erroneously believed to be caused by the biting of the worms. The irritation causes a free discharge of nmcus from the lining membrane of the intestine, and the child con- stantly voids this at stool by straining, and thereby often produc- ing prolapsus ani. The worms appear in the motions in great numbers, and escape of their own accord from the anus ; they even enter the vagina in female children, and set up leucorrhoea. Symp- toms of vesical irritation also develop themselves, sometimes simu- lating calculus, more usuall}^ seen in the form of a frequent desire to pass water. Priapism is also not unfrequently observed in male children troubled with threadworms, and Lallemand was of opinion that in this manner the parasites produced the habit of masturba- tion, with its consequent evils. All general disorders, especially those of the nervous system, are aggravated by the presence of threadworms ; this particularly applies to the spastic contractions of muscles which produce some forms of talipes. Treatment. — As the threadworms are mostly confined to the lower part of the large intestine they are within the access of enemata. An injection of infusion of quassia, mixed with table- salt or sulphate of iron, is perhaps the most effectual method of treatment ; but as it seldom or ever effects a cure at once it must * Dr. Goubert, in his recent work, Des Vers chez les Enfants, remarks thai " they can never reach the stomach or tlie small intestine, and consequently can never be thrown up in vomiting, as Brera and P. Franck have asserted." But Dr. Parapa de- scribes a case wliere a child aged ten was ti'oubled by Oxyuri appearing in her mouth _in the evening, Lond. Med. Eecord, 1878, p. Q'lL 304 DISEASES OF CHILDEEN. be frequently repeated.* Lime-water is another good application.f Since the bowels generally act irregularly when threadworms have remained long in the large intestine, the treatment should be com- menced in all cases by the administration of an alterative aperient, such as gray powder and rhubarb, or rhubarb and soda. When children are strong enough, one grain of calomel and three of scammonj* is a good aperient to start with. The mucous discharge produced bj' the irritation of the parasites appears to afford lodg- ment for them, and so must itself be cleared away to insure their complete expulsion. They rapidlj' reappear. Two or three grains of santonin at night, followed by a dose of castor oil in the morn- ing, will efi'ect the discharge of these threadworms. Afterwards steel wine, or the tincture of perchloride of iron, will be useful. " Iron, in these circumstances, acts, I believe, not merely as a tonic, but also by its admixture with the secretions, it renders the intes- tinal mucous membrane unsuitable to serve as a nidus for the re- production of the worms.":]: Dr. E. Liveing informs me that as a local application, about an equal quantity of mercurial ointment and lard, smeared on the anal aperture at night, will prove effectual in relieving the itching and preventing the escape of the worms and ova. The child thus gives up the habit of scratching with the fingers, by which the ova are introduced under the nails and then convej^ed to the mouth. Children should not be permitted to drink 'unfiltered water, nor to eat salad, radishes, or cress, unless thoroughly washed, as the ova of the Oxyuris are possibly transmitted in this way. It is significant that of country children, the peasant class are the most subject to intestinal worms. Of course they have more opportu- nities of drinking out of wells or brooks, and of eating raw food, than have young people in town. So long as infants are fed with breast-milk they are not troubled with worms. * Formula 46 : R. Sodii chlorid. vel Ferri eiilph., ......... ^,j Inf. quassiae, ......... Oj Fiat enema. A third part to be used every morning, f Formula 47 : R. Liquor, calcis, . . . . . . . . • ^^j Fiat enema. To be used every morning. X West, on Diseases of Infancy and Childhood, 1859, p. 637. INTESTINAL WORMS. 305 The Ascaris lumbi'icoides, or round-worm, by no means rare, is however less frequent than the threadworm. It is best to dis- tinguish the two species by their English names, for, as I have above remarked, the generic name Ascaris is still retained by many in speaking of the Oxyuris^ though the two worms are very different in appearance. The round-worm is a very large parasite, always several inches in length when full grown, and sometimes a foot long. It bears a strong superficial resemblance to the com- mon earth-worm [Lumbricus terrestris)^ which is not a nematode at all, nor even does it belong to the class Scolecida. The earth- worm is included in the sub-kingdom Annulosa, and, like the leech, it differs from the Crustacea in lacking true feet. Inde- pendently of the different internal structure this worm is much stouter than the Ascaris, and bears eight rows of minute bristles, which give its integuments a rough feeling. The male Ascaris is rarer and smaller than the female, and its anal extremity is curved as in Oxyaris. Davaine has shown that the female produces over 50,000 eggs ! That observer, confirming previous researches, has proved that the eggs do not hatch in the intestine of the child in whom the parent worm dwells. The ova are expelled in the fseces, and find their way into sewage-water, etc. They are absolutely indestructible by any natural force, though boiling, or many other artificial processes, will destroy them. They are introduced into the bowels by unfiltered drink- ing-water, etc., and, being dissolved by the action of the digestive juices, the embryos which they contain are set free.* Not only does the Ascaris difter from the Oxyuris generically,, but it difiers also in habitation. It dwells in the small intestine,, often in numbers, but never in such masses as are seen in bad cases of accumulations of threadworms in the rectum It is not unfrequently vomited. A countrywoman in one of the wards of the Samaritan Hospital, in the autumn of 1878, brought up a lum- bricus during an attack of sickness after ovariotomy. Mr. Albam Doran informs me that a man in St. Bartholomew's Hospital, in * Davaine, Traitd des Entozoaires et des Maladies Vermineuses de THomme et des Animaux Domestiques. Goubert's work, already quoted, contains a very clear, yet short, description of Ascaris and Oxyuris. The works of Cobbold and Kiichenmeister- should be consulted by tliose desiring minute details with regard to entozoa. 20 306 DISEASES OF CHILDREN. 1870, vomited several when dying of dysentery contracted a few months before in Buenos Ayres. Still oftener do children throw up round-worms, and in violent retching the parasites may be expelled through the nares as well as by the mouth; or they may remain in the nasal cavities a short time, and suddenly appearing out of the nostrils cause great alarm to the patient and his parents. The Ascaris sometimes escapes out of the cavities of abscesses formed after perityphlitis when such collections of pus are opened spontaneous!}' or surgically. They may also enter the peritoneal cavity through tjqjhoid or gastric perforating ulcers. But Davaiue has shown that it is quite impossible for the worm to force its own way through the coats of the intestine, as it is not provided with cutting or boring appendages. Symptoms. — This worm gives more trouble than the Oxyuns^ and often produces much reflex irritation. The bowels act in an irregular manner, dull pain is felt around the umbilicus or in the epigastrium, and there is itching at the nose and anus. Any malady from which the patient is already suiFeriug will be aggra- vated. But since, as in the case of the threadworm, the appear- ance of the worm itself is the only reliable symptom, it is most "unjustifiable to subject a child to a long course of worm medicines on suspicion alone. If the worm real!}' exist in the intestine, it will soon be discharged in the motions after a few days of treat- ment. It must be remembered that in cases of round-worm some morbid condition of the intestinal mucous membrane very often pre-exists. Treatment. — Prophylaxis is more important and more efficacious in the management of disorders caused by this parasite than in cases of invasion of the Oxyuris^ for the round-worm always appears to be introduced, as an egg, in water, whether taken pure or with raw food washed for the table. As for cure, the physi- cian, knowing that these parasites often do little harm, must not forget that Davaine has recorded several fatal cases where a round-worm has found its way through the glottis during a fit of vomiting. JSIoreover, the reflex results of the presence of the parasites induce dirty habits, such as picking of the nose or scratching the anus. By far the best remed}^ for the round-worm is santonin. From ■one to six grains should be given to a child, according to age ; it INTESTINAL WORMS. 307 may be administered in a powder mixed with sugar,* or as the compound scammony powder. f Dr. Eustace Smith speaks highly of santonin in the form of confection.:}; It is advisable to follow up its administration by a dose of castor oil, and then to give tonics, particularly steel wine, or the mineral acids with some bitter infusion. I am in the habit of giving the santonin every other night for about four nights, and daring the day a tonic of iron, arsenic, or quinine. I sometimes combine these three reme- dies together, but I am generally content with the two first (Form. 93). The persistence of the parasite after long treatment will most likelj^ be due to the neglect of prophylactic measures, such as a careful examination into the water-supply and the sani- tary measures. Another nematode, TrichocejoJialiis dispar, infests the caecum and colon. It measures over an inch in length, and the anterior part of its body is filiform, the posterior being much stouter. It is remarkable for producing, as a rule, no symptoms of irritation, and it is only recognized in lifetime by the appearance of its ova in great quantity in the fseces. It may be expelled by doses of santonin, or active aperients. § Tapeworm. — The tsenise are Scolecida, arranged in a distinct order very different from the nematodes. Their anatomy is very at bedtime. Pulv. jalapse, Sulphuris loti, Conf. Sennee, 3j tliree times a day. gr. iv-vj * Formula 48: R. Santonin, Saccbari, Fiat pnlvis. To be taken every third night. t Formula 49 : li. Santonin, ..... Pulv. scaramonii co., . Fiat pulvis. To be taken X Formula 50 : R. Santonin, Pulv. zingib., gr. V. gr. XV gr. V 3ss. 5J--M. ? The practitioner wishing to identify a parasite which he believes to be Tricho- cephalus clispur, will find specimens (Nos. 8(3 and 87) in the collection of Entozoa at the Museum of the Eoyal College of Surgeons, arranged by Dr. Cobbold. 308 DISEASES OF CHILDEEN. complicated, and their method of propagation has ah'eady been described in the chapter on " Hydatid Diseases."* " The tseniaf is rare in childhood ; in 206 of Wawruch's cases, 22 were children under fifteen years of age, the youngest was 3| ; Legendre {Archives Generale de 3Jedecine, vol. iv, p. 642) has collected from different authorities 26 cases of tapeworm in chil- dren under twelve. (In children from fourteen to fifteen months of age, 2 cases ; two years old, 1 case ; three years old, 2 cases ; four years old, 2 cases; five years old., 3 cases; six years old, 3 cases ; seven years old, 4 cases ; eight and nine years old, 1 case ; ten years old, 2 cases; eleven years old, 4 cases; twelve years old, 1 case.) Hufeland, quoted by M. Davaine, has seen an infant six months old, and at the breast, subject to tapeworm; 'on different occasions he passed up to twenty meters (over sixty-five feet) of tasnia, sans accident retentissant sur sa sante."^ The treatment will be similar in childhood to that adopted for adults. The remarkable words which we have left in their origi- nal language at the close of the above quotation fortunately apply, at least to a^ great extent, to most cases. The extract of male- fern is as efiicacious in the young as in the old. It is a good plan to see that the bowels are effectually emptied before beginning the specific treatment, and to attain this end a mild aperient should be given occasionally, and the diet, for a few days, ought to consist only of milk and beef tea. When the attempt is made to dislodge the parasite a dose of castor oil should be given at night, and the oil of male-fern early on the following morning.:]: Foreign writers prefer pomegranate and kousso for children. Goubert gives 15 grams (equivalent to 231 grains) of pomegran- ate-root-bark, in decoction, to children under five, and 20.40 grams for a child from six to twelve, in 750 grams of water, t . * The Mnseuni of the College of Surgeons contains numerous specimens of the beef tapeworm {T. mediocanellaia) . One of these is from a little girl (Entozoa series, No. 116). This is much nioi-e common than the pork tapeworm {T. solium). Dr. Cobbold estimates tlie jij-oportion in England at 94 per cent, in favor of the former species, f (jroubert, op. cit. J Formula 51 : R. Ext. filicis li(}uid., J5ss.-3j Syr. zingib. . . 3,j Pulv. acaciae, ......... gr. x Afpiam cinnamoni ad ^j. — M. Fiat haustus. For a child from five to ten years old. INTESTINAL WORMS. 309 to be taken in three doses at intervals of half an hour, followed by castor oil if the parasite be not passed within six hours. The exotic and rarer parasites hardly come within the scope of this work. But, in conclusion, a few general remarks may be made on the symptoms which worms are capable of producing, and how difficult it is sometimes to form a diagnosis. Symptoms of an obscure and deceptiv^e character, which cannot be classified under any definite disorder, and which vary from day to day, are frequently cleared up by the discovery of worms. Lurking mischief in the lung or brain has been apprehended in some cases, or the approach of fever has seemed imminent in others. Fits of passion, violent screaming, restless sleep, and even fits of epilepsy or chorea, have been ascertained to depend upon these parasites in the intestines, and the symptoms have been found to pass away on their expulsion. A child so affected loses its animation, and is languid and out of sorts ; it suflTers from headache, and its temperature is high in the evening. This has been known to reach 103°, or more. The child becomes weak and thin, and ceases to thrive ; the appetite is capricious, and it some- times refuses almost any kind of food that is offered, while at others it is quite ravenous ; the eyes are dark and hollow, the tongue is furred, and there is sometimes a dry hacking cough, which makes parents anxious, although they are assured that no lesion in the lungs can be discovered. Such cases are often ascribed to commencing tubercular mischief in the lungs or brain, and the best observers have been misled in their di§,gnosis. The cough being the result of intestinal irritation the child recovers its usual health as soon as the worms are removed. These symptoms are very treacherous, and they continue so obstinate in some cases that only time can clear up their true meaning. They may simulate brain disease by the occurrence of a convulsion followed by squinting. Vogel mentions the case of a child who was attacked by convulsions, and a few days after with all the symptoms of acute hydrocephalus, followed by death in a few hours. On a post-mortem examination, the brain and all the internal organs were found in a perfectly healthy state, " but in the intestinal canal there were more than a hundred round-worms, rolled up in small and large balls, at some points completely choking up the calibre of the canal ; the mucous mem- brane itself in the same regions had become reddened."* * Diseases of Children, 1871, p. 207. 310 DISEASES OF CHILDREN". CHAPTER XXVIII. DISEASES OF THE NASAL CAVITIES. CoRYZA — Nasal Catarrh (Common Cold, or Cold in the Head) : Nature — Causes — Pathology — Symptoms — Treatment. Oz^na: Nature — Causes — 3 Forms. 1. Scrofulous Oz^na. 2. Syphilitic Oz^na. 3. Traumatic Oz^na : Siimptoms — Treatment. Epistaxis: Nature — Causes — Treatment. Laryngeal and Tracheal Irritation in Young Children : Symptoms and causes — Diagnosis from croup — Local and general treatment. The entire mucous membrane in infancy and childhood is prone to morbid action, commencing at the mouth or nostrils, and fre- quently exciting catarrh, not only in the larynx and air-passages, but in the intestinal tract also. The mucous membrane of the nose is liable to hypersemia, in- flammation, and tumefaction. Coryza, or cold in the head, is a common ailment, and is fre- quently observed in delicate and strumous children. It is most common in winter, but it may occur at all seasons of the year. It may be associated with bronchitis, laryngeal catarrh, measles, whooping-cough, etc. Causes. — These are exposure to cold when the surface becomes chilled. There is, according to Eosenthal, a heat-producing area and a heat-radiating area, and when a loss of balance takes place between the two, a chill to the surface brings about this frequent ailment. If heat-loss and heat-production are equivalent, no harm results from exposure. Whenever a person is exposed to cold, the cutaneous vessels undergo contraction, so that the blood accumui- lates in the internal organs, and more animal heat is evolved than is usual. Hence a child more easily catches cold if it is not suffi- ciently protected hy proper clothing, or the temperature of the rooms in which it lives and sleeps is too low. When, on the other hand, the atmosphere of the room is too hot, or active exertion is undertaken in it, so as to induce free perspiration, the vessels of the skin dilate, and animal heat is freely given olF. The vaso- motor nerves of the vessels of the air-tubes become partially para- lyzed, and hence a catarrhal state is easily set up. If now, as often happens, the child exposes itself to a draught of cold air, or goes into an apartment that is many degrees too low, then the vessels which are dilated lose their power to contract, and the DISEASES OF THE XASAL CAVITIES. 311 blood, instead of passing freely through them as before, stagnates in them, or accumulates in the deeper tissues or organs of the body. All the morbid elements, instead of finding an outlet through the skin,, accumulate in the blood, to the detriment of the imtient's general nutrition. If the atmospheric air inhaled at the same time be not pure, another evil is added ; the lungs, like the skin, do not part with a sufficient quantity of carbonic acid, and the condition of cold may lead to some more serious state. Every case is not equallj^ severe. When the blood is only slightly con- taminated with refuse products, the cutaneous vessels, after mod- erate dilatation, soon resume their normal calibre, and a cold is either avoided altogether, or it is very transient in duration. Living in rooms above a temperature of Q5° predisposes to cold by weakening the system. " There are few causes which promote susceptibility to cold so much as sleeping in close rooms ; the blood being thus charged with carbonic acid and other foul gases is prone to stagnate, and thus congestion, the first step to catarrhal inflam- mation, occurs."" Local irritation arising from fog and mist, the entrance of dust into the nostrils, air laden with pollen from hay, and repeated blowing of the nose, are all excitants of nasal catarrh. The most intense nasal catarrh is sonietimes induced by taking a few grains of iodide of potassium. I myself suffered from sleep- lessness and severe pain across the frontal sinuses, with great irri- tation of the lining membrane of the nose, and a peculiar sensation of fulness and tightness across the forehead, in consequence of taking this drug. The discomfort was so peculiar and severe, that I never before experienced anything at all like it from the most severe catarrh. Pathology. — The capillaries are swollen and engorged with blood, producing hyperemia and congestion of the mucous membrane. This furnishes an acid, saline, and watery secretion, which inflames and even excoriates the lips. In severe cases, the submucous tis- sues are infiltrated, and the pharyngeal glands are enlarged, or even ulcerated. As the swelling of the mucous membrane dimin- ishes, the discharge becomes thicker in consistence, and even puru- lent in character. As to the possible contagion of catarrh, it cannot be denied that the frequency with which colds run through a household seems * Colds and Coughs, by E. Symes Thompson, M.D., 1877, p. 26. 312 DISEASES OF CHILDEEN. to prove that those who sufier may by contact impart it to the healthy. Using the same pockethandkerchief ma}^ become an- other medium of conveyance. The contagions principle given ofl" by sneezing or coughing may excite irritation in a healthy mucous membrane, and produce catarrh. Symptoms. — The earliest sjnuptoms are those of dryness and titillatiou, with the sensation of obstruction in the nostrils, which induces a disposition to blow the nose frequently. This is accom- panied with sneezing and pain across the frontal sinuses, or even headache ; the voice is thick and nasal, the conjunctivae are in- jected or inflamed, and tears run down the cheeks ; if the discom- fort is so great that there is much blowing of the nose, considerable epistaxis may result ; the larynx may be involved, inducing sore- ness and hoarseness, whilst the catarrh may extend up the Eus- tachian tube, producing deafness and singing in the ears. There is more or less febrile disturbance, loss of appetite, and thirst. A large number of cases of incurable deafness, chronic conjunc- tivitis, and lachrymal disease have been traced to frequent attacks of coryza.* Treatment. — When an acute catarrh is developed with febrile disturbance and running of the nose, confinement to bed in a warm room, fluid food, and diluents will be necessary to encourage dia- phoresis, and so relieve the internal organs from mischief. A warm linseed poultice covering the entire chest is often comforting and beneficial. Ipecacuanha, small doses of tartarated antimony with liquor ammonite acetatis (Form. 7) will be suitable ; while a saline aperient (Form. 8) will cool the sj'stem, and bring down the fever. A pleasant cooling drink may be made b}^ adding one tea- spoonful of acid tartrate of potash (cream of tartar) to a pint of barley-water, sweetened and flavored with lemon-juice. It acts as a refrigerant, diuretic, and aperient. A correspondent speaks highly of full doses of the tincture of belladonna night and morning in severe coryza. Two doses generally complete the cure. As children bear this drug so well it may be given in suitable cases.f Fruit lozenges, and lozenges of Iceland moss and chlorate of potash are demulcent, and encourage secretion. Morphia and other seda- tives require to be given with great care to children, for by arrest- * Brit. Med. Jour., vol. i, 1S80, p. 490. t lb., vol. i, 1877, p. 220. DISEASES OF THE NASAL CAVITIES. 313 iiig secretion they may increase the congestion of the mucous membrane, and derange the health. • Ozcena. — The mucous membrane of the nose is also liable to an eezematous or ulcerating surface, from which a thick, irritating discharge escapes. The mucous membrane is thickened and con- gested, as in ordinary catarrh. This is followed by the drying up of the secretion into thick crusts, which almost close the nasal cavities, and become a source of great annoyance to the child. "When these crusts are removed the surface is found ulcerated be- neath. " In many instances we find the posterior wall of the pharynx covered with similar crusts."* The discharge is muco-purulent and bloody, escaping from one or both nostrils, highly offensive in odor, tedious in duration, and difiicult of cure. When the patient lies down the discharge may trickle into the larynx, and set up congestion and irritation there. The leading feature of ozfena is intense fetor of the breath. The discharge may be too oflensive for the patient to go into society, and yet the nasal bones remain unaffected. When the discharge is of this character w^e may suspect that diseased bone is at the root of the evil. There is sometimes burning and throb- bing pain in the nostrils, and the integumental covering of the nose is red and swollen when the discharge does not freely escape. Causes. — These discharges are met with in delicate children, and not unfrequently follow tedious catarrh or the eruptive fevers, as measles and scarlet fever. Oz?ena may be associated with syphilis and scrofula. A blow on the nose may act as an exciting cause. Mr. Warrington Haward, in an excellent paper on oztena, from which I have gathered much information for this article, classifies the disease under three principal heads : 1. Scrofulous ozpena. 2. Syphilitic ozsena. 3. Traumatic ozpena. He also mentions an "idiopathic ozpena" not referable to either of the above causes. f 1. Scrofulous Ozffna. — A large number of cases of ozfena appear to arise from scrofula in children. The skin and mucous mem- branes are especially liable to be affected in this diathesis, and hence we see troublesome eczema, strumous ophthalmia, otorrhoea, bronchial affections, and chronic diarrhcea. Children with this * Niemeyer's Textbook of Practical Medicine, 1875, vol. i, p. 290. t St. George's Hospital Reports, 1874-1876, p. 130. 314 DISEASES OF CHIEDEE^■. constitutional taint suffer from enlarged cerv,ical glands, whieh sometimes ulcerate and are slow to heal. The nasal mucous mem- brane is thickened and swollen, and pustules and small round ulcers are seen on the lining membrane. This form of scrofula is often accompanied by troublesome eczema (Haward). The horri- ble fetor of ozfena is owing to the discharge being either pent up in a cavity from which it cannot escape, and therefore it decom- poses, or to the presence of a piece of dead bone. In the latter case no antiseptic injection will be of any service till the necrosed bone has been removed. 2. SyphUiiic Ozcpjia. — Syphilis is the next most common cause of ozffiua, of which there are symptoms not to be mistaken. The ulcers are superficial or deep, excavated and sloughing ; they are larc^er, fewer in number, and more irregular in outline than in the preceding variety. A\'hen the bone becomes affected the discharge is most offensive. '6. Trauraaiic ozcEna is the result of injury to the nose, or of the presence of some foreign body. This sets up periostitis, followed by necrosis of the bone, and the cure depends upon its removal. In children, peas, beans, bits of wood or pencil are sometimes thrust up the nose, giving rise to inflammation and ulceration of the mucous membrane. If the offending body is removed before the bone is diseased, the discharge, which depends on a local cause, usually soon ceases. " IdiojMthic ozcena,'' according to Mr. Haward, seems to fre- quently follow scarlatina and measles. In my own experience a very severe case of ozEena followed measles in a child who had no constitutional taint. A thin, semi-purulent, and sometimes gleety discharge continued for many weeks, but ultimately ceased. The nasal mucous membrane was red and swollen, and easily bled on examination or blowing the nose. When purulent matter is pent up in the sinuses there is severe frontal headache and sleeplessness at night. Cases are mentioned where the discharge has found its way into the cranium, or the sinus has become so distended that it has encroached on the orbit and displaced the eyebalL Treatment. — With the aid of the laryngoscope, the nasal cavi- ties, previously washed out by means of the nasal douche, can be well examined. Mr. Haward also recommends that the nostrils be dilated by Fraenkel's speculum, which he says is the best. DISEASES OF THE NASAL CAVITIES. 315 ^ In the treatment of scrqfaloas ozcena, the general health must be attended to. Cod-liver oil, steel wine, the ammonio-citrate of iron, or reduced iron, will be necessary. The nasal cavities may- be washed out frequently with a solution of common salt (half an ounce to a pint of slightly warm water), or tincture of myrrh oij, chlorate of potash 5ij to a pint of water, or 5ij of Condy's fluid to a pint of water. Sea air is of the greatest utility. In the treatment of s^phUitm ozcena mercury must be emploj-ed, and the best mode of using it, according to Mr, Haward, is the calomel vapor-bath, recommended by Mr. Henry Lee. Ilyd. c." creta for children is valuable, whilst iron, bark, cod-liver oil, and iodide of potassium are to be given at the same time. As a local application, when the bone is not affected, Mr. Haward recom- mends an ointment of fifteen or twenty grains of red oxide of mercury, and olive oil and lard, of each half an ounce. After syringing with the nasal douche, this should be applied with a brush. He also speaks well of the ammonio-chloride of mercury ointment, with olive oil. In the treatment of the traumatic form^ antiseptic washings will be needed, and the necrosed bone must be removed if present. For the management of the idiopathic forms^ the general health will require attention, and the application from time to time of a lotion of chlorate of potash and myrrh. Glycerin of tannic acid and dilute mercurial ointment are also useful in some cases. Carbolic acid has been found very serviceable in ozcena, and in other discharges from the nose and throat. All mucus should be first cleared from the afiected parts by a weak alkaline solution, and then carbolic acid (1 in 4:0) should be injected along the floor of the nostrils, or into the pharynx, as the case may be.* A diluted tincture of iodine (1 in 30) may be sometimes injected into the nostrils with advantage. In chronic ozsena, where the mucous membrane is in a relaxed and weak condition, twenty to thirty grains of alum, added to eight ounces of water, form an excellent application. It should be injected up the nostrils with a bottle syringe, or one end of an elastic tube may be inserted in a basin containing the solution, at a proper height, and the other placed in the nostril. If the head is bent forward and the mouth kept open, the fluid will permeate * Brit. Med. Jour., 1869, vol. i, p. 145. 316 DISEASES OF CHILDRE^^. the nasal cavit}' and run out of tlie other nostril. Carbolic acid is preferable where there is much fetor. Mr. Pugin Thornton recommends a cold lotion* to be injected daily up the nostrils by means of a hand-ball spraj^ apparatus. He says it has succeeded in very obstinate cases, after the inhala- tion of camphor, benzoin, and carbolic acid had failed. Eight or ten applications have cured the most obstinate cases.f Glycerin of tannin is another application, particularly useful in syphilitic ozpena. Iodide of potassium may be cautiously given, but small doses of mercury with bark or iron in such a case would be preferable, as this salt so often induces nasal irritation. Nitrate of silver (gr. v ad .5J) is serviceable where the mucous membrane is swollen, and the complaint seems within reach. In those cases that resist all medical treatment, a surgical operation may become necessary. JEpistaxis is the most common form of spontaneous hsemorrhage, arising in all likelihood from the slender resistance which the walls of the vessels afford to tbe force of the blood-current. The rupture, too, in many instances, probabl}'' depends upon a morbid state of the capillary walls or the hsemorrhagic diathesis. Among the causes which predispose to this affection are catarrh and whooping-cough, tuberculosis, disease of the spleen, and the exanthemata. A blow or fall on the nose may excite bleeding at once. One of the worst cases I ever saw was tbat of a girl suffer- ing from typhoid fever, where the blood had become thin and deteriorated. Plugging of the posterior nares was required to arrest the profuse bleeding ; the patient bled from the bowels and urinary tract at the same time, and the body was covered with hsemorrhagic spots (petechiEe). Epistaxis is rarely seen in very young children or in those who are strong and well developed. It is most common in the delicate, who have weak muscles and thin bones. The blood may flow from one or both nostrils, either in drops or a full stream. If the haemorrhage should happen during sleep, the blood flows back into the pharynx, and excites cough if it gets into the larynx, or * R. Sodse carb., Sodse bihorat., aa gij Liq. sodpe clilorinatse, 35s.-3ij Glycerini, 5j Aquam ad . . S^'iij- — M. t The Treatment of Ozseaa, Brit. Med. Journ., 1880, vol. i, p. 475. DISEASES OF THE NASAL CAVITIES. 317 vomiting if it goes into the stomach. If, as often happens, coagu- lation takes place quickly, the hoemorrhage is speedily checked; but if the bIood_he thin, the tendency to coagulation is so slight that the patient may bleed till the lips and face are pallid, the conjunctivfB blanched, and the skin is of waxy whiteness. After continued and great loss of blood, the heart becomes weak and irritable, there is faintness and prostration, the surface is damp and sweating, there is restlessness, headache, and even delirium. Treatment. — Absolute rest in bed, in a semi-erect posture, should be observed in all cases of nasal hemorrhage where the loss is con- siderable, and the eftects of the drain are telling upon the system. It is most important to avoid blowing of the nose, which, how- ever, in children is by no means easy to prevent. Holding the nostrils tightly between the fingers, and applying cold to the bridge of the nose will stop the haemorrhage in most cases. If this fail, the injection of iced water up the nostrils with an ordi- nary bottle syringe maj^ prove eflectual. The introductiou of powdered alum, or ox-galls has sometimes succeeded. Internally, gallic acid, sulphuric acid, tincture of the perchloride of iron, and ergot will be suitable remedies. Sir T. Watson mentions the sim- ple'expedient of the patient raising one or both arms above his head, and of maintaining them in this position for some time.* In cases which resist all ordinary treatment, we must have re- course to the unpleasant operation of plugging the posterior nares. Laryngeal and Tracheal Irritation in Young Children. — No sooner is the respiratory apparatus called into play than it becomes liable to disease, and it remains so from infancy to old age, especially in this variable climate. We have recorded, on the authority of Orfila, Cruveilhier, and others, that traces of inflammation and its products are even sometimes met with in the bronchial tubes and structure of the lung during fetal life. "The great transition," says Dr. Churchill, "from the atmosphere of uterine life to the severe and changeable atmosphere of extrauterine existence, renders the infant peculiarly susceptible." Exposure, as in dress- ing, to draughts of cold air, readily excites the mucous membrane of the air-passages, which becomes vascular, tender, and irritable. At certain seasons of the year, when the thermometer is lower than usual, affections of the breathing organs are very common among young children. * Principles and Practice of Medicine, 4th edit., vol. i, p. 795. 318 DISEASES OF CHILDREN. Bronchitis, croup, pneumonia, arising from cold or as a sequence of scarlatina and measles, come constantly before us ; but there is a condition, not expressed by either of these terms, which is apt to be overlooked, from the absence of marked physical and general signs, and from the insidious manner in which it commences and steals on. This condition is at first one of purely local irritation, occupying the larynx and trachea, neither extending to the pharynx and tonsils nor into the bronchial tubes. A ver}^ conmion mode of its commencement is the following: The nurse observes that the child (probably from one to two years old) is quite well, with the exception of a slight cold, but there is no cough or other disturbance of the system ; all the functions are regular, and the child sleeps well ; it perhaps looks pallid, and the nostrils and upper lip are red, caused by frequent wiping of the nose, as in older children and adults when euftering from catarrh. This state of things goes on for several days, and if the weather should become mild, the child goes out of doors as in health, and the cold — for it seems no more — passes away. Should circum- stances, however, prove unfavorable, these symptoms are soon succeeded by a short, shrill, barking cough, unattended by the prolonged inspiratory eiibrt of croup and laryngismus ; the pulSe is quiet, and there is no fever. If the medical attendant is consulted at this stage he observes nothing of importance, the muscles of the larynx and neck are tranquil, and the child when asleep leans his head forward on his chest. The nurse will tell you that the cough is the only symptom worth notice ; that it wakes the child, and makes him peevish and fretful — no doubt from the extreme tenderness and irritabiliry of the membrane involved. The chest is clear on percussion, and there are no moist sounds from base to apex. The affection is often ascribed to teething, and on looking into the mouth the gums may be inflamed from the pressure of new teeth. Another day elapses, and perhaps in the night the child starts up in his sleep, flushed and excited, with one or both cheeks red ; the skin is hot, and the little patient is irritable and alarmed ; the cough is louder, more barking, and resembles croup ; the respiration is not quickened in proportion to the pulse, the alse nasi are not active, nor is the countenance anxious and distressed, as would be the case in pneumonia or croup. On looking into the throat no redness or change of any sort can be observed. As the disease creeps on, the child becomes prostrate, loses appetite, and DISEASES OF TPIE NASAL CAVITIES. 319 will not leave the nurse's arms or lie down in bed. If you apply the ear or stethoscope between the scapulae at the upper part, you may hear a little crackling at each inspiration, or slight rhonchus; but the percussion-sound is clear throughout the chest, and the respiration is normal in all other parts. If these symptoms are not relieved, genuine bronchitis, pneumonia, or convulsions may supervene — conditions favored by the state of the atmosphere and the constitution of the patient. So far as I have seen, the face never, at any period of the com- plaint, assumes that bluish tinge from imperfect aeration of the blood unless these complications arise. The physiological causes of this condition must be ascribed to nervous excitation ; and in very young children, we see how this may be set up. The trifacial nerve, the pneumogastric nerve, and the spinal nerves are all sepa- rately irritated and disturbed in their functions during the period of dentition, and in gastric and intestinal disorder. Under the combined influence of cold, teething, and gastric disturbance, how easy of explanation are these laryngeal symptoms. Now croup is the disease most likely to be confused with this afiection, and when we are first consulted we may reasonably pause before com- mitting ourselves to an opinion ; but there are the following broad distinctions: If the child can talk, there is neither hoarseness nor huskiness of voice; the fever is never high; the respiration not perceptibly hurried ; the cough may be sudden, convulsive, and ringing, but the crowing inspiration is absent, and there is not the restlessness and anxiety of croup, nor is the larynx either tender or apparently the seat of uneasiness. The cough and expiratory bark are the symptoms of all others that resemble croup ; and, at an early stage, it is difficult to decide on the disease that may be about to spring up ; but when twenty-four or thirty hours have elapsed, we shall have very little difficulty. When this condition has lasted a few days, the child being one day better and another worse, you may almost with certainty give a favorable prognosis of the termination. As a rule, the precursory stage of croup does not last beyond a day or two ; the hoarse voice and catarrhal sjaiip- toms being rapidly succeeded by more marked and decided proofs of a dangerous disease. As to the treatment of these cases, first and foremost is a warm, moist, and equable temperature, not lower than 60° Fahr., or above 70°. In the acute stage of genuine croup, it might be necessary 320 DISEASES OF CHILDREN. to raise the temperature of the apartment higher than this. The cases under consideration are less acute and threatening, and it is therefore necessary that surrounding influences should not be too exhausting. If there is a choice of an apartment it should be large and airy, and candles should be used in preference to gas and lamps. On many occasions I have noticed two large gas-burners in small, I'ow nurseries at the top of the house, where one or two •children with their nurse are living through the day ; so that the allowance of oxygen for each person must be very limited, and cal- culated to impair the general health, and to keep up rather than subdue the tracheal irritation. On removing such patients to larger and better-ventilated apartments they have speedily im- proved ; but it is necessary to maintain a moist atmosphere, and for this purpose it is an excellent plan to place a Hat kettle on the fire, with a long tube projecting above the guard of the fireplace into the room. At the end of the tube should be a transverse top, perforated with holes, like a garden flower-pot, to allow the steam to escape gradually. Such kettles are sold by Swan JSTash, in Ox- ford Street, under the name of "-Bronchitis Kettles ;" in all cases of croup and laryngeal irritation they will be found of great value. "Where they are not obtainable, an ordinary kettle of water should be kept boiling on the fire; and even a hot brick or fire-ball should be thrown into a pan of hot water. This keeps up warmth and moisture in the room, and soon exerts a soothing effect on the ir- ritable membrane. When the symptoms are urgent and the cough distressing, a sponge wrung out of hot water and kept constantly applied to the throat will give relief. Unless the management be carefully looked after, the nurse is apt to make the child's clothes wet, and even to neglect the application. I therefore usually em- ploy a piece of rag wetted in tepid water, and apply it round the throat under oil-silk. This is both a convenient and good remedy. Mustard and vinegar poultices to the throat, strong liniments, and other applications of a stimulating character distress and irritate the child, and are not to be thought of. If, as will generally be found, the stomach and bowels are not satisfactorily performing their functions, we should lose no time in applying suitable treat- ment. The motions are often scanty and light-colored, sometimes containing undigested articles of food ; sometimes of a greenish hue and highly oftensive. A grain of calomel, if the child is from one to two years old, with two grains of jalapin and two of white \ DISEASES OF THE XASAL CAVITIES. 321 sugar, will be necessary, and this will usually stir up the liver and small intestines ; after a free action of the bowels the breath- ing will improve. In some cases I have seen, the breathing has been good in the morning and the child has appeared lively, and even played with his toys ; but towards the afternoon and evening, cough has come on, and he has been more than once sick in the attempt to dislodge a little glairy mucus from the larynx. Succeeding in this, the child has gone on again comparatively well, as in whooping-cough, till the returning spasm and vomiting. But in most cases the discomfort is aggravated towards evening, and he passes a restless night, getting no sleep from the irritating cough. Under these circumstances, it is a good plan to give an emetic at bedtime ; say thirty drops of ipecacuanha wine in an equal quantity of simple syrup. This will usually cause vomiting, and if not, it may be repeated in ten minutes, or even a larger dose given ; but this is sufficient in most cases, and the child is not depressed by it. A saline and diaphoretic mixture, with two or three minims of ipecacuanha wine, and the same quantity of the compound tincture of camphor, will relieve the cough and calm the nervous system. "When the more acute symptoms have subsided, a grain or two of bromide of potassium may be added to each dose of the mixture with advantage. Where the cough is very irksome, a teaspoonful, of a mixture composed of equal parts of aromatic syrup of senna, syrup of poppies, and syrup of squills, is worth giving occasionally. I sometimes substitute the syrup of buckthorn for the senna. This generally opens the bowels, and saves the necessity for more active medicine. Debility, pallor of foce, and a wasted and wan look overtake the child when shut up in one room long together; and this is soon accompanied by a thick white fur on the back of the tongue, darkness under the eyes, and tremulous pulse. A grain of the carbonate of ammonia should be given at this stage, with a few drops of syrup of Tolu, under the influence of which the tongue cleans and the child resumes his liveliness ; to this should be added a few drops of the tincture of cinchona. The child may now be brought downstairs into a large room, and gradually prepared to be taken out of doors. Throughout an illness of this kind it is most important to support the bodilj^ strength with beef tea, veal or chicken broth, milk, thin arrowroot and water, to which a third part of milk is added, or a little isinglass in milk and water. 21 '322 DISEASES OF CHILDREN. CHAPTER XXTX. CROUP (lartngo-tracheal diphtheria of some writers). Pathology: Nature of the exudation — Tico varieties of croup — 1. The mucous or catar- rhal — 2. The fibrinous or inflammatory — Symptoms, course, and progress of each form — Morbid appearances — Clinical characters of true or typical croup — Diagnosis from diphtheria and laryngismus — Treatment by the vapor-bath and emetics — Antimony — Mercury — Aconite — Tracheotomy. Among the diseases of young children croup occupies a foremost position from the occasional suddenness of its accession, the rapidity of its course, and the danger attending its termination. Parents readily recognize the first symptoms and are at once alarmed, and the child itself soon becomes terrified to a degree rarely seen in any other disease. True croup consists in an inflammatory condition of the mucous membrane of the larynx and trachea, with the exudation of plastic lymph, -vrhich is quickly transformed into a firm adhesive mem- brane. The inflammation has a tendency to seriously impede the func- tions of respiration by extending down the air-passages and pro- ducing troublesome and dangerous inflammatory complications in the lungs. The disease is generally acknowledged to be more frequent among male than female children. In my own experience three-fourths of all the cases that have come under my notice have happened to males. The varieties of croup enumerated by difierent authors are not clearly to be recognized in practice. AYe may fairly speak of two varieties: 1. The mucous or catarrhal. 2. T\\e, fibrinous or wflam- matory (croupous membrane), according to the predominance of certain symptoms. The disease is modified by the age and con- stitution of the child, and spasm or inflammation may be more severe in one case than in another. 1. The catarrhal or mucous form is attended with hyperemia of the mucous membrane, followed by excess of secretion and dyspnoea. The sj'mptoms may be slow and insidious in some cases, and the catarrh and cough, which precede the stage of development, excite no alarm till the hoarse voice and ringing cough announce the true character of the aftcction. In some instances we learn that the child has always had a delicate chest, that any exposure to damp CROur. 323 weather brings on cold and congh, or it may he traceable to bron- chitis. The temperature in these cases rarely exceeds 101°. 8uch a history is favorable to an attack of croup in a yonng child. In another case the symptoms are more sudden in their accession. Delicate young children are sometimes seized whilst playing. In one case that came under my observation, a boy, ?et. 8, left his play at 4 p.m., complaining of an uncomfortable feeling in his throat, and before six hours had elapsed the symptoms were severe and dangerous. In another case, a strong and healthy child, pet. 2|, was seized with croupal symptoms at 11 a.m., and in eight hours afterwards they had attained alarming severity. Her parents assured me that she had slept well, and was very brisk and lively till the attack came on. In these cases laryngitis would seem to begin at once. Still it will be found, with few exceptions, that some catarrhal and feverish symptoms had been present a day or two previous to the attack of croup. If an active emetic be given at this stage the breathing may rapidly improve, though the symp- toms may recur and require similar treatment in the course of a few hours. In the majority of cases the following day will see the child in a fair way of recovery. 2. Fibrinous croup [tracheo-h iryii gitis — croupous or membranous) is the typical variet}^ of the affection in its severest form. This is a more acute or intense inflammation; it is a true tracheitis, with exudation of plastic material, because the inflammation affects not only the mucous membrane but the fibrous tissue beneath. I will describe the course of the disease according to my own per- sonal observation. It generally begins with hoarseness of voice and a peculiar harsh and ringing cough, because there is absolutely no secretion ; for the same reason there is a sense of constriction in the trachea. The respiration is hurried, and the inspiratory effort is long and crowing. In some cases a few hours will bring about the most severe symptoms; the pomum Adami may be seen rising and falling very conspicuously with respiration ; the eyes become swollen and bloodshot, the lips dusky, and the alse nasi active; the skin is hot and dry, and the pulse small, hard, and rapid. Unlike the variety which has just been described, the temperature may reach 103° or more. The child may put his hand to his throat, and, in a deep hoarse voice, say or express that he cannot fetch his breath. At this stage the percussion-note is clear over the thorax, the respiratory murmur is much diminished 324 DISEASES OF CHILDREN. througlioLit the chest, and a loud sonorous rale attends it. ^o moist sounds have as yet been heard. As the case goes on, the croupal exudation becomes more organized and clings to the larynx, when, if the case progresses favorably, either the cast is thrown off or resolution ensues with absorption. If the disease is extending, inspiration is now greatly impeded from blocking of the trachea by the false membrane ; there may also be a tough piece of lymph in the trachea which cannot be dislodged. The larynx and mus- cles of the neck are very active. Notwithstanding the laborious and painful respiration the child may, nevertheless, sleep soundly, though waking occasionally in terror. Thirst is generally present, and swallowing may be painful, but I have known a child drink a large cup of milk half an hour before death. Still, any attempt at deglutition is generally painful and brings on the cough. The pulse now becomes small and weak, and reaches 160 ; the crowing and hissing sounds in respiration increase, and the cough is inces- sant and painful. When the symptoms have attained this inten- sity, recovery is rare; the voice falls to a whisper, or departs alto- gether, and the cough is weak and suffocating. Sometimes, even at this stage of strangulation, shreds of lymph and false membrane are expelled by a violent effort and paroxj-sm of coughing ; but the relief is only temporary, and the agony of oppressed breathing soon returns. The countenance now betrays the most painful anxiety ; it is bloated and distressed, the tongue and lips are dusky, and the forehead and surface of the body are bathed in sweat. The pulse becomes feeble and threadlike, occasionally intermitting, or falling in frequency. The child is restless, and constantly turning about for relief, throwing the head back against the spine, or from side to side, while the j&ngers are bent in the palms of the hand. Agoijiy is depicted in every feature. The struggle for breath goes on till the little sufferer dies convulsed, or passes into a state of stupor from which it never wakes again. A case that came under my notice illustrates the sudden fatal termination not infrequent in this disease. The child, tet. 3, had been going on well for two days, and was sitting up in bed play- ing with her toys, and breathing tranquilly. In the night the respiration became embarrassed, and she died asphyxiated twelve hours from the period of relapse. After death a thin piece of partially detached croupal exudation was found lodged in the CROUP. 325 glottis, and this caused the fatal symptoms by occluding the larynx. The false membrane found lining the air-passages varies in ex. tent; in one of my cases I found, on opening the larynx and trachea, three long and narrow pieces of lymph, one upwards of two inches in length, and the others nearly as long, between the lower border of the cricoid cartilage and the last rings of the trachea, without any extension to the bronchi. In this case moist sounds were heard in the chest on the second day of the illness ; but they had disappeared on the fourth and fatal day, ]^ear the level of the upper border of the cricoid cartilage were to be seen small tough fragments of lymph, not readily detached from the surface beneath. The mucous membrane was everywhere red, and in places vividly so ; but there was not any evidence of sub- mucous effusion, for it must be remembered that the connective tissue of the larynx is very small in quantity. In other cases, lymph may be observed throughout the trachea, and the mucous membrane may be pale, except in isolated patches, where it is red and vascular. The false membrane varies much in form and con- sistency ; sometimes it is cylindrical in shape, and loose, or ad- herent to the mucous membrane beneath, from which it is not readily separated ; in other instances it is moulded to the shape of the bronchial tubes, where the inflammation has extended into the lungs, and in these cases the efforts of vomiting fail to bring away the source of irritation, and the danger to life is thereby increased. When the false membrane is loose and fragile, it is easier of expectoration ; and it is these cases that have the best chance of recovery, particularly if limited to the larynx and trachea, the lungs not being involved in the inflammatory process. Of late so much difference of opinion has arisen on the pathology of croup that we are induced to ask what is understood by the term?* Until recently it has generally been regarded as a local disease, an inflammation of the trachea attended with the forma- tion of false membrane (croupal exudation), though the practical physician most commonly recognizes the disease by the spasmodic closure of the glottis, the prolonged and crowing inspiration, and * The result of the discussion on membranous croup and diphtheria at the Royal Medical and Chirurgical Society in 1879 was, that membranous laryngitis may arise from common inflammation, or in connection with specific disorders of various kinds, but that the most frequent cause is diphtheria. 326 DISEASES OF CHILDREN. the fear of impending suffocation. If to these symptoms are added fever and inflammatory excitement, he has no doubt what- ever that he is dealing with a case of genuine typical croup, such as had been known before diphtheria was recognized and dis- tinguished in this country. To me it appears that croup, whether simple or membranous, is a totally different disease from diph- theria, and that they only approach an}'' degree of relationship when the latter disease has invaded the larynx, and then the symptoms due to obstructed breathing are much the same in both cases. We constantly meet with genuine croup of an acute and local inflammatory character, leading to the well-known false mem- brane in the trachea and larynx, as described by the old-fashioned authorities. It seems impossible that we can mistake this true croup (which we have been in the habit of meeting with all our lives) for the peculiar membranous inflammation of the trachea sometimes seen in cases of diphtheria. It is well to glance at some remarkable points of dift'erence in the two affections. 1. True croup is prone to attack the healthiest children, and in districts where diphtheria does not prevail.* 2. True croup is apt to come on very suddenly, and in cases of recovery the general health is rapidly re-established, as compared with diphtheria. 3. In diphtheritic croup the disease is of a well-marked consti- * There are many instances on record of a whole family of children dying of diph- theria in the course of twenty or thirty days- Malignant epidemics of this nature have prevailed in this country since 1857 ; but we have never known of three cases of genuine croup happening at one and the same time to a single family, and we have never known them last so long. The recurrence of diphtheria in the same house has been noticed over and over again, and traced to bad drainage, proving that the power of contagion lurks and lingers about, ready to seize on any person lowered in liealth or 8uscei)tiljle to its influence. The disease is most prone to attack delicate children, whose iionies are badly ventilated, and where sanitary precautions are neglected. It would be impossil)le for the want of space to enter here into the long and vexed question as to whether the croup of Home and Chsyne in tliis country is the same dis- ease as the "diphtiierite" of Bretonneau. I can discover nothing to warrant this conclusion, for, if identical, surely modern writers would have had their attention di- rected to the resemblance in the course of long and varied experience. Diphtheria is a disease only recently described with precision; as soon as attention was directed to it pliysicians at once recognized a new disorder, both in its anatomical and clinical features, entirely dilPerent from anyiliing tliey had previously seen, and presenting symptoms at complete variance with the so-called inflammatory or true croup. CROUP. 327 tutional character, and is always accompanied by great depression and nervous symptoms. 4. Croup is a local disease ; diphtheria is a constitutional affec- tion, in which the kidneys and intestines may be involved. Croup is neither infectious nor contagious ; diphtheria is both. 5. The cases that recover from diphtheritic croup are few, and the convalescence is not only very slow and tedious, but the throat affection is usually preceded by a characteristic membrane on the palate, and the prostration is always great. Partial loss of voice, fetid breath, swollen neck and glands, diminution of muscular power, paralj'Sis of the muscles of deglutition, and albuminuria are common in diphtheria ; but they are not witnessed in inflam- matory croup. 6. Between croup and diphtheria there is also another very im- portant diagnostic difference ; diphtheria generally begins in the pharynx, croup in the larynx.* The false membrane found in the larynx in cases of genuine croup is quite different from the leathery or yellowish-gray exudation found on the tonsils, in the larynx, and bronchial tubes in cases of diphtheria. The pathological differ- ences between croup and diphtheria are open to further contrast. In the early stage of croup there is an increase in the vascularity of the affected membrane, as in severe catarrh, with a trifling amount of inflammatory exudation. This is succeeded by fibril- lation of the exuded lymph, which, with the new-formed cellular elements, becomes transformed into the characteristic false mem- hrane. Its consistence varies, being in some cases tough, in others soft and amorphous, and easily removed from the mucous mem- brane beneath. In the larynx and upper part of the trachea, where the inflammation is most acute, the exudation is croupal or membranous, and is very characteristic of true croup, but in the lowest part of the trachea and diverging bronchi, there may be nothing more than a scanty superficial layer of mucus. -X- " ]yjy ifiga, of the problem to be solved is, in fact, this : It must be admitted that the diphtheritic poison is capable of giving rise to a plastic inflammation of the larynx, apart from the existence of any similar afl^ection of the pharynx. But there is good reason to believe that during epidemics of diphtheria the cases in whicli tliis occurs are in the highest degree exceptional. If, therefore, it can be shown that in the practice of a general hospital the cases of plastic laryngitis, of uncertain origin, bear a large proportion to the total number of cases of diphtheria, tliere will be a strong probability that the majority of the former cases are dependent upon some other cause than the diphtheritic poison." — Diphtheria and Croup, by W. H. Lamb, M.B., and C. Hilton Fagge, M.D., Guy's Hospital Eeports, 1877, p. 345. 328 DISEASES OF CHILDREN. " It is difficult in mauy cases to draw any line of demarcation between the histological changes occurring in diphtheria and those of croup. In diphtheria, however, the submucous tissue usually becomes more extensively involved, so that the false membrane is much less readily removed. The circulation also often becomes so much interfered with that portions of the tissue lose their vitality, and large ash-colored sloughs are formed, which, after removal, leave a considerable loss of substance."* 7. If croup Avere identical with diphtheria, it seems to me that the operation of tracheotomy would rarely succeed ; whereas it is often successful when false membrane has blocked up the tracheal tube, and has been removed from time to time after the operation. The following affords an excellent illustration of the comparison between croup and diphtheria. Dr. Sansom has related a case of pharyngo-laryngeal diphtheria with albuminuria, in a female child four and a half years old, where tracheotomy was resorted to on account of dyspnoea and embarrassed breathing. AVhite patches were observed on the pharj-nx and right tonsil. The edges of the wound were covered with diphtheritic false membrane, and sloughing proceeded, accom- panied with extreme prostration. A wound of the ring finger of the right hand was covered by false membrane, and from this wound ulceration extended, and involved a part of the right hand. During the following week there was little change, then extreme adynamia ensued, pneumonia attacked the bases of both lungs, and the child died sixteen days after the operation of tracheotomy. After death the larj^nx was covered with false membrane, the tissues around the tracheal wound were infiltrated, and there was sloughing of the soft structures. The kidneys were in a state of acute nephritis, and the lungs showed diffused brouchopneumonia.t The treatment that would put an end to catarrhal croup would hourly aggravate a case of diphtheria and hasten death. This alone is sufficient to convince us that the two diseases are essen- tially different. A child is put to bed in an atmosphere of steam, suffering from acute croup, and after the action of tartar emetic, and perhaps a grain of calomel, the alarming symptoms gradually subside. This is never seen in a case of diplitheria ; the nervous * Pathology and Morbid Anatomy, by T. H. Green, M.D., 3d edition, 1875, p. 303. I Croup and Dii)htheria: a Contrast, Med. Soc. Proc, vol. iii, 1875-77, p. 105. CROUP. 329 prostration which invariably accompanies it would be aggravated, and life probably sacrificed, by the adoption of such treatment. Laryngismus striduhis is another disease which is apt to be mis- taken for croup; but the following diagnostic points of difference are so broad and clear that in ordinary and well-developed cases it would be inexcusable to confuse them : 1. Laryngismus usually sets in suddenly with alarming sj-mp- toms, and terminates abruptly ; in true croup the invasion is less sudden, there has been cough and febrile disturbance for a day or two, and the symptoms, instead of declining, go on increasing in severity. 2. In a typical case of larjaigismus the voice is unaffected, and there is no cough ; in croup there is both cough and change of voice, and the latter is often weak and feeble from the commence- ment. 3. In larjargismus there is no expectoration nor any catarrhal sounds in the chest ; in croup such symptoms are constantly met with. 4. In laryngismus there is no fever (that is, sufficient rise of temperature to deserve the name of fever), and the circulation is undisturbed, except during the paroxysms ; in croup the fever runs very high, there is thirst, heat of skin, and quick pulse. 5. Age comes greatly to our aid. Laryngismus is most common in infants during dentition ; croup is most frequent between the second and fifth j^ears. 6. Larjmgismus is most common among strumous and rickety children, and those who have been ailing and out of health. It is constantly associated with dentition, and overfeeding or improper food ; croup often attacks the healthiest and strongest children, and generally arises from exposure to cold winds, or damp; it is far more frequently fatal than laryngismus, which is only excep- tionally dangerous. 7. In croup there is not the same immediate violent struggling for breath as in larjaigismus ; then, too, in laryngismus there is complete recovery between the paroxj'sms. 8. In laryngismus the condition is one rather of sjnicope or fainting ; the attacks are usually too short to produce permanent lividity from imperfect aeration of the blood. 9. In larjmgismus death may occur from complete asphyxia ; in croup a sudden termination may result from a portion of detached 330 DISEASES OF CHILDREX. false membrane exciting fatal spasm of the larynx ; but death usually happens from interrupted respiration and circulation through the lungs, with gradual depression of the vital powers. 10. In a case of larj-ngismus the inspiratory effort is tempo- rarily affected, arrested, or even stopped entirely; whilst in croup, the embarrassed breathing is permanent, and expiration as well as inspiration are both involved. 11. The treatment of the two affections is diametrically op- posed ; the remedies that would relieve the one would aggra- vate the other. So much for the distinctions of laryngismus from croup. But I must not dismiss this question of diagnosis without admitting that there are complicated or mixed cases, attended with wheez- ing and catarrhal s^miptoms, where a degree of catarrhal inflam- mation is mixed up with the spasmodic affection. These are the cases which more nearly resemble true croup, cases of modified larj'ngismus happening to young children, where we have no such precise landmarks as those I have attempted to define. They commence with slight catarah [catarrhal laryngitis)^ hoarse and noisy cough a day or two before the characteristic crowing inspi- ration, and they sometimes precede an attack of pneumonia or measles. It is cases of this kind, attended with a croupy cough, which are apt to deceive and mislead us ; there is, in fact, some swelling and inflammatory action of the larynx and vocal cords added to the original spasmodic affection. The presence of cough, with wheezing and dyspnoea, might induce even a practiced observer to think he was dealing with an ordinary case of croup, but as it advances he is able to satisfy himself that genuine spasm is at the root of the evil. In the simplest forms of catarrh in some young children, the voice is hoarse and the cough barking. To such an extent does this prevail, that a diagnosis is not in vari- ably' easy at the beginning of an illness. The mucous membrane of the larynx is highly irritable and sensitive, and readily becomes inflamed and swollen on exposure to cold air. This is probably the condition that is present in those cases of laryngismus attended with incessant and croupy cough. Though we must not expect to find the same pathological change, or the same catalogue of symptoms, in all cases of larj-ngismus, still, viewing these cases from what point of view we may, I can seldom imagine any real difficulty to obscure the diagnosis of these two affections, if we CEOUP. 331 bear in mind that in genuine laryngismus the larynx and trachea are free from inflammation, that the attacks are sudden and tem- porary, that there is no cough and no fever; all which symptoms are the accompaniments of croup. Of the forms of croup, there is : 1. The catarrhal croup, a mild class of cases of frequent occurrence, which rarely places the life of the patient in imminent danger. It may come on in the night, with some heat of skin, frequent husky cough, quick pulse, and flushed face ; and for a few hours the symptoms are severe and alarming to the parents ; even the medical attendant is doubtful about the issue of the case ; but after a dose of calomel and the free action of an emetic (the room being kept moist, and its tem- perature high), the symptoms soon decline, and the child is himself again, with the exception of being a little prostrate and pallid. 2. The fibrinous croiq^ or tracheitis, happening to healthy chil- dren, wdiich comes on suddenly and is attended throughout with danger. These cases are rapid in their onset, and are quickly fatal. The tendency to a recurrence of croup in some children is a favorable sign so far as regards its severity ; such cases seldom terminate fatally, for these are of the catarrhal form. If we are told that the child has had one or two previous attacks, we may generally regard the case as satisfactory. Such cases stop short of actual exudation, and spasm also plays an important part in the production of the symptoms. The mucous membrane of the larynx and trachea is in a state of inflammatory excitement, and the vessels are full and congested. Prompt treatment rapidly unloads the distended vessels and encourages expectoration. In- telligent mothers, whose children are so attacked, come at last to view the symptoms with little or no anxiety, feeling confident that a good flre, with a steaming kettle in the room, a brisk emetic, and hot sponges kept constantly applied to the throat, will soon bring the child round. The lesson to be learnt here, as in every other variety of croup, is to lose no time, for success in treatment depends on meeting the symptoms w^th promptitude. Above all, care must be taken not to confound these cases w'ith laryngismus, for in the one there is fever and persistent difiicult breathing, whilst in the other there is no fever, and the breathing between the paroxysms is calm and tranquil. 332 DISEASES OF CHILDEEN. Treatment. — Careful study of the disease lias done much to instruct the medical attendant, and the knowledge that no time is to be lost is so commonly spread, that before we are summoned to give relief some useful measures have been tried, and thus many lives are saved which neglect would have rendered hope- less ; 3'et for all this it is estimated, according to the returns of the Eegistrar-General, that about 6000 children die annually of croup in the United Kingdom, a mortality which ought to en- lighten us as to its fatal nature, and induce us to study the best method of dealing with it. I have observed nothing of late j^ears to induce me materially to alter my opinion from the following conclusions, at which I arrived in 1863 :* 1. The temperature of the room should not be lower than 65°. 2. The vapor-bath is indispensable in the treatment of croup, and should be used at the commencement in every case, and con- tinued unremittingly until all fear of a relapse has departed. 3. All cases of croup are invariably relieved by the vapor-bath, especially if the tracheal membrane is dry ; when it is moist there might be fear of causing too much depression. 4. The earlier that a case comes under treatment the greater the probability of a successful termination, because it is then possible to prevent the tracheal secretion becoming organized. 5. The most trying difficulty we have to contend wdth in the management of croup in the catarrhal form is a relapse, because with it comes exhaustion ; and the weaker the patient the less will be the chance of recoverj-. 6. Tartarated antimony is our sheet-anchor as a medicinal agent, not so much from any specific effect it exerts on the tracheal mem- brane as from its certainty in effecting free and speedy vomiting. 7. When the emetic has fully operated, if there be much febrile excitement and disordered primse vi^e, which aggravate the laryn- geal symptoms, a grain of calomel every four hours, or one full dose for the purpose of emptying the bowels and controlling the fever will be found necessar3^ In the fibrinous form, when there is violent and acute inflammation, with a firm hard pulse, and a full reserve of strength, two or three leeches may be applied over the thyroid cartilage, and bleeding can easily be arrested by pres- sure with the finger, and if need be with cotton-wool ; then mer- * Brit. Med. Journ., May 30th. CEOUP. 333 carj may prove a valuable addition to the antimonial treatment. Some of my cases improved from the moment the mercury aftected. the bowels, the fever diminishing, and the expectoration of the false membrane being promoted. When employed in small doses at regular intervals, it would appear to diminish the cohesive at- tachment to the mucous membrane, and to render the lymph less fibrinous and more readily absorbed. 8. AYhen in a case of croup, seen at an early stage, and satisfac- torily progressing, forty-eight hours have elapsed, we may gener- ally augur a favorable termination ; and we should then begin, if not before, to support our patients with good beef tea, milk, and arrowroot, and (it may be) a little wine and water. If after vomiting the temperature remains high, and especially when the bowels have acted freely, minim doses of aconite every two or three hours are of great service in inflammatory croup. This keeps up a gentle diaphoretic action on the skin, diminishes tension of the pulse, and controls vascular excitement in a very striking manner. At this stage it comes in well, because antimony should not be long continued in any of the diseases of children, and it certainly ought not to be in this disorder. On the question of tracheotomy, I am inclined to think we may urge a great deal in its favor.* ^yhen the respiration is so in- volved as to produce almost complete unconsciousness, swelling and distension of the features, and lividity of the lips (convulsive efforts that indicate approaching suffocation), we should cling to the chance it holds out. When all remedies have failed to improve the patient's condition, and death is near at hand, we should not let the patient die without giving him the chance of life which an operation affords. In most of the cases of tracheotomy that have fallen under my notice I have almost invariably observed an improvement for a time in the respiration, and the fact that a few days have been gained when death must have terminated in as many hours is a great point in favor of the operation, and for not delaying it too long. If tracheotomy is to succeed, it must be done before the strength is quite exhausted and asphyxia has thoroughly set in. M. E. Dudon, of the Hopital St. Andre, Bordeaux, performed the operation in twelve cases, with six recoveries ; and he is of opinion that could he have performed the operation earlier in some of the * See the remarks on tracheotomy in the next chapter. 334 DISEASES OP CHILDREN. otlier cases lie would have had more recoveries. When medical means have failed, and the larynx is invaded by false membranes, which cannot be got rid of by vomiting or other means, M. Dudou thinks tracheotomy justifiable.* It should be onr earnest endeavor to recognize whether we are dealing with the catarrhal or the fibrinous form of croup. If we are convinced it is the fibrinous form, then it must be at the dis- cretion of the surgeon whether or not the symptoms are such as to lead him to expect that resolution will take place. If not, tracheotomy should be performed at once, as its postponement would render a successful issue less probable. Tracheotomy in itself is not a dangerous operation, but if it be delayed till the lining membrane of the larynx and trachea are covered with false membrane, extending as far as the primary divisions of the bronchi, and the constitutional symptoms are be- coming severe, the chances of its success are materially diminished. This we often see when tracheotomy has been performed at too late a period of the disease, and the operation has the discredit of the fatal result. When extensive, or loose, or purulent portions of false mem- brane occupy the primary branches of the bronchi, and extend to and choke up the smaller or minute bronchi, the operation cannot be expected to succeed. It is frequently performed as a last re- source, when the respiration is impeded and embarrassed, and ex- haustion has advanced too far. Under a combination of asphyxia and asthenia the child sinks. In those children who survive the operation for some days, bronchitis, pneumonia, bronchopneumonia, and convulsions are the most frequent causes of death. A tendency to pulmonary ex- citement already exists, and indeed the operation itself is calcu- lated to originate it. Tracheotomy is a very successful operation when performed for the relief of chronic laryngeal diseases, or for the removal of foreign bodies from the air-passages. But it is significant that this operation does not generally yield satisfactory results when undertaken in cases of oedema of the glottis, occur- ring in children who have sucked boiling water from the spouts of kettles. After this grave accident, lung affections very often supervene, from the inspiration of scalding vapor simultaneously with the boiling fluid. Tracheotomy aggravates the pulmonary * The Lancet, July 20th, 1872. CROUP. 335 complication ; yet it must be done, on account of the oedema of the glottis. Yeiy similar considerations apply to croup. In some cases where children have been saved from the prospect of imme- diate death by tracheotomy, and the canula cannot be removed •with safety for a moment without the danger of asphyxia, the chances of ultimate recovery are ver}^ slight. The little patient, having rallied from the operation, goes on satisfactorily for some days, when it becomes restless and feverish at night, with a hot skin and a quick pulse. If we auscultate the chest, we find exten- sive bronchitis, and perhaps some pneumonia. No more sputa are evacuated through the canula, and the child soon becomes con- vulsed, or dies in a comatose condition. There may be no accu- mulation of false membrane in the larynx ; but if the glottis is nearly closed by swelling and oedema, and the mucous membrane injected and vascular, the extension of inflammation down the trachea and bronchi into the tissue of the lung is almost certain to ensue. If the case goes on, abscess of a portion of the lung, pleurisy, or empyema are among the morbid changes discovered after death. From all I have been able to ascertain, the operation of tracheotomy is less likely to succeed in children under two 3^ ears of age than in those above it. The trachea is small and unde- veloped, it is not so easily reached as in older children, and haemor- rhage may occur, but a competent surgeon may readily overcome it. Yet in the face of these diificulties infants have survived the operation ; but the greatest number of recoveries has occurred be- tween the ages of five and six years. It has been alleged that the direct admission of air to the luno's without having previously passed through the mouth and nasal passages, is attended with real danger, and that congestion of the lungs is another danger induced by the operation. But seeino- that the temperature of the room can be raised to any extent, and that appliances for the supply of warm moist air are to be pro- cured, congestion of the lungs from this cause alone ought not to occur. 336 DISEASES OF CHILDREN. CHAPTER XXX. DIPHTHERIA. Stiiptoms: Period of incubation — Insidious approach of the disease before any complaint of illness is made — Elevation of temperature — Weakness of the pulse an early and sig- nificant feature of the disease — Albumen in the urine — Character of the throat affection and peculiarities of the exudation — Constitutional depression and implication of the larynx and voice — Diphtheritic croup — Tendency to delirium and restlessness — Death by suffocation or asthenia. Causes: Influence of a specific cause — Debility and exhaustion predispose to the affection — Effects of locality and moisture in favoring its occurrence. SEQUELiE: Anaemia, debility, and paresis — Weak action of the heart, secondary endocarditis — Paralysis of the tUuscles of deglutition and upper and lovjer extremities — Impaired vision and deafness — Bronchitis and pneumonia — Albuminuria — Hcemorrhage from nose and bronchi. Morbid Anatomy : Bronchitis and pneu- monia — Fibrinous coagula in the heart — Congestion of kidneys, brain, and spinal cord. Diagnosis of the affection from croup, scarlet fever, and tonsillitis — Theory of contagion. Treatment : Local and constitutional — Necessity of supporting the gen- eral strength by nourishment and stimulants — Value of iron and other tonic prepara- tions — Applications to the throat as in .scarlet fever — Importance of tracheotomy in imminent death from suffocation — Statistics of Professor George Buchanan, of Glasgow, in croup and diphtheria — Strychnia and galvanism in diphtherial paralysis. Diphtheria (diplitherite of Bretonneau) is a contagious and epidemic disorder, characterized by a specific inflammation of the pharynx and air-passages, attended with the exudation of fibrin or other lymph, and the enlargement of the cervical glands. Other mucous membranes or the skin may be sometimes involved. The vital powers are greatly prostrated. Death takes place from ex- haustion or suffocation through diphtheritic deposit in the trachea and larynx. Diphtheria bears an aflinity to the exanthemata in the fact that it chiefly attacks the young. The mortality is greatest between the ages of five and ten years, but infants of a few days old have been attacked. Evidence of the antiquity of the disease is to be found in the writings of Hippocrates, Celsus, Aretseus, Galen, and Ccelius Aure- lianus. In more modern times, descriptions of it are given by Spanish, Italian, French, and English writers, and traces of its progress have been met with in America, Africa, aud Hindostan. It prevailed in Holland in the sixteenth century. By some writers it is thought to be the same disease that was known a hundred years ago under the name of epidemic croup and malignant sore throat.* It made its appearance at Tours, in France, in 1818. * Dr. Fothergill's account of the sore throat attended with ulcers, 1748. DIPHTHEEIA. 337 This disease, until the last few years, has been confouiidecl with erysipelas and scarlet fever during their epidemic prevalence. The credit belongs to Bretonneau of being the first writer to define its exact nature, and to show that the local appearances on the throat and fauces are the manifestations of a general and constitutional disorder. Since the beginning of this century, cases of diphtheria have been recorded from time to time by English physicians. In the years 1858 and 1859 the epidemic attained its maximum in this country, and in two years about 20,000 persons fell victims to it.* Symptoms. — The incubation period is usually very short. " Ac- cording to Oertels, the latest and best writer upon the disease, it may be stated positively' to occupy from two to five days. His own experiments also show that in from twelve to twenty-four hours after artificial inoculation upon the surface of wounds, we can detect a grayish-white discoloration, a dirty-grayish layer, and the other signs of infection. "t Dr. Morell Mackenzie has given an instance of a prolonged period of incubation, fifteen days elapsing from the exposure to contagion to the appearance of diphtheria.:}: The disease creeps on very insidiously, and may have advanced considerably before any complaint is made about the throat. The earliest symptoms are chilliness, weakness, and lassitude, with pain in the back and limbs, followed by febrile disturbance of varying duration. In some severe cases the fever is transient and soon passes ofi", but in mild cases it is of longer duration. Elevation of temperature generally marks the com- mencement of the disease, it may soon reach 103° or 104°, when delirium is often present ; but in many cases the temperature appears to fall as the disease advances, the skin becoming cold, and the pulse slow. These symptoms often precede death. There is headache, thirst, and pallor of the face ; the .sleep is restless and uneasy, the mental faculties are clouded or excited ; the pulse is almost always quick at the beginning of the complaint, and soon becomes weak and compressible. Cases are recorded of unusual slowness of the pulse, and Dr. Heslop mentions one in a child of five years of age, where it did not exceed forty beats a minute.§ * On Diplitheria, by Dr. Squire, Eeynolds's System of Medicine, vol. i, p. 11. f Article Diphtheria, Ziemssen's Cycloi)Eedia of Medicine, vol. i, p. 594. Quoted hy Murchison, Clin. Trans., 1878, p. 218. X On Diphtheria, 1879, p. 19. \ Greenhow on Diphtheria, p. 211. 22 338 DISEASES OF CHILDREN. The tongue is covered with a thin, creamy fur, or it is quite clean except at the posterior part. The appetite for food is small, and the prostration of strength so great that the patient is too weak to exert himself to take food, and consequently many patients die, who reasonably might be expected to recover if they could take a proper amount of nourishment. The urine is pale; it contains urates or even phosphates, and at an early stage albumen is frequently found. Albuminuria is one of the most interesting features of the disease. Attention was first drawn to this symptom by Dr. Wade, of Birmingham.* It gener- ally appears at an early period of the disease. It is a frequent complication of diphtheria, and increases the danger to life. "Whether albumen is present in large or in small quantity, it is a serious symptom. But albumen bears no relation to the other sj-mptoms, as it is equally present in mild as in severe cases. Casts of the urinary tubes do not invariably accompany the most pro- fuse albuminuria,! and the albumen may disappear altogether in the course of a few days, as the approach of convalescence is reached. Greenhow remarks that he has " several times been un- able to detect albumen by the proper tests in very malignant cases of diphtheria.":}: On looking into the throat, some redness or swelling may be observed on the fauces, pharynx, and tonsils; the cervical glands are enlarged ; there is pain in deglutition, and stiflfness of the neck in separating the jaws. The eyes have a heavy, languid look, and the conjunctival vessels are injected ; the nostrils are in- flamed, or obstructed from swelling of the Schneiderian membrane, or the presence of a tenacious secretion. Between the first and second day from the commencement of the throat symptoms, the tonsils become more swollen, and a fibrinous exudation can be seen coating them, as well as on the back of the pharj-nx, which is now turgid, and assumes a claret hue. Over a part of the inflamed sur- face, a tough la3'er of gray -looking lymph is deposited, resembling wetted chamois leather or damp parchment, which continues to increase in thickness ; in some instances it is very thin and super- ficial. This false membrane (which is pathognomonic of the dis- ease) is not invariably of the same color ; in some cases it presents * Midland Quarterly .Journal of the Medical Sciences, 1858. f Greenhow on Diphtheria, p. 204. + Ibid., p. 207. DIPHTHERIA. 339 a clirty white or 3'ellowish appearance ; in others it is of a brown- ish or ash-colorccl hue, and in exceptional cases it has a blackish, gangrenous look, and is horribly offensive.* In some cases the exudation is first seen on the soft palate, or on one or both tonsils, but wherever it may be, it either extends from one part to another, or it simultaneousl}^ appears on several parts at the same time. Spots of exudation, which at first are separate and distinct, will coalesce and form a continuous layer in a few hours. The extent and color of the exudation are generally in proportion to the severity of the disease. When there is a light and small distinct patch the disease is mild and runs a favorable course ; but when the exudation is extensive or thick, or the patches unite or form a continuous layer, then the constitutional depression is great, and the patient is in imminent danger of his life. In some cases cough is a very early symptom. In June, 1869, a boy, aged six years, presented himself in the out-patient department of the Samaritan Hospital, whose illness began with a slight cough on the 5th. On the 8th, when he came under notice, he had a hoarse and frequent cough, and his voice was subdued and husky. On the lower part of the pharynx and right tonsil was the characteristic membrane ; the child was very weak and pallid, the tongue coated, and the pulse 140 and feeble. He made a good recovery, the only sequelae being enlargement of the tonsils. "When the exudation has fully formed, it mingles with the secre- tion from the mucous follicles, and the cervical and submaxillary glands become enlarged, and the whole neck swells. The child is now much distressed, as there is great pain in swallowing, and the poisonous secretion excoriates the mouth and nostrils. As portions of the deposit separate from the throat and are coughed up, there * " The diphtheritic pseudo-membranes, or, to speak more precisely, the diphther- itic sloughs, result from superficial gangrene of the mucous membrane, which again depends on compression of its nutrient vessels by an interstitial fibrinous exudation, or from swelling of the tissue elements, which are filled with a cloudy substance." — Nie- meyer's Practical Medicine, vol. ii, p. 615. Inflammation is not essential to the disease, according to some authorities ; but this is a question which pathology ought to decide. Diphtheria is distinguished by a pe- culiar morbid condition of the mucous membrane of the throat and tonsils. A sero- mucous effusion is poured out on the back of the throat, which becomes changed into a tenacious membrane, followed by the formation of another similar membranous for- mation, till a tough plastic layer is produced. The false membrane can be raised from the surface, which is ulcerated and bleeding. The pellicle of false membrane is chiefly made up of thickened epithelium, coagulable lymph, pus, and blood-corpuscles. 340 DISEASES OF CHILD REX. is great fetor of the breath, and sometimes bleeding from the mouth and nose. This exudation is tough and fibrinous, and does not separate easilj^ except -svhere it is undergoing decomposition. "When it has separated it leaves a smooth bleeding surface, on which the exudation rapidly forms again. As the disease goes on, the respiration becomes impeded by the obstruction to the entrance of air through the larynx, producing diphtheritic croup,* and the breathing is croupy and stridulous. The voice is muffled or reduced to a whisper, and the eyes are staring and suffused. The vessels of the neck are distended, and at each inspiration the depressions above and below the clavicles are sucked inwards, and the epigas- trium is retracted. With these alarming symptoms there are also pains in the head, which the child moves incessantly ; the surface of the skin is cold and clammy, and there is extreme agitation and restlessness. The consciousness becomes more and more impaired, and the child dies suflbcated and exhausted. Death ensues as in fatal cases of croup from asphyxia. When the pharyngeal afiection is acute and severe there is great j)ain and difiiculty in swallowing food, but as the disease advances the sensibility becomes blunted, and there is no complaint of pain. The patient sinks low in the bed on his back, and is insensible to all that goes on around him, or he is delirious and muttering ; the imf)ulse of the heart against the walls of the chest grows weaker, and the pulse becomes feeble and imperceptible. In such cases death ensues fi'om asthenia or sj-ncope. When laryngeal s^-mp- toms occur the patient may die in the course of two days, but when they are absent death may not happen for two or three weeks. In cases that recover convalescence begins about the second week. " Of the seventy-four cases collected by the British 31edical Journal^ twenty-six died — fourteen from asthenia, eight from im- plication of the larynx, three from syncope, and one from subse- quent bronchitis."! Causes. — A specific poison, either generated within the body or external to it, is the cause of diphtheria, which spreads by * Diphtheritic croup is more common in some epidemics than in others. The dis- ease shows no uniform disposition to attack tlie larynx and trachea; many cases have terminated throiigli slieer exhaustion, though there has been severe throat complica- tion and sloughing; whilst other cases, and even .some epidemics, liave been marked by the extension of the disease into tlie larynx, and the symptoms of croup, with the throat and fauces comparatively free. f On Diphtheria, by Dr. Squii'e, op. cit., p. 139. DIPHTHERIA. 341 contagion and infection. Sir W. Jenner traces "diphtheria (like erysipelas) to cold when the exposed person is depressed from fatigne, mental or moral causes, etc.""'^' It spares no class of the community, affecting the poor as well as the rich, when an epi- demic prevails; but it is probable that, notwithstanding the evi- dence that has been brought forward to the contrary, defective drainage, debility, and exhaustion favor its development. The disease is not peculiar to any particular locality; it has been as prevalent in high and exposed situations as in low and sheltered places; on clay and damp soil and on dry and light soil ; on richly cultivated soil and on barren moorland ; in the open country and in the densest towns. f It does not, however, appear to be so frequent in dry districts, where the drainage is good and the soil permeable, as in damp, marshy districts in the vicinity of water. Still this does not clear up the cause of the epidemic, for dry places have been severely visited and damp places have escaped. "In- deed, it is evident that some other factor besides damp is required for the causation of this disease, seeing that humidity in every conceivable form and degree always exists in one place or another; whereas diphtheria had been unknown as an epidemic in this country for three-quarters of a century previous to its recent invasion. Dampness must, therefore, be regarded rather as an auxiliary than as a principal cause of the disease.":}: As to the outbreak in iSTorth London, in 1878, Mr. W. H. Power found that, with regard to time, the customers of milk retailers who bought their milk of the same proprietor bore almost the whole of the brunt of the outburst, which first attracted attention to the district, and which was referred to sewer causation. It seems probable that Mr. Power's observations must be regarded, in the present state of our knowledge, as rather suggestive and incitive than conclusive. What the exact nature or essence of the disease is we do not at present know. How the germs of the disease are first developed, whether they ever arise de novo (which is not improbable), or w^hether the soil into w^hich they have been introduced is peculiarly adapted for their growth, are questions which the science of medi- cine has still to deal with, but certain it is that when a person is struck down with the disease, he is capable of contaminating the * Introductory Address before the Clinical Society, 1875. t Dr. Greenhovv on Diphtheria, p. 12-1. % Ibid., p. 125. 342 DISEASES OF CHILDEEIS". surrounding air and drinking-water, and so of communicating the disorder to others. Bretouneau held the view that the atmosphere could not trans- mit the contagion of diphtheria. He taught that the only way iu which it can be contracted is by inoculation — that the diphtheritic secretion must come in contact with " a soft or softened mucous membrane, or with the skin on a point denuded of epidermis."* This is a subject still open to discussion, but most authorities agree that the disease is contagious, and can be conveyed by the atmosphere, invisible emanations from the sick, or even from sewer gas. Eamily susceptibility is sometimes very great. All the members of one family may be attacked, whilst those of another family living under the same roof may escape. Some may have the dis- ease slightly, and others severely ; the delicate succumb more readily than the strong. A correspondent throws out the hypothesis that as the disease often spreads iu a family, and does not extend to other persons going freely about the patients, " the poison germ of diphtheria is modified by its habitat, becomes in fact a new variety growing out of and specially adapted to the constitution in which it has developed, and that this contagion finds in the kindred constitu- tions of brothers and sisters fit soil for its growth, while it is thrown off by stranger organisms to which it is unadapted."f Dr. Alfred Carpenter also supposes "that diphtheria is dependent upon a germ of living matter, which is capable of reproducing itself when it meets with a congenial soil." He considers that there is a close analogy between it and potato blight ; the conditions which pro- mote the one have also an influence upon the other. He adds that sulphurous acid, locally and generally applied, is the best applica- tion, and that the germs cannot grow in a creasote atmosphere.:}: The clothes of a person may be infected with the poison, and he may thus transmit the disease to others, though he is not laboring under it himself. An instance came under my notice in November, 1878, where a little bo3' in health called at a house in which a child was lying ill * New Syd. Soc. Trans. f On the Contagiousness of Diphtheria, the Lancet, Jan. 4th, 1879, p. .34. X A Possible Predisposing Cause of Diphthei-ia, Brit. Med. Journ., Jan. 4th, 1879, p. 8. DIPHTHERIA. 343 of the disease ; he returned home, was struck down with the dis- ease within forty-eight hours, and died on the seventh day. He conveyed it to two brothers and a sister. The little girl, eight years of age, walked eight miles one daj^, was prostrate with the disease on the next day, and expected to die on the third or fourth day, but eventually recovered. Sequelce. — The heart is prone to become enfeebled, notwithstand- ing the free exhibition of stimulants and the progress towards re- covery. Sudden failure of the pulse and circulation now and then comes on, and the weakness continues till death. Valvular disease of the heart has been known to result from diphtheria. The pro- cesses involved in this disease may bring about morbid changes of the endocardium affecting the valves. Dr. Burdon Sanderson* has shown the identity of the valvular lesions after diphtheria with the ulcerative endocarditis of Kirlvcs, well known to result from several acute specific diseases. Sanderson continues by demon- strating what he happily terms the " doubly infective character " of those forms of endocarditis after acute diseases. They result from specific infection, and in turn produce morbid changes in the organs. Infective material becomes detaclied from the diseased valves, and distributed to the kidnej's, liver, and lungs.f Heiberg and Weigert go further, and pretend to have discovered the very fons et origo mali in colonies of micrococci, which they believe pro- duce the endocardial disease. Sometimes the muscular system is fearfully depressed, and the patient loses all power over his limbs, so that he cannot support himself or put on his clothes. Diplitheritic Paralysis. — Authorities difl:er as to the nature of this paral3'sis, some regarding it as of reflex origin, and others as due to exhaustion of the cerebro-spinal centres. " The paralysis is more deserving_ of the name general than any other which I know, for all the physical powers are aflfected, and sometimes the mind is enfeebled.":}: The affection generally comes on during convalescence from diphtheria. It appears to bear some resemblance to locomotor * Lectures on the Infective Processes of Diseases, Lect. IV, Brit. Med. Journ., Feb. 9th, 1878, p. 179. t See Chap. XLT, on Ulcerative Endocarditis. X Diseases of the Nervous System, by S. Wilks, M.D., 1878, p. 234. 344 DISEASES OF CHILDREN, ataxy, but galvanism, whicli is of uo use in this disorder, has con- siderable power over diphtheritic paralysis. " It is probable that inflammatory disease of the pharynx, such as tonsillitis, general pharj-ngitis, putrid sore throat, or syphilis, may give rise to more or less disturbance of the motor apparatus of this region ; but it is onlj^ in diphtheria that other nerve-centres sufler, so that this fact affords a means of diflierential diagnosis. The voice acquires a characteristic nasal timbre, the modification of certain articulate sounds being very characteristic, owing to the impossibility of closing the naso-pharyngeal passage. Thus rub^ head, and egg, become r?/?7i, hent, and enk."* Syiivptoms. — Frequently the muscles of deglutition are seriously involved, and the sensibility of the fauces is so affected that there is difficulty in swallowing, and fluids regurgitate through the nose, or pass into the larynx. The voice is weak and nasal, the uvula and velum are relaxed, the power of expectoration is lost or impaired, mucus accunmlates in the pharynx, and the taste and smell are more or less blunted. Deafness sometimes ensues. According to the experience of Dr. Maund, "the frequency of these paralytic aftections is in inverse ratio to the severity of the attack of diphtheria." Out of tw^o hundred cases at- tended in East Kent in 1858 and 1859, not more than ten exhib- ited an}^ secondary nervous sjmiptoms f In other cases the sight is impaired, but the weakness of vision resulting from paralysis of the ciliary muscles passes ofl:' when the health is restored. Diphtheritic ophthalmia has been known to occur in connection with malignant diphtheria of the throat and air-passages. ;}; Occasionally there is a general loss of sensibility coming on during convalescence. The paralytic symptoms are geneyalh' most severe on that side of the body corresponding to the throat disorder. Paralj'sis of the lower limbs, and wasting of the extremities, occur in some cases. The upper extremities are rarelj' atlected. Where the muscles of respiration are attacked, danger is imminent. The paralysis is, however, generally curable, and yields to treat- ment in time. * Diseases of the Throat and Nose, by Morell Mackenzie, M.D., 1880, p. 115. t St. And. Grad. Assoc. Journ., 18G9, p. 89. X Diphtheritic Ophthahuia, by Edward Kettleship, St. Thos. IIosp. Ecp., vol. x, p. 27. DIPHTHERIA. 345 The tliree following cases, in cliildren of the same famil}', came under my notice in July and August, IbHO. They illustrate many of the preceding observations. Case 1. — D. A , a female child nearly four years of age, had a severe attack of diphtheria, with copious membranous deposit on the tonsils and pharynx. There was high fever, drowsi- ness, and albumen in the urine to the extent of one-sixteenth of the quantity passed. The albumen persisted for some weeks. The paralytic symptoms that followed consisted in indistinct articulation and slight squinting. Under tonic treatment the recovery was perfect. Case 2. — H. A , a healthy boy, eight years of age, had membranous exudation on both tonsils and back of the pharynx. The constitutional symptoms were more severe than in the pre- vious case, but there was very little albumen. The paralysis consisted in double vision, squinting, articulation almost gone. Could not see black objects, but all other colors. When walking in the street, he ran up against people in passing. Two months after this illness he was quite well. Case 3. — A. A , a boy, aged fourteen, of nervous tempera- ment, was taken ill August 8th. Diphtheritic membrane ex- tended over the arch of the palate, back of pharynx, and left ton- sil, thick, tenacious, and wash-leather like. Albumen appeared on the fifth day to the extent of one-half. The two following days the urine w^as nearly solid, then it gradually diminished, and tem- porarily disappeared on September 9th. It returned from time to time, and disappeared altogether on September 20th. The paral- ysis consisted in almost complete loss of sight, succeeded by double vision, imperfect articulation, choking, and occasional fainting. An ophthalmoscopic examination showed hypermetropic refrac- tion, and thinness of choroid. On nasal side, and in substance of disk, there were seen two distinct nodules of lymphlike deposit, clear and well defined ; vascularity normal. The patient made a good recovery. Hfemorrhage from the throat, nose, and bronchial mucous mem- brane occurs occasional!}^ in conjunction with diphtheria; also eruptions of the skin, resembling typhoid fever and measles, are mentioned by difierent observers. Erj^thema, urticaria, and dark claret spots like purpura have also been noticed. Mot hid Anatomy. — On examining the bodies of children and 346 DISEASIS OF CHZLDEES". adults v^ho have died of diphtlieria, evidences of brouehitis aud pneumonia are frequently seen. In the trachea and bronchial tubes the peculiar membranous formation is found, and on the removal of the exudation'the mucous membrane is seen congested and excoriated, and there are small bloodv points similar to those observed in the fauces. As the disease descends into the larvnx and trachea, the false membrane becomes thin and spreads out like a transparent film, or the exudation is converted into a thick creamy fluid. The false membrane has been observed lining the bronchial tubes to the third or fourth bifurcation. It sometimes extends to the oesophagus and stomach, which are found red and covered with exudation. The mucous membrane may be thick- ened or ulcerated, and the tonsils gangrenous. The heart has been found small, and its muscular tissue pale; cases, too, of fatty degeneration have been recorded, and the parietes have been studded with black infiltrated patches and petechial spots from sanguineous extravasation. Fibrinous coagnla sometimes occur in the cavities of the heart, as in scarlet fever and the pneumonia of children. They may be seen in the right auricle or ventricle, or in all the four chambers of the heart, of firm consistence, and so adherent to the chordae tendinece, that the deposit must have happened during life. The kidneys have been found quite healthy after death, as may be ex}:)ected when the urine has been free from albumen during life ; but careful microscopical examination usually reveals some change of a special character. The kidneys are sometimes only congested in simple cases, but where albumen has been a f»er- sistent symptom, some change in the intratubular structure will generally be found ; the tubules may be blocked with granular matter, oily globules, blood-corpuscles, and fibrinous exudation. The sinuses and membranes of the brain and venous system generally, have been found remarkably full of blood. In a fatal case recorded by Sir William Gull, and quoted by Dr. Greenhow, the membranes of the brain and spinal cord were in a state of suppurative inflammation.* Diagnosis. — The diagnosis of diphtheria from croup is given in the previous chapter. I may here quote an interesting passage from Xiemeyer on the anatomical appearance of the exudation. " If the larynx and * On Diphtheria, p. 239. DIPHTHERIA. 347 trachea participate in the disease, the croupous, not the diphthe- ritic form of inflammation of the mucous membrane occurs — that is, the surface of the mucous membrane is covered with a more or less tough and consistent false membrame, which may readily be removed, and leaves no loss of substance after its removal. This circumstance has induced some physicians to identify primary genuine croup, which is due to catching cold, etc., with croupous laryngitis caused by infection with diphtheritic contagion. I con- sider this a false view. The division of diseases, according to the pathologico-anatomical changes they induce, is only a makeshift. In all cases where, as in genuine and diphtheritic croup, we find that two anatomically similar disturbances of nutrition depend on very different causes, we should consider them as distinct."* It is this similarity in the character of the exudation between in- flammatory croup and diphtheria which has continually led ob- servers to consider them as one and the same disease ; but this certainly cannot decide the question. The throat in malignant scarlet fever and diphtheria is very much the same in appearance, and may be confounded the one with the other. As regards tbe diagnosis at tbe beginning of diphtheria, the more circumscribed redness and the peculiar yellow patch of the exudation is, from an anatomical point of view, so characteristic, that it is conclusive evidence of the disease. Yel- lowish or grayish-brown sloughs of plastic lymph on the tonsils and pharynx, leaving later on a bleeding surface where the mem- brane is removed, are common in diphtberia ; but in severe in- stances of either disease, ashy-looking, gangrenous deposits may be seen, and owing to this circumstance, a diagnosis would be im- possible. In scarlatina, the constitutional symptoms preceding the throat affection are more marked, the skin is pungent and hot, and the temperature is high ; whereas in diphtheria, tbe throat may be severely aftected in the absence of these symptoms, and the pulse and respiration are low. In both diseases the lymphatic glands are involved. The throat generally presents a more uniform redness, and the tongue is characteristic in scarlet fever. The soft palate and tonsils have a milky or creamlike aspect ; there is a thick layer, which soon clears off, leaving the parts beneath angry and red. In diphtheria the exudation is more deeply seated, ■^ Xiemever's Practical Medicine, vol. ii, p. 615. 348 DISEASES OF CHILDREN". and it comes off in dense membranous laj'ers, representing a cast of the surface on which they have formed. At a verj earl}^ stage it is not easy to distinguish the redness of diphtheria from the inflamed sore throat of inflammatorj^ catarrh, in which the tonsils are tumid, and have a thin \ayev of lymph upon them. The pharynx is vascular and irritable, and the lym- phatic glands are tender and enlarged ; but they go down when the cold is relieved. In healthy subjects, however, an inflamed state of the cervical glands is -exceptional in cases of tonsillitis. I have many times known children with a temperature of 103°, or more, in this complaint, and the throat so swollen and the fauces narrowed, that the swallowing of liquids was most painful, and yet the glands in the neck were not enlarged. When they are swollen there is fear of a strumous taint, and the specific inflam- mation is often sufiicient to excite chronic enlargement, if not sup- puration. Then there is a discharge from the nose, and the fever is considerable, with thirst and difficulty in swallowing. The diagnosis from tonsillitis can generally be made ; in the latter affection the constitutional symptoms are not of the low and adynamic type which belong to diphtheria, and one tonsil is more affected than the other. Scarlet fever and diphtheria have prevailed together at the same time and place, and each disease has exhibited the characteristic local symptoms. One member of a family has had the peculiar exudation of the fauces, but no rash or desquamation which occurs in scarlet fever. "Sometimes," says Dr. Greenhow,* "cases of diphtheria and scarlet fever have even been intermingled in the same family, or diphtheria has appeared in persons who have been in communication with patients sufiering from scarlet fever." Another difference between the two diseases is, that the albumi- nuria of scarlet fever comes on at a late stage, often at the end of a week or month, after the eruption has left, during the period of desquamation, and it goes on to dropsy and anasarca with ho?ma- turia. In diphtheria, albuminuria is an earlier symptom when it does occur ; hoematuria is rare, and dropsy does not result, nor is the excretion of urea lessened. The urine does not present the smoky appearance which is common in scarlet fever, but casts of the urinary tubules are generally found. f The presence of albu- men in the urine is hj no means a constant symptom, even in On Diplitheria, p. 102. t Ibid., p. 2U5. DIPHTHERIA. 349 severe cases, but when it is present in large quantity it is a serious indication. Anasarca is rarely present except in cases complicated with scarlet fever. Umcmia has not been observed in connection with the albuminuria of diphtheria ; but excess of phosphates and urates, with high specific gravity of the urine, is of common oc- currence.* It has been asked whether there is any relationship between diphtheria and enteric fever, and it appears certain that the two diseases are not unfrequently associated. Dr. Murchison considers that it is not true diphtheria, the throat complication in enteric fever being frequently found where there is no diphtheria. As the causes of the two diseases are much alike, we should exjDCct them to prevail together, and not look upon their existence as a mere coincidence. Dr. Greenfield brought before the Pathological So- ciety (ISTovember 6th, 1877), a specimen of diphtheritic membrane from the larynx and pharynx of a child, aged five, who had been under the care of Dr. Murchison at St. Thomas's Hospital, sufit'er- ing from unmistakable enteric fever. There was ulceration of Peyer's patches, and also swelling and round excavated sloughing ulcers in the lower part of the ileum. In addition there was bronchopneumonia ; but no false membrane could be seen on the fauces or the tonsils, which were red and swollen. As to the communicability of the disease, it is held to take place through the secretions of the throat by Bretonneau and others ; but the experience of many medical men during the epidemic of 1858 and J 859, does not concur in the opinion that the disease is communicated in this way.f In contemplating the record of cases, however, we can hardly fail to observe that the diphtheritic secre- tions have induced ophthalmia and throat afitections in those per- sons who have been nursing the sick, or have seized upon the medical attendants who have been close enough to receive particles of the exudation when the patients have coughed or sneezed dur- ing an examination of the throat and fauces, or the application of some local agent. The character of the disease so induced, has been in a few instances that have come within my knowledge, so precisely like the diphtheritic exudation, that I think the evidence of propagation by contact with the secretion, cannot be set aside. The disease has spread with rapidity in the cottages of the poor, where the appliances of the sick are scanty, and cleanliness is dis- * On Diphtheria, p. 208. f Ibid., p. 137. 350 DISEASES OF CHrLDREX. regarded. Then, again, a child laboring under diphtheria has been brought from a distance to its own hon e, and soon afterwards the disease has attacked other members of the family, when previous to its return, not a single case had happened in the house, or the surrounding district for many miles. Dr. Squire notices that the more abundant the secretion in particular cases of diphtheria the greater the danger of infection."^ I think we shall be forced to admit that diphtheria, like tj'phoid fever, has sometimes a spontaneous origin, when soil and^ season, temperature, filth, and uueleanliness combine to lower the general health and contaminate the blood. If it were not so, how shall we explain the alarming outbreaks of these diseases in schools and isolated homes, and their tendency to remain within a limited area, and not to spread in an epidemic form ? The infection of the atmosphere by the exhaled air of the sick patient, leaves no room for doubt that this is another mode by which the disease is propagated. Children who have been in the same house with diphtheritic patients have contracted the disease, when they have not ventured near the sufferer ; and there are no doubt other vehicles for the transmission of the poison, subtle, tenacious, mysterious, ever ready to seize upon the young, " The greater frequency of the disease among children than adults does not seem to be due to greater predisposition of the former, but to their being more exposed to infection than adults ure."t Treatment. — This is a disease demanding local and constitutional measures, and from the first neither should be disres^arded. Some- times the local should be the most energetic, and sometimes the constitutional ; but from the commencement the treatment must be supporting, if not stimulating, and those measures that are most to be relied on in exhaustion and syncope are to be held in close reserve. Like other epidemics, the disease does not admit of depletory measures, and all practitioners who have had a large experience of it insist upon the necessity of employing a support- ing plan of treatment. Each case will require some modification in accordance with its peculiarities and tendencies, so that it is not easy to lay down any exact rules to follow. The patient should be placed in a large and well- ventilated room, the tem- perature of which should range from 60° to 65°. He should be * Reynolds's System of Medicine, vol. i, 3d edit., p. 115. f Niemeyer, op. cii., vol. ii, p. 615. DIPHTHERIA. 351 kept absolutely quiet in bed, with the head low, and all excite- ment carefully guarded against. At the commencement of the disease, a purge of calomel and rhubarb is sometimes required, so that some of the poison may be eliminated by the intestinal canal. This has been insisted upon by Sir William Jenner ; and other observers have advocated this treatment at the beginning of the disorder, when the strength is equal to it. Under most circumstances, a mild saline aperient, to keep the bowels regular, will be occasionally required, or a small dose of castor oil ; still, caution must be observed in the adminis- tration of aperients. Our best guide in this matter is the mildness or severity of the attack, for in tbe malignant form the child is overpowered by the poison at once, and tbe pulse is so feeble that any depressing remedy would only hasten the tendency to fatal syncope. Milk in large quantities, beef tea, chicken broth, and eggs are the forms of nourishment best suited to maintain the flagging strength. Wine or brandy will be almost invariably needed, and the quantity must be regulated by the strength and frequency of the pulse. Where there is a tendency to syncope or failure of the heart's action, or the pulse is slow, very frequent, or irregular, considerable quantities of alcohol can be taken with advantage. Perseverance in the administration of food and medi- cine is imperatively demanded, and the attempt must not be abandoned under the impression that the child is unable to swal- low, for this is constantly found to be erroneous. When exhaustion is the leading feature of the case, the child should not be allowed to sleep too long without nourishment. If the throat is painful, and there is thirst, a piece of ice to suck is very grateful and refreshing. A small quantity of iced water should be oftered frequently if the mouth and lips get dry quickly. In the shape of medicine, the carbonate of ammonia, with the tincture of bark (Form. 11), is an excellent combination for sup- porting the system against exhaustion. When the skin is hot and the temperature high, ice, cooling drinks, and diaphoretics* * Formula 52 : R. Liq. amm. acet., ^ij Spt. aether, nitr., 3j Syr. rospe, ^iij ■Aquam ad §iv. — M. A tablespoonfiil to be taken every four hours. 3£2 DISEASES OF CHILDREN. will be useful ; with these may be combined the tincture of the perchloride of iron,* or the iron may be given alone or with chlo- rate of potash. In most of the inflammatory throat aiiections of children, this preparation of iron has a wonderful effect, and is as specific as in erysipelas, which may be possibly due to some antisep- tic properties which it exerts locally, and possesses after its entrance into the blood. It requires to be given frequently, and, according to some authorities, in large doses. A small dose (rrj^v to ttj^x), with or without the dilute hydrochloric acid, once in four hours, is often enough in mild cases. If the tongue is furred and the breath fetid, chlorate of potash, in combination with the acid, is an excellent remedy, and recover}^ will take place under its steady continuance. Quinine, salicylic acid, benzoate of soda, when the temperature is high and the system depressed by the septic nature of the disease, are all useful. When the throat exhibits dark and softened portions of exudation, with a tendency to bleed when touched, or there is hsemorrhage from the mucous surfaces, then the perchloride of iron must be combined with it ; and in this formidable complication, a full dose should be given ever}' hour or two, till the urgent symptoms are relieved. In most cases I prefer a mixture consisting of iron, chlorate of potash, and hydro- chloric acid.f It is particularly suitable when the exudation is firm, the tongue coated, and the throat exhibits no hemorrhagic tendency. The chlorine drink recommended in scarlet fever is equally of service here. It is grateful to the little patients by relieving the throat and febrile symptoms when they are present. It also possesses antiseptic properties, and improves the character of the exudation. Quinine and the mineral acids are also useful variously com- * Formula 53: R- Tinct. ferri perclilor., Glycerini, ......... Aquam ad ........ • A tablespoonful every four liours. For children five rears t Formula 54: R. Tinct. ferri perchl., Pota.ss. chlorat., . Acid, liydrochl. dil., Syrupi, Aquam ad . A tablespoonful every four hours. For children five years .5J ;ss. 6' giv. of age. ^xl gr. xl "Kxl 3 S3. Siv.- of age. M. M. DIPHTHERIA. 353 binecl. External applications to the throat, in the shape of leeches, blisters, and counter-irritants, are in no case requisite, and will do harm. Warm poultices, fomentations, or water-dressing, are com- fortable and useful. The applications to the throat internally, are those indicated in scarlet fever, and the same precautions as to strength are to be observed. In 3'oung children who cannot gargle, a solution of borax may be applied to the throat (.53S. to the 5j), or equal parts of the liquor ferri perchloridi and honey may be used with ad- vantage. This is perhaps the best astringent application. In a case that came under my care a few years ago, a thick solution of chlorate of potash, borax, glycerin, and honey,* gave much relief to the throat. At an early stage, when the membrane is thin on the fauces and tonsils, a solution of nitrate of silver (gr. x or gr. XX to the 5j), applied with a camel-hair brush, twice in the twenty- four hours, has been of benefit. The application of the solid nitrate of silver must be cautiousl}^ resorted to ; indeed, it is questionable whether this or any other caustic, as hydrochloric acid, or the acid nitrate of mercury, is ever necessary. They increase the pain and difficulty of swallowing, and at the same time aggravate the local mischief. If there is fetor of the breath, and the parts incline to be sloughing and gangrenous, the solution of chlorinated soda, in the proportion of one drachm of the solution to two ounces of water, is an excellent application. This, and the iron solution, are two most valuable measures, according to my experience, in every stage of diphtheritic sore throat. Some children are so alarmed and frightened at the attempt to press down the tongue, and apply applications to the throat, that these measures had better he given up altogether in such cases. I^ervous and delicate children are almost thrown into convulsions by their struggles and resistance, , and where these applications cannot be used there is consolation in remembering that escharotics are of doubtful efficacy, and even, according to some English and foreign physicians, who have had great experience of the malady, decidedly injurious. In diph- » * Formula 55 : Be. Potass, chlorat., Boracis, aa . . ^j Glycerin!, Mellis, aa gss. — M. The throat to be mopped out with a little of this solution frequently during the day. 23 354 DISEASES OF CHILDREN". theritic afi'ections of the throat, the carbolic acid spray will often be found very useful, just as it is in the faucial affections of scarlet fever and measles. Lime-water, sulphurous acid, lactic acid, etc., have been also used in like manner with success. The most con- venient plan of using the spray is to employ Siegle's apparatus, or the hand spray of Dr. Andrew Clark. As regards the operation of tracheotomy when death threatens from suffocation and dyspnoea. Professor George Buchauau, of Glasgow, has recorded some -interesting cases of success. Out of thirty cases he had eleven recoveries.* He has subsequently in- formed me that in every eight tracheotomies performed on chil- dren practically moribund from suffocative membranous effusion into the trachea, he has saved three children, and this is true of over fifty cases operated upon.f Two interesting cases of successful tracheotomy, in the last stage of diphtheria, were brought before the Clinical Society by Mr. George Lawson and Mr. Pugin Thornton (Feb. 28th, 1879). Two cases of diphtheritic larjmgitis have been recorded in which recovery also followed tracheotomy. The first case was that of a boy, six years of age, who was admitted into the Middlesex Hos- pital, under the care of Dr Coupland, May 30th, 1880. The suc- cessful issue was owing to the operation having been performed at an early period of the disease before much false membrane had formed. The second case was also that of a boy, seven years of age, who was admitted into the Children's Hospital, under the care of Dr. Gee, on Sept. 15th, 1879. Recovery followed quickly, notwithstanding the extreme dyspnoea at the tim.e of operation, and the large quantity of membranous casts expelled through the tube afterwards.:]: The following case had a different termination, owing, as I believe, to the delicate health of the child, the delay of the operation, and the collection of pus and false membrane in the trachea. On June 18th, 1880, a female child, three years of age, was admitted under my care into the Samaritan Hospital * Brit. Med. Journ., 1875, vol. ii, p. 293. f A statistical table of all the cases, with remarks on the conditions demanding tracheotomy, will be found in the British Medical Journal, vol. i, p. 555, 1880. "Taking the whole of the cases, the result is that nearly two out of every five opera- tions were successful ; and as the operation was never performed unless there was no hope of recovery otherwise, it may be fairly stated that the lives of these nineteen children were saved by tracheotomy." i TJie Lancet, 1880, vol. i, p. 950. DIPHTHERIA. 355 with diplitheria, symptoms of commencing laryngeal obstruction, and great prostration of the strength. The face was pale and the cervical veins normal, but the respiration was wheezing and noisy, and the cough frequent and laryngeal. xVir entered the lungs. At 4 P.M. the child was not so well, the head was thrown back against the spine, the respiration was more embarrassed, and the epigastrium w^as retracted at each inspiration. Tracheotomy was performed at my suggestion by Mr. Knowsley Thornton, the pa- tient being under the influence of bichloride of methylene. As soon as the trachea was opened, a teaspoonful of purulent matter escaped, and the child shortly after expired from shock and as- phj'xia. A post-mortem examination revealed the upper surface of the soft palate and uvula uniformly covered with diphtheritic patches. Another patch lined the mucous membrane of the larynx immediately below^ the right vocal cord and projected into the glottis ; a long slough lined the mucous naembrane of the trachea, below the incision, extending almost to the division of the bronchi. The larynx and trae previous winter. Was suddenly taken ill on August 11th, and complained of pain in head, neck, and chest. On admission (four days later) right front of chest dull at apex ; increased vocal resonance and fremitus ; broncliial respiration. Left back hyper-resonant. Temperature 102.2° ; pulse 133 ; respirations 48, to-ngue covered with a yellow fur, red at tip and edges ; constipation. On the. 17th there was vomiting ; temperature 98.4°. On the 22d there was scarcely any difference on tlie two sides of the chest. Feels well. Secondary pyrexia followed after tlie physical signs had cleared up, which was considered due to the absorption of inflammatory products, or allied to septicajmia, as there were no signs of tuberculosis. On the 13th of Sep- tember he was discharged. — Cases of Apex Pneumonia, Medical Times and Gazette, October 6th, 1877, p. 386. 456 DISEASES OF CHILDREN. early period of the illness are not unlike approaching meningitis. In those eases of meningitis complicated with pneumonia, broncho- pneumonia, pericarditis, etc., great difficulties often present them- selves in arriving at a correct diao;nosis till the characters of one or the other disease predominate. Causes. — These are predisposing and exciting. Among the former are the previous state of health, and the liability to pul- monarj" disease. Among the latter are exposure to cold in winter and spring, particularly after measles and the eruptive fevers, debility, privation, violent exercise, congestion from heart or kidney disease, or from tubercular dej)Osit in the lung. The exciting causes, too, are exposure to cold when the body is heated, croupous exudation in the lung, and the deposit of diphtheria. Injury to the chest, or a blow setting up abscess in the walls of the chest, is another ascertained cause. Pathology. — The epithelial lining is unaltered in croupous pneu- monia. The exudation tilling the alveoli consists of iibrin and leucocytes, or "exudation cells," which readily undergo fatty de- generation; they are partly thrown off in the sputa, or disappear by absorption, which is quite different to what happens in catar- rhal pneumonia. In the first aftection the whole lung, or one lobe, is consolidated, whilst in the last-named variety isolated patches (lobules) are affected, surrounded by pulmonary tissue permeable to air. Terminations. — Pneumonia generally ends in resolution in healthy subjects. A crisis takes place in the form of sweating or diarrhoea, or there is an abundant urinary discharge, and forth- with all the symptoms speedily decline. This may be usually looked for at the end of a week, when the pulse and respiration become reduced in frequency, but the crisis may not occur for another five or six days, leaving the child prostrate, thin, and pale. In other cases, when convalescence appears to be approach- ing, a relapse takes place, and the child may die of asphyxia or convulsions from a clot of fibrin blocking up the pulmonary artery and obstructing the circulation through the lungs; or it drags on, and at last perishes from exhaustion. In another class of cases the exudation thrown out is never absorbed, but it provokes fever and cough, and ultimatel}' leads to phthisis or chronic pneumonia, which is slowly recovered from if the general health can be main- tained and proper treatment is emploj'ed. PNEUMONIA. 457 Prognosis. — From the liability of young subjects to tubercular disease, pueumonia is full of peril to tbe weak and delicate, par- ticularly if the pleura or pericardium has been involved, or there is renal or heart disease. If both lungs are affected, and there is copious secretion (especially if dark or prune-juice in color), the respiration increases in urgency, and collapse is to be apprehended. In such cases profuse perspiration breaks out, low muttering de- lirium sets in, and the child gradually sinks. The diagnosis of croupous pneumonia is to be sought in the tubular breathing, tine crepitation, dulness on percussion, elevated temperature, and rapid respiration. Change from the normal ratio between frequenc}^ of pulse and frequency of respiration is very marked is this disorder. In any febrile disturbance in young children the temperature is apt to run rapidly high, even in den- tition, but then it is of very brief duration compared to pneumo- .nia, and in bronchitis it is not usually so high, though I have known it reach 105° when the disease has been limited to the bronchi alone, and the pulmonary tissue has escaped. The rhonchi of pneumonia are more sonorous and scanty, and the moist crepi- tation is not so loose and bubbling as in bronchitis. When acute lobar pneumonia attacks the upper lobe of a lung, it is liable to be mistaken for phthisis. The exudation poured out in these cases, and the dulness and tubular breathing, are just the signs which ensue from tubercular deposit. The local indications are often trifling, however, compared to the febrile disturbance and prostration, and time alone may be capable of clearing up the diagnosis. In the case of simple inflammation the local and gen- eral symptoms soon pass off, whilst in tubercular cases they gradu- ally become worse, or merge into the chronic form, when the diag- nosis is all the more difficult, if not impossible. Physical signs cannot clear up the difficulty, for both in pneumonia and apex consolidation from tubercle there is great dulness, bronchophony, and bronchial respiration, to indicate that the lung-tissue at this part is consolidated. Miliary tubercle may give rise to no signs whatever, and the disease usually creeps on but slowly, with fever and emaciation, cough, and loss of appetite. Tubercle may be present in some other parts of the bod}^, and there may be a his- tory of it in the family. The diagnosis from pleurisy is given in the chapter devoted to that subject. The symptoms of lobar 'pneumonia differ from those of lobular 458 DISEASES OF CHILDREN. or catarrhal imeuinonia in the greater dyspnoea of the latter affec- tion, the duskiness of the lips, and the pallid and hloated counte- nance. There is more restlessness and anxiety, the cough is loose and choking, and mucopurulent phlegm is often dislodged frora the air-passages by a paroxysm of suffocative cough or vomiting. AVhen the child is too young or feeble to expectorate, the sounds over the affected tubes are loose and extensive. The symptoms in this variety come on earlier, and the vital prostration is more marked. Pneumonia may be distinguished from oedema of the lungs by the dulness on percussion and the tubular breathing, whilst in the latter affection the sputa are frothy and thin, and the complaint occurs as the consequence of long-continued congestion from heart or kidney disease. The onset of pneumonia may be mistaken for typhoid fever, and even meningitis, but these have been alluded to in another place.* Ireatment of Lobar Pneumonia. — In the acute congestive stage, if the child is strong enough, and there is much pain in the side, the application of a few leeches, or even venesection, is not to be neglected. But it is of the greatest importance to be verj^ cautious in the selection of cases for this heroic treatment ; these will almost invariably be found in country practice, and seldom in large towns and cities. Ko doubt children have been so saved when all other remedies have failed,f and the plan is always one to be held * See Chap. VIII, On Tvplioid Fevei-, and Chap. XLII, On Diseases of tlie Brain. t " In a heahhy child of four years old a vein may be opened in the arm, and four ounces of blood may be allowed to flow, provided that faintness be not earlier produced, without tliere being any reason for us to apprehend that tlie plan we are adopting is too energetic. It often liappens that the child faints before this quantity of blood has been drawn, while in other cases not above one or two ounces can be obtained ; still, whenever the patient is seen at the commencement of the attack, general depletion is desirable, even though it should be necessary to follow it up by local bleeding ; for the immediate effect which it produces is greater than that which follows depletion, and the quantity of blood abstracted by it is definite ; while, if both the nurse and the med- ical attendant understand how to manage children, it may be conducted so as to cause them but little excitement or alarm. If but very little blood can be drawn frora the arm, or if, as is not seldom the case with infants under two years of age, it be not possible to find a vein, depletion nuist be accomplished by means of leeches, which, for reasons already stated, it is desirable to ajjply beneath the scapula. How great soever may have been the relief which followed the first bleeding, it is not always permanent, and hence tlie child sjiould Ije seen again in from six to eight hours; and if the symp- toms ajjpear to be returning with any tiling of tlie former severity, depletion must be PNEUMONIA. 459 in mind, as it frequently saves the lung from organic change and preserves life. Every case, however, must be treated on its own merits, and if suitable diet and rest are observed the patient may be left to nature in many cases. Two or three leeches to the side in sthenic cases have relieved pain and rapid breathing, causing the blood to circulate more freely through tlie lungs, controlling the temperature, and lessening the violence of the heart's action. This treatment should be resorted to early in the disease. Tartarated antimony is a most useful drug, and in strong children it may be given advantageously for a short time in small doses, as gr. ,'.^th to ^th, with the solution of acetate of ammonia, or the dilute hydrocyanic acid (Form. 60). The antimony acts best when it does not provoke vomiting, but simply determines to the skin and lowers vascular action. Valuable as antimon}^ undoubtedly is, it must be used with great caution, and watched very care- fully, for in young children it soon causes depression and faintness, and if the occurrence of these symptoms is not guarded against, the local signs increase instead of improving. This again, like bleeding, is only suitable for strong children in the early stage of the disease, and not for those w^ho have been reared in the con- taminated atmosphere of large towns. A few drops of antimonial wine, with citrate of potash and the solution of acetate of ammo- nia or spirit of nitrous ether, wnll keep up a gentle action of the skin and brino; relief. Emetics are not indicated in this form of pneumonia. With the tendency to exudation of lymph mercury ma}'' be employed, but more sparingly in this than in some other paren- chymatous inflammations. When the constitution will bear it, its action as an antiphlogistic may shorten the stage of exudation, and promote and hasten the absorption of the newly effused lymph repeated, though then local bloodletting is to be preferred to venesection, even in cases in which bleeding from the arm had been resorted to in the first instance. It must never be forgotten that in the child, as well as in the adult, no subsequent care can make up for the inefficient treatment of the early stage of pneumonia ; if the first twenty-four hours be allowed to pass while you are employing inadequate remedies, the lung, which at first was merely congested, will have become solid, and recovery, if it takes place eventually, will be tardy, and perhaps imperfect. On the other hand, cases that set in with the greatest severity sometimes appear to be at once cut short by free depletion ; the violent symptoms being arrested, and recovery going on uninter- rn[)tedly, almost without the euiployment of any other remedy." — West, Diseases of In- fancy and Childhood, 1859, 4th edition, p. 321. 460 DISEASES OF CHILDREN. before it has had time to become organized, and to act as an irri- tant to the surrounding healthy textures. Small doses of calomel with a few grains of James's powder maj be sometimes given with advantage (Form. 62). Minim doses of tincture of aconite are also useful from their power in promoting diaphoresis. The anti- phlogistic effects of aconite are very marked in relieving tension in the pulse, and lowering arterial pressure, but this drug tends to reduce the respiratory movements as well as the temperature, and acts as a sedative on the cardiac circulation. I have never ob- served any bad effects follow its administration in acute pyrexia in small and repeated doses, but great benefit where the vascular excitement has been considerable, and the skin pungently hot.* When the physical signs announce that the lung is freely secret- ing, and sthenic action is reduced, a grain or two of the carbo- nate of ammonia may be given, particularly if the pulse is weak or unsteady, and there are signs of collapse, when it may be safely combined with decoction of oak bark, or senega. Whilst the sputa are viscid and the urine turbid, alkalies are indispensable. A few grains of hj^drate of chloral may be of service where de- pression is to be apprehended from the want of sleep. We should bear in mind that it lessens the activity of the respiratory centre and enfeebles the vasomotor system — a state of things we are most anxious to guard against. Its action is also very manifest on the circulation, lowering and weakening the action of the heart, by paralyzing its sympathetic ganglia. The combination of bella- donna tends to obviate this. I should never administer it where the pulmonary circulation was much involved, for fear of increas- ing relaxation in the vessels and further enfeebling the action of the heart. f Bromide of potassium is a safer remedy, having a sedative in- fluence on the nervous system, and so inducing sleep, without de- pressing the heart's action. In the shape of local applications, nothing equals a warm linseed or jacket poultice. It should be applied over the whole of the affected lung, as hot as can be borne, and changed once in two or * See the action of Aconite in Chap. XI, On Scarlet Fever. f " The breathing tends to become shiwer, and finally to cease, from paralysis of the respiratory centre ; but urgent dyspnciea has occasionally been observed, and this has been ascribed to dilatation of the pulmonary vessels,- causing an increased afflux of blood to be directed suddenly to the lungs." — Guide to Therapeutics, by Dr. Farqu- harson, 1877, p. 132. PNEUMONIA. 461 three hours. The fault of poultices in general is that they are not made large enough to envelop the diseased organ, for the object aimed at is, not only to relieve pain but to draw the blood to the surface, and so to act as a sedative on the inflamed or congested parts beneath. "In lung diseases of children, whose chest-walls are very thin, the value of poultices has seemed to be much greater than in corresponding affections in adults ; and it is not illogical to believe that the difl^erence may be dependent upon the irregu- larity of the chest-walls."* When moderately and cautiously used a turpentine stupe is very serviceable. A piece of thick household flannel should be folded the required size, then wrung out of hot water, and a few drops of turpentine sprinkled over it. This should be laid over the affected part of the lung, and covered with a piece of oiled silk, or a dry fold of linen rag, and kept on for twenty minutes. When it is removed the skin will be found of a bright erythematous hue, and the cutaneous vessels will be kept dilated for a considerable time. The diet should be light, and at first without stimulants. After about five days or a week, when the temperature falls (perhaps with crisis of diarrhoea or sweating), wine, eggs, and additional nourishment are needed. In all cases, milk, beef tea, and cooling drinks from the onset, should be given freely. The temperature of the room should be about 60° and well ventilated ; the head raised, and the position changed frequently. In the treatment of the second stage, or that of hepatization, a flying blister, or the application of iodine may be needed, but this will be more fully alluded to when we come to speak of the disease in its chronic form. The perchloride of mercury in small doses, iodide of potassium, and cinchona, are valuable remedies in their turn. The ammonio-citrate of iron, or the syrup of the iodide, are both useful remedies, particularly if the child is antemic. In the third stage, carbonate of ammonia, brandy, quinine, and the mineral acids may be required, followed by cod-liver oil and change of air. 2. Catarrhal Pneumonia [acute lobular j^neumonia^einthelial j)neu- wonia), Bronchoimeumoma. — In this variety distinct and separate lobules are affected. The inflammation extends along the smaller bronchial tubes to the air-vesicles, or it originates in collapsed * Wood on Therapeutics, 1876, p. 558. 462 DISEASES or childeen. lobules, which are firm and red. On section they are smooth and give exit to a bloody fluid. It is very common in whooping-cough, measles, and diphtheria, but it may arise apart from these diseases in consequence of debility and an impure atmosphere. Cold and changes of weather appear to be the most common causes, and any exhausting disease which has kept the child for a long time in the recumbent posture is capable of originating this mixed disorder. Children who are delicate from birth and have bronchitis are sub- ject to it. I have met with children of fifteen months old with symj)toms of wasting and marasmus who get bronchitis. The wheezing extends down the bronchi, and involves the smaller bron- chial tubes of one lung, increasing the frequency and urgency of the respiration, and by retarding the circulation through the lower portion of the lung leads to dulness and consolidation of it. The lips become blue, and the skin breaks out into a cold clammy perspiration. The temperature may reach 104° or 105°, but it is not maintained at this height, the pulse 200, small, thrilling, and collapsing, and the respirations 60 or even 100 per minute. The child is extremely restless, turning about and hiding the ball of the eye beneath the upper eyelid. The dulness may creep up- wards above the spine of the scapula, and tubular breathing be detected below the clavicle on the same side. There is phlegm, which cannot be dislodged, and the child cries out when he coughs, and only gets snatches of sleep. Soon the lung is dull throughout, and the alse nasi are active ; large and loose crepitation succeed, the respiration becomes rattling, and the child may die in a con- vulsion, or pass into coma and sink. In other cases the crepitation which has been heard during the pure bronchitic stage is succeeded in a day or two by tubular breathing, harsh and dry; .the dulness increases, and becomes apparent in front as well as behind. Lobular pneumonia, when it is at all severe, is a frequent out- come of bronchitis, indeed the two conditions constantly occur too-ether, but they must be recognized as separate and distinct diseases, having a different clinical and pathological importance. " Lobular pneumonia is always a secondary disease, either to those specific disorders which are accompanied by bronchitis almost as one of their elements (in which rank measles and whooping-cough stand obviously first), or to bronchitis of a primary kind. So far as careful post-mortem observation permits a generalization to be made, the course of the disease is invariably through the occurrence PNEUMONIA. 4G3 of collapse. After a lobule has become emptied of air, and after more or less of the bronchial contents have been forced by inspira- tory action into the alveoli, the lobule itself passes into a state of active congestion, and then of hepatization, and by degrees the test of inflation gives only a partial result, and eventually no air can be forced into the lobule. The microscope shows in the earlier periods of this consolidation the parenchyma of the lung unchanged, but the alveoli stufied with cells and their epithelium occasionally undergoing some fatty change. The next anatomical change is the coalescence of these collapsed and inflamed lobules into larger masses, which frequently give rise to consolidation of large por- tions of the lung, especially of the posterior surface. In these, next, a softening change goes on, and the centre of the lobule loses the dull-brown color of the rest, and becomes gray and dif- fluent, the liquid part having all the characters of pus. Or another process may be set up in the occluded lobule, and a cheesy matter be formed, which to the microscope presents various fatty elements and nuclei. This occurs at a later stage of the disease in unhealthy children, in whom, however, miliary tubercle need not exist.'"* Pathology. — Unlike the croupous form of pneumonia we have just considered there is no fibrinous exudation, but a cell pro- liferation which distends the alveoli at the termination of the smallest bronchi. These cells are derived from the epithelial lining of the alveoli where they remain, and as they cannot be readily discharged by expectoration, they accumulate, cause local irritation, and form into masses, which undergo retrogressive changes. Hence the inflammation may lead to abscesses in the lungs or to caseous degeneration [scrofulous pneumonia)^ or to tuberculosis, and that terrible acute form of phthisis known as '■'■ galloping consumption." In some protracted cases the disease may terminate in chronic pneumonia. Treatment. — In this variety lowering measures must be dis- carded. Ipecacuanha wine in a saline mixture, and carbonate of ammonia, senega, and tolu, are the remedies to be depended upon (Form. 61, 65, ^Q). When there is an accumulation of phlegm in the air-tubes an emetic at night to dislodge it will relieve the breathing and insure rest. Some of the best effects have followed the use of mild emetics at bedtime in these and other similar * Lettsomian Lectures — On the Diagnosis and Management of Lung Diseases in Children, by George Buchanan, M.D., F.R.C.P., The Lancet, Feb. 8th, 1868, p. 215. 464 DISEASES OF CHTI.DREN. cases, as broncliitis or whooping-cough, where the bronchial tubes are loaded with mucus. I have not observed any bad effects follow the use of a teaspoonful of ipecacuanha wine, followed by a little warm water, till vomiting ensues, unless the child is very- exhausted. Generally one or two doses will be enough, but if the child is prostrate, and there is lividity of the face and mucous membranes, with a feeble pulse and shallow respiration, the ipecacuanha failing to excite cough or vomiting will increase the general distress. The bronchial tubes remain loaded with phlegm and mucus, and the general discomfort and pain in the chest cannot be relieved so long as the mucus remains. In these cases it may be well to combine the ipecacuanha with a stimulant like the carbonate of ammonia, or a few grains of sulphate of zinc, and if its action is delayed, to tickle the fauces with a feather, but even these attempts sometimes fail, and then our only chance is to place the child in as upright a position as possible in bed and support the failing circulation by ammonia, spirit of chloro- form, wine, and beef tea. When an emetic acts efficiently it excites the action of the respiratory muscles, empties -the larger tubes of their tough or fluid contents, and stimulates the smaller, bronchi to renewed secretion and activity. The dry sounds and hyper£emia of the mucous membrane diminish and give place to moist crepitation, and resonance on percussion. The expression changes and becomes lively and animated, the duskiness of surface passing off as the blood is better aerated, and the child is restored by refreshing sleep. The carbonate of ammonia is an excellent remedy by loosening the contents of the bronchi, and favoring expectoration, I have many times known children expectorate or bring up phlegm by coughing, just in proportion as they have taken the remedy or not. When the temperature is high and the pulse weak and quick, I have seen excellent efiects from combining the ammonia with quinine and senega.* This encourages expectoration and improves the pulse and appetite. If the tongue is furred, and the sputa * Formula 69 : R. Aram, curb., gr. viij Tinct. qiiinia', . . S'n'] Spt. cliloroform, "Kxx wSyr. to] lit., .^iij Decoct, senegfc ad ^iv. — M. A table.spoonful every four hours. For children five or six years old. PNEUMONIA. 465 thick and tenacious, the ammonia may be given with bicarbonate of potash and ipecacuanha.'^ When there is no tendency to ac- cumulation in the bronchi, and the cough is irritating and the child restless, a few drops of the compound tincture of camphor, or henbane, may be safely added. As to diet, the child should be fed with milk and lime-water, chicken or veal broth, and a few drops of brand v may be added to the milk three or four times a day. In feeble children of only a year old I have sometimes given a little champagne in potash- water, with excellent results, and I consider that recovery is often due to the rallying effect of the wine. As regards local applications, warm linseed poultices, with or without mustard, as we have mentioned under lobar pneumonia, will be of most benefit. Later on, the preparations of iron — the syrup of the iodide, the syrup of the phosphate (syrup, ferri phosp., B. P.), the chemical food (syrup, ferri phosp. comp.), or the vinum ferri, will be neces- sary to strengthen the system and improve the quality of the blood. During convalescence cod-liver oil or Squire's malt extract will be found serviceable, or they may be combined with great advantage. The latter remedy may be given in milk. 3. Chronic Lobular Pneumonia. — This is a disease of great in- terest and importance from its liability to be mistaken for tuber- culosis or chronic phthisis. The connective tissue between the lobules is atfected, leading to induration and consolidation of the pulmonary tissue. It generally follows bronchitis, pneumonia, measles, or diphtheria, or, what is far more common, it creeps on insidiously in bad states of health, and may prove persistent and troublesome. I have met with it in feeble children of rickety con- stitution, and for weeks together could not decide whether the disease was tubercular or not. In fact, until a case of this form of pneumonia had been for some time under observation, it is im- possible to come to a decision. When we are sure that a child has * Formula 70 : R. Amm. carb., . . . . . . . . gr. vii Potass, bicarb., . . . . . . . • 9ij Vin. ipecac, njjxl Syr. tolut., giij Aquam ad Jiv. — M. A tablespoonful every four hours. For children five or six years old. 30 466 DISEASES OF CHILDEEX. enjoj'ed good health till an attack of bronchitis or whooping- cough has happened, and then the complaint passes into localized dulness below one clavicle or scapula, with or without moist crepi- tation and bronchophony, we are generally correct in assuming that the complaint is of simple origin. The two following cases exemplify this condition. Chronic lobular pneumonia, simulating tuberculosis ; recovery. Case 1. — V. B , set. 9|, was admitted into the Samaritan Hospital, under my care, on March 25th, 1875. He was a pale, thin, emaciated boy, with light hair and gray eyes, and had been ailing in health, more or less, for five years. There was no history of an acute attack. Had had both whooping-cough and measles; his mother dated his delicacy to an attack of quinsy three years previously. On examination there was a general flattening of the thorax below the clavicle, especially on the left side, to the inner aspect of the corresponding nipple, and this was in a great measure due to imperfect development of the left half of the thorax. He could take a full inspiration, at the termination of which was a cooing, dry, bronchial sound, not heard on the right side. The percussion- note was good in front, but nowhere clear behind ; the respiration was harsh and irregular, and there was distinct bronchophony, but no moist sound ; the pulse was variable, the least fatigue or ex- citement at once accelerating it, and I have felt it one day as low as 72, and another as high as 112 ; the respirations were tranquil, and did not exceed 20 per minute, the morning and evening tem- perature 99.2°. He was ordered a diet of milk, eggs, and beef tea ; a mixture of hydrochloric acid and quinine ; diluted tincture of iodine (one in seven) to be painted under the left collar-bone night and morning. ' In May he was much better, and in June he had gained in flesh and weight, and his general health was most satisfactory. Tem- perature normal ; pulse 72, respirations 20. The pliysical signs still indicated some remaining dulness and bronchophony between the scapulse. He was discharged well on June 23d. Readmitted February 17th, 1876. — Some time after leaving the hospital he seemed to be in perfect health, but latterly he had lost much flesh and strength. The wasting was most apparent about the temples, in the arras and legs, and in the shrunken hands, the sternum and scapular region. He looked like a child PNEUMONIA. 467 in the last stage of plitliisis. The chest was clear on percus- sion, and expansion was everywhere good, the inspiration was rather short and harsh, but there was no dnlness, and the vocal vibration was slight. As the expiratory note was not caught at all, its suppression was probably due to nervousness. In the right supra-scapular space, inspiration was short and rather harsh, but there was neither dulness nor vocal vibration. Immediately below the spine of the scapula, and over the centre of the bone, small crejDitant rhonchus was most distinct, which disappeared between the inner border of the scapula and the spine; over the middle lobe of the lung there were coarse, loose, and moist bubbling rhonchi (suspected softening of middle lobe\ and dulness was very marked from this point downwards. There was no bron- chophony, the complete absence of which I could not explain, but on inspiration the air seemed to be entering some small cavity, the thin sternal walls only intervening between it and the ear, when applied to the chest-wall. There was some consolidation of the lung. In the middle and lower lobes of the right side there was heard crepitant rhonchus, precisely resembling the small crepi- tant rlionchus of pneumonia; over this the percussion-note was resonant. The urine was turbid, slightly alkaline, and rather high- colored, with a sp. gr. 1024 ; on boiling, flakes like albumen floated freely in the specimen, which immediately disappeared with effer- vescence (phosphates) on the addition of nitric acid. The pulse was 96, and of good calibre ; the respirations 20 ; the morning tem- perature was 99.4°, the evening 100°. The variation in breathing was very noticeable here — one minute only breathing twenty times, and another as many as twelve times in the quarter of a minute, just as we see in some cases of tubercular meningitis, and gradual death from exhaustion.* He was never fl.ushed,and there was no sweating. He was ordered quinine, phosphoric acid, and cod- liver oil. 22d. — The urine was unchanged — he was ordered port wine. 24th. — There was more loose crackling in the lung, which ap- peared to be breaking down, as gurgling and pectoriloquy were distinct, and when he whispered the sound travelled up the stetho- scope distinctly. March 9th. — During the last few days no bronchophony or gurgling was to be heard. * See Chap. XLII, On Diseases of the Brain. 468 DISEASES OF CHILDREN. 24tli.— ^Ile had gaiuecl flesh and looked better, and although his appetite was good his cough was still troublesome. The change in the physical signs of the lung was very remarkable ; the note was clear throughout the surface of the right lung, there was no trace of bronchophony or moist sound of any kind, except a little dry crackle ; all the characteristic signs of breaking-down of lung- texture on the 24th ult. had disappeared. The only sound now was prolonged expiration and diminished expansion on this side. It is possible that the cause of this was due to some ^'- lobular "pneu- monia^' of a chronic character pressing on the tubes, and that con- solidation of lung-tissue was set up. April 21st. — The only change now detectable was that the respi- ratory murmur was weaker over the affected side than the left, every trace of crackling and consolidation having disappeared. lie was ordered the ammonio-citrate of iron in five-grain doses twice a day and to leave the hospital. A year later (April, 1877) he was in perfect health. Case 2. — This case presented considerable interest, and when sent to me an abscess communicated with the left lung and pleura. B. M — , set. 3, a fair and very intelligent child, was admitted into the Samaritan Hospital, under my care, on December 22d, 1876. The mother stated that the child had been ailing with bronchitis and cough ever since the previous September, and had not enjoyed a day's health since. There was no history of an acute illness; on the other hand, the symptoms were gradual, and at no time marked by fever or inability to leave her bed. On examina- tion there was a prominent and circumscribed swelling on the left side, over the lower ribs, about two inches below the nipple. On auscultation there was considerable dulness and imperfect expan- sion below the left clavicle; the voice was bronchophonic and the respiration harsh and bronchial. The heart's sounds were distinctly heard throughout the thorax. Posteriorly the dulness extended downwards to the middle of the scapula, and the note was not at all clear below this ; the respiration was dry and harsh. There was scarcely any cough to speak of, and the temperature was normal, but the pulse was 160, small and weak ; the respirations 56, short and catching; the bowels regular and the urine free and clear. A poultice was ordered to the swelling, and a grain of carbonate PNEUMONIA. 469 of ammonia in tincture of cinchona every four hours.* The diet consisted of beef tea, milk, and two eggs daily, beaten up with sherry. On the 24th the abscess was opened and a small quantity of laudable pus escaped ; the child had slept tranquilly, without cough, but the pulse was very weak and small. On the 2Gth the temperature was 98°, pulse 128, respiration 48. The abscess had discharged a large quantity of matter in the night, and this had given her ease; she sat up in bed and was aware of all that went on around her, but she was peevish and fretful, and looked very pallid and exhausted. The upper third of the left lung was very dull posteriorly, and the breathing dry, shrill, and tubular, but descending downwards these physical signs became less marked, though everywhere they presented a striking contrast to the oppo- site side. On the 28th the pulse was 96, respiration 32; the ab- scess was discharging freely and there w^as no cough; over the lower lobe on the left side the percussion-note was becoming reso- nant, and the dry breathing was supplanted by coarse crackling respiration. On January 4th, 1877, the respiration was clearer under the left clavicle, but still showed a marked contrast to the opposite side; posteriorly the dulness was diminished, and in the lower half of the lung the moist rales were nearly absent, whilst in the centre of the lung the voice was bronchophonic. A mixture of iron, carbonate of ammonia, and a very small dose of iodide of potassium was ordered three times a day.f On the 19th the ab- scess reformed, and it was necessary to make a counter-openino-. On March 2d the patient had gained a stone in weight since ad- mission under the effect of good diet, cod-liver oil, and the syrup of iodide of iron. The patient shortly after sickened for measles, gr. viij 3iij 5 iv.— M. * Formula 71 : B. Tinct. cinch, co., ........ ^iiss. Amm. carb., ..... Tinct. campli. co., .... Syr. tolut., Aqnam ad .... . A dessertspoonful every four hours. For children five or six years old. f Formula 72 : R. Ferri et amm. citr., ' . . . gr. xij Amm. carb., ......... gr. viij Potass, iodidi, . . gr. iv Syrupi, 3ij Aquam ad ^iv. — M. A dessertspoonful to be taken three times a day. For children five or six years old. 470 DISEASES OF CHILDEEX. and was consequently detained in hospital till April 13tli, when the wound had soundly cicatrized, and no difference could be dis- covered in the physical signs of either lung, which presented every sign of health. Chronic pneumonia appears to be sometimes caused by disease of the tracheal and bronchial glands. Dr. Gee has related some interesting cases.* Measles, scarlet fever, pertussis, and chronic cough were the causes of the glandular affection. In one case (aged 3 years 9 months} a cavity in the bronchial glands was found, containing a slough, which opened into the oesophagus and left bronchus; the tracheal glands were enlarged and caseous; the riccht lung; was studded with miliary tubercles. In a second case (aged 6 years) the bronchial glands at the bifurcation of the trachea were transformed into a cheesy mass ; the right bronchus was per- forated by an ulcer. There was hectic fever during illness. In a third case (9 years old) at the bifurcation of the trachea there was a sloughing cavity, and the right bronchus opened into it ; the right lung was entirely solidified; there was hectic fever through- out the illness. In a fourth case (aged 2| years) the tracheal glands compressed the lung, and on section the tumor contained a cavitj', the size of a walnut, filled with thick creamy pus. The bronchial glands were also enlarged. (Edema of the lungs^ though rare in children, is of sufficient im- portance and frequency to deserve careful consideration. There is no evidence of inflammation in the tissue of the lungs, but it is infiltrated with watery fluid, so that it is firm and inelastic; it contains very little air, scarcely crepitates, and sinks in water. On examination of the lungs after death there may be found an effusion of clear serum into the cavity of the pleura, or even a thin layer of lymph, proving that some degree of inflammation has taken place. The lungs are of a deep-red color. On cutting into their substance reddish serum exudes, and as it escapes the pulmonary tissue becomes crepitant and lighter in color. The air-cells and pulmonary connective tissue contain so much fluid that it inter- feres with the free entrance of air, and explains the cause of the rapid and difficult respiration. " This is a condition very frequently found in Bright's disease, or where there is a disposition to dropsy ; the lung is found filling the chest and heavy, and on a section * On the Chronic Pneumonia which attends Disease of the Tracheal and Bronchial Glands, St. Barth. Hosp. Rep., vol. xiii, p. G3. PNEUMONIA. 471 beino; made a quantity of serum drains out, leaving the tissue healthy and firm. It is thus distinguished from the first stage of inflammation, in which the texture is very lacerahle."* Causes. — We may attribute this peculiar state in most cases to a passive or mechanical obstacle to the free circulation of the blood, as in pneumonia, valvular disease of the heart, and pressure on the pulmonary veins. " Laennec taught that pulmonary oedema may occur as a primary and idiopathic condition, and that the suftbcative orthopnoea, which sometimes cuts ofi:' children after measles, arises from such oedema. "f Cases have resulted from anasarca after scarlatina, from morbid states of the blood, as in Bright's disease, purpura, and the continued fevers. I have seen two cases which occurred as the consequence of constitutional debility, and a low state of the general health. Both were pre- ceded b}^ slight catarrh (a subacute form of bronchitis), and no alarm was realized till the respiration became rapid, out of all proportion to the pulmonary state. The condition is one not only associated with debility and relaxation of the vessels and tissues, but the quality of the blood has probably undergone a change similar to what occurs in passive dropsy. It is thinner and more watery than in health, the corpuscles and organic matters are diminished, and hence the transudation of the serous parts through the vessels and capillaries. The physical signs which indicate this condition are not very characteristic or reliable ; there is some dulness on percussion, and increase of vocal fremitus ; the respiration is weak and often mixed with rather loose rales and subcrepitant rhonchus ; " the fine bub- bling rhonchus. when very liquid and well marked, is the most characteristic sign.":{; Treatment. — This will depend upon the cause. If the disease comes on during the anasarca of scarlet fever, the hot-air bath, and diaphoretics to act on the skin will be needed to remove renal congestion. Small doses of tartarated antimony and spirit of nitrous ether will relieve the dj'spnoea, whilst a poultice may be necessary if the bronchial congestion is suflicient to demand it. But it often happens that oedema of the lungs, coming on gradu- ally in strumous and delicate children, demands a supporting line * Wilks and Moxon, Pathological Anatomy, 1875, p. 323. t Disenses of the Lungs and Heart, by W. H. Walshe, M.D., 1854. p. 448. X Walshe, op. cit., p. 449. 472 DISEASES OF CHILDREN. of treatment, as spirit of chloroform, ammonia, brandy, and good nourishment. CHAPTER XXXIX. ON TUBERCULOSIS. Nature and Definition of Tuberculosis. Artificial Production of Tu- bercle. Gray and Yellow Varieties. Anatomical Characters and Appearances found in the Lungs in Tuberculosis. Comparative Fre- quency OF Tubercle in the various Organs of the Body. Usual Prog- ress OP Tuberculosis. Causes: Hereditary predisposition — Influence of age — External causes, as bad air and ventilation — Insufficient food — Chronic diarrhoea and indigestion — The eruptive fevers and whooping-cough — Inflammation an exciting cause of tuberculosis. Symptoms : Pain in epigastrium and indigestion — Temperature of the body in tuberculosis the surest means of diagnosis in the absence of physical signs — Sweating, pulse, and respiration as diagnostic aids— Illustrative cases which may bemis- takenfor tuberculosis. By the term tuberculosis we mean a general condition of ill- health, attended with the deposition of tubercle in one or more organs of the body. It is a constitutional febrile affection, which is usually associated with inflammatory action in the lungs, bron- chial glands, cerebral meninges, and peritoneum. We say asso- ciated., because its precise relation to inflammation, whether as a mere variety or as a concomitant, or a result, is still a great patho- logical question, which we will discuss further on. In childhood it has some special and characteristic symptoms which we do not observe in later life, and the causes and history have a separate and distinct character. In well-marked cases of tuberculosis the children are usually good-looking, with prominent veins, long eye- lashes, and dilated pupils ; the figure is erect and slim, the joints are small and slender, and the shafts of the bone thin and straight ; the growth of mind and body is active, and the nervous system is highly impressible ; the child is sensitive to reproof or kindness, quick and clever at lessons, and does not exhibit the backwardness which belongs to the phlegmatic temperament. These children are not subject to enlargement of the lymphatic glands, nor have they the thick lips and dull expression of the truly scrofulous diathesis. Tuberculosis, then, or the tuberculous cachexia, sig- nifies that state of constitution which arises from the presence of tubercles ; and by tubercles is meant a species of new matter, or ON TUBERCULOSIS. 473 growth, prone to degeneration and decay. In its crude condition it resembles concrete albumen, and consequently becomes soft and friable, and acquires the consistence and appearance of thick cream, or cheese, or pus. But a variety of circumstances will determine the character of the exudation, and it may abound in elements at one time which are not to be detected in it at another. It is de- posited upon the surface of the mucous membrane of the air-cells, or within the parenchymatous structure of the lungs, where, in- stead of being absorbed or excreted, as happens in the simple exu- dative inflammations of the healthy, it slowly degenerates by reason of its inherent faulty con'.position and deficient vitality. This question is discussed further on. Tubercles are the local ex- pression of a depraved constitutional state, and most likely repre- sent enfeebled nutritive energy. When few in number they occa- sionally become hard and indurated, and do not interfere with the organic functions ; but when they are numerous they affect the general health, and if deposited in the lungs, cause in most in- stances an alteration in the physical signs, and lead to softening and suppuration of the tissues in which they are deposited. The gray and yellow varieties are the kinds with which we are familiar. Under the microscope a section of a miliary or recent tubercle shows numerous leucocytes generally included in a network of delicate fibres — the '•'•adenoid tissue^' seen in glands. In the centre of the tubercle are large multinucleated cells, sometimes called '■'•giant cells" the processes of which are directly continuous with the reticulum. The caseous tubercle shows cells in all stages of deo;eneration and disintegration. Tubercular exudation is most commonly met with in children and young adults. It occurs in the lymphatic glands, the lungs, and serous membranes, and its progress is generally slow and in- sidious ; but, on the other hand, it is sometimes rapidly roused from latency into activity, or set up anew by some commonplace disorder. There is no attempt at absorption or perfect cell forma- tion, but a tendency to ulceration and disintegration, with a cer- tain train of general symptoms, recognized by failing health and strength, and persistent derangement of the digestive functions. According to Virchow, although tubercle is the result of the death of healthy or diseased tissues, the local process — tuberculosis — also results in the exudation of a' material during tuberculous inflammation ; such material undergoing a kind of organization, 474 DISEASES OF CHILDEEJST. succeeded by its death, and by its breaking and shrivelling up into a tubercle. This gradual change is termed tuberculization,* There is much evidence to be adduced in support of that theory which classifies tubercle as a primary formation, like cancer and epithelial and melanotic growths. All the changes that take place are secondary, and without the presence of malnutrition it seems highly probable that no lesion can produce it.f The conditions, then, under which tuberculosis originates are not precisely known, as low inflammatory products may cause in- duration or suppuration, and yet the disease may not be developed. It is not known whether the disease is specific or not, or how it is generated within the body. When the sputa of phthisical patients have been given to dogs and poultry, tuberculosis has sprung up; and the same has been the case with cattle fed with tubercular or scrofulous products.^ Villemin was the first to show, by a series of experiments, that when finely divided masses of gray or yellow tubercle were introduced under the skin of guinea-pigs, rabbits, and some other animals, a local form of inflammation ensued, and at the end of two or three weeks miliary tubercles were discovered in the lungs, and at a later period in the intestines and peritoneum. Villemin, therefore, concluded that it was possible to propagate tuberculosis by inoculation, in the same way that occurs with small-pox and syphilis. Many pathologists have carried out Ville- min's experiments, and they have arrived at precisely the same results; whilst Burdou Sanderson and Wilson Fox made the fur- ther discovery that miliary granulations arose in some of the chief organs of the bodj^ when pus, putrid tissue, and portions of a pneumonic lung were introduced subcutaneously. Dr. Burdon Sanderson'sg experiments on the artificial production of tubercle in the lower animals throw much light on the pathology of the aftection as it occurs in man. He found that it is most readily produced in the guinea-pig, next in the rabbit, and lastly in the dog. "For three reasons," says Dr. Sanderson, " the guinea-pig is preferable ; (1) because it is absolutely free from liability to natural tubercle; (2) because it is little liable to acute inflammation ; and (3) because it can be inoculated with absolute certainty." An in- * Dictioiiiiry of Medical Sciences (Dimglison), article Tubercle, 1874, p. 106'A f Jones and Sieveking's Pathological Anatoin}^ by Payne, 1875, p. 203. X See The Lancet, Nov. 23d, 1878, p. 741. § Recent Researches on Artificial Tuberculosis, Edin. Med. Journ., Nov., 18C9. ON TUBERCULOSIS. 475 finitesimal close of the infective material is taken from the diseased gland of an infected animal, and, after being mixed with a little distilled water, is injected into the peritoneum, the pleura, or sub- cutaneous areolar tissue. Drs. Sanderson and Wilson Fox, in 1868, produced tuberculosis in the guinea-pig by the insertion of setons and non-tubercular products. An abscess followed around the foreign body, and tuberculosis supervened. Professor Cohnheim also confirmed these experiments, and produced tuberculosis trau- matically by introducing harmless foreign bodies into the perito- neum. The result obtained by these researches was to produce nodules of new growth, having a lymphatic structure, and termed lymphomas hy Virchow, because they are commonly found in cer- tain organs of the lymphatic system. Dr. Sanderson proposes the term adenoid, because he says in certain parts of the body there are organs like these growths we are considering which possess a structure identical with the follicles of the lymphatic glands, and that where they exist naturally, as beneath the pleura and perito- neum, there' these tubercular nodules or overgrowths are most frequently found. These nodules or tubercles appear in fact to be nothing more than overgrown masses of pre-existing tissue, or en- larged adenoid bodies.* In fact, these pathologists ascertained that simple mechanical irritation set up the sanie morbid process as the inoculation of the specific products I have alluded to. Thus it seems satisfactorily demonstrated that general tuberculosis may arise from the inocu- lation of a morbid poison into a wound, or from the absorption of inflammatory products ; and although the injection of tubercular matter does appear to induce the disease with greater certainty and celerity, there is no reason whatever to suppose that any specific inoculation is necessary. These carefully conducted experiments * " I am quite willing to acknowledge a close aflBnity between lymphatic glandular swellings and tubercles, for they affect the same subjects and run a similar course. But these glandular swellings also have a close resemblance on the one hand to swellings from inflammation, and on the other to tlie simple enlargement of tlie spleen and liver occurring in leukaemia. In both these cases there is doubtless hypertroi)hy or hyper- plasia, but this may be in the way of exudation or cell pi-oliferation, without the de- velopment of complex tissue which constitutes agroivth. If the addition of cells, fibres, and other products of inflammation in a tissue constitutes a growth, then common cutaneous pimples, tubercles, and boils are growths, and the swelling from erysipelas or cellulitis must be included under the same term ; but this surely would exceed its usual acceptation." — Pulmonary Consumption, by Drs. C. J. B. and C. T. Williams, 1871, p. 17. 476 DISEASES OF CHILDEEX. have had a surprising eflect in modifying our views regarding the prevailing doctrine of tubercle, and, as we shall subsequently see, they have an important practical bearing. It decides the long- disputed question that low forms of simple or even acute inflam- mation in some subjects may eventuate in tubercular disease, without any original deposition of tubercle; and in support of this view I may allude to the circumstance that neglected pleuritic effusion in children is often followed by empyema and occasionally by tuberculosis. A common cold in delicate children, or those pre- disposed to the affection, will now and then give rise to it ; indeed, no vascular excitement in such subjects is to be disregarded. With regard to the history of the above researches it may be stated, that for the last two hundred years, tubercles were con- sidered to be allied to scrofulous lymphatic glands till the time of Bayle, who regarded tubercle as a peculiar product, and the result of a special constitutional diathesis, — a deposit depending on a morbid state of the blood. Eayle gave the name of tubercle to the gray and yellow masses which he found in the lungs. Virchow proved that yellow caseous matter was not the character of true tubercle, and that it might arise from fatty degeneration, and the products of pus, and cancer, and so forth. He called the gray granulation of Cayle the typical form of tubercle, and considered infiltrated tubercle and caseous masses as the consequence of inflammation. Dr. Wilson Fox entertains the view that the caseous products arising in the lung in phthisis are due to the destruction of vessels by a new growth in the walls of the air- vesicles, and that the typical gray granulation is not the only form in which tubercle occurs.* jSTiemeyer considers that phthisis, as a disease, has nothing to do with tubercle, which is only an accidental and secondary product when found in the lung, and the result of inspissation of inflammatory products, leading to destructive and ulcerative changes in the lung-tissue. Dr. Fox's researches seem to show that the changes found in the lungs, in acute tuberculosis in children, are the same as those observed in the ordinary forms of phthisis. According to this authority ,t the following are tlie chief appear- ances found in the lungs of children dying of acute tuberculosis: * Trans. Path. Soc, 1873, vol. xxiv, p. 287. t Discussion on the Anatomical Rehitions of Pulmonary Phthisis to Tubercle of the Lung, Trans. Path. Soc, 1873, vol. xxiv, p. 291. ox TUBERCULOSIS. 477 "The semi-transparent granulation of Bayle. Opaque white granulations, for the most part soft, but with varying degrees of firmness and difficulty of crushing. Granulations like the semi- transparent granulations of Bayle, and also like the soft granu- lations, hut more or less caseous in their centres. Yellow soft granulations, easily crushed, but not easily removed from the pulmonary tissue, varying in size from that of a poppy seed to a mustard-seed, rarely of the size of a hemp-seed, and slill more rarely of the size of a split pea. Caseous granulations, dry, opaque, and friable; sometimes with, sometimes without, a gray trans- parent zone of induration surrounding them. Groups of granu- lations, mostly like the semi-opaque, sometimes entirely opaque, rarely semi-transparent ; two or three, or four, or more in number, reaching the size of a split pea, or a bean, or even a small walnut, or hazelnut. Indurated pigmented granulations, singly or in groups, like the last described. And lastly, tracts of indefinite extent, one or two or more inches in diameter, irregular in outline, prominent above the surface, granular on section or tearing of the tissue, but passing sometimes insensibly into the so-called gray infiltration. Cavities, from infinitesimal specks to the size of a hazelnut or larger. Granulations softening into cavities — either the softer, the white or the yellow. The semi-transparent granu- lation in the lung is not, as far as I have seen, found softening into a cavity without some intermediate change. Tracts of gray semi-transparent appearance, known as the ' gray pneumonia ' or 'gelatinous pneumonia,' or 'gray infiltration,' or gelatinous infil- tration of Laennec ; spots also of red pneumonia ; in some cases cedema ; in some cases injection or punctiform extravasation ; in some cases emphysema and collapse ; in some cases capillary bron- chitis and dilatation of bronchi. The point on which I Avish especially to insist is, that the gray granulation of Bayle is very seldom found alone. They are sometimes found as isolated struc- tures scattered throughout the whole lung, but this is compara- tively rare. In the combinations of eleven cases they were only found alone in two. They either coexisted with caseous, or with the white and the soft, or with the caseous, or with the soft and caseous, or with the indurated, or with the soft, yellow, and caseous, or with the soft and caseous alone ; most of these being combined either with red or gray pneumonia, or with tracts of caseous infiltration. Those are the forms of the combinations of 478 DISEASES OF CHILDEEX. which I made notes in eleven cases that died under my own obser- vation. The gray granulation of Bayle, the typical tubercle of Yirchow, does not therefore exist alone in the majority of cases of acute tuberculosis in the lungs of children. It is most com- monly associated with other granulations, which have a difierent appearance to the naked eye, and also a difierent anatomical structure; and the latter, in some cases, are the predominaut change, so that in some lungs the gray granulation is compara- tively rare." UnUke the case of adults, gray granulations and crude miliary granulations frequently exist in children as the only form of tuber- cular deposit. In the adult, M. Louis discovered miliary tubercles alone in 2 out of 123 cases (1.6 per cent.), and gray granulations alone only in 5 more (4 per cent.). In the child, Rilliet and Barthez found miliary tubercles without gray granulations in 107 cases out of 265 cases, and gray granulations alone in 36 out of the same number of cases. In 102 cases of phthisis in children. Dr. West* found miliary tubercles alone in the lungs in 20 instances, and gray granulations alone in 17 more. Another anatomical pecu- liarity in early life is the great frequency of yellow infiltrated tubercle. It seldom exists alone, but is generally associated with crude yellow tubercle and gray granulations, and sometimes with advanced disease of the bronchial glands. Rilliet and Barthez met with it in 88 out of 265 children, or in 33 per cent, of their cases. As to the frequency with which we meet with tubercle in the difierent organs in the body, Steiner found the intestine involved in a third of all his cases; the most frequent seat being the small intestine, and the least frequent the large. From 302 dissections made in the Prague Hospital by Drs. Steiner and Neureulter tubercle was found In 1 organ in 42 cases. In 5 organs in 42 cases In 2 organs in 48 " In 6 " in 28 " In 3 " in 62 " In 7 " in 20 " In 4 " in 47 " In 8 " in 6 " Five times in nine cases, and twice in ten different organs. The bronchial glands were affected in 275 cases, the lungs in 175, and the stomach in 4.f In 812 children in whom Rilliet and Bar- * Diseases of Infancy and Childhood, 4th edition, 1859, p. 448. f Steinei-'s Diseases of Children, by Lawson Tait, 1874, p. 328. ox TUBERCULOSIS. 479 tliez found a deposit of tiil)ercle in one or more of the viscera, the kings -were heaUhy in 47 cases ; whilst in 123 simihir instances in the adult, Louis only found one such exception.* Dr. Wilson Fox mentions 61 cases which he examined for the chief purpose of illustrating the pulmonary manifestations of the disease. All were ahove ten years of age, and only 2 below fifteen and two ages not stated. In all the cases hut one the lungs were afiected, and in this was a combination of tubercular pleurisy with tubercular peritonitis. In 7 cases the data were uncertain; in 3 cases the disease was limited to the lungs ; in 7 cases two organs were affected; in 16 cases three organs; in 12 cases four organs; in 9 cases five organs ; in 6 cases six organs ; in 1 case seven organs. f M. Louis entertained the opinion that when tubercle appeared in any part of the body it was sure to exist in the lungs also, and that the apices of these organs were the selected seat of deposit. AVe now know that this is by no means the universal law, which the propounder considered he had established, but it holds good with a few "exceptions, and is of vast assistance in diagnosis. I have heard it asserted, and I have also seen it in books, that in every case of tubercular meningitis j'ou will find, on examination alter death, evidence of tubercle in the lungs, kidneys, peritoneum, or spleen ; but twice I have made a post-mortem of this well- developed cerebral aflection without finding a trace of the peculiar exudation in any other organ or tissue of the body. The sudden manner in which tubercular disease sometimes springs up without any obvious exciting cause, is alarmingly sug- gestive that an over-excited or ill-nourished organ may initiate the peculiar deposition in the track of the bloodvessels, and there set up decay and destruction, having no inclination to spread and contaminate other organs and tissues. Dr. Fox mentions a case recorded by Ilerard and Cornil, in which the disease was limited to a single lung, and he S2:)eaks of three other recorded cases where, in addition to other lesions, one lung was aftected, and the other remained free. It was long held that when tubercle was deposited in the lungs it would sooner or later proceed to a fatal issue; but repeated ex- amination goes to prove that it is sometimes spontaneously arrested, * IMeigs and Pepper's Diseases of Children, 1874, p. 843. t Trans. Path. Soc, 1873, vol. xxiv, p. 375. . 480 DISEASES OF CHILDEEN. and it has been said that tliis happens in one-third of the persons aiiected with tuberculosis. This is confined to no stage or period of the disease; it may be stopped in the early stages when the deposit is small and trifling, and instances are met with w^here large cavities have healed and cicatrized. " Nothing is more com- mon," says the late Dr. Ilughes Bennett,* "in examining dead bodies than to meet with cretaceous and calcareous concretions at the apices, of the lungs more or less associated Avith cicatrices. Of 73 bodies, which I examined consecutively some years ago in the Royal Infirmary, I found these lesions in 28. Of these, puckerings existed with induration alone in 12 ; with cretaceous or calcareous concretions, in 16. Since then I have examined many hundred lungs at the inspections in the infirmary, and am satisfied that these proportions exist pretty constantly. At the Salpetriere Hospital, in Paris, Roger found them in 51 bodies out of 100; at the Bicetre Hospital, in the same city, Boudet found them in 116 out of 135 bodies." In 1868 a young man who had a vomica in the apex of the left lung, brought me from time to time portions of calcareous matter, the size of a pea, which he coughed up with expectoration. He was greatly reduced in flesh and strength, but when I saw him, five years afterwards, he had improved in every respect, and the cavity in the lung was apparently contracting. I met with a similar case in 1874, and the patient was living in 1878, and in health. The following facts, according to Dr. Bennett, are proof of arrested tubercle: " 1. A form of indurated tubercle is frequently met with, gritty to the feel, which, on being dried, closely resembles cretaceous concretions. " 2. These concretions are found exactly in the same situation as tubercular deposits are. Thus they are most common in the lungs, and at their apices. " 3. When the lung is the seat of tubercular infiltration through- out, whilst recent tubercle occupies the inferior portion, and older tubercle and perhaps caverns the superior, the cretaceous and calcareous concretions will be found at the apex. "4. A comparison of the opposite lungs will frequently show, * Braitliwaite's Retrospect, vol. xlvii, 1863, p. 55. ON TUBERCULOSIS. 481 that whilst on one side there is firm encysted tnbercle, partly transformed into cretaceous matter, on the other the transforma- tion is perfect, and has occasionally even passed into a substance of stony hardness. " 5. The puckerings found without these concretions exactly resemble those in which they exist. Moreover, whilst puckering with gray induration may be found at the apex of one lung, a puckering surrounding a concretion may be found in the apex of the other. " 6, The seat of cicatrices admits of the same exceptions as the seat of tubercles, and in about the same proportion. There can be no question, therefore, that these cicatrices and concretions for the most part indicate the arrestment, disintegration, and trans- formation of pre-existing tubercular exudation into the lungs." Causes. — Of the causes of tuberculosis, and the deposition of tubercles in the lungs, the progress of medical science has not yet enabled us to speak with any degree of certainty; and the same may be said of that variety of disease classified under the compre- hensive term scrofula, with its external abscesses and disfiguring ulcerations. It is very difficult to assign the correct value to hereditary transmission from parent to offspring, regarded as a predisposing cause of tuberculosis, because a large proportion of the population is subject to anti-hygienic conditions, which call the disease into existence. The lives of so many young persons are passed in these days of hard toil under such unhealthy condi- tions that it is readily acquired. What is gleaned from parents respecting their family history is frequently vague and deceptive. Some will tell you that consumption is not known among them, when closer investigation satisfies us that some member of it has suffered from hip-joint disease, open abscesses in the neck, and even fatal affections of the head which must have had a strumous origin. Instances of hereditary transmission are constantly seen in the emaciated frame of the infant whose consumptive mother barely survives the birth. When the child dies, the lungs and other internal organs are so studded with tubercles that little doubt can be entertained that the disease originated at the earliest period of utero-gestation. It may be laid down as a law, having few exceptions, that the union of healthy parents results in the birth of healthy children, and that they grow up to be strong and vigorous ; but that when one parent is tuberculous and the other 31 482 DISEASES OF CHILDREX. healtli}', tuberculosis is apt to show itself in the offspring. As the children one after another reach a certain age thej begin to lose flesh and strength, and at last die with all the sj-mptoms of pulmonary phthisis, or tubercular disease in some other organ. The best explanation for this large class of cases, which we observe where the victims have been carefully shielded from exhausting or depresing influences, is to be found in a blood djscrasia or some chano-es in the vessels or tissues. Youth is one of the most fertile predisposing causes of tubercu- losis, the blood in childhood having a great susceptibility to un- dergo those changes which constitute the peculiar pathological transformation. TVe can only conjecture what the specific change is ; but we do know that in early life the blood is deficient in solid constituents, and in blood-corpuscles. As children grow to ma- turity, and life advances, the quality of the circulating fluid is enriched, the tendency to tubercular change becomes less and less, and the power of arrest or elimination is acquired if the constitu- tional strength can be maintained. It may be that the diminished number of red corpuscles in chlorosis and antemia is one reason of their fatal termination being frequently accompanied by the de- posit of tubercle and the gradual development of phthisis. The effect of intermarriages has been well pointed out by Sir William Jenner. " That tuberculosis is transmitted from parent to child is one of the Vjest established facts in medicine. The ex- treme frequency of tubercular diseases in some circumscribed country districts is, in part at least, explicable by the frequency of intermarriage amongst persons living in such districts ; and conversely, the exception of particular circumscribed districts from tubercular disease is due to the same cause. In one case, from some special circumstance, tuberculosis has been introduced into the district, and then spread in it from the cause I have mentioned, i. e., intermarrying; in the other case, the freedom from the dis- ease of the district, at any given time, is the cause of its continued freedom. Intermarriage of the inhabitants, the disease being ab- sent, prevents its introduction."* Where hereditary transmission is so strong (and that it is so daily experience affords the most conclusive evidence), the germ of the disease either lies in a latent state, or is actively transmitted by the parent. Rilliet and Barthez furnish some interesting facts * Address before the Epidemiological Society of London, 1866. ON TUBERCULOSIS. 483 to the effect that, " of 20 cliildren whose fathers were tuberculous, or probably so, 22 died tuberculous, and 4 non-tuberculous ; of 32 children whose mothers died tuberculous, or probably so, 22 died tuberculous, and 10 non-tuberculous; of 6 children whose fathers and mothers died tuberculous, 4 died tuberculous and 2 non-tuber- culous. There were 4fi cases, or about 1 in 7, in which the heredi- tary influence more or less prevailed, and 11 in which it was the sole probable cause."''' There are many points of extreme interest on this part of the subject, such as the relative frequency of its transmission by the two sexes, and the manner in which this takes place. Children brought up by hand, and weaned too soon, or neglected by the mother, are very liable to the disease. A case is related by Meigs and Pepperf of a healthy woman, who had several vigorous children whom she had nursed. She gave birth to one which she could not nurse, and this child, after pining for many months, died of tubercular meningitis. Bad or insufficient food, leading to prolonged indigestion and diarrhoea, exert a powerful influence in the production of tubercle. Artificial foods of all kinds, when too exclusively relied on, may awaken the disease ; and defective nutrition and mal-assimilation, however brought about, are common causes of tuberculosis in those who are not even predisposed to the aft'ection. The eruptive fevers and whooping-cough frequently act as a starting-point, the disease having an admitted tendency to spring up after these acute affec- tions. The continuance of febrile action is liable to alter and de- teriorate the quality of the blood, and to render the system liable to tubercular deposit. If we look back in memory only to our experience of the number of children who have exhibited sjmnp- toms of tuberculosis, as the consequence of febrile disorders, we are in a great measure driven to embrace the doctrine that such dis- eases as whooping-cough and measles not unfrequently originate the disease in constitutions not hereditarily tainted. In those cases in which pneumonia and bronchitis are associated with tuberculosis, it is a disputed question whether the inflamma- tion is a secondary afiection, or whether it has been the essential and true cause. Both views have some show of reasoning, and I shall therefore consider the subject at some length. We may * Ancell, on Tuberculosis, 1852, p. 377. f Diseases of Children, p. 842. 481 DISEASES OF CHILDREN. repeatedly witness children whose general health fails for months together, when the physical signs afforded by auscultation and per- cussion reveal no evidence of abnormal change in the pulmonary organs. The disease may advance considerably before they afi'ord any proof of alteration, and there may be extensive tubercular deposit, which is unsuspected. The plasma exuded in states of acute inflammation resembles so closely that which is poured out in low forms of disease, happen- ing to cachectic and tubercular subjects, as to be almost identical. In the former case, the essential difference consists in its vital endowments, or capacit}^ for higher organization ; whereas in the latter it has no power to advance in this direction, and the exuda- tion remains much in the same condition as when it was first secreted. The ph3^sical and general signs, too, between a case of chronic pneumonia in a weakly person and tubercular infiltration, are so closely allied that, notwithstanding that the historj' and progress of the two afi'ections may be some guide to diagnosis, they constantly fail to put us in possession of any conclusive evi- dence. Now, it is worthy of notice, that a general cachexia regu- lates the anatomical character of all these exudations, and that in the absence of any apparent exciting cause there has still been a factor in operation, which deals a fatal blow to the doctrine of spontaneous origin. The children of consumptive parents may bear characteristic proofs of the disease, but all do not die of phthisis — some may attain to a ripe old age, and others as they reach maturity drop off one by one. Every child bears traces of the constitutional diathesis in the delicacy of form, accelerated circulation, and general appearance ; but some have escaped the circumstances which call tuberculosis into action. The different functions of the body are languidly carried on, and enough nourish- ment is appropriated for the maintenance of life ; or from some unforeseen causes (ever ready to come into operation) a period arrives when an inflammatory affection of the lungs, or some other part, springs up. Through perverted nutrition, the exudation or eftusion of coagulable lymph takes place, and local disease is initi- ated. Here is an argument suggesting the probabilit}' of a new power or agent suddenly altering the nutrition of an organ ; but it may be contended, with equal force of reasoning, that the exu- dation was there slumbering and undiscovered, and only required the stimulus of external causes to rouse it into action. I think ox TUBERCULOSIS. 485 strong arguments may be adduced on either side. It is evident that the earliest signs of inflammation should be looked for in those persons who manifest the tubercular cachexia ; and it will, I think, accord with the experience of most physicians when I add that there is a susceptibility to irritation and congestion of the pulmonary organs from trivial causes in these cases, similar to what occurs in the different textures of the body, when the blood is contaminated by the detention of noxious elements, which the impaired or damaged secretory organs are unable to elminate from the system. " Catching cold " is so constantly assigned as the starting-point of active pulmonary disease, that we cannot escape from the con- clusion that it is no mean factor in the development of tuberculosis. There is a case recorded by Dr. Hermann Weber* of a boy, ten years of age, the son of healthy parents, who had an ordinary sore throat, in August, 1871. This was followed about the twelfth day by pain in the right side of the throat, extending to the ear, and causing deafness ; the tympanic membrane became yellowish and prominent, and Dr. Weber suggested that it should be perforated, and if the advice had been carried out it might have saved the child's life. In ISTovember, 1871, he began to cough, and was sick and feverish; the pulse was 139, and the temperature 103°. The chief symptoms were headache, sleeplessness, constipation, and dry cough ; crepitant rhonchi were heard, but no dulness. There was deafness, but no discharge from the ear, and the urine was non- albuminous. There were two temperature elevations every day between 103° and 105°, and two depressions to between 98° and 100°, and the pulse varied from 65 to 160 in the minute. The boy died, November 26tli, and during the last few hours of life the temperature rose from 101.5° to 106°. On a post-mortem exami- nation gray miliary tubercles were discovered in the pleura, peri- cardium, liver, and meninges of the brain. The right temporal bone and internal ear were normal, but the tympanic cavity was filled with soft caseous matter. Indifferent health may be present in a large number of cases for years, and the patient may remain free from any actual disease ; but when exposure has led to cough and febrile symptoms, then ensue the usual signs of bronchiiis, accompanied with expectora- tion. I^To dulness is to be detected below the clavicles at first, or * Clinical Transactions, vol. viii, 1875, p. 135. 486 DISEASES OF CHILDREN. above the spine of the scapula ; but, at a later period, this signifi- cant sign is added to the rest, and we are irresistibly led to believe that we are dealing with a case of pulmonary phthisis, originating in catarrh. In manj' young persons, when the chest yields a clear note on percussion, and there is bronchitis affecting the smaller as well as the larger tubes, the lungs are found studded with miliary tubercles after death. Death has been so rapid in many instances that the development of these granulations must have preceded the last inflammatory attack to have reached such a mature stage. The diminution of resonance (often not to be detected) does not become apparent in these cases till the bronchitis has existed for some considerable length of time. I do not think that this view altogether invalidates the doctrine that the tubercles may not have initiated the bronchitis. The same causes originate varied affections, modified by susceptibility and constitution, though not following the same order. In the progress of ordinary phthisis, wdiich continues for years, each fresh attack of tubercular deposit is preceded by bronchitis. It is of common occurrence to meet with children who have dul- ness under one clavicle, harsh or feeble respiration, defective ex- pansion, and prolonged expiration. Such a patient takes cold or gets wet through, and then the dulness on percussion is increased, and the inflammatorj- process leads to a farther deposit of tubercle. When tubercle is being deposited in the lung, bronchitis is one of the most common attendant symptoms in young subjects. If the bronchitis is persistent, and does not yield as readily as the uncomplicated aflection,it excites suspicion of tuberculosis ; when tubercle is disseminated equally through the pulmonary organs, the sign of consolidation is sometimes wanting, and this is apt to lead us astraj^. In a depraved state of health, the formation of tubercle takes place rapidly or slowly, and general crepitation may be detected throughout the chest ; but there may be neither dul- ness nor prolonged expiration. There is but little cough, and if the subject is young the expectoration is swallowed. As the dis- ease advances these last symptoms become more developed, haemop- tysis occurs, the lips become livid, the extremities cold, and delirium may supervene. These are, of course, rapid cases, and strictly bear the name of acute phthisis.* Febrile symptoms are significant, and when the attacks are * See C'hiip. XL, On Plithisis Pulmonalis. ON TUBERCULOSIS. 487 severe or frequent tliey will generally be found dependent on the rapid formation of tubercles. But persistent feverish symptoms are sometimes met with in young children when there are no signs of a local character in the chest — no cough, no wheezing — and yet after death the lungs are found to contain tubercles. " I attended a little boy," says Dr. James Russell, of the Birmingham General Hospital, "aged six, with one of the most experienced surgeons of this town. His illness lasted for eight weeks ; my attendance comprised the last week only. His sole symptom was persistent feverish reaction, though with scarcely any delirium ; the one single symptom of a local character was constant rapidity of breathing. The child's chest was searched over and over again, both by mj' colleague and by myself, for any indication of disease, but to the very last percussion was normal ; not even a wheeze could be discovered ; and there was entire absence of cough and expectoration. Death was rather sudden, I suspect, from fainting. On examination, both lungs were positively filled with tubercles."* 'So mention is made of the temperature, but the feverish reaction and rapid breathing were very significant. If the half of one lung is obstructed in its functions by the rapid development of tubercles, they must occasion serious mischief by diminishing the power of the respiratory apparatus. In some cases where the pro- duction of tubercles is rapid and general, a state of tubercular asphyxia takes place, attended with embarrassed breathing border- ing on suflnocation, without suppuration in the lung or the usual symptoms of phthisis. What is the pathology of such a frequent case as this ? A young person takes cold in winter and is seized with cough — spittingUnd dj'spnoea. During the cold weather he is tormented with his ail- ment, and cannot lose it till the warm weather returns. The pa- tient appears in good health, and has not lost flesh or strength; he relishes and digests his food, and there is neither sweating nor diarrhoea. He is well in the summer, but every winter has a re- turn of the symptoms, and each succeeding attack is more trouble- some to shake off than the one that has preceded it. B^'-and-by the disease does not subside in the summer, and general and physi- cal signs are added, which prove the serious nature of the afiection ;. he now slowly begins to lose flesh and strength, and the expecto-- * Braithwaite, On Fever and Bronchitis as early signs of Plithisis, vol. Ixi, p. 70,^ 1865. 488 DISEASES OF CHILDEEX. ration becomes thicker and purulent ; cTulness is detected in one or both apices of the lungs, followed by softening, and a fatal termi- nation. So much for bronchitis as a cause. I am not sure that the means employed to reduce pneumonia in some constitutions may not prostrate the vital powers and lead to degeneration of the effused lymph, which otherwise might become organized and cast off in the healthy progress of the disease. jS'o problem in medical practice demands more consideration for its solution than that which requires us quickly to determine at the bedside, how far we may safely venture with antiphlogistic reme- dies in acute disease. If active inflammation long assails vital organs like the lungs, and is timidly dealt with, the effused prod- ucts after a while resist absorption and become irritating ; and if the measures emploj'ed are too vigorous, then the general strength may either fail at once or decline more gradually. But a deadly disorder may grow out of the attack. Eare as it is for tubercu- lization of the lung to succeed pneumonia, recent investigations haveshowm how numerous are the sources of blood contamination, and from what slight irritation it may arise, so that we cannot dismiss the dano-er from our minds where a laro-e extent of luno; is involved in inflammation, even if no predisposition exists. Symptoms. — It is a distinguishing feature of tuberculosis in childhood that several organs may be affected at one and the same time, — the lungs, the liver, the pleurfe, the spleen, kidneys, and peritoneum, when special symptoms common to disturbance in an}' of these organs become developed. The general s^-mptoms, however, may be present for an indefinite period without our being able to trace any local lesion, and w-hen this is so we shall presently see that the elevation of temperature is the only reliable ground for diagnosis. The symptoms will vary according to the seat of the tubercular lesion. Among the earliest I have noticed is pain in the stomach, the child being frequently brought under our notice b}^ his parents for this solitarj' s^-mptom, when the more general and common features of the disease, as loss of flesh, thirst, and evening paroxysms of heat, have not yet indicated its approach. I have particularly noticed this symptom of gastric pain, and occa- sionally vomiting, even in those exceptional instances where I have had reason to think considerabe care has been bestowed on diet and regimen. For weeks together I have known this symptom continue, and while it lasts digestion is interfered with, the chil- ON TUBERCULOSIS. 489 dren have a pinched and exhausted look, and they lose flesh quickly. It demands attention and care, for it may be the evidence of mis- chief springing up in the abdomen or peritoneum when the lungs are free from any infiltration of tubercle. Among other common symptoms is a capricious and irregular appetite, sometimes amounting to hunger, while at other times food is so disliked that the weak stomach can retain it only for a short time. When the meal lies too long undigested in the stom- ach it creates flatulence, pain, acid eructations, and diarrhani. The motions vary in color and consistence, sometimes being deficient in bile and costive or loose ; at other times they are dark, or have a glairy appearance resembling the white of an eg^g ; the urine is acid and turbid on standing, throwing down pink or even white lithates; the tongue is glazed or furred at the dorsum, or it is of a bright red at the tip and edges, the papilla being prominent. When the appetite is capricious there is a dislike for any fatty kind of food, thirst is commonly present, and the pulse is habitu- ally quick and weak. If the local symptoms remain obstinate, a state of hectic fever is established, and under emaciation, high temperature, and diaphoresis, the patient gradually dies with the local determination of tubercle to some special organ, as the lungs, brain, or peritoneum. Temperature. — Wherever the deposition of tubercle is taking place, the temperature gradually increases in elevation, and the destructive changes in the lung continue. Of twentj-four cases recorded by Dr. Ringer, in which tubercle was being deposited, in twenty-one there was a continued elevation of the temperature of the body, and in these twenty-one cases the deposition of tubercle was proved, during life, by increase of physical signs, or after death by the post-mortem appearances.* The temperature, according to some observers, has been noticed not to exceed 99° in some cases of acute tuberculosis, and that in the evening, when the maximum temperature is usually attained. It must be admitted that these cases are exceptional; and here I would give my own experience, that the temperature has been persistently higher in the evening than in the morning. But when this process of deposition has ceased, the lung becomes tough and puckered, and the cavities lined with fibrous walls, whilst the temperature falls to the normal * On the Temperature of the Body as a means of Diagnosis in Phthisis and Tuber- culosis. Walton and Maberly. 1865, p. 5. 490 DISEASES OF CHILDREN. point. So it seems evident that when the granulations have under- gone this change, or have become quiescent and ceased to irritate, tuberculosis is curable. These cases are not unusual. Bronchitis, which is so commoulv associated with softening; of tubercle, and recognized by rhonchus and moist sounds, is a symptom to be expected and watched for. Here we have a rise of temperature proportionate, probably, to the tubercular infiltration and the bronchitis set up by it, though there may not be enough to inter- fere with the proper aeration of the blood, or to excite cough or dyspncea. Small deposits of tubercle, when scattered through a consider- able portion of the lung, are not to be detected by physical signs, and we may not suspect such a condition till a disease like pneu- monia or pleurisy sets in. Most of the symptoms of failing health and delicacy in a 3^ouug person are put down to some change of constitution in the absence of frequent cough and expectoration, but the mischief has long been resident in the lungs, and the inflammatory attack only was wanting to rouse the graver evil. Some years ago I met with a young person who caught cold, and got an attack of pneumonia. There were frequent dry cousfh, increased frequency of respiration, bronchial breathing, accelerated pulse, wasting, and high temperature, but no expectoration or moist rales. Percussion was dull and bronchophony was general over the posterior surface of the lungs. The patient apparently recovered, but two years later died with all the symptoms of pulmonary tuberculosis. For years she had been delicate, and her fiimily feared she might die. of consumption, but one medical man after another assured her friends there was no deposit of tubercle. There are many cases of children dying of tubercular menin- gitis, in whom tubercle is also met with in the lungs and peri- toneum, who have exhibited no symptoms of its presence during life, and yet after death it is found so abundantly scattered through these organs, that it becomes a mystery how it was that we did not discover the morbid changes that were going on by some general or physical signs. Even the cerebral symptoms are sometimes so rapid and unexpected that the source of mischief must have been lying dormant for some considerable time. AVhen, moreover, it happens in tuberculosis that the weight of the body is kept up (and this is not uimsual if the appetite is ON TUBERCULOSIS. 491 good, and there is no exhausting diarrhoea going on), we are the more driv^en to rely on a continued elevation of temperature as the only sure point of diagnosis in doubtful eases. For a consid- erable time the temperature may continue high and the weight of the body remaiji undiminished, as in many cases of ordinary and advanced phthisis the patients retain their weight when eating well and taking cod-liver oil. But this symptom would not justify us in concluding that the disease was arrested, unless physical signs were present also, and showed improvement. It will be acknowledged that, when patients with considerable lung disease are progressing most satisfactorily, they are liable at any moment to a relapse with the complications of profuse expectora- tion or haemoptysis. In these cases, if we watch the physical symptoms, we could scarcely be unprepared for the changes. The temperature in tuberculosis is subject to so much variation that a large field of observation is required to draw any practical conclusions from it, and cases require careful and diligent watch- ing. When, in any given case of illness in a young person, the temperature is daily elevated for a , considerable period, and the continued fevers can be excluded, we may suspect tuberculosis, even if the general symptoms scarcely point to the possibility of this condition. We must be sure that the thermometer is cor- rectly registered before it is placed in the axilla, and that the arm is kept well against the side for ten minutes or a quarter of an hour.* The temperature is said to be so slightly altered in some cases that it scarcely exceeds the normal standard, but my expe- rience induces me to think that it never remains so if tubercle is being deposited. Soon the evening temperature is slightly ele- vated, and later on, in some instances, there is a rise both morning and evening. At midday, or about 5 p.m., we often observe a regular and well-marked rise, varying according to the activity of the disease. Dr. Wilson Foxf says that "Lebert found in 22 cases the mean evening temperature of acute tuberculosis w^as as follows : in 2 not exceeding 100.4^; in 8, including those last mentioned, not exceed- ing 102.2°; in 9, more than 103.4°; in 4, from 103.4° to 104°; in * In the case of young and fractions children, the thermometer may be inserted into the rectum, and one minute will be long enough for it to remain there. t On the Temperature, Pulse, and Respiration in Phthisis and Acute Tuberculiza- tion of the Lungs, Med.-Chir. Trans., vol. Ivi, p. 397. 492 DISEASES OF CHILDEEN". ],from 104° to 105.5°." Dr. Fox found that a temperature of 104° was not exceeded by 62.5 per cent, in acute tuberculosis, and by S6 per cent, in acute phthisis. Temperatures exceeding 105°, with two exceptions (acute rheumatism and phthisis), are found exclusivel}'^ in acute tuberculosis. Both Wiinderlich and Lebert record cases of hyperpyrexia! temperature before death. The latter mentions one case where it rose to between 107° and 108°, and, as we have noticed (p. 485), the temperature reached 106° shortly before death in Dr. Weber's case. The more I have thought and pondered over the fluctuations of temperature in disease, the more I have doubted the possibility of constructing any classification from which to draw any accurate conclusions. Diseases "like tuberculosis and phthisis, which are usually protracted and tedious, are those generally selected for experiment ; but even these give such varying results that noth- ing absolutely definite or uniform can be gathered from them.* Patients must live under preciselj^ the same circumstances if deductions are to be of anj^ practical value ; the hygienic condi- tions must be alike, the age and constitutional tendencies must be weighed and balanced ; the state of the lungs must correspond, the disease being either active or quiescent, and the treatment must be the same. When tubercle is forming, the temperature may rise to 106° or more. Dr. Theodore Williams has recorded a case of phthisis in the " active third stage," in which the maxi- mum temperature was 104.6°, and the minimum as low as 93. 6°. f There is often a rise after 2 p.m., or, as is frequently the case, about 5 P.M. At the latter time it not unfrequently rises to the highest point in tuberculosis. It is possible that tubercle may form and the disease advance without any rise of temperature, which is perhaps due to exhaustion and collapse. The last writer also mentions a case of phthisis in which active disease was going on, and there were nightsweats and haemoptysis, and yet the tem- perature was normal throughout. J Sweating^ which so certainly reduces the general strength, is a common feature in cases of phthisis, though it is not even a neces- * If it is the rule to meet with liigh temperatures in tuberculosis, it should not be forgotten that the lungs may be studded with tubercles and the temperature remain persistently low. t On the Temperature in Phthisis Pulmonalis, Med.-Chir. Trans., vol. Iviii, p. 95. X Ibid., p. 79. ON TUBERCULOSIS. ' 493 sary feature here. Where the temperature remains persistentlj'- high for some time and then begins to decline, sweating is met with. In cases of nervous exhaustion and general weakness it is to he anticipated, so that, though it is not an invariable rule in phthisis or tuberculosis, the debility consequent upon either of these last conditions may produce it independently of elevation in temperature. The sweating that is due to a febrile condition of the body is generally noticed as the fever declines, and it thus becomes a natural and efficient means of reducing the fever with- out the aid of drugs; but when it comes on from sleep or exertion or fasting, it is due to exhaustion. How far these conditions may coexist, viz., fever and debility, is a point we cannot always easily decide, but, as th6 case advances, the difficulty is cleared up. Sv/eating, therefore, is a far less certain indication of tuberculosis than a persistent elevation of temperature; though, where the latter condition exists, too much weight should not be attached to its importance as a significant sign. Pulse. — The pulse is another and more valuable guide than sweating. As the temperature rises the pulse usually increases in frequency ; but this is not an invariable rule, for the temperature may reach a high point, as 103° or 104°, and yet the pulse remain infrequent, and the respiration quiet. I am inclined to think that when the pulse and respiration remain slow, and the temperature goes on rising, the patient is often in a perilous position, and that more correspondence in the relations are preferable for a hopeful diagnosis, than when the variance is so great. The pulse, there- fore, is no guide in the absence of fever, or the deposition of tubercle. Then, too, when the temperature is falling, debility and exhaustion may send up the pulse, so that this is not an infallible guide — a nervous or hysterical temperament will accelerate the circulation, and this may deceive some persons if they are not aware of the condition. The pulse, therefore, as a guide to the diagnosis of tuberculosis, is of less value than the elevation of tem- perature. Dr. Wilson Fox says that an accelerated pulse is not constant in acute tuberculization of the lungs. He contends that it may be frequently less than 100, and in some fatal cases below 70 both in the morning and in the evening. When the disease is progressing or established the pulse is quickened. When it is slow, and accompanied by a low temperature, there is more chance of the disease being arrested or cured. Of the relation between the 494 ' DISEASES OF CHILDREN. pulse and the morning and evening temperatures, wMcli is not without scientific interest and practical value, Dr. Fox found in 54 cases that the evening pulse was quicker than the morning in 20 cases ; it was slower than the morning in 22 cases ; the evening pulse equal to the morning in 12 cases. Of the mean pulses, in 46 cases the evening pulse was quicker than the morning in 28 cases ; the evening pulse was slower than the niQrning in 12 cases ; the evening pulse was equal to the morning in 6 cases. The respiration becomes accelerated in proportion to the severity of the disease, and that in the evening is somewhat in excess of the morning. Sometimes quickness of breathing is the chief but over- looked sj^mptom in acute tuberculosis ; and I should attach extreme weight to such a symptom, as I should also t'o oppression of the cardiac region and dyspnoea in rheumatic pericarditis before physical signs were present. The respiration, as maj' be expected, bears a close relation to the quickness and slowness of the pulse. In health thej^ correspond, and in fever as the circulation is acceler- ated the respiratory movements become more frequent ; blood is transmitted with greater frequency to the respiratory centre, and stimulates it to discharge an increased amount of work. In double pneumonia, when the blood is more venous, the dyspnoea and res- piration become so increased that by this symptom alone we judge of the perilous state of the patient. When the tuberculosis is in- tense there is usually acceleration in breathing, and both in the morning and in the evening the respirations are above 30 in the minute. In 54 cases of the quickest pulse, the evening respiration was quicker than the morning in 25 cases ; the evening respiration slower than the morning in 23 cases ; the evening respiration was equal to the morning in 6 cases. In 54 cases of the slowest pulse the evening respiration was quicker than the morning in 24 cases ; the evening respiration slower than the morning in 17 cases; the evening respiration equal to the morning in 13 cases. Of the mean respiration in 46 cases the evening respiration was quicker than the morning in 20 cases ; the evening respiration slower than the morning in 20 cases ; the evening respiration equal to the morning in 6 cases. But between the rate of the pulse and the temperature, as I have previously stated, there is no necessarj^ relation. The tem- perature may be high, and the pulse slow, or vke versa. We may have a morning pulse of 140 and the temperature 97° ; the evening ON TUBERCULOSIS. ' 495 pulse ma}' be 130 and the temperature 95° or 96° (Wilson Fox). We must infer tliat the variation in temperature may he accom- panied with a pulse of the same frequency ; those cases which are distinguished by a rapid pulse are commonly those where the temperature is highest, and low pulses are generaly met with where the temperatures are lo\v. These conclusions of Dr. Fox accor