" * w Columbia Umtiergttp wtht€itvt£Mm$oxk (£aiy$f> of Jiff yairiattH ano ^urgnma l&tfttmtt Stbranj Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofdiseasesOOruhr „ A MANUAL OF THE Diseases of Infants AND Children BY JOHN RUHRAH, M.D. PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE ILLUSTRATED Fourth Edition, Thoroughly Revised PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1914 *>• i Copyright, 1905, by W. B. Saunders and Company. Reprinted August, 1906. Revised, reprinted, and recopyrighted February, 1908. Revised, re- printed, and recopyrighted January, 1911. Reprinted August, 1913. Revised, reprinted, and recopy- righted September, 1914. Copyright, 1914, by W. B. Saunders Company. PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA E THIS LITTLE BOOK IS AFFECTIONATELY DEDICATED TO MY FATHER. PREFACE TO THE FOURTH EDITION. This little book has been so cordially received that a fourth edition has been prepared with the idea of bringing it up to date. Numerous minor changes and additions have been made, and among these may be mentioned the insertion of an article on pellagra in children, the use of the soy bean, and some other methods in the section on infant feeding, a chapter on drug eruptions and a full account of the Binet- Simon test for the mentality of children. It has been the aim of the author to keep the book a small one so that the student may use it for rapid references in the wards or clinics, and it will also be found useful as a desk book for practising physicians. The references throughout the book will be found of great use when the student wishes more extended information than is given in the average text-book. For the most part these references are in readily accessible journals in the English language and the articles referred to contain, in most instances, extensive bibliographies. Baltimore, Md., September, 1914. PREFACE. The average medical student attending the third and fourth sessions has about fifteen different brandies with which to familiarize himself. The text-books treating of these subjects average about 1000 pages each, or a total of some 15,000 pages. The student is busy all day at the college or in the hospital. In the evening he is expected to review the subjects which he has considered during the day, as well as fill in the many gaps in the college curriculum. Small wonder is it that, as the German proverb puts it, he cannot see the wood for the trees. This little book has been prepared for the medical student, not to supplant the larger and necessary text-book, but to enable the student to grasp quickly the more important parts of the subject of pediatrics, and to furnish him with a rapid reference-book for clinical use. It is hoped that the volume is not too condensed to be of service to the busy practitioner. In preparing this book all of the more important text- books have been consulted, as well as the literature as found in the journals. The chapter on Infant Feeding has been made more comprehensive than might be expected in a work of this scope, owing to the great importance of the subject. A large number of references to journal articles have been added as footnotes to enable the student to look up any given subject in the medical library. Almost all of these references will be found to contain a more or less complete 9 10 PREFA CE. bibliography of the subject. As many teachers suggest that students look up various topics in the medical library, a short chapter has been added on this subject. The illustrations are partly original and partly from other authors. For these latter the writer wishes to express his obligations to the authors from whom they have been bor- rowed. Many thanks are also due to Dr. W. E. Magruder for assistance in reading the proof and to Messrs. W. B. Saunders and Company for their courtesy during the prepara- tion of the work. CONTENTS PAGE Care of the Newborn 17 The Anatomic and Physiologic Peculiarities of Infancy and Childhood 20 Teeth, 28 — Anatomic Peculiarities, 29 — Premature and Delicate Infants, 34. The Examination of Sick Children 36 Diseases of the Newborn 50 Asphyxia, 50 — Congenital Atelectasis, 52 — Icterus, 53 — Acute Infections, 54 — Pyogenic Diseases, 54 — Ophthalmia Neonatorum, 56 — Tetanus, 58 — Pemphigus, 60 — Fatty De- generation of the Newborn, 62 — Epidemic Hemoglobinuria, 62 — Hemorrhages, 63 — Intestinal Obstruction, 65 — Diaphrag- matic Hernia, 66 — Mastitis, 66 — Umbilical Hernia, 67 — Lesions of the Umbilicus, 67 — Sclerema, 68 — Edema, 68 — Inanition Fever, 68. Infant Feeding 69 Breast-feeding, 69 — Mixed Feeding, 76 — Artificial or Bottle- feeding, 76 — Milk Modification, 80 — Feeding during the Sec- ond Year, 97 — Diet from Two and One-half to Six Years, 100 — Diet of School Children, 102 — Other Factors in Infant Feeding, 106— The Feeding of Sick Infants, 109. Diseases of Nutrition 114 Inanition, 114 — Marasmus, 115 — Malnutrition, 117 — Food Intoxications, 118 — Acid Intoxication, 119 — Rachitis, 120 — Adolescent Rachitis, 123 — Scurvy, 124 — Diabetes Mellitus, 126. Diseases of the Mouth and Pharynx 128 Perleche, 128— Harelip, 128— Cleft Palate, 129— Congenital Hypertrophy of the Tongue, 130 — Other Deformities, 130 — Epithelial Desquamation of the Tongue, 130 — Glossitis, 130 — Tongue Swallowing, L31 — Ulcer of the Frenum, 131 — Riga's Disease, 131 — Alveolar Abscess, 131 — Difficult Dentition, 131 — Diseases of the Uvula, 132 — Bednar's Aphthae, 132 — Catarrhal Stomatitis, 133 — Herpetic Stomatitis, 133 — Thrush, 133 — Ulcerative Stomatitis, 134 — Gangrenous Stomatitis, 135 —Other Forms of Stomatitis, 136. 11 12 CONTENTS. PAGE Diseases of the Tonsils and Esophagus 137 Croupous Tonsillitis, 137 — Ulceromembranous Tonsillitis, 137— Follicular Tonsillitis, 137— Phlegmonous Tonsillitis, 139 — Chronic Hypertrophy of the Tonsils, 140 — Retropharyngeal Abscess, 140 — Acute Pharyngitis, 142 — Retro-esophageal Abscess, 142 — Inflammation of the Esophagus, 142 — Mal- formations of the Esophagus, 143. Diseases of the Stomach 144 Vomiting, 144 — Cyclic Vomiting, 144 — Gastralgia, 145 — Acute Gastric Indigestion, 146 — Acute Gastritis, 147 — Chronic Gastric Indigestion, 148 — Dilatation of the Stomach, 149 — Congenital Stenosis of the Pylorus, 150 — Ulcer of the Stomach, 151 — Tumors of the Stomach, 151 — Hematemesis, 151. Diseases of the Intestines 152 Malformations of the Intestines, 152 — Congenital Absence of the Abdominal Muscles, 152 — Gastroduodenitis, 153 — Diarrhea, 154 — Acute Intestinal Indigestion, 155 — The Infec- tious Diarrheal Diseases, 157 — Acute Gastro-enteritis, 157 — Acute Ileocolitis, 161 — Chronic Ileocolitis, 162 — Amyloid Degeneration of the Intestines, 163 — Amebic Colitis, 164 — Chronic Intestinal Indigestion, 164 — Intestinal Colic, 165 — Chronic Constipation, 166 — Intussusception, 167 — Appen- dicitis, 168 — Dilatation and Hypertrophy of the Colon, 170 — Intestinal Worms, 171 — Diseases of the Rectum, 174. Diseases of the Peritoneum 176 Peritonitis, 176 — Ascites, 177 — Chylous Ascites, 178. Diseases of the Liver 179 Chronic Family Jaundice, 180. Respiratory System of Infants and Children 181 Coryza, 182 — Chronic Nasal Catarrh, 183 — Adenoids, 184 — Diseases of the Larynx, 187 — Catarrhal Spasm of the Larynx, 187 — Acute Catarrhal Laryngitis, 189 — Edema of the Glottis, 190 — Chronic Laryngitis, 190 — Tumors of the Larynx, 191 — Foreign Bodies in the Larynx, 191 — Laryngismus Stridulus, 192 — Congenital Laryngeal Stridor, 192 — Diseases of the Bronchi and Lungs, 193 — Bronchitis, 193 — Acute Catarrhal Bronchitis, 193 — Fibrinous Bronchitis, 195 — Chronic Bron- chitis, 195 — Bronchiectasis, 196 — Nervous Cough; Reflex Cough, 197 — Asthma, 197 — Pneumonia, 198 — Bronchopneu- monia, 199 — Lobar Pneumonia, 205 — Hypostatic Pneumonia, 207 — Pleuropneumonia, 208 — Chronic Interstitial Pneumonia, 208 — Gangrene of the Lung, 209 — Emphysema, 209 — Pleurisy, 210— Empyema, 212. Heart and Circulation in Infancy and Childhood 214 The Heart in Older Children, 215 — Congenital Heart Dis- ease, 217 — Pericarditis, 219 — Other Pericardial Lesions, 221 — CONTENTS. 13 PAGE Chronic Pericarditis with Adhesions, 222 — Endocarditis, 222 — Chronic Valvular Disease, 224 — Myocarditis, 228 — Hemic and Functional Murmurs, 229 — Functional Heart Disorders, 229 — Diseases of the Blood-vessels, 230. The Blood in Infancy and Childhood 231 Frequency of the Various Forms of Leukocytes, 235 — Sig- nificance of Blood Changes, 235 — Blood Changes in Disease, 236 — Chlorosis, 237 — Pernicious Anemia, 238 — Secondary Anemia, 239 — Leukemia, 240 — Splenic Anemia of Infants, 241 — Hemophilia, 242 — Purpura, 243 — Purpuric Diseases, 244. Diseases of the Ductless Glands 246 Hodgkin's Disease, 246 — Status Lymphaticus, 247 — Simple Acute Adenitis, 248 — Simple Chronic Adenitis, 249 — Diseases of the Thymus Gland, 250 — The Adrenals, 251 — Addison's Disease, 251 — The Spleen, 251 — Primary Splenomegaly, 253 — Dystrophia Adiposogenitalis, 253. The Urine in Infancy and Childhood 254 Functional Albuminuria, 255 — Hematuria, 256 — Hemo- globinuria, 256 — Glycosuria, 256 — Pyuria, 257 — Lithuria, 257 — Indicanuria, 257 — Acetonuria, 258 — Diaeeturia, 258 — Anuria, 258 — Diminution of Urine, 258 — Diabetes Insipidus, 259 — Diseases of the Kidneys, 259— Malformations and Mal- positions of the Kidney, 259- — Uric Acid Infarctions, 260 — Hyperemia of the Kidney, 260 — Acute Congestion of the Kidney, 260 — Chronic Congestion of the Kidney, 261 — Inflammation of the Kidney, 261 — Acute Nephritis, 261 — Chronic Nephritis, 264 — Amyloid Degeneration of the Kidney, 236— New Growths in the Kidney, 267— Pyelitis, 267— Cystitis and Cystopyelitis, 268 — Renal Calculi, 269 — Peri- nephritis, 270. The Genital Organs 271 Malformations of the Genitalia, 271 — Diseases of the Male Genitals, 272— Diseases of the Female Genitalia, 272— Dis- eases of the Bladder, 274. Diseases of the Skin 277 Congenital Ichthyosis, 277 — Eczema, 278 — Dermatitis Ven- enata, 280— Miliaria, 278— Seborrhea of the Scalp, 282— Fu- runculosis, 283 — Impetigo Contagiosa, 283 — Echthyma, 285 — Urticaria, 285— Alopecia Areata, 286— Pediculosis, 288— Scabies, 289— Ringworm, 290— Favus, 291— Gangrene, 292— Drug Eruptions, 293. Acute Otitis 294 Diseases of the Nervous System 296 The Examination of the Nervous System and the Signifi- cance of Symptoms, 296 — Convulsions, 301 — Epilepsy, 303 — 14 CONTENTS. PAGE Tetany, 305 — Laryngismus Stridulus, 306 — Chorea, 307 — Other Spasmodic Affections, 309 — Hysteria, 312 — Tic, 313 — Headache, 313 — Disorders of Sleep, 314 — Speech Disturb- ances, 315 — Wyllie's Physiologic Alphabet, 316 — The In- jurious Habits of Infancy and Childhood, 319 — Angioneurotic Edema, 320— Exophthalmic Goiter, 320— Malformations, 320 — Birth Palsies, 323 — Inflammation of the Brain and Its Membranes, 326 — Chronic Basilar Meningitis in Infants, 328 — Thrombosis of the Sinuses, 330 — Abscess of the Brain, 330 — Cerebral Tumors, 331 — Hydrocephalus, 332 — Infantile Cere- bral Paralysis, 334 — Myasthenia Gravis, 337 — Idiocy, 337 — Cretinism, 346 — Infantilism, 349 — Achondroplasia, 350 — Dwarfism, 351 — Cleidocranial Dystosis, 352 — Insanity, 352 — Developmental or Juvenile General Paralysis, 352 — Stigmata of Degeneration, 353 — Deaf-mutism, 354. Diseases of the Spinal Cord 355 Malformations, 355 — Spinal Meningitis, 356 — Myelitis, 356 — Compression Myelitis, 357 — Tumors of the Spinal Cord, 358 — Syringomyelia, 358 — Hereditary Ataxia, 358 — Cerebellar Hereditary Ataxia, 359 — Landry's Paralysis, 360 — Atrophies of Nervous Origin, 360 — The Progressive Muscular Dystro- phies, 362 — Peroneal Muscular Atrophy, 365 — Hypertrophic Interstitial Neuritis, 365 — Multiple Neuritis, 366 — Facial Paralysis, 368 — Diphtheritic Paralysis, 368. Acute Infectious Diseases 370 The Transmission of Infectious Diseases, 370 — Scarlet Fever, 371 — Measles, 375 — German Measles, 381 — Erythema Infectiosum, 384 — Varicella, 385 — The Fourth Disease, 387 — Vaccinia, 388— Pertussis, 390— Mumps, 394— Diphtheria, 396 — Typhoid Fever, 409 — Cerebrospinal Fever, 413 — Anterior Poliomyelitis, 419 — Influenza, 424 — Epidemic Pneumococcic Infections, 425 — Tuberculosis, 425 — Acute General Miliary Tuberculosis, 428 — Tuberculosis of the Respiratory Organs, 429 — Tuberculous Bronchitis, 432 — Tuberculous Meningitis, 432 — Tuberculous Adenitis, 435 — Tuberculosis of the Bron- chial Lymph-nodes, 436 — Tuberculosis of the Intestines and Mesenteric Lymph-nodes, 437 — Tuberculous Peritonitis, 438 — Tuberculosis of the Kidney, 440 — Syphilis, 440 — Malaria, 451 — Hook-worm Disease, 455 — Rheumatism, 457 — Chronic Fibrous Rheumatism, 460. Diseases of the Joints 461 Arthritis Deformans, 461 — Acute Arthritis of Infants, 462 — Tuberculous Arthritis and Ostitis, 463 — Other Forms of Arthritis, 468. Diseases of the Bones 471 Acute Osteomyelitis, 471 — Multiple Exostoses, 471 — Osteogenesis Imperfecta, 471. CONTENTS. 15 PAOE Diseases Not Otherwise Classified 473 Pellagra, 473. Therapeutics for Infants and Children 470 Size of the Dose of Medicine, 476 — Antipyretics, 481 — Anesthetics, 483 — Opiates, 484 — Somnifacients, 485— Stimu- lants, 485 — Tonics, 487 — Alteratives, 488 — Stomachics, 490 — Digestants, 491 — Cathartics, 491 — Diuretics, 492 — Diaphoret- ics, 493 — Expectorants, 493 — Antacids, 496 — Anthelmintics, 496 — Astringents, 496 — Antirheumatic Remedies, 497 — Anti- spasmodics, 498 — Urogenital Antiseptic, 498 — Vasomotor Stimulant, 499 — Antimalarial Remedies, 499 — Remedies for Common Skin Diseases, 499 — Escharotics, 501 — Stomach Washing, 501 — Irrigation of Colon, 501 — Enemata, 502 — Hot-air Bath, 503— Hot Pack, 503— Hot Bath, 503— Salt Bath, 503— Soda Bath, 503— Bran Bath, 503— Starch Bath, 503 — Counterirritants, 503 — Liniments, 504 — Inhalations, 505 — Nasal Sprays and Washes, 505 — Subcutaneous Injec- tion of Saline Solution, 505 — Vaccine Therapy, 506. The Medical Inspection of School Children 508 School Hygiene, 508— The Eyes, 508— The Ears, 509— The Nose and Throat, 510— The Teeth, 511— Mentally Defective Children, 511 — Nervous Diseases, 512 — Physical Defects, 513 — Skin Diseases, 514 — Other Symptoms, 514 — Infectious Diseases, 515. The Measuring of the Development of the Intelligence of Children 518 Sample Pamphlet of Information for Distribution Among the Poor in Summer 526 Directions to Mothers of Mentally Defective Children, 528 — Home-made Refrigerator, 529. Pediatric Literature 531 Index 533 MANUAL OF THE DISEASES OF INFANTS AND CHILDREN. CARE OF THE NEWBORN. Care of the Cord. — Dust with powdered starch (19 parts) and salicylic acid (1 part), and cover with sterile gauze. Avoid strong antiseptics, as they delay separation — which normally occurs about the fifth day. When the cord drops off a small pad of gauze should be placed over the umbilicus and held in place with the abdominal binder. This prevents the formation of umbilical hernia. Care of the I£yes. — Prevent gonorrheal ophthalmia and possible blindness. In every case, in hospital and in private practice, where the mother has a purulent discharge from the vagina the child should receive a drop or two of a 1 per cent, solution of protargol or, preferably, of a 2 per cent, solution of silver nitrate. When the mother is free from any suspicious discharge a solution of boric acid (10 gr. to 1 oz.) may be substituted. This latter may be used daily during early life if there is any tendency to inflammation about the eyes. The eyes of the infant should be protected from strong lights. Bathing. — After birth the child should be thoroughly oiled, to facilitate the removal of the vernix caseosa, and bathed in warm water (100° F.). After this, until the cord separates, a sponge bath only should be used. After that a full bath once daily. 2 17 18 DISEASES OF INFANTS AND CHILDREN. Temperature of the Bath for Healthy Infants. Up to six months 98° F. Six to twelve months 95° F. One to two years 90° F. The bath should be given in a warm room, preferably before an open fire. Older children may have a cold douche (70° F.), for half a minute, at the end of the bath. If the child does not react after the bath, and becomes pale and blue about the lips and finger-nails, the full bath is doing harm, and a warm sponge should be substituted. If the skin is chafed, or if eczema is present, a handful of common salt or sea salt may be added to the bath, or a bran or starch bath may be used instead. Clothing". — The clothing should be suited to the season and to the weather. The child is to be kept warm with light, loose unirritating clothing. There is great liability to overclothe. The abdominal binder should be used for the first few months, after which it may be dispensed with, unless the child is thin or suffers from colic. A long flannel band is best for the first month, after which a knit band, with shoulder-straps, should be used. Diapers or napkins should be soft and warm. Canton flannel or stockinet is the best. The arms and legs should be covered in cold weather. The child should not sleep at night in the clothing which it wears during the day. A union suit with feet is best for older children. The child should not be overloaded with bedclothes, but should be comfortably warm. Mouth and Teeth. — The mouth should be kept clean with plain water. Should thrush appear or the mouth be- come inflamed, boric acid solution (10 gr. to 1 oz.) should be used. Borax or sodium bicarbonate (20 grs. to 1 oz.) is also useful. The teeth should be kept clean, and carious teeth filled or removed. Too much stress cannot be laid on the care of the tempo- rary teeth. If they are neglected and become decayed the) are a source of danger, as the child is constantly absorbing toxic material. They also cause enlarged glands or even abscesses in the neck. When the teeth are bad, mastication CARE OF THE NEWBORN. 19 is difficult or impossible ; the child may Buffer from ind _ tion in const'ijiicnce, or be unable to take the proper amount of food. The loss of the first teeth may cause the second t<< th to be irregular and out of alignment. The second teeth should receive most careful care, all carious spot- being filled as soon as discovered. The first molars are often lost, as they are mi-taken for temporary teeth and allowed to decay. Where the teeth are not in alignment or are irregular, a well-trained denti.-t can usually straighten them, but the treatment must be begun early and continued over long periods of time. Care of the Skin. — Chafing and eczema are common in infancy. The use of clothing which does not bind or irri- tate, plain Castile soap, and bland unirritating powder will prevent much trouble. Napkins should be changed as soon as they are soiled, and the child dried and powdered. If irritation is already present the child should be wiped with an oiled cloth and then powdered. Oxid of zinc ointment and stearate of zinc powder are also useful. Salt, starch, or bran baths may be used. Care of the Genital Organs. — In girls the genitals should be kept clean, as neglect leads to vulvo- vaginitis. In boys the foreskin should be retracted during the first few weeks. If this cannot be done, and the preputial orifice is very small, the child should be circumcised. The foreskin should be retracted daily, and the parts cleansed. Vaccination. — Every healthy child should be vacci- nated before the fifth month. Training the Bladder. — This can usually, not always, be accomplished by the end of the first year by persistent efforts. The child should be instructed to indicate when he wishes to empty his bladder. Training the Bowels. — The child should be placed on a small chamber about the time that it usually has a stool. Just after a morning feeding is the best time. The back should be supported. Training should be begun early — before the third month — and persisted in until regular habits are established. Regular habits and regular bowels mean 20 DISEASES OF INFANTS AND CHILDREN. health for the child and much saving of trouble for the nurse. Care of the Nervous System. — The child should be kept quiet, and its surroundings carefully regulated. Only simple toys should be allowed during the first two years. Romping with young infants is injurious. After 4 o'clock in the afternoon the child should be kept very quiet. THE ANATOMIC AND PHYSIOLOGIC PECULIAR- ITIES OF INFANCY AND CHILDHOOD. For further information the reader is referred to the arti- cles on the different organs, and to Dwight\s Frozen Sections of a Child, Stratz's Der K'orper des Kindes, Rotch's Text- booh, Stanley Hair's Adolescence. Sleep. — The newborn child sleeps soundly for several days ; later it sleeps less soundly ; but after three years of age the sleep is very profound. Average Length of Time for a Child to Sleep. First month 20-22 hours. One to six months 16-18 " Six to twelve months 15-17 " One to two years 14-15 " Two to three years 13-14 " Three to four years 12-13 " Four to five years 11-12 " Five to ten years 9-11 " Ten to fifteen years 9-10 " One or two daily naps are taken until about four years of age. Dry napkins, a satisfied appetite, and a quiet darkened room, are all that is necessary. Good habits should be established early. Rocking to sleep is not necessary, and, if properly trained, an infant will sleep without it. Occasion- ally a child is found which cannot be trained to regular habits of sleep, but this is much more rare than is usually supposed. Exercise. — The average infant in a family gets suffi- cient exercise. In hospitals and asylums the babes do not. They should be picked up and carried about the room, and^ PECULIARITIES OF INFANCY AND CHILDHOOD. 21 wherever possible, not fed in their cribs. For older children out-of-door exercise is necessary. Airing. — In summer and in suitable temperatures a child may be taken out-of-doors at the end of the first week'. Sleeping out-of-doors is not injurious. In winter it should be accustomed to the fresh air by dressing as if for the street and then opening the window. The first airing may be fifteen-minutes long, and lengthened from day to day until it may be taken out in fine weather. Avoid high winds, wet, raw days, and very low temperatures. Otherwise, the little one should spend as much of its time in the open air as possible. The room in which it sleeps should be well-aired and ventilated. The Nursery. — Choose a light well-ventilated room. If heated by a furnace or steam radiators, supply moisture by having a pan of water in the room. Avoid gas stoves. The furniture of the nursery should be plain and easily cleaned. The temperature should be 70° F. (68° is prefer- able to 72°). At night, during the first year, 65° F. ; later, the temperature may fall to 50° F. Have plenty of fresh air. Infants require about 1000 cubic feet of air-space; older children several hundred less. Weight. 1 — The weight is of especial value in early life, and it is the best index of the nutrition. If the child is not gaining regularly, it means something is wrong. The infant should be weighed once a week for the first six months ; after that, twice a month. The weighing should not be done by the mother or in her pres- ence if she is nursing it, as a loss of weight may cause such a strong mental impression that her milk secretion may be inhibited. The average child weighs a trifle over 7 pounds at birth. The first two days it loses about 11 per cent, of the original weight. This is called the physiologic loss of weight. After the third day the child begins to gain. During the first six months 4 ounces is an average weekly gain ; later, it is slightly less. At the end of the first year the 1 See Boas, Science, Apr. 2, 1895. 22 DISEASES OF INFANTS AND CHILDREN. infant weighs about three times its weight at birth. The average gain during the second year is 6, during the third year 4J, and during the fourth year 4 pounds. Height. — The average length at birth is about 20.5 in. (55 cm.). During the first year there is an average gain of about 8 in. (21 cm.). During the second year the gain is about 3J in. (9 cm.), and thereafter the average gain is about 2J in. (6J cm.) a year until the eleventh year, when the growth becomes more rapid. Closure of the Sutures.— Ossification is usuallvcom- 1 15 Q 13 17 21 Fig. 1.— Diagram showing proportionate growth of different parts of the hody at various ages from 1 to 21 years (J. P. C. Griffith). plete by the sixth month. It may be delayed until the ninth month. Distinct separation after birth is abnormal, and is usually due to premature birth or syphilis. Closure of the Fontanels. — The posterior fontanel closes about the end of the second month ; the anterior about the eighteenth month. There is considerable variation in the time of closure. After two years an open fontanel is abnormal and is usually due to rickets. Cretinism may be a cause. PECULIARITIES OF INFANCY AND CHILDHOOD. 23 Rate of Growth in Height of American Children (Boas). Approximate average age. Number of observations. Boys. Average height for each year. Absolute annual increase. Annual increase. Years. 5* 6* n 8* 9* 10* 11* 12* 13* 14* 15* 16* 17* .... . 18* 1535 3975 5379 5633 5531 5151 4759 4205 3573 2518 1481 753 429 229 Inches. 41.7 43.9 46.0 48.8 50.0 51.9 53.6 55.4 57.5 60.0 62.9 64.9 66.5 67.4 Inches. 2.2 2.1 2.8 1.2 1.9 1.7 1.8 2.1 2.5 2.9 2.0 1.6 0.9 Per cent. 5.3 4.8 6.1 2.5 3.8 3.3 3.4 3.8 4.3 ■ 4.8 3.2 2.5 1.4 Rate of Growth in Height of American Children (Boas). Number of observations. Girls. average age. Average height for each year. Absolute annual increase. Annual increase. Years 5* 6* 7* 8* 9* 10* 11* 12* 13* 14* 15* 16* 17* 18* . 1260 3618 4913 5289 5132 4827 4507 4187 3411 2537 1656 1171 • 790 Inches. 41.3 43.3 45.7 47.7 49.7 51.7 53.8 56.1 58.5 60.4 61.6 62.2 62.7 Inches. 2.0 2.4 2.0 2.0 2.0 2.1 2.3 2.4 1.9 1.2 • 0.6 0.5 Per cent. 4.8 5.5 4.4 ' 4.2 4.0 4.1 4.3 4.3 3.2 2.0 1.0 0.8 24 DISEASES OF INFANTS AND CHILDREN Weight of American Children (Burke). Boys. Age. Average for each Absolute annual Annual increase. age. increase. Years. Pounds. Pounds. Per cent. 6* 45.2 7* • 49.5 4.3 9.5 8* . 54.5 5.0 10.1 9* . 59.6 5.1 9.3 10* . 65.4 5.8 9.7 n* • 70.7 5.3 8.1 12* . 76.9 6.2 8.7 13* . 84.8 7.9 10.3 14* . 95.2 10.4 12.3 15| • 107.4 12.2 12.8 16* . 8 121.0 13.6 12.7 171 18* Weight of American Children (Burke). GlRLS Age. Average for each age. Absolute annual increase. Aunual increase. Years. 6* 7* 8* ....... . 9* 10* ii* 12* 13* 14* 15* 16* 17* 18* • Pounds. 43.4 47.7 52.5 57.4 62.9 69.5 78.7 88.7 98.3 106.7 112.3 115.4 114.9 Pounds. 4.3 4.8 4.9 5.5 6.6 9.2 10.6 9.6 8.4 5.6 3.1 Per cent. 9.9 10.0 9.3 9.6 10.5 13.2 12.7 11.9 8.5 5.2 2.8 INFANT'S WEIGHT CHART. Name, . Date of Birth,. u .l , , j i 6 e 1 8 » 10 11 IS IS H IJ It 1? 18 10 SO Jl IS 2J It Pounds Weeks, i s t '• » n u is n » *» a a w s» »i »» » » »» « l «»«•««» »> " 60 6 * ** "?» If » H K II » »00 10* PECULIARITIES OF INFANCY AND CHILDHOOD. 25 Si^e of the Head.— Thomson gives the following fig- ures for the size of the head : At birth 13 to 13| inches. At six months 16 inches. At one year 18 inches. At two years 19 inches. At five years 20 to 20£ inches. At ten years 21 inches. There are, however, a great many normal variations in the size as well as in the shape of the head. Shape of the Head. — Congenital deformities are fre- quently seen. These usually disappear early. Deformities due to difficult labor are generally corrected by the end of the first month. Lying in one position may change the Fig. 2.— Natiform cranium. shape of the head, as may also premature ossification of the sutures. A square head, with prominent bosses, is seen in rickety children. (See also Microcephalus and Hydro- cephalus.) The Chest. — At birth the anteroposterior and transverse diameters of the chest are about equal. As the child grows, the transverse becomes longer and the chest assumes an elliptical shape. Muscular Development. — Voluntary movements usu- ally begin about the fourth month. At this time the head can be held up. Near the seventh month the child can sit erect, and about the tenth month it can stand. Walking is begun toward the twelfth month, and the child can usually 26 DISEASES OF INFANTS AND CHILDREN. walk alone by the fifteenth month. There are great varia- tions, however. In asylums the children walk late. 1 Special Senses. — Sight. — After the first week the child can usually distinguish the difference between light and dark- ness, and will very often follow a light about with the eyes. Toward the third month the mother's face or other familiar objects may be recognized, and in about the sixth mouth various things are recognized. The color sense is slow in developing. The difference between red and yellow may be noted during the first year, but blue and green may not be distinguished for a year or two later. It is important to recognize whether the child is blind or not. Older children are tested in the same manner as adults, and in younger children various tests may be made, by seeing if the pupils contract to light and, after a few months of age, to accom- modation ; by seeing if the eye is winked on bringing the finger close to the cornea without touching it (this test is of no value under two months of age) ; by seeing whether the child recognizes a bottle or other object when it is approached without making any noise ; by seeing if the eyes follow a light or bright objects. Ophthalmoscopic examinations are valuable. It should be remembered that the choroidal pig- ment is irregularly distributed in infants and may be mis- taken for diseased conditions. Amaurotic family idiocy can only be diagnosed by ophthalmoscopic examination. If the child does not see and the fundus of the eye is normal, one should suspect mental deficiency. Temporary amaurosis is sometimes seen, however, after coma, convulsions, severe whooping-cough, and basic meningitis. The condition known as congenital word blindness 2 should be borne in mind, as children so afflicted may be mistaken for idiots. Training of Blind Children. 3 — It is important to treat them as nearly like normal children as possible, and this should be begun earlv. Thev should be taught to exer- cise, to wash and dress and feed themselves, to play with 1W, Preyer, The Senses and the Will, 1888; The Development of the Intellect, 1889. Fred. Tracy, The Psychology of Childhood, 2 Hinshel Wood, Lancet, May 26, 1900, p. 1506. 3 Drummond, Pediatrics, June, 1899. PECULIARITIES OF INFANCY AXD CHILDHOOD. 27 toys of all kinds, and to indulge in games with other chil- dren. All of these things make a good foundation for the subsequent training of the child. Above all, they should be prevented, as tar as possible, from acquiring the numerous disagreeable habits, as twitching, swaying, moving the head, etc., to which blind children are especially prone. Hearing. — The child is usually deaf at birth, and this persists for two or three days. Loud noises are usually recognized at the end of the first or second week, and if at the end of two months the child dues not pay any attention to loud noises it should be suspected of being either deaf or idiotic. Deafness rnav come on during childhood, and that which is seen apart from visible changes in the ear is apt to have a grave prognosis, such as that following whooping- cough, meningitis, and various infectious diseases where the middle ear is not involved. The Early Training of Deaf and Dumb Children. 1 — They should be treated as much like normal children as pos- sible, and encouraged to play with other children and with all sorts of toys. Thev should be talked to by the parents or other people as much as possible, for a little child who does not hear may in this way learn that there is a means of communication, and will understand better when it is taught lip reading. When possible a child should be taught a sign language, the manual alphabet, articulation, and lip reading. Touch. — This is well developed at birth in the lips and tongue. After the third month it is noted that the surface of the entire body is sensitive to touch. Pain-sense is not so well matured as it is later in life. Temperature-sense is present very early. Taste. — This is well manifested at birth. Smell. — This probably develops last of all. Speech. — Children differ greatly in the time at which they begin to talk. Girls usually commence a month or two be- fore boys. Words are spoken at the end of the first year, and short sentences by the end of the second. After the sec- 1 Drummond, Pediatric.?, December 15, 1901, p. 440. 28 DISEASES OF INFANTS AND CHILDREN ond year dumbness should suggest mental deficiency. It should be remembered that some children talk late without any apparent cause. Examine the hearing and for tongue- tie in all these cases. TEETH, Eruption of the Milk Teeth. 1. — Two lower central incisors 6 to 9 months. 2. — Four upper incisors 8 to 12 " 3. — Two lower lateral incisors and four anterior molars 12 to 15 " 4. — Four canines 18 to 24 " 5. — Four posterior molars 24 to 30 " At one year a child should have 6 teeth. At one and one-half years a child should have ..... 12 " At two years a child should have 16 " At two and one-half years a child should have 20 " The above gives the average according to Holt. There are wide variations. Some children are born with teeth, but these are usually shed early. Others may not cut one until the end of the first year. About one-third of the children cut their teeth without any symptoms whatever. In a sec- ond third there are slight symptoms of discomfort with great nervousness and some digestive disturbances, and the remain- ing third usually are really ill each time a tooth is coming through the gum. There may be attacks of gastro-intestinal disturbances, such as indigestion, vomiting, and diarrhoea ; bronchitis or eczematous eruptions, which disappear promptly when the tooth is cut. Syphilitic children are said to have their teeth early, and that they decay rapidly. Late dentition is usually due either to rickets or cretinism. Eruption of the Permanent Teeth. First molars 6 years Incisors • 7 to 8 Bicuspids 9 to 10 " Canines 12 to 14 " Second molars 12 to 15 " Third molars 17 to 25 " PECULIARITIES OF INFANCY AND CHILDHOOD. 29 Mercurial Teeth (See also Hutchinson Teeth). — The per- manent teeth may be of a bad color, dirty, with irregular and pitted surface. The incisors, canines, and first molar- arc most often affected. The teeth are not dwarfed, as in syphilis. The defect may be due to the administration of mercury and also to other causes. Anatomic Peculiarities. — The lachrymal glands are not developed until three or four months, sometimes earlier. In- fants under this age do not shed tears. If a child has shed Fig. 3.— Diagram showing the temporary teeth : o, Central incisors ; b, lateral incisors ; c, canines ; d, anterior molars ; e, posterior molars (J. P. C Griffith). tears and ceases to do so during a severe illness the return of the tears may be regarded as a sign of convalescence. The salivary glands are not very active, and the mouth is rather dry in early infancy. The parotid gland is developed at birth. The diastasic action is not seen in the saliva from the sublingual glands until the end of the second month, and is not very active until the end of the first year. The diastasic action of the saliva is feeble in early infancy. The amylolytic ferment in the pancreatic juice is also said to be feeble at this time. The sweat glands are not active until after the first week of life. Profuse sweating, especially about the head, nearly always indicates rickets. The sebaceous glands are active before and after birth. The secretion at birth is called vernix caseosa. After birth it is liable to collect on the scalp (see Seborrhea). The breasts of babies (both sexes) contain a secretion looking like colostrum and having the composition of adult milk. This increases for a week or so and, if undisturbed, 30 DISEASES OF INFANTS AND CHILDREN. usually disappears in two or three weeks. There is great danger of infecting the breast at this time, and abscesses and mastitis may result from attempting to squeeze out the milk. Fig. 4.— One-sided mammary development. Note the " adenoid " expression. The breasts should be kept clean and left alone. In girls when the breasts begin to develop, from the tenth to the Fig. 5.— Diagram showing the permanent teeth : a, Central incisors ; b, lateral incisors ; c, canines ; d, first bicuspids ; e, second bicuspids ; /, first molars : o, sec- ond molars ; h, third molars (J. P. C Griffith). fifteenth year, one or both breasts may become enlarged and tender. This is often unilateral. If let alone the condition causes no trouble beyond the inconvenience. PECULIARITIES OF INFANCY AND CHILDHOOD. The testicles usually pass clown through the inguinal canal during the ninth month of intra-uterine life. This may be delayed, and they may be in the inguinal canal or in the ab- domen at the time of birth, and make their descent during the first month or later. They may remain in their fetal position. If descent takes place after the first month after birth a hernia is liable to occur at the same time. The thymus is relatively large in infants. 1 It increases in size until the end of the second year. It then remain- sta- tionary until puberty, when atrophy occur-. The stomach is tubular in form and nearly vertical at birth. During the first year the position becomes more horizontal. At birth the stomach holds about li ounces. At three months the stomach holds about 4J ounces. At six months the stomach holds about 6 ounces. At twelve mouths the stomach holds about 9 ounces. The stomach digestion is not nearly as complete in infants as in later life, and it begins to empty itself shortly after a nursing, and in breast-fed children the stomach is empty in from one to one and one-half hours in the young, and in about two hours in later infancy. In bottle-fed babies the time is half an hour or more longer. The intestines are relatively longer in infancy and the muscles are weak. This accounts for the frequency of con- stipation and also of distention of the abdomen from gases. The sigmoid flexure is larger than in later life. The liver is relatively larger in infancy, and at birth ex- tends 1 to 2 cm. below the costal margin. The bladder is almost entirely an abdominal organ in in- fancy, owing to the small size of the pelvis. The Back. 2 — The child's spine is supple and flexible, and this gradually lessens as the child grows older, but any stiff- 1 J. M. Brickdale, " Thvmns Gland, Observations on, in Children," Lancet, October 7, 1905, p. 1029. T. G.Moorhead, " The Thvmns Gland. ' Practitioner December, 1905, p. 733. Bovaird and Xicoll, "Weights of Vis- cera in Infancy and Childhood, with Special Reference to the Weight of the Thymus Gland," Archives of Pediatrics, Sentember, 1906, p. 641. 2 Owen, " On Children's Spines, Healthy and Otherwise," Pediatrics, March 1. 1896. 32 DISEASES OF INFANTS AND CHILDREN ness should be regarded as a sign of disease. In a sitting position the child's back forms a graceful curve, broken only Fig. 6. — Normal spine. bv the prominence of the seventh cervical vertebra, which should not be mistaken for a deformity. Any stiffness or Fig. 7.— Normal spine. straightness of the lumbar or cervical regions is as pathogno- monic of disease as an angular deformity would be in the PECULIARITIES OF INFANCY AND CHILDHOOD. 33 dorsal region. Lateral deviation should also be looked for. The child faces away from the examiner, who holds the hips firmly and directs the child t<> look at him firsl from one side and then the other. Any difficulty in rotation i- very easily noted. Tuberculosis of the vertebrae and rick- ets are the most frequent causes of stiffness. In the former there were pain, stiffness, and deformity, and in the latter Fig. 8.— Funnel-shaped chest. the deformity may be overcome by traction, and there is little or no pain. Deformities of the Thorax.— In the infant the chest is normally more or less barrel shaped; that is, the an- teroposterior and the transverse diameters are nearly the same. This is seen in later childhood in emphysema, 3 34 DISEASES OF INFANTS AND CHILDREN. whooping-cough, and sometimes in bronchiectasis and pneu- mothorax. The chest is contracted or flattened when there is obstruc- tion to the breathing, as in adenoids, chronic stenosis of the larynx, etc., and it may be seen in weak sedentary chil- dren. The funnel-shaped chest, in which there is a depression of the lower part of the sternum, is seen in rachitis, and it may occur as a congenital deformity. The pigeon breast, in which the sternum is prominent and the sides of the chest depressed, is seen in rachitis, in stenosis of the upper air-passages, as in adenoids, and sometimes in congenital heart disease. Harrison's sulcus, a depression of the ribs about the level of the ensiform cartilage, is frequently seen in rachitis. Asymmetry is seen in rachitis and in the deformities ac- companying or following pleural effusion, empyema, pneumo- thorax, chronic pleurisy, tuberculosis, and diseases of the spine. PREMATURE AND DELICATE INFANTS, Premature and small delicate children require especial care. If the weight is below 4 lbs., or the length below 9 in., an incubator should be used to maintain the body heat. If this is not possible, wrap the body in cotton, with a sep- arate piece of absorbent cotton in place of a napkin, roll in several blankets, and place in a basket and surround it with hot- water bottles. The room temperature should be 80° F. The absorbent cotton should be changed when soiled. The body should be rubbed with olive oil every three days. No bathing is permissible. If placed in an incubator, the tem- perature should be from 80° to 85° F., according to the size and strength of the child. Oxygen is useful when there are attacks of asphyxia or cyanosis. Feeding". — If possible, the child should take the food from a small bottle with a soft nipple. If it cannot suck it may be fed with a spoon, medicine dropper, or by gavage. The Breck feeder is most useful for this purpose. The food PECULIARITIES OF INFANCY AND CHILDHOOD. 35 should be given slowly to avoid regurgitation. The quantity and quality, as well as the interval, should be regulated by Fig. 9. — Modified Auvard incubator. the size and condition of the infant. From 2 dr. to J oz. every hour, until the child is about the size of a full-term Fig. 10.— Breck feeder for premature and weak infants. infant, is an average allowance. With great care and ex- perience many premature children may be saved. 1 1 Voorhees, Archives of Pediatrics, May, 1900. 36 DISEASES OF INFANTS AND CHILDREN. THE EXAMINATION OF SICK CHILDREN. The history of the child is very important, and should in- clude the family history, especially with reference to syphilis, tuberculosis, and nervous diseases, the history of the mother during pregnancy, and the nature of the birth, as well as a consideration of the hygienic surroundings of the child. Inquiry should especially be made concerning the character of the food and feeding from birth, the condition of the teeth, whether or not the child walks and when it began, the same of talking, and also how the child sleeps. It should be ascertained what infectious diseases the child has had, whether it has ever had snuffles, and whether it has ever had any dis- eases of the ear. It is well to find out to what symptoms the mother attaches the most importance and why she has sought advice. The child should be carefully observed before it is touched. If the child is shy, it should be ignored at first, and the conversation directed to the mother. Friendly rela- tions may often be established with the child by first examin- ing its toys. Young children are usually more docile when in their mothers' laps than on the bed. The examination should be as thorough and of the same nature as that made in adults, but one should learn to make it rapidly, so that it may be completed before the sick child becomes tired and fretful. The pulse and respiration should be counted first, if possible, during sleep, as it is sure to be disturbed later by the examination. In fact, much of the examination may be made with the child asleep, but, if it is aroused, try to have the mother or nurse do it, or at least try to have the child see some familiar face on waking, lest it become frightened. As much of the examination as possible should be made with the child sitting up, as most young children resent being placed on their backs. Perhaps more can be determined by inspection and palpation than in the adult. It is often sur- prising how much can be learned by palpation. The pres- ence of enlarged lymph-nodes, of other swelling, of tender points or places, the presence of rickets and other deformities THE EXAMINATION OF SICK CHILDREN. 1)1 of the bones, the presence or absence of bronchial rales and vocal fremitus, the size of liver and spleen, the presence of gas in the intestines, or of ascites, the condition of the ab- dominal muscles, whether rigid or not, as well as the condi- tion of the other muscles. The ears and throat should be examined last, as it is usually impossible to do much with a child after this is done. Fig. 11.— Facial expression in pneumonia. Note the herpes. They should not be omitted from the examination, as they are frequently the seat of disease. The facial expression is often suggestive, and may be pathognomonic. If the child is feeling well it generally looks it, and if not, pain, anxiety, or distress will be depicted in its expression. One often hears the remark : " The diagnosis must be very difficult with infants, as they cannot tell you anything." My invariable reply is : "That is balanced by the fact that they never lie." If the child has adenoids, the expression will vary with the amount of obstruction. The month is usually open, the nostrils narrow and the nose small, and the general expression is dull. One should not forget that sometimes the obstruction is due to nasal diseases. 38 DISEASES OF INFANTS AND CHILDREN. In meningitis the expression is staring, there is often squint and inequality of the pupils, there may be also wrinkles in the face, giving it the appearance of an adult in distress. There is often retraction of the head and a bulging fontanel. In pneumonia the expression is anxious, the mouth is usually partly open, and the nostrils dilated and moving with the respirations. The face is often flushed. In diarrhea or vomiting the expression is staring, the eyes are sunken and there are hollows under the eyes, the cheeks may also be sunken. In nephritis there is often marked puflmess and edema of the face, with its characteristic expression. The anterior fontanel should be carefully observed as regards the size and tension. It often closes early even in normal children, and always very early in microcephalus. It is usually closed by the eighteenth month, and if open after the second year it may be regarded as abnormal. The delay in closure may be due to hydrocephalus, rickets, or to cretin- ism. The fontanel pulsates, the pulsation increasing when the blood-pressure within the head is raised, and decreasing or ceasing altogether when the pressure is lowered. A sys- tolic murmur may occasionally be heard over the fontanel, but apparently this has no diagnostic significance. The ten- sion of the fontanel is very important. It is increased in cerebral hyperemia, which occurs in most acute fevers. It is increased on crying and on coughing. Bulging of the fontanel may be seen in meningitis and in brain tumor. Depression of the fontanel is noted when there is lowering of the blood- pressure in weakened conditions, and is noted in loss of fluid from the body, as in severe diarrheas. With meningeal symptoms in the course of the diarrhea the depression is a valuable indication that the meninges are probably not in- volved. In the same way a normal tension with meningeal or cerebral symptoms is of great value in making differential diagnosis between meningitis and pneumonia, or diarrhea with meningeal symptoms. Craniotabes. — The thinning out of the bones of the skull in spots, so that they are no thicker than parchment, is THE EXAMINATION OF SICK CHILDREN. 39 seen in early rickets and congenital syphilis. The same thinning is seen in premature infants along the sutures. The sensation to the finger is that of pressing in a derby hat and allowing it to reshape itself. The pupils contract from light and after a few months on accommodation. Contracted pupils are noted in sleep, after the administration of opiates, and sometimes in menin- gitis, especially in the early stages. Dilated pupils are noted just before death in severe auto-intoxication, especially that from the intestinal tract, and often in meningitis. Inequality of the pupils may be seen in meningitis and other serious brain diseases, as well as in diseases of the sympathetic nervous system. Hippus, or rhythmic contrac- tion and dilatation of the pupils, may be noted in nodding spasm and in some other diseases. Strabismus. — This is a puzzling symptom and requires especial study, for which the student is referred to the text- books on diseases of the eye. The squint may be due to paralysis of the eye muscles, as after diphtheria, or, in the course of meningitis or brain tumor, it may be due to errors of refraction, and it is often due to a disturbance of the coordination of the muscles, as in high fever. Amaurosis. — Blindness without apparent eye disease is met with in some forms of idiocy and sometimes after men- ingitis and in chronic hydrocephalus, after some infectious diseases, as whooping-cough, and in uremia. Congenital word blindness may occasionally be noted in school children. Ophthalmoscopic examination may be useful in meningitis, brain tumor, amaurotic family idiocy, and diseases of the eye. The indirect method is most useful. In infancy the pigment of the choroid is arranged irregularly and should not be mistaken for diseases of the eye. Nystagmus is seen with nodding spasm, sometimes in tuberculous meningitis, and in brain tumor or other nervous affections. It may also be present in diseases of the eye, as in choroiditis. 40 DISEASES OF INFANTS AND CHILDREN. The ears 1 should be examined, and this may usually be done without a speculum, owing to the short meatus. Otitis is a frequent cause of fever, and is usually overlooked until rupture of the drum occurs. Deafness. — This is usually the result of middle-ear dis- ease or adenoids, but may follow various infection, such as cerebrospinal fever, whooping-cough, and mumps. It is fre- quently seen in late cases of congenital syphilis, and forms one of Hutchinson's triad of signs of congenital syphilis. The prognosis depends on the cause. Adenoids should be removed and otitis media persistently treated. After the in- fections the outlook is bad. Deaf children should be talked to as much as possible, and efforts made to teach them how to read the lips. (See p. 354.) An acute nasal discharge suggests coryza, diphtheria, scarlet fever, or influenza. A chronic nasal discharge is seen in adenoids and congenital syphilis. The normal child sleeps with the mouth closed. If it is open in acute disease it usually means an acute coryza, swell- ing in the throat, as in diphtheria or scarlet fever, or retro- pharyngeal abscess. If it is chronic it usually indicates the presence of adenoids. The Palate. — High arching of the palate is frequently noted, especially after the development of the second teeth. Much can be done by a skilful dentist to prevent this. It is very frequent in the mentally deficient. Epithelial Pearls. — These are little inclusions of the mucous membrane in the median line of the palate, appear- ing as little white or yellow bodies about the size of a pin's head. They are most frequently seen in early infancy and sometimes ulcerate, leaving small oval ulcers which heal very slowly. The pearls should not be mistaken for any disease. Perforation is nearly always due to syphilis. Sucking Pads. — These are little masses of fat outside' the buccinator and masseter muscles which prevent the cheeks 1 J. F. McKernon, "Aural Examination in Acute Diseases of Children," Journal of the American Medical Association, January 7, 1905, p. 23. THE EXAMINATION OF SICK CHILDREN. 41 from going in during sucking. They are especially notice- able when there has been rapid emaciation in children under one year of age, occasionally older children, and are best seen when the child cries. The Sputum is coughed up and swallowed until the child is five or six years old. It may sometimes be obtained bv swabbing the throat immediately after coughing. Hemopty- sis is rare in children. The spitting of blood is usually from the throat or gums. The cry of the child is of some value. Infants cry from many causes besides pain. The more delicate the child and the more unstable its nervous system the more easily it cries. Cold feet, uncomfortable clothes, soiled napkins, anger, and hunger are the most frequent causes. The cry of hunger is irregular and fretful, and ceases when the child is fed. The cry of indigestion is very similar, but feeding aggravates, rather than lessens, the crying, except for a few moments after taking food. The cry of pain is a sharp, piercing cry. Sharp, piercing screams — the " hydrocephalic cry " — may be noted in chronic hydrocephalus, meningitis, idiocy, mental deterioration, acute otitis media, and at night in early hip-joint disease. General or local tenderness may cause screaming, as in handling a child with rickets, scurvy, or other disease, in voiding irritating urine, and in anal fissure. Pain. — Pain lohich is localized by the child in the same place should always be regarded seriously, as it is usually due to organic disease. Pleuritic pains may be referred to the median line, or to the epigastrium, and pleurisy with pneumonia often causes pain and rigidity in the abdomen, and if on the right side it may be mistaken for appendicitis. Abdominal pain is usually due either to gastro-intestinal disorders, in young infants to wind colic, to caries of the spine, to appendicitis, or peritonitis. Pain in the thigh or the inner side of the knee is usually due to hip-joint disease. 42 DISEASES OF INFANTS AND CHILDREN. Pain or aches on both sides of the body or in both arms or legs should always lead to a careful examination of the spine. Sleeplessness. — Disturbances of sleep in children, as a rule, are distinctly abnormal. They may be due to many causes. Any disease in which there is pain or itching will produce sleeplessness, and the same is true where there is cough, dyspnea, or diarrhea. Obstruction to breathing through the nose is another very important cause, and this most fre- quently is due to adenoids. Fever usually produces drowsi- ness, but in some children may cause wakefulness. Nervous children usually sleep badly. Disturbed, restless sleep is one of the characteristics of rickets and often of congenital syph- ilis. Indigestion is, of course, a very important cause. Some children normally sleep but very little, apparently not needing so much sleep as the average child, and these children are a source of considerable worry. Another ne- glected cause of sleeplessness are the noises about the child. Under ordinary circumstances these seem to be disregarded, but certain neurotic children are very much disturbed by unusual or unaccustomed noises. Sleeplessness in these cases may make a very marked difference in the child's health, and these children usually do well when moved to a quiet place, and frequently their health again becomes poor on their re- turn to the locality in which they get insufficient sleep. Sleeplessness may also be due to too much excitement, es- pecially in the evening, to a lack of ventilation, and, above all, to improper training. The lymph-nodes 1 should always be examined. The cervical are the most frequently enlarged, the most frequent cause being inflammations in the throat. The posterior cer- vical nodes are enlarged in measles and German measles, and in inflammations of the scalp. The position of the child should always be noted. It there is pain in the abdomen the child lies on its back with its legs drawn up. Opisthotonos is seen in meningitis and 1 Alfred Friedlander, " Lymph-nodes, Diagnosis of Enlaged," Journal of the American Medical Association, January 7, 1905, p. 19. THE EXAMINATION OF SICK CHILDREN. 43 tetanus. Retraction of the head is seen in meningitis, maras- mus, and retropharyngeal abscess. The skin should be examined for eruptions, as to whether it is dry or moist, and whether there is any pigmentation or cyanosis. Desquamation of the skin is seen in many skin diseases, after scarlet fever and measles, and in poorly-cared-for chil- dren the skin usually desquamates after a few baths. Tache cerebrale is the name given to the red line seen, in some conditions, after drawing the finger or a blunt instru- ment over the skin. It is seen in meningitis and many febrile and nervous conditions. Chills or Rigors. 1 — Chill in a child is usually replaced by a convulsion, but occasionally a chill may be noted, or if not a distinct chill, a cyanosis and coldness of the body or of some part of it. This may be seen in malaria. Thomson has called attention to the fact that a distinct rigor in a child under two practically always means an acute pyelitis. Temperature. 2 — There are certain differences in the temperature of children and in adults which are well to bear in mind. The first is that the child's heat center is not as well balanced as it is later in life, and smaller things may cause considerable variations in temperature. In premature children and very young children, and perhaps to a lesser extent in small children, the temperature is usually influenced by external heat and cold. The temperature may be sub- normal after long periods, due to insufficient warmth and clothing, and this usually has a very detrimental effect on the child's nutrition. On the other hand, the temperature of such children may be raised and even pyrexia caused by having hot-water bottles about the child. I have been con- sulted on a number of occasions to explain fever in prema- ture children that were being raised in home-made incubators ; an explanation was found in the use of too much heat. 1 Baldwin, "Rigors in Children," Lancet, June 13, 1896, p. 1635. 2 " Temperature, Pulse, and Eespiration in Infancy and Childhood," Archives of Pediatrics, December, 1905, p. 909. 44 DISEASES OF INFANTS AND CHILDREN. The temperature will vary according to the method used in taking it. The best temperatures are those taken in the rectum, and the thermometer should be left in until it ceases to rise, quite regardless of whether it is a half-minute or a three-minute thermometer. The temperatures taken in the axilla or groin are usually from 0.5° to 1.5° F. in well children, and 0.5° to 2° F. in sick children. Sometimes the difference is not marked, particularly in temperatures taken in the groin, but at other times it may be. I have given up the use of axillary and groin temperatures entirely and depend upon the rectal temperatures in young children, and after four years of age, either on that taken in the rec- |SjUXhW> OL.Wl. HaW\_ P.1M.. \oa° .5 f* \ V !w \ y 1 Vj / ^ Fig. 12.— Normal daily range of temperature in children. (After Finlayson, Glas- gow Medical Journal, February, 1869, page 186.) turn or in the mouth. It is well to have colored thermome- ters for rectal use and plain white ones to be used in the mouth. The temperature will also be found to vary slightly with the extent that the thermometer is placed in the rectum, but this is usually but a trifling difference. The daily range in the temperature, even in healthy chil- dren, is much greater than it is in adults. In some children it may vary from 2° to 3° F., while in others it may only be 1° F. In infants and young children the temperature is highest during the day, from the time the child wakes until evening. In the early evening the temperature starts to fall, and may drop from 1 to 3 degrees either before or after the THE EXAMINATION OF SICK CHILDREN. 45 child goes to sleep. This low temperature continues until about 2 or 3 o'clock in the morning, when there is a gradual rise until about the rising time. The fall in the evening is most marked between 7 and 9 o'clock. It may begin as early as 5 o'clock, and there is considerable variation in different children, depending upon external circum- stances and the child's individual peculiarities. A rise of temperature in the evening in a child is always sig- nificant, and if there is nothing else to account for it, and it recurs day after day, one should think of tuberculosis or typhoid fever, although there may be innumerable other causes. Persistent high temperature 1 is seen in quite a number of different diseases — tuberculosis, typhoid, bron- chial pneumonia, infections of the urinary tract, diseases of the bones and joints being the most frequent examples. One occasionally meets with a child who apparently has some disturbance of the heat center; such children apparently have perfect health and have normally a high temperature. I have seen one or two examples of persistent temperature of 100° or 101° F., which continued for years without any ap- parent disturbance of the child's health. On the other hand, one frequently sees children who normally seem to have low temperature. These children usually have a poor peripheral circulation, suffer with cold hands and feet, and complain a great deal in cold weather, and usually suffer from changes in the temperature. Some of these children suggest a pos- sibility of disturbance of the internal secretions, and which in turn might of course affect the heat center. A sudden high temperature in a child is most frequently due to indi- gestion or some disturbance of the stomach or intestines. It is seen also in the onset of the exanthems, especially scarlet fever. It is frequently seen in the onset of influenza and in pneumonia. Hyperpyrexia 2 is most frequently due to dis- ease of the stomach and bowel, particularly in certain forms of summer diarrhea. It may also be noted from 1 Bovaird, Jr., " The Differentiation of Common Types of Protracted Fever," American Journal of Medical Sciences, vol. cxxxvii, 1909, p. 49. 2 Longwell, " Hyperpyrexia," Scottish Medical and Surgical Journal, January, 1899, p. 39. 46 DISEASES OF INFANTS AND CHILDREN the external application of heat in a premature child, as noted above. The pulse l varies greatly in infants. It may be rapid and even irregular from slight causes. The regularity and volume are of greater importance than the pulse rate. A slow, irregular pulse suggests meningitis, and also occurs in brain tumor. The respiration may be rapid and irregular from slight causes while the child is awake. It is frequently irregular during sleep in meningitis. Dypsnea is present in all severe diseases of the lungs and pleura — as in pneumonia, severe bronchitis, and empyema, It causes rapid respiration with sinking in of the supraclavicular, suprasternal, and inter- costal spaces. Pleural effusions 2 are frequently called pneumonia on account of the presence of bronchial breathing. A pleural effu- sion in a child under three years is nearly always purulent. Palpation of the Abdomen. — If the abdomen is rigid and it is not advisable to give an anesthetic, the child should be immersed in a bath-tub in hot water. After five or ten minutes it will be found that in many cases the abdomen will be suffi- ciently relaxed to permit of a fairly satisfactory examination. I/umbar puncture is of value in making a diagnosis of meningitis. If properly done it is perfectly harmless. (For procedure, see Cerebrospinal Fever.) The muscles of the young child contract very easily, and may often be in a state of partial or even complete contrac- tion. Too much stress should not be placed upon rigidity of the neck or other muscles, as trifling often unexplained causes may be responsible. Myatonia. — A condition of general muscular weakness. There is a congenital form (myatonia congenita, Oppenheim) 3 in which there is pseudoparalysis with loss of deep reflexes and lessened electrical reactions. Lesser degrees of myatonia 1 Nicholson, "The Pulse in Infancy," Scottish Medical and Surgical Jour- nal, May, 1901, p. 419. 2 G. S. Middleton, " Pleural Effusion and Empyema in Children, Diagno- sis of," Practitioner, November, 1906, p. 602. 3 Haberman, The American Journal of the Medical Sciences, March, 1910, p. 383. THE EXAMINATION OF SICK CHILDREN. 47 are seen in rickets, congenital syphilis, in marasmus, Mon- golian idiocy, and in advanced stages of the myopathies. Edema if general and marked is usually from nephritis. It may result in the more dependent parts from heart or liver disease or any obstruction to the circulation. Edema of the eyelids may be seen in urticaria and in whooping- cough. Edema may be .-ecu in severe anemia-. General edema may occur as a complication of marasmus, independent of any disease of the heart or kidneys. The edema may come on suddenly or gradually and may be slight or severe. It may disappear and reappear. It is evidently due to the hydremia and weakened blood-vessels. It is most frequent under six months of age, but may be seen in older children. Acute Circumscribed Edema. 1 — Angioneurotic edema, or giant urticaria, may affect infants and children, causing an acute swelling of almost any part of the body, usually the skin, but sometimes the mucous membranes, joints, or muscles. It may cause puzzling symptoms if it affects stomach, intestines, or the srenito-urinary tract. In the larynx it mav be a source of great danger. Edema of the Face. — Edema may be caused by a great variety of things, chief of which are acute or chronic nephri- tis ; and in all cases of edema the urine should be carefully investigated. The swelling almost always begins about the eyes and forehead, and practically one rarely sees edema due to nephritis that does not affect these parts. It may also be due to edema in the course of anemia, and to food poisoning in which the edema has the manifestations of urticaria. Swelling of the face may also be seen in children who have been exposed to cold winds, and in these cases it is usually, if not always, accompanied by small, round, hard, bluish patches which may give rise to considerable alarm the first time they are seen. Angioneurotic edema may also affect the face. The swelling may be due to insect stings. It is usually more or less localized and frequently there is a his- tory of being stung. The skin is reddened and the central puncture may often be made out. The swelling may be due 1 Smith and Meara, " Edema, Acute Circumscribed," Archives of Pedi- atrics, May, 1906, p. 361. 48 DISEASES OF INFANTS AND CHILDREN. also to inflammation, abscesses about the teeth being the most frequent form. The obstruction to the veins in the thorax may cause edema and cyanosis of the face, and may be due to enlarged thymus, enlarged lymphatics, or to new growth-. The Hands. — Changes in the hands are important, as the hands are always visible. Clubbing of fingers, usually with cyanosis and changes in the nails, is seen in congenital heart disease, in chronic sup- purative diseases of the chest, as empyema and bronchiectasis, in tuberculosis of the lungs or pleurisy, or in chronic pleu- risy or pericarditis with adhesions. It is said to occur in cirrhosis of the liver. The shape of the hand is characteristic in achondroplasia, the little finger is curved in Mongolian idiocy. In rickets the phalanges may be larger than the joints, causing a beaded appearance. Marked deformities are caused by arthritis deformans, and a dactylitis or inflammation of the fingers may result from either syphilis or tuberculosis. The #-ray may aid in differentiating these. In syphilis there is a gummatous periostitis, the interior of the bone being un- affected or sclerosed, while in tuberculosis there is a carious interior, the periostitis being secondary. There may be characteristic movements, as in chorea and athetosis. Nervousness may also be revealed by clenched fists or movements. The presence of edema or cyanosis is easily seen, and the habits of sucking thumbs or fingers and biting the nails leave their traces. Examination of Stools. — The length of time the food takes to pass through the bowel may be easily determined by marking any given meal by administering a teaspoonful of charcoal and noting when this is passed. It is highly im- portant for the physician to examine the stool himself, for, as a rule, the nurse and attendants are not competent to de- scribe them satisfactorily and, indeed, many physicians are lacking in knowledge on this point. Mucus is frequently present in the stools of infants and young children, and is seen in diarrheas of all sorts. If there are shreds and strips of mucous membrane, mem- branous colitis should be thought of. Large quantities are THE EXAMINATION OF SICK CHILDREN. 49 seen in mucous colitis of the nervous type, which i.* how- ever, rare in children. Blood in the stools may be due to bleeding fr< m anal fissures, in which ease the hard fecal massses are streaked with blood. Apart from this, small patches of bright red blood in otherwise more or less normal stools should sueeesi polypus of the rectum, and an examination should be made for it. Blood mixed with mucus is frequently noted in coli- tis, enterocolitis, and ulcer of the bowel. The stools should also be examined for parasites of various kinds (see Intestinal Parasites and Hook-worm Diseasej. If the flow of bile is interfered with, there wdl be white stools with a soft consistency and an offensive odor. See also page 106 for further points on the examination of the stools. Sudden Death. — This is not uncommon in infants, and may occur in those previously healthy, but usually is seen in children, especially in asylums. It may lead to unjust suspicion as regards attendants. The more common causes are as follows: 1. Malformations of internal organs which may have es- caped attention. This usually occurs in the first few days. 2. Internal hemorrhage. This is usually during the first or second week. 3. Asphyxia. a. From overlying. b. To the aspiration of regurgitated food. In older infants the asphyxia may be due to rupture of a retropharyngeal or mediastinal abscess, or from pressure of an abscess or enlarged lymph-nodes on the pneumogastric nerve, or from sudden dislocation of the cervical vertebra in a course of caries of the spine. 4. Marasmus, apparently from heart failure. These chil- dren are often found dead in the morning, and there is uot infrequently more or less atelectasis. 5. Enlarged thymus. Children with lymphatism are liable to die from slight accidents, the administration of anesthetics during a convulsion, or during slight or severe illness. 6. Convulsions without reference to their cause. 7. In high temperature after a few hours' illness, seen in the course of acute infections, toxemias, and heat-stroke. 4 50 DISEASES OF INFANTS AND CHILDREN. DISEASES OF THE NEWBORN. Intra-uterine. Due to any disturbance of the placental circulation during labor. ASPHYXIA. This may be intra- or extra-uterine, and the causes are given in the following table : f Hemorrhage, j Convulsions, f Mother, -j Use of ergot in second stage. I Prolonged second stage. [_ Death of mother. Pressure on cord. Twisting of cord. Pressure on brain. Child. -| Early separation of placenta. Entrance of mucus, blood, amniotic fluid, or meconium into air-passages. Malformations of brain, circulatory, or respiratory organs. Extra-uterine. . Intra-uterine disease of brain, circulatory, or respiratory (Bare.) ' organs. Injury of brain, circulatory, or respiratory organs. In premature infants from weakness. I/esions. — There are congestion and punctate hemorrhages of the viscera, aspirated material in the air-passages, and if the child has breathed or has been forcibly inflated there may be emphysema. In the extra-uterine form, malforma- tion, disease, or injuries may be found. Symptoms. — Two forms may be described, between which there are all grades : Asphyxia Livida. Cyanosis. Vessels of cord full and firm. Pulse full, slow, and strong. Muscle tone good. Responds to external stimuli. Symptoms disappear with beginning respiration. Prognosis good. Recovery usually prompt. Asphyxia Pallida. Pallor (lips may be blue). Vessels of cord almost empty and relaxed. Pulse absent or nearly so. It may be impossible to make out heart- beat. Muscle tone poor, child relaxed. Does not respond to stimuli. Symptoms are liable to persist. Prognosis bad. Recovery slow ; symptoms liable to recur and child may die even after several days have elapsed. DISEASES OF THE NEWBORN. 51 Diagnosis. — Cerebral compression from hemorrhage may present similar symptoms and may be associated with asphyxia. There is usually the history of compression from a long labor or from instrumental delivery. The fontanel bulges, there is coma, and often paralysis. Anemia from a large hemorrhage, as from cord rupture, may resemble asphyxia pallida. Prognosis. — This depends upon the grade of the condi- tion, and to a slight extent upon the skill with which the child Fig. 13. ?chultze's method of artificial respiration : A, Inspiration ; B, expiration (Hirst). is treated. Attempts at resuscitation are apt to be abandoned too early. Treatment. — Full accounts of the various methods of treatment will be found in the text-books on obstetrics. Clean out the mouth and pharynx with the finger swathed in absorbent cotton. Stimulate respiration by spanking, alternate hot and cold baths or douches, by swinging in the air, and other means. If very livid, allow half an ounce of blood to flow from the umbilical cord. If it is thought that the bronchial tubes contain amniotic fluid or mucus, insert a 52 DISEASES OF INFANTS AND CHILDREN. small soft-rubber catheter and try to remove it by suction. Laborde's method of resuscitation may then be tried. This consists in placing the child, wrapped in a blanket, on a chair or table, so that the head hangs over the edge. Trac- tion is then made on the tongue, pulling it out as far as pos- sible and then letting it recede at the rate of about fifteen times a minute. This often starts the respiration by irri- tating the superior laryngeal, glossopharyngeal, and lingual nerves, which in turn affects the phrenic nerve, causing con- traction of the diaphragm and intercostal muscles. This is one of the best methods of resuscitation ; if it does not suc- ceed, artificial respiration must be tried. Schultze's method is most efficient. Grasp the child with the thumbs on the chest, the index-fingers in the axilla?, and the remaining fingers supporting the back. The child is held feet down- ward, face forward, between the physician's legs. The child is then swung upward until the physician's arms are about horizontal ; the sudden stopping causes the child's body to double up, and expiration is produced. The inspiration is caused by the return to the original position. This should not be done too rapidly. This may be too severe for very weak infants, and other methods may be substituted. Inhala- tions of oxygen are sometimes of great service. The lungs may be inflated artificially by the mouth-to- mouth method, by using a catheter in the larynx, or by Ribemont's inflator. Too much force should not be used. CONGENITAL ATELECTASIS. At birth the lungs are solid, but are rapidly expanded as soon as the child is born. This process of expansion is gradual, and may take one or two days or more before it is complete. It may be irregular, and areas of solid lung may remain, especially in the case of weak children. The lower part of the lungs, in the back, are said to be the last to ex- pand. Where this fetal condition of the lungs persists it is called atelectasis. Pathology. — The lung is only partly expanded, usually DISEASES OF THE NEWBORN. 53 the anterior part or in spots. These spots are generally em- physematous. Only one-quarter or one-third of the lung may be dilated ; the older the child the more expanded lung it is apt to have. Marked atelectasis may be found as late as three months where it was not suspected. There may be evidences of pneumonia, and it may take a microscopic ex- amination to decide whether there is hypostatic pneumonia or atelectasis, or both. The spleen is usually enlarged. Symptoms. — The child may be asphyxiated at birth and only recover partly, dying after one or more relapses. The asphyxia may be apparently recovered from and not recur, but the child may never seem to thrive. The tem- perature of the body is low, the child feeble, and more or less cyanosed. The infant becomes weaker and weaker, and may die without any assignable cause. Diagnosis. — This may be difficult. Symptoms and his- tory are to be relied on more than physical signs, which may be wanting. The percussion note may be resonant over the entire chest, even when there is considerable solid lung, owing to the fact that the solid lung is surrounded with em- physematous lung. In other instances the areas of dulness are distinct, and over them there is absence or diminution of breath sounds. There may or may not be rales. Treatment. — Full inflation of the lungs should be se- cured by seeing that the infant either cries or takes full, long, deep breaths. If the child is feeble, it should be made to cry at least once a day, if it does not do so of its own accord. Spanking, frictions, and alternate hot and cold douches may be used to this end. The child should be kept warm. It should be taken up and carried about and fed on the nurse's lap, never in the crib. ICTERUS. 1. Physiologic. — This occurs in about one-third of all children born. Eunge places it as high as 80 per cent. It comes on during the first week, usually from the third to the sixth day. It increases for a day or two and then dis- appears, taking a week or two to clear up entirely. The 54 DISEASES OF INFANTS AND CHILDREN. urine is not usually bile colored, but may be. The stools are normal. Kehrer states that it is more frequent in the first child. It does not affect the child in any way, but it is said that these children do not gain as rapidly as those with- out it. It is liable to be more intense in weak children. There are numerous theories, the most plausible being that it is due to resorption of bile and of destroyed red blood-cells in the liver. 2. From Malformation of the Bile Ducts. 1 — The bile ducts may be absent or impervious. There is increasing jaundice coming on after birth. The urine is deeply colored, and the stools white. The liver and spleen are enlarged. Hemorrhages under the skin and from the mucous membranes are common. Vomiting is usually absent. Death usually takes place within three months, from wasting or convul- sions. 3. Syphilitic hepatitis is a rare cause of icterus in the newborn. 4. In septic infections there may be slight icterus. ACUTE INFECTIONS. Any of the infectious diseases may be seen in the newborn, especially if the mother has the disease at the time the baby is born. There is, however, a natural immunity to most of the infectious diseases of childhood during the first few months of life. The symptoms are the same as in later life. The prognosis is bad, owing to the diminished resistance of early life. PYOGENIC DISEASES. 2 (Sepsis of the Newborn ; Puerperal Fever of the Newborn ; Septicemia ; Pyemia* etc.) Definition. — A variety of conditions, due to infection of the child with the ordinary pus-forming bacteria, are met with. The staphylococcus pyogenes aureus and albus and the streptococcus pyogenes are most commonly met with. 1 Thomson, Edinburgh Medical Journal, 1892. 2 Snow, Archives of Pediatrics, 1903, p. 659. DISEASES OF THE NEWBORN. 55 Etiology. — The infection may be localized, and the ab- sorption of toxins may cause constitutional symptoms, or there may be a septicemia or pyemia. Infection frequently takes place through the umbilical stump ("omphalitis); this may extend to the umbilical vessels or even to the peri- toneum. Peritonitis is one of the most frequent forms of septic infection met with. Bronchopneumonia, associated with pleurisy, may also be met with complicating infection of the umbilical vessels or other inflammations. Pericarditis is rare. Streptococcus infection of the throat may occur with the formation of a false membrane, which resembles that seen in diphtheria. Gastro-enteritis may be caused by pyogenic organisms. Inflammation of the cellular tissue with abscess formation is common, and septic arthritis and osteomyelitis are also seen. Erysipelas may start about the umbilicus during the first two weeks of life, and tliis form is usually fatal. Symptoms. — Certain general symptoms are common to all infections in the newborn ; fever, if present, is of the most irregular type. Icterus is common, and hemorrhages frequent. Loss of appetite, vomiting, and diarrhea are fre- quently seen. There is always loss of weight. The pulse is rapid and weak, and the respiration is irregular. Convul- sions, twitching, and rigidity may be present, and coma may come on later. Symptoms of special infections, as peritonitis, are, if pres- ent, like those seen later in infancy. There may, however, be little to call attention to the seat of the greatest trouble. Prognosis. — This is always bad. Prophylaxis, along general antiseptic lines, should always be carried out, to prevent infection, always bearing in mind that a young infant is easily infected. Treatment. — This is symptomatic. Collections of pus should be evacuated. Ichthyol (o to 30 per cent, in oint- ment) or glycerin is useful in skin infections. 56 DISEASES OF INFANTS AND CHILDREN. OPHTHALMIA NEONATORUM, 1 Ktiology. — This is caused by the gone-coccus, infection taking place from the vagina of the mother during labor, occasionally in other ways. Symptoms. — There is great swelling of the lids, chemo- sis, and a profuse purulent discharge. If the progress of the disease is not arrested, ulceration of the cornea, or panoph- thalmitis, with total loss of the eye, may result. The dura- tion of the disease depends largely on the treatment. Gonor- rheal arthritis may occur from these infections. „.:ssa«=s».== Fig. 14.— Ophthalmia (conjunctivitis) neonatorum (de Schweinitz). Prognosis. — The outlook is good if the case is taken early and energetically treated. If handled late or if im- properly treated the prognosis is bad. Nearly one-third of all blindness is from this cause. Prophylaxis. — Every child born in an institution, and every suspicious case in private practice, should receive 1 or 2 drops of a 1 or 2 per cent, solution of nitrate of silver in each eye (Crede's method). The excess of silver may be neutralized afterward by flushing the eye with normal salt solution. 1 Weeks, Archives of Pediatrics, May, 1905, p. 346. DISEASES OF THE NEWBORN. 57 Treatment. — Isolation of cases, strict antiseptic precau- tions, and cleanliness are necessary. If only one eye is affected, the other should be protected by pads moistened in some antiseptic solution. Cold compresses of surgical gauze should, almost constantly, be kept on the eyes. These may be changed every few minutes, taking them directly from a block of ice and applying. Every twenty minutes, night Fig. 15.— Arrangement for application of ice to the eyes (De Lee). and day, the eye should be irrigated with a solution of boric acid (10 gr. to 1 oz.). A bulb-tip eye-dropper should be usec l — alternately at the inner and outer canthus of the eye — and the fluid injected with sufficient force to wash out the conjunctival sac. Once or twice a day a few drops of a 3 per cent, solution of protargol (in resistent cases a 10 per cent, solution), or a 1 or 2 per cent, solution of nitrate of silver 58 DISEASES OF INFANTS AND CHILDREN. should be dropped into each eye. Atropin should be in- stilled if the cornea is affected. Later on a very mild oint- ment containing yellow oxid of mercury may be used to keep the abraded conjunctiva from adhering. TETANUS. 1 Definition. — An acute infectious disease characterized by tonic muscular spasms (which increase in severity by ex- acerbations) and by general convulsions. Ktiology. — The disease is caused by Nicolaier\s tetanus bacillus, which produces a powerful poison — tetanotoxin. The bacilli are never found anywhere in the body except at the site of infection. The tetanus bacillus is found in the soil. In some places, as the Hebrides, Faroe Islands, and various places in the tropics, the disease is endemic, and a large percentage of the newborn die from tetanus. Infection in infants usually takes place through the umbilical wound. Pathology, — About the only thing found is hyperemia, sometimes accompanied with small hemorrhages of the spinal cord. Congestion of the lungs is also usually noted. Symptoms. — The disease comes on usually about the fifth or sixth day, rarely later than the twelfth. Trismus (stiffness of the jaws) is the first thing noticed, and this pre- vents nursing. The body next becomes slightly stiffened, and this increases by paroxysms until the whole body is rigid. The head is generally retracted, and the fixation of the mus- cles of the face gives a peculiar expression. Convulsions are apt to be excited by any manipulation. The pulse is rapid and weak, the temperature in the mild cases is low, 100° to 101° F., but may be 104° to 105° F., or even higher in the severer cases. In the fatal cases death usually takes place in from twenty-four to forty-eight hours, sometimes later ; those which recover last from one to three weeks, the spasm gradually passing away. Death takes place from exhaustion or from spasm of the glottis or of the muscles of respiration. Prognosis. — This is always bad — 90 to 95 per cent, of the cases die. 1 Hartigan, American Journal of the Medical Sciences, 1884. DISEASES OF THE NEWBORN. 59 Treatment. — Drugs tending to lower the spinal excita- bility should be used, in repeated doses, in quantities suffi- cient to produce some effect. Chloral and bromides, either alone or in combination, are most used. Calabar bean is also recommended. From 3 to 5 gr. or more of bromid of soda or potash may be given every two or three hours, re- ducing the dose as improvement takes place. Chloral may be used in 1 or 2 gr. doses, and may be increased. It may be given every hour or two until some effect is produced. Phenol has given remarkable results. It is used in a 10 per cent, solution, the adult dose being 10 drops, children in proportion. This should be diluted with 25 to 30 minims of water. It should be given deep into the muscles. It may be repeated at intervals of three hours, and less fre- quently as improvement takes place. The urine should be watched, and if it becomes dark it should be stopped, at least temporarily. Tetanus antitoxin should be given as soon as possible. From 1500 to 3000 units of the standard adopted by the United States Public Health and Marine Hospital Service may be given, and repeat it once or twice if necessary. Tetanus in Older Children. — A very large number of cases of tetanus occur every year, usually about the Fourth of July, as a result of injuries received from the explosion of fire- works, a large majority of cases coming from the use of blank cartridges. Toy pistols made for the explosion of blank cartridges should be prohibited. To prevent tetanus, the wound should be freely incised and every particle of foreign matter carefully removed. It should then be cauterized with a 25 per cent, solution of car- bolic acid and a loose wet boric acid dressing applied, and the wound allowed to heal by granulation. The dressing should be changed once a day or oftener if necessary; 1500 units of tetanus antitoxin should be administered, and this is almost a certain prophylactic. The child should be kept absolutely quiet and not touched unless absolutely necessary. Food and medicine may be given by means of a nasal tube, 60 DISEASES OF INFANTS AND CHILDREN. PEMPHIGUS, This disease is characterized by a blister-like eruption, which may be due to a variety of causes. The lesion is a bulla, varying in size from one-quarter of an inch to several inches,filled with clear serum, and usually upon a reddened base. Btiology. — Epidemic pemphigus of the newborn some- Fig. 16.— Pemphigus. times occurs in institutions. It usually begins the latter part of the first week, but may be seen later. It is probably due to several sorts of pus-forming bacteria. Staphylococcus pyogenes albus and aureus have been found in the bulla?. Symptoms. — There are twenty or thirty bulla? scattered over the body, but seldom on the soles or palms. They may appear on the mucous membranes. After a day or two they burst and dry up, and a few days later the scab falls, leaving DISEASES OF THE NEWBORN. 61 a. reddish-violet base. New crops may appear. The disease lasts a week or two. Prognosis. — This is usually good in strong infants. Sep- sis may develop and prove fatal. Diagnosis. — Impetigo may resemble it very closely, and the two may be only different forms of the same process. Treatment. — Keep the child clean by bathing in mild antiseptic solutions, such as boric acid (10 gr. to 1 oz.) or 1 : 10,000 bichlorid of mercury. An antiseptic powder (mixture of boric acid and starch) or an ointment may be used. The best ointments are either a 1 per cent, ichthyol or a 1 to 2 per cent, ammoniated mercury ointment. Fig. 17.— Pemphigus. Traumatic pemphigus may result from bathing the child in very hot water. Syphilitis pemphigus may be present at birth, or may develop during the first two weeks of life, rarely later. It is frequently seen upon the soles and palms * other manifesta- tions of congenital syphilis are present. (See Syphilis.) 62 DISEASES OF INFANTS AND CHILDREN. FATTY DEGENERATION OF THE NEWBORN. (Buhl's Disease, 186 J.) Definition. — This is a rare disease, seen usually in infants who have been asphyxiated at birth and in whom the symptoms have persisted to a greater or less degree. The attempts at resuscitation may not always be successful. The cause of the disease is unknown. Pathology. — The features of the disease are fatty de- generation of the organs (especially the heart, liver, and kidneys) and hemorrhages into the organs, the serous cavi- ties, and from the mucous membranes. There may be hem- orrhage from the cord when it separates. Symptoms. — There is prostration, loss of weight, and sometimes icterus and edema ; external hemorrhages may occur. There is no temperature. The disease usually proves fatal within two weeks. Diagnosis. — This is made by microscopic examination of the organs, and may be of some medicolegal importance in cases of asphyxia. It resembles the pyogenic infection of the newborn. Phosphorus and arsenical poisoning should also be excluded. Treatment. — This is symptomatic. Nothing known has any influence over the course of the disease. EPIDEMIC HEMOGLOBINURIA. 1 ("wmckePs Disease, 1879; Maladie bronse'e.) Definition, — This is a rare disease of the newborn, usually occurring epidemically in institutions. It is charac- terized by hemoglobinuria, icterus, and cyanosis. Etiology. — It is probably due to some sort of infection as yet unknown. Pathology. — The lesions are swollen kidney, large hard spleen, hemorrhages into the various organs, and sometimes fatty degeneration of the heart and liver. The umbilical vessels are almost always normal. Symptoms. — The disease attacks previously healthy in- fants, and comes on from the fourth to the eighth day after 1 Boston Medical and Surgical Journal, March, 1875. DISEASES OF THE NEWBORN. 63 birth. It begins suddenly, with restlessness, followed by great prostration, rapid pulse, and respiration. The increas- ing cyanosis and icterus together give the child the appear- ance of a mulatto. The urine is dark and cloudy, is passed in small quantities, with pain and straining, and contains hemoglobin, kidney epithelium, and sometimes granular casts and blood, but no bile. The temperature is either normal or elevated. The child usually dies in thirty or forty hours from asthenia, coma, or convulsions. Treatment. — This is symptomatic. Nothing known in- fluences the course of the disease. HEMORRHAGES. Hemorrhages are common in early life. They may be (1) traumatic ; (2) spontaneous, the so-called hemorrhagic disease of the newborn. 1. Traumatic hemorrhages are due to injury during labor — if the skin is unbroken a hematoma results. Cephalhematoma is due to prolonged labor or forceps. It Fig. 18.— Cephalhematoma (Hirst). is a collection of blood under the scalp, usually over one parietal bone. It may be noted any time — from birth to the fourth day. It increases in size for about a week and then slowly disappears. Xo treatment is required. Differential Diagnosis. — Cephalhematoma. — Soft ; fluctuates ; not reducible ; no pressure symptoms ; no pulsation (may rarely pulsate) ; no heat ; marginal ridge ; skull felt at bottom ; disappears in from one to three months. Caput Succedaneum. — Edematous ; does not fluctuate ; dis- appears in two or three days. 64 DISEASES OF INFANTS AND CHILDREN. Abscess. — Soft ; fluctuates ; not reducible ; no pressure symptoms ; local heat ; redness ; often fever. Encephalocele. — Along line of sutures partly reducible; pressure causes symptoms. Increases on crying (see En- cephalocele). Depressed Fracture. — Depression of skull felt ; sometimes paralysis, coma, etc. Hydrocephalus. — Symmetrical enlargement of the head. Hematoma of the Sternomastoid. — A condition noted during the second or third week, most frequently after breech pre- Fig. 19.— Longitudinal section through a cephalhematoma: a, Dura mater; b, cranium ; c, pericranium ; c' , c', beginning hyperostosis ; e, scalp (Davis). sentation. It is a hard tumor, about the size of a pigeon's egg, situated in the muscle. It is immovable and sometimes slightly tender. It disappears spontaneously, leaving no de- formity. Treatment is contra-indicated. Visceral Hemorrhages. — These may be in the brain, lungs, or abdominal organs. The intracranial may be diagnosed by the nervous symptoms (see Birth Palsies) ; that of the lungs may occasionally cause hemoptysis ; abdominal hemor- rhage causes obscure symptoms, often fatal collapse, and diag- nosis is rarely made during life. 2. Spontaneous Hemorrhage. 1 — Small hemorrhages may occur in the course of syphilis, pyemia, and other infec- tions. Small or large hemorrhages may occur without any apparent cause. Do not confuse with hemophilia (see Hemo- philia). Various bacteria have been demonstrated in the blood of these patients. The hemorrhages may vary in size from a pin-point ecchymosis to a large loss of blood. 1 Townsend, Archives of Pediatrics, August, 1894, p. 559. DISEASES OF THE NEWBORN. 65 They may be single or multiple and may occur in any organ, into any serous cavity, from any mucous membrane, or under the skin. Townsend gives oO cases as follows : Intestine, 20 ; stomach, 14; mouth, 14; nose, 12; umbilicus, 18 (umbili- cus alone, 3) ; subcutaneous, 2 ; abrasions of the skin, 1 ; meninges, 4 ; cephalhematoma, 3 ; abdomen, 2 ; pleura, 1 ; thymus, 1. The hemorrhages occur usually on the second or third day, rarely later than the seventh day. There may, or may not, be temperature. There is rapid loss of weight. Death takes place in most cases in three or four days, or else the hemorrhages stop spontaneously (generally within the first day or two of the disease), and recovery takes place. Town- send collected 709 cases ; 79 per cent, of these died. Treatment. — Keep up nutrition. Local treatment, where the hemorrhage can be reached. One drop of the 1 : 1000 solution of adrenalin diluted with normal salt solution may be given hourly for a few doses or until some effect is noted. The dried gland may be given in J-grain doses internally. For local bleeding, adrenalin solution 1 :1000 diluted 1 : 10 with normal, salt solution may be used. Gelatin (2 per cent, solutions) in normal salt solution sterilized several times has been recommended. It should be boiled for several hours. Injections of from 2 drams to \ ounce may be used, and repeated if no effect is produced. Normal horse serum has also been suggested as an injection. Human blood serum has also been used, 10 cc. subcutaneously three times a day, or even every two hours in severe cases. Intracranial hemorrhage is sometimes amenable to surgical treatment. 1 INTESTINAL OBSTRUCTION. 2 In the newborn this is most frequently due to an imper- forate anus, usually only the external orifice being absent. 1 Gushing, American Journal of Medical Sciences, October, 1905, p. 563. J. E. Welch, " Normal Human Blood Serum," etc., The American Journal of the Medical Sciences, June 1910, p. 800. ' Journal of the American Medical Association, January 21, 1905. Arthur Edmunds, " Intestinal Obstruction in Children," Practitioner, August, 1906, p. 173. G. P. la Eouge, "Intestinal Obstruction, Diagnosis of Affections Characterized by," Journal of the American Medical Association, April 7, 1906. J. E. Erdmann, " Intestinal Obstruction in Children," Journal of the American Medical Association, January 21, 1905, p. 171. 5 6Q DISEASES OF INFANTS AND CHILDREN. The rectum may be absent in part or entirely or be closed by a septum. The obstruction may be due to malformations higher up in the gut. The symptoms vary with the grade of obstruction. Ab- sence of stools — or, if high up, absence of stools after the first few — vomiting, and distension of the belly are the most common symptoms. These may, in some instances, come on after a week or two. The lower the obstruction the longer the child lives. The higher up the obstruction the earlier the symptoms come on. Imperforate anus and rectal septum may be treated surgi- cally with success. The other forms are practically always fatal. DIAPHRAGMATIC HERNIA, 1 This is a congenital deformity. More or less gut is found protruding upwards through the diaphragm, usually on the left side. If the hernia is small the child may live. The symptoms are usually dyspnea or asthmatic attacks. There may be signs of a pneumothorax and, if on the left side, the heart is pushed to the right. Diagnosis is difficult or impos- sible, and there is nothing to do for it. MASTITIS. In the breast of the newborn it is very common, to find milk secreted. This is most marked about the second week, but it may be noted for several months. Left to itself, it rarely causes any trouble, but if squeezed out or handled roughly the breast is apt to become inflamed and an abscess caused, which may prove fatal. The breast of infants should be kept clean and let alone. Treatment. — For abundant milk paint the gland with tincture of belladonna and apply a large pad of cotton, and over this a roller bandage, making moderate pressure. If !Abt, Archives of Pediatrics, April, 1900, p. 261. Stiles, "Operative Treatment of Hernia in Infants," British Medical Journal, October, 1901, p. 813. W. B. Coley, " Hernia, Management of, in Infancy and Childhood, - ' Journal of the American Medical Association, January 11, 1905, p. 112. R. H. Russell, "Hernia in Children and Their Relation'to Adult Conditions, Pa- thology and Treatment of," Lancet, January 7, 1905, p. 7. Edmund Owen, " Hernia, Reducible, in Boyhood," Practitioner, March, 1906, p. 289. DISEASES OF THE NEWBORN. 67 the gland becomes inflamed apply hot boric-acid solution on compresses. If an abscess forms it should be opened. UMBILICAL HERNIA. The ordinary form consists of a small protrusion of gut through the umbilical opening. It is most frequently seen in poorly nourished, rachitic girls. A carefully applied abdominal binder during the first few months does much to prevent its occurrence, and in the smaller ones a pad of gauze, held in place by the binder, is all that is necessary to effect a cure. Later on a piece of cork or a button, covered with a gauze and held in place with two strips of zinc oxid adhe- sive plaster, applied at right angles and crossing at the um- Fig. 20.— Adhesive plaster applied for the cure of umbilical hernia (De Lee). bilicus, will be found efficient. The tendency is for these hernias to disappear even without treatment. LESIONS OF THE UMBILICUS. Granuloma. — This is merely an excess of granulation tissue. It forms a small tumor mass, has a small amount of discharge and bleeds readily. Powdered burnt alum may be used as a dusting powder or sulphate of copper or nitrate of silver may be applied. If large, it may be cut off. 68 DISEASES OF INFANTS AND CHILDREN. Adenoma ; Mucous Polypus ; Diverticulum Tumor. — Names applied to a tumor mass at the umbilicus caused by a prolapse of the mucous membrane of Meckel's diverticulum. Various sizes and degrees are met with. The tumor is of a pink color, smooth, irreducible, and has a slight mucous discharge. There may be a fecal fistula. The treat- ment is surgical, SCLEREMA. A curious, hard, board-like condition of the skin and sub- cutaneous tissues occasionally seen in the newborn and also in older infants. It occurs in weak infants. It may be in small areas or may extend to nearly the entire surface of the body. The temperature of the body is lowered and the skin feels like a cadaver. There is no pitting on pressure. The body may be rendered quite stiff if the sclerema is extensive. The circulation is very feeble. Most of the cases die, but not all. Treatment. — The baby should be put in an incubator and kept warm. The heart should be stimulated and the feeding carefully regulated. EDEMA. Edema may be seen in young infants not associated with disease of the heart, liver, kidneys, or blood. It is usually seen in very weak infants ; it may be general or local, and is most frequent in the dependent parts. As it occurs in the very weak the children often die, but some of them recover. The edema lasts a week or so and disappears. It may recur. Treatment. — Keep the child warm and stimulate the heart and circulation. Give digitalis, strychnia, and alcohol. In the very severe cases citrate of^potassium may be given. INANITION FEVER. Inanition must not be forgotten as a cause of fever in the newborn. (See Inanition). INFANT FEEDING. 69 INFANT FEEDING. 1 There are four methods of feeding infant- : 1. Breast or maternal feeding. 2. Wet-nursing. 3. Mixed feeding — i. e. 9 breast-feeding supplemented by bottle-feeding. 4. Bottle or artificial feeding. BREAST-FEEDING. The milk from a healthy mother is by far the best nour- ishment for an infant during the first year, and cannot be fully replaced by any other form of feeding. Infants fed on breast milk are stronger and better able to resist disease. While it remains true that babies may be reared on artificial foods and remain healthy and grow strong, the percentage of robust bottle-fed babies is much smaller than that of healthy breast-fed infants. This is particularly true of the lower classes, who often lack both the time and intelligence re- quired to rear a healthy infant by bottle-feeding. Contra-indications to Maternal Nursing. — The following rules, adapted from Holt, will be found a reliable guide in determining whether or not a mother is fitted to nurse her child : 1. If the mother has tuberculosis in any form, latent or active, she should not nurse her child. A tuberculous mother not only exposes her child to infection, but hastens the prog- ress of the disease in herself. If the mother has pulmonary tuberculosis, nursing is almost certain to prove fatal to her. 2. When the mother has had any serious complication, such as nephritis, convulsions, severe hemorrhages, or septic infection, during pregnancy or parturition, she should not nurse her child. 3. If the mother is choreic or epileptic, nursing is contra- indicated. 4. If the mother is very feeble or has any serious chronic disease the child will derive little, if any, benefit from breast- feeding, and the mother will be greatly injured. 1 A very complete discussion of this subject will be found in Diet in Health and Disease, by Friedenwald and Ruhrah. 70 DISEASES OE INEANTS AND CHILDREN. 5. Nursing should not be attempted where experience has shown on two previous occasions, under favorable conditions, that the mother is unable to nourish her child. 6. Where no milk is secreted nursing is impossible. Good artificial feeding is to be preferred to poor breast feeding. If artificial feeding is to be resorted to it is well to begin early, while the infant's digestive organs are in com- paratively good condition. The question must always be carefully considered. During pregnancy the breasts should be examined, and if the nipples are short, gentle traction should be made on them daily. If there is retraction the breast-pump may be needed to evert them. During the entire nursing period the breasts Fig. 21.— Breast-pump. should be kept clean ; they should be washed after each nursing, preferably with a boric-acid solution. During the first forty-eight hours the child receives practi- cally no nourishment from the breast ; the only fluid secreted during this time is colostrum. This has a laxative effect upon the infant's bowels, emptying them of the dark, brown- ish material known as meconium, which has accumulated in the intestinal canal during uterine life. The child should, however, be put to the breast at regular intervals, so as to establish a free flow of milk ; this generally begins on the third day, but is sometimes delayed. During the first two days of its existence the child gets about six ounces of colostrum a day, which is all that is needed. It may, however, be given a teaspoonful or two of warm, boiled water or of a 5 per cent, solution of sugar of INFANT FEEDING. 71 milk. In unusually robust and fretful children, or when there is fever, a small amount of nourishment may be re- quired ; this should be given according to the rules for arti- ficial feeding. If the milk is delayed beyond forty-eight hours, it becomes necessary to feed the child by the bottle until the flow is established. The child should be put to the breast regularly, or the breast-pump may be used to stimulate the secretion of the milk. Fennel, catnip tea, and the like should be excluded from the child's dietary. Many mothers do not nurse their infants because they have not been properly instructed as to the importance of doingit. The mental attitude of the mother has a marked effect on the milk secretion, and if she has been properly instructed and encouraged beforehand, there is usually no difficulty. If, on the other hand, she has grave doubts as to her capa- bility, the milk secretion may be inhibited. The mental condition of the mother is often affected as the result of weighing the child. It is very desirable that the child be weighed regularly and the weight recorded ; but if the mother is at all nervous, or if the child is not doing well, the weigh- ing should not be done by the mother or in her presence. Breast-nursing often proves a failure because the mother does not understand how to give the breast to the child. The child should lie on the right or left arm, according to whether the child is to nurse at the right or at the left breast. If the mother is in a sitting posture, her body should he inclined slightly forward. With her free hand she should grasp the breast near the nipple between the first two fingers. If, owing to the free flow of milk, the child takes the milk too rapidly, this may be checked by slight pressure of the fingers. The child should nurse until satisfied. The contents of one Fig. 22.— Colostrum and ordinary milk- globules, first day labor ; primipara aged nineteen (Durlandj. 72 DISEASES OF INFANTS AND CHILDREN. breast are generally sufficient for one nursing, and the breasts should be used alternately. When satisfied, the infant will usually fall asleep at the breast. Under ordinary conditions the nursing should last from ten to twenty minutes. If the milk is taken too rapidly, vomiting may ensue immediately after or during feeding. If too much is taken, it is regurgi- tated almost immediately. If the infant consumes more than half an hour in nursing, the breast and the milk should be examined. As the infant grows older it requires and takes more food, and consequently will require a longer time to nurse than it did during the early days of life. The inculcation of good nursing-habits cannot be too strongly insisted upon. Many attacks of indigestion, colic, and diarrhea may be traced to improper nursing. When good habits are once established, there is generally very little trouble, the success of the training depending largely on the manner on which it is done. Regular hours for feeding should be fixed and adhered to ; and if the child is asleep at the feeding-hour, it may be aroused, for it will almost invari- ably go to sleep after nursing. After the last feeding, which should usually take place at 9 or 10 o'clock, the child should be quieted and allowed to sleep as long as it chooses. During the first month or two the infant will, as a rule, awaken between 1 or 2 o'clock and again at 4 or 5 o'clock. After two or three months it will require but one night feed- ing, and after five months of age the average infant will sleep all night without nursing. When the change is being made and the child awakens for its accustomed nursing it should be given a little warm water from a bottle and quieted, but not taken up. Regular nurs- ing habits induce regular bowel movements and sleep, and the three combined insure health and comfort not only for the infant, but for the mother as well. A healthy child, if trained to do so, will sleep without rocking or coddling. Three things are, however, essential to secure success in this training : a satisfied appetite, dry napkins, and a quiet dark- ened room. If it has colic, the warm milk may soothe the child for a time, but later aggravates the trouble, which in many cases is due to overfeeding or too frequent feeding. INFANT FEEDING. 73 The following table, from Holt, may be used as a guide in breast-feeding Age. First day Second day , Third to twenty-eighth day Fourth to thirteenth week Third to fifth month . . Fifth to twelfth month . Number in Intervals Night nursing twenty-four during between 9 I . M. hour-. day. and 7 A. M. 4 6 hours. 1 6 4 " 1 10 2 " 2 8 2^ " 1 7 3 " 1 6 3 " In case of sickness and when the infant is feeble and below the average, especial rules are required, and directions should be modified to suit each individual case. A good general rule is to feed the child according to the age to which the weight corresponds. The child'.- weight is the best index of its nutrition. During the first six months it may be weighed once a week ; after that time twice a month is suffi- cient. The average minimum gain for an infant is four ounces a week. If the weight falls below this for several weeks consecutively, it is evident that something is wrong. During illness, of course, there may be no gain or loss ac- cording to the severity of the condition. When the breast milk is insufficient for, or unsuited to the needs of the infant, it becomes fretful, colic occurs, and the baby appears to be "cross/' Disturbances of the alimentary tract, diarrhea with greenish stools containing a large amount of mucus and undigested curds, takes place at times. At times the stools are brownish, and contain mucus and numerous curds the size of a grain of wheat or larger. In other cases there may be chronic constipation with small, hard, dry stool-. If the infant is getting too little milk, it is fretful and gains slowly or not at all, but there is rarely any disturbance of the stomach or bowels. In these cases the nursing is con- tinued for over thirty minutes without satisfying the child, or it may nurse a minute or two and then refuse because the supply is so scanty. AVheu the breast milk is nearly normal in quantity and in quality, certain measures, which will be discussed, may be taken to augment the supply and enrich the quality, or it may be supplemented by artificial feeding. 74 DISEASES OF INFANTS AND CHILDREN. When the milk is very poor in quality, as, for example, when the specific gravity is from 1.015 to 1.025 and when only 2 or 3 per cent, of cream is present, the child should be weaned at once, for the condition is not amenable to treatment. Mother's milk may easily be tested by means of Holt's milk set, which consists of a lactometer and a cream gauge. 1 With this the specific gravity and the amount of cream may easily be estimated. Estimated with this instrument the cream is to the fat as 5 is to 3. The following table will help in estimating the quality of human milk : Specific gravity, 70° F. Cream, twenty-four hours. Normal average . . . Healthy variations . . 1.031 1.028-1.029 7 per cent. 9-12 per cent. Healthy variations . 1.032-1.033 5-6 per cent. Unhealthy variations Below 1.028 High (above 10 per cent.). Variations Below 1.028 Below 1.028 Normal (5-10 per cent.). Low (below 5 per cent.). Above 1.033 High. Above 1.033 Above 1.033 Normal. Low. Proteins. 1.5 per cent. Normal (rich milk). Normal (fair milk). Normal or slightly below. Low. Very low (very poor milk) Very high 'very rich milk). High. Normal or nearly so. When the mother's milk is found not to agree with the infant, it may often be modified by the following means : 1 . If the milk is too rich, the diet should be limited, espe- cially as to the amount of meat taken. All alcoholic and malted drinks should be prohibited. With plenty of fresh air and exercise, such as walking, the desired effect will gen- erally be brought about. The exercise should be carried to the point of fatigue. 2. When the milk is good, but deficient in quantity, the supply may be augmented by massage of the breasts three times a day for from five to ten minutes. A good malt ex- tract may be given with the meals, and fresh air and exercise prescribed. Sufficient fluid should be given, preferably milk. 3. When the milk is deficient in quantity and poor in quality, improvement may be brought about by various means ; massage, malt, and iron are to be prescribed if there 1 This may be obtained from Eimer & Amend, New York. INFANT FEEDING. ?5 is anemia. An alcoholic malt extract combined with pep- tonate of iron, or of iron and manganese, is a good combina- tion, and may be had in very palatable form. The diet should be ample and contain sufficient nitrogenous food. Milk should be taken with the meals, during the intervals between meals, and at bedtime. 4. When the quantity is sufficient, but the quality is poor, little can be done, and the child must generally be weaned. The foregoing measures may be tried, but not for too long a period, as the child may suffer in consequence. After the second month the child may be given a bottle once a day. The child learns to take its milk from the bottle, which facilitates weaning when the time comes ; it also allows the mother greater liberty. Wet-nursing". — Some infants will thrive on nothing but breast milk. If the mother cannot nurse her child a wet- nurse should be chosen according to the following rules : The woman should be healthy and of good habits. The absence of syphilis, tuberculosis, alcoholism, and other dis- eases should be determined by careful examination. The nipples should be carefully examined for fissures and ulcera- tion. The breasts should be examined before and after nurs- ing, and the milk tested as previously described. The size of the breast alone is not a good guide as to the amount or quality of the milk it secretes. The quantity may be judged by the size of the breast before and after nursing or by weighing the babv before and after nursing. This latter method, although a good oue, is not usually resorted to. The wet-nurse should always be one who has nursed her own child successfully for at least a month. If possible she should be a primipara between twenty and thirty-five years of age. Younger or older women should not, as a rule, be employed. If the infantas condition permits, the purse should be given at least a week's trial, for often the change in her mode of living may cause a scanty flow of milk or render it otherwise unsatisfatory. When she has become accustomed to her surroundings, the milk may become perfectly normal. Owing to idleness and a too abundant diet the milk may become too rich. In these cases the rules previously laid down may correct the condition. 76 DISEASES OF INFANTS AND CHILDREN. Wet-nursing is now largely replaced by correct artificial feeding. MIXED FEEDING. The child is fed partly on the breast and partly on the bottle. This method is indicated when the mother's milk is poor or scanty, owing to some intervening illness, or when, owing to deficient quantity, the mother cannot entirely nurse the child ; it is also useful in weaning. Weaning is accom- plished with less discomfort to mother and child if done gradually. If the mother is nursing the child but once or twice a day, her milk may become very poor, and conse- quently should be examined from time to time. In these cases the child is usually satisfied after a bottle, but not after the breast-feeding. ARTIFICAL OR BOTTLE-FEEDING. When it becomes necessary to feed the child artificially the physician must understand the nature of the milk mix- ture that he prescribes, so that he may vary it to suit the child's digestion and modify it to meet the requirements of the growing infant. In the United States the only milk available for infant feeding is cows' milk. To insure success by artificial feeding an accurate knowledge of the composition of the milk and in how much it differs from mother's milk is essential. A knowledge of the methods for overcoming these differences is also necessary. It should constantly be borne in mind that, while general deductions may be made and average figures given, the element of personal equation enters largely into the problem, and each infant must be considered a law unto itself. Children living in the country and in the smaller towns, where there is no overcrowding and where an abun- dance of fresh air can be had, seem to thrive on cows' milk that has been modified but little, perhaps merely by the addi- tion of water in various proportions. In the larger towns, where overcrowding is frequent and fresh air and sunlight are not easily secured, the question is a more difficult one. Children with these environments require a more exact milk INFANT FEEDISG. 77 mixture and additional care. City milk is often stale and preserved by the addition of chemicals. The first requisite in artificial feeding is a pure, fresh milk. This can be obtained only by having the dairy farms, rattle, milk production, and distribution under competent supervision, and by cleanliness and care in the handling and transportation of the milk. Clean cows, clean stables, clean milkers, sterile milk pails and utensils are necessary, and the milk should be cooled rapidly after milking and kept cold until used. Pas- teurization and sterilization should be necessary only under unusual conditions. They are often necessary now, because the milk is impure to start with and improperly cared for. Xo coloring matter or preservatives should be allowed. In the home the milk should be kept in closed jars or bottles until used, and it should be kept cold. Pure milk is best secured by having the supervision of the dairies and market- ing under the same management. Bacteriological and chemical analyses are necessary from time to time to control the work. In order to adapt cows' milk to the infant's digestion several changes must be made in it. These become apparent by studying the nature and composition of the milk. Composition of Cows' Milk. — The proteins differ not only in amount, but also in character. In human milk the proteins consist of lactalbumin and casein, in the proportion of two-thirds of the former to one-third of the latter. In cows' milk one-sixth of the protein is lactalbumin and the remainder is casein. The protein of human milk precipitates in fine flakes ; that of cows' milk, in heavy curds. The total amount of protein material also varies, being from 1.5 to 2 per cent, in human milk and, on the average, 3.5 per cent, in cows' milk. The modification consists in diluting the milk until the protein is from 0.6 per cent, or more, accord- ing to the age of the infant and its digestive ability. In some cases of difficult feeding the lactalbumin and casein may be separated and added in the required amounts. This is not, however, usually necessary. The proteins may be prevented from forming large curds by the addition of lime-water or of barley- or oatmeal-gruel. With the smaller percentages this is not ordinarily required. AYhen necessary, as during ill- ness, the proteins may be predigested. 78 DISEASES OF INFANTS AND CHILDREN. Sugar. — The milk-sugar of human milk is present in a very constant proportion — from 6 to 7 per cent. In cows' milk it averages about 4.5 per cent. Diluting the milk, of course, decreases the proportion, and the amount must be made up by adding either milk-sugar or cane-sugar. The former, being that normally present in the milk, seems the most suitable. Cane-sugar has, however, many advocates, among them being Jacobi. Cane-sugar, owing to its excess- ive sweetness, is used in just half the quantity of milk-sugar. As it is inexpensive, it is useful in practice among the poor. During the first few days of life sugar may be given in the proportion of 5 to 5.5 per cent. ; from the second week to the third month, 6 per cent. ; and from that time until the eleventh month, 7 per cent, may be used. At the eleventh month it may be reduced to 5, and a few months later to 4.5 per cent. There is no advantage in giving over 7 per cent., and it may give rise to symptoms of excessive sugar- feeding. Fat. — The fat of human milk averages 4 per cent. ; that of cows' milk is the same. When the milk has been diluted the amount must either be made up by adding cream or by using the upper one-third or upper half of the milk after the cream has risen. It is preferable to use fresh cream that has risen by the gravity method or the top-milk method. There are objections, based on theoretic grounds, to the use of centrifugal cream ; these are of less practical interest in infant-feeding than was formerly supposed. The amount of fat to be given varies with the age, weight, and digestive ability of the infant. For an average infant 2 per cent, the first week, 2.05 per cent, the second, and 3 per cent, the third week are the amounts usually prescribed. At four months the amount may be increased to 4 per cent. ; after that time this amount must not be exceeded, or the infant is apt to develop indigestion, with the large whitish stools giving off the characteristic odor of the fatty acids. Salts. — The mineral constituents of human milk make up about 0.2 per cent, of its entire bulk ; those of cow's milk are three or four times greater. These inorganic salts vary in about the same proportion as the proteins. When the milk is INFANT FEEDING. 79 modified for the purpose of increasing or diminishing the per- centage of proteins it is, at the same time, modified for the salts. Reaction. — The reaction of human milk is always alkaline. Since cows' milk is usually acid or neutral, this acidity must be corrected by adding either 5 per cent, of lime-water or sodium bicarbonate. The sodium salt is used in the propor- tion of 1 grain to the ounce. As the lime precipitates at the higher temperatures, when the milk is to be boiled it is better to add the bicarbonate. For young infants, when there is a hyperacidity of the stomach or acute illness, larger quantities than those just mentioned may be used. Coit recommends the use of potassium bicarbonate. Caloric Needs of Infants. — There have been very few studies made in America on this subject, but Camerer, Henbner, Finkelstein, and others have made careful estima- tions, chiefly on breast-fed infants. Finkelstein observed that the average breast-fed infant draws daily during the first weeks of life one-fifth of its body weight ; from the middle of the first to the end of the second quarter of the first year, one-sixth to one-seventh, and during the latter half of the first year, one-eighth of its body weight. Expressed in round numbers per kilo of body weight, during the first three months it draws 150 cc. ; ^during the second, somewhat less, and during the third period, ^20 to 130 cc. Expressed in calories per kilo (Heubner's en- ergy quotient), the requirement during the first three months is 100 per kilo (45.4 calories per pound), during the second three months between 100 and 90 (40.9 calories per pound), during the latter half of the first year the requirement gradually sinks to 80 or a trifle below (36.4 calories per pound). In regard to artificially fed children, Heubner is of the opinion that the assimilation of cow's milk requires more work than breast milk, and places the energy quotient at 120. Czerny and Keller at times regard both breast and cow's milk as about equal in this respect. It is, perhaps, well in any case to avoid excessive overfeeding. The Determination of the Calorie Value of Modified Jlill:. — Moorehouse has given a very simple method for estimating the caloric value of infants' food when the total quantity of the percentage formula is known. The method is as follows : 80 DISEASES OF INFANTS AND CHILDREN. Reduce the twenty-four-hour amount to cubic centimeters, one ounce being equal to 29.5 cc. Next, determine the number of grams of fat, sugar, and protein in the mixture by multiplying the number of cubic centimeters and daily amount by the percentages of fat, sugar, and protein. The calories from each constituent may be determined by remem- bering that a gram of fat furnishes 9.3 calories and a gram of \ sugar or protein furnishes 4.1 calories. The calculation may be simplified by expressing the arithmetic process by equations, \ thus : Calories from fat equal Q XF X 2.74; calories from s sugar and protein equal Q X (S + P) X 1.21. The sum of \ ^ N these two values gives the total calories furnished by the mix- ture, and this figure, divided by the weight of the child in pounds, gives the calories per pound per day. In the above formula Q equals the twenty-four-hour amount in ounces, F, ^ S, and P, the percentages of fat, sugar, and protein expressed as whole numbers; for example, 1 per cent, equals 1, and not 0.01. Fraley's Method. — This is not strictly accurate, but suffi- ciently so for all practical purposes. In calculating milk mixtures he uses the following formula : 2F + P + S X 1| = Calories, or twice the fat percentage plus the protein percentage and j the sugar percentage multiplied by 1J times the total quan- tity in ounces gives approximately the number of calories. MILK MODIFICATION. (Methods of Practical Value in Modifying Milk.) There are a number of methods of milk modification that may be used with good results in the artificial feeding of infants. A practical knowledge of these methods is a de- sideratum in the rearing of bottle-fed infants. Those most in use are : 1. Laboratory feeding. 2. Top-milk method. 3. Materna graduate. 4. According to Maynard Ladd's table (after Rotch). 5. Baner's method. 6. According to Louis Starr's table. 1. laboratory Feeding. — In cities the best substitute for breast-feeding is furnished by milk laboratories, where INFANT FEEDING. 81 modifications are made according to the physician's prescrip- tion. The Walker-Gordon laboratories, now established in many cities, supply an ideally clean milk, unsterilized, pas- teurized, or sterilized at any temperature desired. The milk is supplied in nursing-bottles, each bottle holding enough for one feeding and being ready for use. Beyond warming the bottle and putting on a nipple no further preparation is necessary. In winter the milk is delivered in baskets, and in summer in small refrigerators. When economy must be practised, the milk may be obtained in larger jars and divided into the requisite number of feedings by the mother or nurse. Blank forms on which to write prescriptions arc furnished physician?. The following is an example of such a prescription : ^ Per Cent. Fat 4 Milk-sugar .... 7 Proteins 2 Lime-water . . . . 5 Other Diluent • • Heated at 167° F. Number of feedings ■ • Amount at each feeding Infant's age Infant's iv eight 7 ounces. Ordered for. Date, Signature, 190 M. D. These prescriptions are filled at the laboratory by mixing together milk, cream, standard sugar solutions, and water in the proper proportions. In some cases a 16 per cent, gravity cream is used, and in others a 20 per cent, centrifugal cream. Other things being equal, it is more desirable on theoretic grounds to use gravity cream. Sometimes the casein and whey are separated by using rennin or Fairchild's Essence of Pepsin, and so more diges- tible mixtures made. The whey must be heated to 150° F. 6 82 DISEASES OF INFANTS AND CHILDREN for five minutes before being added to the milk to destroy the enzyme or it will cause coagulation. The Walker-Gordon Company supply the following table : Theoretical Bad s for Feeding a Healthy Infant. Proteins if split. tf'O & %%2 •d-* Age. Fat. CO a CO , j & a d •r- CO be o P4 Oj C<0 co O u Amou each ing i Inten twee ingii No. of ings hour 1.00 1.50 4.00 4.50 0.25 0.25 0.25 0.50 0.25 0.25 Vs-% i-iH 24-18 At term 2.00 5.00 0.50 0.50 0.25 1 2 10 End of second week . 2.50 5.50 0.50 0.50 0.25 ±a 2 10 End of third week . . 3.00 6.00 0.75 0.75 0.25 o 2 9 End of fourth week . . 3.50 6.50 1.00 0.75 0.50 PA 2 8 End of sixth week . . 4.00 7.00 1.00 0.90 0.60 3 214 7 End of eighth week . 4.00 7.00 1.25 0.90 0.75 3^ iy 2 7 End of twelfth week . 4.00 7.00 1.50 0.90 1.00 4 i x A 6 End of fourth month . 4.00 7.00 1.50 0.75 1.25 ^A PA 6 End of fifth month . . 4.00 7.00 1.75 &A 3 6 End of sixth month . 4.00 7.00 2.00 6 3 6 End of eighth month . 4.00 7.00 2.50 7 3 6 End of ninth month . 4.00 7.00 3.00 8 3 6 End of tenth month 4.00 6.00 3.00 8 3 6 End of eleventh month 4.00 5.00 3.00 10 3 5 End of twelfth month | 4.00 4.75 3.50 10 3 5 In most cases whey mixtures are unnecessary. In acute illness or when there is decided lowering of the protein diges- tive power they may be of great service. The percentage of fat, protein, and sugar required by an infant of any given age must be borne in mind if one is to use any method of percentage feeding. The following sched- ule will be found useful as an aid to the memory. The figures for intermediate ages are easily calculated : Schedule for Average Infants. Age. Percentage. Average quantity for one feeding. Number of feedings 24 hours. Interval Fat. Sugar. Protein. Ounces. Grams. by day. Premature infants . . First to second day . Second to eighth day Third week Second month .... Third month .... Fourth month .... Fifth month Sixth to tenth month Eleventh month . . . Twelfth month . . . Later 1.0 2.6 2.5 3.0 3.0 3.5 3.5 4.0 4.0 4.0 4.0 4.0 5.0 6.0 6.0 6.0 6.5 7.0 7.0 7.0 5.0 5.0 4.5 0.25 0.50 0.75 1.00 1.25 1.50 1.75 2.00 2.50 3.00 3.50 2 3 4 5 7 8 9 9 10-20 30-45 45 60 90 110 125 160 220 250 280 300 12-20 4-6 10 10 9 8 7 7 6 5 5 5 1-1£ hrs. 6-4 " 2 " 2 2* " 3 3 3 3 4 4 4 " INFANT FEEDING. 83 The quantity should be increased half an ounce or an ounce at a time. Later, as the child's appetite grows stronger — that is, when he seems dissatisfied after his bottle — the quality is raised. The fat may usually be increased 0.5 per cent, at a time; the sugar, 0.5 to 1 per cent, at a time ; the proteins, from 0.1 to 0.25 per cent, at a time. Strong, healthy, large babies require more and richer milk than those of frailer constitution. Ssnitkin, of St. Petersburg, has estimated the amount to be fed to a child according to the weight. He ascertained that a baby's stomach held about one-hundredth of its weight at birth, and that the increase amounted to about a gram a day. By taking one-hundredth of the initial weight at birth and adding a gram for each day the average amount required for each feeding is ascertained. 2. Top-milk Method. — Many methods have been de- vised for obtaining the desired percentage from milk as it is used in the home. Holt's top-milk method is a very satisfactory one. Care should be taken to secure good, fresh cows' milk. The top-milk method con- sists in using the mixture of cream and milk in the upper one-third or upper one-half of a jar of milk that has been allowed to stand for some time. Later, the whole milk may be used. This method works satisfactorily only when the milk is bottled soon after milk- ing, before the cream has separated. For those who cannot obtain such milk the necessary mixture of cream and milk may be made as indicated in the table. The top layer of cream may be removed from the bottled milk with a spoon ; the remainder, by means of a small dipper; for this purpose a Chapin milk-dipper, which may be obtained at any drug- Fig. 23.— The Chapin dipper. 84 DISEASES OF INFANTS AND CHILDREN. store, will be found very useful. Another method is to use a siphon. The plan of pouring off the upper third is not nearly so reliable. After it has been removed, and before the required portion is taken out, the entire upper one-third or one-half, as the case may be, should be thoroughly mixed. The following tables require no explanation. When de- sired the percentage of lime-water may be increased, or it may be replaced by sodium bicarbonate, one grain or more per ounce, if the milk is to be boiled. If the quantity required exceeds twenty ounces the smaller supplementary tables may be used, or the quantity may easily be calculated by adding an additional one-fourth to each item for twenty-five ounces, or one-half more for thirty ounces, etc. The sugar may be measured by means of a pill-box hold- ing exactly an ounce, or very conveniently by allowing two and one half level tablespoonfuls of milk-sugar to the ounce. When cane-sugar is used only one-half the quantity is re- quired. Dry measure of sugar is just twice that of weigh- ing. Thus, one ounce of sugar by weight would measure two ounces in a measuring glass. The following formulas have been taken from Holt : l First Series of Formulas — Fat to Proteins, 3:1. Primary Formula. — Ten per cent, milk — fat, 10 percent. ; sugar, 4.3 per cent. ; proteins, 3.3 per cent. Obtained — (1) as upper one-third of bottled milk or (2) equal parts of milk and 16 per cent, cream. Derived formulas, giving quantities for 20-ounce mixtures : f Milk-sugar . 1 oz. 1. -j Lime-water . 1 oz. \ with 2 oz. 10 p.c. milk ( Water, q.s. ad. 20 oz "2. " " " « 3 oz. 3. " " " " 4oz. 4. " " " " 5oz. 5. " " " " 6oz. 6. " " " "7 oz. 1 Diseases of Infancy and Childhood, pp. 189, 191, 192. Fat Sugar Proteins per ct. per ct. per ct. 1.00 5.50 0.33 1.50 5.50 0.50 2.00 6.00 0.66 2.50 6.00 0.83 3.00 6.00 1.00 3.50 6.50 1.16 INFANT FEEDING. 85 Table Giving in a Condensed Form the Quantities Usually Re- quired for Obtaining the Different Fat-percentages. ABCDEFGHIJKL M N O T pe°r b cent ^ } °- 50 L0 L5 2, ° 2 '° 2 ' 5 2Si " 7;3 3 -° 30 : '° s - 25 :; "' 3 ' 7 40 ^nSfJ f00d 4 0.20 20.0 20.0 20.0 25.0 25.0 28.0 28.00 30.0 33.0 36.0 36.00 37.0 38.0 40.0 ^^n-'^f.lfhi-O.lO 2.0 2.0 4.0 5.0 6.0 7.0 8.00 9.0 10.0 11.0 12.00 13.0 14.0 16.0 III 1 IK, OUIlCcS ) Proteins : The percentage in each case will be one-third fat. Sugar: 1 ounce in 20, or 1 tablespoonful in 8 ounces, gives 5.5 per cent. for the lower and 6.5 for the higher formulas. Lime-water : 1 part to 20 of the food, the average required. Water: Sufficient to be added to the foregoing ingredients to bring the total to the number of ounces specified ; in part of this water the milk-sugar is dissolved. Barley-water or any other dilutent may be added in the same manner. Second Series of Formulas — Fat to Proteins, 2:1. Primary Formula. — Seven per cent, milk — fat, 7 percent. ; sugar, 4.4 per cent. ; proteins, 3.5 per cent, Obtained — (1) as upper one-half of bottled milk, or (2) by using 3 parts of milk and 1 part of 16 per cent, cream. Derived formulas, giving quantities for 20-ounce mixtures : p.c. milk T Milk-sugar . 1 oz. ) 1. \ Lime-water . 1 oz. V with 3 oz. 7 1 Water, q.s. ad. 20 oz. . ) 2. a a It a 4 oz. 3] a u u a 5 oz. 4. a if a u 6 oz. 5. it il a it 7 oz. 6. a (I u a 8oz. 7. a (( a a 9 oz. 8. a a a n 10 oz. ( Milk-sugar . 3 4 OZ. " 1 9. \ Lime-water . 1 oz. " 12 oz. Fat Sugar Proteins per ct. per ct. per ct. ■ . . 1.00 5.50 0.50 . . 1.40 5.75 0.70 . . 1.75 6.00 0.87 . . 2.10 6.00 1.05 . . 2.50 6.50 1.25 . . 2.80 6.50 1.40 . . 3.15 7.00 1.55 . . 3.50 7.00 1.75 4.00 7.00 2.00 ( Water, q.s. ad. 20 oz. Table Giving in a Condensed Form the Quantities Usually Re- quired for Obtaining the Different Fat-percentages. ABCDEF G HIJKLM To obtain fat. per cent. 1.0 1.0 1.4 1.8 2.0 2.33 2.75 2.75 3.1 3.5 35 4.0 4.0 For total food, ounces . 20.0 30.0 30.0 33.0 33.0 36.00 36.00 40.00 40.0 40.0 44.0 44.0 48.0 Take 7 per ct. milk, ozs. 3.0 4.0 6.0 8.0 10.0 12.00 14.00 16.00 18.0 20.0 22.0 2o.O 28.0 To obtain the exact fat-percentages take one-third the number of ounces of top-milk in a 20-ounce mixture and add 0.15 to the result. In practice this slight error may be disregarded. 86 DISEASES OF INFANTS AND CHILDREN. Proteins : The percentage in each case will equal one-half of the fat. Sugar: 1 ounce in 20, or 1 even tablespoonful in 8 ounces, until the food becomes half milk ; after that 1 ounce in 25, or 1 even tablespoonful to each 10 ounces of the food, will give the proper amount. Lime-water : Usually in the proportion of 1 part to 20 of the total food. Water or other diluents: Sufficient to be added to the foregoing ingre- dients to make the total number of ounces specified ; in part of this the sugar is dissolved. Third Series of Formulas — Fat to Proteins, 8:7. Primary Formula. — Plain milk — fat, 5 per cent. ; sugar, 4.5 per cent. ; proteins, 3.5 per cent. Derived formulas, giving quantities for 20-ounce mixtures : 1. f Milk-sugar . 1 oz. ' -j Lime-water . 1 oz. \ with 5 oz. plain milk . Fat per ct. . 1.00 Sugar per ct. 6.00 Proteins per ct. 0.87 2. ( Water, q.s. ad. 20 oz. , a. a a i " 6 oz. it ti . 1.20 6.00 1.00 3. it a it " 8 oz. a a . 1.60 6.50 1.40 4. u a tt " 10 oz. a a . 2.00 7.00 1.75 5. f Milk-sugar . J oz. " -j Lime-water . ^ oz. 1 " 12 oz. a a . 2.40 5.00 2.10 6. ( Water, q.s. ad. 20 oz. , it a a 1 " 14 oz. a a . 2.80 5.50 2.50 7. a a a " 16 oz. a a . 3.20 5.50 2.80 Table Giving Quantities of 16 per cent Milk Required for Ob- taining Formulas with High Fat and Low Proteins. A "R r 1 T) "R Th 1 C* TT T T "K* To obtain fat, per cent 1.6 1.6 2.0 2.5 3.0 3.0 3.0 3.5 3.5 4.0 4.0 For total food, ounces 20.0 30.0 30.0 32.0 32 37.0 42.0 36.0 40.0 40.0 44.0 Take 16 per cent. milk, ounces ... 2.0 3.0 4.0 5.0 6.0 7.0 8.0 8.0 9.0 10.0 11. Proteins in all cases will be one-fifth the fat. Sugar : 1 even tablespoonful for each 8 ounces will give 5.5 per cent, for the lower formulas (A, B, C, etc. ) and 6 per cent, for the higher formulas (G, H, I, etc.). Lime-water : 1 ounce to 20 ounces of the food will give 5 per cent. 3. Holt's Percentage Milk Method. — Holt has de- vised another method of modifying milk which is very use- ful. The following method at first sight looks very compli- cated, but it is not, and it permits of great numbers of reasonably exact formulae. The first step is to obtain milks con- taining definite amounts of fat from 7 per cent, down to 1 per cent. Ordinary market milk from mixed herds averages 4 per cent, milk, from Jerseys and Alderneys 5 per cent, or more. INFANT FEEDING. 87 Uniform results may be obtained by having patients use milk from one dairy, or by having them buy milk containing a certain percentage of fat from milk laboratories. For convenience the formulae are calculated for 20-ounce mixtures. Every ounce of 7 per cent, milk in 20-ounce mixture has one-twentieth of 7 or 0.35 per cent. fat. Every ounce of 6 per cent, milk in 20-ounce mixture has one-twentieth of 6 or 0.30 per cent. fat. Every ounce of 5 per cent, milk in 20-ounce mixture has one-twentieth of 5 in 0.25 per cent. fat. Every ounce of 1 per cent, milk in 20-ounce mixture has one-twentieth of 0.05 per cent. fat. The variations in protein and sugar used may be con- sidered. Four per cent, milk contains 4.50 per cent, sugar and 3.50 per cent, protein, so each ounce of 4 per cent, milk in any of the formulae in a 20-ounce mixture will contain one- twentieth or 0.225 per cent, sugar and 0.175 per cent, protein. The tables from Holt (p. 88) show the variations that may easily be obtained. To raise the fat without the protein use a milk of a higher fat percentage. To raise the protein and not the fat use more ounces of the same milk or even of a weaker one if need be. The necessary sugar is added, remembering that each ounce of milk-sugar by weight in a 20-ounce mixture increases the sugar 6 per cent., or each ounce by volume about 3 per cent., and that each level tablespoonful in a 20-ounce mixture in- creased the sugar about 1.75 per cent. These formulae give rather low fat percentages, but other- wise are sufficiently elastic to suit all needs. As a matter of fact, comparatively few variations are required except in difficult cases. 4. Materna Graduate Method. — The very simple and useful apparatus known as the Estrans Materna Graduate is of great value where one cannot secure intelligent coopera- tion in the home, and also where there are no facilities for milk preparation. AVith its six formulas, however, it is not adaptable to all cases, some infants being totally incapable of taking the step from one formula to another. 88 DISEASES OF INFANTS AND CHILDREN. -to "to ^5 -to t3 05 05 Pi o d P-t o> C'Ofi MOfi -# «5 S .s-gg HP-S5 i CN CN CN (M CN CO CO si be: 53 CO. >ioooaioooooooiooo - co io i> xqji't to i> c. r-j ei tjh cq D'doddrtHHiHHr4ci:i:i:i iff o iff o iff o iff o iff o iff c l" C l'. OHnCKMMMTr^LllOffiC f- t> OOOOOOOOOOOOOOO OOOOOCCOOrtrHrH^-^i-i OOOO OO' doOOHHi-iHnNNNWflM CN iff t- O ff4 iff C- O CN >n I> O tN lO orfdi-lHrHHCidlN CN CO CO CO ©ocoooooooooo cc to ~ c-i io ooHTft>qMtcoi o o © i-< r-t i-t cc 32 o r- -l co ~r iff - 3 53 01 if. f. t/j O 05 05 05 OOOO sees seer! OOOO CI CO iff CO ie&fcfcSfc: OOOO CJDCJDbCbD cess r-, ,- -4 ,_ . O ccc B-g o 2 £ S £ S Si ga ssas 5 53 O O CN N o to t*H tt-l <4-< t+_| J ■ „ oj cS o3 oj O jj 05 2 o O O O^r! O C G'O" ^^^ o-CS oj aj u0 O O O c fl a OOO S c3cm ^ ^ h O 05 05 cco^ p b£ be bt-. g SSSoS .S.S-S w bo M CO IC B id ^ ^ «h bC r- -S5-2S be <<-■ C. Vh 3 o3 oi cSrfi o ^ ^ ^ be a 05 05 O J- O 'C'C'C o . £.£.SS > cS ci ~ .rS £ss>q pi s s =3 n c (h o . O05050505OO •>-,. 55 CC CO CO CO OQ on P— t K* - mini II ^^^^^^^^^ O O O 05 O O OrCJS ooooooo.-^+j O 05 O 05 05 05 05 >>* >> I> CO iff ^* CO CN rH CCCCCCB — ~ t: T. ~?. ~ T. +3 -^ +j +j +^ -u +j ,o ,o ,o .c ,£ ,o .Q o o o o c c o c o o c o o o IXFA NT FEEDING. 89 The apparatus consists of a glass jar with a lip and seven panels, and a capacity of sixteen ounces. One of the panels exhibits an ordinary ounce graduation ; the other six panels present six different formulas for the modification of cows* Fig. 24.— The "Materna" glass (De Lee). milk, each formula being so arranged as to keep pace with the infant's growth. (See Table, next page.) Having decided which formula is to be used, the panel containing that formula is the only one to be followed. The quantity desired for twenty-four hours is next to be con- sidered, and the apparatus filled — once if 16 ounces or less are required for the twenty-four hours; twice if from 16 to 32 ounces are required for the twenty-four hours ; three times if from 32 to 48 ounces are required for the twenty-four hours. Fat .... 2 per ct. 2£ per et. 3 per ct. 34 per ct. 4 per ct. oh per et. Sugar 6 " 6" " 6 « 7 " 7 " 3£ " Protein . ... 0.6 " 0.8 " 1 " 14 " 2 " 2\ " 90 DISEASES OF INFANTS AND CHILDREN. Modification According to Growth. Milk parts Cream " Lirne-water .... " Water " Milk-sugar .... " ^ o -t^> ,d c M . . 5^ ta O > (XI O ; CD+5 .s +j +i -e^J -M^ O 0) rH CD Olr^ ^ o IK 1% 2 4K 6 IK 1% 2 2 2 l 1 3 4 8% % 12^ UK UK ?K 1 1 i 1 IK Milk .... parts Cream ... " Barley-gruel " Granulated sugar, parts ~ o .5 a 1 Maynard Ladd's Table. Prescriptions call- Fat free milk in ounces ing for a mixture Cream m ounces. used with 3reams , of- of 20 ounces. a CD u +^° 4-5 ^ -t> u n -t-" "S a. c a a fl c -u • oS . o O O O CD CD CD S-i *H CD Fh "f ° d| P 35 CO o3 bo o 0) ft CD ft CD ft CD ft CD ft CD ft CD ft CD ft CD -h 3^ o ° » CD N ft 3 o CI I— 1 .-1 O CM o r-l CM rH i-H O CM 1-^ pq 3 0.50 5.00 2.00 5 1 4 3 4 1 94 9* 9* 9f 1 84 14 0.75 6.00 1.00 5 1* 14 1 3 4 3* 3f 4 44 1 14 24 1.00 5.00 0.75 5 2 H 1* 1 2 2* 9 1 3 1 15 2 1.50 4.00 0.50 5 (*) 2* 2 i* ( l ) i 4 3 4 14 1 164 1* 2.00 5.00 0.75 5 4 3 2* 1* 1 1* 24 1 15 2 2.00 5.50 1.00 5 4 3 2* if l* 2i 2f 3* 1 13* 24 2.50 6.00 1.00 5 5 4 84 2* 1* 24 3 1 14 2* 3.00 6.00 0.50 5 n n Sf 3 ft n 3. 4 1 154 if 3.00 6.00 0.75 5 C 1 ) 5 3f 3 14 2 1 14 2* 3.00 6.00 1.00 5 (M 4* 3* 2f (') 3 4 if 2* 1 13* 24 3.50 6.50 1.00 5 n 5* 4* 3* I 1 ) l 2 1 13* 2* 3.50 6.50 1.50 5 7 5* 4* 3* l 9A- 3* 4* 1 11 2* 3.00 7.00 1.00 5 n 4f 8} 2f (') 3 4 13- x 4 24 1 13* 24 3.00 7.00 1.50 5 6 4f 8} 2f 2 34 44 54 1 11 2* 3.00 7.00 2.00 5 6 4f 34 2f 4* 5f 6} 74 1 84 2i 4.00 7.00 1.00 5 ( x ) H 5 3* ( x ) ( l ) i If 1 13* 24 4.00 7.00 1.50 5 8 64 5 3* l 3 - x 4 3 44 1 11 24 4.00 7.00 2.00 5 8 64 5 3f 2* 4* 5* 6| 1 . 8* 2* 4.00 7.00 2.50 5 8 64 5 34 5 6f 8 94 1 6 2 4.00 7.00 3.00 5 8 64 5 34 7* 9* 10* llf 1 3* 2 4.00 6.00 3.00 5 8 6* 5 8f 7* »* 10* 11* 1 3* 14 4.00 5.00 3.00 5 8 64 5 n 7* 94 10* 114 1 3* l 4.00 5.00 3.50 5 8 6i 5 3| 10 11| 13 144 1 1 i ( x ) indicates that the combination is impossible with the percentage of cream given. INFANT FEEDING. 91 5. Maynard I,add's Table. 1 — Another method of modifying milk is according to Maynard Ladd's table (pre- ceding page). In this the quantities have been estimated. This method is useful in hospitals where there is a milk laboratory. In general practice it is of slight value, for it necessitates memorizing a lengthy table, or carrying it about, both of which methods are open to objection. 6. Baner's Method. — Many attempts have been made from time to time to compute a table of equations from which the quantities of milk, cream, etc., may be determined for any given mixture ; the simplest of these is that of Baner ; 2 = F. Quantity desired (in ounces) Desired percentage of fat Desired percentage of sugar =S. Desired percentage of protein = P = P. To find in ounces — Cream (16 per cent.) = o x ( F ~ P ">' Milk =-22LP_g 4 Water =Q-{C+M). S-Px Q Dry milk-sugar = 100 Example. — Suppose it is desired to make 40 ounces of a 4 per cent, fat, 7 per cent, sugar, 2 per cent, protein mixture. By substituting the figures in the equations above we have — Cream = — x 2 — 61 ounces. 12 Milk = ^^ - 6| = 13£ ounces. 4 Water = 40 - 20 = 20 ounces. c 5x40 o Sugar = = 2 ounces. & 100 7. I/OUis Stands Table. — This is a frequently used guide to milk-prescribing. It may be employed as a basis for modification by those who object to the percentage method. The latter method, however, once mastered, will be found more satisfactory for general purposes. 1 Taken from Rotch's Pediatrics. 2 New York Med. Jour., Mar. 12, 1898. 92 DISEASES OE INFANTS AND CHILDREN. Louis Starr's Table of Ingredients, Hours, and Intervals of Feed- ing, and Total quantity of Food for a Healthy Artificially Fed Infant from Birth to the End of the Seventh Month. 1 i u Hours for •vals f ing. Total Age. oj V X -1-3 feeding. 3cc quantity. 2 g* 02 fS Hours f 5 A. M. to 1 | I 11 p. m. ; During 1st wk foij fSiij gr.xx fSiij ■{ sometimes | 1 a. M. and [ 3 A. M. 1-2 j fsxij From 2d to) 6th week . J f5ij f3SS gr.xx a pinch f3j (5 A. M. to (.11 P. M. \* fSxvij From 6th wk. "| to end of >- fSss f5x 5ss a pinch f3x (5 A. M. tO \11 P. M. } 2 fSxxx 2d month J From 3d to \ 6th month J fSss fSij 5j a pinch fsiss (5 A. M. tO 1 10.30 P.M. }VA fSxxxij During 6th"] /7 a. m. to (10 P. M. } 3 and 7th > fSss fSiiiss 5j a pinch fSij fgxxxvj months . J Throughout the eighth and ninth months five meals a day will be sufficient, each meal composed of : Milk fgvj Cream fjfss Milk-sugar • oj Water f^iss This allows 40 fluidounces of food a day. Malted Gruels. — Malted gruels are advocated by some, especially in preparing milk for infants with weak digestion. They are prepared in the following manner : A tablespoonful of barley flour, or of any other flour desired, is boiled in a little more than a pint of water for fifteen minutes. As soon as it has cooled, a teaspoonful of good malt extract or a teaspoonful of diastase is added. This mixture is stirred thoroughly, and may then be used in the place of ordinary barley-water. Diastase preparations are made by most of the leading manufacturing chemists. Diastoid, maltine, and dyazyme are preparations of this class. The thick malt ex- tracts are sometimes given to infants just before a feeding. Of these, several doses may be given daily for indigestion and constipation. 1 From Diseases of the Digestive Organs in Children, p. 24. INFANT FEEDING. 93 Farinaceous Gruels. — In the methods of feeding just described the addition of farinaceous gruels — i. e., barley, oat- meal, arrow-root, rice, etc. — to some of the foods has been recommended by certain observers. That such addition to the infant's dietary during the first year is advisable is a question that has not been fully decided. When deemed necessary, it is probably best to begin the addition of a starchy gruel to the milk at about the eighth or ninth month in nor- mal infants. In those infants who experience difficulty in digesting the proteins, and for the purpose of preventing co- agulation of the milk into large clots, the addition may be made earlier. It is well to begin by adding a half-ounce or an ounce for each feeding, and, as the infant's starch-digest- ing power increases, to increase this amount proportionately. Condensed Milk. — This is most useful in many cases as a temporary expedient, especially where children are not gaining, and those that have been fed on too high fat and protein. It should be used in dilutions of 1 in 16, 1 in 12, and 1 in 8. It should be measured in a measuring glass, otherwise too much will be used. It may be diluted with plain boiled water or, if desired, with a thin cereal gruel. Cream may be added later, or olive oil may be given in addition. Orange juice should be given every other day or every day as an antiscorbutic. If condensed milk feeding is con- tinued too long, anemia, scurvy, or rickets is liable to develop. Buttermilk. — Real buttermilk may be used, which has the advantage of having a low fat and sugar content and the presence of large numbers of lactic-acid bacilli. If de- sired, whole milk, which has been soured by the addition of lactic-acid bacilli, may be used. It may be diluted with water or cereal gruels the same as whole milk. It is very useful in diarrheas, especially where abnormal bacteria are present in intestinal indigestion and other difficult cases. Albumin Milk. 1 — This is made from curd and butter- milk. It is useful in diarrhea, indigestion, and certain forms of nutritional disturbances. It should be carefully studied before being used. (See Friedenwald and Ruhrah, " Diet in Health and Disease," Fourth Edition.) 1 Hess, American Journal of Diseases of Children, December, 1911, vol. iv., p. 222. 94 DISEASES OF INFANTS AND CHILDREN. The Soy Bean. 1 — This is very useful when milk is badly borne, and in certain forms of intestinal disorders and con- valescence after diarrhea, in marasmus and malnutrition. Soy- bean flour made by the Cereo Company, Tappau, New York, contains 120 calories per ounce. A gruel may be made by using one tablespoonful of soy-bean flour, two tablespoonfuls of barley flour, and one quart of water. It should be boiled hard for twenty minutes or longer. This may be diluted, if desired, and may be increased in strength up to double the quantity stated. It may be used plain for short periods and for long periods with the addition of condensed milk. Cream may be added, if desired. Orange juice should be given as an antiscorbutic. Other Methods. — Chapin, Coit and many others have devised methods of milk modification. Gartner's milk is a milk modified by centrifugalization, and Backhaus' milk is prepared in a somewhat similar way, but is previously partially digested by the use of rennet, trypsin, and sodium carbonate. Sodium Citrate. — Poynton, Shaw, and others, following the suggestion of A. E. Wright, recommend the use of sodium citrate. The soda forms a compound with the casein and alters the curd produced, rendering it more digestible. The citric acid forms calcium citrate by uniting with the calcium salts. The use of sodium citrate enables one to give a milk containing more protein than would otherwise be digested. It is useful in weaning infants, in practice among the poor where milk modification is imperfectly done, and is useful in protein indigestion, and in some other cases where milk is not well borne without the sodium citrate. From 1 to 3 gr. to the ounce may be used. It may be ordered in solution in water in which it is freely soluble. A drop or two of chloro- form should be added to prevent the growth of organisms which is liable to take place. Beginning Bottle-feeding. 2 — In order to succeed it is necessary that this method be begun properly. The percent- age used to begin with should always be well within the 1 See Friedenwald and Ruhriih, "Diet in Health and Disease," Fourth Edition. 2 H. L. K. Shaw, " Citrate of Soda in Infant Feeding," Archives of Pediatrics, March, 1906, p. 161. INFANT FEEDING 95 infant's digestive powers, and raised as rapidly as possible to a milk suited to the age of the infant. It is a good plan to start with a milk given in the schedule for a babv one-third the age of the one to be fed. Each day, or even at longer intervals if necessary, the milk may be made slightly stronger. If the milk is made too strong at first or the percentage raised too rapidly, indigestion, colic, and offensive stools will be the result. On the other hand, the opposite mistake, that of feeding an in- fant on a milk too weak, should also be avoided. When the mistake is made, the infant becomes pale, cries, and does not increase in weight. Severe hunger may result, and symptoms of inanition may follow. Technic of Modifying- Milk at Home. — To insure success a very care- ful technic must be followed. In the ab- sence of a nurse specially trained for the purpose the physician should give careful written and verbal instructions, and then to see personally that these are carried out. Knowledge on the part of the mother or nurse should not be assumed, for, as a rule, she does not possess it. The vessels and instruments used should be kept scrupulously clean, and be used solely for the purpose intended. After use, or what is decidedly better, just previous to being used, they should be either boiled or scalded with boiling water, preferably the former. The nursing-bottles should have rounded bottoms, so that there are no corners for holding dirt, and also that they can- not be stood about the room. If only one or two bottles are used, they should be scalded after each feeding and filled either with boric acid or sodium bicarbonate solution, made by adding a teaspoonful of either drug to a pint of water. When the bottle is to be used again, the solution should be poured out and the bottle rinsed with plain sterile water. Fir;. 25.— Hygienic nurs- ing bottle (De Lee). 96 DISEASES OF INFANTS AND CHILDREN. The nipples should be of the ordinary short black-rubber variety. White nipples, which are said to contain lead, as well as all complicated nipples and tubes, should be avoided. These latter cannot be kept clean, and are a source of infec- tion diarrhea. In some cities their sale is prohibited by law. _After each feeding the nipple should be washed, turning it insicle out to do this thoroughly, and then placed in a glass of boric acid solution (3J-Oj). It is a good plan to have several nipples on hand and to boil them before using them for the first time, and then for five minutes every day. The hole or holes in the nipple should be just large enough to allow the milk to drop out somewhat rapidly. It should not flow out in a stream. If the holes are too small, they may be enlarged or new ones made by using a red-hot darning- needle. Some nipples are made without holes, and these may be perforated in the same manner. Preparation. — It is best to pre- pare the entire quantity for twenty- four hours at one time. If the weather is warm, the milk must be Fig. 26.— Freeman's pasteurizer. Fig. 27.— Arnold sterilizer. pasteurized or sterilized immediately. If neither can be done, then, unless the weather is cold and a clean milk can be obtained, but one feeding should be prepared at a time. The physician should always write out the quantities to be used for preparing the milk. The milk- or cane-sugar is dis- solved in hot water. Care should be taken to use a sugar INFANT FEEDING. 97 that gives a clear .solution without filtering. If the solution is not clear, it should be filtered through a wad of cotton placed in the bottom of a funnel or through a piece of drug- gist's filter-paper. This solution, together with the lime- water or sodium bicarbonate, should be poured into a pitcher. Into this the milk, or milk and cream, should be poured, and the remainder of the water added. The water should always be boiled. The mixture should then be stirred and poured into the nursing-bottles. The bottles should then be stoppered with moderately tight plugs of non-absorbent cot- ton, to keep out bacteria. The bottles are then pasteurized or sterilized and placed in a refrigerator. At the feeding hour the bottle is taken out of the refriger- ator, placed in a pitcher or tall vessel of hot water to warm it, the cotton plug removed, and a nipple substituted. The milk should be heated until it is lukewarm — about 98°-99° F. The nipple should never be placed in the mouth to test the heat, but the milk may be allowed to drop on the wrist, where it should feel warm, but not hot. FEEDING DURING THE SECOND YEAR. During the second year of life as much care is required in feeding as during the first. The fear of the second sum- mer would largely be overcome if the child were not allowed to eat food unsuited to its digestion. Most of the illness and many of the deaths of childhood are traceable to improper diet. During the second year milk should form the basis of the diet. In cities or where the milk-supply is not above sus- picion, it is best to pasteurize the milk until the second sum- mer has been passed, or even longer if circumstances war- rant. As a rule, the milk requires but little modification, and after the eighteenth month, and often before, may gen- erally be taken unmodified. As the child is now able to digest starchy food, milk-sugar may be omitted. In cases where the milk is not thoroughly digested, as is evidenced by curds in the stools, lime-water may be used, and may be added in quantities of from 5 to 10 per cent., or even more if necessary. During illness and often under other circum- 98 DISEASES OF INFANTS AND CHILDREN. stances the alkaline carbonated waters will be found useful for diluting the milk. If the milk is poor, another plan is to use the upper two-thirds of the milk. Starchy food may be given in the form of gruel, either alone or, what is better, mixed with milk. Barley-gruel or, if there is a tendency to constipation, oatmeal-gruel is added, one-fifth or one-fourth part of gruel being added to each feeding. The gruel should be freshly prepared and mixed immediately with the milk. A pinch of salt and a very small quantity of cane-sugar may be added to render it more palatable. During the second year five meals at about four-hour intervals should be given. The bottle should be dispensed with, and the food be taken from a cup or spoon. If the bottle is not taken from the child early, it may be difficult to break it of the bottle habit. The following diet-lists for different ages will be found useful : Twelfth to Fifteenth Month. — Milk, barley, oatmeal, wheat- flour, farina, or arrow-root gruel ; barley or oatmeal jelly ; lightly boiled yolk of egg, given with stale bread-crumbs. Beef, mutton, and chicken broth, chicken jelly, beef-juice. Orange-juice or the juice of other ripe fruit, as of peaches. First Meal. — On waking, the child should receive a cup of warm milk, modified as previously suggested. If the child is accustomed to waking very early, more milk may be given at about 7 A. M. ; otherwise this last may be regarded as the first meal. Second Meal (10.30 A. m.). — Eight ounces of warm milk and barley-gruel. Third Meal (2 p. m.). — One of the following : (a) Eight ounces (a cupful) of beef broth. (b) " " " veal " (c) " " " mutton " (d) « " " _ chicken " (e) Yolk of a lightly boiled egg with stale- bread crumbs. Fourth Meal (5 p. m.). — Eight ounces of milk and barley- gruel. INFANT FEEDING. 99 Fifth Meal (10 p. m., if required). — Eight ounces of milk. Orange-juice, one or two tablespoonfuls at a time may be given one hour before the 10.30 A. m. feeding. If there is a tendency to loose bowels, this should be omitted. If the child's appetite is very good, a small piece of zwie- back may be given with either the second or the fourth meal. This should not be soaked in the milk, but the child should be allowed to nibble at it dry. Fifteen to Eighteen Months. — Same as above, together with zwieback, stale bread (oven dried), whole eggs very soft boiled ; strained oatmeal, barley or wheat porridge ; bread and milk, thin biscuit (crackers), junket, scraped raw beef or mutton in very small quantities. Eighteen Months to Two and One-half Years. — Milk is to be regarded as the chief article of diet. Many children have no desire for other foods until after the second or third year. These children will generally be found to thrive on milk alone or with slight additions to the diet. As the child's digestive power increases, the following articles may, how- ever, be added one at a time : Fruits. — Juice of ripe fresh fruit, that of oranges and peaches being best. Ripe fresh grapes skinned and seeded. Baked apple — pulp only, the skin and seeds to be carefully removed. Stewed prunes, the skins to be removed by passing through a sieve. Meats. — Scraped raw beef or mutton ; rare roast-beef or mutton pounded to a pulp. Chicken or turkey, the lean white meat minced to a pulp. Vegetables. — Mashed baked potato with cream or covered with gravy from roast meats. If the latter is very fat, the fat should be removed by skimming or by means of a piece of blotting-paper. Very well-cooked spinach, celery, and cauliflower tops. Cereals. — Well-boiled rice and other well-cooked cereals already mentioned. Desserts. — Boiled custard, milk and rice puddings, junket. Four meals will generally suffice after the eighteenth month. From two and one-half years up to the sixth year the diet 100 DISEASES OF INFANTS AND CHILDREN. of the child may gradually be increased. Milk .should still, however, be taken in large quantities — about a quart daily — as well as some form of cereal for breakfast, with or without an egg, or fresh fruit if there is a tendency to constipation. Meat prepared as above should be given once a day, and pref- erably at the midday meal, together with potato and some green vegetable, as spinach, asparagus, or cauliflower tops. The evening meal should be light, and consist of bread and milk. It is well to prepare two lists, which may be given to the nurse or mother as a guide. One list should contain the food allowed, and the other list those forbidden. It is not well to depend on verbal instructions as they are easily forgotten or misconstrued. THE DIET FROM TWO AND ONE-HALF TO SIX YEARS, Milk may be allowed with every meal (may be omitted from dinner if desired). The average child should take a quart a day, plain or, when plain milk is not thoroughly digested, modified as for twelve to fifteen months. Cream. — Two to eight ounces a day mixed with the milk, taken as a beverage, with cereals, etc. Bread and biscuit may be allowed with every meal, stale bread, dried bread, also the so-called " pulled bread," zwieback, and the various forms of biscuits or crackers. Cereals. — Almost any kind of cereal for breakfast ; oat- meal and wheaten grits are the best. Rice and hominy for dinner. Barley is useful in soups. Vegetables may be allowed for dinner — potatoes in some form or a cereal with one green vegetable ; spinach, cauli- flower tops, and the like are the best. Eggs are very good, but children are liable to tire of them easily. They should be given for breakfast, as a rule, but never day after day. Meats. — Allowed once a day for dinner and in older chil- dren for breakfast occasionally. Boiled or broiled fish may be given for breakfast or dinner. INF A NT FEEDING. ] 01 Broths and soups of simple composition may be eaten. Meat 1 >roths with cream and cereals are especially nutritious. Desserts. — Once a day, with dinner. Plain custard, milk and rice pudding, bread and custard pudding, and junket are the best; ice-cream once a week. Fruit should be given once daily, and only ripe fresh fruit, in season, should be used. The best are oranges, baked apples, and stewed prunes. Ripe peaches, pears, grapes without skins or seeds, may also be given. Fresh juice of berries in small quantity, straw- berries in perfect condition sparingly. Ripe cantaloupe and watermelon in moderate quantities may also be allowed. Great care should be used in choosing and giving fruit to children. It is a very important article of diet, but if stale, spoiled, or unripe, is capable of doing much harm. Too much should not be given in hot weather. Lemonade is useful during very hot weather. Articles Forbidden (after Holt). — The following arti- cles should not be allowed children under four years of age, and with few exceptions they may be withheld with advantage up to the seventh year. Meats. — Ham, sausage, pork in all forms, salted fish, corned beef, dried beef, goose, game, kidney, liver, bacon, meat-stews, and dressing from roasted meats. Vegetables. — Fried vegetables of all varieties, cabbage, potatoes (except when boiled or roasted), raw or fried onions, raw celery, radishes, lettuce, cucumbers, tomatoes (raw or cooked), beets, egg-plant, and green corn. Bread and Cake. — All hot bread and rolls ; buckwheat and all other griddle-cakes ; all sweet cakes, particularly those containing dried fruits and those heavily frosted. Desserts. — All nuts, candies, pies, tarts, and pastry of every description ; also salads, jellies, syrups, and preserves. Drinks. — Tea, coffee, wine, beer, and cider. Fruits. — All dried, canned, and preserved fruits ; bananas ; all fruits out of season and stale fruits, particularly in sum- mer. The meals should be given at fixed hours, which practice should be strictly adhered to. Feeding between meals, even i02 DISEASES OF INFANTS AND CHILDREN. when consisting of the most trifling things, should be avoided. If the child cannot go from one meal to another without discomfort, the intervals should be shortened. In certain cases it may be advisable to give a small cup of milk or broth and a cracker between the meals, at stated intervals, as in feeding younger children. Caiwiies, cakes, and the like should be kept from young children. In well-regulated homes, if he once learns that he cannot have them, the child will soon cease to demand sweets. The frequent indulgence in sweets of various kinds creates a desire for them to the exclusion of other food. This cra- ving is analogous to that for alcohol in adults. Overindul- gence in sweets causes indigestion, headache, and the like, ailments that may easily be prevented. The child should be taught to eat slowly and to chew the food well. To this end, some older individual should always be present at meal-time to see that sufficient time be taken for the meal, and that the food be finely divided, as young children do not, as a rule, chew very well. The quantity given to a healthy child should depend on his appetite. In sick children this is not a reliable guide, and, where possible, fixed amounts may be given. The child should not be forced to eat, nor should he be given special articles to tempt the appetite. If the food offered is not taken, it is well to wait until the next meal, when it will generally be found that the appetite has returned. Loss of appetite is often merely an indication that the digestive organs require a slight rest. During the heated portions of the year the child will re- quire less solid and more liquid food. The same is true during sickness. Many of the gastro-intestinal disturbances attributed to teething are the result of improper feeding. DIET OF SCHOOL CHILDREN. The period usually spoken of as " school days " is an ex- tremely active one physically. The vast number of meta- bolic changes going on and the growth of the body demand a plentiful and a suitable diet. Both in and out of school and in seminaries careful attention should be given to food, fresh INFANT FEEDING. 103 air, and exercise. In other words, the physical develop- ment should receive as much attention as the mental growth. In boarding-schools especially the diet should be the subject of careful study, the aim being to avoid monotony and to provide a sufficient and satisfying diet. In many schools the dietary is left to the discretion of the cook. In consider- ing school dietaries several points are worthy of consideration. Milk, being easily digested in most cases, is of great value, especially for children whose nutrition is below normal. It should be furnished as a beverage daily for breakfast and supper, and is advisable even with dinner. It may also be used in the preparation of puddings and soups. Cream is very valuable, and whenever possible should be supplied in sufficient quantities. A cup of warm milk with bread or crackers is helpful during the middle of the morning, and as a substitute for tea in the afternoou. Delicate children and others may with advantage take a glass of warm milk a short time before going to bed. If the rising hour is some time before that set for breakfast a cup of milk or of bread and milk should be given on rising. I$ggS may be used alone or in the preparation of various dishes. They may be used in almost any way, except fried. Fried eggs are liable to be very indigestible. They are often prepared in this way in order to disguise the stale taste of an egg that has been in storage for some time. Meat is a very important part of the diet, as it contains a larger quantity of protein, from which the tissues are built up, and in a more available form, than in any other form of food. Milk and eggs are also valuable sources of protein. Meat should be provided, therefore, in sufficient quantities, half a pound a day being, perhaps, a good average allowance for a growing boy, the larger and more robust taking some- what more. Steaks, chops, and roasts of beef, mutton, lamb, fowl, and bacon are the most suitable meats, although pork, together with meat stews, meat puddings, sausages, and hashes may be allowed in small quantities. These last, while generally relished, are not so digestible nor such good sources of nutriment as those first named. With care and proper 104 DISEASES OF INFANTS AND CHILDREN preparation many of their ill effects can be obviated. More meat is required in winter than in summer, and more in cold climates than in warm.. Yeo states that too much meat may give rise to eczema. Meat may be given twice a clay, and eggs or fresh fish may be substituted for it about three times a week. When these do not satisfy the appetite meat may be added. For this purpose cold sliced meat is useful. Bread and butter should be given with each meal. Bread made from the whole wheat-flour may be used in the largest quantity, but it is well to supply various kinds of bread to avoid monotony. "Brown bread" given continuously be- comes very tiresome. Rye bread may be given occasionally, and bread made from mixtures of wheat and rye is very palatable. Rusk, biscuit, and crackers may also be supplied. Corn-bread, when properly made, may be given once a week or oftener, and griddle cakes of buckwheat, corn, or wheat flour two or three times a week. These last may be served with syrup or fruit-juices. Cereal porridges of all kinds may be given for break- fast, oatmeal being probably the most desirable. Vegetables of almost all varieties may be used. For dinner two varieties should be given — one green vegetable and potatoes. Salads made of the green vegetables, with the very simplest dressings, are useful additions to the diet. Fruit should invariably be given once a day. Sugar should be provided for in the dietary. Candies and many of the sweets given to children are harmful and cause indigestion and dyspepsia. If proper sweets were pro- vided there would be slighter tendency to indulge in the less desirable forms whenever opportunity afforded. With the meals, and when the appetite demands satisfying between meals, they may be given with or without a glass of milk. Regularity should, however, be observed, and they should not be ffiven immediatelv before or after a meal. Fruit syrups, sugar syrups, honey, preserved fruits, and jam may be eaten with bread. Caramels, chocolates, maple sugar, and plain sugar taffies are the best of the other forms of sweets. INFANT FEEDING. 105 Simple desserts, such as custards, milk puddings with rice, tapioca, and the like, bread puddings, plain cakes, and properly prepared pastry may be \\>v<\. The beverages should be water and milk. Weak cocoa or chocolate may be given after the seventh year. Tea and coffee should not be given before the thirteenth year, and may be withheld advantageously still longer. Alcohol is not to be used except by a physician's direction. Especial care should be taken to avoid a monotonous diet, for there are many instances where the constant repetition of a certain form of food has created a dislike for it that has persisted throughout life or been overcome only with diffi- culty. A second point to be remembered is that the food should be well prepared and attractively served. This has more to do with influencing the appetite of delicate, nervous children than is generally supposed, and cannot be insisted upon too strongly. Overeating should be avoided, and to this end an older person should always be present when practicable ; in school this should be insisted upon. On the other hand, a child should not, through caprice or habit, be allowed to eat too little. By exercising a little tact most of the dislikes which are not deeply rooted, but which may become so if persisted in, may generally be overcome. These dislikes are often the result of imitation. Sufficient time should be allowed not only for the meal, but for the performance of whatever small duties may be required of the child. A time should be set for one or two regular daily visits to the water-closet. Hurrying to school should be avoided. Reading and studying immediately before and after meals should be prohibited, as should bath- ing or any very active exercise. Some light form of recrea- tion may, however, be indulged in. The hours for meals should be so arranged that the child may have freshly pre- pared meals, and not cold luncheons or warmed-over dinners. Lastly, nibbling and eating between meals, except under the conditions previously described, should be strictly prohibited. 106 DISEASES OF INFANTS AND CHILDREN. In spite of stringent rules, however, many infringements will occur. It is by neglect of the diet, fresh air, and exercise that many cases of tuberculosis gain headway ; anemia may result from such- neglect, and a delicate, nervous child be the out- come of one that should by right be healthy. OTHER FACTORS IN INFANT FEEDING* Feeding in Infant Asylums. — The feeding of infants in overcrowded infant asylums, with their lack of fresh air and paucity of attendants, is a matter of great difficulty. Any attempt at scientific feeding under such circumstances will ultimately lead to failure, the method in these cases being held to blame. The primary cause of malnutrition and marasmus in institutions is the lack of fresh air and in- dividual care, and until these are obtainable it is useless to attempt to accomplish anything by special feeding methods. In smaller institutions the use of the Materna graduate will be found satisfactory. In the larger asylums it is well to have two or three gen- eral working formulas, such as fat 3 per cent., sugar 6 per cent., protein 1 per cent. ; and fat 4 per cent., sugar 7 per cent., protein 2 per cent. These may be varied by adding more or less water to them to adapt them more closely to special needs. The younger infants rnjiy, when possible, re- ceive special mixtures. For substitute feeding, condensed milk, barley- and egg-water will be found most useful. The allowance of a few cents a day generally made for an infant's entire care is quite inadequate to accomplish any good. The Infant's Stools. — An examination of the stools should be regarded as part of the routine examination. The number of stools in the twenty-fours is not as important as their character. As long as the character of the stool is normal the child is not said to have diarrhea even if it has a number of stools daily. The normal stool is smooth, about the consistence of butter INFANT FEEDING. 107 and contains no curds or solid masses. Mucus is not seen in the perfectly normal stool, but can usually be demonstrated microscopically. The reaction of infants' stools is usually acid or neutral, although sometimes it is alkaline. Either acid or alkaline stools may be altered in color. A return" to a normal color is usually brought about in these cases by the administration of an alkali when the stools are acid, and vice versa. Alka- line stools, green in color, may be produced by giving alkalies in large doses for several days. The color of the stools fur- nishes considerable information as to the condition of the infant. Normally the color is a light butter-yellow, but the stools may vary somewhat in this respect and be lighter or darker. In young breast-fed infants the stools may be a dark yellow, like the yolk of an egg. In artificially fed babies the stools are frequently very light in color, or even decidedly whitish. Rhubarb imparts a yellow color to the stool. White stools are seen sometimes in artificially fed children that seem to be otherwise in normal condition. As a rule, however, white stools are either the result of the ingestion of excessive quantities of fat or indicate an absence of bile. In the former cases the stools are large, whitish, and have the characteristic odor of fatty acids, which resembles that of rancid butter. The stool may be dried and burnt with the same odor and the fat may be dissolved by ether. AVhen bile is absent, the stools are white and have a very foul, almost cadaveric, odor. Red stools may owe their color to the presence of fresh blood from the rectum or the lower part of the intestinal tract. When it comes from the upper parts, the blood is always black. The streaks of fresh blood frequently seen where hard stools are passed come from slight excoriations of the anus. Black stools are caused by the presence of blood. In this case the stools are black and tarry. The blood may come from the intestines or stomach, or from blood swallowed, especially that from hemorrhage from the posterior nares. 108 DISEASES OF INFANTS AND CHILDREN. Black or blackish-brown stools may also be caused by the administration of bismuth, iron, or tannic acid. Brown stools are frequently seen as the result of bacterial and chemic changes in the intestine in the course of intestinal indigestion and intestinal infection. Raw beef-juice may give rise to foul-smelling brownish or grayish-colored stools. Green stools are due to a large number of causes. This may result from intestinal indigestion and infection due to improper food, usually either an excess of sugar or of fat, or to the presence of bacteria. Calomel causes green stools, and alkalies, if continued and not neutralized in the stomach, may produce the same effect. Symptoms of Dietetic Errors. — Too much stress can- not be laid upon the importance of investigating the source of disturbances due to dietetic errors. Too Low Protein. — The stools are small and constipated, if the other food elements are low, as they usually are. The child does not gain weight so rapidly as a normal child, or it may remain stationary or even lose weight. It is anemic, and if the low protein is continued the child becomes marantic. Too High Protein. — The child is liable to have colic, vom- iting at any time, but usually half an hour or more after feeding. The stools contain undigested curds and mucus, and may be yellowish green or otherwise discolored. Too Low Sugar. — The gain in weight is liable to be slow, and the child may be constipated. These infants are usually thin. Too High Sugar. — Vomiting an hour or two after meals, the vomited matter usually being sour. Acid eructations are common. Colic is frequent. The stools are generally grass green and very irritating, the buttocks often being exco- riated. Too Low Fat. — The child gains weight slowly, and is usually constipated unless an excess of sugar is given, as in condensed-milk feeding. Too High Fat. — The child vomits an hour or two after feeding. Colic is common. The stools may be thin and INFANT FEEDING. 109 green or greenish yellow, and contain small masses of undi- gested fat and considerable mucus. These small lumps are often mistaken for curds. They are more or less translucent, and when burnt give off the odor of fatty acids ; they may be dissolved in ether. Curds are not, however, dissolved in ether. Too much fat may also cause large, white, rather dry stools having the odor of rancid butter. It must be remembered that the condition of the stools may be due to one or more of the food elements, and expe- rience in these cases is the best teacher. THE FEEDING OF SICK INFANTS. The Feeding of Difficult Cases — At the outset it must be remembered that the fault may not be due to the food itself, but to its preparation or to the mode or time of administra- tion, and to improper surroundings and care. To succeed in these difficult cases it is necessary to look diligently into the minutest details of the infant's life. I,OSS of Weight. — Loss of weight in an infant should always be considered a very serious symptom. During an acute illness, such as pneumonia or diarrhea, this is to be expected. In chronic conditions the weight may fluctuate, going up and down, or remaining more or less stationary. If, however, in a period of a month or two there is no general tendency to gain, in spite of the fluctuation, this indication is a serious matter. Where an infant is losing weight with- out any special cause, this may be attributed to insufficient or improper food. In all cases a careful study of the food is essential. Accu- rate charts of the quantity of food taken, the time, whether the child vomits and at what time, and the number and character of the stools, etc., are of great help. If the food is increased or decreased, as the case may be, to an average strength for a child of the size and weight of the one under consideration, and there is then no change in the child's con- dition, the food should be peptonized, either partially or com- pletely, or mixed with albuminized or malted food or with 110 DISEASES OF INFANTS AND CHILDREN. barley water. The addition to the dietary of albumin water or of small quantities of one of the predigested beef prepara- tions (Panopepton, 5 to 30 drops ; Liquid Beef Peptonoids, 5 drops to 1 dram ; or one of the other beef preparations in similar doses mixed with water) is indicated. Minute doses of nux vomica, or strychnin, with or without an alkali, as bi- carbonate of soda, or creasote (Liquid Beef Peptonoids with creasote, 5 to 20 drops, of the Arlington Chemical Company, is an excellent form in which to give creasote) are often of value, especially where tuberculosis is suspected. Loss of weight may be caused by persistent vomiting (see Vomiting). The physiologic loss that occurs during the first forty-eight hours of life should not be forgotten. Stationary Weight. — This frequently follows where an infant is weaned or when one is fed artificially from the outset. Even if the child is receiving a correct percentage of food it may not gain for several weeks. So long as the infant is well and the percentage and quantity given correspond to those directed for an infant of the same age and Aveight no alarm need be felt, even if a month should elapse without showing an increase in weight. However, once the regular gain in weight is established it should not remain stationary, but should increase gradually from week to week. The aver- age weekly gain during the first year of life is between four and eight ounces. Colic. — This is more liable to occur in breast-fed than in: bottle-fed babies on the percentages usually recommended. It is especially likely to come on during the first three mouths. In breast-fed infants it is often a difficult matter to overcome. If on examination the proteins are found to be too high, an effort should be made to reduce them, and the intervals of nursing may be lengthened. In bottle-fed infants colic is usually due to the fact that the percentage of protein is too high. The condition may also be caused by the food being given too cold, as well as by a host of causes that bear no relation to the food. Vomiting. — Immediately After Feeding. — (a) From the food being given in too large quantities. Reduce quantity. INFANT FEEDING. Ill (6) From food being too dilute, and so necessitating the taking of too large quantities. Reduce the quantity and increase the strength. (c.) From taking food too rapidly. Give it more slowly — in breast-fed children, by regulating the flow by grasping the nipple between the fingers; in bottle-fed babies by using a nipple with a smaller hole. At Any Time. — Due to the abdominal binder being too tight, or to shaking or holding the infant with the head over the nurse's shoulder, patting on the back, etc. From too high proteins — this is more liable to be accompanied by other symptoms, as colic, curds in stools, etc. One or Two Hours After Feeding. — The vomited material is usually sour and curdled, or it may be watery and contain mucus. This is due to the percentage of fat or sugar being too high. The fat, or both fat and sugar, should be decreased, and the food be given slowly and at longer intervals. Vomiting also occurs in many diseased conditions. It is a frequent accompaniment of gastric and intestinal disorders, infection, and all acute diseases ; it occurs in nervous dis- eases, such as meningitis, and in brain tumor, in peritonitis, and in intestinal obstruction, with coughing spells, as a habit, or reflexly from intestinal or pharyngeal irritation, or in toxic conditions, such as uremia. The treatment depends on removal of the cause where possible. When it occurs in. ordinary acute diseases, however, much can be done in a general way to overcome vomiting. The food should be given in sufficiently small quantities at two-hour intervals, or in some cases a teaspoonful of food may be given every hour, or even every half-hour where larger quantities are not re- tained. If the case is acute it may be necessary to secure a w r et-nurse. Washing out the stomach and gavage are two very important means (which should not be forgotten) of treat- ing persistent vomiting. Gavage, 1 or feeding by means of a stomach-tube, is a method used in various diseases and conditions of infancv and childhood. In cases where the child is not able to take nourishment, or only an insufficient amount, and in cases of 1 Battanis, " Forced Feeding," Lancet, June 16 and 23, 1883. 112 DISEASES OF INFANTS AND CHILDREN. uncontrollable vomiting, this method may be resorted to. It is used in the feeding of premature infants, whether in an incubator or not, and in cases of small, weak, marantic ones, who, owing to weakness or lack of appetite, do not take sufficient nourishment. It is also employed after surgical Fig. 28.— The practice of gavage (De Lee). operations about the head or neck where swallowing is inter- fered with, and in acute diseases, such as pneumonia, in fevers, and delirium or coma. The results that follow this method of feeding are surpri- sing, especially in cases where there is constant vomiting or INFANT FEEDING 113 where the stomach has a very small capacity. In the former case the vomiting may cease and the food be retained ; in the latter, the capacity of a stomach that previously held only an ounce or two may rapidly be increased until an average- sized feeding is retained with ease. The technic of the method is simple, and the procedure con- ducted without difficulty in children under two years of age ; above that age it may be difficult, and a mouth-gag may be required; in some cases nasal feeding must be substituted. The apparatus employed is the same that is used for washing out the stomach, and since it is frequently desirable to wash out the stomach before introducing the meal, the same tubing may serve for both purposes. It consists of a soft rubber catheter connected, by means of a piece of glass tubing, to a piece of rubber tubing, to the other end of which a funnel is attached. The nurse reclines the child on her lap, with the head held straight — not inclined in either direction. The catheter is moistened with warm water and held several inches from the end, so as to allow enough of it to pass into the esophagus with the first attempt at introduction. The mouth is opened, if necessary, and the catheter passed rapidly into the pharynx ; there is usually a swallowing movement, and the tube is readily passed into the stomach. If the procedure is carried on too slowly, the tongue may interfere, or if the catheter is held too near the end, it may cause gagging. Before introducing the food it is well to wash out the stomach with a normal salt solution. As soon as all the food has entered the stomach, the catheter is pinched and rapidly withdrawn. If it is withdrawn slowly the food may come up with the tube. If the catheter is left open as it is withdrawn, the dripping into the pharynx may cause vomit- ing. If the child is young, it is a good plan to keep the finger between the jaws for a few moments to prevent gag- ging. If the food comes up the feeding must be repeated. Nasal Feeding", — For this purpose a catheter in pro- portion to the size of the child should be used. The catheter is well oiled and passed through the nostril and esophagus into the stomach. 8 114 DISEASES OF INFANTS AND CHILDREN. DISEASES OF NUTRITION. There are three conditions which cannot be clearly sepa- rated : Inanition j a condition of acute starvation. Marasmus, a sub-acute condition but a very serious one. Malnutrition, a chronic condition, of poor assimilation. These terms are often interchanged by medical writers. INANITION. Definition. — This is acute starvation due to insufficient or improper food. It is most often seen in very young in- fants, but may also be met with in the older ones. Etiology. — It is seen where the child gets no food (as in abandoned infants) ; where the supply of food is insufficient ; where the infant refuses to nurse ; where the food is suddenly changed, and where the food is not adapted to the infant's digestion, and where the infant's digestion is too weak to utilize the food supplied. Symptoms. — These may come on gradually or suddenly, or the onset may be gradual with the sudden appearance of severe symptoms. The child is usually under three months of age, and the most striking symptom is the rapid loss in weight. The child is pale or cyanosed, the temperature may be subnormal, or there may be fever. The fontanel is de- pressed. The circulation is poor and the respiration irregu- lar. The child is fretful at first, but later may become com- atose. The urine is scanty and low in chlorids. There is generally some disturbance of the gastric and intestinal digestion, and often vomiting and diarrhea. Prognosis. — This is usually bad, but some cases recover if properly managed. The weight and general appearance are the best guides as to how the child is doing. The pres- ence of vomiting or diarrhea, cyanosis, very high fever, or great prostration is of grave significance. The duration of the disease is usually a few days or a week or two. Diagnosis. — This is made on the absence of other dis- DISEASES OF NUTRITION. 115 eases and on recognizing the cause. Where there is fever these cases may be mistaken for either pneumonia or diarrhea. Fever in a young infant should always lead to a careful in- quiry into the amount and character of food taken. Treatment. — General treatment like that given for ma- rasmus. The feeding is the most important thing. Br< -a-t milk from the mother or a wet-nurse should be given, either with a spoon, medicine dropper, or by means of a stomach tube. The milk may be diluted with limewater, and if very rich the cream may be partly removed by skimming. If a wet-nurse is not obtainable, whey, peptonized milk, con- densed milk, very weak modifications of milk, malted, fari- naceous gruels, or predigested-beef preparations may be given. The child should be kept warm, or if there is fever, this should be reduced by sponging or bathing. Whiskv or strychnin or both may be administered by mouth and, if they cause vomiting, by rectum. Oxygen should be administered by inhalation. Normal salt solution injections into the rec- tum may help supply the lack of fluid in the body. Infants over a year old may thrive on solid food where all liquid foods are refused or vomited. See Management of Marasmus. MARASMUS. 1 (Athrepsia; Simple Atrophy ; the "Wasting Disease of Infants.) Definition. — This is a subacute condition where there is extreme wasting, usually terminating fatally. It is due to the lack of ability on the part of the tissues to utilize the food taken. I£tiologry. — It is due to the lack of proper feeding, lack of fresh air, lack of care, and an absence of " mothering." Any or all of these may be the cause. It is common in overcrowded institutions for infants, and infrequent in the 1 A. H. "Wentworth, "Atrophy, Infantile, Etiology and Dietetic Treat- ment of," Journal of the American Medical Association, August 26, 1905, p. 579. "Atrophic Infants and Children, Metabolism in,*' Journal of (he American Medical Association, September 9, 1905, p. 771. 116 DISEASES OF INFANTS AND CHILDREN. country or in private practice among the well-to-do. In some instances the child is congenitally weak. Iyesions. — Great wasting of the muscles and body-fat and an atrophy of the thymus gland are the only constant lesions. Atrophy of the intestinal mucosa has been described. Secondary lesions such as pneumonia may be found where death is due to a terminal infection. Symptoms. — There is a steady loss of weight, until the child is reduced to mere skin and bones, and the skin hangs in folds on the limbs. The cheeks are sunken and the fon- tanel depressed. The abdomen is enlarged, and the hands and feet are like claws, so that these children suggest young birds in appearance. The circulation is weak and respiration feeble. The temperature is usually subnormal. The child is very pale or may be somewhat cyanosed. There may be marked digest- ive disturbance, as vomiting and diarrhea. In other cases the child takes its nourishment well almost to the time of death. There is usually stiffness of the muscles in the severe cases and retraction of the head. The course of the disease is Fig. 29.— Marasmus with purpura. weeks or months, and, as a rule, the children become weaker and weaker and finally sleep away. Prognosis. — This is bad. Cases in institutions invari- ably die. In private practice, where every care can be given, the outlook is better. Diagnosis. — This by exclusion. Care should be taken not to mistake tuberculosis for marasmus. Several careful examinations should always be made before a final diagnosis is made. Treatment. — Plenty of fresh air, individual care, light, DISEASES OF NUTRITION. 117 mid "mothering." Remove to the country where possible. I)o not allow the infant to lie in the crib all the time. It should be picked up and carried about. It should never be fed in the crib, but on the nurses' arm or lap. It should be kept warm. Hot-water bottles may be used or the child placed in an incubator. It should not be bathed too fre- quently. It should be rubbed gently, twice daily, with cocoa- nut butter or some bland oil. It should be encouraged to cry sufficiently to expand the lungs. The feeding is very important. A wet-nurse is best. Next to that, carefully modified milk or whey mixtures may be used. If necessary these should be wholly or partially peptonized. Predigested-beef preparations are useful. Drugs are of little use, but small doses of alcohol or con- densed milk is often of great service. Strychnin sulphate, gr. 4^0, or atropin sulphate, gr. 10V0; ma J De use & where the circulation is very weak, and the peptonate of iron and manganese Avhere there is severe anemia. The doses should be small, and if digestion is interfered with the drugs should be stopped. Small doses of thyroid 1 (gr. -J-j) are sometimes of value, but should be used with caution. MALNUTRITION, Definition. — A chronic condition in which there are no apparent lesions, but a decidedly faulty nutrition. This con- dition is a matter of months or more, often of years. Etiology. — It may be inherited from weak, puerile, or aged parents, and where there is an alcoholic, syphilitic, gouty, or tuberculous taint in the family. It may result from some severe disease from which the child does not recover its strength. It may be caused by lack of food, fresh air and exercise. Symptoms. — These children are small, poorly nourished, and badly developed. They are under-sized, under-weight, flabby, pale, and anemic. The circulation is poor and they are easily chilled. They are nervous, sleep badly, and are easily tired out. Mentally, the older children may be very 1 Simpson, " Thyroid Treatment in Infantile Wasting," British Medical Journal, April 30, 1910, p. 1049. "Thyroid Gland in Relation to Marasmus," Scottish Medical and Surgical Journal, Dec., 1906, p. 50-4. 118 DISEASES OF INFANTS AND CHILDREN. bright. Digestive symptoms are common. As a rule, the appetite is poor and they are difficult to feed. Prognosis. — In institutions the outlook is bad. Where directions can be fully carried out many cases recover. They usually require care for years. Diagnosis. — By excluding tuberculosis and other dis- eases. Several careful examinations should always be made. Fig. 30.— Malnutrition after intestinal diarrhea. Treatment. — Careful feeding, as directed for difficult cases, if the child is an infant, or along the lines laid down for the feeding of children. Often a child must be fed in a way that would suit a healthy child of half the age. Fresh air, country life where possible, exercise, baths, massage, rubbing with oil, and a life free from excitement are indicated. Regular habits are very important. Medicine is less important than the above. Cod-liver oil in winter, iron, arsenic and occasionally strychnia and alcohol are indicated. The less medicine the better. FOOD INTOXICATIONS. 1 Definition. — A form of auto-intoxication due to taking more food than can be properly assimilated, whether too much carbohydrate, fat, or protein. The maximum amounts that can be utilized normally differ greatly in different individuals. Symptoms. — The most striking feature is attacks coming 1 Ruhrah, Journal of the American Medical Association, July 10, 1909, p. 105. DISEASES OE NUTRITION. 119 on periodically. These attacks vary in their character. There may be vomiting (see Cyclic Vomiting), headaches, recurring fever, with or without diarrhea, asthma, and other symptoms too numerous to mention. Diagnosis. — Careful physical examination to exclude any disease of any organ, and this having been done, a study of the child's habits and food should be made. In over half the cases the error is evident, in others it may require trial diets to determine the cause. Too Much Food of all Kinds. — This usually causes such attacks as are called biliousness. There is fever, a coated tongue, foul breath, headache, malaise, and often drowsiness. There is often vomiting or diarrhea or both, the liver may be somewhat enlarged and tender. Too Much Protein. — The symptoms are as in the preced- ing. Sometimes one symptom is especially prominent, as recurring headache or attacks of vomiting, or in milder cases periods when the tongue is furred and the breath foul with- out much other disturbance. Too Much Fat. — The child's general health is poor, the skin is pale and muddy, there are large dark circles under the eyes, the tongue is coated, the breath is exceedingly fetid, and there is frequently gastric disturbance and vomiting, and there is often diarrhea with the passage of undigested fat in the stools. Too Much Carbohydrate. — This is the most frequent form, owing to the fact that many children are given large quanti- ties of starches and sugars. Recurring attacks of vomiting, diarrhea with fever, often headache, or asthma are the most frequent symptoms. Prognosis. — Where the co-operation of the parent can be secured the results are usually satisfactory. Treatment. — The intestinal tract should be cleaned out with a brisk purge and occasional doses of phosphate of soda given. The diet should be carefully regulated to suit the child's age and condition. Where any special class of foods is at fault, it should be reduced to the minimum. ACID INTOXICATION. Disturbances of metabolism are characterized by the pres- ence in the urine of acetone and oxybutyric acid. This may be caused in children by many things : starvation changes in 120 DISEASES OF INFANTS AND CHILDREN. the diet, infectious diseases, especially pneumonia, late in diabetes, poisoning by salicylic acid, and as a sequela of anesthetics. In cyclic vomiting (see same) it is also present. In milder cases symptoms are slight or absent. In the severe cases there is a more or less comatose condition, loss of eye- ball tension, slow deep breathing, sometimes called air-hunger, and usually marked and persistent vomiting. The diacetic acid is present in the urine. Treatment. — Some forms of sugar, particularly glucose, by rectum or even subcutaneously, and sodium bicarbonate by mouth or by rectum. RACHITIS (Rickets). 1 Definition. — Rickets is a constitutional disease caused bv faulty feeding and improper hygiene. The bones show the principal changes, but almost all the tissues of the body are af- fected. etiology. — Rickets is usu- ally seen in artificially fed chil- dren, rarely in the breast-fed. It is primarily caused by a food too low in fats and proteins. Such foods usually contain an excess of carbohydrate material. Rickets may be experimentally produced in young animals by such food. In addition, however, in human beings there seem to be other factors in its causation, such as bad hygiene, particularly over- crowding. Rickets is seen in the temperate zones and most often in Southern races which have moved to the North. In the United States it is especially common among the negroes and the Italians. 1 James, " Late Rickets," Scottish Medical awl Surgical Journal, January, 1897. William Ewart, "Rickets, Abdominal Atony in, its Significance and Treatment," British Medical Journal, October 13, 1906, p. 920. R. W. Mars- den, " Rickets, Late," Edinburgh Medical Journal, vol. xvii., 1905, p. 344. Fig. 31.— Rickets. DISEASES OF NUTRITION. 121 I/esions. — The bone changes are the most striking. The growth of the epiphyseal cartilages, especially in the long bones, is rapid and excessive, and there is a similar process in the production of cells beneath the periosteum. Ossification takes place slowly and irregularly. Instead of the bone con- taining about two-thirds mineral matter and one-third ani- mal matter, the composition is about one-third mineral mat- ter and two-thirds animal matter. The bones are deformed and soft. After from three to fifteen months the pathologic process in the bone stops. Other lesions frequently seen are enlargement of the spleen and lypmph glands and catarrhal conditions of the mucous membranes. Symptoms. — Rickets comes on usually between the sixth and fifteenth month. It may, however, be seen earlier. In the early cases, and especially so in young infants, the early symptoms are great restlessness at night, sweating, especially about the head, beading of the ribs, craniotabes, and constipation. After a short time the disease becomes well developed. The following conditions may be noted. As a rule not all of them are present in any one case. The head is large, the bones of the skull thickened, the fontanels remain open late, and the union of the sutures is delayed. The head is generally square and shows deform- ities in about one-third of the cases. Craniotabes, a crackling sensation produced by slight pressure of the fingers over the parietal and occipital bones and due to thinning of the bones in spots, is rarely seen after six months. It is also found in syphilis. Dentition is delayed and irregular. The lymph-glands all over the body are enlarged. The mucous membranes are relaxed and catarrhal condition- are frequent. The chest shows enlargement of the ribs at the junction of the bone with the cartilages, the so-called rickety rosary. The chest is frequently deformed by vertical and transverse sulci. There may be a funnel breast. The ribs often flare at the bottom. There may be kyphosis of the dorsal spine ; lordosis may also be present. 122 DISEASES OF INFANTS AND CHILDREN. The abdomen is enlarged, and the child is pot-bellied. This is due to deficient tone in the intestinal and abdominal muscles. Constipation is associated with this. The spleen is enlarged. The children are flabby and weak. They are generally under-sized, under-developed, and walk late. The blood is more or less normal, although anemia may be present, due to other causes. Fig. 32.— Rickets. Fig. 33.— Rickets. The most marked changes are seen in the long bones. They are bent, irregular in shape, and usually have marked thickening of the ends about the epiphyses. The tibia and fibula and radius and ulna show the most marked deform- ities. The pelvis may be deformed. Kachitic children are usually nervous and convulsions are common. DISEASES OF NUTRITION. 123 After an active stage of several months the process sub- sides and the child generally recovers. The deformities remain for years and may never disappear. Prognosis. — As far as life is concerned it is good, and with proper treatment the cases eventually do well. Rachitic children are liable to convulsions, bronchitis, pneumonia, their resistance is generally lowered, and they are liable to die with intercurrent affections. Diagnosis. — As a rule this is easy. Syphilis shows other symptoms of the disease, and the shafts of the bones are affected rather than the epiphyses. Syphilitic bones are apt to break down. Xecrosis is never seen in uncomplicated rickets. Antisyphilitic treatment helps to' differentiate ob- scure cases. Rickets of a severe type must be separated from actual paralysis. The reflexes are preserved and the muscle can be stimulated to move. Scurvy is differentiated by the cardinal svmptoms of scurvy and antiscorbutic treatment. Treatment. — Good hygiene and proper food are essen- tial. Fresh milk properly modified, fresh meat juice, cream or other fat should be added to the dietary. Eggs, fresh meat, vegetables, and fruit for older children. Cod-liver oil and olive oil are the best medicaments. Phosphorus has been advised in yttS*- doses. Iron, hypophosphites, and arsenic may also be used. The deformities should be treated by orthopedic means. ADOLESCENT RACHITIS. This is regarded as a recrudescence of a condition which existed in infancy, occurring about puberty, due to a dis- turbance in nutrition at the time of great bone activity. The pathologic and histologic changes approach those seen in the infantile type. In general the symptoms resemble the infantile type, but the acute form is rare, and the local changes are more marked than the general. In girls scoliosis is the most common deformity, while in boys disturbance in the legs is most frequently observed. Changes in the cranium are rarely seen. 124 DISEASES OF INFANTS AND CHILDREN. SCURVY. 1 (Scorbutus; Barlow's Disease*) Definition. — A constitutional disease due to errors of diet, characterized in infants by hemorrhages from the mucous Fig. 34.— Infantile scurvy: Characteristic attitude of the legs (Northrup and Bovaird). membranes and under the skin, by swelling and pain about the larger joints, by an ulcerative stomatitis, and a severe anemia. It is frequently associated with rickets. Etiology. — Food which is not fresh seems to be the causal factor. The American Pediatric Society found that the kind of food used in the cases reported was as follows : 111 American Pediatric Society Report," Archive* of Pediatrics, July, 1898, p. 481. J. L. Morse, " Scorbutus, Infantile," Journal of the American Medical Association, April 14, 1906, p. 1073. G. F. Still. 'Scurvy, Infan- tile," British Medical Journal, July 28, 1906, p. 186. DISEASES OF NUTRITION. 125 Proprietary infant food, sterilized milk, condensed milk, pas- teurized milk,cows 5 milk unboiled, breast milk. Theformerare common, and the latter rare, causes. The use of the improper diet usually covers a period of several month.-. The greatest number of eases are between seven and ten months of age. lyesions. — Hemorrhages, especi- ally under the periosteum, about the large joints, and hemorrhages else- where and changes in the blood-ves- sels, are the common findings. Other changes are aiven under the head of symptoms. Symptoms. — The child becomes anemic, sometimes cachectic in appear- ance, and it is fretful and irritable. Pain in one or more joints is one of the earliest manifestations. The gums -well and bleed readily, and sooner or later there is an ulcerative stomatitis. There is a great tendency to hemor- rhage, and this may take place almost anywhere, as nosebleed, hemorrhage from the stomach or bowel, or any of the mucous membranes. There may be hematuria. Hemorrhages may take place under the skin, and ecchymoses (black and blue spots) may be noted, especially about the larger joints. There may be effusion or hemorrhage into the larger joints, causing swelling, or it may be under the periosteum or between the muscle?, causing swellings. These are liable to be symmetric. Hemorrhage into the orbit may cause protrusion of the eye. There may be edema or ecchymoses of the eyelid. There may be pseudoparalyses, and separation of epiphyses is not uncommon in advanced cases. There may be edema, espe- cially of the extremities. Slight fever is not uncommon. Diagnosis. — The character of food is important, and scurvy should alwavs be borne in mind when there is a his- Fig. 35.— Vertical section of the thigh and leg in a case of infantile scorbutus. The dark areas along the femur and tibia represent subperiosteal hemorrhage (W. P. Xorthrup). 126 DISEASES OF INFANTS AND CHILDREN. tory of an absence of fresh food. Rheumatism is rare under one year of age, yet the pain and swelling most often lead to the erroneous diagnosis of that disease. Scurvy may be mistaken for sarcoma, osteomyelitis, or abscess, acute anterior poliomyelitis, or other joint or spinal disease. If separation of the epiphysis occurs it may be mistaken for fracture. It may be confused with nephritis. Antiscorbutic treatment clears up the diagnosis in almost all cases. Prognosis. — Good if seen early ; poor if seen very late. Untreated cases usually end fatally. Treatment. — A proper diet and the administration of fresh fruit juice. One-half to three or four ounces of orange juice a day, given in four or five doses. Fresh ripe peach juice, grape juice, or lemon juice may be substituted. For older children the addition of fresh-beef juice and potato is of service. DIABETES MELLITUS. 1 Definition. — A symptom complex, the most marked symptoms being glycosuria, polyuria, increased thirst, and a progressive loss of weight. Btiology. — Rare in infancy and childhood. Undoubted cases have been reported as early as four months. The ten- dency to the disease increases with age. Heredity is marked as a cause. Blows on the head may precipitate the disease. Too much starch and sugar may bring it on where there is a predisposition. Pathology. — Not clear. Lesions have been found in the floor of the fourth ventricle, and in the pancreas. Symptoms. — Polyuria is marked, more during the day than at night. From 1 to 5 liters or more may be excreted daily. The child's napkins must be changed twenty or thirty times a day. Enuresis is frequent. Thirst is marked. The appetite is usually ravenous. Mouth and tongue are dry ; the gums bleed easily. Constipation is usually present. Skin is dry and scaly and frequently eczematous. Furunculosis and pruritus are common. Edema may be present. 1 Stern, Archives of Pediatrics, June, 1902, p. 425, and Aug., 1904, p. 617. DISEASES OF NUTRITION. 127 The wasting is rapid and marked. Headache and neural- gia are common. Patellar reflexes may be diminished or absent. The child becomes irritable and capricious. Insom- nia is marked. There may be blindness or diabetic cataract. The disease comes on suddenly and runs a rapid course, lasting usually a few weeks or months, although it may last a year or two. Death is from pneumonia- tuberculosis, or coma. Diabetic Coma. — There may be prodromes, a sweetish chlo- roform-like odor to the breath and diacetic acid in the urine. There is apathy and then loss of consciousness. The pupils are fixed and equal, either dilated or contracted ; patellar re- flexes are lost. Temperature may be lowered or sometimes raised. Pulse rapid and breathing irregular and sighing. Child becomes algid and cyanotic and death takes place in from eighteen to thirty-six hours. • Urine in Diabetes. — As in adults. Specific gravity, 1.030 to 1.040 ; marked glycosuria ; and there maybe acetone or diacetic acid in the urine. Diagnosis. — From diabetes insipidus, lactosuria, and ali- mentary glycosuria. Prognosis. — Always bad. Treatment. — Dietetic measures are rarely tried with dia- betic children, owing to the hopelessness of the condition. They should, however, be given a trial. Feed on proteid food, fats, and alcohol. Reduce starches and sugars or absolutely prohibit them. v. x^oorden's oatmeal cure may be tried. (AYell-cooked oatmeal, to which vegetable or egg albumin and butter has been added ; alcohol is also allowed. Meat or vegetables allowed once a week. Gradually return to regular diet.) Soy beans in combination with an otherwise carbo- hydrate-free diet may reduce the amount of sugar in the urine. Prophylactic Diet. — In diabetic families the amount of carbohydrate food should be limited. Drugs. — The following are a few of those recommended : morphin, codein, bromid of potassium, antipyrin, and lacto- phosphate of lime. 128 DISEASES OF INFANTS AND CHILDREN. DISEASES OF THE MOUTH AND PHARYNX. 1 PERLECHE. (Lemaistre, 1886.) A grayish-white ulceration, usually at the angle of the lips, caused by constant licking. It may be confused with a Fig. 36.— Double harelip and cleft palate. The prominence on the left side of the deformity shows the protruding intermaxillary bone, with the slcin of the median line of the lip covering' it (skin of frontonasal process) (Eisendrath). syphilitic mucous patch. Burnt alum or nitrate of silver should be used with antiseptic washes and dusting powders. HARELIP. 2 Due to incomplete fusion of one or both lateral processes to the central process in the development of the face. May 1 Mayer, " Affections of the Mouth, Throat," etc., American Journal of the Medical Sciences, 1902. 2 G. V. I. Brown, " Hare-lip and Cleft Palate, Surgical Correction of," Journal of the American Medical Association, March 18, 1905, p. 848. DISEASES OE THE MOUTH AND PHARYNX. 129 be single or double. Interferes with sucking and is an un- sightly deformity. Operation should be performed. Opinions differ as to the best time to operate. In simple eases it may be performed alter one month, and the more serious ones after six months. CLEFT PALATE. 1 This is frequently associated with harelip. The children are generally weakly and apt to die from inanition or inter- current affections. Great care in feeding and great cleanli- Fig. 37.— Macroglossia (Dandridge). ness about the mouth are required. Feeding may be done with a spoon, a long medicine dropper, or by a stomach tube. The mouth should be frequently swabbed with a mild anti- septic solution. Operations should be deferred until the child is from two to six years old, according to the general condition and the severity of the deformity. 1 Brown, Journal of the American Medical Association, March 18, 1905. 9 130 DISEASES OF INFANTS AND CHILDREN. CONGENITAL HYPERTROPHY OF THE TONGUE. This is due to disease of the lymphatics, and demands sur- gical treatment. It should not be confused with the pro- truding tongue of the cretin. OTHER DEFORMITIES. Tongue-tie. — This is due to the frenum extending to the tip of the tongue, holding it down, and interfering with speech and sometimes with sucking. Inability to speak may depend solely on this cause. It should be divided with the scissors and separated to the normal length by pressing back with the fingers. Bifid tongue and bifid palate may be met with. EPITHELIAL DESQUAMATION OF TONGUE. Acute Forms. — The margins of the tongue are red ; the center white. The red, or denuded, parts of the tongue advance in crescentic areas until the entire tongue is red. Lasts several weeks. Chronic Form. — The epithelium desquamates slowly and irregularly. The denuded patch is red and is bounded by a crescentic white line of white and thickened epithelium. The remainder of the tongue is normal. These lines of desquamation move about over the tongue. It lasts months or years, is of no importance and requires no treatment. It is often a cause of worry to mothers. GLOSSITIS. Acute swelling of the tongue may occur in urticaria. Inflammation of the tongue may occur from infection — usually from a tooth. Local inflammations, with thickening of the tongue, are common from the same cause. Treatment. — Liquid food, nasal feeding if necessary. Cold mouth-washes or ice in the mouth. If interfering with respiration, scarification or needle punctures. DISEASES OF THE MOUTH AND PHARYNX. 131 TONGUE SWALLOWING. May occur in pertussis and other conditions. If not relieved may cause death by interfering with respiration. In weak infants the tongue may fall back into the pharynx and cause asphyxia. ULCER OF THE FRENUM. This is usually seen in weakly infants, and especially in those who have pertussis or some other form of cough. It is caused by the central incisors coming in contact with the tongue. Burnt alum or nitrate of silver application is usually efficient. RIGA'S DISEASE. This is a rare condition where there is an ulcerated papil- loma of the frenum. It is an indolent ulcer, quite hard, and covered with a grayish false membrane. It requires surgical treatment. ALVEOLAR ABSCESS. This comes from decayed teeth, and causes great swelling at the side of the face and of the jaw. The abscess, of its own accord, generally breaks into the mouth. It may open exter- nally or into the nose or antrum, or it may cause necrosis of the bone, and open into the maxillary sinus. Decayed teeth should be filled or drawn, and an antiseptic mouth-wash used to prevent abscess. When it has already formed it should be opened and treated like any other abscess. DIFFICULT DENTITION. 1 Roughly speaking, about one-third of all infants cut their teeth without any trouble, about one-third have slight disturb- ance of their general health, while the remaining third are made really ill by the cutting of each tooth. Sometimes one tooth will cause trouble, while others do not. Before making a diagnosis of difficult teething a most careful examination should be made. The following symptoms may at times be 1 L. Guthrie, " Dentition, Primary, Disorders Associated with," Practi- tioner, October, 1905, p. 547. 132 DISEASES OF INFANTS AND CHILDREN. caused by, or accompany, difficult teething : Restlessness, sleeplessness, fever,- stomatitis, vomiting and diarrhea, en- largement of the cervical glands, eczema and urticaria, bron- chitis, and convulsions; this last especially in rickety chil- dren. Treatment. — If the gum is swollen and the tooth nearly through, the former may be lanced ; rubbing it with a silver thimble or with the finger covered with gauze may give relief. A dose of calomel often relieves the fever or gastro-intestinal symptoms. The restlessness and sleepless- ness may be relieved by rubbing the gum with a drop or two of paregoric, or applying sodium bromid in solution with a little glycerin, or by the internal use of bromids, or of bromids and chloral, or of bromids and phenacetin, or codein and antipyrin. DISEASES OF THE UVULA. Uvulitis. — This is rare. There is swelling, elongation, and edema of the uvula. There is an irritating cough, and there may be interference with swallowing. Ice in the mouth, needle puncture, and astringent applications are indicated. Elongated Uvula. — This is probably congenital, but is increased by repeated inflammations. There is an irritating cough and often asthmatic attacks on lying down. Diagnosis is made by inspection. A small amount of the uvula should be cut off. BEDNAR'S APHTHAE. There are two symmetric ulcerations over the hamular process of the palate bone. The mucous membrane at this point has poor circulation, owing to frequent stretching every time the pterygomaxillary muscle is contracted, as in opening the mouth. Any abrasion of the mucous membrane at this point, as by rough washing of the mouth, results in an intractable ulceration. Treatment. — Touch twice daily with 10 per cent, silver nitrate solution and keep the mouth clean. DISEASES OF THE MOUTH AND PHARYNX. 133 CATARRHAL STOMATITIS. This is caused by taking irritating or overheated things into the mouth, and is also present as a complication of many of the infectious diseases and in teething. There is redness and swelling of the mucous membrane with an increased flow of mucous and saliva. There may be slight swelling of the tongue and lips. The cervical glands are slightly enlarged, and there is some pain on taking food. Treatment. — Keep the mouth clean by using antiseptic and mildly astringent washes. If food is refused give it cold. If any ulcerations occur powdered burnt alum may be applied. HERPETIC STOMATITIS. (Aphthous Stomatitis; Vesicular Follicular Stomatitis.) This is caused by herpetic eruption (fever blisters) in the mouth. The top of the little vesicle is rubbed off and a small round or oval, punched-out ulcer with bright-red edges and a white base remains. It is common after the first year. The ulcers are over the tongue and also on the cheeks, and come on in successive crops. They are very painful. Diagnosis. — From diphtheria, which it may somewhat resemble if several ulcers coalesce, and from Koplik spots. Treatment. — Apply burnt alum or touch with nitrate of silver and use antiseptic mouth washes. THRUSH. 1 (Sprue; Soor; Muguet.) This is a form of stomatitis due to the growth of a fungus (the Saccharomyces albicans, Grawitz) in the mouth. It is most frequently seen in the mouths of nursing infants where there is a lack of cleanliness. It rarely affects other parts of the body. It occurs as white flakes or crusts which look like milk 1 Langford Syrnes, International Medical Magazine, vol. iii., No. 12. 134 DISEASES OF INFANTS AND CHILDREN seen in the mouth immediately after feeding. It cannot, however, be wiped off, and when it is removed leaves some bleeding-points. The diagnosis is easy. The fungus may be easily de- monstrated under the microscope. The outlook is good, but in very weak infants it may interfere with the taking of food. Treatment. — Cleanliness regarding nipples, nursing-bot- tles, and everything which comes in contact with the infant. Nipples should be kept in boric acid solution. Cleanse the mouth carefully but gently, before and after feeding, with some mild antiseptic mouth-wash. Where this does not relieve it paint the mouth with a boric acid solution or a solution of protargol (3 per cent.) three or four times a day and feed by gavage. ULCERATIVE STOMATITIS. Definition. — An ulceration of the mouth starting on the gums at the edges of the teeth and spreading to the other tissues. Etiology. — It is seen only in children with teeth. It occurs in mercurial, lead, and phosphorus poisoning, in scurvy, from uncleanliness, and also in children who are weak and run- down in health. Symptoms. — The ulcers are covered with a yellowish- gray deposit, the gums are swollen, congested, and bleed easily. The teeth may loosen and fall out. Necrosis of the jaw may occur. There is a very foul odor to the breath and profuse salivation. The cervical glands are swollen, tender, and may suppurate. As a rule, there is marked con- stitutional disturbance consisting of high fever, loss of appe- tite, malaise, and the like. Diagnosis. — The condition is self-evident. The cause should be sought. Prognosis. — Good with proper care and treatment. If neglected it may prove fatal. Treatment. — Remove cause when known. In scurvy give fresh fruit and proper diet, and in all cases keep the mouth DISEASES OF THE MOUTH AND PHARYNX. 135 clean with antiseptic mouth-washes. Peroxid of hydrogen (1 : 4), permanganate of potassium (1 : 4000), or a saturated solution of chlorate of potassium are the most satisfactory. Burnt alum or nitrate of silver may be used to hasten the healing of the ulcerations. Internally, chlorate of potassium is almost specific. Two grains (half a teaspoonful of the saturated solution) may be given hourly for the first day and every two hours for one or two more days. It should be well diluted. The urine should be watched. Later, acids and iron should be used with gen- eral building-up treatment. The diet should in all cases be antiscorbutic and as nourishing as possible. GANGRENOUS STOMATITIS, (Cancrum Oris; Noma.) 1 Definition. — A form of gangrene seen in children, usually in the mouth, but also affecting other mucocutaneous orifices, as the vulva, anus, prepuce, the external auditory canal or the nose. Etiology. — It is rare and is seen usually in institution children and almost always follows an attack of some of the infectious diseases, as measles or scarlet fever. It is appar- ently contagious, but no one organism has been described as the cause, although many have been mentioned as the etio- logic factors. Symptoms. — It begins as a small discolored spot on the lip or cheek. This is hard and becomes rapidly larger. It soon becomes black and breaks down at the center with the formation of a dark necrotic mass which has a very offensive odor which may be the first thing noted. There is edema of the cheek, and the gangrene spreads rapidly. The teeth loosen and fall out, and the jaws necrose. The cheek may be perforated, and most of the face may slough away. There is little or no pain. There may be high temperature, which 1 Bloomer and Macfarland, American Journal of the 3Iedical Sciences, November, 1901. " Noma," British Medical Journal, April 15, 1909, p. 473. Neuhof, " An Epidemic of Noma," American Journal of the Medical Sciences, vol. cxxxix., 1910, p. 705. 136 DISEASES OF INFANTS AND CHILDREN. grows less as the child weakens. The child is apathetic and dull ; may be almost comatose. There is muscular relax- ation and often diarrhea. Diagnosis. — This is, as a rule, easy. Prognosis. — The disease lasts from a week to ten days, and death occurs in three-fourths or more of the cases. Treatment. — Radical early treatment is the only hope. Fig. 38.— Gangrenous stomatitis. The diseased area may be removed by excision or by actual cautery. Another method of treatment is to cleanse with peroxid and then paint twice daily with a 10 per cent, chromic acid. Injections of carbolic acid may be made around the entire area, a little outside of the gangrene. Nitric acid may be injected into the mass. Antistreptococcic and antidiphtheritic serum have been used with benefit in some cases. The fre- quent use of antiseptic washes is required. The cases should be isolated. OTHER FORMS OF STOMATITIS. Stomatitis may occasionally be caused by the gonococcus, the diphtheria bacillus, and other organisms. A syphilitic stomatitis is also seen. DISEASES OF THE MOUTH AND PHARYNX. 137 DISEASES OF THE TONSILS. 1 Acute catarrhal tonsillitis is >v^n in acute pharyngitis, but rarely alone. CROUPOUS TONSILLITIS. This is a more severe form in which there is a fibrinous exudate which first tills the crypts and then spreads over the entire tonsil, usually affecting both sides. The exudate pro- duces a grayish-yellow film (which can be swabbed off with- out any bleeding-points) over the tonsil. The streptococcus is usually present. Symptoms and treatment like follicular tonsillitis. Diagnosis. — From diphtheria by the high fever and that it may be wiped off without leaving bleeding-points. ULCEROMEMBRANOUS TONSILLITIS Vincent, 1896). 2 A process similar to ulcerative stomatitis caused by Vin- cent's bacillus. It is often unilateral. There is a dirty -gray false membrane with superficial ulceration. The breath is very foul, as in ulcerative stomatitis, with which it may be associated. The lymph glands at the angle of the jaw are swollen. There is no constitutional disturbance of any moment. Diagnosis. — From diphtheria by means of bacteriolog- ical examination, by absence of constitutional symptoms. Treatment. — Chlorate of potassium internally, as in ulcerative stomatitis, the local application of nitrate of silver, and the use of antiseptic mouth-washes. FOLLICULAR TONSILLITIS. Definition. — An inflammation of the entire tonsil where the crypts are filled with plugs of exudate. The constitu- tional disturbance is very great for the small amount of local trouble. 1 G. B. Wood, " Tonsils, Lymphatic Drainage of," American Journal of (he Medical Sciences, Aug., 1905, p. 216. Chapin, Medical News, V( >1. lxxiv. . Xo 9. 2 Sobel and Hermann, New York Medical Journal, December 7, 1901. 138 DISEASES OF INFANTS AND CHILDREN. Etiology. — Rare in infants, but common during child- hood. Frequent attacks in the same child. Often associated with the presence of rheumatism. The staphylococcus and the streptococcus can usually be found in the exudate. Pathology. — Acute swelling and congestion of the whole tonsil, with an exudate plugging up the crypts, and some- times a fibrinous exudate covering the remainder of the tonsil, but not extending beyond it. Symptoms. — On inspection the tonsils are seen to be swollen and the crypts filled with yellowish plugs, which may be pressed out, and sometimes there is a film of exudate Fig. 39.— Acute infectious pseudomembranous tonsillitis (follicular) : The two whitish points on the posterior wall represent exudate formed on isolated muco- lymphoid follicles (Casselberry). (which can be wiped off with a swab) over the tonsil. Both sides are affected. There is sudden onset, often with a chill, followed by high fever, which may be 104° or 105° F. There is headache, backache, and pains in the limbs. There may be vomiting and diarrhea, especially in young children. The glands at the angle of the jaw are, as a rule, not much enlarged, and the throat is not very painful. The symptoms gradually grow better and disappear in three or four days. Diagnosis. — From diphtheria, scarlet fever, influenza, pneumonia, and malaria. By inspection of the throat and DISEASES OF THE MOUTH AND PHARYNX. 139 the presence or absence of the signs and symptoms of these diseases (which see). Prognosis. — Good. Treatment. — Relieve the pain by using phenacetin or antipyrin and codein. Give salicylate of sodium where there is a history of rheumatism. Give effervescing draught or lime water and cinnamon water to relieve nausea. Antiseptic mouth-washes may be used. PHLEGMONOUS TONSILLITIS. (Peritonsillar Abscess ; Quinsy.) Definition. — A unilateral inflammation of the tissues about the tonsil, and often of the tonsil itself, which usually suppurates, but which may go on to resolution. Sometimes it may extend to the pharyngeal wall. It is rare in children. Fig. 40.— Peritonsillar abscess : a, Point for puncture (Casselberry). Etiology. — Exposure or excesses. Infection with pus- forming bacteria. Symptoms. — Like follicular tonsillitis as regards general symptoms, but less intense the first day, and increasing as the disease progresses. There is pain in the throat, difficult swallowing, and pain on opening the mouth. There may be tenderness externally. On the first or second day little can be seen which, with the 140 DISEASES OF INFANTS AND CHILDREN. presence of symptoms of sore throat, is extremely suggestive. After one or two days there is marked swelling in and about the tonsil, and the uvula may be pushed to one side. Fluc- tuation may be made out after the first few days. If left alone the abscess forms and breaks, as a rule, inside of a week. Treatment. — Salol in rather large doses may be given if the case is seen early. Phenacetin and codein may be given to relieve the pain. Hot or cold applications, which- ever is more grateful to the patient, may be used. Open as soon as fluctuation is well determined. Eelief after opening is usually immediate. CHRONIC HYPERTROPHY OF THE TONSILS. (Chronic Tonsillitis.) Definition. — A general enlargement of the tonsil. Both the lymphoid tissue and the connective tissue are increased — all grades are met with. The degree of hardness depends on the amount of connective tissue present. Etiology. — Associated with adenoids ; also in " lymph- atism." It is found in certain families. It is quite a com- mon affection. Symptoms. — Similar to those produced by adenoids, with which this condition is usually associated. Difficulty in swallowing and disturbed sleep may be troublesome. Diagnosis. — By inspection, when the enlarged tonsils can be readily made out. Prognosis. — After puberty they atrophy somewhat. Treatment. — If sufficiently enlarged to cause symptoms they should be removed by using a tonsillotomy. Syrup of the iodid of iron is a useful tonic for these children. RETROPHARYNGEAL ABSCESS. 1 There are two forms : The idiopathic abscess of infancy, and that secondary to Caries of the vertebra?. 1 Ripley, Archives of Pediatrics, February, 1884, p. 104. DISEASES OF THE MOUTH AND PHARYNX. 141 Idiopathic Abscess. — This is a suppuration of the retropharyngeal lymph nodes and is the same process as that described as the acute adenitis of infants. Etiology. — Three-fourths of the cases occur under one year of age. They follow rhinitis, pharyngitis, or the acute in- fectious diseases. Symptoms. — There is usually a history of an attack of one of the above. A week or two later there are fever and con- stitutional disturbance. The cause of this may not at first be apparent. Local symptoms soon make their appearance. These are dyspnea, which may be mostly inspiratory and most marked on lying down ; difficulty in swallowing and refusal to nurse ; regurgitation of the food through the nose ; there may be cough and a nasal character to the voice; there may be complete aphonia. Snoring is noted. The head is thrown back and torticollis may be the first symptom ob- served. There is an abscess swelling, to be made out by inspection or palpation, in the back of the pharynx, and it may also be apparent just below the angle of the jaw to the front of the sternomastoid muscle. Diagnosis. — By digital examination of the pharynx, which should be made in every case where there is dyspnea. Ke- traction of the head with dyspnea, difficult swallowing, and mouth-breathing are the principal symptoms. Exclude sar- coma. Prognosis. — This is fairly good if the diagnosis is made. The abscess may open itself. Death may result from asphyxia or from rupture during sleep, when the pus may block the larynx, or from a secondary pneumonia or septi- cemia. Treatment. — Hot applications to the throat until fluctua- tion can be ascertained, and then open immediately. Opening through the mouth is ordinarily to be preferred, but some- times it can be opened to advantage externally. Retropharyngeal Abscess from Pott's Disease. — This is similar to the above, but comes on very slowly, and generally there are symptoms of Pott's disease for some time before there is any abscess. They do not heal promptly as the idiopathic abscesses do, but leave a suppurating sinus. 142 DISEASES OF INFANTS AND CHILDREN. The diagnosis is made by digital examination. The opening should be made externally, just below the jaw and in front of the sternomastoid muscle. ACUTE PHARYNGITIS. Definition. — An inflammation of the pharynx which may be primary or may occur as a part of some other disease, especially the exanthems. Symptoms. — There is at first dryness of the throat; later redness, swelling, edema, and increased secretion. There is pain at the angle of the jaw, which is increased on swal- lowing. The cervical lymphatics are slightly enlarged. There is fever, from 100° to 103° F. or even higher, and there may be considerable malaise. The symptoms generally pass off in a day or two. Diagnosis. — Measles may generally be distinguished by Koplik spots and the other catarrhal symptoms. Scarlet fever cannot be excluded until sufficient time has elapsed to be sure there will be no rash. Influenza can be told by the presence of the other catarrhal and constitutional symptoms. Treatment. — Open the bowels with calomel or castor oil. Rest in bed, liquid diet, ice to suck, and an effervescing draught if there is vomiting. Phenacetin or codein and antipyrin can be used if there is much pain or nervousness. RETROESOPHAGEAL ABSCESS. 1 A rare condition due to Pott's disease or to breaking down of the retro-esophageal lymph nodes. Symptoms are dyspnea, often spasmodic, and usually most marked on inspiration. There may be spasmodic cough and a change in the voice. Most cases die from pressure on the pneumogastric or from rupture. Rupture into the esophagus may rarely result favorably. INFLAMMATION OF THE ESOPHAGUS. The esophagus is seldom diseased. Diphtheria may very rarely extend into it from the pharynx. Lacerations due to 1 Griffith, Archives of Pediatrics, January, 1898, p. 1. DISEASES OF THE MOUTH AND PHARYNX. 143 swallowing rough or sharp objects usually heal promptly. Ulcers are rare in early life. Catarrhal inflammations from swallowing hot or irritating food cause slight pain on swal- lowing. This form heals in a few days. Corrosive Ksophagitis. — This is comparatively fre- quent and results from the child drinking lye or strong acids. If the patient survives the poison, extensive ulceration re- mains, which gradually heals, leaving large scars. These gradually contract, producing stricture of the esophagus. The immediate symptoms are severe burning, great thirst, inability to swallow, or great difficulty and pain on swallow- ing. Edema of the glottis may prove fatal. Symptoms of stricture come on after several months or years. The treat- ment of the stricture is surgical, generally consisting of the passing of bougies, although some cases are amenable to operation. MALFORMATIONS OF THE ESOPHAGUS. 1 These are of various kinds. Fistulse may open into the trachea or through the neck. The esophagus may be absent, end in a blind pouch, or be strictured or constricted. Many of these deformities may be corrected by surgical operation. Complete obstruction is always fatal. The symp- toms are vomiting after a very small amount of food has been taken and inability to pass a stomach-tube. 1 Marsh, American Journal of the Medical Sciences, August, 1902, p. 304. 144 DISEASES OF INFANTS AND CHILDREN. DISEASES OF THE STOMACH. VOMITING. Vomiting is an exceedingly common symptom in infancy and may be due to the following causes : 1. Overfilling the stomach. 2. Outbursts of anger. 3. Stricture or obstruction in the esophagus. 4. Acute gastric indigestion. 5. Pyloric stenosis. 6. Acute intestinal obstruction. 7. Appendicitis and peritonitis. 8. Acute infectious diseases, especially at the onset. 9. Fever from almost any cause in infants may be accom- panied by vomiting. 10. Brain-pressure, as in acute meningitis and brain tumor. 11. Any persistent prolonged cough, but especially whoop- ing-cough. 12. Toxic. From the accumulation of poisons in the blood, as in cyclic vomiting, uremia, the absorption of ptomaines from the intestinal tract, etc. 13. Reflex irritation of the pharynx, as in sucking the hands. 14. Habit. Chronic vomiting is generally xlue to habit or to chronic indigestion. The treatment depends on the cause. CYCLIC VOMITING. 1 Definition. — Attacks of vomiting lasting several days, uninfluenced by any known treatment, and recovering spon- taneously. The attacks come on at regular or irregular in- tervals without any apparent cause. Etiology. — It may begin as early as two years of age. 1 Shaw", Archives of Pediatrics, November, 1902, p. 825. Shaw and Tribe, " Recurrent Vomiting," British Medical Journal, February, 1905, p. 347. F. Langmead, "Vomiting, Recurrent, of Children," British Medical Journal, February 18, 1905, p. 350. DISEASES OF THE STOMACH. 145 The sexes arc affected equally. Sometimes fatigue or excite- ment may seem to precipitate an attack. Pathology. — This is unknown, although the condition is apparently an auto-intoxication, usually an acid intoxica- tion. The urine gives evidence of congestion of the kid- neys, and also contains indican and acetone, and usually diacetic acid. Holt and Herter point out that there is a dis- turbance of the ratio of uric acid and urea excreted. Nor- mally it is about 1 to 54. In Holt's case it was 1 to 1 52 on the second day of the attack. Symptoms. — There are often prodromes for a day or less, consisting of languor, headache, and malaise, and then the vom- iting begins suddenly and is forcible and distressing. There may be slight temperature. The violent repeated vomiting causes great exhaustion and the child lies in an apathetic condition. There is great thirst. The abdomen is sunken and not tender. Prognosis. — Usually good, although occasionally a case ends fatally. The vomiting ceases spontaneously after a few days. Toward puberty the attacks become less frequent and may stop altogether. Diagnosis. — Meningitis, brain tumor, nephritis, acute in- digestion, intussusception, and appendicitis must be excluded. Treatment. — Calomel at the outset if seen before vomit- ing starts. After it begins nothing can be done to stop it, although large doses (3i-ij) of sodium bicarbonate, given by rectum, sometimes seem to shorten the attack. Give enemata of water every four or five hours and nutrient enemata when the case lasts over three days. When the vomiting stops, food may be cautiously given, albumin-water, barley-water, and milk and lime-water. Convalescence is rapid. Between the attacks a carefully regulated out-of-door life with a diet in which there is a lessened amount of sugar and starch, giving plenty of milk, eggs, meats, green vegetables, and stale bread. (See Auto-intoxication.) GASTRALGIA. Severe pain in the abdomen, which may be due to a num- ber of causes. It recurs frequently in some children and causes great distress. It may be due to indigestion, to cold 10 146 DISEASES OF INFANTS AND CHILDREN. feet, to chronic malaria, to drinking iced water, and in some cases apparently to irregular contraction of the intestines. Severe abdominal pain may also be caused by dorsal Pott's disease, pneumonia, diaphragmatic pleurisy and various dis- eases of the abdominal organs. Treatment. — Rest in bed. Keep the child warm if chilled. Hot applications over the epigastrium, using either a hot water bottle, mustard plaster or turpentine stupes. Spirits of chloroform in five-drop doses with the compound tincture of cardamom given in very hot water usually gives prompt relief. Tincture of ginger, brandy and gin in hot water are also much used. A few drops of peppermint in water is a frequent household remedy. In the interval a correct diet, careful hygiene, and in the frequently recurring attacks mix vomica or Fowler's solution of arsenic may be given. ACUTE GASTRIC INDIGESTION. 1 Etiology. — Usually from errors in diet, the use of indi- gestible, stale or unsuitable food. Frequently seen in other forms of illness from continuing diet suitable for health, but not for the weakened condition. It may be caused by ex- posure, overheating, and in infants from difficult teething. Symptoms. — Pain and discomfort in the stomach fol- lowed by eructation or vomiting. There is distention of the abdomen in most cases. There is usually fever which may be alarmingly high. There are often marked nervous symp- toms such as dulness or even stupor or extreme restlessness and often convulsions. These usually disappear promptly with proper treatment. Diagnosis. — From acute gastritis and other conditions mentioned as causing vomiting. Prognosis. — Good in previously healthy children. Weak children sometimes do badly. Death may be caused in either case from convulsions. Treatment. — Empty the stomach and keep it at rest. In infants wash out the stomach ; in older children give a 1 Clarke, " Gastric Digestion in Infants," American Journal of Medical Sciences, vol. cxxxvii., 1909, p. 674. DISEASES OF THE STOMACH. 117 large quantity of warm water and induce vomiting. "With- hold all food for half a day, when, if the stomach is quiet, a little albumin-water may be given. Egg-water or whey may be substituted if desired. On the second day the same may be given with the addition of weak broths. After a day or two longer, if all goes well, peptonized or malted milk may be given or equal parts of milk and barley-gruel boiled together. If the child is breast-fed take it off the breast for a day and feed albumin-water or barley-water. The following day nursing may be allowed for a few minutes at a time and albumin-water and plain boiled water given in addition. The nursing time may be gradually increased. Calomel may be given in small doses until the bowels move freely. After that equal parts of lime-water and cin- namon-water may be given in teaspoonful doses to allay the nausea. Chalk mixture or small doses of bismuth may be used in place of the above if it is necessary. Heat over the epigastrium is grateful ; a hot water bag, mustard plaster, spice bag or turpentine stupes may be used. ACUTE GASTRITIS. Definition. — An acute inflammation of the stomach. Usually seen as a part of a gastro-enteritis, rarely uncom- plicated. There is a catarrhal, a membranous, and an ulcera- tive form. I^esions. — There is hyperemia of the stomach-wall and a marked increase in the mucus secreted. The glands are swollen and the stomach-wall infiltrated with an inflamma- torv exudate. In the membranous form there is a false membrane similar to that seen in diphtheria. It may be caused by true diphtheria, pseudo-diphtheria or occasionally complicating membranous entero-colitis. In the ulcerative form there are one or more small ulcerations. Various forms of bacteria have been found in cases of gastritis. ^ Gas- tritis due to taking irritant poisons produces changes similar to those found in corrosive esophagitis. Symptoms. — Similar to acute gastric indigestion, but more severe, more prolonged, and often there is vomiting of 148 DISEASES OF INFANTS AND CHILDREN blood, especially in the ulcerative form. The membranous form presents no especial symptoms. Diagnosis. — It is impossible to distinguish it from acute gastric indigestion at the outset. Prognosis. — Usually good, except in the corrosive form, which is usually fatal. Treatment. — Wash out the stomach and give it rest. Diet and drugs as in acute gastric indigestion. Bicarbonate of soda or other alkalis may be given. Bismuth is one of the most efficient drugs. CHRONIC GASTRIC INDIGESTION. (Chronic Gastric Catarrh; Chronic Gastritis.) Definition. — The symptoms of these conditions are about alike and they may be grouped together. Etiology. — Repeated attacks of acute gastric indigestion, or the continued use of improper food, may cause it, or it may be a complication of other diseases. Pathology. — -There is infiltration of the stomach-wall, and in rare instances the presence of considerable connective tissue. Symptoms. — There are lessened digestive ability, in- creased mucus, fermentation, and motor insufficiency. There are also vomiting, regurgitation of food, acid eructations, distention of the stomach, and pain. Tongue is coated ; the appetite varies ; there is restlessness and sooner or later malnutrition. Prognosis. — Good under favorable surroundings and where proper treatment can be carried out. Bad where they cannot be properly managed. Treatment. — In Infants. — Good hygiene is essential. Wash the stomach once a day, or oftener, if necessary. Proper food. (See Infant Feeding.) The meals must be smaller than recommended for a normal child and at greater intervals. Drugs are of little value. Hydrochloric acid and pepsin may be given. For eructations, if they continue after stomach washing, grain doses of sodium salicylate may be given. Older Children. — Large quantities of hot water with bicar- DISEASES OF THE STOMACH. 149 bonate of soda in it or Vichy water, may be taken slowly on rising and an hour before each meal. Diet. — Milk which has been diluted with a carbonated water, lime-water or peptonized milk, koumiss, and rare meat should be given at the outset. Then the following anay be added one after the other : Zwieback, toast, stale bread, Fig. 41.— Stomach, showing ulcers and pseudomembranous exudation (Wollstein). spinach, well-cooked cauliflower tops, asparagus tops, young peas (mashed), young green string beans, well-baked mealy potato (in small quantity). Later on, vegetables and more starchy food. Prohibit all undigestible articles (see List, page 101). Drugs. — Nux vomica or some other bitter tonic before meals, and hydrochloric acid after meals, are usually all that are needed. The peptonate of iron may be used if there is anemia. DILATATION OF THE STOMACH. This may be seen even in young infants, especially a moderate degree with chronic gastritis. There are usually symptoms of gastric indigestion and motor insufficiency. 150 DISEASES OF INFANTS AND CHILDREN. The stomach is distended and can often be seen through the abdominal walls. The size may be determined by giving water and percussing the lower border of the stomach. If it is near the umbilicus it is dilated. The size may also be measured by filling the stomach with water and withdrawing it with a stomach tube. Diagnosis. — Usually easy, from physical signs. Exclude dilated colon. Prognosis. — Good if properly treated, bad if not. Bad in pyloric stenosis. Treatment. — Smaller meals at greater intervals and treat the indigestion. Nux vomica is the most useful drug. CONGENITAL STENOSIS OF THE PYLORUS. 1 Definition. — This is a congenital hypertrophic stenosis of the pylorus. Pathology. — The condition is congenital and the lesion consists of a funnel-shaped thickening of the pylorus. The stomach is dilated in most cases, and the intestines are empty and collapsed. Symptoms. — There are vomiting, constipation, and a progressive loss of weight. The dilatation of the stomach can usually be demonstrated. The gastric peristaltic move- ments can be seen. The thickened pylorus can often be felt. Diagnosis. — This may be difficult. In wasting infants with chronic vomiting unrelieved by the treatment of a skilled pediatrician, the condition should always be suspected. Prognosis. — Practically all cases die unless treated surgi- cally. About 50 per cent, recover with operation. Treatment. — Three operations have been tried. Gastro- enterostomy, Loreta's operation of forcibly dilating the pylorus, and pyloroplasty. The last has thus far given the best results. If operation is impossible, systematic washing of the stomach may be tried. 1 Scudder and Quinby, Journal of the American Medical Association, May 27, 1905, p. 1665. Thomson, "Pyloric Hypertrophy," Scottish Medical and Surgical Journal, June, 1897, p. 511. Fischer and Sturmdorf, "Pyloric Stenosis," Archives of Pediatrics, May, 1906, p. 341. DISEASES OF THE STOMACH. 151 ULCER OF THE STOMACH. 1 This is rare in infa nts and young children. It may 1 >e seen in the hemorrhagic disease of the newborn, in acute gastritis, in tuber- culosis, and there is an idiopathic form which tends to perforate Symptoms. — Pain, tenderness, vomiting (often with blood), bloody stools (black). If perforation occurs peri- tonitis follows. Diagnosis. — Forms cannot be distinguished. The above symptoms are characteristic. Prognosis. — Bad in most cases. Death may be due to perforation or to hemorrhage. Treatment. — Rest in bed for at least three weeks, longer if necessary. Hot fomentations may be used if there is much pain or tenderness. Small frequent feedings are best, as a rule. Bismuth subnitrate may be used in large doses. If perforation occurs, immediate operation. TUMORS OF THE STOMACH. Carcinoma, 2 sarcoma, and lymphadenorna have been reported in infants and young children. They are all very rare. HEMATEMESIS. (Hemorrhage from the Stomach.) This may be caused by the following : The hemor- rhagic disease of the newborn, ulcer of the stomach, acute gastritis, the swallowing of blood from the nose or pharynx, and in nursing infants, blood from a fissured or ulcerated nipple, hemophilia, purpura, the purpuric forms of the infec- tious diseases, scurvy, and in young girls about puberty from vicarious menstruation. If the blood is immediately ejected it may be bright red in color. If it has been in the stomach any length of time the color is dark and it is grumous. The stools are a tarry black. If from a lesion in the stomach keep at rest, and give adrenal extract. Do not feed by the mouth, but by the rec- tum for a day or two. i " Gastric Ulcer in the Young," New York Med. Jour., Oct. 3, 1909, p. 837. 2 Osier and McOae, New York Med. Jour., April 21, 1900, p. 581. 152 DISEASES OF INFANTS AND CHILDREN DISEASES OF THE INTESTINES, MALFORMATIONS OF THE INTESTINES. There may be stenosis or atresia at any point in the intes- tinal canal. The lesions are frequently multiple and usually at the upper part of the small intestine. Atresia is the more common. In stenosis the child may live weeks or even months ; in atresia death usually takes place within a week after birth. Meckel's Diverticulum. — This is the remains of the omphalomesenteric duct which connects the umbilical vesi- cle and the intestine during fetal life. When it persists it is usually seen as a blind pouch several inches long, coming off from the lower part of the ileum. It may occur in hernias. There may be a fibrous cord from it ending at the umbilicus, which is a cause of intestinal strangulation. Deformities of the Rectum. — There are three deformi- ties of the rectum. It may end in a blind pouch some distance above the anus. There may be an anus, and the lower part may be present, but separated from the upper by a membranous sep- tum, or there may be a complete rectum but no anus. The last-named is easily operated upon successfully. The second may be sometimes, while the first is practically always fatal. CONGENITAL ABSENCE OF THE ABDOMINAL MUSCLES. This is a rare condition in which the abdominal muscles are either partially or entirely absent. The abdomen is enlarged and pendulous. The folds of the intestines and the peristaltic movements are plainly visible. On palpation the abdominal organs can be plainly felt, as the abdominal wall consists of only skin and connective tissue. In cases where the muscles are only partially absent the bands of muscle fibers can usually be seen and felt. In rickets the rectus abdominalis is frequently deficient. Children whose abdominal muscles are defective are generally constipated. Where there are other malformations, or an absence of ab- dominal skin as well as muscles, the child may either be born dead or die soon after birth. DISEASES OF THE INTESTINES. 153 Treatment. — In the more severe grades the abdomen should be supported by a snugly fitting supporter. A flannel Fig. 42.— Congenital absence of abdominal muscles. bandage may be all that is required where the muscles are partially present. CATARRHAL JAUNDICE— GASTRODUODENITIS. Definition. — A catarrhal inflammation of the stomach and upper part of the small intestine which extends into the bile duct. Btiology. — It is rare under two years of age, but is seen in older children. It may come on without apparent cause or it may complicate any of the infectious diseases. Pathology. — Besides the catarrhal condition of the 154 DISEASES OF INFANTS AND CHILDREN. stomach and intestine the bile-duct is inflamed, and frequently there is a plug of tenacious mucus filling Vater's diverticu- lum and causing an obstructive jaundice. Symptoms. — There is a sudden onset with pain in the right hypochondrium, vomiting, and slight fever. After several days jaundice appears. This varies in intensity, but is generally not very severe. The liver is usually somewhat enlarged and tender, the urine is bile-stained, the stools are white and with a foul odor, the tongue is coated, with com- plete loss of appetite and great lassitude. Itching of the skin and slow pulse are rare under seven years of age. After a week or two the symptoms pass off and the jaun- dice disappears a little later. Diagnosis. — See Diseases of the Liver for symptoms of the other diseases. Prognosis. — Good. Treatment. — Diet. — Give little or no starchy food or fats. Give a moderate amount of milk peptonized or diluted with a carbonated water or lime-water. Give fresh green vegetables, fruit, and rare meat. Diet until the jaundice has disappeared. Medicine. — Vichy water to drink. Calomel at the outset. Phosphate of soda in hot water every other morning or every morning. Treat gastric symptoms like acute gastric indi- gestion. If there is pain use counter-irritation. DIARRHEA, Diarrhea is a term used to designate frequent loose move- ments of the bowel. Diarrhea is most common in hot weather, especially seen in frequency and severity in July and August. It is more common and also more fatal among poor children whose surroundings are unhygienic, where there are filth, overcrowding, and lack of fresh air. The weak and diseased suffer more than the healthy, and the teething child more than the one who is not teething. Four-fifths of the cases are under two years of age, and the greatest number of these between twelve and eighteen months. The mortality corre- sponds with the frequency of attack. One of the greatest DISEASES OF THE INTESTINES. 15S factors in causing diarrhea is the use of improper or impure food. Spoilt milk is the most common cause. Impure water may also be a causal factor. Over 95 per cent, of the cases of the so-called summer diarrheas occur in artificially fed babies. Diarrhea may be classified as of simple and infectious origin. In the simple forms there are only present the normal bacteriologic flora of the intestine. In the infec- tious form there are present bacteria not normally present in the intestine, and which, we may assume, are causal factors or the cause of pathologic complications. The simple diarrheas, according to Holt, are : 1. Mechanical. — From indigestible articles taken into the intestine. These may be taken as food or otherwise. Green fruit is the most common example. 2. Medicinal. — From laxative drugs. 3. Reflex. — From fright, overheating, or chilling, and the like. 4. Blitninative. — As the diarrhea of uremia. The first causes what may be described as intestinal indi- gestion. There is at present no very good classification of the infec- tious forms. They are described below under the following headings : Acute gastro-enteritis, including cholera infantum, acute ileocolitis and colitis, chronic ileocolitis, and amebic colitis. ACUTE INTESTINAL INDIGESTION. Etiology. — The same as acute gastric indigestion, which it may accompany. It is frequently seen, however, without any gastric involvement. Symptoms. — If the stomach is involved as well there will be symptoms of gastric indigestion. There are pain and diarrhea. There may or may not be distention of the abdomen. There are present prostration and fever ranging from 100° to 105° F. or more. The stools are at first the normal feces, but loose and fre- quent. Later there are thin movements which are greenish or brownish in color, which may have a very foul odor and which contain particles of undigested food, fat, the curd of 156 DISEASES OF INFANTS AND CHILDREN. the milk, or other things if they have been taken. After a day or two there may be mucus in large quantity. Diagnosis. — Diagnosis from the infectious forms is made by its comparative mildness, the infrequency of vomiting, and short duration. At the outset there is absolutely no way to tell what form of diarrhea one has to deal with. Prognosis. — Good in strong children where the attack is properly treated at the time and subsequently. May cause death in weak infants and predisposes to other bowel disease. Treatment. — Clean out the stomach and bowel. Wash out if necessary. Give calomel (10 y 1 ^- gr. doses) if there is vomiting, or a full dose of castor oil if there is not. After the bowel has been thoroughly emptied (but never until then) small doses of paregoric or Dover's powder may be given if there are very frequent stools or very much pain. Opium should always be used with great caution. After the bowels are emptied bismuth may be given in combination with chalk mixture. Subcarbonate (1-2 gr.) or subnitrate (5-10 gr.) every two or three hours. Essence of pepsin may be added if desired. Withhold all food for the first twenty-four hours, except a little albumin-water. This is best given in small doses at not too great intervals. Plain boiled water may be used instead. Very weak tea to which a little red wine has been added may be given if the child is weak. On the second day the albumin- or barley-water may be given with the addition of weak strained broth, and on the third day malted milk may be added to the list. After four or five days cows'' milk diluted and boiled or peptonized may be tried. It is best mixed with a farinaceous gruel or with malted milk to start with. It may be given every other feeding for a day or two if it agrees, and the former feeding gradually resumed. In nursing infants withhold the breast twenty-four hours and feed as above. After that the breast may be given once for a few minutes and the feeding pieced out with albumin- or barley-water. If it agrees the breast may be given for three or four feedings, every other feeding followed by albu- min- or barley-water. On the following day the breast may be given at each feeding. The time of nursing should be increased gradually until the child is back on its old schedule. DISEASES OF THE INTESTINES. 157 THE INFECTIOUS DIARRHEAL DISEASES. 1 The infectious diarrheal diseases are not very thoroughly understood as yet, and there are, in consequence, numerous classifications and a diverse nomenclature. There may be severe symptoms, with few or no lesions in the bowel, or there may be extensive lesions. The disease may run a rapid course or a prolonged one. Toxic symptoms may be pro- nounced or wanting. The differences seem to depend on the virulence of the infection and the condition and resistance of the child. In the very acute cases the symptoms are chiefly of a toxic nature, from the absorption of the poisons produced by the bacteria in the bowels. There are practically always some pathologic lesions, usually of an inflammatory type. In the more prolonged cases they are liable to be more severe and may result in ulceration of the intestine. Certain fairly well-marked clinical forms may be described, but it is sometimes difficult to draw hard-and-fast dividing lines. ACUTE GASTRO-ENTERITIS. 2 (Summer Diarrhea; Summer Complaint; Acute Intestinal Intoxication; Cholera Infantum, Etc.) Definition. — An acute infectious diarrhea occurring most frequently in summer. Etiology. — While it is seen the whole year the greatest number of cases occur in hot weather. Nearly all the cases and nearly all the deaths are in bottle-fed babies. It is most prevalent among the poor and overcrowded. It is most fre- quent in children under two years of age. The bacteria findings are various. It appears that many different organisms may under certain conditions multiply in the intestinal tract and cause diarrhea. The Shiga-Flexner bacillus (Bacillus dysentericus) has been found in the stools i Studies of the Diarrheal Diseases of Infancy, from the Eockefeller Insti- tute for Medical Research. , 2 Maurice Ostheimer, " Diarrhea, Summer, Preventfon of, Journal of the American Medical Association, August 26, 1905, p. 595. ,158 DISEASES OF INFANTS AND CHILDREN. in some instances, but the majority of the cases are not caused by it. Pus germs are found in some cases, usually in the severer forms described as cholera infantum. Pathology. — The bowel contains mucus and fecal mate- rial similar to the stools. There may be some congestion of the mucous membrane and some swelling of the lymph- nodes. There are degenerations in the epithelium. There may be an associated nephritis, bronchopneumonia, and de- generations in the liver cells. Symptoms. — The onset may be gradual, with but little fever and symptoms of intestinal indigestion, or it may be Fig. 43. — Acute intestinal intoxication. Note the facial expression and corneal ulcer. sudden with high fever. In the first class the child is not quite well, has loose stools, usually undigested and discol- ored. Recovery may be prompt or the disease may assume the. character of the severe form. In the severer form fever and prostration exist ; the child is at first restless and nervous, but later on may become listless and semicomatose. There may be delirium, convulsions, or coma. There is vomiting, frequently continuous, and of everything that the child swallows. The stools are frequent. First the natural intestinal contents are passed, then mucus mixed with fecal matter, usually greenish or brownish in color. There may be blood or pus. The loss of weight is great and the child becomes weak, pale, and a few days may so change a child's appearance that it is unrecognizable. The child may recover, die, or tbe disease may become chronic DISEASES OF THE INTESTINES. 159 and change into an ileocolitis. Relapses are frequent, usually due to errors in diet. Cholera Infantum. — This is a form of diarrhea char- acterized by marked toxic symptoms, high fever, severe vomiting, profuse discharge of copious thin stools, great loss of weight, and usually death. A small percentage recover. The symptoms resemble those seen in Asiatic cholera ; hence the name. Diagnosis. — At the outset it is impossible to tell whether a diarrhea is of the severe type or merely an intestinal indi- gestion. The latter usually responds to treatment, and when the bowel is cleansed the symptoms subside. A continuance of the symptoms means an infectious diarrhea. Acute diseases, such as pneumonia or scarlet fever, may start in with a diarrhea. Meningeal symptoms may be marked and the case mistaken for a meningitis. A sunken fontanel belongs to diarrhea rather than meningitis. Lum- bar puncture may be resorted to. Prognosis. — In good surroundings with proper treat- ment, fair ; in weak children and in poor surroundings or with improper care, bad. Prophylaxis. — Fresh air ; cleanliness ; pure food ; more water and less food during the hot weather ; disinfection of the stools and things which have been in contact with the case. Treatment. — If in city send to country where it is pos- sible. Keep the child in the fresh air. Keep the child clean. Cold sponging or bathing should be used to reduce fever. An ice-bag may be used on the head. Dietetic Management. 1 — Breast-fed Infants. — In Winter. — Lengthen nursing periods to six hours. In the meantime give boiled water, whey, albumin-, rice- or barley-water. After a day or two, if all goes well, resume nursings on the regular schedule. In Summer. — Withhold all milk for twenty-four hours and give above-mentioned articles every three or four hours. Plain boiled water is perhaps best, allowing the bowel a per- fect rest. This alone often cures the diarrhea promptly. Whisky and water, or one of the liquid beef preparations, may 1 See Diet in Health and Disease, by Friedenwald and Rulirali. 160 DISEASES OF INFANTS AND CHILDREN. be given in water if the child is weak. If the child is better on the second day it may be allowed to nurse a few minutes. If this does not cause an increase in the diarrhea nursing may be grad- ually resumed. The mother's breasts should always be pumped out at the nursing intervals to maintain a free flow of milk. Bottle-fed Babies. — Withhold all fresh milk until complete recovery. During the first twenty-four hours nothing but boiled water. Whisky and water, or liquid beef preparations and water, may be used if baby is very weak. On the second day albumin-, barley-, or rice-water. On the third or fourth day try malted milk. If this is well borne, milk and barley or rice-water, equal parts, well boiled, may be tried. The return to fresh milk should be gradually made. Whey is useful. If there is vomiting withhold food and wash out the stom- ach. Equal parts of lime water and cinnamon water in tea- spoonful doses is useful to stop vomiting. Tiny bits of ice may be given to allay thirst. Lime-water with the food in 20 per cent, to 30 per cent, proportion is useful if gastric symptoms persist. If tbe fluids are abstracted from the body so that collapse threatens give several ounces of normal salt solution under the skin. Other Treatment. — Wash out the stomach and bowel. If seen early administer calomel (-^ gr. every half hour for ten doses) if there is vomiting, or castor oil if there is not. Salines may be used. After cleansing the bowel give one of the following : Bismuth subnitrate (5—10 gr. every two hours) ; bismuth subcarbonate (1-5 gr.) ; bismuth subga 7 - late (1—5 gr.). Resorcin, bismuth salicylate, salicylate of soda, salol, and beta-naphthol bismuth may be used. Bis- muth subnitrate in chalk mixture is about the best. Avoid too much drugging. Opium should be used with great cau- tion to diminish the number of stools, relieve pain and pro- duce sleep. It should never be used until the bowel has been thoroughly cleansed, as it may cause the retention of very toxic fecal material. Paregoric and Dover's powder are most frequently used. Strychnia and whisky may be administered if stimulants are needed. Use small doses well diluted. DISEASES OF THE INTESTINES. 161 ACUTE ILEOCOLITIS. Enterocolitis; Enteritis; Dysentery; Inflammation of the Bowels. Definition. — An inflammation of the large and small bowel characterized by frequent bowel movements, tenesmus and marked constitutional disturbance. Three forms may be described : catarrhal, ulcerative and membranous. It is often impossible to distinguish cases of acute gastro- enteritis from cases of ileocolitis. The classification is by no means perfect. Etiology. — The causes are the same as for acute gastro- enteritis. The Shiga-Flexner bacillus can be demonstrated in many cases. There may be pus germs present as well. Many cases follow the milder forms of diarrhea. Pathology. — The lymph follicles are enlarged and ulcer- ated in most cases. In others there is a simple catarrhal inflammation and there may be simple ulcerations of the mucous membrane. In other cases there is a membranous inflammation. The lesions are for the most part in the colon and lower part of the ileum. The most frequent compli- cating lesions are bronchopneumonia and nephritis. Symptoms. — Catarrhal Form. — There is usually a sud- den onset, vomiting and diarrhea ; the stools contain blood and mucus. There is great pain wirh tenesmus. The stools are very frequent. There are fever and toxic symptoms with more or less prostration. In mild cases the acute symptoms last about a week, but there is a great tendency to become chronic. In severe cases the acute symptoms may last weeks. Ulcerative Form. — This is usually secondary to a gastro- enteritis. There is not so much temperature as in the pre- ceding, and the stools are not as frequent. Blood is seen sometimes. There is progressive emaciation with great weak- ness. The diagnosis is made from the general history. Membranous Form. — This is always severe. There is a sudden onset with vomiting and high fever, as in the catarrhal form, but if anvthin^ more intense. There mav be marked nervous svmptoms. The diagnosis is made on the presence 11 162 DISEASES OF INFANTS AND CHILDREN of pieces of membrane in stools otherwise like those seen in catarrhal ileocolitis. Diagnosis. — From typhoid by the Widal reaction and the slower invasion of typhoid. From intussusception by the constipation following the onset and the symptoms of obstruc- tion. The membranous form is sometimes mistaken for meningitis if the cerebral symptoms are marked. Diarrhea is rare in meningitis. Prognosis. — Bad in all cases. Many of the catarrhal forms recover, but relapse is frequent. The ulcerative form is usually fatal, but sometimes partial recovery takes place, and the child may die of some intercurrent affection. The membranous form is usually, though not always, fatal. In the poor, in previously ill children, and in hot weather the out- look is especially bad. Treatment. ^Very much the same as in acute gastro- enteritis. Fresh air or a change of air is important. Opium is needed for the pain and frequent stools. Irrigation of the bowel is also useful. Flush the bowel with normal salt solu- tion and then use fluid extract of witch-hazel (1 dr. to 1 pint) or some other astringent. Nitrate of silver is sometimes useful. CHRONIC ILEOCOLITIS. (Chronic Dysentery.) Definition. — A chronic inflammation, often with ulcera- tion of the ileum and colon, characterized clinically by pain and chronic diarrhea. Etiology. — It almost always follows the acute form of the disease. Pathology. — There is a catarrhal form in which there are present an increased amount of mucus, pigmentation of the mucous membrane, proliferation of the lymphoid tissue of the intestines and of the lymph-nodes connected with it. There is also an ulcerative form in which, in addition to the above, there are ulcerations. These may be follicular or of a broad flat type. Cystic degeneration of the intestine is a rare lesion. The liver is fatty, nephritis is not uncommon, DISEASES OF ?HE INTESTINES. 163 and lesions in the lungs, either tuberculosis or bronchopneu- monia, may be present. Symptoms. — Emaciation and weakness, little or no fever. Numerous thin, brownish or greenish stools contain- ing undigested food and pus and occasionally blood. Colic and pain in the abdomen may be present. The abdomen is usually distended with gas. There are frequently ulcerations about the mouth and anus. Nervous symptoms may be marked. Diagnosis. — It may be impossible to tell the disease from tuberculosis, as tuberculosis is not uncommon as a com- plication. Fever is absent or slight, while it is nearly always present, though irregular, in tuberculosis. Prognosis. — Cases last from weeks to a year. The longer the preceding acute stage has lasted the worse the prognosis. Death frequently takes place within several months. Remarkable recoveries may take place. Treatment. — Good care and careful diet is the most important part. A change to mountains or seashore may work wonders. Foods leaving but little residue should be used. Predigested milk and beef preparations, white of egg, rare or raw scraped beef, malted foods, and alcohol are the most useful. Washing out the bowel is of value ; a cleans- ing enema of warm salt solution, followed by a small injec- tion of fluid extract of witch-hazel or some other mild astringent, is best. Opium may be used to lessen the num- ber of stools if excessive. Drugs may be given for flatulence, pain, or other symptoms. AMYLOID DEGENERATION OF THE INTESTINES. This is sometimes seen in older children. The causes are the same as for amyloid changes in other organs. There are anemia and cachexia, enlargement of liver and spleen, a cause of amvloid disease, and in some cases there mav be a diarrhea. In many instances of the disease diagnosis is not determined until after death. The treatment is to remove the cause where possible. 164 DISEASES OF INFANTS AND CHILDREN. AMEBIC COLITIS. 1 Definition. — A form of colitis associated with the pres- ence of the ameba coli in the stools and lesions. Etiology. — This is rare in children, but is perhaps more frequent than is generally supposed. The ameba coli is re- garded as the cause of the disease. The youngest case reported was in a child about two years old. Pathology. — This is the same as in adults. There are Fig. 44.— Ameba coli. ulcerations in the colon, which undermine the mucous mem- brane. Symptoms. — The disease is usually subacute or chronic, although acute cases may be seen. The onset is frequently abrupt, with fever and diarrhea. The symptoms frequently disappear to recur after a short interval. During the ex- acerbations there is diarrhea accompanied with pain and tenesmus and some fever. Diagnosis. — This is made on finding the ameba in the stools, or, better still, from scrapings from the ulcers. Prognosis. — The disease lasts months or years and fre- quently ends fatally from exhaustion, hemorrhage, or liver abscess. Treatment. — General supporting treatment, together with irrigation of the bowel with normal salt solution, fol- lowed by quinin solution from 1 : 5000 to 1 : 1000. CHRONIC INTESTINAL INDIGESTION. Definition. — A condition in which food in the intestine is imperfectly digested. 1 Amberg, Bulletin Johns Hopkins Hospital, Dec, 190L DISEASES OF THE INTESTINES. 165 Btiology. — It may follow acute attacks, improper feed- ing, or general debility. Pathology. — There is usually an associated catarrh of the intestinal mucous membrane. Symptoms. — In infants gastric indigestion is frequently associated. Malnutrition is the most prominent symptom. There may be diarrhea or constipation. Undigested food is seen in the stools. The stools are frequently discolored (see Infant Stools, p. 106). Symptoms in Older Children. — These children are emaciated, nervous, and capricious. There is flatulence and often a distended abdomen. There may be chronic diarrhea, or a diarrhea alternating with constipation, or more rarely consti- pation. The stools are, as a rule, very offensive and contain a great deal of mucus. Fever and nervous symptoms may be present at times. The symptoms are very numerous and varied. Diagnosis. — This usually presents no difficulty. Prognosis. — This is good if seen early and the child can be properly cared for and dieted. Treatment. — This is mainly hygienic and dietetic. In- fants should be cared for as suggested for malnutrition, and the food regulated according to general principles. Consid- erable experience is often required to adapt the food to the infant's digestion. In older children the diet should be milk, meat juice, and rare meat and egg albumin. Later malted food, zwieback, orange juice, and other articles of diet mav be cautiously added. INTESTINAL COLIC. Definition. — Severe paroxysmal pain in the intestines. Etiology. — Flatulence from indigestion, especially in nursing infants ; in artificially fed babies, excesses either in proteins, sugar or fat ; indigestible articles of food ; inflam- mation of the abdominal viscera and reflexly from cold feet and exposure to cold. Symptoms. — Crying, evident discomfort and pain, and 166 DISEASES OF INFANTS AND CHILDREN. a hard tympanitic abdomen. There may be cyanosis of feet and hands. Relief frequently follows the expulsion of gas. Diagnosis. — Exclude peritonitis, appendicitis and in- flammatory conditions. Prognosis. — Good as regards attack. The disease may recur frequently. Treatment. — An enema of warm water or of water and glycerin to expel the gas. Heat or counterirritation to abdomen by hot-water bottle or spice bag. Internally, aro- matics, and in very severe cases doses of codein or pare- goric. In the intervals treat the indigestion. CHRONIC CONSTIPATION. 1 Definition. — A condition where the stools are less fre- quent or harder than normal. Etiology. — Constipation may be due to a large number of causes. Improper diet is one of the most frequent. A diet which gives too little volume of refuse, or one lacking in fat in younger children, or in fruits and vegetables in older children, may be the cause. Atony of the intestines is also a frequent cause. Insufficient secretion from the intestinal glands or the liver may also be a cause. Pain on defeca- tion, caused by fissures of the anus and the like, may result in infrequent stools. Symptoms. — Discomfort, pain in the abdomen, and straining at stool. In some cases there are no apparent ill effects, whereas in others there may be toxic symptoms, headache, languor, and disturbed sleep. Diagnosis. — The cause should be sought. The anus and rectum should be examined. Prognosis. — Often persists for a long time. Treatment. — Regular habits of stool. Regulation of the diet. In infants see that they get sufficient fat and pro- tein. Well-cooked and sweetened oatmeal gruel is useful. Orange juice, baked apples, or prune juice taken on an empty stomach is of service. Olive oil, the malted foods, or malt 1 Pritchard, "Constipation in Infants," The Practitioner, May, 1910, p. 583. Poynton, " Constipation in Childhood," The Practitioner, May, 1910, p. 567. DISEASES OF THE INTESTINES. 167 extracts are also useful. In older children fresh fruits, vege- tables, and oatmeal porridge are of value. Graham bread, dates, figs, and prunes may be used. Massage of the abdo- men is of some value. A glass of water taken immediately on rising is also advisable. Enemata should be used to empty the bowel in case of need. Suppositories, either plain or gluten, or containing mix vomica, belladonna, or hyoscyamus, may be tried. From one to four teaspoonfuls of pure liquid petrolatum may be given at bedtime in obstinate cases. Of the drugs, castor oil, calomel, and the salines should be used only when it is desired to empty the bowels quickly, never as a routine ; mix vomica, belladonna, hyoscyamus, and cascara are the best for chronic constipation, and are usually given in combination. The aromatic syrup of rhubarb is frequently used. Phosphate of soda is useful in some cases. INTUSSUSCEPTION* 1 Definition. — The invagination of one piece of gut into another is called intussusception. Intestinal obstruction re- sults. The commonest form is that occurring at the ileocecal valve (ileocecal), but intussusception of the small intestine (enteric) or colon (colic) may occur. Postmortem intussusception is a frequent autopsy find- ing. It occurs just before or after death and causes neither local reaction nor clinical symptoms. It is of no import- ance. Etiology. — Intussusception is more common in boys than girls, and the majority of cases occur before the third year, most frequently between the sixth and ninth month. It is caused by irregular intestinal contraction. This is sometimes produced by injury, but generally no exciting cause can be determined. Pathology. — Congestion and swelling of the gut follow, rendering reduction difficult or impossible. Gangrene may follow unreduced intussusception. The portion of the gut 1 Snow, Archives of Pediatrics, vol. xxi., p. 494. I. H. Hess, "Intussus- ception in Infancy and Childhood," Archives of Pediatrics, September, 1905, p. 655. Dunbar, " Acute Intussusception," Scottish Medical and Surgical Journal, August, 1906. 168 DISEASES OF INFANTS AND CHILDREN. sloughed may be passed through the rectum. In chronic intussusception adhesions take place, but gangrene is less common. Symptoms. — The onset is sudden, with pain and vom- iting. The pain recurs in paroxysms ; the vomiting con- tinues and may become fecal. There are one or two loose stools, after which only blood and bloody mucus are passed. The abdomen is relaxed, and a tumor is felt either in the right iliac fossa or through the rectum. There is marked shock. If not reduced the vomiting continues, tympanites occurs, and later on fever. There may be symptoms of peri- tonitis. A rapid rise in temperature usually means death within twenty-four hours. Occasionally there may be sub- acute or chronic cases with less intense symptoms. Diagnosis. — The symptoms are characteristic. Make careful abdominal and rectal examinations in all suspicious cases. Do not mistake ileocolitis. Prognosis. — This is always bad. Death usually takes place between the third and the fifth day. With prompt diagnosis and treatment the outlook is somewhat better than formerly. Recurrences may take place, usually within twenty-four hours after reduction. Treatment. — Anesthetize and either inflate with air or inject salt solution. Rumbling, uniform filling of the colon, and sometimes the passing of feces determine if reduction has occurred. The disappearance of the tumor is important. If doubt exists or the symptoms return perform a laparotomy. Act promptly ; delay means death. In using injections do not raise the syringe over three feet above the patient's body for fear of rupturing the bowel. After operation keep quiet, give opium, very light diet, and avoid cathartics. APPENDICITIS- 1 This is rare in infants. More frequent in boys than girls. Foreign bodies are an occasional cause, digestive disturbances 1 Kelly and Hurdon, The Vermiform Appendix, p. 450. Vincent, " Acute ' Appendicitis in Children," Boston Med, and Surg. Jour., Sept. 24, 1908, p. 427. DISEASES OF THE INTESTINES. 169 especially j constipation may precede it in some cases; in most there is do apparent cause. Catarrhal, suppurative, gangrenous, and chronic forms have been described in infant-. Catarrhal Appendicitis. — Rarely diagnosed as such. The appendix is thickened. There is pain with tenderness over the abdomen. This may be extreme, and is located midway 1 >et ween the umbilicus and the right iliac spine. There may be vomiting and some fever. A tumor can sometimes be felt in the right iliac fossa. The attack passes off in a few days or a week or passes into one of the severer forms. Entire recovery may take place or a chronic form may follow. Recurrences are frequent. Suppurative Appendicitis. — Onset as above. It may end in any of the following : Localized Peritonitis. — The acute symptoms last a week or two. There is a diffuse hardness in the right iliac fossa, which becomes more definite and then gradually disappear-. Abscess. — A tumor mass can easily be made out. There are fever, pain, and tenderness. Pus is present early. Sub- sidence sometimes takes place or it may rupture into the bowel. Rupture into the peritoneum causes peritonitis. General peritonitis, which may also be caused by perfora- tion in gangrenous appendicitis. Gangrenous Appendicitis. — Onset as in catarrhal form. May become rapidly worse at any time with sudden pain, vomiting, and symptoms of shock. Peritonitis follows with tympanites and great tenderness. There may be a lull in the symptoms, but death takes place in nearly all cases in from one to five days. Prognosis. — The prognosis of appendicitis is worse in children under six or seven than in the adult. Over seven it is somewhat better. Much depends on good judgment and skilful treatment. Diagnosis. 1 — Sudden onset, pain in the abdomen, vomit- ing, tenderness, rigidity, and sometimes tumor in the right iliac fossa, are the principal points. Colic is of shorter duration ; 1 J. N. Hess, " Appendicitis in Children, Diagnosis of," Archives of Pedi- atric.?, May, 1905, p. 329. 170 DISEASES OF INFANTS AND CHILDREN. there is no fever and no localized tenderness. Intussusception is rare after two years of age ; the sudden onset, with a tumor at the start and the more intense symptoms, paroxysmal pain and the bowel obstruction, usually suffice. Acute in- digestion cannot be differentiated at the start, but it is re- lieved by treatment. Pneumonia or pleurisy may cause extreme abdominal tenderness. Psoas abscess generally presents no difficulties. Blood-counts are of some value in the hands of an expert, but do not draw too definite conclu- sions from blood-counts. Leukocytosis over 20,000 may mean abscess and may be helpful in differentiating appen- dicitis from other intestinal disturbances. Rapidly increasing leukocytosis is of more value. Leukocytosis may occur in any severe intestinal disorder, and is present in pneumonia. Treatment. — Rest. If very restless use a long side splint or a light plaster cast. Watch carefully. Opiate for pain. Give castor oil at the outset and then wash out the colon daily, and the stomach, too, if there is vomiting and it is possible to do it without too much excitement on the part of the child. Avoid cathartics. Operate at once in localized abscess and the gangrenous form. In other forms, if seen during the -first forty -eight hours, operation may be done at once ; if seen later wait until the process becomes localized and walled off by peritoneal adhesions. Operation between the attacks may be considered in the catarrhal form. DILATATION AND HYPERTROPHY OF THE COLON. 1 This is a rare disease seen in infants and older children. There is hypertrophy of the muscular coats of the colon, together with marked constipation and distention of the abdo- men. The distention may disappear temporarily after a stool. The patients are emaciated. Some die early, whilst some live to be adults. The treatment is symptomatic. Treves has operated on a case with good results. A certain amount of simple dilatation of the colon is seen in infants with chronic constipation, especially the rachitic ones. This usually disappears during early childhood. 1 Osier, Archives of Pediatrics, February, 1893, p. 111. DISEASES OF THE INTESTINES. 171 INTESTINAL WORMS. 1 Cestodes (Tapeworms).— The eggs of these worms are taken into the body of certain animals (intermediary host), and the embryos are set free in the stomach. These em- bryos migrate and become en- cysted in the muscles. When such meat is eaten by man the embryo is set free and attaches itself to the mucous membrane of the bowel and grows into an adult worm. The eggs are contained in the mature seg- ments, which are furnished with the male and female sexual organs. Taenia Mediocanellata or Saginata (The Beef Tape- worm). — This is the common tapeworm of America. In- Fig. 4o.-T£enia mediocanellata : Small Fig. 46. -Taenia elhptica (Mosler portions from different parts in the length and Peiper). of the tapeworm (J. P. C. Griffith). ^Schloss, "Helminthiasis in Children," Amer. Jour, of Med, f«.,voL cxxxix., 1910, p. 675. Still, " Thread- worms," Brit. Med, Jour., Apr. lo, 1899. 172 DISEASES OF INFANTS AND CHILDREN. fection takes place from eating "measly" beef. The adult, worm is from ten to twenty feet long. The head has four suckers, but no hooks. The adult segments are about as long as they are broad. Taenia Solium {The Pork Tapeworm). — This is rare in America. It is shorter than the preceding, and the head has four suckers and a circle of booklets about the proboscis. The adult segments are nearly square. Hymenolepis Nana (The Dwarf Tapeworm). — This will doubtless prove a common parasite in Amer- ica. It is the smallest cestode par- asite affecting man. The worms are present in great numbers. The ova are found in the feces, are col- orless or brownish, and are easily seen with the low power of the microscope. The eggs have two membranes, and the six hooklets of the embryo are seen inside. The worm is from 12 to 15 mm. long and 0.5 to 0.7 mm. broad at its widest part, There are from 110 to 200 segments. It is delicate and easily i broken. The head has suckers and worm has hooklets. A similar been found in rats. 1 Taenia Cucumerina or Elliptica. — The embryos are found in dog and cat lice. Infection occurs by get- ting the embryos on the hand from dogs or cats. The adult is from six to twelve inches long. Bothriocephalus latus, the fish tapeworm, and Tarnia flava punctata are rare forms occasionally met with. 1 Bulletin No. 18, Hygienic Laboratory of the Public Health and Marine Hospital Service, 1904. Fig. 47.— Ascaris lumbri- coides : A, Female ; B, male ; C, egg (X 300) ; b, head (magnified) (after Perls). DISEASES OF THE INTESTINES. 173 Symptoms. — There are no distinctive symptoms, but in- creased appetite, unpleasant abdominal symptoms, bad breath, and sometimes pain and diarrhea are complained of. Usually the first knowledge of the parasite is the finding of the seg- ments in the stool. This is the only certain means of diag- nosing it. Anemia of a severer grade may be met with and the bothriocephalic may cause pernicious anemia. Eosino- philia is present. Prophylaxis. — Thorough cooking of meat. Careful govern- ment inspection. Treatment. — Light diet for a day and a laxative to empty the bowel. Oleoresin of male fern in several doses at inter- vals of an hour. From 10 to 20 minims may be given at a dose to children. Give a purge a few hours after the anthel- mintic, and a milk diet for the remainder of the day. Examine the stools for the head, which is about the size of a grain of mustard. If the head is not passed the worm will grow again. Pelletierine (3-12 gr.) or pumpkin seed (J oz.) may also be used. Nematodes. — Ascaris Lumbricoides (Roundworm). — The eggs are taken in with water or food, and they develop in the intestine into round worms from 4 to 6 inches long, \ of an inch in diameter. The females are longer than the males. A number are present at one time. Symptoms. — Often none, but at other times colic, indiges- tion, loss of appetite, disturbed sleep, picking at the nose and all sorts of curious reflex nervous symptoms, such as convul- sions, vertigo, and paralyses. Occasional febrile disturb- ances may be present. Obstruction of the bowel has been caused by masses of the worms. They migrate and may crawl out of the nose or into the larynx or Eustachian tube. Their presence in the stools is the only positive way to diag- nose them. Treatment. — Empty the bowl as for tapeworm, then give three or four doses of santonin, | to 1 gr. Follow by castor oil or calomel. Give the santonin in powder with sugar. Oxyuris Vermicularis (Seatworm; Pinworm). — These are 174 DISEASES OF INFANTS AND CHILDREN. small round worms as thick as a pin and from J to } in. in length. They are found in the lower colon and rectum. They cause intolerable itching of the anus, sometimes proc- Fig. 48.— Oxyuris vermicularis and egg : a, Natural size ; b, egg (after Heller). titis. There may be large quantities of mucus in the stools. They may cause convulsions. Treatment. — Require persistent treatment. Wash out the bowel with borax and water (teaspoonful to the pint) and then inject half pint of quinine sulphate solution (2 gr. to 1 pint) or 1 : 10,000 bichlorid of mercury. Infusions of quassia or garlic are also useful. Garlic may be given by the mouth. In resistant cases try santonin. DISEASES OF THE RECTUM. Prolapse of the Anus. 1 — This may be simply of the mucous membrane, or the entire rectum may be everted. It is most frequent in the second and third year and is fre- quently caused by prolonged straining at stool. Symptoms. — Usually occurs at stool and frequently can be easily reduced. Where several inches of the rectum are everted there is a red tumor-like mass which may be more or less difficult to return. Treatment. — Oil the finger and return by pressure. Keep the child quiet for an hour afterward. If difficult to return apply cold cloths. Painting with 4 per cent, cocain may be used in obstinate cases. In recurring cases have child defecate on its back or while using a seat inclined to 1 Kelsey, " Prolapse of the Rectum," Archives of Pediatrics, 1885. DISEASES OF THE INTESTINES. 175 an angle of 45 degrees. Keep the bowels well open. Inject tannic acid (5 grs. to J oz.) water twice daily or anoint with belladonna ointment. A pad and a T bandage may be used as a support where the bowel tends to come down between stools. Local injections of strychnia (y^o S r or nnear marking with the cautery may be tried. Fissure of the Anus. — Looks like a tear or an ulcer- ated surface. Causes very great pain, especially at stool. Treatment. — Keep clean and the bowels open. Touch with nitrate of silver. If not relieved anesthetize and stretch the sphincter of the anus. Fig. 49.— Prolapsus of the rectum (after Bryant). Irritation of the Anus and Hemorrhoids. — Irri- tation of the anus is frequent, while hemorrhoids are com- paratively rare. Constipation should be relieved, the child should be kept clean, and the following ointment used liberally : li Tannic acid, Powdered camphor, Ichthyol, Zinc oxid ointment, gr. x ; gr. v ; 3iss; 3J.— M. (Kerley.) Proctitis. — This occurs with inflammations of the colon, but may occur alone from suppositories, pin worms, gonor- 176 DISEASES OF INFANTS AND CHILDREN. rhea, or from syphilis, scarlet fever, measles, and other infec- tious diseases. It may be catarrhal, ulcerative, or mem- branous. Treatment. — Regulate the bowels. Magnesia or sodium bicarbonate by mouth if stools are acid. Keep clean with normal salt solution injections, follow with injections of oil and lime-water in the acute cases, fluid extract of hamamelis, teaspoonful to the pint in the chronic forms, and boric acid in the ulcerative cases. Nitrate of silver (1 gr. to the ounce) may be used in very resistant cases. Neutralize the excess of silver with salt solution. Incontinence of Feces. — Seen in injuries and diseases of the spinal cord, in comatose conditions, and in very severe illness of any kind. Is also sometimes seen in very nervous children. This last form may be benefited by local injec- tions of strychnia (y^ g r -) twice daily and by using ergot in a suppository or by mouth. PERITONITIS. All forms of peritonitis are rare in early life. Acute Peritonitis. — In the newborn it may be caused by infection through the umbilicus. In later childhood it may follow wounds, surgical operations, burns, and exposure. It may be a sequela of appendicitis or be caused by an ex- tension of other purulent inflammations or it may be a com- plication of the infectious diseases. Pathology. — It may be localized or general. It may be fibrinous, serous, or purulent, according to the nature of the exudate. Adhesions are frequent. Symptoms. — Sudden onset, vomiting, usually high fever, crying, and fretfulness. The abdomen is distended, tym- panitic, and tender. The muscles are rigid. There may be convulsions or collapse. In young infants it may be found at autopsy where it was not suspected during life. Prognosis. — In infants it is very fatal, the average duration being four days. In older children the outlook is better, DISEASES OF THE INTESTINES. 177 especially if the inflammation becomes localized. If the child lives over a week the chances are then much better. Treatment. — An initial purge of calomel or a saline or both, opium in some form for the pain, stomach washing if there is vomiting, high saline injections into the rectum sev- eral times daily. Abdominal applications of cold, heat, or counterirritants may be used. Do not irritate the skin if a surgical operation is to be performed. Careful feeding with liquid predigested foods. Stimulants as required. Surgical operation may be indicated. Exploratory laparotomy and the evacuation of pus may be considered. Chronic (Non-tuberculous) Peritonitis. — This is a rare disease of late childhood. The cause is unknown. It has been supposed to follow measles, rheumatism, and ex- posure. There is usually a considerable serous exudate with fibrin flakes. Numerous adhesions are present. Symptoms. — Gradual enlargement of the abdomen, which is somewhat tender. There is gradual loss of weight and strength. There is slight fever, as a rule. The disease runs an irregular course with periods of improvement and relapses. Diagnosis on above symptoms with absence of evidence of disease of other organs. (See Tuberculous Peritonitis.) Treatment. — Rest, careful diet, restricted fluid, and salines. The abdomen may be opened and flushed out with salt solu- tion. ASCITES. An effusion of fluid into the peritoneal cavity. It is usually a clear serous fluid, but may be bloody (sometimes in tubercu- lous or malignant disease) or milky. (See Chylous Ascites.) It may be part of a general edema, as in heart disease, chronic pleurisy, interstitial pneumonia, nephritis, anemia, etc., or it may be due to portal obstruction caused by cir- rhosis of the liver or the pressure of a gland or adhesions on the portal vein, or it may be seen when there is an abdominal tumor. 12 178 DISEASES OF INFANTS AND CHILDREN. The abdomen is enlarged, and the fluid can usually be made out by fluctuation or by the alteration in the position of dulness on changing the position of the patient. Fig. 50.— Omental cyst. (Courtesy of Dr. J. N. Mendelsohn.) CHYLOUS ASCITES. 1 Ascites in which the fluid contains fat, giving it a milky appearance. Simple or tuberculous peritonitis may be present. It has been caused by wounds in the thoracic duct, but also occurs where the lymphatics appear normal. The prognosis is, as a rule, bad. Treatment as in tuberculous peritonitis. 1 Letulle, Revue de Medecine, 1884, No. 9. DISEASES OF THE LIVER. 179 DISEASES OF THE LIVER. Icterus. — Jaundice is only a symptom, and may be due to a number of different causes. These may be either obstructive or toxic. Under the first heading may be men- tioned stricture or obliteration of the ducts ; inflammation of the ducts, as in catarrhal jaundice ; foreign bodies in the duct, as a roundworm ; and pressure on the ducts from an enlarged gland or tumor. The toxic forms are sometimes seen in malaria, scarlet fever, Weil's disease, and other infectious diseases. Icterus in the newborn is usually the physiologic jaundice, but maybe stricture or occlusion of the duet or WinckePs disease. In older children icterus is nearly always the catarrhal jaundice: all other causes of icterus are extremely rare in children. The skin is yellow, and the secretions, urine, etc., are tinged yellow and contain bile pigment, the stools are whitish and very offensive, there is a great irritability and many other nervous symptoms, and also a tendency to hemorrhage. Slow pulse and itching of the skin are not common until after seven years of age. Acute congestion of the liver may be met with as in the enlarged and tender liver of malaria. Chronic con- gestion results from general venous obstruction, as in heart and lung diseases. The liver is enlarged, but there are rarely symptoms referable to it. Patty liver is common in infancy and childhood. About half the cases autopsied show this lesion. Tuberculosis is a frequent cause. The liver is enlarged, sometimes enor- mously so. It is smooth and has rounded edges and is not tender. There are no symptoms referable to the liver. Treat the accompanying disease. Amyloid liver is seen as a sequela of long-standing suppuration, especially of the bones. It is supposed to be due to poisoning with the toxins of the staphylococcus pyo- genes aureus. Amyloid changes are present in the other organs, and there is always an enlarged spleen. The liver is enlarged, hard, waxy, and gives a characteristic brown reac- tion with iodin. There is no jaundice and no symptoms referable to the liver. Edema, ascites, and albuminuria may 180 DISEASES OF INFANTS AND CHILDREN. be present from the kidney degenerations or from pressure. The condition is chronic and usually means a grave prog- nosis. The treatment is to get rid of the focus of suppura- tion. Antisyphilitic treatment should be given if indicated. Cirrhosis of the liver l is very rare in infancy and childhood. In infancy it is usually syphilitic, while in older children the cause is obscure and probably due to infectious diseases. The morbid anatomy, symptoms, and treatment are as in adults. Antisyphilitic treatment should be tried. Abscess 2 of the liver is rare in early life. It may be due to the migration of roundworms, or may be secondary to suppuration elsewhere in the abdomen or may be seen as a complication of an infectious disease. Symptoms are chills, fever, and sweats, pain in liver or referred to other regions, vomiting, diarrhea, loss of weight, and a septic appearance. Mild icterus is present in about half the cases. The liver is enlarged and fluctuation may be made out. Treatment is incision and drainage. Gallstones 3 are very rare in early life. They may, how- ever, be met with in infants, where it is a fatal condition. Hydatid cysts may be met with in childhood, but this disease is practically unknown in America. Acute yellow atrophy 4 has been reported as early as the twentieth month. CHRONIC FAMILY JAUNDICE. 5 A peculiar form of jaundice may be seen in several members of a family, sometimes in two, three, or even four generations. It does not interfere with growth, and may be present from birth. There is a mild icterus with the other symptoms, usu- ally present with jaundice or absent. The spleen is enlarged and there is a moderate anemia. Bilious attacks are common. There is no known treatment that influences the conditiou. 1 Howard, American Journal of the Medical Sciences, 1887, p. 350. 2 Musser, Keatiug's Cyclopedia, vol. iii., p. 466. 3 John Thomson, Edinburgh Hospital Reports, 1898. i A. H. Wentworth, " Yellow Atrophy, Acute," Archives of Pediatrics, February, 1906, p. 81. Clark and Dalley, " Hepaptosis, Congenital," Amer- ican Journal of the Medical Sciences, December, 19U5, p. 969. 5 Tileston and Griffin, American Journal of the Medical Sciences, June, 1910, p. 847. THE RESPIRATORY SYSTEM. 181 THE RESPIRATORY SYSTEM OF INFANTS AND CHILDREN, Respiration according to Uffelmarm : At birth 35 End of first year -±~ At second year 25 At sixth year 22 At twelfth year 20 At birth the anterior and posterior diameter of the chest arc about the same, and the thorax nearly the same size at the top and bottom, or cylindric in shape. Later, about the third year, it becomes flattened, and this increases until puberty, when the chest is wider below and being pointed like a cone above. The greatest part of the lung in in- fants and young children is at the back. One should also remember that in early childhood the chest walls are thinner and softer, and changes in shape due to disease, as in pleural effusion, are more frequent than in later life. The diaphragm is higher, and may be still further pushed up by gas in the stomach and intestines, the frequent source of dyspnea in dis- eases of the lung in the young. The thymus is larger and occupies a considerable portion of the anterior part of the mediastinum. The respiration in the infant is more or less irregular when it is awake, and the movements of the two sides of the chest may be unequal. After the second year there is the tendency for the respiration to become more reg- ular, and it is also regular when the child is asleep. The chest walls move less in children and the diaphragm more, so that the respiration rate is more easily counted by watch- ing the epigastrium. About the sixth year and later the respiration becomes more like that of adults. The trachea and bronchi are relatively much larger than in adults, while the air cells are smaller and there is more interstitial tissue. The percussion note is louder and more resonant than in older people, owing to the thinner chest wall and the larger bronchi. Abdominal tympany is more easily transmitted. Between the scapulas and below the clavicles the note is often tym- 182 DISEASES OF INFANTS AND CHILDREN. panitic, rather more pronounced on the right side. Cracked- pot sound can frequently be elicited even in health in these regions. The thymus dulness can frequently be made out over the upper part of the sternum, especially in children of the lymphatic type. The respiratory murmur is more bron- chial than in later life. This may be mistaken for bronchial breathing. Bronchial rales may be mistaken for friction- rubs. Flatness on percussion usually means fluid, even though bronchial breathing is plainly heard. Absence of dulness does not exclude consolidation, as the note may be aifected by small areas of supervening normal or emphy- sematous lung. CORYZA. 1 (Acute Rhinitis, Cold in the Head.) Definition. — An acute inflammation of the nasal cavities and of the rhinopharynx. Etiology. — Most frequent in children housed too closely. Is brought on by exposure to cold and wet, irritating vapors, and is seen as a complication of infectious diseases, especially measles, influenza and nasal diphtheria, and as a symptom of iodism. The associated organisms are most frequently the micrococcus catarrhalis, micrococcus paratetragenous, bacillus septicus, Friedlander's bacillus, and it is probable that the pneumococcus and the bacillus of influenza may be associated with mild catarrhs. Pathology. — The mucous membranes are reddened and swollen ; later there is a profuse discharge. Symptoms. — It begins with sneezing, malaise, fulness in the head, and after the onset a profuse discharge which may become mucopurulent. The nostrils may be occluded by the swelling, and the child breathes through the mouth. Complications. — Adenitis may follow in young infants. Conjunctivitis or catarrh of the middle ear may be present. Diagnosis. — Examine for diphtheritic membrane and in young infants for syphilis. In measles and influenza there is more constitutional disturbance, and in measles Koplik spots may be present. 1 Allen, " The Common Cold," Lancet, December 5, 1908. THE RESPIRATORY SYSTEM. 183 Prognosis. — Good. Treatment. — Open the bowels, keep in a warm room (70° F.) and give light diet. Atropin gr. YGTV ^ or eaca year of the child's age, or belladonna. In older children a quarter of a grain of camphor and qninin may be added. Use cleansing sprays, as Dobell's or Seller's solution, and fol- low by oily applications, as R. Menthol gr. v (0.3); Eucalyptol gr. vi (0.4); Camphor gr. v (0.3) ; Liquid petrolatum 5J (30.0). — M. Sig. — Use in an oil atomizer after cleansing the nose. CHRONIC NASAL CATARRH. ( Chronic Rhinitis. ) Chronic inflammation of the nasal mucous membranes may be due to a number of different causes. Among them are aden- oids, deviation of the septum, hypertrophy of the mucous membrane, polypi, repeated attacks of coryza, and syphilis. A one-sided nasal discharge is usually due to a foreign body in the nose or to a new growth or tertiary syphilis. Symptoms. — A mucous or mucopurulent discharge from the nose, mouth-breathing, obstruction of the nostril, nasal voice, diminution, or loss of the sense of smell, irritation of the upper lip, frontal headache, and catarrh of the neighbor- ing organs. Three varieties are described : simple, hypertrophic, and atrophic. Simple Rhinitis. — This is rare in children, and when seen is usually due to adenoids. There is profuse discharge and swelling of the mucous membranes. Prognosis is good if the cause is removed. Hypertrophic Rhinitis. — This is rare in early childhood, but it is seen in older children. The tissues covering the turbinated bones are inflamed and thickened. Adenoids are usually present. There is marked nasal obstruction and a mucopurulent discharge. Prognosis is good if persistent treatment is carried out. 184 DISEASES OF INFANTS AND CHILDREN. Atrophic Rhinitis. — This is occasionally seen in late childhood. The mucous membranes of the nose are atrophied, and there is a scanty discharge which tends to dry and form crusts which cause a very disagreeable odor. The sense of smell of the patient is usually lost. This form can be relieved by constant treatment, but a cure is not to be expected. Treatment. — The health of the child should be looked after, and it should have plenty of fresh air, good food, and tonics. Adenoids and obstructions should be removed. Hypertrophies may be cauterized if they persist after local applications. In all cases cleansing sprays should be used. In the hypertrophic form apply astringents to the mucous mem- brane (6 gr. of iodin, 12 gr. of potassium iodid, and 1 oz. each, of glycerin and water ; J per cent, solutions of silver ni- trate ; 20 to 40 per cent, aqueous solutions of ichthyol). In the atrophic form the nose must be cleansed twice daily with copious douches of hot antiseptic solutions and oily sprays used to keep the mucous membranes moist. Solutions of potassium permanganate, formaldehyd, or peroxid of hydro- gen may be used to lessen the intolerable odor. Syphilitic Rhinitis.— In early hereditary syphilis this is a most constant symptom, coming on usually between the third and sixth week. There is a profuse discharge and the child sniffles. In late hereditary syphilis, rhinitis is usually due to the breaking down of a gumma, with subsequent ulceration and necrosis, which may be very extensive. The bridge of the nose may sink in. Membranous Rhinitis. — This is almost without ex- ception diphtheritic and should be treated as such. ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX (Meyer, J868). 1 Definition. — Hypertrophy of the mass of lymphoid tis- sue normally present in the vault of the pharynx, and often called the pharyngeal tonsil. 1 Glogau, " Nasal Obstruction in Children," Am. Med., April, 1909, p. 195. THE RESPIRATORY SYSTEM. 185 Etiology. — Often hereditary, frequently .-ecu in rachitic children, and also a part of the general lymphatic enlarge- ment known as "lymphatism." A small percentage are of tuberculous origin, and in others they are first noted after some acute infectious disease or after frequent colds. Symptoms. — May be present at birth, but usually not until the child is several years old. The symptoms increase with the age of the child until about puberty, when there is Fig. 51.— Adenoid vegetations. a gradual atrophy of the adenoid tissue and a lessening of the symptoms. Adenoids cause : Chronic rhinopharyngitis with frequent attacks of coryza, especially in winter. Obstruction of the air-passages causing mouth-breathing, which may be constant or only when the child lies down, a nasal twang to the voice, inability to blow the nose, attacks of dyspnea at night and night terrors ; a dyspnea on lying on the back, consequently the child in sleep assumes other positions. There is frequently a paroxysm of coughing which may be mistaken for whooping-cough. The child fre- quently snores at night, and there may be enuresis. There is also frequent deformity of the chest, due to deficient expansion (pigeon-breast), most marked in rachitic chil- dren. 186 DISEASES OF INFANTS AND CHILDREN. In infants adenoids may cause difficulty in sucking, so that the child takes only sufficient food to satisfy the pangs of hunger, is consequently underfed, and malnutrition follows. There are also frequent attacks of coryza, bronchitis, and even a catarrhal laryngitis and croup. Deafness of a more or less severe grade is present in nearly every case. This may be due to otitis or to obstruction of the Eustachian tube. Mental dulness and apathy, indis- position to exertion, anemia, and general malnutrition are also present. Enuresis is also frequently present. Diagnosis. — The above symptoms and the typical ex- pression of nasal obstruction should lead to a digital exami- nation. The growths are easily felt by the finger, except in young infants or children with a very small nasal pharynx. In these latter the diagnosis may often be made by lifting up the soft palate, when in young infants the adenoid growths may usually be seen, as the nasal pharyngeal vault is much lower in infants than in older children. It should be borne in mind that mouth-breathing may sometimes be due to ob- struction in the nose, and careful examination for this should always be made. Prognosis. — This is good if the growths are removed, and the earlier the operation is done the better the ultimate results. If delayed until after puberty the breathing may be benefited, and by that time there may be incurable de- formities of the chest or tuberculosis or deafness may have resulted. Treatment. — The growths should be removed by means of a curet, best under the first stage of ether anesthesia. Children who have been mouth-breathers usually have to be taught to breathe through the nose by daily breathing exer- cises. In most cases a local astringent may be tried : R Iodin, gr. \ to £ ; Menthol, gr. j ; Camphor, gr. v ; Liq. petrolatum, 3j. — M. Sig. — Five drops in each nostril three or four times a day. THE RESPIRATORY SYSTEM. 187 DISEASES OF THE LARYNX, 1 Note that in all laryngeal affections in early life the amount of spasm is always much greater than the amount of disturbance and may be the cause of the principal symptom. CATARRHAL SPASM OF THE LARYNX (Goodhart). (Spasmodic Croup; Catarrhal Croup; Fake Croup; Spasmodic Laryngitis.) Definition. — A spasm of the larynx caused by a mild catarrh. Fig. 52— Croup tent (J. P. C Griffith). Ktiology. — This is most frequently seen between the sixth month and the fourth year, in certain children who are predisposed to it and who have frequent attacks. Exposure to cold or indigestion is usually the exciting cause. 1 Sutherland and Lack, " Laryngoscopy," Lancet, September 11, 1897. 188 DISEASES OF INFANTS AND CHILDREN. Symptoms. — During the evening the child has a barking cough and is slightly hoarse. During the night the child wakes with a hard metallic cough, marked dyspnea, loss of voice, and cyanosis. There is a loud inspiratory stridor. The child is frightened and struggles for breath. There may Fig. 53.— Croup kettle. Fig. 54.— Steam atomizer. be a slight fever. After an hour or two the attack wears off, but may recur the same night. A recurrence is to be looked for on the two or three following nights, but during the day the child is perfectly well, save for slight cough and hoarse- ness. Diagnosis. — From laryngismus stridulus (which see) and laryngeal diphtheria (membranous or so-called true croup, both unfortunate names). The sudden onset, the spasmodic character of the dyspnea and the remissions, together with a history of previous attack, usually makes the diagnosis from diphtheria easy. If there is doubt, give a little chlo- roform. The catarrhal spasm relaxes immediately while THE RESPIRATORY SYSTEM. 189 the laryngeal obstruction from a diphtheritic membrane is unaffected. Prognosis. — ( rood. Treatment. — During the attack relax the spasm by applications of heat, inhalations of steam or emetics. Syrup of ipecac, in tcaspoonful doses every fifteen minutes until vomiting occurs, is a favorite remedy. A tablet of antimony and ipecac (each yi-g- gr.) is also efficient, but is more depressing it' vomiting does not occur promptly. To prevent recurrence a dose of antipyrin (1 to 3 gr.) with or without sodium bromid or codein should be given and repeated if necessary. On the following day small doses of ipecac (10—15 drops) or the tablet mentioned should be given every four hours, and a dose of antipyrin with or without codein at night. ACUTE CATARRHAL LARYNGITIS. This is more rare than catarrhal spasm, and is usually due to exposure to cold or to irritating vapors. Symptoms. — The principal symptoms are hoarseness, occasionally aphonia, pain on speaking and swallowing, a barking cough, slight, sometimes high fever, and attacks of dyspnea. The vocal cords are red and swollen. Edema of the glottis is a serious complication. Diagnosis. — From catarrhal spasm by the more con- tinuous symptoms. From laryngeal diphtheria the diagnosis may be difficult. The more intense symptoms and the loss of voice suggest diphtheria. In laryngeal diphtheria after the first twelve hours the dyspnea is inspiratory and expira- tory, while in catarrhal laryngitis it is chiefly inspiratory. With diphtheritic membrane elsewhere, enlarged glands, or albuminuria, the diagnosis of diphtheria is almost certain. Make cultures from the larynx and watch the patient closely. Prognosis. — This is usually good except in the cases following the infectious diseases or in very young infants. Treatment. — Put the patient to bed, open the bowels, give ipecac or squills to reduce the spasm, or use inhalations of steam from water to which tr. benzoin comp. (1 dr. to 1 190 DISEASES OF INFANTS AND CHILDREN. pint) has been added. Hot applications may be used. In- tubate if dyspnea is urgent. In doubtful cases not improving under treatment give diphtheria antitoxin. Membranous Laryngitis (True Croup). — A name applied to laryngeal diphtheria. Occasionally a membrane may form in the larynx from some other infection, usually strepto- coccus, as a complication or sequela of one of the infectious diseases, most frequently scarlet fever or measles. The symptoms in the latter are nearly similar to laryngeal diph- theria (which see). EDEMA OF THE GLOTTIS. This may occur as a part of general edema, as in nephritis, or it may be due to injury or to the extension of an inflam- matory process (submucous laryngitis). Symptoms. — There is marked inspiratory dyspnea with normal expiration, pain, cough, hoarseness, and dysphagia. Diagnosis by digital examination. Treatment. — Scarification, application of adrenalin or astringents (alum, 3—5 gr. to the ounce), external application of cold, leeches over the larynx, tracheotomy if necessary. Intubation is of no service. CHRONIC LARYNGITIS. Simple I/aryngitis. — In children this is nearly always caused by adenoids. It may be due to irritating vapors. Symptoms. — There are hoarseness, aphonia, cough, and some expectoration. Laryngoscopic examination is difficult and reveals redness and swelling of the vocal cords or of the entire larynx. Treatment. — Remove the adenoids and use cleansing sprays, inhalations of benzoin, etc., and if necessary local applica- tions of astringents. (Alum, 3-5 gr. to the ounce ; sulpho- carbolate of zinc, 1—3 gr. to the ounce.) Tuberculous laryngitis. — This is almost unknown in early life and is rare in later childhood. When it occurs there is tuberculosis elsewhere, usually in the lungs. THE RESPIRATORY SYSTEM. 191 Symptoms. — There may be hoarseness, aphonia, cough, pain, in the throat, increased on swallowing, speaking or coughing. Laryngoscopic examination shows tuberculous deposits or ulcerations, but these are not characteristic of tuberculosis. Diagnosis on general condition. Treatment. — Keep clean with sprays, apply astringents locally — nitrate of silver, sulphate of zinc, or iodoform. Syphilitic laryngitis. — Frequent in early life as a symptom of early hereditary syphilis, less often as a mani- festation of late hereditary syphilis. There is usually ulcera- tion with great destruction. Symptoms. — These are the same as in other forms of chronic laryngitis. In hereditary syphilis there may be little or no pain. There is nothing characteristic on laryngoscopic examination. The diagnosis is on the general condition. Treatment. — Iodid of potassium and mercury internally. Local applications and sprays as in above. Intubation may give great relief. TUMORS OF THE LARYNX. These are usually papillomata, but granulations following tracheotomy may be seen. Symptoms. — These are the same as any form of chronic laryngitis, but there is slowly increasing dyspnea. Diagnosis by laryngoscopic examination. Treatment. — Operation by a specialist. FOREIGN BODIES IN THE LARYNX. 1 This may happen by the inspiration of the object from the mouth during laughing or crying. It causes coughing and dyspnea. The object may be forced out by the coughing or may be drawn into the trachea or bronchi, or it may remain in the larynx. Death may occur from suffocation. If drawn into the trachea there are pain, cough, and sometimes bloody 1 J. P. Clark, "Papilloma of the Larynx in Children," Boston Med. and Surg. Jour., Sept. 28, 1905, p. 377. John Kogers, " Larynx, Chronic Obstruc- tion of," Amer. Jour. 2Ied. Sci., Nov, 1905, p. 293. Clark, " Treatment of Laryngeal Papilloma," Boston Med. and Surg. Jour., Oct., 1905. 192 DISEASES OF INFANTS AND CHILDREN expectoration. There is absence of breath-sounds, according to the location of the object. Abscess may follow. Treatment. — Invert the patient and it may be coughed out. If lodged in the larynx and suffocation is imminent perform a tracheotomy. Operation for removal should be done by a skilful surgeon. LARYNGISMUS STRIDULUS. (Seepage 306.) CONGENITAL LARYNGEAL STRIDOR. Definition. — A curious stridor or crowing sometimes seen in early life, coming on immediately or shortly after birth. Ktiology. — The attacks may be increased by excitement and exposure to cold. Pathology. — There is an increase in the infantile char- acter of the larynx, the sides of the epiglottis being turned back so that they almost meet, making the opening of the larynx smaller and of a peculiar shape. In cases lasting a long time there may be a pigeon-breast deformity of the chest. Symptoms. — " The stridor consists of a croaking sound, which accompanies inspiration and which rises to a high- pitched crow on quicker or deeper breathing. Expiration is usually noiseless, and sometimes when the inspiratory noise is loud it is accompanied by a short croak " (Thomson). There is little or no cyanosis. The stridor may be present all of the time or may intermit, or may only come on in attacks due to excitement. The child appears otherwise normal and unconcerned. There is no disturbance in the voice. The disease reaches its height about the sixth month, and begins to diminish and usually ceases entirely by the eighteenth month or the second year. During the later months the stridor only comes on during excitement. Diagnosis. — This is easy. The congenital character of the disease and absence of other symptoms separating it from laryngismus stridulus, and the normal cry from laryngitis and papilloma of the larynx. There may be croaking in cases of adenoids, which disappears on their removal, and in enlargement of the mediastinal lymph-nodes ; this latter is THE RESPIRATORY SYSTEM. 193 usually coupled with marked disturbance of health, with hoarseness, and is sometimes suggestive of whooping-cough. Prognosis. — This is good. > Treatment.— Protect the child from excitement, regulate the diet carefully, and have the child out of doors as much as possible. Diseases of the Bronchi and Lungs. BRONCHITIS. Definition.— An inflammation of the mucous membrane lining the bronchial tubes or, in infants, of the entire tube, characterized by cough, expectoration, soreness about the chest, and moist and dry rales. # Varieties.— Acute catarrhal bronchitis, chronic catarrhal bronchitis, and fibrinous bronchitis. ACUTE CATARRHAL BRONCHITIS. Etiology. The primary form usually results from ex- posure to cold, wet, or draughts, but may also be due to irritating vapors or dust. The secondary form is seen as a complication of almost all of the infectious diseases, especially of measles, influenza, and pertussis. Pathology. — There are swelling and congestion of the mucous membranes lining the tubes, together with an inflam- matory exudate mixed with mucus, pus cells, and desqua- mated epithelium. The ordinary "cold" is a tracheobron- chitis- the severe "cold" involves the medium-sized tubes, while' the severe forms in infants extend to the smallest tubes (capillary bronchitis). Symptoms.— In Infants.— Bronchitis of the larger tubes (mild form). The onset is gradual, with coryza, pharyngitis, and cough. The respiration is rapid and irregular, and there are loud rales which can be easily heard and felt. There may be fever (100°-102° F.). Vomiting may result from the severe coughing spells. The attack usually lasts about a week. Kelapses are common. Bronchitis of the smaller tubes, capillary bronchitis (severe 194 DISEASES OF INFANTS AND CHILDREN form). The onset may be gradual or sudden. All the symptoms of the mild form are inereased. There may be high fever, marked dyspnea, prostration, and cyanosis. It may resemble a pneumonia for a few days. Death may take place in young or weak infants from respiratory failure or from suffocation due to the inability to cough up the sputum. The severe stage lasts two or three days and then changes into a milder form. (For differential diagnosis, see Broncho- pneumonia.) In Older Children. — Either mild or severe forms may be seen, but there is little tendency to extend into the smaller tubes. The symptoms as given in the mild form in infants are present. The breathing is less rapid and more regular, and the cough is more pronounced. In the severe forms there are fever, pain in the head and chest, and general malaise. The attack lasts from one to three weeks. Relapses are frequent. Prognosis. — In weak and young (under six months) in- fants the severe form may prove fatal. In strong ones (over six months) the outlook is good. Prophylaxis. — Well-ventilated rooms, neither too hot nor too cold. Cold sponging over neck and chest, night and morning. Cod-liver oil every winter to susceptible children. Treatment. — Keep indoors and, if there is fever, in bed. Open the bowels and, if seen early, sweat by means of a hot bath (foot or full) and Dover's Powder and phenacetin. Rub chest with camphorated oil. If fever is not too high use an oiled-silk jacket over the chest. In severe forms use counterirritation over the chest ; a mustard plaster just to redden the skin is best. This may be repeated every three or four hours. In the first stage inhalations of steam from lime water ; later from creosote or compound tincture of ben- zoin (1 dr. to pint of water). Strychnin and atropin may be used to stimulate respiration, and alcohol given if the heart is weak. Attacks of suffocation are best treated by hot bath, mustard plaster, and stimulants. In mild cases in infants the Jackson mixture containing syrup of squills may be used ; otherwise in infants it is best to avoid expectorants. THE RESPIRATORY SYSTEM. 195 Id older children squills, ipecac, 6r Dover's powder in the dry stage. Later, ammonium muriate and mistura glycyr- rhiza composite or citrate of potassium may be used. If there is pain and cough is troublesome, codein with antipyrin or phenacetin may be used. Heroin hydrochlorate, with or without terpin hydrate, may be used if the cough is exces- sive. For persistent bronchitis creosote or terebene is best. Cod-liver oil may be used during convalescence. A change of air is advisable where circumstances allow. FIBRINOUS BRONCHITIS* Primary fibrinous bronchitis is a rare disease, more fre- quent in children than in later life. A secondary form may be seen complicating laryngeal diphtheria. Casts or strings of mucus are expectorated, and the diagnosis rests on finding the casts. The symptoms are like ordinary bronchitis, but there are few T or no rales. It may become chronic, attacks occurring every few days or weeks. The acute form is fre- quently fatal (75 per cent.), but the chronic form is not. Treatment. — Not satisfactory. Inhalations, counterirri- tation, and the administration of stimulating expectorants or emetics. Iodid of potassium is useful in the chronic form. CHRONIC BRONCHITIS. 1 This is not common in early life, but may be seen asso- ciated with heart disease, emphysema, interstitial pneumonia, tuberculosis, hereditary syphilis, and following the acute in- fections. It may also be seen in malnutrition and rickets. Symptoms. — There is cough, which is frequently parox- ysmal and is liable to be more severe at night. The sputum may be scanty or abundant. There may or may not be coarse rales. Exacerbations are common. Diagnosis. — From pertussis by the course of the dis- ease. A marked leukocytosis is suggestive of pertussis. From tuberculosis by fever and loss of weight with progres- 1 Allan, "Persistent Chronic Bronchitis in Children," The Practitioner, April, 1910, p. 532. 196 DISEASES OF INFANTS AND CHILDREN. sive weakness. A positive diagnosis can be made by finding the tubercle bacilli in the sputum. Treatment. — The associated disease should receive atten- tion. Creosote is the most satisfactory drug. Cod-liver oil is of great service. Terebene and iodid of potassium may be used. If the cough is excessive heroin may be prescribed. A change of climate is beneficial. BRONCHIECTASIS. 1 Definition. — A dilatation of the bronchial tubes. Etiology. — This is seen in weak, syphilitic, or rickety children who have had bronchitis. It often follows influenza. Lord has isolated the influenza bacillus in cases of bronchi- ectasis. Pathology. — The lung presents a honeycombed appear- ance throughout part or even all of the lungs, due to the dilated bronchioles and small cavities. The bronchi are sur- rounded by a small zone of inflammation. On the surface of the lung there are small vesicles which contain air. Symptoms. — There is cough, paroxysmal in character, and relieved by the expectoration of a considerable quantity of foul-smelling pus. In some cases the sputum is swallowed, and only expelled by vomiting. There is usually some de- formity of the chest, and often clubbing of the fingers. There is anemia and often fever. The physical signs consist in tubular breath-sounds, together with rales, which vary with the size of the cavities and the amount of pus in them. If the lesion is limited there may be dulness. Diagnosis. — Principally from tuberculosis. In the cases where there is no expectoration this may be very diffi- cult. In tuberculosis, fever is more constant, the disease progresses more rapidly, and there may be involvement of the lymph-glands. Prognosis. — Bad. Some of the cases live for many years, ■ 1 Godlee and Fowler, Diseases of the Imngs. Stanley Box, " Bronchiec- tasis, Treatment of," Practitioner^ June, 1906, p. 839. THE RESPIRATORY SYSTEM. 197 hut almost invariably the disease sooner or later causes death. Treatment. — Fresh air, good hygiene and food, tonics, especially cod-liver oil, and creosote are advised. Locally inhalations of creosote, eucalyptus, or sprays of iodoform emulsion may be tried. NERVOUS COUGH; REFLEX COUGH, These terms are applied to cough produced by disease of other organs than those of respiration. It may be caused by adenoids, elongated uvula, enlarged mediastinal glands or abscess in the posterior mediastinum (as that caused by Pott's disease), heart disease, anemia, and general nervous- ness. Symptoms. — The cough is usually worse at night, and is liable to be paroxysmal in character, especially if due to intrathoracic causes. Diagnosis. — This is possible only by the most careful observation and examination. Treatment. — Treat the underlying cause when found. To relieve the cough phenacetin or antipyrin, combined with sodium bromid, may be given at bedtime. ASTHMA. 1 This is a term applied to most conditions where there is dyspnea, but it should be limited to the spasmodic attacks associated with catarrh of the bronchi. It is not a very common disease in early life, but may be seen in later child- hood. Etiology. — It may be hereditary and is most frequently seen in gouty or neurotic families. It may be due to local causes, as rhinitis, adenoids, or elongated uvula. The pollen of certain plants and numerous other things may cause it. Symptoms. — Adult type. — There are wheezing respira- tion, cough, and dyspnea. Loud rales are heard on ausculta- tion. The attack passes oif with treatment or after several 1 La Fetra, Archives of Pediatrics, December, 1904, p. 904. 198 DISEASES OF INFANTS AND CHILDREN. hours without treatment, but recurs after hours, days, or weeks. Emphysema may result. Attacks simulating capil- lary bronchitis may occur in infants, but lasting only a few hours or a day. Some children get spasmodic dyspnea with every attack of catarrhal bronchitis. Hay fever is rarely seen before puberty. Diagnosis. — This is, as a rule, easy. Sometimes the dis- ease can only be told by the recurring attacks. Prognosis. — If due to a removable cause, as asthma, the outlook is good. The infantile forms usually have a favor- able outlook, but death may occasionally result. The danger usually is that the disease becomes chronic. Treatment. — Examine nose, throat, and chest, and treat all abnormalities or diseases as far as possible. During an attack place the child in a tent filled with the fumes of stra- monium leaves and niter paper. (Himrod's, Kidder's, or Kutnow ? s cures are convenient mixtures to use.) Emetics may be given if the stomach is full. To prevent recurrence full doses of antipyrin may be given. A change to another climate is best where the disease shows a tendency to become chronic. Iodid of potassium and tonics may be used between the attacks. PNEUMONIA. 1 This is one of the most frequent diseases of infancy and childhood, and is often a cause of death. It is an inflam- mation of the lung. There are two principal forms — broncho- pneumonia, also called catarrhal or lobular pneumonia, and lobar or croupous pneumonia. Other forms are hypostatic and chronic bronchopneumonia. Pneumonia is frequently complicated with pleurisy, and then the condition is called pleuropneumonia. Pneumonia may also be due to tubercu- losis or other diseases. In a general way the diagnosis of pneumonia may be suspected when a child is taken suddenly ill with fever, cough, and depression, with rapid respiration, in which the ratio of the pulse is about 1 to 3, and if added to 1 W. P. Northrup, " Pneumonia, Cold Fresh Air Treatment in," Boston Medical and Surgical Journal, February, 1906, p. 216. THE RESPIRATORY SYSTEM. 199 this there is flaring of the nostrils, a change from the or- dinary breathing, which is first inspiration, then expiration, then a pause, to what might be called pneumonic breathing, which is inspiration followed by a pause, then expiration fol- lowed by a grunt, and if there is also slight rigidity of the neck and upper extremities, the diagnosis is almost certain, and can easily be confirmed by a careful examination of the chest. BRONCHOPNEUMONIA, This is seen most frequently in infancy. Etiology. — Somewhat over half the cases occur during the first year and one-third more during the second year. After the fifth year it is very rare. The primary form affects males more frequently than females (5 : 4). In the secondary form the sexes are affected about equally. It is most often met with in the weak, the sick, poorly nourished, and poorly housed. It is common in asylums. Over half the cases are secondary to other diseases, especially to measles, pertussis, diphtheria, and ileocolitis. Xo one organism is found in all cases. Most frequently there is the pneumococcus, the streptococcus, or the staphylococcus aureus. Other organisms are found more rarely. There are frequently two or more forms of bacteria found in the same case. The secondary cases are often due to streptococci, and the areas are small and separated. Large areas of consolidation are usually due to the pneumococcus. Pathology. — The disease involves the smaller bronchi- and the adjacent air cells. The walls. of the bronchi, the air cells, and the interstitial tissue of the lung are infiltrated with an exudate, and the bronchi and 'air spaces are filled with it. The areas of consolidation are usually small and are scattered through the lung, and are separated by patches of normal lung. They may run together, however, and form areas of consolidation of considerable size. The patches vary in size from less than a millimeter to several centimeters. The disease is usually bilateral, but in about one-tenth of the cases one lung only is involved. In this case the apices 200 DISEASES OF INFANTS AND CHILDREN. (right) are most frequently affected. As a general rale the left lower lobe is most frequently involved. The exudate consists of red and white cells, and differs from the exudate of lobar pneumonia in that it contains numerous epithelioid cells and very little fibrin. In some cases the process is not unlike the lobar pneumonia, and in these cases the fibrin is more abundant. The disease runs no definite course. During the first clay or two there is congestion of the lungs, but after several days the process becomes localized in certain areas which are reddish and semisolid. There may be hemorrhages. After a few more days there is more complete consolidation, and the lung presents a mottled red and gray appearance which turns to gray almost entirely after the first two weeks. (The bronchi are filled, as well as the air cells, and not empty as in lobar pneumonia.) Sometimes one part of the lung clears up and another becomes affected. There is compen- satory emphysema over the unaffected part of the lungs. The bronchial lymph-glands are swollen. Pleurisy is common if the disease reaches the surface of the lung. Death or resolu- tion may occur at any time, or the disease may last for weeks. Gangrene and abscess or empyema may follow. Symptoms. — Bronchopneumonia has no regular course. The primary form may come on suddenly or gradually, while the secondary form has nearly always a gradual onset. In most cases the disease starts in as a pneumonia, but some- times it is apparently a bronchitis for several days and then changes into a pneumonia. In other cases the dominant symptoms are vomiting and diarrhea and the real disease may be overlooked. The pulse is rapid, the respiration is labored and rapid, the child is depressed, and usually has an appear- ance suggesting pneumonia. There may be vomiting, chill, or convulsions, at times there are intense nervous symptoms at the onset, even delirium, and later coma. The disease may ter- minate at any time either in death or by getting well. Some cases last only a few days and are called the abortive form. The average form lasts from two to three weeks, and the pro- tracted form from one to four months and occasionally longer. The very protracted cases usually die from exhaustion. THE RESPIRATORY SYSTEM. 201 The temperature is extremely irregular, going up and down without apparent reason. In vigorous children and in severe cases the tendency is to be high, in weak depressed children it may be low, and some cases run a subnormal temperature. The respirations vary from 40 to 60 and sometimes go as Temp. | 1 — T~ 1 | — 1— 109 1 1 \ ! 1 ; j i 1 108 " ! I i 1 ! i 1 107 1 I I- I 106 i 1 i i - 1 ! \ 105 1 1 ...[_ ; i : \ !• ' \ I 104 i '/' :. \h i \ w ' ' 1 1 1 1 f \ \ j \P \7\ I i i j 103 i J\ \l v\ »! 7\ | «i \ \l l/;\ / vp i / I . 102 i , J Vi U :/l r V ! J: i !/ 1 / 1 101 V i! 1 1 ; i I; 1 I | , A ; 100 i ii j \/\ V. k 1^ VJ*- 99 1 I ! | j 1 V i 1 >< 98 | ! l 97 r 98 j i i Temp. . i Pulse j i 1 1 1 ! j i | I I Stools 1 \ | 1 1 i 1 | 1 1 | 1 1 1 Urine 1 j | 1 1 1 I i | | | I 1 I | 1 1 1 1 Day of Disease / 2- i Y- J- (, •? J- f /o // /2- s* /^ /j- /& O /* . Wlnnonuct °-ar s •5 C _!^. It"* Po5* rLO^HvUSj — — , Fig. 63.— Differential percentage counts during first fortnight (Hutchison, after Carstanjen). Eosinophils. — Same as preceding, but the granules are larger and stain deeply with acid dyes. Mast Cells. — Much like preceding, except the nucleus may be mono- or polynuclear and the granules stain with basic dyes. Abnormal White Cells. — Myelocytes. — Found nor- 234 DISEASES OF INFANTS AND CHILDREN. mally in bone marrow. A very large round or nearly round cell with a large feebly staining nucleus and neutrophilic granules. These cells may vary in size. Eosinophilic Myelocytes. — Like preceding, except the gran- ules are stained by acid dyes. O i-l 72 fc I " 88" 1 I 64" 1 ? ?M mi rz. PA &£ • v 60" 1 1 A 'v > *N V » V* 56" 1 1 / ' s » V \/ ' \>' 52" I / / \' k / ' V' 48" t • t •» / / 44" [• [: '"•< 40" (i r .s ' \ 36" c 1 32" V • ***« /. /-/■ K?, fol ir- 7 " 28" i • • '*• 1 , /-•- .., r^j > s.> *! .' nr- 4 /r ft? it- 1 :S. Fig. 64.— Differential percentage counts throughout life (Hutchison, after Carstanjen) Nongranular Myelocytes may be seen in severe anemias. Degenerated Leukocytes. — Stain irregularly and may con- tain vacuoles and no nuclei. Blood-plates. — Small cells half size of a red blood-cell, colorless, and usually clumped together. Their significance is not known. THE BLOOD IN INFANCY AND CHILDHOOD. 235 Blood-dust. — Numerous highly refractile, actively mov- ing bodies seen in fresh blood. These are supposed to be granules from the eosiuophiles. FREQUENCY OF THE VARIOUS FORMS OF LEUKOCYTES. Infancy. Adult (Cabot). Lymphocytes 40-60 20-30 per cent. Large mononuclears 4-12 4- Polynuclears 20-40 62-72 u Eosinophils 2-4 £-4 " Mast cells The total number per cubic millimeter is somewhat larger in infancy than in adults. At birth they are from 12,000 to 25,000. This number diminishes rapidly during the first few days to 9,000 to 14,000. In childhood 6,000 to 12,000 may be regarded as an average. SIGNIFICANCE OF BLOOD CHANGES* Red Blood-cells. — The number is diminished in pri- mary and secondary anemia. Normal in chlorosis. Increased in cyanosis, in high altitudes, and at sea coast. Hemoglobin. — The total quantity is diminished in all forms of anemia. The corpuscle contains less in chlorosis and secondary anemia. The corpuscle contains a normal amount or more in pernicious anemia. White Blood-cells. — Lymphocytes. — Normally more present than in adults, and in many severe diseases of child- hood the blood tends to revert to the infantile type. Lymphocytosis (increased number of lymphocytes) is seen in lymphatic leukemia, whooping-cough, scurvy, rickets, and hereditary syphilis. Leukocytosis (neutrophilic). Physiologic. — This is marked in infancy. Is seen in the newborn, after meals, after massage, cold baths, exercise, etc. Pathologic. — In numerous conditions ; in toxemias, after severe hemorrhages ; in inflammatory conditions, when there is pus-formation, septicemia and pyemia, pneumonia, etc. 236 DISEASES OF INFANTS AND CHILDREN. Normal Number of Leukocytes and Disease. — There are many diseases where leukocyte count is unaffected, as malaria, typhoid, tuberculosis, mumps, measles. Leukopenia. — (Diminution of the white blood-cells.) — Seen in severe anemias, malnutrition, leukemia complicated by in- fectious diseases, and in severe disease when there is no re- action — i. e.j leukopenia in pneumonia usually means a fatal prognosis. Eosinophilia. — Found in many conditions, among which may be mentioned : the infection of the body with animal para- sites, as in trichinosis, in malignant tumors, in many skin diseases, in leukemia, scarlet fever, etc. Mast Cells. — Said to be more numerous in the lower classes. Are increased in some forms of leukemia and some other diseases. Myelocytes. — Seen in most cases of leukemia, in small num- bers in severe anemias, in the leukocytosis of some diseases, as diphtheria, and after any severe blood disturbances, as asphyxia, uremia, etc. BLOOD CHANGES IN DISEASE. Pneumonia. — Diminution of hemoglobin and of red blood-cells, leukocytosis, except in very mild and very severe forms. Absence of leukocytosis in severe cases means a grave prognosis. Eosinophiles diminish, and their reappear- ance means the height of the disease is over. Leukocytosis may be of value in diagnosis of doubtful cases. Leukocyto- sis after normal has been once reached usually means a com- plicating empyema. Diphtheria. — Great diminution in hemoglobin and red blood-cells after a few days. Leukocytosis usually present. Myelocytes in severe cases ; where they exceed 2 per cent., a fatal prognosis may be made (Engel). Scarlet Fever. — Diminished hemoglobin and red cells. Leukocytosis varies with intensity of the disease. Eosino- philes, beginning after two or three days, increasing to 8 to 15 per cent, in two or three weeks, gradually reaching normal THE BLOOD IN INFANCY AND CHILDHOOD, 237 about the sixth week. Eosinophiles are increased in favora- ble cases and decreased in unfavorable ones (Neusser). Leu- kocytosis, after third day, is of value in differentiating scarlet fever from measles in doubtful cases. Whooping-cough. — Marked leukocytosis comes on early and persists through the entire disease. It averages 25,000 to 30,000, and is more marked under four years of age. Half the cells are lymphocytes. Leukocytosis is useful in differentiating spasmodic cough from other causes. Meningitis. — Septic meningitis has leukocytosis. Cere- brospinal fever has leukocytosis in about two-thirds of the cases. Tuberculous meningitis may or may not be accom- panied by leukocytosis. Congenital Cyanosis. — Increase in hemoglobin and in number of red cells (6,000,000 to 12,000,000). There may be an increase in the leukocytes. CHLOROSIS. (Green Sickness.) Definition. — A primary anemia with a lowering of the hemoglobin without any great decrease of the red blood-cells, except in severe cases. Etiology. — L^sually occurs about or just after puberty, It may occur earlier and is rarely seen in boys. Previous ill health, overcrowding, lack of fresh air and sunshine, and overwork are the predisposing causes. Pathology. — Some fatal cases have shown a small heart and congenital narrowness of the aorta and other vessels. Complicating tuberculosis or ulcer of the stomach is the most frequent cause of death. Symptoms. — Blood-changes are characteristic. Low hemoglobin, 20, 30, or 40 on von Fleischl's scale is com- mon ; red blood-cells, normal in number or nearly so ; in severe cases poikilocytosis ; no leukocytosis. Other symp- toms are the general symptoms of anemia ; a greenish pallor ; weakness without loss of flesh ; nervousness ; perversions of appetite (pica) ; and in girls, menstrual disorders. Hemic 238 DISEASES OF INFANTS AND CHILDREN. murmurs are heard over the base of the heart and larger ves- sels. The heart may be dilated or the left ventricle hyper- trophied. Complications. — Constipation, gastric ulcer, gastralgia, hyperacidity, amenorrhea, albuminuria. Prognosis. — Good, but relapses are common. It may last months or even years. Treatment. — Fresh air, sunshine, good food, rest, and baths if there is a reaction after them. Solutions of iron and manganese peptonate or Blaud's pills may be given. Saline laxatives are needed. In hyperacidity give alkalis, especially calcined magnesia. Arsenic may be tried, but is of less value than iron. PERNICIOUS ANEMIA. Definition. — A grave anemia, which is usually fatal, having the characteristic blood-changes given below. Etiology. — Very rare in infancy. It may follow a severe secondary anemia, it may be caused by intestinal para- sites, or it may come on without assignable cause. Pathology. — Severe anemia of all the organs and fatty degeneration in most of them. Small hemorrhages ; deposits of iron in the liver ; hemolymph glands may be enlarged and congested ; bone marrow is dark red and soft with numerous nucleated reds ; there may be atrophy of the stomach mucosa. Blood-changes. — Specific gravity lowered ; hemoglobin very low, but color index of the cell normal or above normal ; great reduction in the number of the red cells ; megalocytes common ; marked poikilocytosis ; red cells may be polychromatophilic ; normoblasts and megaloblasts present; polymorphonuclear leukocytes diminished. Symptoms. — The symptoms are those of a severe anemia. Skin has a light lemon tint ; there may be slight edema ; there may be effusion into the serous cavities ; there may be but little emaciation. Great weakness ; later prostration. Nervousness and sleeplessness. Heart may be dilated ; hemic murmurs common. Shortness of breath on exertion. Digestive disturbances. Diagnosis.— Great diminution of red cells, high color THE BLOOD IS INFANCY AND CHILDHOOD. 239 index, diminution of polymorphonuclears. An eosinophilia points to intestinal parasites. Retinal hemorrhage is nearly always present in pernicious anemia and rarely seen in sec- ondary anemias (Hesse). 1 Prognosis. — Bad ; recovery is of very rare occurrence. High color index, increase in size of red cells, degenerative changes, numerous megaloblasts, few or no normoblasts, and lymphocytosis are all bad signs. Treatment. — Good hygiene and diet. Mountain or sea air. Baths, glycerin extract of red bone marrow, arsenic, and for digestive symptoms bitter tonics and hydrochloric acid. SECONDARY ANEMIA. Definition. — A secondary anemia is one that is due to some known underlying cause. The blood-changes are char- acteristic. Etiology. — Very common in infancy and young chil- dren. It may be due to lack of food, bad hygiene, drugs, para- sites (malaria), hemorrhage, or practically any disease. Blood- changes. — Remember that in infancy any change tends to bring blood back to the embryonic type. The num- ber of the red cells and the hemoglobin are lowered propor- tionately. The specific gravity is lowered. There is poikilo- cytosis in the severer cases. Mierocytes may be present, as may also nwalocvtes. Normoblasts are seen in the average cases and megaloblasts may be present in the severe ones. There may or may not be leukocytosis. Symptoms. — The symptoms common to all anemias are present : pallor, languor, digestive disturbances. In infants and children irritability and peevishness are nearly always present. There may be slight edema and hemorrhages. Prognosis. — This depends on the cause. Where it can be removed the prognosis is usually good. Red blood-cells below 2,000,000, megalocytes, megaloblasts, polychromasia, and a high color index are all bad signs. Treatment. — Remove cause when possible, good hygiene, fresh air, and good food. Iron, arsenic, tonics. 1 W. d'Este Eneiy, "Anemia, Pernicious, Diagnosis of," Practitioner, December, 1905, p. 755. 240 DISEASES OF INFANTS AND CHILDREN. LEUKEMIA. ( Leukocythemia. ) Definition. — Leukemia is a disease characterized by a persistent increase in the number of white blood-cells, with lesions in the spleen, bone marrow, and sometimes in the lymph glands. Ehrlich calls it a " mixed leukocytosis." Etiology. — The causes are unknown. It is rare in infancy and childhood, but may be seen. The acute lym- phatic form is the most frequent in early life. It is more common in boys. Congenital syphilis, rickets, malaria, and the various infectious diseases may precede it. It has been regarded by some as having an infectious origin. Lowit claims to have found a hemameba. Varieties. — (1) Myelogenous and (2) lymphatic. The lymphatic has two forms : acute and chronic. Pathology. — The blood may contain so many white cells as to resemble pus. The bone marrow is affected in the myelogenous type, the fat being largely replaced with red or white marrow cells. The myelocytes are largely increased. The liver is enlarged and contains lymphomatosis nodules. The spleen is enormously enlarged and contains a great in- crease in the number of leukocytes. In the lymphatic form the lymph glands are enlarged, but generally movable. The lymphoid structures in the intestinal tract and about the mouth may also be affected. In the acute form the spleen is moderately enlarged, and there is a great tendency to petechia and hemorrhages. This has been regarded by some as an infection. In the chronic form the spleen is very much enlarged. Lymphomata may be found in the other organs. Blood-changes. — The hemoglobin is lowered. The red cells are diminished in number. Normoblasts may be found. Splenomyelogenous form. White cells enormously increased in number. Myelocytes numerous. Polynuclear neutrophiles actually increased, but the percentage may be diminished. Lymphocytes vary, being increased in some cases more than in others. There is an increase in eosino- philes, large mononuclears, large eosinophilic mononuclears, THE BLOOD IN INFANCY AND CHILDHOOD. 241 and mast cells. The last are of considerable diagnostic im- portance in some cases. In the lymphatic form the small mononuclears arc enormously increased, and may be 80 or 90 per cent, of all white cells present. There may or may not be myelocytes. The white cells may fall to normal just before death or during some intercurrent infectious disease as typhoid. Symptoms. — The symptoms are those of an anemia. Onset is usually insidious. Hemorrhages are common. The ] tailor, muddy skin, enlarged glands, enlarged spleen and liver make a striking picture in a developed case. There may be disturbances of vision and hearing and of the nervous system. There may be fever. Diagnosis. — From leukocytosis by the actual increase in the number and percentage of polyuuclear neutropenics. The number of white cells; is never so high as that which may be seen in leukemia. Prognosis. — Unfavorable. In early life the course is rapid, and cases last but a few weeks or months. Occasion- ally a case may last a year or two. Treatment. — Rest, good hygiene, and proper diet. Ar- senic. The Rontgen rays are said to be beneficial when applied over the spleen or lymphatic glands. SPLENIC ANEMIA OF INFANTS. 1 (Pseudoleukemia of Infants (von Jaksch, 1889); Anaemia Infantum Pseudoleucaemica. ) Definition. — A rare grave anemia characterized by leu- kocytosis, enlargement of the spleen and lymph glands and often of the liver. Etiology. — Seen in infants, especially between .-even and ten months, always under four years. Rickets is present in many cases. Pathology. — Simple hyperplasia of the spleen ■; enlarge- ment of the liver with infiltration of white cells ; enlarge- 1 Wentworth, Boston Med. and Surg. Jour., Oct. 3, 1901, p. 374. Scott and Telling, " - Splenic Anemia, Infantile, Case of," Lancet, June 17, 1905, p. 163b. 16 242 DISEASES OF INFANTS AND CHILDREN. ment of the lymph-glands. Bone-marrow changes may he present. Some observers believe that these are due to rachitis. Blood-changes. — Lowered specific gravity; lowered hemoglobin; great diminution of red blood-cells; microcytes, megalocytes, megalo blasts, and normoblasts are present, and there is poikilocytosis ; leukocytes increase and myelocytes may be present. The large mononuclears are usually in- creased. The cells stain irregularly with the ordinary dyes. Symptoms. — General symptoms of anemia ; cachectic appearance, loss of appetite, and digestive disturbances. Drags along with improvement and relapses. Diagnosis.— Difficult. A term used to classify little understood cases of infantile anemia. Any severe anemia of infancy may be accompanied by leukocytosis. From leukemia by recovery and lessened number of myelocytes. Prognosis. — About 25 per cent, of the cases die. Treatment. — Good hygiene and proper diet. If there is rickets, give cod-liver oil ; if syphilis, give mercury, with or without iodid of potassium, alternating with iron. Arsenic or iron may be tried. HEMOPHILIA. 1 (Hemorrhagic Diathesis ; Bleeder's Disease.) Definition. — A family and hereditary disease, character- ized by a tendency to severe hemorrhage from slight causes or spontaneously. Etiology. — Heredity is the chief cause. It is more com- mon in boys than in girls. The tendency is transmitted through the daughters of bleeders even though they may not have the disease themselves. The daughter of a bleeder family, herself a bleeder, is no more likely to transmit the tendency than is her non-bleeder sister. A son of a bleeder family, himself a bleeder, should he live to beget children, does not often transmit the disease to his children, but to his 1 Dunn, American Journal of the Medical Sciences, 1883, vol. lxxxv., p. 68. J. J. Wilson, " Hemophilia," Practitioner, December, 1905, p. 829. R. C. Larrabee, " Hemophilia jn the Newborn," American Journal of the Medical Sciences, March, 1906, p. 497. THE BLOOD IN INFANCY AND CHILDHOOD. 243 grandsons through his daughters. Again, should he have non-bleeder brothers, their grandsons seldom bleed. Pathology. — Unknown. In some cases the artery walls have been thin and degenerated. Symptoms. — It usually begins in the first two years of life, rarely after ten and practically never after twenty. Per- sistent hemorrhage, which cannot be checked by ordinary means, follows slight injuries or occurs spontaneously from the mucous membranes. Some cutaneous hemorrhages also occur. There may be effusions of blood into the joints, and also other joint troubles not unlike rheumatism. Prognosis. — Bad. Almost all cases die before they are ten years of age, and the remainder before they are twenty. If they live beyond that age they are liable to die of some other disease. Treatment. — Protect such children from injury. Fur the hemorrhage, rest and local pressure and styptics. Gelatin, calcium chlorid, thyroid extract, sulphate of soda, perchlorid of iron, and adrenalin are among the numerous drugs recom- mended. Injection of normal blood serum has been sug- gested. PURPURA. Definition. — Spontaneous subcutaneous hemorrhages are called purpura. These may be small (petechia?) or large (ecchymoses). When the skin is alone affected it is called purpura simplex. When there are hemorrhages from the mucous membranes it is called purpura hemorrhagica. Etiology. — Purpura may be regarded as a symptom and may be due to many causes. The most important are the infectious diseases ; cachectic conditions ; from toxic sub- stances, either drugs, as chlorate of potassium, or from ptomaines ; mechanical, as after the removal of splints; in whooping-cough, in hemorrhage into the adrenal, scurvy, and lastly neurotic. Symptoms. — The appearance of the hemorrhagic spots and the hemorrhages, together with the clinical picture of the disease which causes it. 244 DISEASES OF INFANTS AND CHILDREN. Diagnosis. — This is from the purpuric diseases given below. Prognosis. — As a rule, purpura occurring in the course of a serious disease is a bad sign. Treatment. — Treat the original disease. Prevent bruis- ing. An antiscorbutic diet may be tried. Adrenalin and similar preparations may be tried. Ergot, calcium ehlorid, and many other drugs are recommended. The injection of normal blood serum has been suggested. PURPURIC DISEASES. Purpura Rheumatica (Schonlein's Disease). — This rarely occurs under five years of age. In addition to the clinical picture of acute rheumatism there is a purpura, often urticaria, and erythema multiforme as well. There may be edema. The condition lasts a couple of weeks and tends to relapse. Treatment. — Antirheumatic. Purpura Simplex. — The hemorrhages are limited to the skin. It may appear suddenly, or there may be indispo- sition for several days, with vomiting, diarrhea, and slight fever when the purpura appears. It lasts from one to four weeks. Relapses are common. Recovery is the rule. Occa- sionally death occurs. Purpura Hemorrhagica. — (Morbus maculosus Werl- hofii is often incorrectly used for this.) This is a severe dis- ease with prostration, fever, nausea, vomiting, often diarrhea, and frequently albuminuria. There is a marked purpuric rash and hemorrhages from the mucous membranes ; these may be very severe. Edema may be present. Pains are felt all over the body. There may be marked nervous symp- toms, even delirium and coma. It lasts from one to six weeks and resembles typhoid, from which it is distinguished by the Widal reaction. It may terminate fatally. Giant Purpura Without Symptoms. 1 — WerlhofPs disease (morbus maculosus Werlhofii) is a term frequently applied incorrectly to the severe forms of purpura. 1 Werlhofif, 1735 THE BLOOD IN INFANCY AND CHILDHOOD. 245 Gianl purpura is a rare disease seen usually between five and fifteen years of age. There is a sudden onset, a hemor- rhagic rash, and sometimes hemorrhages from the mucous membranes. There are no symptoms. The hemorrhages under the skin are enormous — several inches in diameter. Thev last about two weeks and disappear. There is a ten- dency to frequent recurrence. The diagnosis is easy. Take care to exclude scurvy in the very young. Treatment. — Unsatisfactory. As in purpura. Purpura Fulminans. — This is an acute fatal form of purpura most frequently seen under five years of age. Large hemorrhages are noted in the adrenals. The onset is sudden, with a chill or convulsion, vomiting, high temperature, and marked prostration. The purpura comes on rapidly and covers the entire body. Death takes place in from ten hours to three days. Henoch's Purpura. 1 — This disease is seen most fre- quently in childhood ; also in later life. Skin Manifestations. — Usually purpura, but there may also be erythema, exudations, circumscribed edema, or urticaria. Any or all of these may be present. Visceral Symptoms. — Gastro-intestinal crises consisting of pain, often with vomiting and diarrhea. These last from a few hours to days. There may be cerebral or pulmouary symptoms. Arthritic Changes. — Swelling of synovial sheaths of one or more joints with pain. The attacks recur at intervals of weeks, months, or years, sometimes manifested by one of the above, sometimes by another, and sometimes in combination. The ultimate out- look is for about 25 per cent, mortality. Treatment. — Between the attacks, good food, quiet out- of-door life, iron if anemic. During attacks, rest in bed and protect from injury. Antiscorbutic diet may be tried or drugs, as in purpura, although little may be expected from the latter. 1 Osier, American Journal of the Medical Sciences, January, 1904. 246 DISEASES OF INFANTS AND CHILDREN. DISEASES OF THE DUCTLESS GLANDS. HODGKIN'S DISEASE. (J832.) (Pseudoleukemia ; General Lymphadenoma j Adenia ; Lymphatic Anemia*) Definition. — A disease in which there is progressive enlargement of the lymph-nodes and the spleen, with the formation of nodules in the internal organs, such as the liver, kidney, and spleen, etc., and sooner or later a secondary anemia and cachexia. Etiology. — It is a disease of early life. In 43 cases 10 were under ten years of age (Clarke). The cause is unknown, but it has been suggested that it is of infectious origin. Pathology. — There is an enlargement of the lymph- nodes, the spleen, and lympno- matous nodules in the internal organs. The marrow of the long bones may be involved. The nodes do not tend to break down unless there is secondary infec- tion, and there is no tendency to invade the surrounding tissue, as in lymphosarcoma. The histo- logic changes are characteristic (Reed). 1 There are proliferation of the endothelial and reticular cells and an increase in the lym- phoid cells. There are also giant cells which differ from the giant cells of tuberculosis. The connective-tissue stroma of the nodes is increased, and eosino- philes are seen in the nodes. Tuberculosis is a frequent secondary infection. Symptoms. — It resembles lymphatic leukemia, but there is no leukocytosis. It usually starts in the neck, and the nodes are first soft, but become harder, and are rarely painful. They are freely movable, and do not suppurate 1 Johns Hopkins Hospital Keports, 1902, vol. x. Fig. 64 a.— Hodgkin's disease. DISEASES OF THE DUCTLESS GLANDS. 247 unless secondary infection takes place, and this is rare. There is often fever of an irregular remittent type. The progress of the disease is steady, but there may be temporary remis- sions. There may be pressure symptoms caused by the enlarged nodes pressing on the trachea, bronchi, nerves, ureters, etc. Diagnosis. — From leukemia, by the absence of leuko- cytosis. From tuberculosis, by the absence of fusion and matting of the nodes, by the tuberculin test, and, best of all, by histologic study of an excised gland. Tuberculosis is a frequent complication, and without the histologic examina- tion may obscure the diagnosis. From lymphosarcoma, by histologic study and the absence of a tendency to invade adjacent tissue. Prognosis. — This is unfavorable. The usual duration is from one to four years after the appearance of the disease, but some last only months. There may be remissions from time to time, but sooner or later the patient becomes cachectic, and frequently dies from tuberculosis or some other intercur- rent infection. Treatment. — This is not very satisfactory. Arsenic is the best drug, and is best administered hypodermatically, or Fowler's solution may be given by the mouth. The Rontgen rays have been used recently and apparently with great ben- efit in selected cases, and further investigation should deter" mine its exact value. STATUS LYMPHATICUS. 1 (Lymphatism; Status Thymicws.) Definition. — A condition characterized by a general hypertrophy of the lymphatic system, an enlarged thymus gland, an enlarged spleen, hyperplasia of the vascular system, particularly of the aorta, a chlorotic condition, and a tendency to sudden death from trifling causes. Etiology. — This condition is frequently associated with rickets. It may be seen at any age, but is most frequent in young children. Symptoms. — The child appears pale and flabby. There 1 Bloomer, Bulletin Johns Hopkins Hospital, 1903, vol. xiv., p. 263. 248 DISEASES OF INFANTS AND CHILDREN. are enlarged tonsils, adenoids, and other structures as given above. Sudden death may call attention to the condition. Death may follow some slight accident, as a fall, or result from chloroform. Sometimes there is a cry and a convul- sion and the child drops dead. Diagnosis. — By the physical findings. Prognosis. — There is a tendency for the condition to disappear about puberty. Treatment. — Careful dieting to avoid convulsions, due to improper food. Good hygiene. Cod-liver oil in winter : syrup of the iodid of iron may be given. Iodid of potassium may be tried. SIMPLE ACUTE ADENITIS. Definition. — An acute inflammation of the lymph-nodes. Either the external or internal nodes may be affected. The external frequently suppurate, while the internal rarely do. etiology. — About three-fourths of cases are seen under two years of age, and the lesion is usually secondary to an adjacent inflammation, as pharyngitis, bronchitis, or tonsil- litis, or it may be due to eczema of the scalp, carious teeth, or stomatitis, or it may be caused by the infectious diseases, as German measles. Pathology. — There is swelling in the node, due to con- gestion and to a hyperplasia of the lymphoid cells. The nodes may suppurate or they may subside entirely after a few weeks, or they may remain enlarged and hard for some time. Symptoms. — There are always the symptoms of the original disease, which may be so slight as to pass unnoticed. The cervical glands are the most frequently affected. The swelling comes on gradually. They are painful, tender, and there may be redness of skin. Suppuration, when it takes place, usually starts before the first or second week, but it may be delayed for three or even four weeks. After the pus is discharged the healing is usually quite rapid. When sup- puration does not occur the nodes remain swollen from a week to two months, and gradually become smaller and harder. Recurrences are not infrequent. Fever is usually present at the height of the disease. The bronchial lymph-nodes are DISEASES OF THE DUCTLESS GLANDS. 249 infected in lesions of the lungs and bronchi, and may be the cause of continued fever. The mesenteric nodes may be in- fected in intestinal disorders. Diagnosis. — The age of the child and the acute onset usually suffice to exclude tuberculosis, but after two years of age tuberculosis of the nodes is common. The location of mumps in the parotid region, with the lobe of the ear as the center of the swelling, and a history of exposure are usually sufficient to differentiate this disease. The other affections of the lymph-nodes are chronic. Treatment. — Where the local cause is apparent, it should be removed if possible. The nodes, throat, or teeth should receive prompt attention. Internally, iodid of potassium or the syrup of the iodid of iron may be used. Externally, local applications of heat or cold — cold if there is swelling and congestion, and heat if the process is one of pus forma- tion. Five to 10 per cent, ichthyol ointment is one of the best external applications. If suppuration takes place the abscess should be opened, it being usually better to wait until suppuration is marked, and make rather a small opening. SIMPLE CHRONIC ADENITIS. Definition. — A chronic inflammation and enlargement of the lymph-nodes. etiology. — Repeated attacks of adenitis or a long-stand- ing irritation, as a chronic eczema or a carious tooth, is the most frequent cause. It is one of the features of the status lymphaticus. Pathology. — The nodes are enlarged, hard, and show hyperplasia of the cells and connective tissue changes. Symptoms. — The chronic enlargement of the disease is the only symptom. The glands are hard, usually not tender, and they suppurate but rarely. Diagnosis. — Usually from tuberculosis or Hodgkin's disease. A node may be removed for microscopical exami- nation if very strong doubt exists. Prognosis. — Good if cause can be removed. Treatment. — Remove cause, as carious teeth, adenoids, or enlarged tonsils. Cod-liver oil, syrup of iodid of iron, 250 DISEASES OF INFANTS AND CHILDREN. iodid of potassium, and Fowler's solution of arsenic may all be recommended. Syphilitic Adenitis. — Syphilis may occasionally cause a marked general or local adenitis. The diagnosis rests on finding other manifestations of the disease and on rapid im- provement by antisyphilitic treatment. DISEASES OF THE THYMUS GLAND. The thymus gland increases rather rapidly in size from birth until about the second year, and more slowly until puberty. Then it remains about the same size until about twenty-five or thirty, when it atrophies and is replaced slowly by fat and connective tissue. In Infantile Atrophy and Marasmus. — The thymus shows marked changes macroscopically and microscopically. There is atrophy of the gland in direct proportion to the atrophy of the body. The severe cases show a decrease in the lymphoid cells and an increase in the connective tissue. The thymus may show changes in syphilis and tubercu- losis, and may be the site of tumors and abscesses. Hem- orrhages may be found especially in children who have been asphyxiated. It is hypertrophied in some cases of acromegaly, gigantism, chlorosis, leukemia, Hodgkin's disease, Graves' disease, and epilepsy. Some authors state that it is also enlarged in infectious diseases. It is found enlarged in thymic asthma and Paltauf's status thymicus. It is atrophied in atrophic conditions, rickets, and Bourneville states that it is present in only 27 per cent, of idiots. Sudden Death, — If sufficiently hypertrophied the thy- mus may be a cause of sudden death in infants. The child has previously been well or slightly cyanosed. Usually found dead. There is marked lividity of the body, and there may be hemorrhages into the gland. The gland may weigh 30 to 45 gm. Important from medicolegal point of view. Thymic Asthma. — When the hypertrophy comes on gradually ; there are symptoms of intrathoracic pressure. Pallor and edema of the face, suffusion and hemorrhages into the conjunctiva ; cyanosis of lips and finger tips ; labored DISEASES OF THE DUCTLESS GLANDS. 251 respiration with inspiratory stridor. This last may be due to laryngeal spasm or direct pressure on the trachea. There is dul- ness over the gland. The Rontgen rays have given remark- able results in some cases. If this is not successful, the gland may be entirely or partially removed by surgical operation. THE ADRENALS. The adrenals are relatively larger in infants than in adults. Hemorrhage into the Adrenal. 1 — May be seen in the newborn in the course of infectious diseases and toxemias, as well as in any condition of general congestion. The symptoms may be asthenic, peritoneal, or nervous. These vary in different cases. One class occurs in previously healthy infants, coming on suddenly with vomiting, diarrhea, and in a few hours a petechial eruption and generally high fever. Death occurs after a short time. (Purpura fulminans.) These cases are sometimes mistaken for purpuric small-pox, measles, or scarlet fever. There may be nothing to suggest an infectious disease in some of these cases. ADDISON'S DISEASE. This is very rarely seen in early life. The lesion is usually a tuberculosis of the adrenal or degenerative changes in the abdominal sympathetic ganglia. The symptoms are bronzing of the skin and pigmentation of the mucous mem- branes. There are great weakness, cachexia, and great irrita- bility of the stomach. The pulse is rapid and weak. Death may take place from tuberculosis, asthenia, coma, or convul- sions. The diagnosis is from arsenical pigmentation and malarial cachexia. The treatment is along general tonic lines. Adrenal tablets or extract should be tried, the effect closely watched, and the dose regulated accordingly. Recovery is the exception. THE SPLEEN. The Normal Spleen. — The spleen lies with the upper border on about the ninth rib, and the lower about the elev- enth rib. Posteriorly it extends to the posterior axillary 1 Dudgeon, American Journal of the Medical Sciences, February, 1904. 252 DISEASES OF INFANTS AND CHILDREN. line, and anteriorly to about the midaxillary line. It does not normally pass a line drawn from the left nipple to the end of the eleventh rib. The splenic dulness corresponds to the above. It is often obliterated, however, by abdominal tym- pany due to inflated stomach or intestines. An overloaded intestine may give rise to dulness and simulate an enlarged spleen. Enlargement of the Spleen. — If the spleen is en- larged it can usually be made out by palpation. A spleen which extends beyond the edge of the ribs may be looked upon as enlarged. A pleural effusion may push a normal spleen downward. An enlarged spleen- during inspiration moves downward and to the right, in the direction of the right iliac crest. If the liver is enlarged the liver and splenic dulness may be continuous. The same is true when there is an effusion in Traube's semilunar space. In a good light, with the abdomi- nal walls properly stretched, an enlarged spleen can often be seen to move up and down. There may be enlarged veins seen in the splenic area, and over a very large spleen there may be a blowing murmur like that over a pregnant uterus. An enlarged spleen is seen in almost all acute infectious fevers. It is especially marked in typhoid fever and malaria, only occasionally enlarged in cerebrospinal fever and rarely in mumps. In almost all the chronic diseases of early life the spleen is enlarged. In active rickets, in leukemia and pseudoleukemia and Hodgkin's disease it is constantly enlarged. It is usually, but not always, enlarged in syphilis. Amyloid Spleen. — (Sago Spleen.) — This is large, thick, and smooth. It is seen in long-standing suppurations, especially of the bones ; also in chronic pulmonary tubercu- losis and in old cases of syphilis. The liver is also enlarged, and there is a cachectic condition. Amyloid changes are not as frequent as formerly owing to the improved surgical treat- ment of suppurative diseases. Chronic Passive Congestion of the Spleen. — This follows stasis in the portal and splenic; vessels. It is seen DISEASES OF THE DUCTLESS GLANDS. 253 in diseases of the liver, especially cirrhosis, from lesions in the lungs, which obstruct the blood-current, and especially in acquired or congenital heart disease. The liver is always enlarged at the same time, except when the spleen vessels are alone involved. New Growths. — These are rare in infancy and child- hood. A new growth may be suspected if the surface of the spleen is nodular. This may be tuberculosis, sarcoma, car- cinoma, syphilis, cysts, or parasites. Tuberculosis is the most frequent. Splenitis. — Splenitis may occur from extension of a neighboring inflammation. The diagnosis is always doubtful. Perisplenitis. — This may follow- injuries, hemorrhagic infarcts, or be caused by extension, tuberculosis, or syphilis. A friction-rub can often be heard. The spleen may become adherent and immovable in cases of long standing. Floating Spleen, — This is occasionally seen as a con- genital condition. The diagnosis is made from its shape and the presence of tympany over the area of splenic dulness. It must be differentiated from tumors of the same size and from fecal masses. PRIMARY SPLENOMEGALY (Gaucher). 1 A rare form of splenic enlargement without any apparent cause. There is a hyperplasia of the endothelial cells of the spleen and of the connective tissue of the liver. The disease is slow and progressive. It begins between the second and seventh year. There are anemia and symptoms referable to the enormous spleen. The prognosis is bad. DYSTROPHIA ADIPOSOGENITALIS. Frohlich's syndrome is due to inactivity of the pituitary gland, characterized by obesity and a lack of development of the genital organs, an increased assimilation limit for carbo- hydrates, often dry skin, subnormal temperature, and lack of development of the hair. Pituitary gland administrations have been administered occasionally with benefit. 1 Bovaird, American Journal of the Medical Sciences, October, 1900. 254 DISEASES OF INFANTS AND CHILDREN. THE URINE IN INFANCY AND CHILDHOOD. Character of the Urine. — The urine of the newborn is highly colored, stains the napkin, and often leaves deposits of urates or uric acid. Later the urine is pale and often contains considerable mucus, which makes it cloudy. The specific gravity varies, but is high during the first two days, lowest from the fourth to the sixth day, and gradually increases to puberty. Hyaline, and more rarely granular, casts may be found. Phosphates, chlorids, and sulphates all increase with age. Albumin may be present in early infancy. Sugar, usually lactose, may sometimes be found in early infancy. Collecting the Urine. — For male infants place the penis and scrotum in a large condom and secure in place with a tape. For girls a small cup may be secured over the vulva. This is rarely successful. The child may be placed on a chamber immediately on waking or it may be catheterized. Age. Quantity. Specific gravity. Urea, daily quantity. Ratio uric acid to urea. Grams. Ounces. Grams. First 24 hours .... 0-60 0-2 | 3^-3 ) 1.010-1.012 0.076-0.114 1:14 Second 24 hours . . 10-90 ) [ 0.140-0.660 3 to 6 days 90-250 3-8 1.004-1.008) 7 days to 2 months . 150-400 5-13) [ 1.004-1.010 0.90-1.40 1 : 60-80 2 to 8 months .... 210-500 7-16 j 6 months to 2 years . 250-600 8-20 1.006-1.012 1 : 60-80 2 to 5 years 500-800 16-26) [ 1.008-1.016 13.09-14.01 1 : 50-70 5 to 8 years 600-1200 20-40 J 1 1.012-1.020 j" 16.05-21.03 1 : 45-60 8 to 14 years 1000-1500 32-48 Quantity. — Relatively more urine is passed by infants than by adults. Infants micturate very frequently, hourly or oftener, while they are awake, and every two or three THE URIXE IN INFANCY AXD CHILDHOOD. 255 hours while asleep. Later the urine is held several hours without difficulty. Well-trained infants control the bladder at two or three years of age. Nervous or untrained children may wet themselves for several years. Sometimes an infant does not void any urine for ten or twelve hours, and then after passing a very large quantity returns to its former habits. The table on the preceding page gives the quantity and other facts about the urine. It has been compiled from various authorities. FUNCTIONAL ALBUMINURIA. 1 (Physiologic or Cyclic Albuminuria.) Definition, — Albuminuria occurring without any de- monstrable signs or symptoms of disease. Ktiology. — It is most frequently seen in boys between five and fifteen years of age. It may be present in the urine excreted while the individual is in the erect posture (ortho- static albuminuria) and absent while he is lying down, and consequently albumin is not present in the urine passed early in the morning on rising. It may also apparently be due to exercise, fatigue, indigestion, and too much protein food. Symptoms. — There are no symptoms. The patients may be well or suffer from other diseases. The albumin is usually discovered accidentally. Diagnosis. — Sometimes difficult. Absence of other signs of disease, absence of casts, passing urine free from albumin at night or in the early morning, and high specific gravity are the most important points. Prognosis. — If albumin is not constantly present and is in small, not increasing, quantities, the outlook is good. If it is increasing and is constant, actual disease of the kid- ney is probably present. Treatment. — General hygiene ; proper diet ; relieve the indigestion. Alkaline mineral waters are sometimes used. Iron should be given if anemia is present. 1 Rachford, "Albuminuria," Archives of Pediatrics, August, 1908. Suth- erland, " Orthostatic Albuminuria," Amer. Jour. Med. Sci., August, 1903. 256 DISEASES OF INFANTS AND CHILDREN. HEMATURIA. (Blood in the Urine.) The red blood-cells may be demonstrated. Is due to in- jury, nephritis, new growths, stone in kidney, ureter or bladder, tumor in the bladder, hemorrhagic disease of the newborn, scurvy, purpura, and similar conditions ; various infections, as malaria and scarlet fever ; and to the adminis- tration of drugs, as chlorate of potassium and quinin. Diagnosis. — Best by microscopic examination. It should be suspected where the urine is dark and cloudy. If from the urethra, the urine first passed is cloudy ; if from the bladder, the blood is often with the last urine passed ; if from the kidney, the blood is thoroughly mixed with the urine. Treatment. — This depends on the cause. Chronic cases may be given alum water or Rockbridge spring water. HEMOGLOBINURIA. 1 Blood pigment is found in the urine with a few or no blood-cells. It may be seen in epidemic hemoglobinuria (Winckel's disease), in acute infections (as malaria and typhoid fever), purpura, poisons (chlorate of potassium or carbolic acid), from the absorption of hemorrhagic eifusions, and there is a paroxysmal hemoglobinuria met with in child- hood. GLYCOSURIA. (Sugar in the Urine.) May be seen in young infants otherwise in good health. The sugar in these cases is usually lactose (milk sugar). It may occur from eating excessive amounts of sugar (alimen- tary glycosuria) ; the kind of sugar given will be found in the urine, as cane sugar, milk sugar, or grape sugar. Gly- cosuria is one of the symptoms of diabetes. 1 Herman, Archives of Pediatrics, February, "903, p. 105. Guthrie, " Hematuria," Lancet, May 3, 1903, p. 1243. THE URINE IX INFANCY AND CHILDHOOD. 257 PYURIA. Pus in the urine usually comes from the pelvis or the kidney, but may come from inflammation of any part of the genitourinary tract or from rupture of abscess into it. The treatment depends upon the cause. Urotropin is useful. It may be given in from 1 to 5 gr. doses several times a day. LITHURIA. Excessive amounts of urea and uric acid in the urine. Uric acid is derived from the destruction of the cell nuclei. The quantity for twenty-four hours must be estimated. Urine of low specific gravity from which amorphous urates are deposited may be regarded as containing excessive amounts of uric acid. The symptoms of the condition are of a general nature, and may be regarded as an indication of disturbed metab- olism. It is seen in anemia, chorea, rheumatism, malnu- trition, etc. Where crystals of uric acid are deposited from highly colored urine of high specific gravity the solvent power of the urine for uric acid is diminished. It may be associated with digestive disturbances. Treatment. — This depends on the existing conditions ; where otherwise allowable, exercise in the open air and alka- line mineral waters, as Vichy, should be ordered. Holt advises cutting off sugars, reducing the starchy food, and giving a diet rich in protein. INDICANURIA. The presence of indican in the urine. A trace may be found in normal urine. A strong reaction is found in urine of children suffering with suppurative conditions, as empyema, constipation, and tuberculosis. Also seen in intestinal fer- mentation and chronic intestinal indigestion. The treatment consists in removing the cause, diminishing intestinal putrefaction, and giving a milk diet. 17 258 DISEASES OF INFANTS AND CHILDREN ACETONURIA. The presence of acetone in the urine is rather a frequent occurrence, and small amounts may sometimes be found in health. It is found in a number of conditions which show no symptoms of acidosis, among these may be mentioned the excessive ingestion of fat, starvation, high fever, gastric ulcer, malignant disease, and many others. There is another group of cases where the symptoms of acid poisoning may be noted in connection with other diseases, as in diabetes, intra- cranial disease, toxic forms of gastro-intestinal disturbance, diarrhea, sepsis, intestinal obstruction, acute peritonitis, and due to the influence of certain drugs used in poisonous doses, as morphin and salicylate of sodium. There is a third group of uncomplicated cases, such as are seen following the administration of anesthetics in recurrent or cyclic vomiting. DIACETURIA. The presence of diacetic acid in the urine. This is found in the same conditions as acetone. It is quite common in high fevers and disappears when the fever falls. It may precede diabetic coma. Where acid autointoxication is present bicarbonate of soda in rather large doses is indicated. ANURIA* An absence of secretion of urine. This may be seen in infants without any apparent cause. As long as there are no other symptoms there is no danger. It may be caused by uric-acid infarcts. The treatment is the same as in dimi- nution of urine. DIMINUTION OF URINE. This may occur from excessive sweating, fever, diminished ingestion of fluid, etc. Treatment. — Hot applications over the kidneys, the ad- THE URINE IN INFANCY AND CHILDHOOD. 259 ministration of hot water and of sweet spirits of niter with or without citrate of potassium. DIABETES INSIPIDUS. (Polyuria.) Definition. — A chronic disease characterized by great thirst and the excretion of large quantities of urine. Etiology. — The disease is rare. It usually begins under ten years of age. It may occur in families. It may follow injuries about the head or brain lesions. Pathology. — Obscure. It is usually classed as a neu- rosis. Symptoms. — The passing of large quantities of urine (from 2 to 10 liters daily), great thirst, and frequently nervous symptoms, as neuralgia, headache, and other motor disturbances, are the principal symptoms. The urine is clear and contains neither grape sugar nor albumin. Diagnosis. — From diabetes by the absence of grape sugar. From interstitial nephritis by careful study of urine and symptoms. Prognosis. — As regards cure, usually bad. A few cases recover spontaneously or with treatment. Treatment. — Good hygiene ; out-of-door life ; good, well- balanced diet. Restrict the amount of fluids taken. Numer- ous drugs have been recommended ; atropin or belladonna, arsenic, and bromids are most useful ; antipyrin or ergot may be tried. Diseases of the Kidneys, malformations and malpositions of the kidney. 1 Only one kidney may be present, the other being rudi- mentary or entirely absent. Both kidneys may be fused together — the so-called " horseshoe kidney." Cystic degen- eration of the kidney is sometimes seen affecting one or both 1 Anders, " Congenital Single Kidney," American Journal of Medical Sci- ences, March, 1910, p. 314. 260 DISEASES OF INFANTS AND CHILDREN. kidneys. The kidney substance is replaced by cysts wnich may reach a considerable size. There are no symptoms referable to the kidneys, but sometimes the enlarged kidney may be felt. Hydronephrosis. — The bladder may be enlarged, the ureters and the pelvis of the kidneys dilated. There is usually — but there may not be — some obstruction to the out- flow of urine causing this. The deformity may be unilateral or bilateral. An abdominal tumor may be felt in some cases. There may be malpositions of one or both kidneys, and movable kidneys may occasionally be met with. There may be additional ureters. URIC-ACID INFARCTIONS. Deposits of uric acid or of urates in the tubules of the kidneys are common during the first few weeks of life. They may or may not cause symptoms. Diminished urine or anuria, pain on urinating, and priapism are symptoms which may be met with. The urine stains the napkin, and the crystals may sometimes be demonstrated upon it. Hot water to drink, together with citrate of potassium (1 gr. every two hours), usually gives prompt relief. HYPEREMIA OR CONGESTION OF THE KIDNEY. ACUTE CONGESTION. Etiology. — From exposure to cold ; the ingestion of drugs, as turpentine, cantharides, etc. ; from injuries or fevers. Symptoms. — The urine is scanty, highly colored, of high specific gravity, and may contain small quantities of blood, albumin, and tube casts. There may be headache, backache, etc. The condition may pass off in a day or two or may precede an acute nephritis. Treatment. — Rest in bed; milk diet; hot packs, hot steam baths, hot applications or dry cups over the kidneys ; saline cathartics. 17 THE tJBINE IN INFANCY AND CHILDHOOD. 261 CHRONIC CONGESTION OF THE KIDNEY. ( Passive Hyperemia. I Etiology. — From impeded circulation, most frequently from chronic diseases of heart or lungs, but also from any- thing which prevents the return circulation of the kidneys, a< tumors or enlarged glands pressing upon the veins. Pathology. — The kidneys are enlarged and of dark-red color. The capillaries are distended with blood. Symptoms. — The urine is scanty, dark, and of high specific gravity. It may contain blood, albumin, and hyaline casts. When dependent upon general stasis, other symptoms, as edema and cyanosis, may be present. Treatment. — The primary condition should be treated. In addition, rest in bed, milk diet, and diuretics. Citrate of potassium, infusion of digitalis, caffeiu, calomel, or sweet spirits of nitre, diuretin. INFLAMMATION OF THE KIDNEY. 1 The student is sometimes confused by the numerous terms applied to various conditions. The simplest classification is into acute nephritis and chronic parenchymatous nephritis and chronic interstitial nephritis. Acute nephritis. (Acute Bright's Disease; Acute Tubular Nephritis; Acute Parenchym- atous Nephritis; Acute Desquamative Nephritis; Acute Diffuse Nephritis, etc*) Definition. — An acute inflammation of the kidney. Etiology. — The principal causes are: (1) Infectious dis- eases, especially scarlet fever and diphtheria ; (2) exposure to cold and wet; (3) toxic agents, such as turpentine, chlorate of potassium, and carbolic acid. Pathology. — There are changes in the vascular, epithelial, and interstitial tissues. These may vary in intensity, and this has led to the numerous classifications. If the entire kidney 1 Morse, American Medicine, April 5, 1905, p. 551. 262 DISEASES OF INFANTS AND CHILDREN. is more or less uniformly involved it is called a diffuse nephritis ; if the tubules are chiefly affected, parenchymatous nephritis ; if the glomeruli are the seat of marked changes, as in scarlatina, glomerulonephritis. In children, after fevers, the interstitial tissue may be the seat of extensive changes. The kidney may not present any marked naked-eye change, or it may be enlarged in the early stages, red and dripping blood, the cortex swollen and turbid, pyramids intensely congested. Later the kidney may be paler. Histology. — The tubular cells show cloudy swelling, and may be desquamated, and the tubes may be blocked by hyaline or granular casts. The vessels are engorged. The interstitial tissue is frequently infiltrated with cells (leuko- cytes and plasma cells). Symptoms. — Nephritis may be primary or secondary to some other disease. Primary Nephritis. — In Infants. — Sudden onset, vomiting, frequently diarrhea, high fever, nervous symptoms, dulness and apathy, marked anemia, sometimes edema. The outlook is bad; the majority of the cases prove fatal. In Older Children.— Onset less often sudden, moderate fever, vomiting, anemia, often edema. Prognosis is better than in infants. Secondary Nephritis. — Comes on usually at the height of the febrile stage of the primary disease. It may be over- looked. There is often an increase in temperature, headache, vomiting, sometimes edema. The nephritis of scarlet fever usually comes on late — at the third or fourth week of the disease. There is fever, with the edema always marked. The Urine. — The urine is at first scanty or even suppressed. It is dark, of high specific gravity, contains blood, albumin, tube casts, and desquamated epithelium. The daily amounts of urea are diminished. Later the urine becomes freer, lighter in color, and of lower specific gravity. Diagnosis. — On the symptoms and examination of the urine. Nephritis should be suspected whenever there is fever with marked pallor. The disease is often overlooked. THE URINE IN INFANCY AND CHILDHOOD. 263 Prognosis. — Under three years the prognosis is grave. If the child does not die in the acute attack it is liable to have evidence of chronic nephritis later in childhood. In older children the outlook is, on the whole, much more favorable. Death may occur from edema of the lungs, uremia, or ex- haustion. The disease may become chronic. Prophylaxis. — In all acute fevers, but especially scarlet fever, bland unirritating diet, principally of milk and carbo- hydrates, should be given. Protect from cold and injudi- cious drugging. Treatment. — Rest in bed ; keep warm. Sponge or warm or vapor baths to promote sweating. Hot wet-packs are useful. Dry cups or warm applications over the kidneys. Saline cathartics. As long as the urine is very scanty or suppressed and water is excreted with difficulty, the amount of fluid given should be rather limited. Citrate of potassium may be given with alkaline mineral waters. If there are any symptoms of uremia, stimulants are indicated; nitro- glycerin is useful. Nervous symptoms are best controlled by chloral or morphin. Xitroglycerin may be tried when there is high pulse tension, vomiting, delirium, and high temperature. Bleeding may be tried where uremia threatens. From two to five ounces of blood may be withdrawn, accord- ing to circumstances. This should be followed by sub- cutaneous injections of normal salt solution. Rectal enemata of hot salt solution may cause free diuresis. As soon as the diuresis becomes freer, hot (105° F.) saline injections into the rectum should be given several times a day. Increased amounts of alkaline mineral waters or imperial drinks (see formulas) should be given. The diet should be milk diluted with mineral waters or thin gruels, buttermilk, koumiss, whey, junket, and farina- ceous gruels. Meat should not be given until convalescence is well established. Where anemia is severe, solid food may be added cautiously, watching the temperature. The diet must be carefully supervised for a long time. If there is edema, a salt-free diet may be tried. 264 DISEASES OF INFANTS AND CHILDREN. Chronic Nephritis. 1 This may be either parenchymatous or interstitial, or a combination of both. Etiology. — It is rare in childhood. It may be seen after acute infections, especially scarlet fever or prolonged suppurative diseases. It may occur in the course of chronic tuberculosis, hereditary syphilis, or chronic heart disease. It may be seen in gouty children and in those rare cases of early arteriosclerosis of obscure origin. Pathology. — In chronic parenchymatous nephritis the Fig. 65.— Chronic parenchymatous nephritis. organs are referred to as " large white kidney." The kidney may be red, however, and show very little change. The his- tologic changes are cloudy swelling of the epithelial cells, or they may be fatty or granular. The cells are desquamated and the tubules contain casts and granular material. In chronic interstitial nephritis the change is the same as in adults. The kidney is small and granular, with adherent capsules, thin cortex, and the histologic changes are an in— Cotton, Archives of Pediatrics, April, 1904, p. 241. Sawyer, "Inter- stitial Nephritis," Birmingham Medical Review, August and September, 2903. THE URINE IN INFANCY AND CHILDHOOD. 265 crease of the connective tissue, arteriosclerosis, and atrophy of the parenchyma. Symptoms. — Chronic Parenchymatous Nephritis. — Fir,. 66.— Showing edema and ascites in chronic parenchymatous nephritis in a child of five years. Edema, effusion into the serous cavities, with digestive dis- turbances, are the most marked symptoms. There are also anemia, headache, occasional vomiting, or diarrhea. There may be enlargement of the heart with murmurs and accentua- tion of the aortic sound. The Urine. — The urine varies from time to time. It con- tains varying amounts of albumin and granular and fatty casts. The specific gravity is high and the quantity normal or less than normal. Prognosis. — The outlook is not very good. The disease lasts from two to four years. These patients frequently die of intercurrent diseases. Chronic Interstitial Nephritis. 1 — This form is very rare in children. Syphilis is the most frequent cause. Edema is rarely marked. The disease begins gradually with headache, neuralgia, and attacks of dyspepsia. There are high arterial tension and arteriosclerosis. Large quantities of pale urine with a low specific gravity are passed. Small quantities of albumin and an occasional tube cast may be present. The outlook in this form is always grave. The disease runs a very chronic course. *W. P. Herringham, " Nephritis, Chronic, Prognosis of, in the Young/' Edinburgh Medical Journal, July, 1906, p. 24. 266 DISEASES OF INFANTS AND CHILDREN. Diagnosis. — The urine should be examined in all cases of headache, pallor, edema, and high arterial tension. Treatment. — This is much the same as in adults, and requires attention and experience. The amount of exercise should be regulated to the child's condition, and many cases should be confined to bed. A daily warm bath is of use. The child should be protected from cold, and a warm, dry climate is best where circumstances allow a change. The diet should consist largely of milk, cereals (oatmeal ex- cepted), bread and butter, and vegetables (legumes spar- ingly, if at all). Meat should be given according to circum- stances, not over once a day, sometimes only every other day. Eggs should be used sparingly as a rule. A salt-free diet may often be used to advantage, especially where there is a tendency to edema. (See' Diet in Health and Disease, fourth ed., p. 543.) Iron is of value in most cases, and the liquor ferri et ammonia? aoetatis a good preparation to use in these cases. AMYLOID DEGENERATION OF THE KIDNEY. (Waxy Kidney? Lafdaceous Kidney.) Etiology. — This is seen in long-standing suppurations, especially of the bones, and in syphilis and chronic tubercu- losis. Pathology. — The kidney is enlarged, firm, and pale. On section it has a translucent appearance. This turns mahog- any brown on being treated with Lugol's solution. The liver and spleen are also affected. Amyloid changes are less common than formerly, owing to the more radical treatment of suppurating foci. Symptoms. — There are anemia and general ill health from the original disease. The liver and spleen are enlarged. The cachexia is sometimes called " alabaster cachexia." The Urine. — The quantity is increased, pale, of low specific gravity, and contains large quantities of albumin. There are casts giving amyloid reaction. Diagnosis. — The history, the cachexia, increased quan- tity of urine with small albuminuria, together with the en- larged liver and spleen, usually render diagnosis possible. THE URINE IN INFANCY AND CHILDHOOD. 267 Prognosis. — Grave unless the predisposing cause can be removed early. Treatment. — Along general lines, both hygienic and tonic. The main thing is the treatment of the original disease. NEW GROWTHS IN THE KIDNEY. 1 Tumors of the kidney in children are usually malignant. The majority of these are sarcomata. The growth is primary in the kidney. The growth usually starts in the pyramids, which is just the opposite of the adult type, which starts in the cortex. The pelvis may be the starting-point or it may begin in the adrenal or an adjacent lymph gland. The tumor may reach an enormous size. Sarcoma is most frequently seen in the left kidney. Symptoms. — The tumor, cachexia, and often hematuria. There may be pressure symptoms, depending on the size of the growth. Diagnosis. — Almost all tumors in the abdomen under ten y r ears are sarcoma. Benign growths usually grow slowly, while these malignant ones grow rapidly. Treatment. — Removal by surgical operation. PYELITIS. 2 Definition. — Inflammation of the pelvis of the kidney, which is often associated with inflammation of the kidney, pyelonephritis ; or of the bladder, pyelocystitis ; or it may lead to accumulation of pus in the kidney, pyelonephrosis. Etiology. — (1) Renal calculi, (2) malformations, (3) tuberculosis, (4) from extension of an inflammation, (5) pyemia, (6) secondary to cystitis. Symptoms. — Pain, and often swelling of the kidney, chills, irregular fever, sweats, leukocytosis, acid urine with blood, pus, desquamated epithelium from the pelvis of the kidney, mucus, and albumin. 1 Strong, Archives of Pediatrics, May, 1903, p. 321. 2 Fischer, Archives of Pediatrics, January, 1901, p. 13. Thomson, "Acute Pyelitis," Scottish Medical and Surgical Jouracd, July, 1902. 268 DISEASES OF INFANTS AND CHILDREN. Diagnosis. — Acid urine with pus and pelvic epithelium are sufficient to make the diagnosis., , , Prognosis. — In the mild forms, good ; in the severe forms with stone or sepsis, bad. Treatment. — Alkaline mineral waters (Celestine, Vichy) may be used to neutralize the urine if acid. Citrate of po- tassium is sometimes given. If the urine is alkaline, benzo- ate of soda may be used or monosodium phosphate. Hexa- methylenamin is of great value, but only when the urine is acid. Surgical treatment is indicated in the stone, pyelo- nephrosis, or in very severe cases. CYSTITIS AND CYSTOPYELITIS. 1 Definition. — An inflammation of the bladder and often of the pelvis of the kidney, due to infection with various bacteria. Etiology. — Usually the colon bacillus is the exciting cause, but pus cocci, gonococci, typhoid bacilli, tubercle bacilli, and other bacteria may be the cause. Congenital malformations predispose to bladder infections. The infec- tion usually takes place through the urethra, may follow the introduction of foreign bodies into the bladder, and very rarely tumors or bladder-stones may be the cause. Some- times the infection seems to come through the circulation, and at others it is apparently an extension from an enteritis or colitis. Most cases occur in infants under eighteen months of age. Symptoms. — The disease is characterized by great rest- lessness, loss of appetite, great thirst, high irregular fever, loss of weight, anemia, and frequently vomiting and some bowel disturbance, which may obscure the diagnosis. There are also mild forms, with only minor local symptoms. In the severe forms there is vesical tenesmus and painful fre- quent urination. There is sometimes pain on pressure over the bladder and kidneys. There is usually a leukocytosis. Urinary Findings. — The specific gravity is usually low 1 Abt, Journal of the American Medical Association, December 14, 3907, p. 1972. THE URINE IN INFANCY AND CHILDHOOD. 269 (1.007-1.015). The urine is cloudy and acid in reaction when the colon bacillus or tubercle bacillus is present, and usually alkaline in infections with the staphylococcus and streptococcus. Albumin is present, as a rule, and pus and epithelium are found on microscopic examination. Diagnosis. — This is made on the urinary findings, and in all cases of high irregular fever the urine should be ex- ainined. In the tuberculous cases there is liable to be marked pallor, cachexia and malnutrition, and blood-clots may l»e passed. In calculus hypogastric pain is more marked, there may be difficulty in urinating, hematuria is frequent, and there may be pain on deep pressure on the perineum. Sounding for stone may settle the diagnosis. Prognosis. — This is variable. Most cases recover in a week or two if promptly treated, while others drag along a most chronic and di -appointing course. Treatment. — In a measure this will depend on the cause. Calculi or tumors should be removed if present. Internally, hexamethylenamin gives the best results, and this may be given in doses of 1 grain four times a day in an infant one year of age, and the dose gradually increased. It acts only if urine is acid. Monosodium phosphate, grains 1 to 5, may be given in sweetened water to render urine acid. Salol has also been advised, and guaiacol in drop doses in orange juice may be used. Guaiacol carbonate may be given in 1 -grain doses. Potassium citrate may be used in place of the above. Irrigation of the bladder is not to be advised except in severe infections with the staphylococcus or streptococcus. RENAL CALCULI Small calculi are frequent in early infancy. These are chiefly uric acid or urates, are quite small, and are apparently usually passed through the ureter. They may cause pyelitis, colic, or give rise to no symptoms. In older children. There is pain over the kidney region, radiating to the opposite side and downward. Renal colic may occur if the stone is passed into the ureter. The 270 DISEASES OF INFANTS AND CHILDREN. Rontgen rays are frequently used to detect stone in the kidney. Treatment. — Alkaline treatment just sufficient to render urine neutral. If diagnosis is clear, surgical treatment. PERINEPHRITIS. Definition. — Inflammation about the kidney. Ktiology. — Trauma. Frequently no cause can be found. Pathology. — An abscess forms which burrows between the muscle sheaths in one direction or another. Symptoms. — The onset may be sudden, with fever, chill, and localized tenderness, or it may be gradual with pain, stiffness of the hip muscles, and lameness. These symptoms increase, fever appears, and child becomes bedridden. There is scoliosis with concavity toward the affected side, the thigh is flexed, extension is painful, but all other move- ments of the hip may be made. The cases last weeks or months, and the abscess may rupture. Diagnosis. — Often mistaken for hip-joint disease. In hip-joint cases there is a more gradual onset, atrophy, limita- tion of all movements, and not of extension only. Psoas abscess from Pott's disease can be differentiated by locating the diseased vertebrae. Prognosis. — Good unless rupture occurs into peritoneal cavity. Treatment. — Rest in bed with hot or cold applications. If suppuration occurs, surgical treatment. THE GENITAL ORGANS. 271 THE GENITAL ORGANS. MALFORMATIONS OF THE GENITALIA. Hypospadias. — The urethral opening is on the under- side of the penis, some distance from the glans. In some cases there may be a fissure in the perineum, which may lead to the diagnosis of hermaphroditism, especially if the testes are undescended. Epispadias. — The urethral opening is on the dorsal surface of the penis. Exstrophy of the Bladder. — A more or less complete absence of the abdominal wall in the median line which exposes the bladder. This organ is also fissured, and appears as a red velvety surface on which the openings of the ureters may be made out. The treatment is surgical. Cryptorchidism (Undescended Testicle). — The testes usually descend from their fetal position below the kidney into the scrotum during the ninth month or shortly after birth. In some cases they may remain in the abdominal cavity or in the inguinal canal. If nearly in the scrotum they may descend on manipulation, otherwise they are best let alone unless they give trouble, when removal may be ad- visable. 1 Adherent Prepuce. — This is found in nearly every male infant. The prepuce should be forcibly retracted, the smegma washed off, and the glans covered with a little oint- ment. This should be done daily until there are no more adhesions. The adherent prepuce may cause frequent and painful urination, and the irritation may lead to the habit of masturbation. Phimosis. — The prepuce has such a narrow orifice that it cannot be retracted. The orifice may be so small as to interfere with the free passage of the urine. It may cause balanitis, painful urination, night terrors, and other reflex conditions, such as retention or incontinence of urine. The 1 Bland-Sutton, " The Value of the Undescended Testicle," The Prac- titioner, January, 1910, p. 19. 272 DISEASES OF INFANTS AND CHILDREN. prepuce may be stretched or cut so as to allow retraction. Thorough anointing with glycerin greatly facilitates retrac- tion. Circumcision is to be preferred in most cases. DISEASES OF THE MALE GENITALS. Balanitis. — An inflammation of the prepuce caused by uncleanliness or phimosis. There are edema, swelling, and a discharge of pus. Cleanliness, the use of antiseptic solutions, and applications of lead water and opium or of ice may be sufficient. It may be necessary to slit up the prepuce in order to clean it properly. Urethritis. — This may result in young children some- times from uncleanliness, more often from gonorrheal infec- tions, from direct contact. The disease resembles that of adults, but constitutional symptoms are not as severe or may even be absent. The treatment is as in adults. Guard against infecting the conjunctiva. Hydrocele. — This is an effusion of fluid into the pouch brought down with the testicle. In the congenital hydrocele there is direct communication between the tunica vaginalis and the peritoneal cavity. The fluid may disappear slowly into the abdomen. It may be mistaken for a hernia. In the ordinary form the canal is closed above and there is a fluc- tuating tumor, translucent and dull on percussion. There may also be hydrocele of the cord, which is sometimes encysted, giving rise to a small tumor. Treatment. — In the congenital form a truss should be worn until adhesions have shut it off from the peritoneal cavity. Absorption frequently occurs. The scrotum may be painted with collodion. Iodid of potassium internally. DISEASES OF FEMALE GENITALIA. Vulvovaginitis. — Definition. — Inflammation of the vulva, vagina, and frequently of the urethra as well. It may be simple or gonorrheal. 1 1 Holt, " Vulvovaginitis," New York Medical Journal, March 18 and 25, 1905. THE GENITAL GROANS. 273 Etiology. — Direct contact, either sexual or by handling; infection less frequently takes place from towels, water- closet seats, and the like. It may be the result of injury. Small epidemics may occur in hospitals and insti- tutions. Symptoms. — Redness and swelling of the parts, excoria- tions of the thighs, pain on micturition. In the simple form, a whitish, yellowish, or greenish discharge. In the gonor- rheal form the discharge is yellow and abundant. Crusts form on the discharge drying. There may be suppuration of in- guinal glands. Iu gonorrheal cases there may be arthritis. Diagnosis. — Differentiation by microscopic examination of the pus. Prognosis. — The simple form is cured in two or three weeks with careful treatment ; without treatment it lasts in- definitely. The gonorrheal forms last weeks, even months, and relapses are frequent. Treatment. — Isolate where there are other children. If severe, keep in bed. Flush vagina several times daily with boric acid (saturated solution): permanganate of potassium (1 : 4000) or bichloride of mercury (1 : 10,000). Follow this in obstinate cases with protargal solutions 3 per cent., and in resistant cases 10 to 20 per cent. Apply oxid of zinc ointment freely over vulva and thighs. Place over this a sterile pad. A napkin should be used in younger children and closed drawers in older ones to prevent infection of the eyes. Gangrenous Vulvitis {Noma). — A gangrene-like can- crum oris beginning either alone or with that disease (see same). The general course and treatment are the same as in that disease. If the patient survives there may be atresia of the vagina. Herpes of the Vulva. — This may occur on the skin or mucous membrane or both. In its appearance and course it resembles the same condition seen in the mouth or about the lips. Cleanliness and a dusting powder are all that is re- quired. 274 DISEASES OF INFANTS AND CHILDREN. DISEASES OF THE BLADDER, Vesical Calculi. — These are rare in infants, but may be met with in older children. They are usually uric-acid stones. Symptoms. — Pain on urination, sudden stoppage of urine, incontinence of urine often absent at night, and prolapse of the rectum. Diagnosis. — By use of a sound. Treatment. — Surgical. Vesical Spasm. — Frequent micturition with intense pain, due usually to very acid urine. Treatment. — Alkaline waters in abundance, citrate of potassium, and hyoscyamus. Enuresis l (Incontinence of Urine; Wetting the Bed). — Definition. — Frequent involuntary urination. Etiology. — It may be due to malformations of the geni- talia, to malformations, injury or disease of the nervous system. The usual form considered here is a neurosis, and both genitalia, and organically the nervous system, are nor- mal. The causes may not be discoverable ; it may be due to reflex action due to very acid urine, worms, adherent fore- skin, and general irritability of the nervous system. The causes are too numerous to mention, but among them enlarged tonsils and adenoids should not be forgotten. In many cases where there is infection of the urinary passages hexamethyl- enamin may be given, and salol is often useful. Symptoms. — The incontinence may occur by day or night, or both, and varies greatly in severity. The urine is passed in considerable quantity at a time and does not drip gradu- ally. It may occur only at times. Prognosis. — The cases due to organic nervous diseases are hopeless. Those due to malformations may be sometimes relieved by surgical measures. In the ordinary cases cure may result at any time. It may last until five or six years 1 Williams, " Nocturnal Enuresis and Thyroid," Lancet, May, 1, 1909, p. 1245. V. C. de Bainville, " Enuresis, Nocturnal, Causes and Treat- ment of," Practitioner, March, 1906, p. 396. C. G. Kerley, "Inconti- nence of Urine," Boston Medical and Surgical Journal, August 16, 1906, p. 172. THE GENITAL ORGANS. 275 of age or even to puberty. With persistent treatment many eases can be relieved. Treatment. — Relieve the cause where possible. Build up general health. If urine is very acid give alkaline diuretics or citrate of potassium. Avoid irritating articles of diet, especially tea and coffee. The child should be taught to urinate as infrequently as possible, so as to train the bladder to be distended. But little fluid should be given after 4 p. m. in the nocturnal cases, and the bladder should be emptied at bedtime. If the urine is scanty see that the child has sufficient water at other times. If the urine is very abundant diminish amount of fluid. Belladonna or atropin is the most useful drug ; loVo" g r - °f atropin may be given for each year of the elii Id's age ; and it is best given at 4 and 10 p. M. ; later at 4, 7-10 P. M. (Holt). The quantity may be gradually in- creased until flushing of the face occurs, and the dose should then be diminished very slightly. This must be kept up a Ions: time. Strvchnin and nux vomica are also valuable, especially in the diurnal cases. Faradism or passage of a sound sometimes gives relief. Williams suggests the use of thyroid extract; from J to 2 J grains may be given three times a day. The initial dose should be small and the increase made gradually. Care should be taken not to give too much, and the patient should be under observation. Cystitis. — Definition. — An inflammation of the bladder. This may or may not be associated with a pyelitis. Etiology. — The inflammation is due to bacteria, usually the colon bacillus, more rarely the typhoid bacillus, tubercle bacil- lus, or pyogenic micrococci. Gonorrheal cystitis is rare. Cys- titis is much more common in girls than in boys. Symptoms. — Infections of the urinary tract are frequently overlooked in children. There are restlessness, loss of appe- tite, an irregular but persistent fever, and pain, usually referred to the abdomen if the child is old enough to locate it. The urine is acid and contains pus and bacteria. In staphylococcic and streptococcic infections the urine is alkaline. There may or may not be symptoms distinctly referable to the genito- 276 DISEASES OF INFANTS AND CHILDREN. urinary tract; if present these are frequent and painful mic- turition and chafing of the external genitalia. Diagnosis. — This depends upon the examination of the urine. The urine may be drawn with a catheter if neces- sary. Prognosis. — This is usually good if the child is properly treated. Occasionally the disease persists in spite of treat- ment. Treatment. — Local treatment and washing of the bladder is liable to do more harm than good in young children. Hexa- methylenamin (urotropin) may be given internally in doses of from J to 1 gr. three or four times a day. Salol may also be used, and in persistent cases guaiacol may be admin- istered in orange juice. DISEASES OF THE SKIX. 277 DISEASES OF THE SKIN. 1 CONGENITAL ICHTHYOSIS. ( Keratoma Diffusum ; Fish-skin Disease ; Xeroderma. Definition. — A congenital disease of the -kin charae- terized by dryness, sealiness, and a thiekening of the skin. Fig. 07.— Ichthyosis congenita : rase photographed when four days old : mother pregnant seven time-, giving birth the fifth and the last (present case* to infants with congenital ichthyosis (from Stelwagon, courtesy of Dr. J. MacF. Winfield). 1 See Stelwagon, A Treatise on Diseases of the Skin, for further references. T. C. F< ix, • Skin Diseases of the Young Child," Practitioner, Oct., 1905, p. 565. 278 DISEASES OF INFANTS AND CHILDREN. Etiology. — There may be an hereditary tendency to the disease. Pathology. — The condition is usually regarded as an inherited deformity. There is thickening of the epidermis, especially of the horny layer. Symptoms. — -This condition may be present at birth or develop later ; it is usually not noted until the end of the first or second year. There are all gradations in severity, from a scaly, parchment-like thickening of the skin to thick plate-like scales. Diagnosis. — Usually easy ; care should be taken to ex- clude scaly eczemas and linear nsevus. Prognosis. — Many of the cases are born prematurely and may die soon afterwards. In the cases noted later the disease does not affect life, but the outlook as regards cure is bad. Treatment. — Thyroid tablets may be given a trial in- ternally. Externally, frequent baths with an ointment con- taining salicylic acid may be tried. ECZEMA. (Salt Rheum; Tetter.) Definition. — An inflammation of the skin, which may be acute, subacute, or chronic. It is characterized by various lesions, as erythema, papules, vesicles, and pustules, either alone or in combination. There is more or less infiltration of the skin, together with a variable amount of exudate, and usually intense itching. Etiology. — Certain children seem predisposed to eczema. The exciting cause may be any irritation — heat, cold, para- sites, rough clothing, scratching, and the like. Intestinal disturbances may also cause it. Pathology. — The changes in the skin are those of an acute or chronic inflammation, as the case may be. Symptoms. — Only the more important infantile forms can be mentioned. Eczema is a disease of countless mani- festations and varieties. The eczema of older children resem- bles that of adults. Eczema Mucosum or Intertrigo. — This develops where two DISEASES OF THE SKIN. 279 surfaces come together, as in the inner side of the thighs or axillas. It is frequently caused by uncleanliness or irritating stools. There is intense redness of the skin and exudate, rendering the surface moist. There is little itching. © © Eczema Vesiculosum (Milk ( Yusf). — A form frequently seen on the face of infants. There is at first redness ; then small vesicles appear which are likely to coalesce ; and when the top is scratched off, a yellowish-brown crust forms. Seborrheic Eczema. — This is most frequently seen on the scalp in connection with seborrhea ; it may, however, be seen elsewhere on the body. There are greasy, yellowish scaly crusts underneath which there is an inflammation of the skin. There is itching. Pustular Eczema of the Scalp. — There are numerous pus- tules which break, and the dried pus and hair form a crust over the head. Lice may be the exciting cause. In some cases no definite cause can be assigned. Simple Chronic Eczema (Eczema Rubruni). — The most fre- quent form of eczema. The face is most often affected, but the body may also be involved. There are first red papules which run together. Exudation follows, and this dries, form- ing crusts. Bleeding is frequent. The itching is intolerable, as a rule. Later, considerable thickening of the skin occurs. The disease can usually be readily relieved, but frequently returns as soon as treatment is discontinued. Diagnosis. — L^sually easy. Syphilis and scabies should be excluded. Prognosis. — In the acute cases the outlook is good. The chronic cases always last a long time and tend to relapse. Treatment. — Good hygiene and proper feeding are essen- tial. Each case demands especial study. Intestinal indi- gestion, if it exists, should be treated. Overfeeding is the most common error ; excesses in carbohydrate the second. In infants the trouble is frequently too high fats and sometimes too high sugar or proteins. Tonics are often necessary. Iron or arsenic or cod-liver oil may be useful. Cleanliness and care in regard to the skin are important. The part should be cleansed and the crusts removed with oil and soap and water. Water often irritates, and when it does 280 DISEASES OF INFANTS AND CHILDREN. a bran or starch bath may be substituted or only oil used. In the acute stage a zinc and calamine lotion is most satis- factory. If itching is severe 1 per cent, carbolic acid may Fig. 68.— Method of treating eczema capitis. be added. Carron oil or a substitute made from equal parts of lime water and oil of sweet almonds is useful. Later, oxid of zinc ointment or Lassar's paste may be used. Tar, salicylic acid, and resorcin are most frequently used to stimu- late the skin. Dusting powders are useful in intertrigo and the milder forms of acute eczema. DERMATITIS VENENATA. (Poison Ivy or Oak Rash.) Definition. — A vesicular eruption caused by contact with plants of the rhus species. It may also be caused by irritating drugs. etiology. — There are too many causes of this eruption to enumerate them in this brief space. By far the most fre- quent, however, is the poison ivy or oak. Some persons are peculiarly susceptible. Symptoms. — A few hours or a day after exposure there DISEASES OF THE SKIN. 281 is an eruption, usually on the face, hands, and arm.-, some- times on the genitalia or other parts of the body. The skin Fig. 69. — Dermatitis venenata from exposure to paison-4vy, following shortly alter exposure ; vesicular and bullous lesions : not an uncommon type ; hands and forearms involved ; a days' duration (Stelwagon), is reddened and covered with numerous small vesicles. There are burning and itching. Diagnosis. — Usually easy. Prognosis. — Recovery usually takes place in a week or ten days. Eczema may follow. Treatment. — The calamine aud zinc oxid lotion is use- ful. The fluid extract of grindelia robusta diluted with water (1 : 5) is frequently used. A lotion of sulphate of zinc (15 gr. to 1 pint) is useful. Mild astringent and antiseptic applications are also of service. Zinc oxid ointment may be applied. MILIARIA. i Prickly Heat ; Strophulus ; Red Gum ; Lichen Tropicus ; Heat-rash, etc. I Definition. — An acute inflammation of the sweat glands, characterized by small papules and vesicles and accompanied by itching and burning. Btiology. — Overheating either from hot weather, over- heated rooms, or too much clothing. It is seen also in fevers. 282 DISEASES OF INFANTS AND CHILDREN. Pathology. — More or less obstruction of the sweat glands, due to congestion and exudation. There are a num- ber of different theories about this condition. Symptoms. — There are several forms, usually seen together. There may be a preponderance of the vesicles or of the papules. These are discrete, but often closely set. They vary in color from transparent vesicles to the intense red papules. There are itching, burning, and a pricking sen- sation. Diagnosis. — When irritated or rubbed, the disease may resemble an eczema ; otherwise the diagnosis is easy. Prognosis . — Good. Treatment. — Proper temperature and clothing. Give a purge. Apply a bland dusting powder liberally. If the itching is intense apply a lotion of carbolic acid, boric acid, alcohol, and water. Resorcin, 1 gr. to the ounce, or satu- rated boric acid solution is useful. SEBORRHEA OF THE SCALP. (Milk Crust.) Definition. — A functional disease of the fat-producing glands, characterized by an excessive secretion which forms greasy, yellowish crusts over the head. Etiology. — This is very frequent in infants and young children, especially where the scalp is not kept very clean. After infancy is passed it is not common until after puberty. Pathology. — An overproduction of fat in. the sebor- rheic glands. Some think it is caused by a short bacillus (Sabouraud). Symptoms. — The scalp is covered more or less com- pletely 'with a greasy, yellowish, scaly crust. This may, if neglected, cause an eczema of the scalp. Diagnosis. — The greasiness of the scales separates it from psoriasis, eczema, and ringworm. Prognosis. — Good, but with a great tendency to recur. Treatment. — Oil the scalp well and wash with soap and water, preferably tar soap. Resorcin ointment (5 to 10 gr. to the ounce) or a mild sulphur ointment is usually quite DISEASES OF THE SKIN. 283 efficient. The scalp must be kept clean by frequent wash- ings with tar soap. FURUNCULOSIS. 1 Boils.) Definition. — A condition in which numerous furuncles or boils are present. Etiology. — Frequent in young infants, in marasmus, and in malnutrition from any cause. Uncleanliness may be another cause. Pathology. — The furuncle consists of an inflammation the center of which becomes necrotic and forms a " core." Pus-forming bacteria are always present. Symptoms. — Furuncles in infants are most frequently upon the scalp, but may be anywhere on the body. Septic infection may result, and gangrene of the skin may be a cause of death. Diagnosis. — This is easy. Syphilis should be excluded. Prognosis. — In very young and very weak children this may prove fatal. In stronger children the outlook is good. Treatment. — Good hygiene and feeding. Syrup of the iodid of iron, arsenic, and other tonics are advised. The boils should be opened and mild antiseptic dressings applied and kept in place with bandages. Chronic furunculosis may be treated by means of vaccines. The variety of organism present should be determined. Vaccines may be made from this or the stock vaccines may be used ; 50,000,000 or some- what less may be given as an initial dose and repeated in a week. The dose may be gradually increased, but should neither be so large nor so frequently repeated as to cause any symptoms. The initial dose for streptococcus vaccine is about one-fourth the above. IMPETIGO CONTAGIOSA. Definition. — A contagious disease seen especially in in- fants and young children and characterized by vesicopustules, especially on the exposed parts of the body. Etiology. — Seen in young children, in institutions, and 284 DISEASES OF INFANTS AND CHILDREN. among the poor. It is readily communicated from one child to another, and it may be inoculated from one part of the body to another. Pathology. — The specific cause is some pus-forming germ; staphylococci and streptococci have both been isolated. Fig. 70.— Impetigo contagiosa (after Lesser). There is a bleb-like vesicle, the contents of which become turbid and then dry. Symptoms. — The lesions are found chiefly on the face and hands and the parts of the body which the child can scratch. The pustule is on a slightly reddened base. The resulting crust looks as if it were "stuck on." When this scab falls off it leaves a reddened area which gradually clears up. Diagnosis. — Easy. It has been confused with pem- phigus, chicken-pox, and small-pox. DISEASES OF THE SKIN. 28o Prognosis. — Good. It lasts several weeks, and by auto- inoculation may be kept up much longer. Treatment. — Some antiseptic wash or ointment should be applied and auto-inoculation prevented if possible. A diluted ointment of ammoniated mercury is a very satisfac- tory application. ECTHYMA. Definition. — A disease seen in poorly nourished chil- dren, characterized by discrete, flat pustules on an inflamed base. Etiology. — In very poor children, in malnutrition from disease, and from irritation, such as from bedbugs. Pathology. — Streptococci are usually found in the pus- tules. They are considered by some to be the same as impetigo. Symptoms. — The eruption is seen on the legs, back, and forearms. The pustule appears about the size of a pea, becomes flattened, and gets a little larger. The base i- indurated, reddened. Hemorrhages frequently take place into the lesion, causing them to turn black. They last a week or two and disappear, new ones forming from time to time. There may be pain and itching. Diagnosis. — From impetigo by the flat pustule on an indurated, very much reddened base, and the absence of any tendency to coalesce. Syphilis should be excluded. Prognosis. — Good. Treatment. — Good food, fresh air, and tonics. Locally, antiseptic dressings. Ammoniated mercury ointment is a satisfactory application. Bacteriologic vaccines may be tried in resistant cases. URTICARIA. (Hives.) Definition. — A condition characterized by the appear- ance of numerous wheals and by intense itching. In chil- dren irregular forms are frequently seen in which vesicles and papules are present. 286 DISEASES OF INFANTS AND CHILDREN. Etiology. — Certain children are particularly liable to urticaria. Indigestion and certain articles of diet are the most frequent causes. At times no cause can be assigned. Symptoms. — There are papules and wheals over the hands, feet, and body. The itching is intense. Scratching may result in infecting the skin. After a few hours or much longer the lesions disappear. Diagnosis.— This is easy. Scabies and chicken-pox should not be mistaken for it. (See Henoch's Purpura, p. 245.) Prognosis. — As a rule good. In some cases it recurs with great persistence. Treatment. — Give a purge and repeat if necessary. Calomel, salines, as phosphate of soda and castor oil, are best. Give a simple, easily digested diet or a milk diet. Treat any attendant indigestion. Locally, applications of hot bicarbonate of soda solutions or hot soda baths may be given ; lotions of menthol (2 gr. to 1 oz.) or carbolic acid (1 per cent.) and water may be applied. Internally, alkaline drugs should be tried, especially if the tongue is clean. Aromatic spirits of ammonia is one of the best drugs to use. Ammonium chlorid is useful and full doses of anti pyrin sometimes give relief. If sleep is much disturbed, bromids and chloral, veronal, or similar drugs may be given. A change of air and an out-of-door life are fre- quently advisable. ALOPECIA AREATA. Definition. — A disease characterized by patches of bald- ness without any apparent changes in the skin. Etiology. — It is slightly more frequent in boys, and rare before five years of age. The exciting cause is unknown. By some it is thought to be neurotic, by others parasitic. Pathology. — There are degenerative changes in the hair bulb and in the hair above it. Symptoms. — The loss of hair over the bald patch is complete. The hairs about the edges of the patch are often DISEASES OF THE SKIN. 287 loose, especially when the patch is increasing in size. There are usually several patches. The entire scalp may be affected. Diagnosis. — Ringworm. — This rarely presents absolutely bald patches ; the hairs are broken off close to the head. The fungus may be demonstrated in doubtful cases. Favus. — There is rarely complete baldness ; there are crusts and some inflammatory reaction. Bald spots from abscesses and boils should be excluded. Prognosis. — Usually good in children. Sometimes the Fig. 71.— Alopecia areata (Hardaway). baldness is permanent. It lasts months or even years. A downy growth on the spot is favorable. Relapses may occur. Treatment. — Internally, touics as indicated. Iron, cod- liver oil, arsenic, and strychnia are the most useful. Locally, washing with green soap or naphthol sulphur soap, and applying stimulating ointment or lotions. Beta-naphthol tar, sulphur, and cantharides are the most frequently used. 288 DISEASES OF INFANTS AND CHILDREN. PEDICULOSIS. (Phthiriasis; Lousiness*) Definition. — This term is applied to the irritation of the skin and scalp caused by lice. There are three species : pediculus capitis, or head louse ; pediculus corporis, or clothes or body louse ; and pediculus pubis, or crab louse. The last- named is not often seen in young children. Etiolgy. — Lice are usually seen in the poorer classes of people. They are communicated by direct infection. Pathology. — The irritation pro- duces inflammation of the skin and enlargement of the neighboring lymph nodes. Symptoms. — Head Lice. — These are rarely seen anywhere except on the head. The lice themselves are seen on the hairs, and there are always Pig. 72.— Male pediculus capitis (after Kiichenmeister). Fig. 73.— Nits of pediculus capitis (after Kaposi). numerous little hard pinpoint-sized bodies, called nits, at- tached to the hairs. There are itching and inflammation of the scalp and nape of the neck, together with enlargement of the post-cervical lymph nodes. Body Lice. — These are seen on the body and in the folds of the clothing. They may be suspected from the many scratch-marks on the body. There may be pigmentation. DISEASES OF THE SKIN. 289 Crab Lice. — In older children they may be found about the genitalia, as in adults. In young children, if seen at all, they are usually on the eyebrows or eyelashes. Diagnosis. — This is made by finding the lice. Prognosis. — It requires considerable time to rid the body of lice if once infected. Treatment. — Head Lice. — Anoint the hair with crude petroleum. (Caution, very inflammable.) Put on a cap and allow to remain on twelve hours. Wash the head in soap and water. The nits may be removed by using hot vinegar and a fine-tooth comb. Tincture of cocculus indicus, diluted several times with water, is also used. Sulphur-naphthol soap may be used in mild cases. The accompanying eczema should be treated as such. Body Lice. — Sulphur-naphthol soap and a full bath should be used. The clothing should be disinfected by boiling or ironing. SCABIES. (Itch.) Definition. — A contagious disease caused by the acarns scabies, and characterized by intense itching and an eruption of papules, vesicles, and pustules. Ktiology. — It is seen mostly in the poorer classes. In- fection occurs from direct contact, unclean bedding, clothing, and the like. Pathology. — The lesions are caused by the irritation of the parasite burrowing in the skin. Vesicles and papules are always present, and frequently pustules, these last prob- ablv from infection with pus germs. The female parasite alone burrows into the skin. The burrows can often be seen as fine dark lines from J to 1J in. in length. Symptoms. — These are the intense itching, which is worse at night, and the characteristic eruption seen, especially on the hand, between the fingers, about the wrists, folds of the elbow, axillas, groins, genitalia, inner side of the thighs, and the back of the knees. The scalp and face are never involved. There may be eczema as a complication. 19 290 DISEASES OF INFANTS AND CHILDREN. Diagnosis. — The intense itching, especially at night, and the character and location of the eruption, make the diagnosis easy, as a rule. The parasite may often be demon- strated. Prognosis. — Good. Treatment. — Full baths with green soap, followed by inunction with sulphur ointment diluted to half strength, or the following : B /?-naphthol 4(3j); Prepared chalk 8(,^ij); Green soap 50 (^iss) ; Benzoinated lard 100 (^iij).— M. This should be repeated for three days and then under- clothing and bedding changed and sterilized. If not per- fectly cured, repeat. Soothing ointments may be applied if eczema exists. RINGWORM. 1 (Tinea Tricophytina ; Tr icophytosis ; Dermatomycosis Tricophytina.) Definition. — A parasitic skin disease caused by fungi of various kinds, chiefly, however, by different species of the genus tricophyton. It may affect the scalp or body. Etiology. — The chief fungi are the tricophyton megalo- sporon. The disease is contagious, and is transmitted by direct contact, brushes and combs, wearing apparel, and the like. Ringworm is most common in the young, and ringworm of the scalp is almost entirely limited to children. Pathology. — The fungus is easily demonstrated in scrapings from the edge of the patch which have been moist- ened with liquor potassse. The fungus grows in the horny layer of the epidermis. Symptoms. — Ringworn of the Body (Tinea Circinata). — This usually begins with one or more slightly scaly, reddened spots, which are sharply outlined and raised a little above the surface. These grow and the center clears up partially, so that the spots are ring-shaped areas with a raised, reddened 1 T. C. Fox, " Ringworm of the Scalp, Treatment of," Practitioner, April, 1905, p. 468. DISEASES OF THE SKIN. 291 border and a slightly scaly center. The appearance is usually characteristic. Ringworm of the Scalp (Tinea Tonsurans). — One or more scaly bald spots are seen. The edges are sometimes slightly hyperemic and raised. The hairs are broken off short near the scalp and can be seen on close inspection. Diagnosis. — Usually easy. In the scalp the scaliness and the short broken hairs separate it from alopecia and favus. In seborrhea the scales are greasy and the affection general, while in eczema there is often an exudation and always itching. Prognosis. — Eventually good. Body ringworm is usually cured. Ringworm of the scalp is difficult, and re- infection is frequent. Treatment. — Separate towels, etc., for the infected child. A cap for the scalp. Scrub with green soap and hot water and apply a parasiticide. Beta-naphthol, sulphur, resorcin, and the tincture of iodin are most frequently used. The Ront- gen rays may be used with good effect in resistant cases. FAVUS. (Tinea Favosa; Porrigo Favosa, etc.) Definition. — A contagious disease usually of the scalp caused by the Achorion Schoenleinii and characterized by cup-shaped crusts which tend to coalesce. Ktiology. — It is seen in poor children in America, espe- cially in immigrants. Pathology. — The Achorion Schoenleinii is a vegetable parasite, consisting of mycelium and spores. Infection occurs about a hair, the hairs fall out, and a pustule is produced. Symptoms. — There are yellowish cup-shaped crusts, often running together. The hairs are either gone or are split or broken. There are atrophy and scarring of the skin. There is a peculiar characteristic mouse-like odor. Diagnosis. — The characteristic crusts and odor, with atrophy of the skin and brittle hairs, usually make the diag- nosis easy, 292 DISEASES OF INFANTS AND CHILDREN. Prognosis. — Good, if treated early. Permanent bald- ness may result. Treatment. — Oil the scalp and wash with soap and water, removing all crusts. Cut the healthy hair short. Pull out the hairs of the affected areas. Apply parasiticides. Resorcin and lanolin (1 : 8), or sulphur, tar, and mercury. The Rontgen rays may be used with good effect. GANGRENE. Gangrene occasionally is seen in infants and young children, and is always a very serious condition. It may be due to a great variety of causes. The commonest form is noma, which has been described under that heading, but which also may Fig. 74. — Gangrene of the great toe. affect the genitalia and sometimes other parts of the body. Gangrene of the skin may occasionally be met with in other infectious diseases, particularly chicken-pox, and it may also be seen to follow septic infections of the skin and pemphigus. Raynaud's disease is sometimes met with in early life, and occasionally gangrene may follow embolus or thrombosis. DISEASES OF THE SKIN. 293 DRUG ERUPTIONS. Erythematous eruptions may be produced by : Antipvrin, resembling measles and diffuse erythema. Arsenic, occasionally. Belladonna, scarlatiniform erythema. Borax and boric acid. Chloral, scarlatiniform rash with desquamation. Copaiba and eubebs, eruption like measles. Digitalis (rarely), scarlatiniform and measly eruption. Iodoform, scarlatiniform. Mercury (rarely), scarlatiniform erythema. Opium and morphia, rash resembling measles or scarlatina. Quinin, scarlatiniform erythema with desquamation, some- times attended with pyrexia. Salicylates and salicylic acid, scarlatiniform. Sulphonal, macular and diffuse erythema. Tar, erythema with fever, sometimes an eruption like measles. Urticarial eruptions : Copaiba and eubebs. Quinin. Salicylic acid and salicylates. Santonin. Tar and creosote. Turpentine. Valerian. Erythema with infiltration and edema resembling ery- sipelas. Aconite, bromid, and iodid of potassium. Vesicular aud bullous eruption- : Arsenic (rare), boric acid (rare), bromids, iodids, and iodoform. Cubebs and copaiba (rare), quinin. Herpes zoster : Arsenic. Pustular eruption : Antimony. Arsenic. Bromids. 294 DISEASES OF INFANTS AND CHILDREN. Iodids. Calcium sulphide. Salicylic acid (rare). Petechial eruption, purpura : Chloral. Copaiba. Iodids. Cyanosis : Acetanilid. Pigmentation : Arsenic (brown). Silver (slate color). Hyperkeratosis, epidermic thickening : Arsenic (epithelioma has been known to arise in an area of arsenical hyperatosis). Borax, eruption like psoriasis. ACUTE OTITIS. Definition. — An acute inflammation of the middle ear. Etiology. — Usually secondary to other diseases. The majority of the cases occur in winter. The most common causes in the order of their frequency are simple catarrhal pharyngitis, measles, influenza, dentition, scarlet fever, and whooping-cough. Other diseases are occasional causes. In- fection takes place through the Eustachian tube. Pathology. — There is a congestion of the middle ear and tympanum. Later, there is either a catarrhal or purulent exudate. There may or may not be rupture of the ear-drum. Symptoms. — In infants fever may be the only symptom, and the ear may not be thought of until the drum ruptures and there is a discharge of pus, usually with a fall of the temperature. If the perforation is near the center of the drum, it suggests infection through the Eustachian tube ; if on the periphery, from disease of the bones. There may be evidence of pain and discomfort and the child may sleep poorly. Sometimes there may be rolling of the head and evidence of pain on pulling the lobe of the ear. In older ACUTE OTITIS. 295 children there is deafness, pain, and great restlessness, and sometimes delirium or convulsions. Complications. — Mastoiditis, thrombosis of the lateral sinus, meningitis, facial paralysis, and involvement of the internal ear. Diagnosis. — Usually by examination of the drum mem- brane, the deafness, and earache. The disease is frequently overlooked in infants. The ear should always be examined, as in unexplained prolonged fever otitis is a frequent cause. If the disease continues for a month, mastoiditis should be suspected, and if the pus returns immediately after being wiped out of the ear, the diagnosis of mastoiditis is almost certain. Pain, fever, redness, jand swelling over the ear are later symptoms. Prognosis. — Catarrhal form good. In the purulent form some impairment of hearing often results. Treatment. — Dry heat applied externally. Salines and leeches if seen early. A 4 per cent, cocaine solution may be dropped in the ear for pain or, better still, a 5 to 10 per cent, solution of carbolic acid in glycerin. If the symptoms persist or rupture of the drum is threat- ened, paracentesis should be done. After that, or if rupture occurs, syringing with warm saturated solutions of boric acid. If there is odor permanganate of potassium solution (1 : 4000) or peroxid of hydrogen (1 : 4) may be used. If long in healing use once daily a few drops of 1 : 3000 bichlo- rid of mercury in 60 per cent, alcohol. Mastoiditis requires prompt surgical treatment. 296 DISEASES OF INFANTS AND CHILDREN. DISEASES OF THE NERVOUS SYSTEM. The nervous system is only partially developed at birth, and during the first few years its functions are easily dis- turbed, even by minor causes. The brain and cord are rela- tively larger and softer than in adults. Reflexes are more marked and brain inhibition absent, or only present to a slight degree. THE EXAMINATION OF THE NERVOUS SYSTEM AND THE SIGNIFICANCE OF SYMPTOMS. The history of the illness, and especially of diseases which may affect the nervous system, should be gone into carefully. The presence or absence of the nervous symp- toms noted below should be determined by direct question- ing of the mother or nurse, and a complete physical exam- ination of the child should be made, with especial reference to the reflexes, the amount of power, the condition of the muscles, and other things having a bearing on the nervous system, as noted below. An exact knowledge of the normal child is indispensable and can only be acquired by experience. In making a diagnosis always have the child undressed, always try to ascertain the family history, especially as re- gards syphilis, alcoholism, nervous and mental diseases. Re- member that development depends much upon environment, and too much is not to be expected from neglected children. It is well to remember that there are more functional than organic diseases of the nervous system in early life, and that it takes but little to upset the nervous equilibrium of the young child. Irritability and change in disposition are seen in the onset of most acute diseases, in chronic bowel and kidney disease, and the auto-intoxications. Delirium is not uncommon in children, and is most often due to fever and, it should be remembered, often with rather low temperatures. It is also frequent as a result of auto- intoxication, as in gastro-intestinal disorders and as the result DISEASES OF THE NERVOUS SYSTEM. 297 of intracranial disease. Belladonna, alcohol, and other drugs may also be the cause. Drowsiness is frequently seen, and may be due to a variety of causes, among which may be mentioned the ad- ministration of alcohol, opium, bromids, soothing syrups, and other drugs ; the poisoning which occurs in diseases of the kidney, liver, and also of the stomach and intestines ; the onset of measles and during the course of many febrile dis- orders, such as typhoid fever and pneumonia, after epileptic seizures, and of very great importance during the onset and during the course of brain diseases, and especially of menin- gitis. Coma is often seen in meningitis, diseases of the brain, and later in any severe affection, as in uremia, diarrhea, and pneumonia. It is always a serious symptom and usually means an unfavorable prognosis. Coma is easily produced in children by sleep-producing drugs. Di^iness or vertigo may be noted, the child com- plains of things turning round or that he is falling when there is no danger of it, as when in bed, and there may be disturbance of gait and station. This may be due to brain tumor (especially cerebellar), to disease of the ears, to men- ingitis, to digestive disturbances, and is occasionally noted in the onset of acute diseases. Photophobia is sometimes seen in meningitis, especially early in the disease, in cerebral hyperemia, and to a lesser degree in measles and sometimes in influenza. It may be caused by local disease of the eye, and at other times is apparently due to irritation of the mouth. The superficial skin reflexes are not observed under the third day, and they develop slowly and are comparatively constant at five months of age, although they are sometimes feeble or even absent during the first year or two of life, and in young infants the area over which a reflex may be elicited is often enlarged. Sometimes they appear at once and at other times successively. In the latter case the upper re- flexes are observed before the lower. The knee jerk is present from the second day and in in- 298 DISEASES OE INFANTS AND CHILDREN fants is rather more marked than in later life, and there may be what is considered a marked increase without any or- ganic disease ; but the deep reflexes may be difficult to elicit in children, owing to only partial relaxation of the mus- cles. It is increased in most cases of infantile cerebral paralysis and is usually absent in cases of poliomyelitis aifecting the extensors of the thigh, in neuritis, progressive muscular atrophy, and pseudohypertrophic paralysis. Plantar Reflex.— In the adult, stroking the sole of the foot causes quick flexion of the toes, inversion of the foot, and often a drawing up of the leg. In the young infant the Fig. 75.— Normal plantar reflex. reflex is usually extension and a spreading out of the toes, and more or less irregular movements of the leg and hip. By the end of the first year 50 per cent, of the reflex is flexion, and by the third year flexion is the normal reflex. Flexion in children who walk late is a good sign. Kernig's Sign. — This consists in the inability to extend the leg fully on the thigh when the thigh is at a right angle with the trunk, or to flex the thigh at a right angle with the DISEASES OF THE NERVOUS SYSTEM. 299 trunk when the leg is extended on the thigh. In other words, when an attempt is made to extend the leg the con- traction of the muscles keeps the thigh at right angles to the body and the legs at right angles to the thigh. This is seen chiefly in cerebrospinal fever, but it may be noted both in tuberculous meningitis and in other forms where the spinal meninges are involved. It may be absent in some cases, but is sometimes present only intermittently. It is more often present when the knee jerk is increased than when it is diminished. It is rarely seen in other diseases of infancy Fig. 76.— Plantar reflex, showing Babinski's sign. except in chronic marasmus, where there is considerable mus- cular rigidity. Chvostek's Sign. — This is the mechanical irritability of the motor nerves and is best observed in the facial nerve, although tapping over the motor points elsewhere will cause contraction of the corresponding muscles. A tap on the cheek below the malar bone causes a sharp contraction of the muscles supplied by the facial nerve. The phenomenon is pathologic, is rarely seen during the first six months, but after that it indicates an abnormal excitability of the nervous system. It is seen in tetany, laryngismus stridulus, also less 300 DISEASES OE INFANTS AND CHILDREN. often in rickets, and in older children in digestive disturb- ances. I/ip Reflex of the Newborn. — This is elicited by a number of taps on the upper lip a little above the angle of the mouth, or on the lower lip a little below it. In some infants touching or tapping anywhere on the cheek will cause it. The reaction consists in drawing the lip to one side or the other, followed by a pouting or pursing up of the lips, as if the child attempted to suck something, and lastly, a marked protrusion of the lips. It is most easily elicited during sleep, becomes less marked as the child grows older, and is rarely noted after the fourth year. In some cases of spastic diplegia there is a similar reflex which may be obtained that is combined with chewing movements. Tremor. — This is very rare in children. It is seen in multiple sclerosis, occasionally in a course of infectious dis- eases, and sometimes in brain tumor. Ataxia is often overlooked, owing to the fact that co- ordination is not very perfect in early life. It is seen in tumors of the brain, especially cerebellar tumors and Fried- reich's disease, also in the severe choreas. In the transient form it is sometimes seen after prolonged rest in bed. Tache Cerebrale. — A very light stroke on the skin produces a persistent hyperemia seen in meningitis, typhoid, and other fevers. It is seen also in children with urti- caria. Electrical Reactions. — These are almost impossible to elicit satisfactorily in young children and perhaps are best left to the expert. Pseudoparalysis. — This is loss of muscular power due to other than nerve lesions. It presents the appearance of a true paralysis, but that differential diagnosis may usually be made by careful examination ; slight movements sometimes being made on pinching or otherwise irritating the skin. Pseudoparalysis is seen in rickets, scurvy, syphilis, as well as in joint and bone disease. In some instances the lack of power is due to weakness ; in others, to the child's inhibiting movement owing to pain. DISEASES OF THE NERVOUS SYSTEM. 301 CONVULSIONS. 1 Definition. — A convulsion is a motor discharge resulting in muscular contractions of one or more parts of the body (Sachs). Etiology. — During the first few days from meningeal hemorrhage due to protracted instrumental delivery, from diseases of the brain as meningitis, or tumors, onset of acute infections in place of a chill ; may be reflex from an undigested meal ; may be due to toxemia — either from intestinal auto- intoxication or uremia ; frequently seen in rickets and in exhausting diseases, from injury, and in epilepsy, which will be considered separately. Convulsions are most frequent under two years of age. Pathology. — There are many theories. The convulsion is produced by irritation of the cortical cells of the brain either directly, reflexlv, or from toxic substances in the blood. A convulsion is to be regarded as a symptom of some patho- logic condition. "Symptoms. — In many cases there are initial cry, devia- tion of the eyes, loss of consciousness, tonic or clonic mus- cular spasms, and the involuntary passage of urine and feces. A convulsion is often seen in a child where an adult would have a chill. ]STo two convulsions are alike, but there is no difficulty in recognizing one. Following a convulsion the child may be dazed, or even remain unconscious for some time. Sev- eral convulsions may follow one another in rapid suc- cession. Death may take place from asphyxiation or exhaustion. Diagnosis. — The convulsion itself is easily recognized. The cause may be difficult to determine. A convulsion coming on without previous illness is usually functional. ^ A general convulsion is usually functional ; a partial convulsion 1 H H. Scott. "Convulsions, Causation of," Practitioner, August, 1906, p. 237. John Thomson, "Convulsions in Early Infancy," Practitioner, October, 1905, p. 510. 302 DISEASES OF INFANTS AND CHILDREN has usually, though not necessarily, an organic cause. A partial convulsion is usually evidence that the corresponding part of the brain cortex is diseased. The history of im- proper feeding may help. The initial convulsion often seen at the outset of an acute disease is generally accompanied with very high fever. The urine should be examined where possible. (See Epilepsy.) Prognosis. — Depends on the cause. Functional convul- sions are rarely fatal except in the very young and the rachitic. A convulsion in a child previously healthy is rarely fatal. A convulsion coming on late in any severe disease is serious. Treatment. — Chloroform to quiet the convulsion, wash Fig. 77.— Paraplegia. Photographed in epileptiform convulsion (Peterson). out stomach and bowel, or give an emetic (teaspoonful doses of syrup of ipecac repeated every fifteen minutes until effectual). Hot mustard pack or bath. Cold applications to the head. Chloral or chloral and bromid, internally, by mouth or rectum. If not effectual give morphia hypo- derm ically. (Six months, ^g- gr. ; one year, -A^ gr. ; two years, -^ gr.) Later on if there is still a tendency to recur- rence an ti pyrin or phenacetin and bromids may be given. Urethane is sometimes used. Inhalations of oxygen may be given if cyanosis is marked. Calomel, castor oil, or salines may be used to clean out the bowel. DISEASES OF THE NERVOUS SYSTEM. 303 FPILEPSY. 1 (Falling Sickness. J Definition. — Periodic attacks of unconsciousness, with or without convulsions. Usually divided into grand rual — major epilepsy — and petit mal — minor epilepsy. Jacksonian Epilepsy. — This is confined to a group of muscles, sometimes called " symptomatic," as it denotes brain disease. Psychic Epilepsy. — A temporary loss of consciousness, without other manifestations. Etiology. — It may be hereditary. A neurotic taint in a family may appear in the form of epilepsy. Reflex con- vulsions from any cause if frequently repeated may cause epilepsy. May begin very early in life, usually between ten and twenty years. It may follow the acute diseases of childhood. . It may follow injury. Pathology. — Probably due to degenerative changes in the cerebral cortex. Symptoms. — Grand Mal. — Often preceded by a warning sensation called an aura, which may be a feeling in a mem- ber or of special sense. There is a cry ; the patient falls in a violent tonic spasm. This is followed by a clonic spasm, which passes off. The patient may remain unconscious for a short or long time after the convulsion, and on recovery com- plain of muscular weakness and mental confusion. Some- times the patient is apparently conscious and comes to himself later with no recollection of what he has done. There may be maniacal attacks after a fit. The face is pale at the outset and the pupils contracted ; later the face becomes cyanosed and the pupils dilate. The tongue is frequently bitten. Petit Mal. — The attack may consist of a transitory pallor, with or without twitching of the muscles, sometimes involun- tary urination. The lapse in consciousness may be but a few seconds long. 1 Smith, " Epilepsy," Lancet, January 24, 1903, p. 221. 304 DTSEASES OF INFANTS AND CHILDREN. Between these two forms there are all grades of se- verity. Status epilepticus is a condition in which the seizures fol- low one another rapidly without any intervening return of consciousness. - In epilepsy there is sooner or later mental deterioration, and stigmata of physical degeneration are frequently pres- ent. Diagnosis. — From Organic Brain Disease. — The con- vulsions are liable to be limited to a group or groups of muscles. Other evidences of brain lesions are frequently present. Hysteria. — By the nature of the seizure, stigmata of hysteria, and absence of injury on falling, tongue is not bitten, etc. Uremia. — History and examination of urine. Epilepsy attacks. Fainting spells. Hysterical attacks. Loss of consciousness very Loss of consciousness Loss of consciousness not sudden. gradual. absolute. Warning of short dura- Warning of some minutes The attack often preceded tion. before consciousness is by emotional excite- lost. ment. Pupils dilated ; do not con- Pupils contracted or un- Pupils not dilated. tract to light. altered. Tonic and clonic spasms Pulse feeble ; no spasms. Tonic rigidity ; exagger- in various parts of the ated conscious move- body, ments; arching of back ; excessive noises. Bloody foam at the mouth. No evident biting of the tongue. Involuntary passage of the No involuntary passage of No involuntary passage of urine and feces urine or feces excepting urine or feces. in rare instances. Prolonged stupor after the Recovery gradual ; no attacks. stupor. The patient may pass, however, into a trance condition. Tonic and clonic spasm. Attacks may be fre- quently repeated. Attacks not frequent, as a Recovery prompt after at- Duration' of the attack rule. tack. much longer than in epilepsy. Prognosis. — Usually bad, but is benefited by treatment, and cases seen early where convulsions are brought on by dietetic errors can often be relieved entirely. Treatment. — Remove all sources of irritation, as ade- noids, phimosis, etc. Good hygiene, open-air life, with mod- DISEASES OF THE NERVOUS SYSTEM. 31 >5 erate exercise and pleasant occupation. Careful feeding, meat but once a day, and not more food than patient can assimilate. Avoid constipation. Intestinal antiseptics, sodium salicylate or salol may be of value. Bromids arc of decided value in control- ling- the seizures. Pro- portionately larger doses are required for children than for adults. Tonics should be used when indi- cated. Clonic spasms can sometimes be suppressed and consciousness restored by placing the epileptic on his left side during the tonic spasm. / TETANY. 1 NS< >.\"A NTS. Voiceless oral Voiced oral Voiced nasal consonants. consonants. resonauts. Labials P B M (First stop position) Labiodentals Linguodentals Anterior Linguopalatals (Second stop position) Posterior K G ~Sg Linguopalatals (Third stop position) Lip Defects. — Instead of W some children say V. In say- ing Tthe lower lip is brought against the upper lip, and for IF the two lips are brought near each other. To change the Vto W, instruct the patient to say "wood" or "war," and just as he begins press the lower lip down with the linger. Tongue Defects. — 1. " S—T" Lisping. — The patient says " toup " for " soup," etc. When " 8 " is said the tip of the t< >ngue is brought against the palate, but a small space is left through which the air may be blown. In this form of lisping the patient presses his tongue too hard, closing the air chan- nel, and " T" results. The treatment for this is to insert a probe just over the middle of the tongue and press it down just as the patient tries to say " T" thus making an air- space and changing it to " S." 2. "TH-T"and " TH-D" Lisping.— This is a very common defect, the children saying "tin" for "thin" and "dis" for "this," etc. In both cases in saying "th" the tongue is placed against the palate, but so slightly that air escapes from both sides. The lisping conies from too much pressure of the tongue. The treatment is to place a probe at the side of the mouth, and when the patient says "t," press down the tongue at the side and he is forced to say "th." 318 DISEASES OF INFANTS AND CHILDREN. 3. " S-TH" Lisping. — An interchange of sounds due to the tongue not rising sufficiently at the edges in front to cut off the air at the sides while having a small channel in the middle. This is the form present when there is tongue-tie. If the frenum is too short it should be cut. The treatment is the same as for No. 1. 4. "T-TIL" Lisping. — "Wather" is said for "water," etc., due to the failure to cut off the air with the tip of the tongue firmly against the palate. It is usually sufficient to explain the formation of the two sounds. 5. "R" Defects. — " W" is used in place of "r," and the patient must be taught how to get the tongue in the right place to say "r." He may be taught to roll the (< r v as in French ; if this fails, have him repeat words which bring the tongue in approximately the same position, as u sun, run, sun, run," or " tun, run, tun, run," etc. 6. Various Substitutes. — " T" may substitute for " k" but not in all words, and this is usually due to negligence. Have the patient repeat the " k " sound before various vowels, and then pass over to the incorrect word, as " kat, kat, kat, ka-ka-kan, ka-ka-, ka-kandy." In cases where the velum action is defective the patient must be taught to say "p, 6, t, d, . . . a, o" without passing air through his nose. A rubber tube with a nose tip on one end and a glass tube on the other is held in a support, so that the glass tube end is just in front of a candle flame. If the air passes through the nose the flame moves. Playing on a mouth harmonica may help in severe cases. laryngeal Defects. — Laxness of the vocal cords is frequently noted both in persons with other defects and in- dependently. There is defective closure of the glottis, and this may be overcome by staccato singing and practising notes on the vowel ah. laryngeal Monotony. — This is seen in epileptics and others. The voice does not rise and fall normally. This may often be overcome by explaining the difference to the patients and having them practice. DISEASES OF THE NERVOUS SYSTEM. 319 THE INJURIOUS HABITS OF INFANCY AND CHILDHOOD. Sucking. — Sucking the fingers is very common in hun- gry infants and is natural. Continued sucking of the fingers or toes, of a "pacifier," or of a nipple is a bad habit; usually easily overcome if taken early, and difficult to control if allowed to run on. It may lead to the habit of masturbation later on, and may cause deformities of the jaws and fingers as well as eczemas and infections. Sucking the hands may be a cause of chronic vomiting. Other bad habits are biting the nails, picking at the face or hands, eating dirt (pica), and making various movements with the head, arms, legs, or body. Treatment. — The hands may be covered with mittens, tied Fig. 86. — Deformity caused by thumb-sucking. (Darby, in Keating's Cyclopedia of the Diseases of Children.) into long sleeves or buttoned under the jacket. Splints may be resorted to in aggravated cases. Masturbation. — Definition. — The habit of producing sexual excitement by rubbing the genitalia or other parts of the body. Etiology. — It may be practised by very young infants, even as early as the eighth month. Girls and boys are both affected. It may be started by rubbing to allay irritation caused by uncleanliness, inflammation, etc. If the habit is formed in early childhood without cause it may be regarded as a stigmata of degeneration. It may be taught by vicious nurses or other children. Symptoms. — Friction with the hands against some object, or by holding the thighs fixed and moving the body. This is followed by Hushing of the face and relaxation. The chil- 320 DISEASES OF INFANTS AND CHILDREN dren are liable to become nervous, and later may develop hys- teria or other functional nervous disorders. In older children the pupils are dilated, the palms moist, and the child is inat- tentive and absent-minded. Prognosis. — If the cause is removed early the outlook is fair. Treatment. — Early recognition and close observation are the most important. Remove all sources of irritation and do a circumcision if necessary. The child's moral nature should be awakened if possible. Out-of-door life and a building-up treatment are essential. ANGIONEUROTIC EDEMA. A rare affection sometimes seen in children. It may occur in families or be hereditary. It is a sudden localized edema which may jump from place to place. Disappears quickly. Frequent attacks may occur. Affected individuals should have good hygiene and tonic treatment. EXOPHTHALMIC GOITERS (Parry's Disease; Graves' Disease; Basedow's Disease*) A disease characterized by rapid heart beat, swelling of the thyroid, and protrusion of the eyes. It is very rare in childhood, but has been described. Enlargement of Thyroid at Pnberty. — Between twelve and fifteen the thyroid may enlarge (in girls), and there may be a rapid pulse and nervous symptoms suggestive of exophthalmic goiter. This condition usually rapidly sub- sides by the use of rest, good feeding, tonics, and fresh air. MALFORMATIONS. 3 The most frequent are meningocele, encephalocele, and hydrencephalocele. 1 T. H. Halsted, " Edema, Angioneurotic, of Upper Respiratory Tract," American Journal of the Medical Sciences, November, 1905, p. 863. 2 Kocher, " Thyroid Gland, Pathology of," British Medical Journal, June 2, 1906, p. 1261. A. F. Martin, " Thyroid 'Gland, Significance of Some Enlargements of," British Medical Journal, Sept. 22, 1906, p. 691. a Ruhrah, Archives of Pediatrics, July, 1902. DISEASES OF THE NERVOUS SYSTEM. 321 Definition. — Meningocele.— A protrusion through an opening of the skull of the brain membranes. The sac so formed is usually filled with fluid. Encephalocele.— A protrusion of part of the brain sub- stance. . Hydrencephalocele.— A protrusion of the brain containing a cavity communicating with the distended lateral ventricles. location.— Thev may be located anywhere, but are most frequently in the median line, either occipital or frontal. They may be small or enormous in size. _ Diagnosis. — In meningocele there is usually a small Fig. 87.— Exophthalmic goiter. Yiq. 88.— Exophthalmic goiter. tumor at birth which increases in size ; it is usually pedun- culated, but may not be. The tumor is smooth, but has a distinctly cystic* feel. It fluctuates, and in some cases is re- ducible/or ' it maybe diminished in size from pressure. It is translucent, if the tumor is not too large nor the walls too thick. Pulsation is rare. Pressure usually produces cere- bral symptoms, such as crying, vomiting, convulsions, and stupor. On crying or forced expiration they become more tense. The skull is normal. In eneephahceJe there is a small, smooth tumor, pulsating 21 322 DISEASES OF INFANTS AND CHILDREN and non-translucent. It is rarely pedunculated. Pressure produces cerebral symptoms. On moderate pressure there is no pain, malaise, nor reduction. On attempting to^ effect reduction by harder pressure there is noted dilatation of the pupil, strabismus, and, more rarely, vomiting and con- vulsions. On crying, it becomes more tense. Pulsation synchronous with the pulse practically always means en- cephalocele. In hydrencephalocele there is a large tumor, generally w Fig. 89.— An unusually large meningocele. pendulous, pedunculated, and lobulated. It is generally not translucent nor reducible. Fluctuation is present, but pulsation rarely. Pressure does not, as a rule, produce symptoms. On crying, it is made only slightly more tense. Very large tumors are practically always hydrencephalocele. From other tumors by their growing more tense on crying. False Meningocele.— A cystic tumor following injury by the history of an injury or operation. DISEASES OF THE NERVOUS SYSTEM. 323 Prognosis. — Serious. Almost all die early. A few attain old age, but are usually weak-minded. Treatment. — Three methods are used : (1) Let it alone ; (2) aspirate and inject an iodin mixture, as Morton's solution ; Fig. 90.— A meningo-encephalocele. (3) removal by excision. This latter is usually preferred. Internal hydrocephalus may follow the operation. BIRTH PALSIES. 1 These are most frequently due to prolonged pressure during difficult labor or to artificial delivery. (See also p. 324.) Cerebral Paralysis. — Most of these hemorrhages are meningeal and at the base of the brain, but they may occur from brain laceration or from depressed fractures. The child may he born dead or asphyxiated. Convulsions are common. There may be general rigidity or, more rarely, general relaxa- tion. The pupils are frequently contracted, and there may be oscillation of the eyeballs. Pulse is slow and weak, and iGowers, " On Birth Palsies," Lancet, vol. i., 1888, p. 709. Spiller, Frazier, and Van Kaathoven, " Palsies, Cerebral, Spinal, and Peripheral, Treatment of Selected Cases of," American Journal of the Medical Sciences, March, 1906, p. 430. 324 DISEASES OF INFANTS AND CHILDREN. the respirations slow and irregular. Death usually takes place during delivery or within three or four days afterward. Cases which survive show monoplegia, hemiplegia, diplegia, or mental disturbance, according to the location of the clot. Treatment. — The judicious use of forceps to hasten slow labors may prevent hemorrhage, which usually is caused by the long pressure. If the diagnosis is made, a very skilful surgeon might operate with success. Spinal Paralysis. — Very rare. Due to hemorrhage or laceration, and results in paraplegia. Paralysis of the Arm in the Newborn (ErVs Fig. 91.— Brachial birth palsy, showing limitation of motion. Paralysis). — This is from injury to the nerves of the brachial plexus during parturition. This may take place in a num- ber of ways. The most frequent form is the so-called Erb's upper-arm paralysis, where the fifth and sixth cervi- cal nerves are injured, causing paralysis, partial or complete, of the biceps, deltoid, brachialis anticus, supinator anticus, supinator longus, and occasionally of the supra- and infra- spinatus. Usually noted on the first day or two, but it may escape notice for several weeks. The upper arm is paralyzed and rotated inward, the forearm is pronated and the palm turned outward. The triceps and the muscles of the forearm DISEASES OF THE NERVOUS SYSTEM. 325 and hand arc unaffected. Atrophy occurs, but is not very noticeable on account of subcutaneous fat. Atrophy is more marked in older children. More rarely the paralysis may be of the lower-arm type, in which the seventh and eighth cervical and first dorsal nerve routes are involved, or there may be a combination of the upper- and lower-arm types, in which all of the nerve routes mentioned above are injured Fig. 92.— Paralysis of right facial nerves. Diagnosis by the group of muscles affected. Look for frac- tures of the clavicle, separation of the epiphysis, and disloca- tion of the humerus. Prognosis varies. If recovery takes place it does so within three months ; it is rare after that time. If the muscles re- spond to faradism the prognosis is good. If the reaction of degeneration is present the prognosis is bad. 326 DISEASES OF INFANTS AND CHILDREN. Treatment as in facial paralysis. Surgical treatment, con- sisting in cutting down upon the brachial plexus, removing the cicatrix, and approximating the ends of the injured nerves, has been tried recently, with success (see Literature). Facial Paralysis of the Newborn. — This is usually, but not always, from the pressure of forceps, and for that reason is generally unilateral. Meningeal hemorrhage may also be a cause. Symptoms are the same as in ordinary facial paralysis, and are noted on the first or second day. Exceptionally facial paralysis may be due to congenital defect of the nucleus of the seventh nerve. Both sides may be affected, as well as some of the eye muscles. There is no treatment for this form. The prognosis is generally good, recovery taking place in two weeks, though in some the paralysis may be delayed months or be permanent. Treatment. — None the first three weeks. If recovery has not taken place, use faradic electricity daily. If muscles do not react to it, use galvanism. INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. Pachymeningitis. — Inflammation of the dura. It may be acute or chronic. Acute Pachymeningitis. — External. — Rare, and usually fol- lows the extension of suppuration, as in middle-ear disease. Internal. — As a part of inflammation affecting all the membranes. Chronic Pachymeningitis. — Internal. — This is seen in cachectic states and marantic children. There is usually hemorrhage. Symptoms. — Usually not marked unless there is hemor- rhage, which may cause vomiting, convulsions, and loss of consciousness. The child may have rigidity of the muscles, enlarged pupils, and paralysis, according to the location of the hemorrhage. Diagnosis. — Cases without hemorrhage are usually only DISEASES OE THE NERVOUS SYSTEM. 327 discovered at autopsy. From acute meningitis by lower temperature ; coma later, and rigidity less marked. Prognosis. — External hemorrhages are usually fatal ; smaller ones are not. Treatment.— Ice cap to head. Bromids and chloral to quiet the nervous symptoms. Acute Meningitis^ Cerebrospinal Fever). — Definition. — An acute inflammation of the pia mater. # (See also Cere- brospinal Fever and Tuberculous Meningitis.) Pathology.— The inflammation may be general, involving the entire meninges, both cerebral and spinal, or it may be more or less limited to an area. In cerebrospinal fever it is liable to be general ; in tuberculosis and cachectic conditions, chiefly basal"; in pneumonia and endocarditis, chiefly cortical; from extension of middle-ear disease it is unilateral, and in- volves the dura more extensively. There is congestion, and later an effusion of greater or less intensity. Etiology. — Osier gives the following table of causes : The Etiology of Acute Meningitis (Osier). r i. U L O 1 Of cerebrospinal fever Pneumococcic . . Tuberculous . . 5 1 1. 2. Pneumococcic . 3. Pyogenic . . . Miscellaneous acute infections. (a) bporadip. 1 Diplococcus intracellulars. (6) Epidemic. J y Meninges alone involved or ) in a general pneumococ- V Pneumococcus. cic infection. ) Bacillus tuberculosis (a) Secondary to pneumonia, 1 endocarditis, etc. (b) Secondary to disease or injury of cranium or its fossae. (a) Following a local disease 1 of cranium or a local infection elsewhere. Y (b) Terminal infection in va- rious chronic maladies. J In typhoid fever, influ- enza, diphtheria, gon- orrhea, anthrax, ac- tinomycosis, and other acute diseases. Pneumococcus. Various forms of staphylococci and strepto- cocci. Typhoid bacillus, in- fluenza bacillus, diphtheria bacillus, gonococcus, etc. Symptoms. — The symptoms are also given under Cere- brospinal Fever and Tuberculous Meningitis. iCohoe " Influenzal Meningitis," American Journal of Medical Sciences, January, 1909, p. 75. W. T. Councilman, " Meningitis, Acute," Journal of the American Medical Association, April 1, 1905, p. 997. 328 DISEASES OE INFANTS AND CHILDREN. Cortical meningitis may not produce any symptoms which may not be produced by congestion or by the toxemia of the specific infections. Basilar meningitis is accompanied by re- traction of the head and symptoms referable to the cranial nerves. There may be ptosis or strabismus ; the pupils are at first contracted ; later, dilated or unequal. There may be twitching or facial paralysis. There is dread of light (pho- tophobia) and, later, often blindness. There is a dread of noises and, later, often deafness. Optic neuritis is common. There may be general or local convulsions, paralysis, ten- derness of the skin and muscles of the extremities. There is delirium, and frequently profound coma. Vomiting is com- mon. Tache cerebrale is common. Kernig's sign is present when the lower spinal meninges are involved. Lumbar puncture is of service. (See Cerebrospinal Fever.) There is an irregular fever curve. Diagnosis. — (See Cerebrospinal Fever and Tuberculous Meningitis.) Prognosis. — Bad. All cases except the cerebrospinal fever cases, and possibly the pneumococcus cases, die. It may be- come chronic. Treatment. — The disease is not influenced by treatment. Open the bowels, feed carefully, keep quiet. Ice bag to head. Counterirritation to spine and nape of neck. Salines if there is much congestion. Lumbar puncture to relieve brain-pressure is advisable. Surgical treatment is advisable in localized suppuration and meningo-encephalitis. Chronic Basilar Meningitis in Infants. 1 (Posterior Basic Meningitis.) Definition. — A chronic non-tuberculous inflammation, especially of the basal meninges, which usually occurs spo- radically, but which may be seen during epidemics of cerebro- spinal fever. 1 Still, " Posterior Basic Meningitis," Journal of Pathology anal Bacteri- ology, May, 1898, p. 147. O. Hildesheim, " Meningitis, Postbasic, Prog- nosis in," British Medical Journal, March 21, 1906, p. 733. H. Koplik, "Meningitis, Postbasic," American Journal of the Medical Sciences, February, 1905, p. 266. DISEASES OF THE NERVOUS SYSTEM. 329 Etiology. — Usually due to the diplococcus intracellularis. There is a syphilitic posterior basic meningitis as well. Pathology. — There is thickening of the pia and dura mater at the base of the brain. Symptoms. — There is usually a gradual onset, followed by retraction of the head, which is continuous, opisthotonos and muscular rigidity. In some instances the disease may come od rather suddenly, with vomiting, fever, convulsions and rigidity. The child may be partially or wholly blind, often without any optic atrophy, and there is frequently nys- tagmus or strabismus. There may be hydrocephalus, and the fontanel, if open, bulges. The position assumed is that of extreme opisthotonos, with the arms drawn in, the forearms, hands, aud fingers flexed, the thighs adducted, the legs flexed, the feet extended, and the toes flexed. There is extreme emaciation and the abdomen is retracted. The temperature is normal or but slightly elevated, with occasional irregular periods of high temperature. Diagnosis. — From muscular rigidity of marasmus by the greater severity of the opisthotonos, the hydrocephalus, and the cerebral symptoms. Lumbar puncture, is of value. A dry tap may result in these cases. Prognosis.— -Usually bad, death taking place in from one to four months. Recovery occasionally occurs. The older the child the better the prognosis. Sudden death some< times takes place, aud the disease is usually followed b\ paralysis or retarded development, and occasionally by in- abilitv to gain flesh, by the persistence of headache and subsequent development of peculiarities of temper, morals, or emotions. Amaurosis and optic neuritis have been met with, but both are rare. The same is true of deaf-mutism. Treatment. — Iodid of potassium and mercurial inunc- tions may be tried, and is of value in syphilitic cases. Lumbar puncture may be done to relieve pressure. Flex- ner's antimeningitis serum might be tried in the cases due to ihe meningococcus. 330 DISEASES OF INFANTS AND CHILDREN. THROMBOSIS OF THE SINUSES, Cachectic Thrombosis. — Definition. — A rare condition where the blood clots in the sinus. Etiology. — It is seen in young children or infants wherever a cachectic condition supervenes, especially in the course of infections, as pneumonia, whooping-cough, and diphtheria. Symptoms. — Usually obscure ; diagnosis is rarely made during life. There may be convulsions, coma, and paralysis. Prognosis. — Fatal. Septic Thrombosis ; Inflammatory Thrombosis ; Sinus Phlebitis. — Definition. — A clotting of the blood in the sinus from meningitis or the extension of an inflamma- tion, as from otitis or pharyngitis. Symptoms. — In meningitis it produces no new symptoms. Headache, localized tenderness of the scalp, and symptoms of meningitis are present. Localized Symptoms. — Superior longitudinal sinus causes cyanosis of the face, nose-bleed, dilatation of the temporal veins. Lateral sinus : Dilatation of veins and edema of the mastoid region. The clot may extend into the jugular vein. Cavernous sinus : Protrusion of the eyeball, • edema of the eyelid, and enlargement of the retinal veins. Prognosis. — Fatal unless operated upon. Treatment. — Surgical. ABSCESS OF THE BRAIN. Abscess of the brain may be single or multiple. etiology.- — Not infrequent in early life ; secondary to inflammations of the ear and petrous bone, or of either cranial bones. It may follow sinus thrombosis. It may follow injury. I/OCation. — Usually in frontal, temperosphenoidal lobes, or cerebellum. Symptoms. — In acute cases there are symptoms suggest- ing meningitis, as headache, painful scalp, vomiting, fever, etc. There may be localized symptoms if motor areas are DISEASES OF THE NEBVOUS SYSTEM. 331 involved. In chronic abscess, which may last a long while, attacks of headache, fever, or vomiting may be noted. Diagnosis. — Always difficult. Marked rigors and very irregular temperature may help in differentiating tumors or meningitis, especially when the symptoms follow ear disease. Prognosis. — Always bad. Treatment. — Surgical. CEREBRAL TUMORS. 1 Starr's table gives the frequency of the various kinds as follows: Tubercle, 152; glioma, 37; sarcoma, 34; gliosar- coma, 5; cyst, 30; carcinoma, 10; gumma, 1; not stated, 30 ; total, 299. I/Ocation. — In order of frequency : Cerebellum, pons, centrum ovale, basal and lateral ganglia, corpora quadri- gemina, and crura ; the other locations are rare. Etiology. — Tuberculous tumors are secondary ; carci- noma and sarcoma may be primary or secondary. Injury is sometimes stated as a cause. Boys are twice as frequently affected as girls, and most cases occur before eight years of age. General Symptoms. — Headache, general convulsions, changes in disposition and mental activity, double optic neu- ritis and nerve atrophy, vomiting, vertigo, and insomnia are the most important general symptoms. I/OCal Symptoms. — These may be wanting, or may be modified by size, rapidity of growth, or by meningitis. 1. Cortex of Cerebral Hemispheres. — Optic neuritis, vom- iting, and vertigo are infrequent. Frontal Lobes. — Mental deterioration, sometimes loss of smell on affected side if tumor presses on olfactory tract. In the third frontal of the left hemisphere of right-handed chil- dren (right side in left-handed) there are aphasia and agraphia. Central and Paracentral Convulsions. — Paralysis and spasm of limbs on opposite side of body. Parietal Lobe. — Xone, or disturbances of muscular tem- perature and pain-sense. Occipital Lobe. — Hemianopsia, psychic blindness, and 1 Starr, Keating' s Cyclopedia, 1890. 332 DISEASES OF INFANTS AND CHILDREN. word-blindness (if on the left side) in right-handed patients ; right in left-handed children. Temper osphenoidal Lobes. — Sensory aphasia or word-deaf- ness if in left first or second convolution ; right in left-handed children. 2. Basal Ganglia. — Marked indirect symptoms from pres- sure on internal capsule ; optic neuritis occurs early. 3. Corpora Quadrigemina and Crura Cerebri. — Rare. Pupil- lary reflex is lost ; there are nystagmus, strabismus, vertigo, and ataxia. Irregular disturbances of sensation of face and body. If large the tumor causes third-nerve paralysis on same side and hemiplegia on opposite side. 4. Pons and Medulla. — Symptoms may be bilateral on opposite side of body ; facial and other cranial nerve paraly- sis on same side. 5. Cerebellum. — Vertigo, cerebellar ataxia, headache, and vomiting. If the patient falls it is usually in same direction. Hydrocephalus, general convulsions, and rolling of head from side to side may occur. 6. Tumors of the Base. — Symptoms referable to the cranial nerves or frontal lobes if frontal, basal ganglia and crura if middle fossa, pons and medulla if posterior fossa. Diagnosis. — Variety. Tubercle most frequent and of rapid growth. Gliosarcoma is of slower growth. From Abscess. — Severe rigors and leukocytosis are most important. Meningitis. — More rapid course and intense symptoms. In chronic cases symptoms are of a diffuse lesion. Prognosis. — Always bad. Treatment. — Surgical if tumor is accessible ; antisyphi- litic in syphilis and palliative in other cases. HYDROCEPHALUS. ("Water on the Brain.) Acute Hydrocephalus. — A collection of fluid either beneath the dura or in the ventricles, due to basilar menin- gitis. This is usually tuberculous, but may be due to DISEASES OF THE XERVOUS SYSTEM. 333 syphilis or to other diseases. The term is often used to des- ignate tuberculous meningitis. Chronic Hydrocephalus. — External. — Very rare. The fluid is between the dura and the pia. Congenital or due to pachymeningitis or subdural hemorrhages. Deform- ities of the brain are usually present. The brain is atrophied or deformed and pressed against the floor of the skull. General appearance and symptoms as in the internal form. The two forms may be associated. Internal or Usual Form. — Congenital or due to tumors at the base of the brain or to basilar meningitis. The lateral Fig. 93.— Hydrocephalus. ventricles are distended with cerebrospinal fluid. The brain substance atrophies and the convolutions are flattened. The disease usually begins early, either in intra-uterine life or soon after delivery. The bones of the skull are forced apart, the su- tures are very wide, and the fontanels enormous. Other deform- ities, as spina bifida and harelip, may be found at the same time. Hydrocephalus may occur with a small head, due to premature ossification. These children are idiots and die early, often during a convulsion. Such cases cannot be diagnosed during life. 334 DISEASES OF INFANTS AND CHILDREN. Symptoms. — All grades of symmetrical enlargement of the head are met with ; the prominent forehead and the white of the eye showing between the cornea and the upper lid give a characteristic expression. The head may fluctuate. The skin is thinned and shiny and the superficial veins dilated. The enlargement of the head may be congenital; it may come on during the first few months of life or occasionally later. These children are idiotic, lethargic, often blind and deaf. The extremities are rigid or relaxed. Nystagmus and convergent squint are com- mon. Convulsions are fre- quent. Occasionally a child may have a moderate grade of hydrocephalus, which is gradually recovered from with only slight mental impairment. As a rule almost all die during t^.e first year and the remain- der before seven years of age. Now and then a pa- tient lives longer. Treatment. — Unsatisfac- tory. All sorts of meas- ures nave been tried. As- piration gives temporary relief, but the fluid soon accumulates. Various op- erative procedures have Fig. 94.— Hydrocephalus. been tried, such as permanent drainage. INFANTILE CEREBRAL PARALYSIS. 1 (Spastic Diplegia, Paraplegia, or Hemiplegia.) Definition. — Paralysis of one or more members due to disease or defects of the brain ; either congenital or acquired in early life. 1 H. W. Noxon, " Paralysis, Infantile," Practitioner, November, 1906, p. 675. DISEASES OF THE NERVOUS SYSTEM. 335 Fig. 95.— Left facial paralysis following delivery by forceps (BudinV Paralysis of Intra-uterine Origin. — These are infrequent and are due to arrested development, hemorrhage, or other lesions. There may be large or small cysts or defects (poren- FlO. 96 — Showing contraction in infantile cerebral paralysis. 336 DISEASES OF INFANTS AND CHILDREN. cephalv) in any part of the brain. There may be cortical agenesia — i. e., want of development of the cortical cells. Birth Paralysis. — These are due to hemorrhage (see page 323). If the child lives there may be meningoencephalitis, cysts, atrophy and sclerosis of the cortex, or secondary de- generation of the cord. Cerebral Paralysis. — This is usually a hemiplegia ; but other forms may be met with. It may follow injury, infec- tious diseases, or from a convul- sion or paroxysm of coughing, as in pertussis. The lesions found may be hemorrhage, meningitis, or atrophy or sclerosis of the cor- tex, with secondary degenerations. Fig. 97.— Right hemiplegia following men- ingeal hemorrhage. Fig. 98.— Infantile cerebral paraly- sis (Gillette). Symptoms. — Paralysis dating from birth is usually either diplegia or paraplegia ; but hemiplegia may be met with. The degree of paralysis and its extent depend on the lesion. There is usually a spastic condition of the muscles with increased tendon reflexes, but the paralysis may be of the flaccid type. Athetoid movements are common. Speech DISEASES OE THE NERVOUS SYSTEM. 337 disturbances may be met with, and there is nearly always mental impairment, often idiocy. Symptoms of Acquired Paralysis. — Sudden- onset, generally with a convulsion, fever, and loss of power. The paralysis is usually a hemiplegia. There may be speech disturbances. Later there is lack of development and contractures. The mental condition is, as a rule, unimpaired. Sometimes there may be athetoid movements. Diagnosis. — It may be impossible to tell the acquired from the congenital forms except by the history ; from spinal paralysis by the wide extent, diplegia, paraplegia, or hemi- plegia, by the spasticity of the muscles,, increased reflexes, contractures, and absence of reaction of degeneration. Often mistaken for rickets. Treatment. — Training of the muscles remaining. If there are deformities and contractures, orthopedic appliances and operations may be advisable. MYASTHENIA GRAVIS. 1 (Erb-Goldflam Syndrome; Asthenic Bulbar Paralysis*) A disease usually beginning in early life and characterized by a marked loss of power on exertion of certain muscles, which is recovered from after rest. The muscles supplied by the nerves emanating from the medulla (bulb) are first affected. Paralysis and atrophy may follow 7 . There is a curious myas- thenic reaction (Jolly), the muscles rapidly tiring on application of the faradic current, but not from the galvanic. About one- third of the cases die; some persist for years and some recover. Treatment. — Mercury and iodide rest, strychnin, and massage. IDIOCY; FEEBLE-MINDEDNESS ; IMBECILITY. 2 Idiocy is mental deficiency depending upon malformations, arrested developments, or lesions acquired before the mental 1 Campbell and Bramwell, Brain, 1901. 2 Ireland, Mental Diseases of Children. Lepage, " Diagnosis of Perma- nent Mental Deficiency in Infancy and Childhood," Practitioner, August, 1909, p. 211. 22 338 DISEASES OF INFANTS AND CHILDREN. faculties have developed. Imbecility is a term applied to mild grades of idiocy which are not severe enough to war- rant the confinement of the individual in an institution. Various classifications of idiots are used. The following is a modification of Ireland's classification : 1. G-enetotis Idiocy. — This form is caused by malfor- mations of the brain. Fig. 99.— Genetous idiot. 2. Microcephalic idiocy is associated with a very small head ; frequently there is premature ossification of the bones of the skull. The fontanels close early or may be closed at birth. The head is pointed, the forehead receding, and the occiput flat. 3. Hydrocephalic idiocy, where the lesion is hydro- cephalus. DISEASES OF THE SERVO US SYSTEM. 339 4. Epileptic idiocy, where the idiot is an epileptic. 5. Paralytic idiocy, in which there are associated pa- ralyses such as described under Cerebral Paralysis. 6. Inflammatory idiocy, following inflammatory changes, usually the result of meningitis. 7. Idiocy by deprivation, where the brain is appa- rently normal, but owing to blindness or deafness and want of instruction the child remains an idiot. Fig. 100.— Congenital idiot of low grade (Mills). Fig. 101.— Epileptic imbecile (Mills). 8. Mongolian idiocy comprises aoout 5 per cent, of all idiots, and in it there are physical characteristics suggesting the Mongolian race, associated with mental and physical de- ficiency. They are usually born of older mothers, the aver- age age being thirty-eight (Thomson). The head is short, small, and round, and the eyes have a decided slant, the outer canthus being higher than the inner, and there is often an 340 DISEASES OF INFANTS AND CHILDREN, epicanthic fold at the inner canthus. There is often blepha- ritis. Adenoids are common, causing month breathing, and the tongue is usually large and protruded. The teeth are small and decay early, and the incisors may be set at an angle. The ears often lack the normal state and are smooth. The extremities are small, relaxed, and soft. The little finger has a curve. Congenital heart lesions are common. De- Fig. 102.— Insane imbecile (Mills). Fig. 103.— Congenital idiot of low- grade (Mills). velopment is slow and they may not walk for several years. They learn to talk slowly and with difficulty. They are usually bright, mischievous, and learn to do a few tricks by imitation. The outlook is unencouraging, for while they may conduct themselves with fair propriety, they never be- come self-supporting. 9. Cretinism. ^-(See below.) DISEASES OF THE NERVOUS SYSTEM. 341 Fig. 104 —Mongolian idiot. Fig. 105.— Mongolian idiot. 10. Amaurotic Family Idiocy. 1 — This is a pecu- 1 Sachs, New York Medical Journal, May 30, 1896. 342 DISEASES OF INFANTS AND CHILDREN. liar disease of unknown origin seen in Hebrew children, several cases often occurring in one family. It begins usually between the third and sixth month, and the men- Fig. 106.— Amaurotic family idiocy,, showing facial expression. tal condition becomes that of a hopeless idiot. There is a vacant idiotic expression. The most characteristic thing is blindness, associated with optic atrophy and a red spot ®n the center of a red spot in the center of a bluish- white disk Fig. 107.— Amaurotic family idiocy, showing flaccid condition of the muscles. on the site of the macula lutea. There" is a relaxed, flaccid condition of the muscles of the entire body, occasionally spasticity, the reflexes are usually absent, but may be in- DISEASES OF THE NERVOUS SYSTEM. 343 creased. The child passes into a condition of malnutrition, and usually dies within a year. The diagnosis is confirmed by ophthalmic examination. The prognosis is hopeless, and there is no treatment known that influences the disease. Diagnosis. — As a rule the exact grade of mentality can- not be estimated in a young infant, but mental deficiency may often be determined early by the presence of some marked physical accompaniment, as microcephalics, hydro- cephalus, or spastic diplegia, and of recent years a great Fig. 108.— Amaurotic family idiocy, showing extreme relaxation. deal has been written about the stigmata of degeneration (see same), or minor physical malformations which may be seen in otherwise normal children, but which in accordance with Warner's law of coincident development ("when any part or parts of the body present signs of defective develop- ment the brain is very apt to be defective likewise ") are most frequent in the mentally deficient. Convulsions are frequent in idiots and imbeciles, and of considerable import- ance are the numerous abnormal gestures and actions, head rolling, and the like. There is sometimes constant crying 341 DISEASES OE INFANTS AND CHILDREN. for no apparent cause, grimacing, or senseless laughter. The child cannot fix its attention, or only for very short periods. The development mentally, physically, and morally is always slow and irregular, even in the milder cases. In estimating a child's mental condition it is important to bear in mind the effect of physical defects on its education, such as blindess, deafness, and other physical defects, also of the effect of serious, prolonged illnesses, and of the child's pre- vious environment. Prognosis. — Many of the Fig. 109.— Idiot. Flaccid type. Fig. 110.— Idiot. Spastic diplegia. mentally deficient die early, and the remainder may be divided into the hopeless cases and those who can be benefited by training. Treatment. — The child's physical welfare should be cared for, suitable food, warm clothing in cold weather, baths, DISK. JES OF THE NERVOUS SYSTEM. 345 and out-of-door life are all important. Adenoids should be removed, if present, and all physical ailments treated. Epi- leptics and cretins need especial treatment. Surgical opera- tions on the bead are of no value. Training of mind and body should be begun as early as possible, and various physi- cal exercises carried out daily ; all sorts of games and drills may be utilized. The child must be taught to chew his food, to wash and dress himself. Arouse his interest, if pos- sible, by music, lights, pictures, and objects. Encourage Fig. 111.— Idiot. Flaccid type. him to play with things and to do things for himself. The acquisition of undesirable traits and habits, such as grimac- ing and making various movements and noises, should be discouraged. Self-control should be inculcated. In most instances these children do better in institutions of the right sort than at home. (See pamphlet, page 528.) High-grade Imbeciles and the Morally Deficient. — These represent a very difficult class to deal with, as the 346 DISEASES OF INFANTS AND CHILDREN. diagnosis and prognosis are difficult and uncertain. These children comprise those from the beginning of the school age up to puberty, and are represented by those children who are nearly normal, both physically and mentally, but who are slow in acquiring the difference between right and wrong, aud who exceed the extreme limit that might reasonably be allowed for childish pranks and juvenile irresponsibility, and who persistently and repeatedly do so. Stealing, arson, de- struction of property, masturbation, uncontrollable fits of temper are the more troublesome features. Sometimes the condition may be ascribed to previous environment or lack of control, and may be entirely overcome by proper training and development, but in my experience the majority of these cases represent high-grade imbeciles with a gloomy prognosis. Treatment. — The child should be removed from its accustomed environment and placed in a good strict school. If possible, they should never be sent to institutions for the feeble-minded nor to penal institutions, as is often done. CRETINISM. 1 (Infantile of Juvenile Myxedema.) Definition. — A chronic disease characterized by a re- tardation in development, both physical and mental, a curious edema-like condition of the subcutaneous tissue, and absence of disease of the thyroid gland. Cretinism may be endemic or sporadic. The sporadic form may be congenital or ac- quired. Etiology. — The endemic form is s£en in certain moun- tainous countries, in dwarfs with short bodies, legs, and arms, a low grade of mentality, a myxedematous condition of the subcutaneous tissue, and many of them have a goiter. The sporadic form is found all over the world. The cause is unknown. The lesion or absence of the thyroid seems to be responsible for the retardation and myxedema. The ac- quired form may come on after the acute infections in which changes in the thyroid have taken place. It may follow removal of the thyroid by operation. 1 Osier, American Journal Medical Sciences, 1897. DISEASES OF THE NERVOUS SYSTEM. 347 Pathology. — Absence, degeneration, or atrophy of the thyroid, or in some cases goiter, together with slow ossifica- tion and growth of the bones, and deposits in the sub- cutaneous tissue giving the reactions of mucin. Symptoms. — These may come on at any time, but are usually not noticed until the second year. In Early Infancy. — Sluggishness, torpor, low temperature, and cretin expression, puffy eyelids, open mouth, and pro- Fig. 112.— Sporadic cretin : before treatment. (From Osier, Sporadic Cretinism in America.) truding tongue. There is hoarseness. The abdomen is prominent. Later Symptoms. — In well-developed cretins the appear- ance is characteristic. The arms and legs are short ; body seems too large and head much too large for the extremities. The fontanel is open for years. The expression is pig-like. The eyes are wide apart and the palpebral fissure is narrow. The eyebrows are scanty or wanting ; the cheeks are prominent. The lips are thick, the mouth open, the tongue 348 DISEASES OF TNFANTS AND CHILDREN, large and protruding. There is drooling of the saliva. Dentition is delayed. The body and extremities are mis- shapen and laek the grace and proportion of normal infants. The hands are thick and broad ; the abdomen prominent, the genitalia undeveloped. The skin is rough and there is an edematous condition which does not pit on pressure. Sub- cutaneous lipomata are common. The voice is hoarse. Some cretins are deaf and dumb. Constipation is present. Walk- ing is begun late. A cretin of twenty may resemble a child Fig. 113.— Sporadic cretin : after treatment. (From Osier. Sporadic Cretinism in America.) of a few years of age, both in stature and mentality. The mental condition of cretins is one of apathy and little or no development. Partially developed cases of cretinism (myxedeme fruste) are sometimes seen. They show the symptoms partially developed. Diagnosis. — Late dentition, open fontanel after two DISEASES OF THE NERVOUS SYSTEM, 349 year-, with mental inactivity, and the changes described above make the diagnosis easy. Differential Diagnosis. — Mongolian Idiocy. — The Mon- golian type of face, brighter mentality, and no myxedema. Infantilism. — (See sam< Achondroplasia. — I See same.) Prognosis. — If untreated, hopeless. They remain idiots and usually die before thirty from some other disease. Treated early, the outlook is most promising for full recovery ; treated late, the results are not satisfactory. Treatment. — The iuterual administration of tablets of the thyroid gland. Small doses increased gradually to 5 grams three or four rime.- a day, or even larger doses. Too much causes rapid pulse, flushing, and fever. Changes begin to take place in a month or six weeks. The child becomes natural in appearance and develops mentally and physically. After the normal appearance and development is reached, reduce treatment to two 5-grain tablets a week. This must be continued. If it is stopped, symptom- of cretinism return in a month or six weeks. Small portions of thyroids are sometimes grafted into cretin-. INFANTILISM. 1 A condition in which the appearance of infancy or child- hood is preserved in the adult. Sexual development is backward, absent, or perverse. Lamy gives the following description : " The face is rounded and chubby; the lips prominent and plump, the nose poorly developed, the face smooth, the skin fine and of a clean color, the hair fine, the eyebrows and lashes sparse, the trunk long and cylindrical. The abdomen is somewhat prominent, the arms and legs plump and tapering from the trunk to the extremity. A layer of adipose tissue surrounds the body and marks the bony and muscular prominences. The genital organs are rudimentary. There is an absence of hair on the pubes and axilla?. The voice is shrill and piercing. The larynx is 1 W. B. Eausom. " InJantilism," Practitioner, September, 1906, p. 339. 350 DISEASES OF INFANTS AND CHILDREN. poorly developed and the thyroid small." These cases may be mistaken for cretinism by careless observers. ACHONDROPLASIA. 1 (Fetal Rickets; Fetal Myxedema.) A curious form of dwarfism, usually congenital, but ex- ceptionally appearing a few years after birth. Most cases Fig. 114.— Achondroplasia (case of Fig. 115.— Achondroplasia : Skeleton. Dr. West and Piper, courtesy of the Archives of Pediatrics) . are born dead or die soon after birth, but some live to old age. They have large heads, very short arms and legs. The humerus and femur are liable to be very short. The trunk 1 Bankin and Mackay, " Achondroplasia," British Medical Journal, June 30, 1906, p. 1518. C. Herrman, " Achondroplasia, Mongolism, and Cretin- ism, Diagnosis of," Archives of Pediatrics, 1905, p. 493. Thomson, ' ' Achon- droplasia, Clinical Features," Edinburgh Medical Journal, June, 1893. DISEASES OF THE NERVOUS SYSTEM. 351 is small and normal. The epiphyses of the long bones are enlarged, the shafts normal. The hands are short and spade- like and the fingers deviate ("Trident Hand"). The intel- lect is about that of a child of the same size ; occasionally the intellect is fair. They are mischievous and, unlike most dwarfs, have strong sexual instincts. DWARFISM, This may be due to a variety of causes, among them cre- tinism, infantilism, mongolism, achondroplasia, and rickets (see same). It may also be due to prolonged periods of Fig. 116. — Achondroplasia : Trident hand. underfeeding, especially when combined with bad hygienic surroundings. Prolonged stomach or intestinal disease, syphilis, severe disease of liver or pancreas, chronic heart or lung disease, and certain forms of congenital brain defects may also at times cause dwarfing. There is no specific treat- ment except in the case of cretinism, but thyroid extract may be cautiously tried in all forms of dwarfing, as occasion- ally a defective thyroid may cause slow growth and little else. Syphilis should be treated if it exists, and other dis- orders relieved if possible. 352 DISEASES OF INFANTS AND CHILDREN. CLEIDOCRANIAL DYSTOSIS. 1 This is a rare congenital condition in which there is an enlarged cranium and small face bones, a late closing fontanel, and an entire or partial absence of the clavicles, so that the. shoulders may be brought together in front of the body. There may be other defects of the bones. The soft parts are normal and the mental condition usually good. The disease most often occurs in families. There is no treatment. INSANITY, Comparatively little is known concerning the psychoses of infancy and childhood. In insanity the mind has been previously sound. Insanity is rare in childhood. The same forms are met with as in adults, mania being the most fre- quent. Epileptic children often show symptoms of mental disease, and the same is true of defective children. Etiology. — Infectious diseases, neurotic taint, reflex disturbances, and mental strains are the most frequent causes. Symptoms. — These are somewhat similar to the adult form of mental diseases. Prognosis. — Good in acute cases with proper treatment. Where the insanity is hereditary the prognosis is bad. Treatment. — As in adults. DEVELOPMENTAL OR JUVENILE GENERAL PARALYSIS. 2 This is a mental deterioration resembling closely the general paresis of adults. It is usually syphilitic in charac- ter. It usually comes on in children who have previously shown some mental defects. Once started, the course is progressive. The symptoms vary considerably, but in younger children there is usually spastic diplegia and often convulsions. There may be optic atrophy, the pupils may be unequal, and there may be an Argyll-Robertson pupil. There may be a tremor. The speech is affected as in adults. 1 Schorstein, Lancet, January, 1899, p. 10, and G. Carpenter, Ibid., p. 13. 2 Thomson and Welch, British Medical Journal, April 1, 1899. DISEASES OF THE NERVOUS SYSTEM. 353 The knee-jerks may be exaggerated and later lost. The plantar reflex may be extension. The disease lasts several years and terminates fatally. No treatment known has any effect. STIGMATA OF DEGENERATION* Stigmata of degeneration are signs of physical, mental, or moral degeneracy, and are to be regarded as indicating a Fig. 117.— Dental irregularities in idiocy and degeneration (Talbot, GaiUard's Medical Journal. 1902). nenropathic taint. Some of the following are always to be regarded as signs of degeneracy, others only when associated. They are divided into anatomic, physiologic, and psychic. Anatomic. — Facial asymmetry, very high arched or other deformities of the palate, pigmentary retinitis, and de- formities of the ear and genitalia are among the more im- portant ones. Anomalies or malformations of any of the 354 DISEASES OF INFANTS AND CHILDREN. organs, infantilism, gigantism, and dwarfism are also to be regarded. Physiologic. — Hysteria, epilepsy, tics, tremors, mi- graine, hyperesthesia, color-blindness, and speech disturb- ances are the most important. Anomalies of the function of any organ may also be considered. Psychic. — Imbecility, idiocy, insanity, moral delin- quency, and sexual perversion are the most important. DEAF-MUTISM. 1 This may be congenital or acquired. The acquired form follows scarlet fever, cerebrospinal fever, or other infectious diseases, or it may be due to otitis from other causes. Treatment. — Educating what little hearing remains and teaching the child to talk. This is best commenced at three years of age, and the child should be in an institution. 1 Drummond, " The Early Care of the Deaf and Dumb," Pediatrics, December 15, 1901, p. 440. DISEASES OF THE SPINAL CORD. 355 DISEASES OF THE SPINAL CORD. MALFORMATIONS. Spina bifida is the most important. The most frequent form is mmingvmydocde (fluid in the meningeal sac) of the F'j ■.. 118.— Spina bifida. Fig. 119.— Spina bifida. sacrolumbal' region. Meningocele or syringomyelocele (the fluid is accumulated in the central canal of the cord) may 350 DISEASES OF INFANTS AND CHILDREN. fluid is accumulated in the central canal of the cord) may also be occasionally seen. Other malformations may be present. The tumor is present at birth and tends to increase in size. Rupture may take place, and death result from infection or secondary infection. Prognosis. — Meningocele covered by skin may be cured. In meningo-encephalocele the prognosis is bad, especially if there is paralysis, and hopeless if there is hydrocephalus. Syringomyelocele is hopeless. Diagnosis. — Meningocele gives usually a pedunculated translucent tumor ; meningomyelocele, a sessile tumor hav- ing a central scar or urabilication, is frequently associated with paraplegia, and a fissure can be felt in the spine ; syrin- gomyelocele is usually associated with hydrocephalus. Treatment. — Protect from rupture. Operations should be done if there is no paralysis or hydrocephalus or severe as- sociated conditions. SPINAL MENINGITIS. Definition. — Inflammation of the spinal meninges. Etiology. — Most frequently associated with cerebral meningitis, or myelitis, occasionally traumatic. External pachymeningitis follows spinal caries. Symptoms. — These are due to pressure on the nerve roots or cord itself. The most marked are rigidity of spine and muscles of extremities, pain in the course of the nerves pressed upon, tenderness over the spine, and from cord-pres- sure, paralysis, atrophy, and anesthesia. Diagnosis. — Irritative symptoms point to meningitis, marked paralysis and anesthesia to myelitis. Treatment. — Rest, immobilization of spine, counter- irritation ; internally, iodid of potassium. MYELITIS. Definition. — An inflammation of the spinal cord. Ktiology. — In children it is usually either acute polio- myelitis or compression myelitis. Acute myelitis may be traumatic or follow the infectious diseases. Chronic myelitis is seen in hereditary syphilis. DISEASES OF TJTF. SPINAL conn. 357 Symptoms. — Acute poliomyelitis and compression-mye- litis are given below. Symptom- depend upon the location of the lesion. There are "girdle pains" at the level of the lesion and loss of reflexes. Below the lesion the reflexes are inereased. There may be loss of control of bladder and rectum, contracture or flaccidity of the muscles, reaction of degeneration, and bed-sores. Localizing symptoms are exactly the same as in adults. Prognosis. — Bad. The course is chronic and progres- sive ; death usually results from intercurrent disease. Treatment. — Rest; counterirritation. Iodid of potas- sium should be given in large doses after the acute stage is CO o passed. COMPRESSION MYELITIS, (Pott's Paraplegia; Pressure Paralysis of the Cord.) Definition, — Myelitis due to pressure on the spinal cord. Etiology. — Nearly always from tuberculous caries of the spine ; exceptionally from tumor or aneurism. It may fol- low injury. Pathology. — The cord is usually compressed in the angle of the spine caused by the caries, or from inflammatory products between the cord and spine, or both together. The cord becomes inflamed and degeneration may take place. Symptoms. — Spastic paralysis and increased reflexes of slow onset usually affecting the legs only ; in cervical caries, legs and arms. Radiating pains and other symptoms, as in myelitis, are present. Diagnosis. — From other forms of myelitis, by the pres- ence of deformity, where this does not exist by absence of other causes of myelitis, tenderness over the spinal processes, and pain with the paralysis are of value. Prognosis. — This depends largely on the course of the original bone disease. Cervical cases are more serious than lower ones. The motor symptoms, as a rule, persist longer than the sensory ones. Treatment. — This is surgical, usually by orthopedic appliances, plaster casts and the like. 358 DISEASES OF INFANTS AND CHILDREN TUMORS OF THE SPINAL CORD. These are very rare in childhood and present the same symptoms as in adults. They may be mistaken for Pott's disease. The diagnosis is not made in infants during life. SYRINGOMYELIA. This is occasionally seen in early life. There is dilatation of the central canal of the spinal cord, with or with- out the pressure of glioma. There is progressive paralysis with atrophy. Cyanosis or other vasomotor disturb- ances ; trophic changes are frequent ulcerations, bullae and even gangrene causing deformities. The deformities in the hands are asymmetric. There is loss of pain and temperature-senses, while . the ordinary touch-sensation is unaffected. The course is exceedingly chronic and nothing influences the course of the disease. HEREDITARY ATAXIA. 1 (Friedreich's Ataxia.) Definition. — An hereditary or family disease characterized by ataxia. Etiology. — It begins in early life between infancy and puberty. In some cases the hereditary factor cannot be found. Pathology. — There are imperfect development of the cord and sclerosis of the lateral and posterior columns. Symptoms. — Usually begins in legs ; child walks with legs far apart and has a staggering gait. 1 Batten, " Ataxia in Childhood/' Brain, Autumn and Winter Number, 1905, p. 484. Fig. 120.— Case of syrin- gomyelia with areas of thermo-anesthesia marked in black. There is cervical kyphosis (Church). DTSEASES OF THE SPINAL OOMD. 359 hater arms are affected and there is general ataxia. There is a nodding of the head and a coarse tremor, nystagmus, scan- ning speech, muscular weakness, scoliosis, little or no dis- turbance of sensation, a hollow foot with marked extension of the big toe. The deep reflexes are usually lost. Diagnosis. — From locomotor ataxia by the absence of Argyll-Robertson pupil, pains, crises and anesthesia, and the presence of nodding, nystagmus, altered speech, and general incoordination. Multiple sclerosis is distinguished by the marked inten- Fig. 121.— Clubbed foot of Friedreich's disease, showing shortened arch and retracted great toe (Church). tional tremor, spastic gait, increased reflexes, and ocular paralysis. Prognosis. — The disease gets steadily worse, and in a few years the patient is crippled and, later, becomes de- mented. Treatment. — Symptomatic. CEREBELLAR HEREDITARY ATAXIA. (Marie^ This is an hereditary affection in which the lesions are m the cerebellum. It comes on about puberty or later, and is 360 DISEASES OF INFANTS AND CHILDREN. distinguished from Friedreich's ataxia by the presence of in- creased patellar reflexes, absence of scoliosis and trophic changes. LANDRY'S PARALYSIS. (Acute Ascending Paralysis.) This is rare in children. It is characterized by a flaccid paralysis, beginning in the legs and progressing rapidly upward, affecting all or almost all the muscles of the body. The reflexes are lost, and there may be some disturbance of sensation. Almost all the cases die within a week or two. Recovery may take place with disappearance of the paralysis. ATROPHIES OF NERVOUS ORIGIN. (Progressive Central Muscular Atrophy.) These are rare in early life, usually coming on after puberty. They are due to changes in the motor cells of the cord and Fig. 122.— Kyphoscoliosis in extreme muscular atrophy. are characterized by their starting in the periphery (usually in the hands), the presence of fibrillary contractions, and the DISEASES OF THE SPINAL CORD. 361 Fig. 123.— Extreme muscular atrophy. Fig. 124.— Pseudohypertrophic muscular paralysis : Postures in rising to the erect position (Gowers). 362 DISEASES OF INFANTS AND CHILDREN reaction of degeneration. Their course is usually progressive and slow, but it may be rapid. There are several types, as follows : Muscular Atrophy of the Duchenne-Aran Type. — Beginning in the hands and extending to the other muscles of the body. The lesion in this is a chronic anterior poliomyelitis. There is chronic progressive atrophy of the muscles, and the tendon reflexes diminished or abolished. Amyotrophic Lateral Sclerosis (Charcot's Disease). — Where there is progressive muscular atrophy with increased tendon reflexes. Glosso-labial-laryngeal Paralysis. — Bulbar paralysis — often seen at a late stage of the preceding. Syringomyelia. — (See same.) Chronic Anterior Poliomyelitis of Childhood (Werdnig, 1891). — A family disease beginning in infancy, characterized by progessive muscular atrophy and great muscular weakness. It resembles in a general way the adult type of the disease, but the following contractions are wanting, and the reaction of degeneration may or may not be present. It progresses slowly, death usually taking place within four years. The progressive Muscular dystrophies. These have certain features in common. They are seen in early life ; the spinal atrophies usually come on after puberty. Hereditary influences are common. The atrophy is usually symmetric and affects the muscles of the limbs near the trunk earlier -and to a greater extent than the distal muscles. Fibrillary contraction of the muscles is generally absent. The tendon reflexes vary with the amount of muscular dis- turbance. There are frequently contractions of portions of the muscle. There may be marked retraction of some of the muscles causing deformities. There is a diminution of the electric excitability of the muscle, but no reaction of de- generation. They have an extremely slow course. In some there may be at the outset hypertrophy of the muscle. Forms of the Disease. — Facial-scapulohumeral Type DISEASES OF THE SPINAL CORD. 363 Fig. 125. — Progressive muscular atrophy, showing hypotonia. (Landouzy-Dejerine). — {Progressive Muscular Paralysis of Childhood, of Duchenne of Boulogne.) — The muscles of the face aucl the scapulo- humeral group are first af- fected. The expression is characteristic, the lips not partaking in the atrophy ; there is the so-called " tapir face " ; there is the " wing scapula." Later the other muscles of the body atrophy. Scapulohumeral Type (Erb). — Same as above, ex- cept face is not affected early. Pseudohypertrophic Paral- ysis (Duchenne) (Muscular Pseudohypertrophy}. — This is more frequent in boys. In this form there is at the start an hypertrophy of some of the muscles, espe- . -n n. tl , r» ,1 Fig. 126.— Pseudohypertrophic paralysis. cially oi the calves ot the legs, but often of other muscles. There is marked loss of 364 DISEASES OF INFANTS AND CHILDREN. power. When lying on the floor they get up by "climbing up," as it were, by resting ihe hands on the legs. Later there is atrophy. Fig. 127.—" Winged scapulae" in progressive muscular atrophy. Prognosis. — The outlook is bad. The disease, as a rule, gets progressively worse. Occasionally it is arrested. 1 Fig. 128.— Progressive muscular atrophy (Aran-Duchenne type). Treatment. — Massage, electricity, and general hygiene. DISEASES OE THE Sl'lSAL colli). 305 PERONEAL MUSCULAR ATROPHY (Charcot-Marie). Progressive Neuritic Muscular Atrophy (Hoffman.) A disease beginning in early life with marked atrophy of the muscles of the feet and legs ; later the hands and forearms Fig. 129.-Hands and feet in muscular atrophy of the Charcot-Marie type. Fig. 130.— Muscular atrophy of the Charcot-Marie type (P. Marie). are involved. The atrophy is extreme. The tendon reflexes are abolished. Sensation is normal or slightly disturbed. There is frequently a distinct family tendency. HYPERTROPHIC INTERSTITIAL NEURITIS (Dejerine and Sottas). This is a disease beginning in early life, sometimes occur- ring as a family disease. It resembles the preceding, with the addition of shooting pains, disturbances and retardation 366 DISEASES OF INFANTS AND CHILDREN. of sensation, kyphoscoliosis, Argyll-Robertson pupil, and marked ataxia. There is distinct hypertrophy of the periph- eral nerves. Late in the course of the disease there is the clinical picture of locomotor ataxia. MULTIPLE NEURITIS. Definition. — An inflammation of the peripheral nerves. It may affect several nerves, usually symmetrically, or it may be general. Etiology. — Diphtheria and occasionally the other infec- Fig. 131.— Foot-drop in neuritis, following typhoid fever. tious diseases ; sometimes exposure or cold ; and rarely alco- hol, arsenic, or lead. Pathology. — There is an inflammation of the affected nerve, followed by more or less complete degeneration of the nerve-fibers. Symptoms. — The onset may be sudden, with chill or convulsion and fever ; generally, however, it is gradual. During the onset there is pain, with great sensitiveness along the course of the nerve; later there may be anesthesia. There is weakness ; then paralysis of the muscle, both arms or legs or all four may be affected, and the extensors of the DISEASES OF THE SPINAL CORD. 367 foot and hand and the peroneal and muscular spiral nerves are usually most severely affected. Tendon reflexes are di- minished or abolished altogether, and reaction of degenera- tion. Marked atrophy follows. Muscular contractions may cause deformities. Diagnosis. — By the association of motor and sensory symptoms to the course of the affected nerves. When the Fig. 132.— Dropped wrist from musculospiral palsy, showing retrocarpal tumor (Church). back muscles are affected it may be mistaken for Pott ? s disease. Prognosis. — The average case begins to improve after the first month, recovery generally being complete in three months. The sensory symptoms clear up first. In some cases the paralysis may be permanent and cases may even be fatal. Treatment. — Rest and hot applications during onset. Later, electricity as in infantile spinal paralysis. Strychnia and tonics. 368 DISEASES OF INFANTS AND CHILDREN. FACIAL PARALYSIS. 1 (Bell's Palsy.) The paralysis may be due to lesioDS in the skull, in the petrous bone, or in the peripheral part of the nerve. The most frequent cause is neuritis. This is usually due to middle-ear disease and affects the nerve in the bony canal. Many cases set down to " cold" are of this form (Reik). Inside the skull the lesion may cause meningitis, tumor, or injuries to the skull ; in the peripheral part inflammation of the lymph glands of the neck or mumps. Symptoms. — There is paralysis of the muscles of one side of face ; it is smooth and does not change on closing eyes, laughing, etc. Sensation is good. Diagnosis. — The causes due to central trouble do not affect the upper fibers ; so the forehead is unaffected. At the base of the brain the auditory nerve is also involved, and there is deafness without ear lesions. The ear trouble is evident, if looked for in the cases affecting the canal. Prognosis. — This depends upon the cause. The cases due to " cold " usually recover in a month or two. Treatment. — Treat the ear where it is a cause. Later, electricity as in spinal paralysis. Central cases are unaffected by local treatment. DIPHTHERITIC PARALYSIS. The paralyses, coming on early, are supposed to be due to the soluble toxins in the blood, and they are a part of the picture of the toxemia. The late paralyses, coming on after the first week after the acute stage of the disease and as late as the sixth week, gen- erally result where there has been an extensive membrane with severe toxemia. It usually begins in the uvula or the larynx, and may spread to other muscles supplied by cranial 1 Taylor and Clark, " Facial Palsy, Results of Faciohypoglossal Anasto- mosis for," Jour. Amer. Med. Assoc, March 24, 1906, p. 856. Rainy and Fow- ler, ''Facial Paralysis," Review of Neurology and Psychiatry, March, 1903. DISEASES OF THE SPINAL CORD. 369 nerves or to the extremities. Usually there is a generalized muscular asthenia (and not an absolute loss by muscular innervation), flaccidity, muscular hypotonus, and loss of tendon reflexes. Voluntary movements to a very slight degree can generally be made. When the soft palate is affected, attempts to swallow fluids result in their return through the nose. This may be the earliest symptom. If the paralysis extends to the pharynx, swallowing may be difficult or impossible. The muscles of accommodation may be involved, as well as the external muscles of the eye, the latter causing strabismus and double vision. The prognosis is good, recovery taking place usually within two months, sometimes later, but it must be remem- bered that fatal cases occur where the heart or respiration or muscles of deglutition are involved. The treatment consists in rest in bed. Gavage may be necessary if the child cannot swallow. Strychnin and atro- pin are the most useful stimulants if the heart and respira- tion become affected. 24 370 DISEASES OF INFANTS AND CHILDREN. ACUTE INFECTIOUS DISEASES* THE TRANSMISSION OF INFECTIOUS DISEASES. 1 Infectious diseases are transmitted in several ways. Per- haps most frequently the patient transmits the disease directly, as in the case of diphtheria or measles. Mild and unrecog- nized cases of the disease are an especial source of danger, as they mingle freely with others. Some diseases may be trans- mitted by an individual apparently in perfect health, who has been associated with some one who has the disease, and harbors in his mouth or elsewhere the disease-producing germs. Such an individual is called a disease carrier. In some instances the disease may also be transmitted by objects which have come in contact with the sick person or with his discharges, and such objects are spoken of under the head of fomites. In other instances an intermediate host is required, and is usually an insect which takes the infectious material into its body and transmits it later on to human beings, and, lastly, some diseases may be transmitted through the air, but this happens rarely and under exceptional circumstances. Air infection is possible over a small range in measles and chicken-pox. In whooping-cough, during the paroxysm, the patient causes a small spray of mucus and saliva which may infect the air for a short time for a few feet in front of him. The transmission of disease by fomites is probably not as great a danger as was formerly supposed, and with rational disinfection of infected articles there is no danger at all. In a general way it may be stated that patients having infectious diseases should be isolated, as the fewer people who come in contact with the disease the fewer will get it. The patient should be protected from mosquitoes, flies, and other insects, especially from mosquitoes in case of yellow fever and malaria, from flies in case of typhoid fever and cholera, and from fleas in case of plague. 1 Doty, American Journal of Medical Sciences, July, 1909, p. 30. Edsall, Journal of the American Medical Association, July 9, 1909, p. 123. Chapin, Ibid., December 12, 1908, p. 2048. ACUTE INFECTIOUS DISEASES. 371 SCARLET FEVER-SCARLATINA. Definition. — An acute infectious disease characterized by a sudden onset, vomiting, a scarlet rash, sore throat, high fever and rapid pulse, and a tendency to nephritis. There are great variations in the intensity and character of the dis- ease. Etiology. — The disease is communicated by direct con- tact, by fomites, and it may be carried by a third person. The poison lingers for a long time and may remain active for a year or more. Epidemics have been started by infected milk. The disease is infectious from the onset until after desquamation has been completed. About 50 per cent, of the persons exposed take the disease. The susceptibility is greatest between three and six years of age and diminishes with age. After fifteen the disease is not common. Fall, winter, and spring are the seasons of greatest prevalence ; in other words, when people are crowded together indoors or when the schools are in session. The disease is much less common in the tropics, and is practically unknown near the equator, while in the cities where there are tenements it is especially common. One attack usually produces immunity, and second attacks rarely occur. The specific organism has not been definitely isolated. Streptococci are almost con- stantly associated with the disease, and are doubtless respon- sible for many of the symptoms. Mallory, of Boston, has described a parasite in the skin of scarlet fever patients. Pathology. — The macroscopic skin changes are not noted after death. Microscopically the changes in the skin consist of dilatation of the blood- and lymph- vessels just be- neath the epidermis and in the papilla?, together with vary- ing amounts of exudation. The same is true of the mucous membranes of the pharynx, soft palate, tonsils, and also of the tongue when the papilla? are markedly affected, causing macroscopic enlargement. Inflammation of varying extent and intensity is seen in the throat and, in some cases, a false membrane may be present. The lymph-nodes of the neck are enlarged. There are degenerations in the muscles and also in the heart muscles. There may be endocarditis, peri- 372 DISEASES OE INFANTS AND CHILDREN. carditis, or myocarditis. The spleen and liver may be en- larged. The kidneys show marked changes, usually a glom- erulonephritis of a hemorrhagic form. Incubation. — This is difficult to determine, and is appar- ently somewhat variable. Cases are said to develop as early as twenty-four hours and as late as twenty-one days after exposure. The consensus of opinion is that the period is usually short, from two to six days. Onset. — The disease begins suddenly, usually with an attack of vomiting; fever is high, often 104° and 105° F. Eruption. — This appears on the first or second day, first on the neck and chest, and from there spreads over the entire body. It consists of a more or less uniform scarlet blush or of fine punctate spots set closely together. The lips are not affected. The rash disappears on pressure and returns the moment that pressure is removed. It is usually punctate in the groins, axilla, and roof of the mouth. It lasts from three to seven days, when it gradually fades, and is followed by a desquamation lasting from two to six weeks. The desquamation, if the skin is not cared for, usually takes place in large pieces. There are many variations from this typical rash. It may be pale and transient, or there may be miliaria and, in severe cases, purpura. Tongue. — This is quite characteristic. On the first day it is furred, then the enlarged papilla? show through the white surface (strawberry tongue). In three or four days the white disappears, leaving a red tongue Avith enlarged papillae (mul- berry tongue). Sometimes the enlargement of the papillae may be the only sign. Throat Symptoms. — These vary greatly. In mild cases there is only redness of the pharynx. In moderate cases there is enlargement of the tonsils, some patches of membrane, and great redness of the entire throat. In the severe or anginoid cases there is a marked membranous angina with involvement of the pharynx, sAvelling of the lymph-nodes and other tissues of the neck, and this condition may be mistaken for diphtheria. Suppuration or a gangrene may follow. ACUTE INFECTIOUS DISEASES. 373 General Symptoms. — The onset is sudden, and gen- erally corresponds in severity with the character of the dis- ease later on. Vomiting is commonly noted, and there is usually also sore throat and high fever; the temperature rises rapidly, and usually reaches its highest point (104° to 105° F.) on the first or second day. In uncomplicated and not very severe cases it gradually falls and becomes normal in from four to seven days or more. A recurrence of the fever nearly always means some complication. The pulse is rapid, the digestion is disturbed, there is scanty, high-colored urine which often contains albumin. There arc restlessness, headache, and there may be delirium or coma. The blood shows a marked leukocytosis. The cases may be classified as mild, moderately severe, auginoid, and malignant. The very mild cases may be overlooked. There is usually fever, sore throat, and the rash is most marked on the body. The eruption and symptoms disappear in from three to five days. In cases of moderate severity all the symptoms are generally present and last from a week to ten days. Anginoid Scarlet Fever. — These are severe cases, with marked throat symptoms. There is a membrane over the tonsils, the throat is swollen and reddened, and there is usually involvement of the cellular tissues of the neck, together with enlargement of the lyinph-nodes. Malignant Scarlet Fever. — This may come on sud- denly with hyperpyrexia and coma (atactic form), death tak- ing place within the first two days, or it may be of the hemorrhagic variety, when there is a purpuric rash and also hemorrhages from the mucous membranes. Death usually occurs within three or four days. Relapses or recurrences are often seen, the disease appar- ently subsiding and then recurring, with the reappearance of all or nearly all the symptoms. Second attacks are rare, the immunity conferred by the first attack being quite perfect. Second attacks are occasion- ally noted, however, and there are cases on record where the child has had three attacks. One must bear in mind the frequent errors in diagnosis in this connection. 374 DISEASES OF INFANTS AND CHILDREN. Complications. — These are numerous and important. Albuminuria is of very common occurrence and nephritis is also frequent. The latter comes on most frequently during the second or third week of the disease, or even later, and presents the usual features of nephritis. It may be mild or severe, and chronic nephritis may result. Otitis media is very frequent, and may result in deafness or impaired hear- ing, or by extension to meningitis. Acute endocarditis, peri- carditis, and myocarditis may occur, and inflammation of other organs and tissues, such as pneumonia and pleurisy, are not infrequent. The lymph-nodes, especially those of the neck, are enlarged and sometimes suppurate. Diagnosis. 1 — This is, as a rule, easy, but at times it may be difficult, chiefly owing to the variations in the rash. Skin eruptions resembling scarlet fever are so common that it is never safe to make the diagnosis on the rash alone. In doubtful cases the entire body should be inspected, special attention being paid to the groins, axillae, and back. It is most frequently confused with the following : Acute Exfoliative Dermatitis. — This may occur again and again. It resembles scarlet fever closely, having a sudden onset, fever lasting a week or so, and is followed by desqua- mation. The desquamation is more marked than in scarlet fever, the tongue and throat are usually unaffected, and the nails and hair are involved. Measles. — The longer period of invasion, the catar- rhal symptoms, the characteristic rash, Koplik's spots, and the absence of leukocytosis should make the diagnosis easy. German Measles. — The enlarged lymph-glands, mild or no throat symptoms, polymorphous rash, and absence of constitutional disturbance usually make the diagnosis clear. Diphtheria. — It may be difficult to tell without cultures 1 Whitfield, " Rashes of Scarlet Fever and Other Skin Eruptions," Prac- titioner, January, 1909, p. 62. Beggs, " Differential Diagnosis of Scarlet Fever," Practitioner, January, 1909, p. 52. Cuff, " Diagnosis of Scarlet Fever and Diphtheria," Practitioner, January, 1909, p. 47. Goodall, " Diag- nosis of Scarlet Fever," Practitioner, January, 1909, p. 38. ACUTE INFECTIOUS DISEASES. 375 whether one has a diphtheria with a rash or a scarlet fever with a bad throat. One shonld bear in mind that the former is the exception, the latter the rule. The history of exposure and the persistence of the rash in scarlet fever are of value Septicemia. — There may be scarlet rashes in blood poison- ing having exactly the same appearance as scarlet fever. Drug Rashes. — These may follow the use of antipyrin, quinin, belladonna, copaiba, potassium iodic!, diphtheria antitoxin, etc. They are not, as a rule, attended with fever, and are usually transient. Prognosis. — The mortality varies in different epidem- ics. As a rule, the younger the child the worse the prog- nosis. The mortality varies from 5 to 20 or even 30 per cent. ' Treatment. — The child should be isolated, and similar prophylactic precautions taken to those recommended in diphtheria. The child should be kept in bed throughout the entire attack, and in severe cases from one to two weeks after- ward. The diet should consist of milk or milk and cereals for at least a month. By following this dietetic treatment the cases of nephritis are reduced to a minimum. Cold packs or sponges mav be used to reduce high fever (over 103° or 104° F.), also to relieve nervousness, delirium, and sleepless- ness. Cold may be applied to the head for headache and to the throat when there is adenitis. The throat may be sprayed, as in diphtheria. Stimulants may be used as indi- cated. Iron and strychnin may be given if necessary during convalescence. The skin should be thoroughly cleansed once or twice a day, and anointed with equal parts of lanolin and vaselin or some other ointment. This facilitates desquama- tion and prevents the fine scales of epidermis from flying about. MEASLES. Definition. — Measles is a specific, acute, infectious dis- ease characterized by extreme contagiousness, catarrhal symp- toms, fever, Koplik spots, and a characteristic red papular 376 DISEASES OE INFANTS AND CHILDREN. eruption, which usually appears on the fourth day, and a branny desquamation during convalescence. Etiology. — Measles is one of the most contagious dis- eases. Infection is usually by direct contact. It may result from being in the same room, as the contagion can be carried through the air for a short distance. It may be carried by fomites or a third person, but this is rarely the case. The disease is contagious during the latter part of the incubation period and throughout the course of the disease. Suscepti- bility is very great and very few are naturally immune. It is seen most frequently in childhood. It is endemic in the larger cities and also occurs in epidemics, most frequently in winter. One attack confers immunity, but second attacks Fig. loo.— Measles temperature chart. Mild case. Fig. 134. — Measles temperature chart, showing initial rise and fall. may occasionally occur. No specific organism has as yet been isolated. Pathology. — There is a catarrhal condition of the res- piratory tract, and often of the gastro-intestinal tract as well. Measles itself rarely kills, and in fatal cases bronchopneu- monia is the most frequently observed lesion. Period of Incubation. — This is variously stated, as to whether one counts to the appearance of the symptoms or to the appearance of the eruption. Symptoms appear from nine to eleven days and the rash quite uniformly on the thirteenth or fourteenth day after infection. Symptoms. — Invasion. — There may be languor for some 1. The pathognomonic sign of measles (Koplik's spots). 1. The discrete measles-spots on the buccal or labial mucous membrane, show- ing the isolated rose-red spot, with the minute bluish-white center, on the nor- mally colored mucous membrane. 2. The partially diffuse eruption on the mucous membrane of the cheeks and lips ; patches of pale pink interspersed among rose- red patches, the latter showing numerous pale bluish-white spots. 3. The appear- ance of the buccal or labial mucous membrane when the measles-spots completely coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthem is at this time generally fully developed. 4. Aphthous stomatitis, likely to be mistaken for measles-spots. Mucous membrane normal in hue. Minute yellow points are surrounded by a red area. Always discrete. (Medical News, June 3, 1899.) ACUTE INFECTIOUS DISEASES. 377 davs, with drowsiness and then coryza, cough, headache, nausea, and lever. The temperature usually reaches its height (about 104° F.) on the second day, but may begin 100 106 104 103 102 101 100 OO 90 i i ■ ; i-P-;4- ! • • • I - • Fig. 135.— Measles temperature chart, showing sudden fall at the appearance of the eruption. abruptly and drop, to ascend later. After the second day the temperature gradually falls and reaches normal in about a week. The temperature varies with the severity of the case. Fig. 136.— Measles temperature chart. Case of moderate severity, showing rather abrupt rise at beginning of eruption. Subsequent rises in temperature are almost invariably caused by complications. Koplik's Spots. — These are of great value in diagnosis. They appear usually the day before the eruption, but often twOj three, or even four days before. They are best seen on 378 DISEASES OF INFANTS AND CHILDREN. the inner side of the cheeks on a level with the second molars, and consist of small bluish-white specks with a red areola. The white spot disappears early, leaving a little red spot about the size of a pin head. The bluish-white spots must Fig. 137.— Measles temperature chart, showing a complicating pneumonia coming on after the temperature had fallen to normal. be looked for in daylight, as it is difficult or impossible to see them by artificial light. As the skin eruption begins to appear the eruption on the mucous membranes becomes dif- fuse and the spots are lost in the general redness. Fig. 138.— Measles temperature chart, showing pneumonia complicating the case from the sixth day. Eruption. — This appears on the fourth day, although some- times on the third or fifth days. It is first seen on the forehead, cheeks, along the margin of the hair and back of the ears, and then on the face, back, sides, arms, front of the From a case of measles. (Photograph by Dr. Jay F. Schambexg.) ACUTE INFECTIOUS DISEASES. 379 body, and legs. It consists of small papules about the size of a pin head, which have a tendency to group themselves in crescentic patches. In many places these patches may be confluent. The rash often has a distinct shot-like feel, the skin is hot and itches. The early spots are a rose-red color and rather bright, and later the color somewhat resembles that of a purple raspberry, becoming darker as it grows older. After several days it fades rather quickly, leaving purplish brown spots, which in a day or two become faint yellowish brown in color. This slight pigmentation persists for two or three weeks. The rash is followed by a fine, branny desquamation. There may be atypical cases, and many variations of the rash have been described. The erup- tion may be hemorrhagic (black measles), and this form is usually very severe. The rash is more intense in a warm room or in a warm bed, and exposure to cold may cause the rash to fade somewhat. Other Symptoms. — During the height of the disease the patient is usually quite uncomfortable, there is marked inflam- mation of all of the mucous membranes, there is conjunc- tivitis and more or less photobia and marked coryza, with considerable discharge from the nose. The mucous mem- branes of the mouth and throat are intensely reddened, there is a bronchitis, and usually a marked disturbing cough. Albuminuria is usually present, vomiting is not uncommon, and sometimes there is diarrhea. There is leukocytosis be- ginning early in the period of incubation, reaching its maxi- mum six days before the appearance of the eruption, and lasting into the first part of the stage of invasion, then the leukocytes fall to normal, or there may be leukopenia. Dur- ing the eruptive period a leukocytosis means a complica- tion, although complications may exist without any leuko- cytosis. Complications and Sequelae, — These are very numer- ous. Bronchopneumonia is most common and may be the cause of death. Laryngitis is also frequently seen. Lobar pneumonia, empyema, and gangrene of the lung may all be noted. Gangrenous stomatitis sometimes follows in weak 380 DISEASES OF INFANTS AND CHILDREN. children. Paralysis is sometimes seen and occasionally in- flammation of the joints and bones. Tuberculosis may be seen following measles, and the resistance to all infectious diseases is lowered. Diagnosis is usually easy. Scarlet Fever. — This is distinguished by the sudden onset with fever, the absence of catarrhal symptoms and Koplik spots, the characteristic eruption, the strawberry tongue, the angina, and the presence of leukocytosis. German Measles. — This differs in the more rapid invasion, the polymorphous character of the rash, the absence of Kop- lik spots, and of symptoms. Drug Eruptions.— Copaiba and other drugs may give a rash which often quite closely resembles measles. The diagnosis is made on the history of the administration of the drug, the absence of fever and other symptoms, the absence of Koplik spots, and the shorter duration. Prognosis. — This varies in different epidemics. It may prove very fatal at times, rarely from the disease, but from complications, especially bronchopneumonia. Prophylaxis. — Care should be taken to prevent infec- tion, especially of young children. Isolation is not effective unless the patient is separated from others by an open-air space. Susceptible children should be sent away as soon as the disease is discovered, and if this is not done promptly infection usually takes place. Isolation in the average household is usually either started too late or is not strict enough to be of service. In hospitals and institutions the rooms occupied by the patient should be disinfected, and also in private houses if the room is to be occupied immediately by susceptible children. If two or three weeks elapse there is no danger from infection. Treatment. — The children should be kept in a well- ventilated room with a temperature of 70° F. and not over- heated. The skin may be anointed with equal parts of vase- lin and lanolin, and kept clean by sponging with warm water and Castile soap. The itching may be relieved by using carbolized vaselin or the free use of powder. High ACUTE INFECTIOUS DISEASES. 381 fever and restlessness are best treated by sponge-baths or cold ] >acks. The mouth and nose may be sprayed with Dobell's solution and a boric acid eye-wash used for the conjunctivitis. GERMAN MEASLES. (Rubella; Rotheln; Epidemic Roseola.) Definition. — Rubella is a specific infectious disease oc- curring in epidemics, and characterized by a polymorphous rash which sometimes resembles that of measles, sometimes that of scarlet fever, and sometimes that of both diseases, but differing from them in incubation, invasion, in having no symptoms and no dangerous sequela?, and by an almost constant enlargement of the cervical and sometimes other lymph-nodes. Etiology. — Rubella exists as a separate disease, and it does not protect against either scarlet fever or measles. It is contagious throughout the attack, and epidemics are most frequent in spring or winter, but the disease may occur spo- radically. It rarely affects children under six months, but after that age the susceptibility is rather general. One attack usually confers immuuity. It is usually transmitted by direct contact, although occasionally by fomites. The con- tagiousness seems to vary in different epidemics, being slightly so in some and intensely so in others. It is more common among the poor, which may be explained by the lesser resist- ance and greater danger to exposure. Period of incubation is from five days to three weeks or longer, usually from ten to sixteen days. Symptoms. — Prodromes are slight or absent. The stage of invasion lasts but a day or less, and during this time there may be slight drowsiness, sometimes slight fever, sore throat, and more rarely a chill or vomiting. The erup- tion begins on the first or second day, and in many instances the child wakes up with the eruption, nothing having been previously noted. Eruption. — This begins on the face, and spreads rapidly 382 DISEASES OF INFANTS AND CHILDREN. over the body to the ends of the extremities, usually in one day. It lasts two to four days and occasionally longer, and when it fades it leaves, especially in brunettes, a slight pig- mentation, which disappears in a day or two. One of the characteristics of the rash is its polymorphous character. It may resemble measles (rubella morbilliforme), or it may be a more uniform blush, like scarlet fever (rubella scarlatini- forme), or there may be combinations and all gradations between the two. The scarlatiniform eruption is liable to occur where there is pressure upon the skin, as around the waist-band or on the buttocks. Slight desquamation follows. The eruption may be seen on the mucous membranes in small red points somewhat raised above the surface on the uvula and soft palate during the first day, and is of some value in diagnosis. During the attack there are slight fever, a little malaise, and swelling of the lymph-nodes, especially of the posterior cervical nodes, which may attain the size of a pigeon's egg. Blood. — Blood findings resemble those in measles. There is a leukocytosis during the incubation, followed by leuko- penia when the eruption appears. After the disappearance of the eruption the blood becomes normal. Complications are rare, as are also recurrences and relapses. Diagnosis. — The polymorphous rash, the eruption on the uvula and soft palate, and the glandular enlargement with an absence of other symptoms, are the most important features. It is not safe to diagnose German measles apart from an epidemic. The absence of Koplik spots is of value in excluding measles, and the rashes due to heat, indigestion, and to drugs, so common in infancy, should be carefully excluded. The rash caused by handling certain varieties of caterpillars should not be mistaken for rubella. Prognosis. — This is almost invariably good. Compli- cations and fatalities are exceptional. Treatment. — As a rule, none is required. The patient may be isolated if in school or an institution. ACUTE INFECTIOUS DISEASES. 383 DIFFERENTIAL DIAGNOSIS OF RUBELLA, SCARLET FEVER, MEASLES, AND ERYTHEMA INFECTIOSUM. 1 RVBELLA. r MEASLES. Contagion. Apparently va- ries in " epi- demics. Di- rect contact. Possibly from fomites, not through the air. Highly conta- gious. By di- rect contact. By fomites. Through the air. SCARLET FEVER. Marked. By di- rect contact. By fomites. Incubation. Prodromes. Variable aver- Average 9 to 14 age, 4 to 3 days, weeks. Average 1 davs. to 6 Slight and of short dura- tion. c c a - sionallya day or two of malaise. Koplik spots. None. Vomiting. Fever. Rare. Slight — aver- age 1 to 2 days, some- times for 4 days, seldom more than 101 to 102 de- degrees. C atarrhal Slight, symptoms. Tongue. Throat. Diarrhea. Lymph-nodes. Slight coat, nothing char- acteristic. Small puncti- form red spots over uvula and palate. Phar- ynx slightly reddened. Pulse. Albuminuria. Varies fever. Rare slight. with > to 4 days. Drow s i n e s s and catarrhal symptoms. Short or want- ing, onset usu- ally sudden. ERYTHEMA INFECTIOSUM. Feeble. Usu- ally by direct contact. Average 6 to 14 days. Very slight and of short duration. Present in 90 or None. 95 per cent, of cases. None. General e n - largem ent, especially of postcerv i c a 1 nodes. Occasional. Marked high curve, lasting about a week, average from 102 to 105 de- grees. Marked. Tongue coated, that of any fever. Moderate phar- yngitis and redness of mucous mem- branes. Frequent. Postcerv i cal , postauricular, and submax- illary nodes enlarged. Common. High fever, lasting about a week, aver- ages 104 to 105 degrees. Absent. Straw b er ry , later mulber- ry tongue. Uncommon. Little or none. None. Sometimes slightly coat- ed. Usually a se- Sometimes vere angina very slight sore throat at onset. / Varies fever. with and Rare. Depends on ex- tent of throat involvement , glands at an- gle of the jaw involved. Very rapid. Common. Not enlarged. Normal. None. 1 Ruhrah in " Osier's Modern Medicine." 384 DISEASES OF INFANTS AND CHILDREN. DIFFERENTIAL DIAGNOSIS OF RUBELLA, SCARLET FEVER, MEASLES, AND ERYTHEMA INFECTIOSUM— Continued. Eruption. Desquamation. Convalescence. KUBKLLA. Begins on face, spreads to neck and breast, then to arms, legs, and feet. Is fading from older parts while spread- ing to new. Two forms — common form, morbil- liform, small, slightly ele- v a t e d pap- ules, dis- crete, some- times conflu- ent, more rare- ly scarlatini- form, lasts 2 to 4 days or less, color rose-red, but this varies. MEASLES. Begins on face, spreads grad- ually over en- tire body. Cov- ering it by the second or third day, con- sists of small papules a r - ranged in crescentic groups, these are confluent in places, lasts 4 to 5 days. Is deep red, of- ten purplish. SCARLET FEVER. Begins on neck and chest, spreads slow- ly over entire body — maxi- mum about the fourth day. Does not affect lips. Consists o f small punc- tate spots or a diffuse blush, disappears on pressure, lasts about a week. Intense red color. Slight branny. and Branny. Rapid, no com- plications. Slow, frequent complica- tions, as pneu- monia. Later other infec- tiousdiseases, as tuberculo- sis. Marked in flakes and large pieces. Slow, compli- cations fre- quent, as ne- phritis, otitis media, etc. ERYTHEMA \INFECTiOSUM. Mrst on face, las symmetri- cal rose-red blush, for the jmost part sharply de- ]fined, and re- jsembles ery- sipelas. It is hot to the touch, but not sensitive, and it does not itch. The second day it spreads to the body and ex- tremities, small dis- crete crescen- tic patches over the body and sparingly on the inner and flexor surfaces of limbs. Mark- ed map -like eruption on outer and ex- tensor sur- faces. Begins to fade on face in 4 or 5 days. Lasts altogether 6 to 10 days. None. Rapid, no com- plications. ERYTHEMA INFECTIOSUM. 1 Definition. — A feebly contagious disease characterized by a maculopapular, rose-red rash and an absence of com- plications and sequela?. Etiology. — Most frequent between four and twelve years. Epidemics are most frequent in spring and summer. No specific organism has as yet been described. 1 Escherich, 1896, named by Sricker, 1899; Shaw, American Journal of Medical Sciences, January, 1905. ACUTE INFECTIOUS DISEASES. 385 Incubation. — Six to fourteen days. Occurrence. — This disease has not been noted in America up to the present time. It has been described in Germany and Austria. Symptoms. — There are slight prodromes, as malaise and a little sore throat. These may be wanting. The rash ap- pears first on face, later on arms, legs, and trunk. It spreads downward, involving hands and feet last of all. The rash is rose-red, macular, raised slightly above the surface. In some places it is sharply defined, suggesting erysipelas ; in other places it shades gradually into the healthy skin. The affected skin is hot to the touch, but is not sensitive and does not itch. The color disappears on pressure, but quickly reappears. On the cheeks it is confluent, on the body it is seen in discrete, crescentic spots, and on the extremities it is most marked on the extensor surfaces ; is not so red as the face and is more measles-like, having a sort of map-like arrangement. It is evanescent, and may disappear and reap- pear. It lasts from six to ten days, sometimes less, and there is no desquamation and no subsequent pigmentation. The lymph glands are not enlarged, and there are few or no subjective symptoms. Prognosis. — Good. No fatal cases have been reported. Diagnosis. — From measles by absence of catarrhal symptoms and of Koplik spots. From scarlet fever by the absence of characteristic tongue, constitutional symptoms, and appearance of rash. From drug rashes by the history, from urticaria by the absence of itching. Erythema exu- dativum multiforme begins in the hands and feet, becomes vesicular, lasts longer, and there are marked constitutional disturbances. Treatment. — Symptomatic. VARICELLA. (Chicken-pox.) Definition. — An acute infectious disease characterized by a typical discrete eruption, slight fever, and trifling con- stitutional disturbances. 25 386 DISEASES OF INFANTS AND CHILDREN. Etiology. — It is very contagious, and is conveyed by direct contact, by fomites, or even through the air for short distances. Isolation, to be effective, must be in a separate building. It occurs sporadically and in epidemics. Children are most often affected, and susceptibility is very general, although adults are but rarely affected. One attack confers immunity. Varicella has no relationship whatever to small- pox. No specific organism has been described as yet. Period of Incubation. — This is usually from fourteen to sixteen days, occasionally longer. Symptoms. — As a rule the prodromes are unimportant or absent and the eruption may be the first thing noted. Sometimes there are chilliness, slight fever, and malaise a day before it appears, and occasionally pain in the back and abdomen, vomiting, and other symptoms. The fever is highest on the second or third day, usually 101° to 102° F. ; sometimes it is less, and it may go as high as 105° F. After a few days it disappears. There are no other characteristic symptoms. Eruption. — This comes out in successive crops. It begins as a small papule, slightly raised above the surface, and sur- rounded by a red areola, not unlike a small flea bite. This changes rapidly to a clear vesicle, which looks almost like a drop of water on the top of the papule. The vesicle drys from the center and sinks in, causing umbilication. Further drying reduces it to a brownish crust. Several days are needed for it to complete its course, and some of the papules go through their cycle more rapidly than others. All stages of the eruption may be seen at one time on the body, and this is one of the most distinguishing 1 characteristics of chicken-pox. The eruption is most marked over the trunk. On the exposed surfaces it is liable to be infected and become pustular, and these pustules may leave deep white scars, while the ordinary eruption leaves none. Under bandages and where there is irritation from discharges, or where the skin is otherwise irritated, the eruption may be usually thick, sometimes even confluent. The number of vesicles varies from ten to eight hundred. They also vary in size, the ACUTE INFECTIOUS DISEASES. 387 average being that of a lentil. Sometimes there is a pem- phigus-like form of varicella, and a rare form is varicella gangrenosa, in which the eruption becomes gangrenous. This latter is usually fatal. The eruption may also be noted on the mucous membranes, in the mouth, on the conjunctiva, or on the genitalia, Complications. — Erysipelas may develop, or there may be ordinary pus infections. Adenitis is common if there are many pustules, and nephritis is occasionally noted. Pains in the joints are sometimes met with. Diagnosis. — The course of the disease, the eruption coming out in crops, the greater frequency on the trunk, and the sparseness of it on the hands and face distinguishes it from small-pox. There is usually little difficulty, except in differentiating the lighter and irregular forms of small-pox, such as occur after vaccination. The differential diagnosis from other conditions usually presents little difficulty. The course of the disease ordinarily makes the diagnosis plain, if the appearance of the eruption does not. Impetigo, urticaria vesiculosa, herpes, pemphigus, and some forms of eczema are sometimes confused with it. Prognosis. — This is usually good. Treatment. — Little or no treatment is required in the average case. If there is fever the child should be kept in bed and carbolized vaseline may be applied to relieve the itching. Cold sponges may be used if the fever is high or the child is nervous. The child should be kept clean, and the hands and finger nails should be kept clean. If the scratching cannot be controlled, the hands and arms should be restrained. THE FOURTH DISEASE. In 1900 Clement Dukes, physician to the school of Rugby, published a description of what he believed to be a disease not before described, to which he gave the name of fourth disease. The chief difference between this supposed disease and German measles is in the rash. It is very probable that the so-called fourth disease is either a scarlatinal form of rubella or mild scarlet fever. 388 DISEASES OF INFANTS AND CHILDREN. VACCINIA. 1 (Cow-pox ; Vaccination.) Definition. — Vaccinia is a disease produced in men by the inoculation with the virus of cow-pox. It is character- ized by a local pock at the seat of inoculation, fever, and some constitutional disturbance. It affords more or less per- fect protection from small-pox. The virus is secured from the vesicles on the calf (animal virus) or from vaccinated persons (humanized lymph). History. — Prior to the introduction of vaccination, small- pox was about as common as measles is now. Since vacci- nation, small-pox has diminished very greatly, and where a second vaccination is compulsory, as in Germany, small-pox has disappeared. Natnre of Vaccinia. — This question is not yet settled. The majority of observers claim that cow-pox is small-pox, modified by passage through the cow. Others, especially French writers, insist that vaccinia and small-pox are sepa- rate diseases. Bacteriology. — Numerous bacilli and other forms of microscopic parasites have been described. The question may be regarded as unsettled. Time to Vaccinate. — As soon as the child begins to gain in weight it may be vaccinated. The second or third month is usually chosen. If done before the fifth month the constitutional disturbance is slight ; if done later there are fever and malaise. Vaccination should be repeated about the seventh year, or when the child starts to school, and again about puberty. Vaccination should always be repeated when small-pox is prevalent. Choice of I,ymph. — Calf lymph is always to be pre- ferred, as syphilis and other diseases have followed the use of humanized lymph. Either the glycerinated lymph or that dried on points may be used. Vaccine virus rapidly loses its virulence if kept at 70° F. or over. It should be kept in a cool place. 1 Edward Jenner, 1798. ACUTE INFECTIOUS DISEASES. 389 Technic. — The skin above the insertion of the deltoid on the left arm is Hsually chosen as the site. Girls may be vaccinated on the leg. Wash the skin well with soap and water. Stretch slightly and cut with a sharp lancet just into the skin. The cut should be quarter of an inch long. Rub in the virus, allow it to dry, and protect for twenty-four hours with sterilized gauze. Symptoms. — The little primary irritation quickly sub- sides. In three or four days there is a little papule with a reddened zone about it. By the sixth day there is an urn- bilicated vesicle. This increases in size for a day or two, and by the tenth day it is a pustule. There is usually considerable swelling about' the arm, and the axillary lymph glands are enlarged. The pustule gradually dries, and by the end of the second week is a brownish scab. This falls off in a week or ten days more. There is marked leukocytosis. There is considerable constitutional disturbance : fever, headache, and general malaise. These are slight in young infants. Irregular Vaccination. — The pock may appear earlier or later than usual or may rarely recur a second time. There may be other vesicles, usually in the neighborhood of the poek. There may be a rash over the body. Complications. — These are rare. Acland gives the following list : 1 . During the first three days : Erythema, urticaria, vesic- ular and bulbous eruptions, in vaccinated erysipelas. 2. After the third day and until the pock reaches maturity : Urticaria, lichen urticatus, erythema multiforme, accidental ervsipelas. *3. About the end of the first week : Generalized vaccinia, impetigo, vaccinal ulceration, glandular abscess, septic infec- tions, gangrene. 4. After the evolution of the pocks : Invaccinated diseases, as svphilis. Treatment. — The pustule should be protected by a dressing of gauze or by a shield, which should be removed every day or two and cleansed. Care should be taken with the shield that it does not press on the pustule and cause in- 390 DISEASES OF INFANTS AND CHILDREN. flammation or upon the surrounding tissue. If the pustule becomes infected, wet dressings with boric acid frequently changed will usually be found satisfactory. If the child has fever, it should be kept in bed with cold sponging used for the temperature. Codein and antipyrin may be used to allay nervousness and pain, especially at night. PERTUSSIS. (Whooping-cough; Kink Cough.) Definition. — An infectious disease characterized by ca- tarrh of the respiratory tract, a paroxysmal or spasmodic cough, usually ending in a long sonorous inspiration or whoop, and this is frequently accompanied by vomiting. Etiology. — The disease is seen sporadically and epi- demically and is endemic in most large cities. It is more frequent in cold climates and epidemics are somewhat more frequent in winter. The susceptibility is very general, and the majority of persons have the disease some time during their life. The greatest predisposition is from six months to five years, and over half the cases occur during the first two years of life. The susceptibility decreases as the individual grows older. Period of Incubation. — This is from one to two weeks. One attack usually protects from a second. The disease may be transmitted from the earliest symptoms until late in the disease. It is usually transmitted by direct contact, and only a very short exposure is necessary for infection. It may, however, be carried by fomites. If after exposure sixteen days pass, and the disease has not made its appear- ance, the chances are that it will not develop. Pathology. — A bacillus has been described by Koplik, Czaplewski, Wollstein, and others. Another organism has been described by Bordet and Gengou, 1 which is found in the mucus from the parts of the respiratory tract below the larynx. It disappears early in the disease. There is more or less congestion and catarrhal inflammation of the larynx, 1 British Medical Journal, October 9, 1909, p. 1062. ACUTE INFECTIOUS DISEASES. 391 trachea, and bronchi, and severe coughing may produce em- physema. Hemorrhages and pulmonary complications are frequent and are the usual causes of death. Coughing also frequently produces a small ulceration of the frenum of the tongue in children who have cut their teeth. Symptoms. — There are three stages : Catarrhal, spas- modic, and the stage of decline. Catarrhal Stage. — The child has a slight bronchitis which cannot be distinguished from an ordinary cold. There is often headache, general malaise, and slight fever. After one or two weeks this passes into the spasmodic stage. Some children whoop almost from the beginning, others may not do so for over two weeks, and some not at all. There may be occasional paroxysms of coughing during the catarrhal stage, and a persistent cough which is more frequent at night should suggest whooping-cough. Spasmodic or Paroxysmal Stage. — The fever and catarrhal symptoms disappear, and the cough becomes more and more paroxysmal, and in nearly all cases there is the long inspira- tion or whoop. The child usually feels the paroxysm coming on and runs to the mother or nurse for support, or grasps the nearest object, and, if there is nothing near, braces the body with the hands on the legs near the knees. There is a severe barking cough of a loud metallic character, the face becomes reddened and cyanotic, the eyes suffused, and the veins of the neck and head stand out prominently. There is protrusion of the spoon-shaped tongue. After a series of coughs there is a prolonged whoop, and "finally a small ball of tenacious mucus is expelled, frequently with vomiting. There are from four or five to thirty or forty paroxysms a day. About twenty is the average. Hemorrhage under the conjunctiva or from the nose may be caused by a paroxysm. Stage of Decline. — The severity of the cough gradually diminishes until it resembles an ordinary bronchitis. After excitement and violent exercise it may become paroxysmal again for a short time, and the paroxysmal character may be added to any ordinary bronchitis which the child may have during the next six months. 392 DISEASES OF INFANTS AND CHILDREN. The Blood. — There is a constant leukocytosis which begins early before the paroxysmal stage, continues through it, and disappears with it. The leukocyte count varies from 20,000 to 25,000, but may run as high as 45,000. The principal increase is in the lymphocytes. In doubtful cases the blood examination is of great value in diagnosis. Duration. — The duration of the attack is variously stated, and differs greatly in different epidemics. Average figures are : Incubation, one week ; catarrhal stage, one to two weeks ; paroxysmal stage, four to six weeks ; decline, two to three weeks. Complications. — These are very numerous. Hemor- rhage from the mucous membranes or into the organs is fre- quent. Bronchopneumonia, acute emphysema, and collapse of the lung may occur. Vomiting and diarrhea are not in- frequent. There are numerous nervous complications, con- vulsions and cerebral hemorrhage being the most frequent. Tuberculosis and chronic bronchitis may follow. Symptoms from drugs are sometimes erroneously attributed to whooping-cough. The most frequent are drowsiness, or even unconsciousness from narcotics ; delirium, dry throat, and mydriasis from belladonna; tinnitus, gastric disturb- ances, rashes, and other symptoms from quinin. Diagnosis. — History of exposure, the frequency of the cough at night and its spasmodic character make the diagnosis easy. In doubtful cases the blood examination is important. If the child does not have a paroxysm in the presence of the physician, one may be brought on for diagnostic purposes by introducing a spoon along the teeth, as in a throat examina- tion, and carry the spoon to the base of the tongue in such a manner that the epiglottis comes into view. Spasmodic cough may occur in catarrhal laryngitis when there is an elongated uvula, adenoids, and enlarged tonsils. Paroxysmal coughing may be caused by foreign bodies in the larynx, trachea, or bronchi. The spasmodic cough of hysteria is rare in children. Enlarged tracheal or bronchial glands produce a cough much like whooping-cough. Barthez and Sannee give the following table of differential points : ACUTE INFECTIOUS DISEASES. 393 WHOOPING-COUGH. ENLARGED GLANDS. 1. Contagious, epidemic. 1. Isolated, not contagious. 2. Three periods, second paroxys- 2. No distinct periods. mal. 3. Paroxysmal cough, with whoop, 3. Paroxysms short, frequently with- vomiting, and viscid expectora- out the whoop, expectoration, don. or vomiting. 4. Respiratory sounds normal. 4. Signs of enlarged glands some- times present. 5. Respiration normal in interval, 5. Asthma in some cases alternating apvrexia if simple. with paroxyms. Febrile move- ments with recrudescence in the evening, sweats, progressive wasting, etc. 6. Voice natural. 6. Sometimes a change in voice. 7. Usually acute. 7. Chronic. Prognosis. — Good in the better classes, especially after the first year. During the first year it is serious, and in overcrowded institutions the outlook is very bad. Prophylaxis. — Children with whooping-cough should be isolated from others, and especial care should be taken to avoid infecting young children and those with other diseases. The patient is to be regarded as a source of infection until the spasmodic stage is over. ^Vhere other children are to use the same room, or in institutions, disinfection should be used after the disease. Treatment. — Much can be done to make the course of the disease less severe, but it is very doubtful if any treat- ment has anv influence in shortening; the duration. Fresh air is of great importance. The child should be kept out of doors as much as possible, if conditions permit, and the house, especially the sleeping-room, should be well venti- lated. The child should be moved from room to room where possible. Protect the child from drafts and excitement. The diet should be light and nourishing, and young children and those where there is much vomiting should be put on a milk diet. If one meal is vomited, a second should be given shortly afterward. Xaojele suggests the following method of stopping the paroxysms : Pull the jaw forward and downward in a man- ner frequently employed by the anesthetists. This can . be 394 DISEASES OF INFANTS AND CHILDREN. done by the mother or nurse if the child feels a paroxysm coming on. A snugly fitting elastic band applied to the abdomen is of use where there is much vomiting. It should be made with a piece of elastic sewed in the front, and should lace up the back, extending from the pubes well up on the chest. No one drug should be given continuously ; changes should be made from one to another as needed. Do not upset the child's stomach by indiscriminate drugging. The following drugs will be found useful : Heroin hydrochlorid (tIto t° 2V g ram )- Belladonna (small doses, increased until slight flushing of face occurs after dose). Antipyrin (1 to 3 grains). Bromoform (1 to 3 drops, with caution). Quinin (1 to 5 grains). Sodium bromid (1 to 5 grains). Anti- septic and sedative sprays are sometimes used, and inhalation of vapors and steam from creosote and water are of value if there is much bronchitis. MUMPS. (Epidemic Parotitis*) Definition. — An acute infectious disease characterized by fever and by swelling and tenderness of the salivary glands, usually of the parotids, but sometimes of the sub- maxillary and sublingual. Metastases occasionally occur in other organs. Etiology. — It is endemic in large cities, and occurs in epidemics and sporadically. Epidemics are apparently un- influenced by the weather and climate, and the sexes are affected about equally. Most cases occur between five and fifteen years of age. Susceptibility diminishes after fifteen, and it is hot very common under five. Almost all children are susceptible, but in any given epidemic only about one- third of those exposed have the disease. Infection is by direct contact, but it may be carried by fomites. One attack usually gives immunity, though second and even third attacks may occur. Pathology. — The parotid gland is inflamed, and the principal change is said to be in the interstitial tissue. An ACUTE INFECTIOUS DISEASES. 395 organism has been discovered by Laveran and Catrin, but it has not been definitely proved to be the cause of mumps. Period of Incubation. — This is usually long, being from seventeen to twenty-one days, and is said to vary from three to twenty-five days or longer. Symptoms. — Prodromes may or may not be present. These consist of fever, with or without chill, general malaise, vertigo, drowsiness, vomiting, or diarrhea and epistaxis. There may also be sweats, fainting spells, pain in the ear, and trismus. The temperature ranges from 101° to 104° F. It disappears as the swelling subsides, and sometimes several days before. After an attack of mumps there may be subnormal temperature for some days. There is pain at the angle of the jaw and in the swollen parotid. One or both sides may be involved, the glands enlarging rather rapidly for from three to six days, then remaining stationary for a day or two, and gradually subside. The subsidence is usually complete in two or three days, although in severe cases it may be three weeks or a month before it disappears entirely. Where both sides are not affected at the onset, the opposite side is generally involved in from one to four days. The swelling is extremely tender and there is painful degluti- tion. The average case presents a much-rounded swelling at the angle of the jaw, with the lower end of the lobe of the ear at its center. It is sometimes boggy at first, but does not pit on pressure. Later it becomes very tense and firm, the skin is stretched and glazed, and there may or may not be redness. All grades of intensity may be seen. Some articles of food, such as lemons, vinegar, etc., may cause intense pain. The saliva may be increased or diminished. In very severe cases there may be enormous swelling and edema of the tissues, which may extend all around the head and neck. The submaxillary and sublingual glands may be affected either after the parotids, at the same time, or alone. Orchitis may occur in boys, coming on usually when the parotid swelling is subsiding, and sometimes after it has disappeared entirely. There is tender and painful swelling of the gland, lasting three to five days, and is often followed 396 DISEASES OF INFANTS AND CHILDREN. by atrophy of the testicles. Vulvovaginitis and, rarely, ova- ritis may occur in girls. Mastitis may occur in either sex. Pancreatitis may sometimes occur, and tenderness over the pancreatic region is not uncommon. There may be con- junctivitis and other eye complications. Tinnitus aurium occurs in some cases, and nervous complications have been described. Cerebral symptoms, like meningitis, convulsions, facial paralysis, and peripheral neuritis, as well as arthritis, albuminuria, and nephritis, may be observed. Diagnosis. — First from adenitis, chiefly by palpation and the location of the swelling. Parotitis occurring in the infectious diseases and septic infections following disease or injury of the abdominal or pelvic organs should be excluded. Prognosis. — As a rule, this is good. Treatment. — Keep the patient in bed. Give a saline purge, and use hot or cold applications locally for the pain. The food should be liquid or soft. Acids and highly sea- seasoned foods should be avoided. The swelling may be anointed with an ointment or a glycerin application, 5 per cent, guaiacol or belladonna may be used. In orchitis sus- pend the gland and apply lead-water and opium and guaia- col ointment. Anodynes may be given if necessary. DIPHTHERIA. 1 Definition. — A specific infectious disease due to the Klebs-Loffler bacillus, usually characterized by the forma- tion of a false membrane locally, generally on the tonsils, pharynx, nose, or larynx, and by constitutional symptoms, chief of which are moderate fever, great prostration, and anemia. It is a disease in which there are great variations, 1 Park and Thorn, tl Diphtheria Antitoxin, Results of the Use of Re- fined," American Journal of the Medical Sciences, November, 1906, p. 686. A. Seibert, "Diphtheria in Early Life," Archives of Pediatrics, February, 1905, p. 116. Joseph Priestley, "Diphtheria Outbreak, History of," Prac- titioner, September, 1906, p. 372. J. D. Rolleston, "Diphtheria, Some Aspects of the Serum Treatment of," Practitioner, May, 1905, p. 660. J. T. C. Nash, " Diphtheria, Treatment of," Practitioner, April, 1905, p. 510. Ker, "Treatment of Diphtheria," Practitioner, January, 1909, p. 94. Rol- leston, " Diphtheritic Paralysis," Practitioner, January, 1909, p. 110. ACUTE INFECTIOUS DISEASES, 397 both in the local and constitutional manifestations. It may be followed by localized or general paralysis. Etiology. — The Klebs-Loffler bacillus causes the for- mation of the false membrane, and the absorption of the toxins formed by it causes the constitutional symptoms. The bacil- lus is found in the local lesions, and sometimes in the blood and the various organs. The disease is endemic in most cities, but may be seen sporadically and in epidemics. The majority of the cases occur in children between one and five, and three-fourths of the cases under ten. The sexes are about equally affected. The disease is most common in winter, but may be seen at any time. Predisposing causes are poor hygiene, poor health from other diseases, chronic catarrh, and diseased tonsils. Infection. — This occurs by direct infection in the great majority of cases. The bacilli may be carried in the dis- charges from the infected part, in the sputum, and mucus. The bacilli may be harbored in the throats and noses of otherwise healthy people (diphtheria carriers), and these are great sources of the spread of the disease. These may be persons who have had the disease, or others who have never shown anv symptoms whatever. These carriers can only be detected by bacteriologic examination. Xurses who have been in close contact with it may transmit the dis- ease. It may be carried in fomites. Domestic animals may be carriers, and epidemics have been spread by milk. The virulence of the bacteria exists for a long time even in the dried state. Diphtheria bacilli exhibit great differences in virulence, and there are great variations in the intensity of different epidemics. Mixed Infections. — Other pathogenic bacteria may be asso- ciated with the diphtheria bacillus, and help in causing both local and constitutional symptoms, usually greatly intensifying both. The pus-forming organisms, streptococci and staphy- lococci, are most frequent. Their presence may usually be suspected from certain symptoms, and they may be demon- strated by bacteriologic examination. 398 DISEASES OF INFANTS AND CHILDREN. Pathology. — The lesions are local and constitutional. The latter are due to the toxin circulating in the blood and lymph, and consist in acute degenerations of the cells of the principal organs and tissues of the body. Local cell changes may be noted in the affected epithelium, in the cells of the liver, heart, kidney, nervous system, and elsewhere. The changes may be only degenerations, but sometimes focal necroses may occur. Constitutional symptoms may be due to other associated bacteria. The local changes are variable. The bacillus may cause only a catarrhal inflammation with certain degenerations in the epithelial cells. This can only be differentiated clinically by bacteriologic examination. The most frequent lesion is the formation of a false membrane. There is necrosis and a hyaline degeneration of the tissues, fibrin is poured out, and this, with the necrotic tissue and cellular exudate, forms a dense, adherent "false membrane." The location of the membrane is usually in the fauces, about 65 per cent., or the fauces and nose, about 15 per cent., or in the larynx, about 15 per cent. The remaining 5 per cent, is distributed in the nose, mouth, conjunctiva, skin, vulva, vagina, etc. Other lesions are fatty degeneration of the heart, anemia, enlargement of the cervical lymph-nodes, enlargement of the spleen, and changes in the blood-vessels, kidneys, and central nervous system. Pneumonia and nephritis are frequent com- plications. The Incubation Period. — This is usually short and varies from two to seven days. Immunity. — This varies greatly, and in cases in which antitoxin is used early is probably short, as the immunity is passively acquired. In cases where it is not used the im- munity is more lasting, having been actively acquired, but on this point there are great differences of opinion. Symptoms. — These vary greatly, differing with the severity of the infection and the location of the local changes. Cases Without Membrane. — These may be noted especially during epidemics and in persons exposed to the disease. ACUTE INFECTIOUS DISEASES. 399 The symptoms are those of an ordinary coryza or pharyn- gitis, as the dase may be. The diagnosis is made by bacteri- ologic examination, but an irritating discharge from the nose, which is persistent and causes excoriations, should always arouse suspicion. Sometimes these cases persist for weeks, and may change into diphtheria of the ordinary type. These catarrhal cases are most common in infants. Mild Membranous Cases. — In these the membrane is, as a rule, limited to the tonsil or near it, and in some cases it may resemble an ordinary follicular tonsillitis. There is little constitutional disturbance. The temperature is usually about 100.5° to 102.5° F., aud the child may complain of slight pain in the throat, and the lymph-nodes at the angle of the j iw are slightly swollen. The disease starts as a red- dened area, which becomes covered with a filmy grayish- white membrane, and this becomes whiter as it grows thicker. The edges are more or less sharply outlined and irregular in shape. It requires considerable force to remove the mem- brane, and a bleeding surface is left. The diagnosis is usu- ally reasonably certain from the appearance of the throat, but sometimes it can only be made by cultures, which should be taken in all diseases where there is an exudate. Without treatment the membrane usually lasts a week or so, but when antitoxin is given it disappears promptly. Severe Cases. — The onset may be abrupt, with a chill, vomiting, headache, and high fever, or it may be gradual, beginning with mild symptoms, which grow progressively worse. The membrane begins as above, but usually spreads rapidly over the fauces, soft palate, and uvula, and extends into and covers the pharynx, and often extends into the nose, causing an irritating discharge. Sometimes the progress of the membrane is more slow. As the membrane gets denser it becomes darker in color and may take on a greenish cast. If it is disturbed, there may be hemorrhage, which may change the appearance to a blackish color. The membrane may extend over the mucous membranes of the mouth, tongue, and lips, although this is rare. The lymph-nodes under and behind the jaw swell and are painful, and there 400 DISEASES OF INFANTS AND CHILDREN. may or may not be considerable pain in the throat. The child usually breathes through the mouth, the breath has a characteristic fetid odor, the tongue is dry and cracked, and there may be hemorrhages. There is usually considerable discharge from the mouth and nose, which excoriates the lips and chin. The constitutional symptoms are all severe. The child shows signs of marked toxemia and is prostrated, very much weakened, has a rapid, weak pulse, is apathetic, and may even become unconscious ; occasionally there is great irrita- bility. There is a severe grade of anemia and the child has a marked pallor, which may become ashy or cyanotic as the circulation fails. The fever is irregular, but usually rather low, unless there are other bacteria present. There is loss of appetite, and there may be vomiting and diarrhea. The urine contains albumin and casts. If no antitoxin is used the disease progresses for about a week, and then after a day or two more begins to subside, the membrane shrivels, loosens, and comes away, and some- times part of it seems to be absorbed. Sometimes the mem- brane and symptoms persist longer. The constitutional symptoms lessen and a slow convalescence begins, character- ized by a weak heart and anemia. Since the introduction of antitoxin the prolonged course is fortunately not often observed. Laryngeal Cases. — Sometimes the disease extends into the larynx, and this most frequently happens between the second and fifth day. The disease may start in the larynx in about 15 per cent, of the cases and be limited to it. In either case there is loss of voice, a hoarse, barking, croupy cough, and dyspnea. The symptoms increase steadily, and the res- piration becomes noisy and labored and cyanosis becomes marked. The expression is anxious and the child is very restless. If not relieved by intubation, tracheotomy, or the disappearance of the membrane due to the administration of large quantities of antitoxin, young children usually die inside of forty-eight hours, in older ones the progress is more slow, especially in robust children. ACUTE INFECTIOUS DISEASES. 401 Atypical Forms. — There may be a catarrhal inflamma- tion only, as n<>ted above. These eases are seen during epi- demics and may be the means of spreading the disease, as the diagnosis cannot be made without culture-. There may be the appearance of an ordinary follicular tonsillitis, or there may be a membrane which occurs only in spots. Nasal Diphtheria. — The usual form of nasal diphtheria is secondary, although it may be primary ; the nose is filled with the membrane ; the nasal discharge is frequently bloody and may cause excoriations of the upper lip. The constitu- tional symptoms are very severe ; there are marked prostra- tion and pallor. This is probably due to the absorption of toxin by the numerous nasal lymphatics. A second form is the so-called membranous or fibrinous rhinitis, in which a thick membrane fills the nose ; the Klebs- Loffler bacillus is present. Constitutional symptoms are absent or slight. Recovery always follows in this class of cases. Mixed Infections. — These are fairly common, the strep- tococcus being the most frequent organism, but pneumococcus and staphylococcus, as well as other germs, may be found. Locally, the membrane is extensive, and there is great redness and swelling of the adjacent tissues. The lymph-nodes and cellular tissue of the neck are frequently involved. All the constitutional symptoms are severe. Death may take place from septicemia, toxemia, involvement of the larynx, or, later, from heart failure. Pneumonia, nephritis, suppura- tion, and hemorrhage may complicate the case later. Complications. — Paralysis. 1 — This is most frequent from two to ten years of age, and is less frequent if antitoxin is used in the first or second day of the disease. Some cases come on during the first week, but by far the greatest number come on in the second, third, and fourth week. Paralysis of the palate is most frequent, of the eye muscles next, and cardiac paralysis most frequent of all. The cardiac, pharyngeal, and diaphragmatic palsies are the most serious, 1 Eolleston, Practitioner, January, 1910, p. 110. 26 402 DISEASES OF INFANTS AND CHILDREN. especially those beginning before the third week, and paraly- sis coming on after the third week usually recovers. Pneuniogastric paralysis usually comes on in the second week ; there is anorexia, vomiting, slow, weak, irregular pulse, anemia, slight cyanosis, often some dyspnea, and ab- dominal pain. These symptoms get worse, and death usually takes place from syncope, especially after exertion. Milder cases may be seen in which recovery may take place. Diphtheria in Other locations. — Conjunctival Form. — This may be primary or secondary, and usually results in the loss of sight. It is frequently fatal. Skin. — In severe cases this may be seen as a complication, but it may occur as a result of wound infection, and occasion- ally more or less chronic skin infections are seen. They have a somewhat characteristic appearance, difficult of de- scription. Ear. — This may be seen as the result of extension from the throat. Complications and Sequelae. — Hemorrhage may fol- low ulceration. Most frequently this is in the nose or throat. Gangrene of the throat and suppuration of the lymph-nodes in the neck may follow secondary infections. Broncho- pneumonia is perhaps the most common of all complications. Albuminuria is present in all severe cases and severe nephritis may be seen. Myocarditis and dilatation of the heart are frequently seen in severe cases, and cardiac thrombosis and endocarditis may also be met with. Diphtheritic paralysis is frequent, and is considered above and elsewhere. Skin rashes of various kinds, erythema, urticaria, etc., may complicate diphtheria. Diagnosis. — Two things must be considered : bacterio- logic diagnosis and clinical diagnosis. The bacteriologic diagnosis is made by passing a sterile cotton swab over the suspected membrane, and then drawing this gently over a culture tube of blood serum agar. This is incubated at body temperature from twelve to twenty-four ACUTE INFECTIOUS DISEASES. 403 hours, and after that time the diphtheria bacillus gives a characteristic appearance in the culture and also in smears examined microscopically. Often a diagnosis may he made by examining: a smear made directly from the membrane, but this i> Dot a very reliable method. The presence of diphtheria bacilli in the mouth does not necessarily mean that the person has diphtheria, but where there are inflammations or membrane, it may usually safely be regarded as the cause and the diagnosis of diphtheria made. A negative culture does not necessarily mean that the dis- ease is not diphtheria, as the bacillus may not be found in early laryngeal or late pharyngeal cases ; when an antiseptic- has been used a short time before taking the culture ; when the culture has been badly contaminated by carelessness in taking it, and when the disease is in a tonsillar crypt or fossa?. Common sense and clinical findings should always be used in judging bacteriologic reports. Virulent bacilli may be found in the throats of those re- cently exposed to the disease, and these may transmit the disease to others. These people are called diphtheria carriers. Non-virulent diphtheria bacilli maybe found in the throats of people who have not been so exposed, and also other organisms more or less closely resembling the diphtheria bacillus. These people are not, as a rule, a source of the disease. Clinical Diagnosis, — The majority of cases can be told clinically by an experienced observer, but atypical cases and membranes seen in the course of other infectious diseases, as scarlet fever and measles, may require cultures to determine their nature. Cases of streptococcus and staphylococcus sore throat offer the most difficulty. Membranous croup is almost without exception diphtheria. A membrane in the throat apart from scarlet fever is more apt to be diphtheria than anything else. 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PCD U %& r< P ^ o a Ph bX.O^cc-cgd bo K 5-p p rt ni > s^ ^ O K S P, Ph '02-cS ^ & 02 M o P P CO d P Pt5 « P U ^ P pjcO.P P .^ K •^ H Pg P03 p oo txi « ^ ^ 2 >» 02 ^ CD oj CO CD •- L d oj O P co co -t^d ^ 2 • CD ■P Prj- P Tj — ' CO Tl +^ ^ Pn o •d^.QjH > . ^.SCO^^'CD^^CD *•% -^■j^SOK CDCw P'P pT'p- P-^i o 02 CO H CD P O-r-l O ,^ 03 es CD cv - 03 ^ Q CD ^> - >• ° CD H °C0 b 03C>» Pcp^ O PCD 3 02 m «d^3 CD 3 h-i 02 P* — «t-i P— . CO^ P- tf.T O CD^-; CO Ci>P< 2 ©is O_03 °'^H P02 V CO '-< 2 += a 03 ^ CO Pi ft M ACUTE INFECTIOUS DISEASES. 405 Scarlet Fever. — The high fever, characteristic rash, and tongue, rapid pulse, and absence of diphtheria bacilli are the distinguishing features. Follicular Tonsillitis.— This is distinguished by the mem- brane being limited to the tonsil, and its being easily wiped off without leaving any bleeding points, and in the follicular form by the plugs of cheesy material. The fever in tonsil- litis is, as a rule, higher than in diphtheria, unless the latter is complicated by a secondary infection. Ulcerative tonsillitis caused by Vincent's bacillus presents a dirty, soft, yellowish slough, and there are few or no con- stitutional symptoms. Cultures should be resorted to in every doubtful case. Prognosis. — This varies a great deal, both in the inten- sity of the infection and as to how much and how early anti- toxin is used. If a sufficiently large dose is given on the first day the mortality is less than 1 per cent., is less than 2 per cent, on the second day, less than 4 per cent, on the third day, and about 12 per cent, on the fourth day. Later it is about 25 per cent. Cases seen late, those with mixed infection, laryngeal, and conjunctival cases, are all severe and the outlook is grave. Death may be caused by heart failure, suffocation, pneumonia, nephritis, and occasionally other causes. Prophylaxis. — All doubtful cases should be managed like diphtheria until the diagnosis is fully established. The case should be isolated, and nobody allowed in the room ex- cept the nurse and physician. Municipalities should provide hospitals to which the children of those unable to carry out the proper isolation could be removed. There should be as little in the room as possible. The nurse should wear wash dresses and change the dress to go out. She should keep her throat sprayed with some antiseptic solution and should be immunized. The physician should wear a gown or long coat and thoroughly disinfect his hands. Everything that goes into the room should be disinfected — dishes by boiling, clothes, towels, and bedding by placing in carbolic solution 1 : 40 to 1 : 20 and boiled later. Unpainted wood work and furniture 406 DISEASES OF INFANTS AND CHILDREN. should be washed daily with 1 : 3000 bichlorid solution and painted surfaces with 1 : 40 carbolic acid solution. Cultures should be taken from the throat of the patient and nurse before quarantine is raised. The nurse and anyone who has been exposed to the disease should be immunized by inject- ing 1000 units of antitoxin or 500 in case of young infants. Where expense is an object, 500 units may be used, although this amount occasionally fails to give immunity. The im- munity lasts from one month to six weeks. Treatment. — Antitoxin should be administered at once. It is best injected under the skin of the abdomen. Five thousand units should be given as the initial dose, and this should be repeated in six hours if the progress of the mem- brane is not checked, and it does not tend to shrivel up or become broken and granular looking. In very severe cases, those seen late and in laryngeal cases, 10,000 units may be given as the initial dose. Where expense is an object, 3000 units may be used as the initial dose in mild cases and 2000 in young infants. There are no bad effects from antitoxin, except an occasional urticaria four to eight days after its ad- ministration and occasional joint pains. Very exceptional individuals are sensitive to the effects of serums of any kind, but these need not be considered in practice. Antitoxin should be injected with aseptic precautions. Local Treatment. — The throat should be sprayed with mild antiseptic solutions. Peroxid of hydrogen (1 to 4) and a saturated solution of boric acid may be used alternately. The nose should be douched with DobelPs solution or peroxid of hydrogen (1 to 10) four to six times daily. General Treatment. — Strychnin and alcohol may be used as heart stimulants as indicated. Iron is always indicated for the subsequent anemia. In all cases where the heart is weak the child should be kept quiet, not allowed to move itself, and all struggling with the child, as in making applications and douching, should be avoided. The Treatment of Laryngeal Obstruction. — If the diphthe- ritic membrane is in the larynx there will be more or less dyspnea. If the dyspnea is urgent, or if the child is not ACUTE INFECTIOUS DISEASES. 407 within easy reach of the physician, an intubation tube should be inserted. Every practitioner should learn how to intu- bate. It should be practised on the cadaver under competent instruction before it is attempted on the living child. The O'Dwyer tubes are the best. The procedure is as follows : The proper-sized tube is selected by measuring it on a gauge which comes with the intubating set. The graduations are according to the age of the child, but it should be remembered that a large child will take a larger tube than the average, and a small one a smaller tube. The tube is threaded with a stout thread, which serves to remove the tube if it is inserted into the esophagus by mistake, or if the child does not breathe properly after the tube is introduced. It is a good plan to keep all the tubes threaded with a single thread, and when a tube is to be used it may be taken out already threaded by pulling the thread out of the other tubes. It frequently happens that in an urgent case time is lost in threading the tube. The arms of the child should be placed straight along its sides, and the child wrapped in a blanket so as to secure both arms and legs. The child may be intubated either lying down or held in the sitting position. All other things being equal, the lying down position is to be preferred, chiefly on there being less danger of heart failure in advanced cases of diphtheria. The child should be placed on a low table or on a bed. If on a bed, the mattress should be very firm. One person holds the child's body still and a second assistant holds the head. The head should be held straight in the median line, and should be neither inclined forward nor backward. If the sitting posture is used the child is held by one assistant, the legs between the lesrs of the assistant, while a second assis- tant, standing behind, holds the head. A mouth-gag is used to hold the mouth open. The tube is held on the introductor in the right hand, and the thread attached to the tube is wound lightly around one finger, care being taken not to get it twisted. The 'index-finger of the left hand is passed into the mouth and the opening of the larynx accurately located. The tube is then introduced, using the finger as a guide. The intro- ductor should be kept in the middle line, and when the end 408 DISEASES OF INFANTS AND CHILDREN. of the tube reaches the opening of the larynx the handle of the introdnctor is raised, and at the same time the tube pressed gently downward. But little force is necessary. The intro- ductor is then removed, the finger in the mouth holding the edge of the tube to prevent its being withdrawn. If the tube is in the right place the child usually coughs a few times to clear it of mucus and the breathing becomes easier, and in a few minutes the color of the child becomes normal. The position of the tube may be verified by the finger. If the tube is accidentally placed in the esophagus it may be with- drawn by means of the thread. As soon as the child breathes easily the thread may be removed, and the child's hands should not be released until it is. The mouth-gag should be introduced, and the finger used to hold the tube in place lest it be withdrawn. If the child coughs the tube up shortly after it is introduced it should be replaced, using a larger tube. If it is coughed up in two or three days after the free use of antitoxin it may be allowed to remain out unless the dyspnea returns. Sometimes, just after the tube is introduced, it is advisable to give the child a teaspoonful of pure whisky to cause coughing, and thus clear out the tube. If antitoxin has been used the tube may generally be removed in four or five days. The same preparations are needed as for the intro- duction. The extraction is rather the more difficult. The index-finger of the left hand finds the opening of the tube. With this as a guide, the extractor is introduced, holding it in the median line. As soon as the opening of the tube is reached the handle of the extractor is raised, and this allows the end of the extractor to enter the tube. The tube is grasped and removed. One difficulty experienced is trying to get the extractor into the tube without raising the handle as directed, another is, that as soon as the extractor touches the tube the larynx is pulled downward by the muscles contracting. The latter may be overcome by holding the larynx down with the finger. The voice is lost when the tube is in, and only a whis- pered voice possible ; the voice returns after the tube is removed, and in some instances the return requires a num- ber of days. ACUTE INFECTIOUS DISEASES. 409 In some instances the child swallows without any difficulty, but in others it must learn to swallow under the new con- ditions. Semisolid food may be used, or the child may take its food with the head lower than the body, as suggested by Casselberry, either from a bottle with a tube lying on the nurse's lap, or, in older children, with the head over the edge of the bed, using a tube placed in a glass. This is usually only necessary for a day or two. Tracheotomy. — If intubation instruments are not at hand, or if for any reason an intubation cannot be done, a trache- otomy should be resorted to if the dyspnea becomes danger- ous. Intubation is always to be preferred. TYPHOID FEVER. 1 (Enteric Fever; Typhus Abdominalis.) Definition. — An acute infectious disease caused by the bacillus typhosus, characterized anatomically by swelling and ulcerations of the lymph-follicles of the intestine, enlarge- ment of the spleen and mesenteric lymph-nodes, and clinically by continued fever, a rose-red eruption, toxemia, abdominal tenderness, and constipation or diarrhea, and often marked nervous symptoms. The course and symptoms are extremely variable. Etiology. — The disease may be transmitted from the mother to the fetus. Abortion usually results, but the child may be born at term suffering with a general typhoid infec- tion. 1 Morse, Boston Medical and Surgical Journal, February 27, 1896 ; Ar- chives of Pediatrics, December, 1900. Adams, " A Study of 550 Cases of Typhoid Fever in Children," American Journal of Medical Sciences, vol. cxxxix., 1910, p. 638. Patterson, " Surgical Treatment of Perforation of Intestines," American Journal of Medical Sciences, May, 1909, p. 660. Jopson and Gittings, " Intestinal Perforation During Typhoid Fever in Children," American Journal of Medical Sciences, vol. cxxxviii., 1909, p. 625. Ker, " Typhoid Fever, Antisepsis and Asepsis in the Treatment of," Edin- burgh Medical Journal, July, 1906, p. 29. W. J. Butler, "Typhoid Fever in Children," Journal of the American Medical Association, November 11, 1905, p. 1468. C. P>. Ker, " Tvphoid Fever, Eecent Work on," Practitioner, December, 1906, p. 780. D. L. Edsall, "Typhoidal Insanity in Children," American Journal of the Medical Sciences, February, 1905, p. 327. 410 DISEASES OF INFANTS AND CHILI) HEN. Typhoid fever is rare in infants under two years of age, but does occur. After the fifth year typhoid is not uncom- mon. Infection takes place usually from drinking contaminated water or milk. Pathology. — There have been but few autopsies, as the disease is rarely fatal in very young children. The lesions are the same as in adults, but, as a rule, less severe. There may be no ulceration of Peyer's glands, but only swelling, together with enlargement of the spleen and mesenteric lymph glands. Definite diagnosis is only by cultures or the Widal reaction. Incubative Period. — Two to three weeks. Symptoms. — The onset may be gradual, general malaise, nervousness, and gradually increasing fever, but in about half the cases the onset is sudden, with vomiting, fever, ner- vous symptoms, and prostration. There may or may not be diarrhea. Constipation is frequently seen in young children, especially at the onset. Temperature. — This is more irregular than in adults. The fever may come on abruptly or very slowly. Throughout the entire disease the fever may be irregular, but is con- tinuous. There may be hyperpyrexia. During convales- cence errors in diet may cause fever. Eruption. — This is not as constant as in adults. It con- sists of the same rose-colored spots, appearing on the back and abdomen about the tenth day. The spots last three or four days and disappear ; successive crops appear for a week or more. Mouth and Tongue. — The mouth is usually dry and the lips dry and parched. The tongue is coated with a white coat early in the disease, and later this becomes brownish or yel- low. The tongue may clear off and become glazed and dry. Fissures of the tongue and lips are not infrequent. Pulmonary Symptoms. — Bronchitis is a common occurrence, and it is usually observed by the end of the first week. Bronchopneumonia and lobar pneumonia are not so frequent, but may be observed. Pleurisy may also be noted. ACUTE INFECTIOUS DISEASES. 411 Lymph -nodes. — These are often slightly enlarged. Abdominal Symptoms. — These are less marked than in adults. There may or may not be tenderness and tym- panites. Diarrhea is present in about half the cases. The spleen is usually enlarged and easily palpated. Nervous Symptoms. — These vary with the fever ; there may be delirium or a general nervous condition, or there may be symptoms not unlike meningitis. Mental symptoms are not uncommon either during the course of the disease or conva- lescence. Pulse. — This is rapid, but in typhoid fever the pulse is lower than in a like amount of fever from other causes. Emaciation. — This is usually marked. Urine. — There is often a little albuminuria. After the first week Ehrlich's diazo-reaction is usually present. Intestinal Hemorrhage and Perforation. — These are both rare in children, especially so in very young children. Course and Duration. — The average duration of the disease in childhood is about two weeks. Many cases have fever only a week or ten days. Some cases last for weeks. Relapses are not uncommon. Complications and Sequelae. — Bronchitis is fre- quent. Pneumonia is occasionally seen. Suppuration of the middle ear or of the bones may follow. Meningitis may also occur. Diagnosis. — The presence of the Widal agglutination reaction is the most positive evidence, and may be demon- strated in about 95 per cent, of the cases. Unfortunately it is rarely obtained before the seventh day and often much later. Typhoid bacilli can often be demonstrated in the urine and feces. A continued fever, with rose spots and an enlarged spleen, is usually typhoid fever if malaria, tuberculosis, and ileo- colitis have been excluded. Ophthalmic tests for both typhoid and colon infection 1 along the same lines as the conjunctival test in tuberculosis 1 Journal of Medical Research, January, 1909, p. 95. 412 DISEASES OF INFANTS AND CHILDREN. have been suggested, and a reaction similar to the Wasser- mann, Neisser-Bruck has also been used and is apparently very reliable. 1 The presence of the malaria parasite and the influence of quinin clear up the question of malaria. General miliary tuberculosis is usually impossible to dis- tinguish (except by the Widal reaction) until lung symptoms appear. The pulse is more rapid in tuberculosis. Ileocolitis is most frequently seen in young children, and the bowel symptoms are, as a rule, more intense than those seen in typhoid. Meningitis may be difficult to distinguish, as marked cere- bral symptoms may simulate it closely. The coma of typhoid is not as complete, the pulse is not as slow or so irregular ; there is rarely paralysis, and the abdomen is not retracted. Prognosis. — During the first year typhoid is a serious disease, after that the prognosis is much better than in adults. The average mortality is from 3 to 5 per cent. Prophylaxis. — Everything used by the patient should be kept separate and frequently sterilized. All laundry articles should be soaked in 1:20 carbolic acid for two hours or more. Stools and urine may be sterilized by mixing them with a 1 : 20 solution of carbolic acid for six hours and then boiled. Blankets, mattresses, and pillows should be sterilized by steam. Antityphoid vaccination may be done on persons about to travel in countries where typhoid is prevalent, or in those constantly exposed. 2 Treatment. — Rest in bed, a liquid diet, consisting largely of milk, cold sponging or bathing to reduce high temperature and allay nervous symptoms. Water should be given at frequent intervals. Alcohol and strychnin should be given as soon as the heart flags, but not until then. The bowels should be moved once a day by enema or occasionally by calomel, and an additional dose of calomel is advisable if toxic symptoms are marked. If diarrhea is present, bismuth and some form of opium or beta-naphthol bismuth, salicylate of bismuth, and codein sulphate may be used. A mixture 1 Progressive Medicine. March, 1910, p. 188. 2 Stone, Jour. Amer. Med. Assoc., October 16, 1909, p. 1253. ACUTE INFECTIOUS DISEASES. 413 of all three of these is of value when the stools are loose and offensive. Tympanites is often relieved by the use of turpentine stupes, and turpentine or chloroform internally. Charcoal mav lessen it. Injections of glycerin and water are often effective. Hemorrhage from the Bowel. — Absolute rest, morphin hypo- dermically to control the bowel; do not give any food for twelve hours, but ice may be given. An ice-bag or coil should be applied to the abdomen. Turpentine is recom- mended. For collapse, infusions of salt solution and stimu- lants hypodermically. Perforation demands immediate operative interference. Convalescence should be managed with care. Liquid food should be continued for about a week after temperature has reached normal. Errors in diet frequently lead to a recrudes- cence. CEREBROSPINAL FEVER. 1 (Epidemic Cerebrospinal Meningitis.) Definition. — An infectious disease characterized by in- flammation of the brain and spinal cord. It occurs sporadi- cally and epidemically. Symptoms and course of the disease present great irregularity. Btiology. — The diplococcus intracellularis meningitidis of Weichselbaum is constantly associated with the disease. Overcrowding, overexertion, and exposure seem to be pre- disposing factors. The meningococcus is easily killed, and the disease is probably transmitted directly and by meningo- coccus " carriers." Pathology. — In cases dying early there is intense con- gestion of the meninges. Later there is a fibrinopurulent exudate between the dura and pia mater. In chronic cases there is thickening of the meninges. Pneumonia is a frequent complication. 1 Councilman, Mallory, and Wright, Massachusetts State Board of Health, 1898. J. L. Morse, " Meningitis in Infancy," Journal of the Ameri- can Medical Association, June 23, 1906, p. 1906. Elser and Hontoon, Jour- nal of Medical Research, 1909, p. 397. G. C. Robinson, " Meningitis, Bac- teriological Findings in Epidemic Cerebrospinal," American Journal of the Medical Sciences, April, 1906, p. 603. 414 DISEASES OF INFANTS AND CHILDREN. Fig. 139.— Cerebrospinal meningitis. Tache cGrebrale shown on left thigh. Stage of Incubation.— Unknown. Symptoms. — There is great irregularity in the course of the disease. Fig. 140.-Extreme retraction of head in basilar meningitis (Great Ormond Street Hospital for Children, London, 1901) (Photographed by Dr. Thursfield). Ordinary Form. — Usually a sudden onset with headache, chill, and vomiting. There are frequently stiffness of the neck, photophobia, and dread of noise. There are headache and pains ACUTE INFECTIOUS DISEASES. 415 in back and limbs. There is stiffness of the muscles and often tonic or clonic spasm. There is restlessness, delirium, or coma. Paralysis of various muscles, especially of those supplied by the cranial nerves, is common. Optic neuritis may occur as a result of cranial pressure, or there may be a direct extension of the inflammation. Skin eruptions are common, especially herpes. There is often a purpuric rash or there may be simple erythema, ery- Fig. 141. — Kernig's sign, showing the strong contraction of the flexors on attempt- ing to extend the leg (Osier). thema nodosum, or urticaria. A flush follows drawing any object across the skin (tache cerebrale, Trousseau). The temperature is extremely variable. It may be high or low. The pulse is at first rapid, later slow and full, be- coming more rapid before death. Deep-sighing respiration is common. Cheyne-Stokes breathing may be noted. In infants cerebrospinal fever usually gives the clinical picture of chronic basilar meningitis (see same). There is always a considerable leukocytosis. Unusual Forms. — Malignant Form. — Fulminating or apo- plectic meningitis. A sudden onset, with chills, headache, 416 DISEASES OF INFANTS AND CHILDREN. delirium, or coma, convulsions, fever, slow, weak pulse, and death within a day or two. Abortive Form. — The disease starts with symptoms of the ordinary form, but rapid recovery takes place after a few days. Intermittent Form. — Cases have been observed with a fever resembling malaria. Chronic Form. — The symptoms may persist for weeks or even months. These cases are usually fatal in the end. Fig. 142 — Anatomic preparation from a child twenty-one months old, show- ing location for lumbar puncture between third and fourth spinous processes (Fruhwald). Complications. — Pneumonia, pericarditis, parotitis, and arthritis are the most frequent. Paralysis, blindness, deaf- ness, or mental deterioration may follow meningitis. Diagnosis. — Fever, headache, retraction of the neck, delirium or coma, tremor or rigidity of the muscles, are the most important signs. Kernig's sign is of value. Contrac- tions of the flexors of the leg prevent the full extension of the leg on the thigh. Leichten stern's phenomenon, a light- ACUTE INFECTIOUS DISEASES. -417 Ding-like contraction of the muscles of the entire body elicited on striking any part of the bony framework with a percussion hammer, may be present. Vincent and Bellot have described a precipitin reaction which is of value in diagnosis. 1 Centrifugalize the cerebrospinal fluid, and place 100 drops in three test-tubes. One is used as a control. To the other two a drop of antimeningitis serum (Flexner or Wassermann) is added, and all the tubes placed in an incubator at a tem- perature of from 50° to 53° C. In from eight to twelve hours there is a clouding ; if the disease is due to cerebro- Fig 143. — Method of inserting needle in lumbar puncture— child in lying posture (.Boston). spinal fever the control remains clear. If the disease is due to any other bacteria or with cerebrospinal from normal per- sons the tubes remain clear. Lumbar Puncture. 2 — With perfect technic this is harmless. A small aspirating needle is introduced into the spinal canal and the fluid then obtained examined for bacteria and cells. 1 Bulletin Academie de Medecine, vol. lxi., p. 326, and Bulletin Societe Medicate des Bopitaux, 1909, p. 952. 2 S. J. Kopetzky, " Lumbar Puncture," American Journal of the Medical Sciences, April, 1906, p. 61.8, Edward Turton, " Cy todiagnosis of Pleural and Cerebrospinal Fluids," Practitionef , April, 1905, p. 497. 27 418 DISEASES OF INFANTS AND CHILDREN. Procedure. — Use strictly aseptic precautions, an anesthetic is rarely necessary. Flex the body, have it held firmly, and introduce the needle between the second and third or, the third and fourth lumbar vertebra. A simple method is to choose the space which corresponds to a line drawn from the crest of the ilium. The easiest method is to go through the median line and slightly upward. Another method is to introduce the needle about 1 cm. from the median line and point it slightly upward and toward the median line. The needle is introduced from 2 to 4 cm. The fluid drops or, if pressure is great, runs from the needle. It is turbid, occasionally purulent or bloody. A fluid may even present its normal clearness and meningitis be present. Cultures should be made, although coverslip preparations from the centrifugalized fluid generally show whatever organ- ism is present. If no centrifuge is at hand, allow the fluid to stand undisturbed for a few hours, when a film w T ill be seen, which may be easily transferred to a slide, allowed to dry, and stain with the ordinary methods. This film con- tains most of the bacteria and leukocytes. Apparently sterile fluid may be tested for tuberculosis by injecting it into guinea- pigs. The tubercle bacilli, if present, can generally be demonstrated if a number of specimens are carefully studied. Prognosis. — The mortality is high. Without treatment it averages about 80 per cent. Lumbar puncture for the relief of pressure reduces this slightly. With the use of the Flexner-Jobling serum the mortality has been reduced to about 30 per cent, or less. Deep coma and a protracted course are both unfavorable signs. Treatment. — This is as outlined in meningitis, with the addition of the use of the Flexner-Jobling serum. The serum should be kept in a refrigerator until it is to be used, when it should be warmed to the body temperature before it is injected. From 30 to 40 c.c. are given at a dose, injected directly into the spinal canal after the withdrawal of the cerebrospinal fluid by lumbar puncture. It is desirable, although it is not essential, to withdraw from the spinal canal at least as much ACUTE INFECTIOUS DISEASES. 419 fluid as the amount of serum to be injected. The injection should be made slowly and carefully, to avoid the production of symptoms due to increased pressure. The injection should be repeated in twenty-four hours, and three or four injections may be made, depending upon the nature and gravity of the case. As much as 120 c.c. have been injected into the spinal canal in four days. The earlier the injection the better the results. If the first fluid obtained by spinal puncture is turbulent, or if it shows Gram-negative diplococci, some of which are within the leukocytes, an injection should be im- mediately made without waiting; for the results of the culture. The treatment should only be continued where the 4Jsease is proved to be cerebrospinal fever. A relapse should be treated in the same manner as a fresh case. ANTERIOR POLIOMYELITIS (Heine). (Infantile Spinal Paralysis; Acute Wasting Paralysis; The Essential Paralysis of Children.) Definition. — An acute infectious disease usually attack- ing the anterior horns of the spinal cord, but sometimes affecting the gray matter in the medulla, pons, or cerebrum. (The varieties of the disease are given below.) The disease is characterized by an acute onset, with or without vomiting, restlessness or apathy, rigidity of the neck and often of other muscles, headache, often general pain, and, most striking of all, a more or less extended paralysis of the muscles, usually of the extremities. Etiology. — Noguchi has announced the discovery of the organism. It has been shown by Flexner and Lewis and others that it may be transmitted to monkeys by inoculating them with emulsions made from the spinal cord and also from the brain, lymph-nodes, salivary glands, mucous mem- brane of the nasopharynx, and in the acute stage by using the blood and cerebrospinal fluid. Other animals have not been found susceptible. The inoculation may be made by injecting the material into the brain, subdurally in either cranium or spinal canal, in or about the peripheral nerves, into the general circulation 420 DISEASES OF INFANTS AND CHILDREN. and the anterior chamber of the eye. It has also been caused by rubbing on the mucous membrane of the nasopharynx, with or without previous scarification, and by placing it into the trachea, stomach, or intestines. The virus will pass through the finest filters, is not de- stroyed by drying or by cold, but is injured by heat (45° to 50° C). The incubation period is from six to over thirty days in monkeys, and doubtless the same is true of human beings. The method of transmission in the case of human beings is not quite clear. It is possible that some insect is the car- rier. Some cases appear to be by direct transmission, but the question is still unsettled. The disease occurs sporadically and in epidemics. It is most frequent in the summer months, and most of the cases occur during the first three years. Boys are more frequently affected than girls. Immunity is conferred by one attack, but individuals affected are liable to develop nervous dis- eases in later life. Paralysis in domestic animals has often been noted during epidemics, but probably there is no rela- tion to the disease. Pathology. — There is congestion and inflammation of the gray matter of the anterior horns of the entire cord, and this may extend to the posterior horn, to the white matter, and also to the meninges. The medulla, pons, and brain may also be affected. There may be hemorrhage into the anterior horns. There is degeneration of the nerve-fibers of the anterior roots and atrophy of some of the cells of the anterior horns. Later there is some sclerosis. Symptomatology. — Wickman has made the following clinical classification : 1. Spinal Poliomyelitie Form. — Sudden onset, followed by paralysis. 2. The Ascending Form (Laundry's Paralysis). — Involve- ment of respiratory centers. Most fatal cases belong to this type. 3. The Bulbar or Pontine Form. — Nerves most often in- volved : facial, ocular, hypoglossal. May exist alone or with/ paralysis of extremities. \_ ACUTE INFECTIOUS DISEASES. 421 4. Encephalitio or Cerebral Form. — May exist alone or with .spinal involvement. 5. The Ataxic Form. — Much like Friedreich's ataxia, 6. Polyneuritic form. 7. Meningitie form. 8. Abortive Form. — (1) Gen- eral infection. (2) Symptoms of meningeal irritation. (3) Cases of much pain, like in- fluenza. (4) Cases with marked digestive disturbances. Symptoms. — The prodro- mal symptoms are irritability and restlessness, or apathy and pain in the spine and extrem- ities. The onset becomes def- inite, with fever ranging from 100° to 106° F. and lasting from two days to a week. In about one-quarter of the cases there is vomiting. There is a tendency to sweating, pain on movement, and hyperesthesia. During the early stage there is leukopenia. The child is very restless and irritable and com- plains of pain and headache, or may be delirious and there may be convulsions. On the other hand, the child may be apa- thetic or pass into a stupor. There is usually photophobia and sluggish pupil reactions. There is often rigidity of the neck and other muscles. The deep reflexes are diminished or lost, and there is coldness of the extremities due to vasomotor changes. There may be difficulty in swallowing. The spleen is enlarged. The acute symptoms last from a few days to a week. The paralysis may appear the same day as the fever, or during the "first few days, and less frequently during the Fig. 144. — Anterior poliomyelitis. Paralysis of both legs. 422 DISEASES OF INFANTS AND CHILDREN. next two weeks. The paralysis may involve any group or groups of muscles, but one leg is the most frequent, and both legs the next, then follow in frequency both arms and legs, back, arm and leg of same side, etc. The paralysis is totally recovered from in 10 per cent, of the cases in a few days to three months' time. About 10 per cent, recover par- Fig. 145.— Club-feet from infantile paralysis. tially. There is marked paralysis left in about two-thirds of the cases, and but little improvement takes place after the third month. The paralyzed limb is atrophied, the circula- tion poor, and there is retarded growth. The reaction of degeneration is seen in all atrophied muscles which are to be permanently affected. The amount of permanent paralysis may be estimated early by the use of the faradic current, as permanently affected muscles do not react at all after a week or two. Muscles which are paralyzed, but which may be ACUTE INFECTIOUS DISEASES. 423 expected to recover, show a diminution in the reaction; healthy muscles give a normal reaction. The ascending form and the bulbar form are liable to prove fatal, either from failure oi heart or respiration or from bronchopneumonia. The onset is usually severe in these cases, and there is paralysis of the facial muscles, as well as of the extremities, with marked vasomotor disturbances, and of heart and respiration. Diagnosis. — See Wickrnan's classification. Pseudopa- ralysis, such as is seen in rickets, scurvy, and syphilis, must be excluded. Multiple neuritis comes on more slowly, is very painful, and there is loss of sensation. Moreover, it is rare, except following diphtheria. Some cases resemble cere- brospinal fever closely and some suggest tuberculous menin- gitis. The diagnosis may be difficult in either case, but a lumbar puncture may help. There is usually an increase in the cerebrospinal fluid in meningitis with a cloudy fluid in cerebro- spinal fever. In anterior poliomyelitis there may be a slight increase in the fluid, but it does not show any organisms. Prognosis. — This is bad as far as permanent paralysis is concerned, although some cases improve and some get en- tirely well (see above). It is fatal in about 8 per cent, of the cases, but this varies in different epidemics. Prophylaxis. — Patients should be isolated in screened rooms. Dust should be suppressed as far as possible, and all objects coming in immediate contact with the patient should be sterilized. Treatment. — Rest, careful feeding, and quiet during the acute stage. Hexamethylenamin has been suggested as a cerebrospinal antiseptic. Hot applications and counterirri- tation over the spine have also been suggested, but are of little value. The throat may be sprayed with some antisep- tic solution, as peroxid of hydrogen diluted with an equal amount of water. As soon as the pain is out of the affected parts, they should be massaged twice daily. Electricity may be used, but only much later. It acts in the same way as the massage in preserving the nutrition of the muscles while the nerves are regenerating. Iron is needed for the anemia and strychnin may be used later, but not in the early stages 424 DISEASES OF INFANTS AND CHILDREN. of the disease. Re-education of the muscles should be sys- tematically undertaken, and much of the helplessness can often be overcome by this method. Later, orthopedic or other surgical treatment may be indicated. The patients should be isolated and the discharges disinfected. INFLUENZA. (La Grippe; Acute Catarrhal Fever.) Definition. — A specific infectious disease characterized by marked catarrhal symptoms. 3$tiology. — The disease is endemic in large cities. It occurs in frequent epidemics, and occasionally very wide- spread epidemics occur. The specific cause of the disease is Pfeiffer's bacillus in- fluenzae. Pathology. — The disease is rarely fatal except from complications. There are inflammatory changes in nearly all the mucous membranes. There may be myocarditis or nephritis. Incubation Period.— This is usually placed at from one-half to three days. Symptoms. — There is a sudden onset, with high fever. There are coryza, pharyngitis, bronchitis, and conjunctivitis. In addition there may be marked disturbance of the gastro- intestinal tract, with vomiting and diarrhea. In other cases nervous symptoms may predominate. These cases may be mistaken for meningitis. The disease lasts from a few days to weeks. Complications. — Pneumonia, pleurisy, empyema, otitis media, meningitis, and colitis are the most frequent. Myo- carditis or endocarditis may be a serious complication. Diagnosis. — Usually easy. The disease is sometimes mistaken for meningitis. Prognosis. — Good in uncomplicated cases. Treatment. — Rest in bed, sponging for fever and ner- vousness. Antipyrin and codein or bromids for nervousness. Drugs may also be administered to relieve severe cough or diarrhea when present. A CI r TE TNFECTIO I 's DISEA SES. 425 EPIDEMIC PNEUMOCOCCIC INFECTIONS. Definition. — A disea.se caused by the diplococcus pneu- mococcus, occurring in epidemics, with production of a catar- rhal inflammation, sometimes with a fibrinous exudate. Etiology. — Usually in family or institution epidemics, and most common in young children under seven years of age. The epidemics occur usually in the spring or fall. Incubation period two to seven days. Symptoms. — Chilliness, slight fever, and occasional night sweats at the onset; temperature usually from 99.5° to 102° F., lasting from three to seven days; sneezing, lacrimation, mucous discharge from the nose, running sensa- tion of the nose, itching of the eyelids, and slight sore throat; spasmodic croupy cough, sometimes vomiting; there is an intense inflammation of the mucous membranes and of the upper air-passages and of the eyes. There may be a purulent conjunctivitis, sometimes corneal ulcers, but little or no mental or physical depression. In some cases there is a light yellow fibrinous membrane on the inflamed surfaces. The cough may persist for weeks afterward. Diagnosis. — One must exclude measles, whooping- cough, and influenza. From epidemic catarrh the diagnosis is only by bacteriologic examination, the presence of the pneumococcus, and absence of the micrococcus catarrhalis. Prognosis. — Good. Treatment. — Rest in bed. Alkaline washes for the nose and eyes. Sodium salicylate or aspirin may make the patient more comfortable. TUBERCULOSIS. 1 Definition. — Tuberculosis is a specific infectious disease caused by the bacillus tuberculosis of Koch. It may be gen- eral or it may affect one or more organs or tissues of the body ; its clinical characteristics are, therefore, almost innumerable. 1 Martha AYollstein, " Tuberculosis, Congenital," Archives of Pediatrics, May, 1905, p. 321. J. H. Parsons, " Tuberculosis, Ocular, in Children," Lancet, November 4, 1905, p. 1308. J. L. Morse, ''Tuberculous Infection, Protection of Young Infants and Young Children from," American Journal of the Medical Sciences, October, 1906, p. 587. 426 DISEASES OF INFANTS AND CHILDREN. Etiology. — Tuberculosis may be inherited directly from the mother. This is very rare, but may occur. What is more frequent is an inherited predisposition to the disease. A general predisposition may be caused by lack of fresh air, sunlight, cleanliness, and food. Any disease which lowers the resistance of the body predisposes to tuberculosis ; measles and whooping-cough may be mentioned especially. Any local lesion may cause a local predisposition. All ages are liable to tuberculosis. The negro when living in towns in crowded quarters seems especially susceptible. Mode of Infection. — The greatest source of tubercle bacilli is the sputum of consumptives. These bacilli in the dust are inspired in the air breathed and also taken into the mouths of children from dust gotten on the hands in playing on the floor. The former may cause lesions in the lung directly ; the latter are carried off by the lymphatics and are liable to cause gland tuberculosis, which may lead to lesions elsewhere. Tubercle bacilli swallowed or taken in with the food, as in tuberculous milk, may infect the intestine or pass into the blood directly by passing through the intestinal wall in a fat-droplet. Infected milk, while a possibility, is not a frequent source of infection. Pathology. — Tuberculosis most frequently affects the bronchial lymph nodes, lungs, and less frequently the brain in children under two years of age. After two years other lymph nodes, the intestine and peritoneum, and the bones are most frequently affected. By the time death takes place the lungs are generally involved. Autopsies on children dead from tuberculosis frequently show lesions in many organs. There are in general two types of lesions : scattered gray miliary tubercles or coalescing yellow tubercles accompanied by caseation. If the process is acute there is but little fibrous tissue ; if it is chronic there is usually marked fibrosis. There may be infection with pyogenic bacteria and suppuration with extensive destruction of tissue. The lesion may be walled off with a zone of fibrous tissue. There are all forms and gradations of the above. The more important forms are described on pages 428-440. ACUTE INFECTIOUS DISEASES. 427 Diagnosis by Tuberculin Tests. 1 — Tuberculin Injec- tions. — These can only be used in fever-free patients. The temperature should he taken at four-hour intervals for the twenty-four hours preceding the injection. For infants under six months J mg. and older infants 1 mg. may be used. This is diluted with a little 0.5 per cent, carbolic acid solu- tion and injected subcutaneously or into the muscles. The temperature is now taken at two-hour intervals, and if the reaction is positive there is a rise, beginning in six to twelve hours after the injection and then falling to normal. The temperature varies in different cases, but is usually over 102.5° F. There may be some general disturbance. If the injection was made subcutaneously, there is a local reaction of swelling and redness. The Cutaneous Test ( Von Pirquefs Test). — The skin of the forearm is cleansed with alcohol and a drop of pure tuber- culin is placed on the skin, and through it a few very super- ficial scarifications are made with the point of a scalpel. The active reaction or the specific normal reaction begins from four to six hours after the inoculation, and attains its maximum in from twenty to twenty-four hours. The reac- tion consists of a redness about the scarifications. This per- sists on the second day, and shows a decrease on the third or, at the latest, on the fourth day. Conjunctival Test (Calmette or Wolff-Eisner Test). — The eyes are first inspected to see that the conjunctivae are alike in appearance and healthy, and then one drop of a 1 per cent, solution of pure old tuberculin is dropped into the left conjunctival sac. The sac is so manipulated that the fluid is equally distributed. If the left eye shows no reaction in from twenty to twenty-four hours, a drop of a 5 per cent, solution is instilled into the right conjunctival sac. If there is no discernible difference in the two conjunctivae the reac- tion is negative. Sometimes a slight doubtful redness occurs. The positive reaction is a marked redness of the conjunctivae. This test should not be used generally, as eyes have been injured by it. 1 flamman and Wolman, Archives of Internal Medicine, May, 1909 c 428 DISEASES OF INFANTS AND CHILDREN. Other Tests. — There are other tests, as the Moro test, which consists in rubbing over a small spot of skin a mixture of 6 parts of old tuberculin with 5 parts of lanolin. This is followed by redness and papules in twenty-four hours. Hamburger uses an injection of a minute dose subcutane- ously. There is a local reaction inside of twenty-four hours in positive cases. Value of Tuberculin Diagnosis. — The injection method gives most reliable results, but cannot be used where there is fever, and requires considerable care in observation. The von Pirquet reaction is fairly reliable in infants, but in older children it is often present when there is no evidence of tuberculosis. A very small inactive lesion may cause the reaction, and an incorrect conclusion may be drawn. Care and common sense should be used in drawing conclusions from tuberculin reaction. If the cutaneous and ophthalmic tests are done simultaneously, and if both are negative, it means an absence of an active tuberculous focus. If both are positive, it points to an active focus, and if one is posi- tive and the other negative the test is of no particular value. Acute General Miliary Tuberculosis. In this form there are miliary tubercles scattered through- out the body in the various organs. The infection is carried by the blood-stream. . The lesions may be rather uniformly distributed with symptoms somewhat resembling typhoid fever, or there may be more marked deposits in certain organs, as in the meninges, causing cerebral symptoms, or in the lungs, causing pulmonary symptoms. Symptoms. — The disease may resemble a case of maras- mus ; sooner or later, however, there is fever. Respiration and pulse are rapid. There may be digestive disturbances. Lesions can usually be made out in the lungs before death. Exposure to tuberculosis and a family predisposition are both important in diagnosis. The disease, if in older children, may resemble typhoid fever. There is loss of weight and a continuous irregular fever. Sooner or later pulmonary, cere- A CUTE INFECTIO US I) I si;. 1 SES. 429 bral, or other symptoms make their appearance. An erup- tion, consisting of scattered, discrete papules the size of a pin-head, dull red in color and slightly elevated, may be noted. It is of great diagnostic value, cases showing it always proving fatal. The tubercle bacillus may usually be demon- strated in them. Diagnosis. — The Widal reaction is important in distin- guishing it from typhoid fever. Malaria should be excluded by blood examination and quinin. Prognosis. — Always bad. Tuberculosis of the Respiratory Organs. 1 Pathology. — There may be miliary tuberculosis of the lungs or tuberculous deposits resembling a bronchopneu- monia. Both lungs are involved, as a rule. There are areas of caseous tubercles which may be large and resemble cheese. This is sometimes called "cheesy pneumonia"; suppuration and breaking down occur sooner or later. The bronchial lvmph nodes are enlarged; in older children there maybe a chronic tuberculosis presenting like features as the same disease in adults. The pleura is involved in nearly every case of tuberculosis. There may be an acute tuberculous pleurisy with or without effusion. Empyema may result. Symptoms. — Tuberculous bronchopneumonia may be seen together with any other tuberculous lesion ; it may be a marked feature of general tuberculosis, occur as a pri- mary disease, or be the cause of death in other forms of tuberculosis. The course of the disease varies. If there are numerous scattered miliary tubercles the course of the disease is very rapid. There are fever, wasting, rapid respiration, cough, 1 J. E. Squire, "Tuberculosis, Pulmonary, in Children," British Medical Journal, July 21, 1906, p. 133. White and Carpenter, "Tuberculous Pul- monary Cavities in Infants," American Journal of the Medical Sciences, vol. exxxviii., 1909, p. 79. 430 DISEASES OF INFANTS AND CHILDREN signs of bronchitis, and later of bronchopneumonia. Death takes place in a few weeks. If there are large caseous deposits there are similar symp- toms running a slower course. There are the physical signs of bronchopneumonia, with larger areas of consolidation ; the course is steadily downward, with death in from one to three or four months. There may be very chronic cases of pulmonary tuberculo- sis, with small deposits and few or no physical signs, and temp. ! j l_ 1 T ! i j j ; i — 100 | 1 i | I i < i ! \ 108 I i 1 1 I i i 1 1 1 I ! 107 i i 1 i i : i ■ 1 • | I ! j 1 106 i 1 ■■ : ! i 1 t i I ! 105 1 1 | 1 ! | 1 t 1 i I 1 ! I-. 1 104 ! 1 i 1 I i | ! i i 1 1 n it ~4/ 103 ! i i 1 J j j |A L 'A i 1 : 'i" A / lA in |/* ID / \1 102 A >jt IjK / A / ^ V P i A IP 1 j \ i/i \l i lL. Vi 101 ./ / vM \l ,1 i | f *\ \fl Vi VI 4 l'A J i i \/j 1 1 1 1 100 Yj M V A i VI i 1 i i vi Tj_ y : \ ■r i i i 90 ! i ' i i I j i ! 1 j i I i l ! 98 i 1 1 | I 1 i ■ i ! 07 i ! i i 1 i I 1 ! i 1 1 i 4 i t 1 1 i _L 1 1 96 I i . ~r i : 1 1 1 : Temp. ! ! i ! i i i 1 ; | 1 i ! i i i i 1 i ] i I i | | i i ! ■ i 1 1 i i 1 1 j i i 1 I 1 1 1 i 1 : ■ 1 1 1 i i ' I i I I Stools | 1 1 1 | i | i 1 1 I 1 Urine 1 | 1 | | 1 1 r i I 1 ! | | l 1 1 1 Day of Disease i V i ¥■ •J' 6 7 r ? p' 3t. 51 i? *\ f* •H •ft - -M -ft "/■&' Fig. 148.— An acute tuberculous bronchopneumonia temperature chart. periods of symptoms and periods of remission. These cases are often called delicate children with chronic bronchitis. Diagnosis. — A history of tuberculosis in the family or of exposure to the disease is important. The irregular fever, rapid pulse, general downward course, are all suggestive ; if ACUTE INFECTIOUS DISEASES. 431 the sputum can be obtained ou a swab immediately after a coughing spell, before it has been swallowed, the tubercle bacilli may be demonstrated. In general the physical signs do not differ from bronchopneumonia. Prognosis. — Always bad, except in cases recognized early in older children. Prophylaxis. 1 — All tuberculosis patients who are expec- torating should use a special spit-cup and see that the sputum is destroyed. Children should not live in close coutact with Fig. 147.— Clubbing of fingers in tuberculosis. a tuberculous patient, and should never occupy the same bed. Where there is a family tendency to tuberculosis the child should, if possible, be brought up in the country and in the fresh air. The general health and strength of the child should be kept up. A sedentary indoor life should be avoided. Treatment. — Fresh air both day and night. A change of climate is often desirable. Careful feeding is of especial 1 See Handbook on the Prevention of Tuberculosis, published by the Charity Organization Society of New York. 432 DISEASES OF INFANTS AND CHILDREN. value. Raw and rare meat, milk, and the whites of eggs should be given in sufficient quantities. The stomach should not be upset by usiDg nauseating drugs. Tonics, as iron, quinin, strychnin, and arsenic, may be used where indicated. Cod-liver oil is one of the most valuable remedies. Creosote, creosote carbonate, or guaiacol carbonate may also be used. Tuberculous Bronchitis. This has been noted of recent years. The symptoms are those of an ordinary bronchitis with a few scattered rales. Later there are fever, weakness, anemia, sweats, etc., and the disease is frequently followed by a tuberculous broncho- pneumonia. A persistant cough in an infant who has been exposed to tuberculosis should suggest the disease. The diagnosis is by tuberculin and finding the tubercle bacillus. Tuberculous Meningitis. 1 (Whytt's Disease; Acute Hydrocephalus; Water on the Brain; Basilar Meningitis.) Definition. — Tuberculosis of the pia mater usually of the cerebrum, sometimes of the cord as well. Etiology. — Tuberculosis is almost always present else- where in the body ; most frequently seen in the first two years of life. Pathology. — Miliary tubercles, sometimes tuberculous deposits, together with an exudate. The principal lesion is usually at the base of the brain. The ventricles may be dis- tended with fluid. Symptoms. — The onset is almost always gradual. Gen- eral malaise, loss of appetite, constipation, and headache are present. There are frequent vomiting and slight fever. There are more or less indefinite brain symptoms, which may be present one day and absent the next. Then there is the appearance of marked cerebral symptoms, as convulsions, delirium, later coma, rigidity of the muscles, retraction of the 1 H. W. Cheney, "Meningitis, Primary Tuberculous," Journal of the American Medical Association, July 8, 1905, p. 105. Robert Whytt, 1768. ACL "/'A' IM'I'J 'Tin I \s DJStiASEti. 133 Fig. 148.— Tuberculous meningitis, showing strabismus from paralysis of eye muscles. neck, and other symptoms mentioned in meningitis. The pulse is at first rapid, then slow, usually becoming rapid before death. The fever is very irregular. There are retrac- Fig. 149.— Tuberculous meningitis, showing convulsion. 2H 434 DISEASES OF INFANTS AND CHILDREN. tion of the abdomen, marked constipation, and often paralysis. The fontanel bulges if it is open. There may be temporary remissions of a marked character. The course after coma starts is usually rapid, death taking place in from one to two weeks. In the last stage there are rapid pulse, relaxation of the muscles, dilated pupils, which do not respond to light, deep coma, and sometimes convulsions. The course of tuberculous meningitis is very irregular. Diagnosis. — In the first stage it cannot be diagnosed. Fig. 150.— Tuberculous meningitis. Note paralysis of eye muscles. In the second stage the most important diagnostic points in the order of their frequency are "constipation, drowsi- ness, irregular respiration, vomiting without apparent cause, irregular pulse, convulsions, opisthotonus, and fever, which is usually slight " (Holt). Strabismus, loss of pupil reflexes, and facial paralysis are of great value if associated with the above symptoms. The tubercle bacillus can usually be found in the spinal fluid if sufficient search is made. Prognosis. — Uniformly fatal. Treatment. — As outlined in meningitis. ACUTE INFECTIOUS DISEASES. 435 Tuberculous Adenitis. (Tuberculosis of the External Lymph Nodes.) Etiology. — The greatest number of cases are seen from two to ten years of age. Local irritation of the nodes from adjacent inflammations may furnish a suitable soil for the tubercle bacillus. An hereditary tendency and a previous attack of measles or whooping-cough may be mentioned as predisposing causes. Pathology. — The cervical nodes are most frequently Fig. 151.— Tuberculous lymphadenitis of the cervical glands (Stengel). affected, the axillary and inguinal nodes at times ; the cervical nodes are usually infected through the mouth. The process involves one or more chains of nodes. There are rapid cases where there are numerous gray tubercles, which caseate and usually become infected \vith pus-forming bac- teria and suppurate with involvement of the adjacent tissue. All the affected nodes do not break down. There are, on the other hand, chronic cases where the formation of connective tissue is marked and the tubercles less numerous. Suppura- 436 DISEASES OF INFANTS AND CHILDREN. tion is not so common in these cases. All gradations between these two forms may be met with. Symptoms. — The process is essentially a chronic one There is enlargement of a few nodes, with a little tenderness. This disappears ; later there is again tenderness, usually with the extension to other nodes. The enlarged nodes vary in size from a split pea to a walnut. There is a tendency to fusion and involvement of the adjacent tissues. Later there is frequently suppuration with breaking down of the skin. A chronic discharging sinus is often left or an ugly irregular scar. About puberty the process usually subsides. Tuberculosis of the Bronchial I,ymph-nodes. — This may exist apparently as a primary lesion, but is usually secondary to a lesion in the lungs. Etiology. — This form of tuberculosis is met with in chil- dren of all ages, but rarely causes symptoms until after two years of age. Pathology. — As in tuberculous adenitis. Symptoms. — There may or may not be general symptoms, as in other forms of tuberculosis. The most striking symp- toms are the result of pressure or irritation. In the pneu- mogastric or recurrent laryngeal there may be spasmodic cough, resembling whooping-cough (see same for differential diagnosis), the effects of which do not entirely subside after the paroxysm, a little wheezing remaining. There may also be hoarseness and dyspnea. Pressure on the superior vena cava results in cough, dyspnea, cyanosis of face, and some- times edema of the face. Sometimes pressure causes diffi- culty in swallowing. Physical signs are only present when the nodes attain con- siderable size. There is dulness over the sternum, and also on each side of the spine, from about the third to the seventh vertebra?. There are changes in the breath sounds, these being more or less amphoric, and may suggest a cavity. Diagnosis. — Syphilis and Hodgkin's disease aifecting the mediastinal nodes are both rare in children. The Rontgen rays are of value in doubtful cases. Prognosis. — Sudden death may follow rupture. The child ACUTE INFECTIOUS DISEASES. 437 may die from tuberculosis of the lungs or elsewhere. Some- times the disease becomes quiescent ;ui len meVcurv ; but inunctions should not ordmardy be used I l\Z young infants or when the skin is tender or broken. Inter/ally it may be given in the form of calomel £ *» IT gr. three or four times daily, mercury and chalk n. 1 ^ doses, or the bichlorid in doses of from ^ to ^ gr. ^ protiodid may be used in doses of from i to TT Jg here is diarrhea, opium or codem may be used in ad» Mercury should be given for a year, wnh occasional >^k in the treatment, giving tonics, as iron (syrup of ^ he 10 did) or cod-liver oil. If symptoms pers.st, it should be used > Fox, Medical Record, March 13, 1909, p. 421. 446 DISEASES OF INFANTS AND CHILDREN. longer Iodid of potassium should then be given with or without mercury, and it should be given subsequently for any tertiary symptoms. When there is a general eruption, bichlorid baths may be used. Fissures may be dusted with calomel or carefully touched with 1 per cent, bichlorid solution. Condylomata should be washed with a 1 or 2 per cent, salt solution and then dusted with calomel. Persistent onychia may have mercurial plaster applied. For snuffles a powder of 1 part Fig. 157.— Syphilitic dactylitis. calomel and 20 parts sugar may be insufflated, or an oint- ment of yellow oxid, gr. j to 3J, may be used in the nose, or the white precipitate ointment 1 part and petrolatum 3 parts may be used. Injections are perhaps best not used in infants, although the method has some warm advocates. They may be used in severe or malignant cases, and where there are severe vis- ceral lesions or intracranial complications. Salvarsan may be given in two or more injections not less than a week apart. The mercurial treatment may be used coincidently or afterward if desired. After five years of age it is best given, as in adults, intravenously, in doses of ACUTE INFECTIOUS DISEASES. 447 0.1 gram to 0.2 gram. In younger children this is difficult, and injections into the muscles, in doses of from 0.03 to 0.05 to 0.1 gram, according to age and size. The drug may be suspended in ben/oinol or any bland oil or in water. The injection should be made into the buttocks in such a manner as not to avoid the neighborhood of the sciatic nerve and the larger vessels. Two sites are recommended : first, a point midway between the anterior superior spine and the top of the internatal cleft, the needle to go forward, outward, and slightly upward. In thin children there is not much tissue at this point ; second, draw a line from the top of the great S'eiaTic Tieri/e Fig. 157a.— Sites for intramuscular injection, showing location where to avoid the sciatic nerve. trochanter to the top of the internatal cleft. Inject at the junction of the inner and middle thirds. This has the ob- jection of being near the gluteal vessels. JNeosalvarsan may be used. It has the advantage of being soluble in water, but the disadvantage of being more unstable, and it must be used as soon as prepared. 0.9 gram of neosalvarsan is equal to 0.6 gram salvarsan. 0.05 gram of salvarsan may be dis- solved in 5 c.c. water and injected intravenously. The dose may be repeated in two weeks and in one or two months until Wassermann reaction is negative. 448 DISEASES OF INFANTS AND CHILDREN. LATE HEREDITARY SYPHILIS.! Symptoms of tertiary syphilis may be seen in late child- hood. Early symptoms may never have existed, or have been overlooked or forgotten. Fig. 158.— Fissures, or rhagades (Dr. Stowell's case). Hutchinson's triad, the association of lesions of the teeth, eyes, and ears, is one of the most important diagnostic feat- ures. There may also be gummata, especially of the bones. Necrosis and suppuration of the bones are also frequent. Necrosis of the bones of the nose with subsequent depression of the bridge of the nose is a striking feature in some case.-. The lymph nodes may be enlarged. Interstitial keratitis is one of the most frequent eye lesions, and the resulting corneal opacities should always be looked for. This is not necessarily syphilitic. The pigment of the choroid may be absorbed in spots, especially toward the periphery. Chronic otitis with deafness is frequent. The teeth show marked changes. This applies only to the second or permanent teeth. Hutchinson's teeth 2 consist of peg- 1 Dunlop, " Arthritis from Congenital Syphilis," Edinburgh Medical Journal, vol. xvi., 1904, p. 516.- 2 Hutchinson, "Mercurial Teeth," Illustration* of Clinical Surgeri/,xo\. i., 1878, p. 53. ACUTE INFECTIOUS DISEASES. 449 like teeth with concavities on the grinding edge, this being noted in the upper central incisors. Teeth which are peg- like or shaped like a screw-driver or which are twisted are more frequently seen. A milk-white transverse line is some- times seen across the upper central incisors. The teeth are abnormally soft and tliev are usually discolored. ■Tig. 159.— Sabre deformity of tibia in congenital syphilis Subcutaneous gummata which break down, leaving ulcers and later irregular scars, are also of frequent occurrence. Joint pains and swellings resembling rheumatism are also frequently met with. There may be periosteal nodes, especi- ally of the tibia, which are usually painful at night. 29 450 DISEASES OF INFANTS AND CHILDREN. Syphilitic children may show stigmata of degeneration, mental backwardness, and nervous affections. Diagnosis. — The presence of bone lesions, gummata, and Hutchinson's triad are the most important points. Fig. 160.— Hutchinson's teeth (after Fournier) Treatment. — Iodic! of potassium should be given in large doses. It may be alternated with the syrup of iodid of iron. If improvement does not occur, mixed treatment, Fig. 161.— Syphilitic teeth (after Fournier). consisting of inunctions of mercurial ointment or the bi- chlorid, internally, together with iodid of potassium, should be tried. ACUTE INFECTIOUS DISEASES. 451 MALARIA, 1 Definition. — This is an infectious disease caused by the hemocytozoa described by Laveran. It is characterized by paroxysms of intermittent fever, which may be of a quo- tidian, tertian, or quartan type, or by a remittent fever. Pernicious and chronic forms are also seen. Etiology. — It is seen in certain localities, especially where there are marshes and undrained land. In temperate climates it is most frequent in August, September, and Octo- ber, but some cases may be seen in the spring. The usual mode of infection is through the bite of a certain genus of mosquitoes, which act as an intermediate host for the malarial parasite. The Parasite. — This is a hemocytozoa or a parasite which Fig. 1R2.— Various forms of hemocytozoa (Stevens). lives in the red blood-cells. It was discovered in 1880 by Laveran. There are three forms of the parasite : the tertian, quartan, and sestivo-autumnal. The tertian parasite completes its cycle of development in man in forty-eight hours. It is first seen as a small un- pigmented mass in the center of a red blood-cell. This looks much like the spore forms seen during a chill. After a few hours pigment may be seen. This is fine and granular. There is ameboid movement of the parasite. The pigment which at first is seen about the periphery becomes grouped in the center of the parasite. The parasite breaks up into about fifteen or twenty segments. These are the so-called spore forms which enter the red blood-cells and repeat the cycle. Some of the full-grown parasites do not segment. They are sexually differentiated parasites and are called gametoeytes. 1 Craig, " Malaria," Boston Medical and Surgical Journal, May 27, 1909. 452 DISEASES OF INFANTS AND CHILDREN. The quartan parasite is rare in the United States. It takes seventy-two hours to complete its cycle. The granules of pigment are larger and darker than those of the tertian organism. The red cell is of a dark-brass color. The seg- ments are larger and only from six to twelve are formed. The chill occurs every fourth day. The cestivo-autumnal parasite is found in the more irregu- lar fevers. Its cycle probably takes from twenty-four to forty-eight hours. It is smaller than either of the preceding. After a week or two in untreated cases curious crescentic forms appear which are larger than the red cells. Both this and the quartan form also have gametocytes. The gametocytes do not develop in the blood. The male parasite gives off flagellar which enter the female parasite, fecundating it. The malaria organism is taken into the stomach of the mosquito with the blood. The fecundated parasite enters the wall of the mosquito's stomach, and two days later small refractive bodies may be demonstrated in the wall of the stomach. These develop in about a week and break up into myriads of spindle-shaped sporozoids. These get into the salivary glands of the mosquito and thence into the individual bitten. Malaria-carrying Mosquitoes. 1 — The species of the genus Anopholes are the only ones which act as intermediate hosts. The common mosquito is the culex. They are easily distin- guished. The culex has small palpi, no spots on the wings beyond the veins, and the body, when resting, is parallel to the wall, the two posterior legs usually crossed over the back. The Anopholes has two large palpi, mottled wings, and the body is inclined away from the wall. Pathology. — Fatal cases are rare in young people in America. The changes are similar to those found in adults. There is enlargement of the spleen and liver, and great de- struction of the blood-cells. There may be pigmentation of the tissues. Symptoms. — The clinical picture is varied. The younger the child the more irregular the form. 1 L. O. Howard, Mosquitoes. ACUTE IXFFrTTOrs DISEASES. 453 In later childhood the attack- are similar to the adult form. In the tertian form the paroxysm occurs every other day. It' there is a double infection, as is frequent in chil- dren, the paroxysm occurs daily (quotidian]. In the quartan form the paroxysm occur- every fourth day. In the aestivo- Temp. 109 ■ : ) 106 . i ; ior 106 105 ; \ : R » K l\ 104 » • ij\ l\ 103 / \ rr j \ I i 102 ! 1 :\ j \ \ 101 1 ! , : j 1 - 1— \ f 100 \ i : : : r \ i. ! 99 i ,i. i V— m septicemia. Treatment. — Surgical. TUBERCULOUS ARTHRITIS AND OSTITIS. Chronic tuberculosis of the joints is really a surgical dis- order, but the early diagnosis and treatment is so important that it is included. Etiology. — The onset rarely occurs before two years of age, and is infrequent after eight. It most often fol- lows an acute infectious disease, as measles or whooping- cough, but may come on in children in apparent health. It is usuallv primary, but tuberculosis of other parts of the body may follow. Sometimes the disease develops after an injury. Pathology. — The spine, knee, and hip are most frequently affected in the order named, and the ankle, elbow, wrist, and shoulder follow, but much less often. The disease usually begins in the bone near the joint, and involves the joint later. There is a tuberculous ostitis, which may become quiescent or which may go on to suppuration. The joint becomes involved by extension. All the structures about the joint may be involved, and the pus may burrow along the muscle sheaths and sinuses result. Caries of the Spine (Pott's Disease). — This is a tuberculous inflammation of the vertebrae which extends to the surrounding structures and involves the joints and sometimes 464 DISEASES OF INFANTS AND CHILDREN? the meninges, nerve roots, and cord. Under the weight of the body the spine becomes deformed, which progresses as the softening goes on. The resulting kyphosis is commonly called " hunch back." Nearly three-fourths of the cases are dorsal ; of the remainder, the lumbar slightly exceed the cervical. Symptoms. — Early symptoms are obscure, and diagnosis may not be made until there is deformity. Early symptoms are very important. (a) Rigidity of spine. In stoop- ing, etc., the back is kept rigid. (b) Referred pain. This may be any place supplied by the spinal nerves of the part affected. Ab- dominal pain is frequent where the dorsal region is affected. Pain may come on at night. (c) The child assumes a position ■V such as will relieve pressure on the i a It vertebrae. (d) There may be pressure paral- Cervical Form. — Pain is usually of a neuralgic type, either occipital or on side of neck. This should always lead to a careful examina- tion of the spine. There may be pain only on motion ; there may be stiff neck. Paralysis or retropharyngeal abscess may be the first thing noted. Dorsal Form. — There may be intercostal neuralgia or ab- dominal pain. Child sleeps lying with abdomen downward (prone position). The spine is stiff and held so. Early there may be frontal lordosis, the backward kyphosis coming later. Lumbar Form. — The pelvis is tilted to one side, causing lateral curvature of spine. The pain is usually referred to hip or knee, and there is usually limping on one side, often Fig. 167. — Tuberculosis of dorsal and lumbar vertebrae. DISEASES OF THE JOINTS. 465 mistaken for hip or knee disease. Deformity is usually late in appearing. Diagnosis. — The child should be naked and the position noted, also the presence of any deformity of spine or else- where, and the mobility of the spine tested. Paralysis and abscess should be looked for. "The child walks with its legs, but not its back." The knee and hip are bent in pick- ing up objects from the floor, while the spine is held stiff. The disease is made more apparent if a normal child is ex- amined at the same time. Lumbar cases should be differ- entiated from hip cases. The spine may be bent in rickets and in malnutrition, but this is most frequent under two years of age ; there are other signs of rickets or malnutrition, and the back is mobile anc* not rigid. The deformity is usually dorsal, and disappears more or less if an attempt is made to straighten the spine. Rotary lateral curvature is usually seen in girls from eleven to fourteen, and there is neither rigidity nor pain. Prognosis. — The disease is very chronic, and it # is usually from one to three years before repair starts. Relapses and exacerbations are common, and are due to traumatism, lack of proper support, and improper treatment. Abscesses occur in about 20 per cent, of the cases, and paralysis in about 50 per cent., when the disease is in the lower cervical or upper dorsal region. Death takes place in about 10 per cent, of the cases. The amount of deformity varies with the site of the disease, the treatment, and especially on how early it is begun. If begun very early there may be little or none. Treatment. — The general treatment is important, and is the same as in any other form of tuberculosis, and is in these cases too frequently neglected. The local treatment is best carried out by an orthopedic specialist, and consists in keep- ing the spine at rest and taking the weight off of it by means of plaster jackets or specially constructed apparatus. Tuberculous Articular Ostitis of the Hip (Hip- joint Disease) ; Morbus Coxarius. — This begins in the head of the femur or acetabulum as an inflammation of the bone — first stage ; spreads to the joint — second stage ; and 30 466 DISEASES OF INFANTS AND CHILDREN. may soften and destroy the joint with considerable resulting deformity — third stage. First Stage. — There is early morning stiffness and slight lameness, slight tenderness about the hip, disinclination to walk, then pain, usually referred to knee. A little later there are u shooting pains " at night, which cause the child to cry out suddenly. Later there is lameness. This stage may last weeks, months, or years. Fig. 168.— Position in early tuberculosis Fig. 169.— First stage in tuberculosis of of the bip-joint. the hip. Note position and apparent lengthening. The physical signs are flattening of the gluteal fold, which may be single, and of the buttock, atrophy of the leg on the affected side ; the trochanter is prominent. The weight is carried on the sound leg. The affected side should be com- pared to the well one standing and lying down, both legs DISEASES OF THE JOINTS. 467 should be rotated, flexed, extended, abducted, and adducted. A comparison with the well leg reveals limitation of motion which could often not otherwise be detected. Later on the hip may be fixed. Second Stage. — This gradually follows the above, occasion- ally it comes on suddenly. The leg is apparently lengthened, the foot turned out, the thigh flexed and rotated outward. There is muscular spasm which limits or prevents movement of the hip ; there may be infiltration of the joint and abscesses and sinus formation. This stage lasts weeks, months, or years, and the disease may not progress further. Third Stage. — There is marked, real deformity, due to de- Fig. 170. — Late tuberculosis of hip-joint. struction of the joint and drawing up of the leg by muscular action. The leg is shortened from one to four inches. The foot is turned inward, the thigh flexed, adducted, and rotated inward. The trochanter is above Nelaton's line and the trochanter against the ilium. There is marked curvature of the spine and atrophy of the leg. There may be abscesses and sinuses. Diagnosis. — Shooting pains, any lameness, pains in knee or leg should lead to examination. In the first stage mistakes are easily made, and sprains, poliomyelitis, rheumatism, tuberculosis of the lumbar vertebrae, and inflammations of the 468 DISEASES OF INFANTS AND CHILDREN. soft parts must all be excluded. Appendicitis or peri- nephritic abscess may cause a drawing up of the hip and be mistaken for the second stage. Prognosis. — About 25 per cent. die. If the disease is treated in the first stage there may eventually be little or no deformity ; if treatment is started in the second stage there is always some deformity, and if in the third, there is always marked deformity. Treatment. — This consists in rest, immobilization, and re- lieving the joint from carrying the weight of the body by means of proper apparatus. The patient can usually be up and about except in the third stage. Tuberculous Articular Ostitis of the Knee (White Swelling). — The changes are similar to the above. The disease usually begins in the inner condyle of the femur and extends to the joint. The amount of change is variable. There may be only a slight synovitis or, on the other hand, there may be complete destruction of the joint. Abscesses and sinuses may be present. Symptoms. — There are slight lameness, tenderness, the knee is flexed, and there is some stiffness and pain. Later there is swelling, atrophy of the muscles above and below the joint, and a deformity, consisting in flexion and outward rotation. The disease lasts months or years, w T ith remissions and relapses. Prognosis. — This is better than the other forms as regards life, and if treatment is instituted early there may be little deformity. This is variable, however. Diagnosis. — In infants scurvy must be excluded, also syno- vitis, and in older children acute rheumatism. Treatment. — Rest and immobilization by means of proper apparatus. OTHER FORMS OF ARTHRITIS, Quite a number of other forms of arthritis are met with in infants and young children, the chief of which is, perhaps, the gonorrheal arthritis which occurs in very early life, usually following a gonorrheal ophthalmia. Gonorrheal Arthritis. — This may be seen in the course of DISEASES OF THE JOINTS. 469 ward epidemics of gonorrhea. There may or not be con- junctivitis or genital lesions. The clinical picture varies a great deal, and in some cases the condition is very acute, the joint looking as if suppuration would take place. As a rule, in three or four weeks recovery takes place without surgical interference. Sometime- the joints suppurate, owing to a secondary infection with pus germs. There may he only one joint or there may be a number of joints affected. Fig. 171.— Syphilitic arthritis. Meningococcal Arthritis. — Arthritis may be met with in epidemic cerebrospinal fever and postbasic meningitis. One or more joints may be affected, the special feature being that the swelling is peri-articular rather than intra-artieular. The swelling is not especially painful. Acute Tuberculous Arthritis. — This is very rare, but is occasionally met with, and should be borne in mind in making a diagnosis. 470 DISEASES OF INFANTS AND CHILDREN. Pneumococcal Arthritis. — This is exceptional. It occurs in the course of pneumonia or a pneumococcal empyema. Acute Kheumatism. — Swelling of the joints in rheumatism in children under five years of age is exceedingly rare, but arthritis due to rheumatism may occasionally occur in young children. Arthritis is Associated with Hemophilia. — Several forms of joint affection may be met with in this condition. There may be an acute infective arthritis ; there may be hemor- rhages into the joints, and there may be an arthritis de- formans. Congenital Syphilis. — This rarely affects the joints under five years of age, and yet occasionally one meets with marked cases. In early life syphilitic epiphysitis is not uncommon, and may be mistaken for a multiple arthritis. It comes on usually in the first three months, there is swelling about the epiphyses, pain, loss of motion. It may be mistaken for a birth palsy. DISEASES OF THE BONES. 471 DISEASES OF THE BONES* ACUTE OSTEOMYELITIS. This may be overlooked on account of several features of the disease. It may be mistaken for rheumatism, especially when it is accompanied with pericarditis and swelling about the joint. It may be mistaken for erysipelas. The diagnosis can usually be made by deep pressure, which in erysipelas produces no especial amount of pain, but does in osteomye- litis. It should be remembered that delirium is one of the characteristic features of the disease, and the bone may be overlooked on account of this. On examination there may be found to be a thickening of the shaft of the bone and ten- derness on pressure. The joint immediately below may ap- parently be swollen, but it is easy to determine by pressure that the pain is in the shaft of the bone and not in the ioint. The treatment is surgical. MULTIPLE EXOSTOSES. These are hereditary and are due to abnormal development of the bones. The exostoses vary in size, and are most fre- quent on the long bones about the epiphyses. They come on most frequently about puberty, when the bone development is most rapid. When the growth of bone ceases, they stop growing. Unless giving trouble, they should be let alone. If they cause symptoms from pressure on the nerves or ves- sels they should be removed. OSTEOGENESIS IMPERFECTA. 1 This is a rare congenital disease of the bones, changes taking place during fetal life and also later. At birth the skin is thickened, and the infants present an obese appear- ance. If the child grows there are bending deformities of the extremities. The bones are exceedingly brittle, and the most characteristic feature is frequent fractures, which usu- 1 Xathan, American Journal of Medical Sciences, January, 1905, p. 1. 472 DISEASES OF INFANTS AND CHILDREN. ally heal promptly. The cranium is usually enlarged and deformed. Little is known about the cause or pathology of the disease. Most of the cases die early, though some sur- vive until later in life. The patient should be handled carefully to avoid fracture, and in mild cases braces may be used to protect the limbs. No effective treatment has yet been instituted. DISEASES NOT* OTHERWISE CLASSIFIED. 473 DISEASES NOT OTHERWISE CLASSIFIED, PELLAGRA. Definition. — A constitutional disease frequently over- looked in childhood. The pathology and symptomatology Fig. 172.— Lesions on hands and face. Photograph from Dr. Eugenio Bravatta, Mombello, Italy. 'Courtesy of Dr. William Weston. Columbia, S. C, from The American Journal of Diseases of Children, February, 1914. j 474 DISEASES OF INFANTS AND CHILDREN. are extremely varied. The chief manifestations are upon the skin in the alimentary canal and the nervous system. Etiology. — Seen at all ages, and sexes are equally affected. Most of the attacks occur in spring or early summer or au- tumn, rarely in cold weather. Sunlight aggravates the rash. It is usually seen in unsanitary surroundings. The cause of the disease is not known at the present. One theory is that it is due to spoiled maize. Sambon believes it to be a para- sitic disease transmitted by a species of simulium. Pathology. — There is usually anemia and cachexia and emaciation. There are changes in the meninges, brain, and spinal cord. The erythema is trophoneurotic in origin. There Fig. 173.— Hands from white girl, aged six. Fifth attack of pellagra. First attack occurred before the age of two. (Courtesy of Dr. William Weston, Columbia, S. O, from The American Journal of Diseases of Children, February, 1914.) are atrophic, sometimes ulcerative, changes in the intestinal tract. Symptomatology. — The disease generally comes on gradually, either with changes in the skin or digestive symp- toms. There is usually diarrhea, sometimes constipation. The digestive disturbances are more common after the fourth year. The nervous symptoms consist of marked insomnia, paresthe- sia, exaggerated knee-jerk, and there is often mental depres- sion. The rash is symmetrical, chiefly on the hands and face, sometimes on other parts of the body, sometimes wet and sometimes dry. It is intensified by light. In the dry form there is an erythema with a tendency to fissures and repeated attacks of thickening of the skin. DISEASES NOT OTHERWISE CLASSIFIED. 475 Diagnosis. — On the symptom-complex, consisting of a red tongue, fissured lips, diarrhea, headache, insomnia, rest- lessness, paresthesia. In the later cases rigidity of the mus- cles and even spasms, and photophobia. There is muscular weakness of the legs. The presence of the skin lesion makes the diagnosis almost certain. Fig. 174.— Wet variety of pellagra in an eighteen-rnonth-old child. Patient of Dr. J. J. Watson. (Courtesy of Dr. William Weston. Columbia, S. C, from The American Journal of Diseases of Children, February. 1914. Prognosis. — The younger the child the less favorable the prognosis. Infants nursing the breasts of pellagrous -mothers become marantic unless the diet is changed. From four to ten years of age the attack is more mild. Treatment. — If the mother has pellagra the child should be weaned. Improved hygiene and change of climate if possible. The child should be kept out of the sunshine. Iron or arsenic may be given internally. 476 DISEASES OF INFANTS AND CHILDREN. THERAPEUTICS FOR INFANTS AND CHILDREN. Prescribing for children and ordering therapeutic meas- ures other than drugs deserve especial attention. There are certain well-known principles and rules that should be borne constantly in mind. These may be briefly expressed as fol- lows : Never give a dose of medicine without a definite indica- tion. Never give an unnecessary dose of medicine. If a placebo is prescribed, give a harmless, palatable dose. Give small doses, often repeated, as a rule, in preference to larger doses at long intervals, unless there is some especial reason for the latter proceeding. Never give an unpalatable dose where a pleasant-tasting one can be given instead. Avoid drugs that produce nausea and so destroy the appe- tite and endanger nutrition, except in the few indications for so doing. Give simple prescriptions. In most instances one drug by itself will give better results than a number mixed together. There are, however, many exceptions to this. As a rule children like syrups without too much flavoring. Avoid as far as possible the highly seasoned and flavored elixirs. Properly diluted, these may be very acceptable. Bitter medicines are frequently well taken, especially by young infants, if they are well diluted with water. In many instances the mixtures intended to disguise bitter drugs are worse than the drugs themselves. As far as possible always see and taste every medicine, unless certain as to what the result of the combination will be. Size of the Dose of Medicine. — This is an important and often a perplexing problem. There have been many rules devised, and probably none better than the old one of add twelve to the age in years and divide the age by the sum. THERAPEUTICS FOB INFANTS AND CHILDREN. 477 This gives the proportion of the adult dose which should be proscribed. Example : For a child of three years, 3 1 12 + 3 5 This does not apply to all drugs, for some are especially well tolerated, while others are badly borne, even in the indicated proportions. Cowling's method is to divide the following birthday of the child by 24. For example, at two years, 3 divided by 24 equals i. Clark has suggested that the dose should correspond to the weight, assuming 150 pounds is the average weight, to which the dose is 1. If the weight be divided by 150 the resulting fraction represents the proper proportion of the dose for that particular case. For example, the proper dose for a baby of 10 pounds would be - 1 - 15. For infants under one year great care should be exercised. Fiud the dose for an infant of one year and give about one- twelfth of the dose for each month of the child's age. Opium should always be used with the greatest caution in the young. The doses in the table on pages 478-480 are what may be re- garded as safe initial doses. It should be remembered that no hard-and-fast rules can be made for estimating the size of the dose for children, and that in some instances the doses given may be rather larger than would be warranted, as in a very small, weak child, for example, and in many more instances the size of the dose may be increased with great benefit. Almost without exception the doses given have been used by the author in actual practice. 478 DISEASES OF INFANTS AND CHILDREN. CO lo i= ^ u ? rrt •r?>4 1 Ho r-»> OO o ►> i -. 1 i _>= CO •i-a "T i (N H CO t-CO Kl 1 MClnCUO 1 C<1 r+» CO r? lO ._CO rl P< >> 0) H bo 1 H lObD (-1 bo I- bC i bobobo^ bcboboboM £= bo bot= bolOttO botO bo bo bo £ "S3 fl.T3 "SS ^S2 ,-* „, cq ..-2 3 — *■< ot 1 cs^ o g go a a oS, H *oo «2 g 2 ™ aS o 5fl f^S fc p h •2 &&£ oi h o «2 sS oS M OS OS - J2 09 OB °a^~ ,d— C °3 OS OOWO THERAPEUTICS FOR INFANTS AND CHILDREN. 479 to .. — / - f > I Q © . i i :=> I :'.:z>:'. — :--.-. .^ >■- = -< _>■-=_., -- -r l I :^> I :'. :z>:'. — :" .-. ,2 i" til Of=tC 5. 5£Tl ~ be be be SblO£ i ~i ~.i ~.f~. u' "^ tx u -^ bfi^^ ti ti^ ti 5: tir^ Ex ti ti BfiM ■ — — ^- — — — " _> -r - eo - — . • b -^ _r __ i~' W~ = <~ tecii=*0 boboti •/.t'^SBi".^ ut-^ : ti si ti= ti= |= si tjf= Tx be bef^bi ti 5: SofcO i s. . . 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CD *+j o tf ^ ci^ttH 00 ^ '— • O co CD a 3 fZ5 -Sgpl^oo^ O p CD —" ■v _ O g CO P O CO CD F-i CD a a P Tt P P C f- / c i - i r ,£ 1 a C a f- i y p_ a •r- c a 4 P > V ~ a CO g; CD P 5a 11 -ci c CD w ^s CO 1 a a -7 4 CI p a P c P •2a O P gj "^ -i as a 'c 'a c - i7 5f- c cr E a V- 43 c P •r- +: ( a p c ex a »P ■— P a P ,C -a > +: 1 t > J; +; a c J r- 1™ = a £ a i- v a +- OS t- > P '2 ?- a Eh • p. ^4 'o'c o a- — +: . c t: a ■ tp .'■^ a • ?• a P C P P a >^ t- a - a > P K THERAPEUTICS FOR INFANTS AND CHILDREN. 481 Antipyretics. — These are used to reduce temperature. Study the natural history of disease, and unless the tem- perature is higher than it should ordinarily be in the disease which causes it, let it alone, unless attended by nervousness, restlessness, or other troublesome symptoms. A temperature of more than 104J° F., from whatever cause, should be reduced if possible. The best antipyretic is the external application of cold. This may be done in the following ways : Ice Bags. — These may be applied to the head, to the carotids, over the heart, and over the wrists. If there is local inflammation they may be placed over the seat of the disease. They are an efficient way of relieving the pain, especially in that caused by the congestion or inflammation of a serous membrane, as in pericarditis or pleurisy. Cold Pack. — This is effective, and is to be preferred to the bath where the patient is weak. Place a rubber sheet on the bed ; over this place an old blanket. Wet a sheet or a very large Turkish towel in water, the temperature of which may be from 70° to 90° F. Wrap the patient up in this and fold the blanket over the patient. Place cold compresses upon the head. Cold water may be poured ou the sheet from time to time, or if the temperature is high, ice may be rubbed over the sheet. This may be continued from five to thirty minutes. Cold packs are useful in high, temperature, ner- vousness from fever or other causes, and often induce sleep. Cold Sponge. — Place a rubber sheet on the bed and a sheet or old blanket upon this, and put the patient upon them. Sponge with water the temperature of which is from 70° to 90° F. Colder water may be used in some cases. After sponging a few minutes take the temperature to note the effect of the cold. (See Cold Baths.) Cold Bath. — These are very useful in treating sick chil- dren, as a child can be tubbed much easier thau an adult. In many cases of high fever this is the only means to control it. If the bath causes great prostration or nervousness it is better to use some other form of cold. The water may vary from 70° to 95° F., according to circumstances. It may be 31 482 DISEASES OF INFANTS AND CHILDREN. used warm at first and reduced after the child is accustomed to it. This is done by adding cold water or placing a piece of ice in the tub. If the child is apprehensive, place him upon a blanket or a sheet put over the tub and allow him to sink into the water. Take the temperature from time to time, and do not reduce too much, as the temperature continues to fall after the child is taken from the bath. If the temperature is reduced to normal in the bath, it may become subnormal afterwards and cause collapse. A reduction of 100° to 101° F. is sufficient in most instances. After the bath, dry rapidly and wrap the child in bed. If there is great prostration, give a small dose of wine or other stimulant. Evaporating Bath. — This is sometimes used, but has cer- tain objections. The child is covered with a wet sheet and the water allowed to evaporate. The sheet is wet from time to time. Sometimes tlie patient is placed in the draft from an electric fan to facilitate evaporation. Certain therapeutic measures of a general nature are very important in the treatment of disease in infancy and childhood, and these are often neglected. If the child has fever it should be kept in bed, and in all cases the child should be kept quiet and not disturbed unnecessarily ; it should not have exciting games or visitors. Rest in bed and quiet are the greatest factors in curing many conditions in which there is a large nervous element. It is particularly needful in the present day. Upset conditions resulting from overwork at school, too much excitement, and too little rest are easily cured in this manner. Fresh air is a second factor on which too much stress cannot be laid. Care should be taken, however, to have the child adequately protected from cold if necessary. Changes in the. climate are of great service and often utilized too late. They are of particular value in tuberculosis and protracted cases of bronchitis, bronchopneu- monia, intestinal indigestion, and ileocolitis. Massage is use- ful, especially in children taking the rest cure, for keeping up THERAPEUTICS FOR INFANTS AND CHILDREN 483 the nutrition of paralyzed limbs, chronic constipation, for stimulating nutrition in cases of marasmus and malnutrition, and other conditions too numerous to mention. Good nurs- ing is of inestimable value, and a well-trained, tactful nurse is an asset in the treatment of all the severer diseases which is hard to overestimate. The nurse should be instructed to care especially for the comfort of the child, a point of greatest importance in the treatment of bed-ridden children. The physician and nurse should both pay careful attention to the treatment of minor symptoms, often of little importance when compared to the real disease, but very annoying and wearing to the patient. Directions in regard to giving drugs and food and the use of other therapeutic measures should always be written and explained to the mother or nurse. By so doing many mis- takes are avoided. Anesthetics. — Under ordinary circumstances ether is always to be preferred. Sometimes it is advisable, if a skilled anesthetist, to administer nitrous oxid or ethyl chlorid before beginning the ether. Children do not bear nitrous oxid well, as a rule, as it is liable to cause convulsions. Ethyl chlorid requires too much care in its administration for ordinary use. Chloroform should be chosen when there is bronchitis, pneumonia, pleurisy, or diseases of the larynx. It is very dangerous and often causes sudden death in the so- called Lymphatic type. Antipyretic Drugs. — These are to be prescribed for the nervous symptoms accompanying fever rather than for the high temperature. The temperature is, as a rule, better con- trolled by cold. Acetanilid is depressing and should not be given to children. Antipyrin is of the greatest service, as it relieves pain and allays nervousness. It has a bitter taste, which is disguised by the syrup of orange. R Antipyrin 1 (gr. xvi) ; Syrup of orange 60 (Jij). — M. Sig. — A teaspoonful every two horn's. Children bear antipyrin well, and it may be given in 484 DISEASES OF INFANTS AND CHILDREN. 1-gr. closes to a child one year old, and in 2-gr. doses at three or four years. Some authors estimate the dose at J gr. for each month of the child's age. This answers for young infants, but later results in too large doses. Combined with small doses of codein it is a good hypnotic, analgesic, cough sedative, and antispasmodic. R Codein sulphate 0.03 (gr. £) ; Antipyrin 1.0 (gr. xvi) ; Syrup of orange 60.0 (^ij). — M. Sig. — A teaspoonful every two hours as needed. (For a child of two years.) The above is better than morphia for children and is one of the most useful prescriptions in pediatric practice. Anti- pyrin sometimes causes a scarlatiniform rash. Phenacetin may be used. It is insoluble and is tasteless. It is best given in powders with a little sugar. Opiates. — Opium and its derivatives should be used sparingly in early life ; for, while they are among the most valuable drugs, they are frequently not well borne. Opium should never be used in diarrhea until the bowel is thor- oughly cleansed. In the infectious forms it should always be used with great caution. It is used to relieve pain and to lessen the number of stools. After two or three years of age opium may be used for the same indications as in adults, but in proportionately much smaller doses. Where possible it is better to resort to other drugs. Codein is of especial value during childhood. Holt gives the following table of the initial doses of the various preparations. These may be repeated at intervals of several hours as needed : Paregoric Deodorized tincture . Dover's powder . . Morphin Codein 1 month. 3 months. 1 year. mi mn mv-x 1TIA m* m Wo gr- 2V gr. tu gr- H gr* To"o"o~ gr- *fa gr. ?hs gr. ¥o"o gr. sfo gr. *V 5 years. m xxx-xl m ij-iij gr- ij-iij gr- 3V-2V gr- tW THERAPEUTICS FOB- INFANTS AND CHILDREN. 485 Somnifacients. — Chloral hydrate is a very efficient drug in producing sleep and allaying spasms. Its greatest use is during or alter convulsions. It may be administered by the rectum where possible or else by the mouth. It some- times causes vomiting. 1 gr. may be given to a child of one month of age, 2 gr. at six months, 3 gr. at nine months, and 4 gr. at one year. 1 or 2 gr. often suffice even at this age and should be tried. It may be combined with bromids to great advantage. R Chloral hydrate 0.5 (gr. viii) ; Sodium broruid 1.0 (gr. xvi) ; Syrup of orange 60.0 ( 3 i j ) - — M. Sig. — A teaspoonful at a dose as a sedative. Repeat in an hour if necessary. For convulsions use larger doses and repeat oftener. Urethan may be used in the same manner as chloral and m the same doses. Veronal is a good hypnotic and may be used in doses of from 1 to 2 gr. It is best prescribed in powder and given stirred up in a spoonful of water or milk. Trional is sometimes used in doses of 1 gr. or a little less for each year of the child's age. Prescribe in powders to be stirred into water or milk. Sulphonal may be used in doses of from 1 to 8 gr. It takes several hours before the effect is produced. Bromids. — These are useful in nervousness, after convul- sions, and in epilepsy. Small doses often produce sleep in children. Sodium bromid is to be preferred as being less irritating than either potassium or ammonium bromid. Com- binations of all three are frequently advised. Bromids are best given in essence of pepsin or in the aromatic waters, as peppermint water. Bromipin (10 percent, brominized sesame oil) is frequently used in epilepsy where it is to be continued for a long time. It may be given in from J to 1 dr. doses three or four times a day. Stimulants. — Alcohol. — This is a most useful drug when given in proper-sized doses, It is also of value as a 486 DISEASES OF INFANTS AND CHILDREN. food in long- continued fevers. It should not be given in high sthenic fevers where there is a full-bounding pulse and a flushed face. In infants pure old whisky diluted at least eight times with water is the best. Pure brandy may be substituted. In vomiting, teaspoonful doses of iced champagne are some- times useful. In older children sherry wine or other wines may be used if desired, or the spirits may be continued with a bitter tonic. The dosage varies with the effect produced. The doses should be small and repeated often. Large doses may cause mental symptoms which are most undesirable. If the odor of alcohol is apparent on the breath, too much is being given. From 5 to 30 drops of whisky may be given at a dose, according to the age and condition of the child. 5 or 10 drops of gin in a little sweetened water is a good carminative in infantile colic. The time-honored brandy-and-egg mixture of Stokes is a useful means of combining food and a stimulant. The fol- lowing is the formula as modified for infants by Louis Starr : Yolk of a raw egg ; 10 drops of brandy ; 1 teaspoonful of cinnamon water ; 1 coffeespoonful of white sugar. Beat together into a smooth mass. Strychnin. — This is useful as a tonic and as a stimulant. Nux vomica is much used as a bitter tonic for older children. Strychnin is best given in small doses well diluted with water. From T -^- to -^ gr. may be given at a time, according to the age of the child. If it causes twitching it should be stopped and smaller doses given subsequently. In giving stimulants it is well to alternate whisky and strych- nin at from two- to four-hour intervals. Do not stimulate too early. Do not use too large doses of stimulants. Re- member, stimulation is usually overdone. Merck's digitalin is a useful heart stimulant. It may be given in doses of from T ^ to -^ gr., according to the age of the patient. It is non-cumulative in its action. Do not confuse this with the ordinary digitalin. Camphor. — This is much used in Germany as a stimulant. THERAPEUTICS FOR INFANTS AND CHILDREN. 487 The dose is from \ to 3 gr. It is usually given hypo- dermatically in 10 per cent, solution in sterilized oil. Digitalis. — This is useful in uncompensated heart disease. In aortic disease it should not be used except as the last resort. The infusion is frequently used as a diuretic. Belladonna and Atropin. — These are both well borne in early life. They are used as stimulants sometimes, but espe- cially to allay irritability, as in whooping-cough. They arc used in enuresis. Large doses are advised in intussusception. The dose should be small at the outset, and increased until slight flushing of the face is observed, twenty or thirty minutes after administration. Blondes require less than brunettes. Overdoses cause a red rash, dry throat, and mydriasis. Too large doses may cause delirium. The dose of the tincture is from 1 to 10 drops ; of the extract, -^ gr. for one year, -^ gr. for two years, -^ gr. for three years, etc. Atropin is best given in solution. Add 1 gr. to 2 oz. of water ; each drop represents 1 ^ 0Q gr., and 1 drop may be given for each year of the child's age, and the dose increased gradually. Do not prescribe strong solutions of atropin where the people are ignorant or careless. Hyoscyamus. — Tincture dose, 1 to 5 min. This is a useful antispasmodic in cystitis, vesical spasm, and whooping cough. R Tincture of hyoscyamus 2 (^ss) ; Potassium citrate 4 f.^j) ; Water q. s. ad 120 (Jiv).— M. Sig. — Teaspoonful in water every two hours. (Two years.) The fluid extract, dose J- to -J- min., is frequently used, in chronic constipation, combined with nux vomica and other drugs. Tonics. — The most important of these are iron, cod-liver oil, and the bitter tonics, such as nux vomica and quinin. Cod-liver oil may be given plain in doses of J a tea- spoonful to a tablespoonful. Small doses are to be preferred, as they do not upset the stomach. A drop or two of oil of wiutergreen added to the bottle of oil makes it more palatable for some children. Do not give cod-liver oil in very hot 488 DISEASES OF INFANTS AND CHILDREN. weather. See that the oil is fresh. Emulsions of cod-liver oil may be used when the plain oil is not well borne. R Cod-liver oil 60.0 ffij); Dry extract of malt 15.5 (^iv) ; Calcium hypopkosphite, Sodium hypopkosphite aa 1.0 (gr. xvj); Potassium kypophosphite 0.5 (gr. viij) ; Glycerin . 7.5 (gij); Pulverized acacia 15.0 (^iv); Water q. s. ad 120.0 ( t ^iv).—M. Sig. — Teaspoonful three times a day. . (Louis Starr.) Iron. — The syrup of the iodid of iron is one of the best preparations for use in childhood. From 5 to 40 drops may be given at a dose three or four times a day. The astringent iron preparations should not be used in infancy, and but little during later childhood. The solution of iron and manganese peptonate, although not officinal, is an excellent way in which to prescribe iron. The dose for infants and young children is from 10 drops to a teaspoonful. Ferrosomatose in doses of from 5 to 10 gr. may be added to milk or broths. Reduced iron, lactated iron, and the saccharated carbonate may all be prescribed in from J- to 2-gr. doses in powders. The bitter wine of iron is frequently prescribed — it may be advantageously added to an aromatic. Arsenic. — This is a valuable tonic in anemic and other conditions. Fowler's solution (liquor potassae arsenitis) is most frequently used in doses of from 1 to 10 drops three times a clay. Arsenious acid in doses of ^-q- gr. or less is often prescribed. Alteratives. — Mercury. — This is most frequently used as a purgative in the form of calomel. Tablet triturates, with or without bicarbonate of soda, are generally employed. It is best given in doses of y 1 -^ gr., repeated every half hour or every hour, and followed in older children by a saline if necessary. Mercury with chalk is often used in doses of from y 1 ^ to 1 gr. THERAPEUTICS FOR INFANTS AND CHILDREN 489 In syphilis calomel (y 1 ^- gr.), mercury with chalk (1 gr.), or bichlorid (y-J-y gr.), given three or four times a day, are most frequently used. Mercurial ointment is used externally once or twice daily. In late syphilis, mercury and the iodid of potassium may often be advantageously combined as follows : R Bichlorid of mercury 0.03 (gr. ss) ; Iodid of potassium 4.0 (3J); Compound syrup of sarsaparilla .... 60.0 (^ij); Water q. s. ad 120.0 (giv).— M. Sig. — Teaspoonful in water four times a day. Iodin. — This is of great value in late syphilis and in strumous conditions. Sodium or potassium iodid are the most frequently used preparations. The former is said to be less irritating to the stomach. They are best given in essence of pepsin. The dosage varies from 5 gr. up to 1 dr. or more. Iodin ointment is frequently used externally. R Iodin 0.06 (gr.j); Iodid of potassium .... .... 4.0 (3J)> Vaselin 30.0 (^j). M. and make into an ointment. Iodoglycerin is frequently used as an application to mucous membranes. R Iodin . . . 0.06 (gr.j); Iodid of potassium 1.3 (gr. xx) ; Glycerin 30.0 (|j).— M. External Use. — Potassium Chlorate. — Dose, J to 2 gr. This may be given in a saturated solution, of which each teaspoonful represents 4 gr. It should be well diluted. It is almost a specific for ulcerative stomatitis, and is useful in follicular tonsillitis. It may be given alone or combined with iron. R Potassium chlorate 1.5 (gr. xxiv) ; Syrup of orange 30.0 (j§j); Water q. s. ad 90.0 (Jiij).— M. Sig. — Teaspoonful every two or three hours. (Two years), or 490 DISEASES OE INFANTS AND CHILDREN. R Potassium chlorate 1.5 (gr. xxiv) ; Tincture of the chlorid of iron .... 2.5 (n\,xxxvj) ; Syrup of ginger 15.5 Qfss) ; Water q. s. ad 90.0 siij).— M. Sig. — A teaspoonful in water every two hours. (Louis Starr.) Stomachics. —Aromatic and bitter tonics are often used either to excite an appetite and for their tonic effect or to allay an irritable stomach. Pepsin is frequently added to such mixtures, or they may be combined with alkalies. R Tincture of nux vomica 1.5 (rr^xxiv) ; Essence of pepsin (Fairchild's) .... 15.5 (^iv); Aromatic elixir q. s. ad 90.0 (^iij). — M. Sig. — Teaspoonful in water three times a day. R Tincture of nux vomica 2.0 (^ss); Dilute hydrochloric acid 8.0 " ( 3 i j ) ; Essence of pepsin 15.5 (,^iv) ; Aromatic elixir q. s. ad 90.0 (,^iij). — M. Sig. — Teaspoonful in water three times a day. The aromatic waters, as anise water, cinnamon water, fennel water, or peppermint water, are frequently used to allay pain in the stomach and to facilitate the expulsion of gas. The dose is from 10 ruin, to 1 dr. They are much used as vehicles for other drugs. An aromatic water and an alkali are very efficacious in checking vomiting and allaying nausea, as R Lime water, Cinnamon water . aa 60 (,^ij). — M. Sig. — A teaspoonful every fifteen or thirty minutes as needed. Dr. Louis Starr recommends effervescing draughts for the same purpose, especially where there is fever, as Solution No. 1 : R Citric acid 5.5 (.^iss) ; Water 90.0 |iij).— M. Solution No. 2 : R Potassium bicarbonate 4.0 (3J); Water 90.0 (ijiij).— M. Sig. — Mix a teaspoonful of each in a glass and drink while it effervesces Dilute with water if desired. THERAPEUTICS FOR INFANTS AND CHILDREN. 491 Another prescription of use in chronic vomiting in in- fants is & Solution of potassium arsenite (Fowler's soution) 0.75 (TTLxij); Sodium bicarbonate 1.50 (gr. xxiv) ; Peppermint water 90.0 (jfiij). — M. Sig. — One teaspoonful three times a day. Cerium oxalate is frequently prescribed for vomiting. The dose is from J to 3 gr., given in powders. Digestants. — Pepsin. — This is frequently prescribed either in scale pepsin (dose, 1 to 2 gr.) or in solutions, as the esseuce of pepsin, which is given in doses of from 10 min. to 1 dr. Taka-diastase is useful in starch indigestions. To chil- dren it is best given in solution in doses of 15 min. to 1 dr. Cathartics. — There are a great many drugs under this head. The most useful are the following : Castor Oil. — Dose, 1 dr. to 1 oz. Castor oil is one of the most valuable drugs we have. In almost every acute illness it is desirable to thoroughly empty the bowels at the start. Castor oil does this effectually and is not irritating to the bowel. It may be diluted with olive oil for very young infants. Ritter gives the following formula for palatable castor oil : £ Saccharini 0.12 (gr. ij) ; Olei menthse piperita? 0.30 (gtt. v) ; Alcoholis, q. s. M. fiat sol. et adde ; Oleiricini 240. (^viij).— M. Calomel (see Mercury). — One of the most valuable cathar- tics, especially in cases where there is nausea and vomiting. Magnesia. — This is frequently used. Calcined magnesia may be given in doses of J of a teaspoonful. In smaller doses it is useful as an antacid. Milk of Magnesia (Phillips). — This is useful as antacid and laxative. The dose is from 1 to 4 teaspoonfuls. Sulphate of Magnesia {Epsom Salts). — This is a useful saline for older children. It may be given in doses of J dr. to J oz. The following is a valuable hospital mixture : 492 DISEASES OE INEANTS AND CHILDREN. R Magnesium sulphate, q. s., to make saturated solution. Aromatic sulphuric acid 4.0 (^j); Water 120.0 (^iv).— M. Sig. — One to two teaspoonfuls in a little water. Kepeat m an hour or two if necessary. Citrate of Magnesia. — This is an effervescent solution of pleasant taste. It may be given to children in doses of from 1 tablespoonful to 1 wineglassful. Rhubarb. — This is a useful stomachic and laxative. It is of especial value in mild diarrhea. The aromatic syrup is the Best preparation for children, and can be given in doses of J to 1 dr. The syrup is sometimes used in similar doses. The rhubarb and soda mixture is used in doses of J to 2 dr. R Sodium bicarbonate 1.5 (gr. xxiv) ; Aromatic syrup of rhubarb 15.5 (,^ss) ; Simple syrup 30.0 (jfj); Peppermint water q. s. ad 90.0 (|iij).— M. Sig. — A teaspoonful at a dose. (At two years. ) Cascara Sagrada. — This is a useful laxative. The dose of the fluid extract is from 5 to 15 drops. It is often pre- scribed in equal parts of simple syrup and water. The aromatic extract in doses of from J to 1 dr. may be pre- scribed. Preparations of cascara are now made in palatable form by the manufacturing chemists. Manna. — This is pleasant to taste and useful. From half to a teaspoonful may be given to the child to eat. The following is a useful laxative for infants : R Manna, Magnesium carbonate aa 8.0 (,"ij); Fluid extract of senna 15.5 (^ss); Simple syrup 30.0 yf j) ; Peppermint water q. s. ad. 90.0 (^iij). — M. Sig. — One teaspoonful two or three times a day. ( Louis Starr. ) Senna. — This is very useful. Senna leaves may be added to stewed prunes and make a pleasant laxative. There is a confection of senna containing tamarinds and senna (dose, J-l dr.), and it is also one of the ingredients of compound licorice powder. The syrup of senna is usually given to children in doses of 5 drops to 1 dr. Diuretics. — These are useful in fevers and to assist in THERAPEUTICS J"i: INFANTS AND CHILDREN. 193 the absorption of serous effusions. Mixtures of calomel and digitalis and squills are useful in the edema due to heart disease. The infusion of digitalis is also of value in such eases. Potassium Acetate. — Dose, 3 to 5 gr. Usually given in simple syrup or syrup of lemon and water. Potassium Bitartrate [Cream of Tartar). — Dose, 1 to 10 gr. ; in larger doses is laxative. Is useful in fevers as the Imperial Drink, which is made by pouring a pint of boiling water over a teaspoonful of cream of tartar and adding the juice of a lemon. It is given cold as a beverage. Solution of Ammonium Acetate [Liquor Ammonii Acdatis, Spirit of Jlindererus). — Dose, 5 drops to 1 dr. This is fre- quently used as a fever mixture. Iron and Ammonium Acetate Mixture (Basham's Mixture). — This is frequently used as a diuretic and tonic in chronic nephritis, and where it is desirable to produce diuresis in anemic subjects. For children tbe dose is from J to 1 dr. Diuretin (Sodiotheobroiaiii Salicylate). — This is given in doses of from 2 to 10 gr. It usually produces free diuresis. It is best given in powders or capsules, followed by water. Diaphoretics. — Sweet spirit of niter is the most fre- quently used diaphoretic. It is usually prescribed in doses of two minims to half a dram combined with simple syrup or some aromatic water. It is frequently used in fever mix- tures. Spirit of mindererus is also used as a diaphoretic in fever mixtures. Expectorants and Cough Mixtures. — Ipecacuanha. — This is of great service in increasing and thinning the bronchial secretions. In small doses it forms part of many cough mixtures. The syrup is usually given in doses of 1 to 5 drops and the wine in J- to 2-drop doses. Larger quantities produce nausea and vomiting. Teaspoonful doses repeated every fifteen minutes until vomiting occurs may be used to empty an overloaded stomach or to afford relief in bronchitis when the mucus is filling up the tubes and cannot be coughed up. 494 DISEASES OE INFANTS AND CHILDREN. Dover's Powder is frequently used. (See Opium.) Antimony and Potassium Tartrate (Tartar Emetic). — This is used in bronchitis and catarrhal spasm of the larynx. It is best given in tablet form in doses of -^q *° Tiro °^ a grain. It may be combined with an equal quantity of ipecac. R Antimony and potassium tartrate . . . 0.0016 (gr. ^q) ; Solution of ammonium acetate 15.5 (^ss); Syrup of tolu 30.0 (|j); Water q. s. ad. 90.0 (jfiij).— -M. Sig. — One teaspoonful every three hours. (Four to six years.) Ammonium Chlorid. — This is one of the best stimulating expectorants. About J- gr. may be given for each year of the child's age. It is frequently added to cough mixtures, par- ticularly to the compound licorice mixture (brown mixture). Senega. — This is a stimulating expectorant of especial value in the later stages of bronchitis where difficulty is ex- perienced in raising the large quantities of secretion. The syrup is prescribed in doses of 5 to 10 min. or more and the fluid extract in doses of 1 to 5 min. Balsam of Tolu. — This is used in the form of the syrup of tolu and makes a pleasant vehicle for other expectorants. Squills. — This is one of the most valuable expectorants and is of especial value after the first stage of bronchitis. The syrup is most frequently used in 2- to 10-drop doses. The time-honored Jackson mixture is an efficient cough mix- ture for young children. R Syrup of squills 8 f.^ij); Oil of sweet almonds 15 ( ^ss) ; Mucilage of acacia 15 (.5ss) ; Syrup of tolu q. s. ad. 120 (giv).— M. Sig. — Shake well. One-half to one teaspoonful every two or three hours. (One to three years.) The compound syrup of squills contains f- gr. of tartar emetic to each J oz., and should be used with caution, if at all, for young children. Terpin Hydrate. — Dose, 1 to 5 gr. Useful as an expec- torant in bronchitis. It is frequently combined with heroin in an elixir. THERAPEUTICS FOR INFANTS AND CHILDREN. 495 Licorice. — This is used as a vehicle for quinin, the elixir being the best preparation. Combined with paregoric, sij, wine of antimony, 3J, and sweet spirits of niter, §ss to the pint, it is the compound licorice mixture or brown mixture frequently used for coughs, either alone or with ipecac, squills, ammonium chlorid, or senega. For children it is advisable to have it made with half the quantity of pare- goric. The dose is from 10 drops to a teaspoonful. The compound licorice powder (dose 10 gr. to 1 dr.) is used as a laxative. Creosote. — This is a most valuable drug, and is used in bronchitis, tuberculosis, bronchiectasis, pulmonary gangrene, and also as an intestinal antiseptic. It is used as an inhala- tion (see Inhalations) or internally. From J to 2 drops are given at a dose. For internal use in young children the liquid beef peptonoids with creosote is the best preparation to use. From 10 drops to 2 dr. may be given at a close. Creosote Carbonate (Creosotal). — This is an excellent preparation, and may be given in place of creosote. It rarely causes any disturbance of the stomach. It may be given in syrup or glycerin and w T ine. The dose is 1 drop for each year of the child's age up to ten. Guaiacol. — This is useful in follicular tonsillitis. It should be combined with an equal part of glycerin and applied directly into the crypts of the tonsil by means of cotton on a very fine-pointed probe. Guaiacol Carbonate (Duotal). — This is used in exactly the same indications as creosote. It is administered in powders or in capsules for older children. The dose is from 1 to 8 gr. Heroin. — This is a useful cough sedative, and may be used to diminish the intensity and frequency of cough as well as to allay irritability. It is most useful in whooping-cough. It is best given in an elixir, and may be combined with terpin hydrate. From -g-J-g- to -^ gr. at a dose. The hydro- chlorate is always prescribed when solutions are ordered. When prescribing with opium or its derivatives the aggre- gate should not exceed the maximum of any single one of the group. 496 DISEASES OF INFANTS AND CHILDREN. Antacids. — This class of drugs is much used in infancy to correct hyperacidity, allay colic, and in intestinal disor- ders. Magnesia is useful, especially when a laxative effect is desired. (See same.) Sodium Bicarbonate. — Dose, 1 to 10 gr. This is useful alone or combined in an aromatic water or with the aromatic syrup of rhubarb. Aromatic Spirit of Ammonia. — Dose, 1 to 30 drops. This is a useful stimulating antacid, used with or without other alkaline drugs. It is often prescribed for colic. Anthelmintics. — Santonin. — This is a specific for ascaris, and may be tried in obstinate cases of oxyuris. It is best given in doses of \ or \ gr., combined or followed by calomel. Four to six doses are usually prescribed. Oleoresin of Male Fern. — This is the best remedy for tapeworm. It is given in \ dr. or 1 dr. doses, either in capsules or in an aromatic vehicle. It should be given on an empty stomach, and the intestinal tract should be previously emptied by means of an active cathartic. A cathartic should be used several hours after the male fern has been given. R Oleoresin of male fern 4 (^j) ; Mucilage of tragacanth 15 ('^ss) ; Syrup of ginger 8 (^ij) ; Water q. s. ad 60 (gij).— M. Sig. — Two tablespoonfuls at a dose. Pelletierin Tannate. — Dose, 2 to 4 gr. This is sold in bottles containing the adult dose, about half of which may be given to a child. The same precautions should be used as for male fern. The dose may be given in sweetened water. Astringents and Drugs Useful in Diarrhea.— Chalk Mixture. — This is a useful aromatic antacid mixture containing chalk, gum acacia, syrup, and cinnamon water. A teaspoonful or two may be given at a dose. It is an excel- lent vehicle for bismuth. Bismuth. — This is one of the best drugs to use in summer diarrhea. THERAPEUTICS FOR INFANTS AND CHILDREN. 497 Bismuth Subnitrate. — Dose, 5 to 30 gr. The best bismuth preparation. Give 1 or 2 dr. a day. R Bismuth subnitrate 15 f^ss) ; Chalk mixture 90 (giij).— M. Sig. —A teaspoonful every two hours. (One year.) Bismuth Subcarbonate. — Dose, 1 to 10 gr. More astrin- gent than the subnitrate. ]& Bismuth subcarbonate 8 (313) ; Essence pepsin 15 (3iv); Mucilage of acacia 15 (giv) ; Elixir aromatic q. s. ad 90 (^iij). — M. Sig. — Shake well. Teaspoonful every two hours. Bismuth Salicylate. — Bismuth subgallate. Dose, 1 to 5 gr. Useful alone or in combination. Beta-naphthol Bismuth. — Dose, 1 to 3 gr. A most pow- erful intestinal antiseptic. Very constipating. Is of marked value when the stools are loose and foul-smelling:. '&' R Beta-naphthol bismuth, Bismuth salicylate aa 1.5 (gr. xxiv). — M. Sig. — Make twelve powders. One every two horn's. Tannin. — Various tannic acid derivatives are employed internally in summer diarrhea in doses from 1 to 10 gr. Among them are tanigen, tannalbin, tannopin, and protan. Thev are best administered in powder form. Antirheumatic Remedies. — These include the salicyl derivatives and similar preparations. They are used in rheumatism to relieve pain, and some of them in stomach and intestinal disorders. Aspirin. — This is an excellent substitute for sodium sali- cylate, and is given in the same doses. It is best given in capsules. Salicylic Acid. — Dose, 1 to 5 gr. This is used in the same indications as sodium salicylate. Small doses are usually well borne. Larger doses are liable to cause vom- iting. Sodium Salicylate. — Dose, 1 to 10 gr. This is generally used as an antirheumatic and to check fermentation. For 32 498 DISEASES OF INFANTS AND CHILDREN. the former purpose it is given in full doses ; for the latter small doses suffice. It may be given in essence of pepsin or as follows : R Sodium salicylate 4 (^j) ; Solution of ammonium acetate 15 (J;ss) ; Syrup of orange 30 ( 5 j ) ; Water q. s. ad 90 (liij). — M. Sig. — Teaspoonful every three hours. rx Sodium salicylate 1 (gr. xvi) ; Syrup of ginger 8(313); Peppermint water ...... q. s. ad. 60 ( ^ij). — M. Sig. — One teaspoonful every two hours. (For a child of two years.) Salol. — Dose, 1 to 5 gr. This is used in rheumatism, in- testinal disorders, and cystitis. It decomposes in the intes- tine into salicylic acid and carbolic acid. Small doses are generally well borne, but larger ones are liable to cause vomiting. R Salol 1 (gr. xvi) ; Aromatic elixir 8 ( ,^ij ) ; Water q. s. ad. 60 (^ij).— M. Sig. — Teaspoonful every two hours to a child of two years. Salophen. — Dose, 1 to 5 gr. This is useful in neuralgia and rheumatism. Salipyrin. — Dose, 1 to 5 gr ; used in same indications as salophen. Antispasmodics for Whooping-cough. — Bella- donna, antipyrin, heroin, quinin, and many other drugs are used. Bromoform. — Dose, 1 to 5 drops. Do not give over 15 or 20 drops a day. A useful but dangerous drug. Do not prescribe it for ignorant or careless people, as there is danger of poisoning from overdoses. In emulsions there is danger that the last dose will contain too much. Urogenital Antiseptic. — Hexamethylenamin (Urotro- pin). — Dose, 1 to 5 gr. This is best given in water. It is very useful in all conditions in which pus is found in the urine. To Render Urine Acid. — Monosodium phosphate, grains 1 to 5 or more in sweetened water. Benzoic acid may be used in older children, but it is liable to cause nausea. THERAPEUTICS FOR INFANTS AND CHILDREN. 499 Vasomotor Stimulant. — Ergot. — The fluidextract is used in doses of J to 2 drops. It is best given in simple syrup and water. It is useful in hemorrhages and in atony of the intestines. Antimalarial Remedies. — Quinin. — Used in malaria and useful as a bitter tonic. May be given by mouth, rec- tum, or in extreme cases subcutaneously. Abscesses are liable to result from the last-named procedure. Quinin Tannate. — In 1-gr. chocolate tablets. The quinin is tasteless, and the tablets are readily taken by children. Euquinin. — Dose, 1 to 2 gr. This is also tasteless. Syrup of cinchona alkaloids is also tasteless and pleasant to take. Quinin Sulphate. — Dose, -J gr. per month for the first year ; later, from 1 to 5 gr. This may be given in warm choco- late, in syrup of yerba santa or in the elixir of licorice. It should be added to the vehicle just before taking, otherwise a bitter taste develops. Quinin Suppositories: R Quinin hydrochlorate 0.4 (gr. vj) ; Cocoa butter 12.0 (giij).— M. Sig. — Make 12 suppositories. One every six hours. Quinin hypodermaticaUy (Bacelli's formula) : R Quinin hydrochlorate .... = ... 1.0 (gr. xv) ; Sodium chlorid 0.06 (gr. j); Distilled water 10.0 (giiss).— M. Remedies for the Common Skin Diseases. — Acute Eczema : R Oxidofzinc 8 (.^ij) ; Prepared calamine 12 (.^iij) ; Lime water 250 (^viij). — M. Sig. — Apply on gauze to the affected part. R Oxid of zinc 8 (^ij) ; Prepared calamine 12 (giij); Glycerin 30 (|j) ; Lime water 60 C.fij); Rose water 250 (;fviij). — M. Sig. — Apply on gauze to the affected part. 1 per cent, carbolic acid may be added to either of the above if there is much itching. 500 DISEASES OF INFANTS AND CHILDREN. Lassar's Paste : R Salicylic acid 0.65 (gr. x) ; Oxid of zinc, Starch aa 8.0 (^ij ) ; Vaselin 30.0 (&).— M. Sig. — Apply several times a day to the affected part. Pick's Paste : R Pulverized tragacanth 4 (gj) ; Glycerin 6 (giss) ; Bose water q.s.ad 120 (^iv). — M. Sig. — To this may be added various medicaments, as zinc oxid (40 gr.), tar (10 min.), or carbolic acid (5 gr.). Tar Ointment: R Ointment of liquid tar 4 (gj ) ; Ointment of zinc oxid 30 (^j). — M. Sig. — External use. Carbolic Acid Ointment : R Carbolic acid 0.3 (gr. v) ; Ointment of zinc oxid 30.0 (^j). — M. Dusting Powder : R Zinc oxid 30 (gj) ; Pulverized starch 120 (^iv). — M. Sulphur and Salicylic Acid Ointment : R Salicylic acid, Sulphur aa 4 (^j) ; Vaselin 30 (3j).— M. Sulphur Ointment: R Sulphur 4 (3j); Vaselin 30 (]jjj).— M. For Scabies : Sulphur and Balsam of Peru Ointment : R Sulphur 4(3J); Balsam of Peru . 15 (,^ss) ; Vaselin 30 (Jj).— M. Resorcin Ointment : R Kesorcin 0.65 (gr. x) ; Ointment of rose water 30.0 (^j). — M. Sig. — Useful in seborrhea and chronic eczema. THERAPEUTICS FOR INFANTS AND CHILDREN. 501 Parasitic Ointment. — For children the ointment of ammoniated mercury (white precipitate) is most satisfactory. It should not be applied to too large an area. Ichthyol. — Useful in 5 to 10 per cent, ointment as an application for various skin diseases and glandular swellings. H Ichthyol 8 (^ij) ; Ether, Glycerin . aa 15 (Jjss). — M. Sig. — Apply with a brush. For i/ocal Inflammations : B Acetate of lead . 2.7 (gr. xl) ; Tincture of opium . . . . „ .... . 15.0 (fss); Water 250.0 (gviij).— M. Sig. — Apply on gauze to the affected part. Carron Oil : R Linseed oil, Lime water aa 120 (^iv). — M. Sig. — Apply to affected part. A good substitute for carron oil : R Oil of sweet almonds, Lime water aa 120 (^iv). — M. Sig. — Useful in inflammations of the rectum and chafing. I^scharotics. — Powdered burnt alum is a simple appli- cation to check the growth of granulation tissue and also as an application in stomatitis. It is best applied with a small camel ? s-hair pencil. Silver nitrate, generally used in the shape of a stick of lunar caustic, is useful to cauterize the ulcers in herpetic stomatitis, etc. It is quite painful. Stomach Washing (see Gavage). — The procedure is the same as for gavage. The stomach is filled with tepid water, which is allowed to siphon off. This procedure is repeated until the water comes back perfectly clear. If there is mucus in the stomach it is advisable to add a teaspoonful of sodium bicarbonate to each pint of water. Boric acid is sometimes used in the same quantity where there is fermenta- tion. Irrigation of the Colon. — This is useful in diarrheal 502 DISEASES OF INFANTS AND CHILD HEN. diseases. The infant is laid face downward on the nurse's lap. A piece of rubber sheeting is arranged to carry the water into a slop-jar. The floor should be protected for several feet by rubber sheeting or oilcloth. A well-oiled catheter is attached to the nozzle of a fountain syringe. The catheter is introduced into the anus with a slight twisting motion. As soon as it is in the rectum the water is allowed to flow in and the catheter inserted to nearly its full length. It is desirable to have it go high up in the colon, but it fre- quently doubles up in the rectum. The water is allowed to flow in, and when the bowel is full it will be ejected around the catheter. This is continued until the water returns clear. Before the catheter is removed any astringent or other appli- cation, as desired, is introduced through it. Enemata. — For the purpose of cleansing out the rectum and lower bowel, from half a pint to a pint and a half, ac- cording to the size of the child, of warm water made soapy with Castile soap may be allowed to flow into the rectum from a fountain syringe or funnel and tube. The nozzle or tube should be well oiled. The child should be face downward on the nurse's lap or bed. For infants, to stimu- late the bowel to move, small rubber bulb syringes holding an ounce or two may be used to advantage. The small one- piece soft bulbs used for washing out the ear are particularly suitable for this purpose. Normal salt solution is sometimes used, and sodium bicarbonate (3J to Oj) if there is much mucus, and boric acid (sj to Oj) if there is inflammation of the bowel. Quinin solutions are used in thread worms. Small injections (ass to ij) of boiled starch solution, to which from J to 5 minims, according to age, of tincture of opium have been added, is useful in relieving tenesmus. Fluidextract of hamamelis (3j to sviij) is one of the best astringents, and may be used in the relaxed conditions of the mucous membranes common in summer diarrheas. Silver nitrate (gr. 1 to Oj) may be used in ulcerative colitis. Enemata of normal salt solution are also used to relieve thirst and supply fluid in cases of great weakness, as in marasmus, in continuous vomiting, after hemorrhage, and plain water enemata may be used in nephritis. THERAPEUTICS FOR INFANTS AND CHILDREN. 503 Hot-air Bath. — This is used to promote sweating in threatened uremia, etc. The bedclothes are raised from the child by means of a wire frame (one can be improvised by using barrel-hoops) and hot air introduced through an elbow of stovepipe. A Bunsen burner or an alcohol lamp is used to furnish the heat. The bath is continued for from ten minutes to half an hour or even longer. Hot Pack. — This is often an efficient way of causing sweating. A rubber sheet is placed on the bed aud an old blanket is laid on this. The child is wrapped in a large Turkish towel or an old blanket which has been dipped in hot water. The blanket is folded over the child, and he is allowed to remain from ten to twenty minutes. Hot Bath. — This is often used in place of the above, the child being .wrapped in blankets inimediatelv afterwards. Salt Bath. — Use a tablespoonful of salt to a gallon of water. This may be used hot or cold, and may follow the ordinary bath if desired. The child is kept in from five to ten minutes, with friction. It is used as a tonic in poorly nourished children. Soda Bath. — A heaping teaspoonful of bicarbonate of soda is used to each quart of warm water. The child should remain in the bath five minutes, with little or no friction. This is useful in diseases where there is itching, as in urti- caria and prickly heat. Bran Bath. — A quart of bran is placed in a cheese- cloth bag, then immersed in the bath and squeezed about until the water becomes milky white. It is used in bathing children with irritating skin lesions and in eczemas. Starch Bath. — Two heaping tablespoonfuls of starch are placed in the bath. It is used for exactly the same con- ditions as the bran bath. CotmterirritantS Only mild counterirritants should be used in infants and children. Blisters and wet cups should not be used, and dry cups but rarely. Camphorated Oil. — This is a mild and efficient liniment much used in bronchitis as an application to the chest- Mustard Plaster. — For children this should be made weak ; 504 DISEASES OF INFANTS AND CHILDREN. 1 part of mustard to from 1 to 6 parts of wheat flour. This is made into a smooth paste and spread between two pieces of cloth or paper. It should be left on until the skin becomes reddened, and the skin should be looked at every two or three minutes to see when this occurs. The skin should be wiped dry. The application may be repeated every few hours if desired. If the plaster is left on too long, the skin will be blistered and further application will be impossible. Mustard Pack. — This is sometimes resorted to in cases of convulsions and in other conditions where it is desirable to bring the blood to the surface. Four tablespoonfuls of mustard flour are moistened thoroughly and stirred into about 2 gallons of hot water. A large towel is saturated with this and the body wrapped in it and then in an old blanket. As soon as the skin becomes reddened the mustard application is removed and the skin thoroughly dried. Mustard Bath. — This is more efficient than the above, but for larger children is often not as conveniently given. Four tablespoonfuls of mustard flour are stirred up with a little water in a cup and the whole stirred into a foot-tub (about 5 gallons) of water. This should be between 101° and 105° F. The child is left in the bath from two to ten minutes, and it may be repeated if necessary. Turpentine Stupes. — These are frequently used over the abdomen or chest. From 1 teaspoonful to 1 tablespoonful of turpentine is added to 1 quart of boiling water. A towel is dipped in this, wrung out, and applied as hot as the hand can bear (do not have it too hot) ; cover this with several layers of woolen cloth. Allow it to remain until the skin is thoroughly reddened. Spice Bag. — The old-fashioned spice bag, made by sewing up in a bag 1 or 2 teaspoonfuls of each of the powdered spices, is a convenient application in colic and the milder pains of childhood. It is placed in hot water, thoroughly squeezed out, and placed upon the painful spot. It is left on until the skin is reddened. I/iniments. — Stokes's, chloroform, and other stimulating THERAPEUTICS FOE INFANTS AUD CHILDREN. 505 liniments are often used ; eare should be taken not to blister the delicate skin of the child by too strong or too frequent applications. Inhalations. — Various drugs are used specially in the treatment of diseases of the larynx and bronchi. The drugs to be vaporized are usually added to water and boiled either in a fruit kettle or in a small teapot. Plain lime-water is often used in bronchitis, and creosote, eucalyptol, compound tincture of benzoin, in proportion of a dram to a pint, are also of service. A few grains of menthol may be added to the last named if desired. Nasal Sprays and Washes. — For cleansing the nose normal salt solution (^ of 1 per cent.), Seller's solution, or Dobell's solution are the most frequently employed. The best method is to use a fountain syringe, having the bag one foot above the nose. The patient may be lying down, in which case the nozzle is placed in the nostril which is upper- most, and the head may be turned to the other side for the other nostril, or the child may be held in the upright posi- tion, the head somewhat forward. The child should breathe through the mouth while the nose is being sprayed. In young infants and children, where it is necessary to cleanse the throat, the fountain syringe may also be used to ad- vantage, the child holding its head face downward over the edge of the bed. Oil sprays used in an atomizer or, in case of young infants, dropped in the nose by a medicine-dropper are of great service (see Coryza). Subcutaneous Injection of Saline Solution. — This is of great service where the fluid content of the body has been rapidly reduced, as in some forms of diarrhea and vomiting. From 1 to 5 ounces of a 0.9 per cent, solution (a teaspoonful to a pint, roughly speaking) of sodium chlorid in sterile water may be given at a time. The injection is given with a funnel, a piece of rubber tubing, which should be interrupted by a piece of glass tubing, and an aspirating needle. Strict aseptic precautions should be used. The loose tissue about the abdomen is ordinarily the best place to give the injection, and the wound should be sealed with collodion. 506 DISEASES OF INFANTS AND CHILDREN. Vaccine Therapy. — This is still in the experimental stage, but certain vaccines are of recognized value either in the prevention of disease or in its treatment. Stock vaccines are prepared from laboratory cultures of the organisms with- out reference to their source. Autogenous vaccines are pre- pared from the organism derived from the patient to be treated. As a general rule the autogenous vaccines are to be preferred, but in many cases stock vaccines are nearly or just as effica- cious and much less expensive. The dose varies with the different organisms. The dose is generally repeated between the sixth and tenth day. If reactions follow the doses must be smaller and the longer intervals used. Typhoid. — Stock vaccines may be used to produce an im- munity, three doses being given at intervals of ten days. From 100,000,000 to 500,000,000 bacilli may be used at a dose. Injections are best given about five o'clock in the afternoon, so that if any reaction occurs it will be during sleep. Occasionally fever for twenty-four hours is noted. Gonococcus. — This is sometimes used in chronic cases of vulvovaginitis which resist other forms of treatment. Five million may be given for the first dose, and this may be in- creased gradually up to 50,000,000. Streptococcus. — In streptococcus infections, apart from scar- let fever and in erysipelas, these may be tried. The autog- enous vaccine is to be preferred — the dose may vary from 2,000,000 for babies under one year of age to two or three times that amount between one and two years and from 10,000,000 to 30,000 ; 000 for older children. Staphylococcus. — The best results are obtained in treatment in furunculosis, acne, styes, otitis media, osteomyelitis, em- pyema, and infection of the various sinuses. Autogenous vaccine is to be preferred, but stock vaccines in many cases are efficient. The variety of staphylococcus should be de- termined or mixed vaccines may be used if this is imprac- ticable. The dose may vary between 50,000,000 and 100,000,000, sometimes more may be given. Meningococcus. — In widespread epidemics of cerebrospinal fever three doses have been suggested to produce immunity. THERAPEUTICS FOR INFANTS AND CHILDREN. 507 Five million has been suggested as the first dose and 1,000,000,000 for the second and 2,000,000,000 for the third. The doses may be given one week apart. Bacillus Coli Communis. — Cystitis and pyelocystitis, resist- ing other methods of treatment, injections from 10,000,000 to 50,000,000 may be tried. Tuberculin. — Koch's old tuberculin may be used in chronic localized lesions, beginning with minute doses of z ^ milli- gram, and this may be very gradually increased to T oV o or i or more. Injections should be made not closer than ten* days as a rule. The temperature should be watched, and if there is a rise the dose should be diminished in size.^ If too much is used, latent foci may be stimulated into activity. 508 DISEASES OF INFANTS AND CHILDREN. THE MEDICAL INSPECTION OF SCHOOL CHILDREN. The following short notes are inserted in this book for the guidance of those who may have to examine school children, or who may be called upon to instruct teachers in such exam- ination. SCHOOL HYGIENE. 1 Where it is possible a record of the physical condition for all students should be kept, showing the principal measure- ments and the weight, so that the development of the child may be followed. Where it is possible, notes should be made concerning the food that the child receives and the kind of a home it lives in. School physicians should have the general supervision of the hygiene of the school, and should give especial care to the lighting, heating, ventilation, drinking-water, closets or outhouses, outdoor and indoor exer- cise for the children, and the adjustment of the seats for the pupils. Where it is possible, they should urge school gardens. Care should be taken to guard the pupils against overpressure and fatigue, and an effort should be made to regulate the length of the school hours to the capacity of the children. It is also advisable to investigate the mental condition of the pupil. THE EYES. Simple tests should be taught the teacher and a vision chart supplied. The chart should not be exposed except when the tests are being made, as the pupil will otherwise become familiar with the letters, and be able to tell them from mem- ory without actually seeing them. Each pupil should be examined separately, and the examination of each one should be made privately, and if the child is already wearing glasses the test should be made with the glasses properly adjusted. Each eye should be examined separately, the other eye being 1 T. F. Harrington, " Child, the, and the Public School Curriculum," Boston Medical and Surgical Journal, September 6, 1906, p. 247. MEDICAL INSPECTION OF SCHOOL CHILDREN. 509 covered with a card, and care should be used not to press upon the eye, as, if pressure is exerted, a correct test cannot be made. The chart should hang in a good light, should not be covered with glass, and should be so hung that the pupil may be twenty feet from it. The line marked twenty on the chart should be read by a normal eye at the distance of twenty feet (Snellen's Test Types). The pupil should read from the top of the card downward with each eye as far as he can, and a record be made of the result. The eyes should be tested each year at the beginning of the fall term, but the test need not be made of the children in the first grade who do not know how to read. If a child cannot read the " twenty " line with either or both eyes, the parents should be notified of the fact, and requested to have the eyes examined by a physician who makes a specialty of the eye. It should be remembered that the child may see the test types correctly, and yet the vision may be defective. The parents should be requested to have the child examined if it complains frequently of headache during school hours, if the eye deviates from the normal position even only now and then, if the book is held nearer than twelve or fourteen inches when reading, if the face twitches, if the child habitually scowls when reading, and if the child does not make progress in studies requiring the use of the eyes, but is bright in other ways. If the eyes are habitu- ally red or inflamed the attention of the parents should be called to this fact. THE EARS. Each child should be tested separately and alone as regards its hearing. The teacher may make this test, or it may be made by the school physician. The ordinary speaking voice should be heard twenty feet in a quiet room. The test should be made by having the child close the eyes and cover the ear which is not being tested with one hand. If the hearing is not equal to this test in either or both ears, the parents should be requested to have the ears examined by a competent phy- sician. A request for such an examination should also be 510 DISEASES OF INFANTS AND CHILDREN. made if the child has a discharge or foul odor coming from either ear or if the child complains of earache. If the child is inattentive in classes which involve the hearing a test should be made. THE NOSE AND THROAT* If there is a discharge from one nostril a foreign body in the nose should be suspected and an examination made. If there is a chronic discharge from the nostrils the nose should also be examined. If the discharge is not chronic, and is purulent in character, diphtheria may be suspected and a cul- ture made. If there is an eczema about the nostrils the head should be examined for lice. If the child has repeated nose- bleed, the nose should be examined, or the parents requested to have it examined by a physician. Adenoids should be suspected, and the parents requested to have the child examined by the family physician or a sur- geon, if there are recurrent attacks of earache or difficulty in hearing, frequent colds in the head, chronic discharge from the nostrils, and mouth breathing. If the tonsils are very large, or if the child has repeated attacks of tonsillitis, or if there are large cervical glands, a request may be made for an examination by the family phy- sician with reference to the removal of the tonsils. It should be remembered that when the mouth is wide open and the tongue depressed in an examination of the throat that the tonsils may seem to be very large, when as a matter of fact they are normal or nearly so. On the other hand, it should be borne in mind that deafness and earache may be caused by the pressure of a large tonsil. It should be noted in cases of recurrent tonsillitis whether or not the tonsil is bound down to the pillars of the fauces by adhesions. These adhesions may be the cause of trouble when the tonsil is not very large. In all acute illnesses the throat should be examined for tonsillitis, for the exanthems of scarlet fever and of measles, and for diphtheria. If diphtheria is suspected a culture should be taken. MEDICAL INSPECTION OF SCHOOL CHILDREN. 511 THE TEETH. The teeth of most school children are badly neglected. The teeth should always be inspected in a routine examination, and if they are carious the parents should be requested to have them attended to. The first molars of the permanent teeth are especially liable to be lost by decay, because they are mistaken for the milk teeth. They are cut about the sixth year, and appear just back of the temporary teeth. Diseased teeth may cause toothache, mouth -breathing, neuralgia, pain in the ear, enlarged glands in the neck, swelling of the face, difficulty in chewing, and consequently indigestion ; there is also indigestion from the poisons from the pus and germs from diseased teeth. Carious teeth may be the site of absorp- tion of bacterial poisons, which may cause very serious con- stitutional trouble and lowering of the vitality. Very irreg- ular teeth should be straightened by a competent dentist. The general public is not educated in the possibilities of the correction of oral deformities. MENTALLY DEFECTIVE CHILDREN.* These form a rather large and a very important class, and provision should be made for their separate instruction. Many a defective child could be educated and made a self- supporting citizen if it could be properly cared for. Great care should be taken to distinguish between tempo- rary backwardness and the mentally defective children. A child may be temporarily backward from various causes, many of which are removable. The history of the child's mental and physical development before entering school is of great value, especially information concerning the age at which it began to walk, talk, etc., as the defective child usually is very much behind the average child. There are a great many causes which may make a child lag behind the others at school. Defective sis;ht and hear- ing, adenoids, any illness causing physical depression, anemia, 1 Love, "Cerebral Physiology and the Education of Abnormal Chil- dren," Glasgow Medical Journal, February, 1909 ; pp. 90 and 242. 512 DISEASES OF INFANTS AND CHILDREN. too little sleep, too much to do outside the school, troubles at home, lack of care, and too little food may all make the child dull or appear so. Diseases of the nervous system, as well as other diseases, should always be taken into account. A child's previous training and education should also be consid- ered, and due allowance made for its surroundings. Mentally defective children are usually incapable of atten- tion for any great length of time. The attention is easily diverted, and the child is easily fatigued mentally. They do not learn easily, and have difficulty in exercising the atten- tion, reasoning power, judgment, and will-power. Some of them memorize easily, but cannot apply what they know. It is common for the child to have attended school for several years without learning to read or cipher. They usually associate with children younger than themselves, and are often precocious sexually. They are often stubborn, excitable, and what is commonly called incorrigible. They are frequently very untidy in their habits. They usually exhibit some of the stigmata of degeneration (see same). Usually the expres- sion denotes a low grade of intellect, the body is ungraceful and unattractive, and the movements are awkward. Some defective children are but little below the average intellect, but are morally defective. They lie, steal, are frequently destructive, and often commit other crimes. Some defective children delight in cruel acts. NERVOUS DISEASES. The teacher should be instructed to refer for examination all cases suggesting diseases of the nervous system. The fol- lowing are points for the teacher to know : Chorea. — A child who was previously quiet becomes very nervous and is not able to sit or stand still. There are awkward twitching movements of the muscles, and the child often drops things which it is holding. Writing and draw- ing are interfered with. The child is irritable, loses its tem- per easily, and is unable to keep its attention fixed. Habit Spasm. — This should not be confused with the above. The habit spasm is characterized by the same move- MEDICAL INSPECTION OF SCHOOL CHILDREN. 513 merit, usually a grimace, a twitching of the muscles about the eye, or a movement of some part of the body. A child with a habit spasm need not leave school. Epilepsy. — The two forms, major and minor, should be explained. In minor epilepsy there is a temporary loss of consciousness, the child stares, stops what he is doing, the lips may become blue, and there may be some unusual move- ment. The child does not remember anything about this. Any senseless movement which the child makes from time to time, and which it does not remember, should lead to an examination for minor epilepsy. The major attack, with its fall, convulsion, jerking movements, cyanosis, loss of con- sciousness, is usually easily diagnosed. The child may injure itself in the fall, and the tongue may be bitten and the urine and feces may be passed. Hysteria. — The convulsion of hysteria should not be con- fused with epilepsy. The hysterical convulsion is a noisy one, the child talks, sings, cries, makes all sorts of move- ments, may answer questions, and rarely hurts itself in the fall, and does not bite the tongue, and rarely passes either urine or feces. Nervousness. — Many children are very nervous, having often a neurotic familv taint, or sometimes have become so through too much work, too little exercise, worry, and a lack of sleep, food, and care. The teacher should be instructed to try to make friends with such children and to determine the cause of the nervousness, and if possible to have it removed. If the cause is not removable, such children should be care- fully looked after to j^revent further development of the trouble. Paralysis. — All children with paralysis should be referred to the school physician for examination. PHYSICAL DEFECTS. All children with physical defects should be examined by the school physician. Children with one shoulder higher than the other and those with stooped shoulders should be looked for especially, as in manv instances proper exercise 514 DISEASES OF INFANTS AND CHILDREN. and proper desks will correct what might otherwise become an ugly deformity. Sometimes these deformities are signs of serious spinal disease. Lameness may be due to improper shoes or to disease of the bone, joints, or nerves. SKIN DISEASES. The teacher should be on the lookout for diseases of the skin, especially the contagious ones. Impetigo contagiosa, scabies, favus, ringworm-, head- and body-lice are the most fre- quent ones, and the ones which should be excluded from school (see Skin Diseases). , OTHER SYMPTOMS* The teacher should be instructed in regard to the follow- ing symptoms, and children with any of them should be referred to the physician for examination. Skin Eruptions. — These may be the eruptions of the infectious diseases — scarlet fever, measles, German measles, or chicken-pox, or some infectious skin disease — and should always be investigated promptly. Irritating Discharge from the Nose. — This may be an indication of diphtheria. Running Nose and Eyes, especially with Drow- siness and Cough. — These symptoms should suggest measles. Flushing of the Face. — This usually indicates that the child has fever, and he should be examined. Cough.— A spasmodic cough may be whooping-cough ; a croupy cough may mean diphtheria, a chronic cough may mean tuberculosis, and a cough which is painful may mean pneumonia or pleurisy. Usually a cough merely means a " cold " ; that is, a simple bronchitis. Vomiting. — This may be the beginning of an acute infectious disease, especially scarlet fever. Usually it means some disturbance of digestion, often caused either by too much or by improper food. Swelling of the Face, Hands, or I^egs. — This may mean serious disease of the kidneys, and should always be MEDICAL INSPECTION OF SCHOOL CHILDREN. 515 promptly investigated. It may also indicate either heart or kidney disease. Shortness of Breath. — This may mean either disease of the heart or lungs. Swellings Ahout the Neck. — These may be enlarged lymph-nodes, the cause of which should always be sought for by the physician. Mumps may be the cause. Paleness. — This means anemia. If associated with emaci- ation it indicates some disease or disturbance of nutrition ; if in a girl who is well nourished, short of breath, and who has a sort of greenish pallor, it may be chlorosis ; if associated with swelling or purfiness of the face it may be an indication of heart disease or kidney disease. Emaciation. — This may indicate malnutrition or some serious disease. INFECTIOUS DISEASES. The teacher and the school physician should exercise great care in watching for infectious diseases. The teacher should be instructed in the detection of these diseases. The follow- ing points will be found useful : Scarlet Fever. — A sudden onset with vomiting, head- ache, sore throat, and high fever should always lead to the isolation of the child. A child coming to school with the skin peeling off, especially after an acute illness, should always be regarded as a source of danger until an examination has been made by the school physician. The same is true of a running ear. Measles. — A combination of sore eyes and a slight dread of light, coryza, sore throat, and a cough should suggest mea- sles. The mouth should be examined for Koplik spots. Chicken-pox. — Small vesicles and a few pustules should suggest chicken-pox, and the black scabs of the later stage may be regarded with equal suspicion. Diphtheria. — A mild, unrecognized case of diphtheria may be responsible for an epidemic in a school. It is impor- tant that all cases of sore throat, running of the nose, especi- ally if the discharge is purulent, or if the upper lip is inflamed, 516 DISEASES OF INFANTS AND CHILDREN. and of hoarseness should be investigated promptly. Any mem- brane in the nose or throat should lead to prompt isolation. Whooping-cough. — A persistent spasmodic cough, cough with vomiting, and cough with ulceration of the fre- niira of the tongue should all be looked on with suspicion, and the case reported. Mumps. — Any swelling at the angle of the jaw and just under the ear should be reported. Danger from Infectious Diseases after Expos- ure. — The question of how long a time must elapse before there is no danger of a child developing an infectious disease after exposure is frequently asked. Also how infectious are the various communicable diseases. Scarlet Fever. — Little danger after one week has elapsed, but ten or twelve days is a safer time to state. About half the children exposed take the disease. Measles. — Little danger after sixteen days and practically none after twenty-two days. Almost every child exposed takes the disease. German Measles. — Little danger after three weeks and none after six. The disease is but feebly contagious ; from one- third to one-half the children exposed take the disease. Varicella. — Little danger after seventeen days and practi- cally none after three weeks. Almost all children exposed take the disease. Small-pox. — Little danger after sixteen days. Almost everyone exposed takes the disease unless protected by suf- ficient vaccination. Diphtheria. — Little danger after four days and practically none after one week. The susceptibility is very general. Whooping-cough. — There is but little danger after sixteen days and perhaps none after three weeks. The susceptibility is general. Mumps. — Little danger after four weeks. Cases are on record thirty-five days after exposure. About one-third of the children exposed to mumps contract the disease. In some epidemics the proportion is very much greater. Typhoid Fever. — Little anxiety need be felt after three weeks have elapsed. The susceptibility is rather general. MEDICAL INSPECTION OF SCHOOL CHILDREN. 517 The Return of Children to School after Infec- tious Diseases. — This is a question which comes up very frequently. Scarlet Fever. — Desquamation should be completed over the entire body, the discharge from ears and nose should have entirely ceased, there should be no albuminuria, and there should be no discharging abscesses or wounds which have resulted from complications. The inflammation in the throat should be entirely well. Measles. — The desquamation should be entirely completed, and the child should be well from the bronchitis which always accompanies measles. German Measles. — The desquamation should be entirely completed. Varicella. — Every scab should have separated and the child be entirely clean. Care should be taken to examine the scalp, as the crusts persist there longer than elsewhere. Small-pox. — A week after the complete separation of every scab and after the skin has become entirely clean. All abscesses and the like should be entirely healed. Diphtheria. — The child should be entirely well. There should be no discharges from the nose, no albuminuria, and the cultures from the nose and throat should be negative. At least two cultures should be taken at intervals of forty- eight hours. The so-called " latent " cases are a great danger in spreading the disease (see Latent Diphtheria, Myer Solis- Cohen, Journal of the American Medical Association, Julv 6, 1907, page 30). Whooping-cough. — The spasmodic cough should have been absent at least two weeks, and a better rule is to wait until the cough has disappeared entirely. Mumps. — At least one week should elapse after the swell- ing and tenderness have disappeared from the glands. In exceptional cases the patient is a source of danger much longer, but the rule given is reasonably safe. 518 DISEASES OF INFANTS AND CHILDREN. THE MEASURING OF THE DEVELOPMENT OF THE INTEL- LIGENCE OF CHILDREN. Binet and Simon have devised a scale for measuring the intelligence of children, and by the use of the scale it is easy to ascertain whether the child under examination gives re- sults equal to the normal child of his age or whether he is advanced or retarded. Feeble-minded children may be divided into three classes : idiots, imbeciles, and morons. The idiot never reaches the plain spoken language, but is limited to the use and understanding of gesture. The imbecile under- stands spoken language and talks himself in varying degrees of fluency. The moron, in addition to using spoken lan- guage, is capable of learning to read and write. In Binet's scale the idiots come in group one or two, the imbeciles cor- respond to the ages three, four, five, six, and seven, and the morons to the ages of eight, nine, ten, eleven, and twelve. The feeble-minded child does not develop beyond this period. Mentality of One and Two Years. 1. Eye follows light. 2. Block placed in hand is grasped and handled. 3. Candy is chosen instead of block. 4. Paper is removed from candy before eating, the child having seen the wrapping. 5. Child executes simple commands and imitates simple movements. Three Years. 6. Shows nose, eyes, and mouth. 7. Repeats two digits, as 2-4. 8. Enumerates objects in a picture. 9. Gives family name. 10. Repeats a sentence of six syllables without error. Four Years. 11. Names his sex, as boy or girl. 12. Names small objects, as key, knife, and penny. MEDICAL INSPECTION OF SCHOOL CHILDREN. 519 13. Repeats three numerals, as 5-2-8. 14. Can tell which is the longer of two lines drawn par- allel an inch apart and one-third of an inch difference in length. 15. Knows family name. Occasional failure in this. Five Years. 16. Tells which is heavier of two blocks of wood of equal size and appearance, one weighted. 17. Can copy a square. 18. Can repeat an easy sentence of ten syllables. 19. Can count four pennies. 20. Can rearrange a rectangular card that has been cut diagonally into two triangles. Ask the child to make a figure like the uncut card. One child in twelve fails. 21. Knows whether it is morning or afternoon. Remem- ber that certain children will always answer the last of two alternatives. If it is morning, put the question "Is it morning or afternoon ? " 22. Executes three commissions, given simultaneously, as, Take this key, put it on that chair, then shut the door. After that bring me the box that is on the chair. 23. Can show right hand and left ear. Say " Show me your right hand," and when this is done, " Show me your left ear." At four, no child points to the left ear. At five, half the children make a mistake. At six, all succeed. 24. Distinguishes pretty from distinctly ugly or deformed faces in a picture. At six, all choose correctly. At five, about half. Seven Years. 25. Counts thirteen. They should be placed in a row and counted with the finger. The finger must touch the piece at the same time that the child names the number, and no piece should be counted twice and none omitted. 26. Describes pictures. Binet used three pictures. ^ The first is a man and a boy drawing a cart loaded with furniture. The second, a woman and a man sitting on a bench in the 520 DISEASES OF INFANTS AND CHILDREN. park. The third, a man in prison looking out of the window, a couch, chairs, and tables. The child of three names the things. The child of seven describes what is going on. 27. Notes omission of nose, mouth, or arms from sketches. 28. Draws diamond shape from copies so that it can be recognized. 29. Names four colors. Use red, green, blue, and yellow papers in pieces of about one to two inches. Touch the color with the finger and ask, " What is this color?" It should be done in six seconds. Eight Years. 30. Compares two things from memory, as " What is the difference between a butterfly and a fly ? " A glass, paper, and cloth ? At least two out of three should be answered correctly. If it takes over two minutes it is a failure. At six, one-third of the children do this test. At seven, nearly all, and at eight, all. 31. Can count backward from twenty to one. This should be done in twenty seconds with not more than one mistake. 32. Names the days of the week in order in ten seconds. 33. Can count the value of six stamps, three ones and three twos, in less than fifteen seconds. Arrange these in order, one, one, one, two, two, two, and ask how much are they worth or how much will it. take to buy them ? 34. Repeats five numerals in order when pronounced once, as 3-7-2-5-4. About 25 per cent. fail. Nine Years. 35. Can give correct change, play store, using real money. The child should be storekeeper with cash consisting of twenty- five pennies, five nickles, and two dimes. One buys some- thing that costs seven cents. The child should return eighteen cents in change as well as say it. At seven none do this, at eight one-third succeed, at nine all do it. 36. Defines the objects fork, table, heat, horse, mamma in other words than the statement of their use. MEDICAL INSPECTION OF SCHOOL CHILDREN. 521 37. Names the day of the week, the month, the day of the month, and the year. If the child gets within three days of the day of the mouth it has passed. 38. Can name the months of the year. Recite them in order within fifteen seconds. One omission or transposition is allowed. 39. Arrange in order and weight boxes of the same size and appearance, weighing 6, 9, 12, 15, and 18 grams. This can be done in two minutes in two out of three trials. Ten Years. 40. Can name nine pieces of money, as cent, nickle, dime, quarter, half dollar, two, five- and ten-dollar bills. This should be done in forty seconds. The pieces should be placed on a table in a row, but not in the order of value, and should be named when pointed to. 41. Can copy simple design from memory after ten seconds' exposure. 42. Can repeat six numerals, as 8-5-4—7-2-6. Can tell what one should do in various emergencies. Ask, for ex- ample, " What would you do if you missed a train ? " Correct answer is, " Wait for another train or take the next." In- correct answers : " I would try not to miss it, run after it, buy a ticket." " What would you do if one of your play- mates should hit you without wanting to do so ? " Correct answer, "Do nothing to him, excuse him, pardon him, tell him to be more careful another time." Incorrect answer : " Tell the teacher or punish him." " What would you do if you broke something belonging to some one else ? " Correct answer is, " Pay for it. Ask to be excused. Replace it. Confess it." Incorrect answers to this are generally unin- telligible. The test is considered passed if two of the three questions are answered satisfactorily. 43. Uses three given words in two given sentences, as Baltimore, money, and river. One minute should be allowed. At eight none succeed, at nine one-third, and at ten one- half. The question should be answered either in a single idea involving the three words or ideas involving conjunction not 522 DISEASES OF INFANTS AND CHILDREN. in three separate sentences. This test shows the distinction between intelligence and judgment. Some children give a complete sentence with three words, but without sense to it. Eleven Years. 44. Detects nonsense in three out of five statements in two minutes. The statement should be made to the child, " I am going to give you some sentences in which there is some non- sense and you listen carefully and tell me what it is. Binet uses the following : 1. A bicyclist fell and broke his neck and died on the spot. He was taken to the hospital and they fear very much that he cannot get over it. 2. I have three brothers, John, Jim, and myself. 3. Yesterday the police found the body of a young girl cut into eighteen pieces. They believe that she killed her- self. 4. Yesterday there was a railroad accident, but it was not serious. The number of deaths was only 48. 5. Some one said if, in a moment of despair, I should com- mit suicide I should not choose Friday, because Friday is an unlucky day and it would bring me ill luck. 6. A man was about to be hanged, and said this will teach me a lesson how to behave in the future. About two minutes should be taken for this test. At least three of the questions should receive satisfactory answers. At nine the child rarely answers correctly, at ten about one-fourth, and at eleven about one-half. 45. Uses three words in a sentence the same as under ten years of age. At eleven all succeed. 46. Can say as many as sixty words in three minutes, as board, chair, table, draw, wagon. 47. Can name three words that rhyme in one minute. Can use a simple word, as day, spring, mill. 48. Can arrange eight words correctly. Three simple sen- tences of eight words should be given. The words should be printed. MEDICAL INSPECTION OF SCHOOL CHILDREN. 523 Twelve Years. 49. Can repeat seven numerals in order when heard once. Give three trials. One success is sufficient, 50. Can give abstract definitions, as of charity, justice, goodness. 51. Can repeat a sentence of twenty-six syllables, as, The other day I saw on the street a pretty young dog. Little Morris has got spots on his apron. 52. Rejects suggestions as to the length of lines. Make a booklet of six pages. On the first page draw two hori- zontal lines in ink. The one to the left 2 inches long, the one on the right 2 | inches. On the second page the one to the left is 2J and on the right 3 inches. On the third the left line is 3^ and the right 3 J inches. On the three remain- ing pages all lines are 3J inches long. When the child has found the right line longer three times in succession, will he continue to make this judgment even when he comes to those that are alike or will he reject suggestions and pronounce them alike ? For the first two pages ask which is the longest line. For the others say merely, " And there ? " 53. Gives the correct inference from a problem of various facts, as What is it? A man was walking in the woods near Baltimore, and suddenly stopped very much frightened, and then ran to the police station to tell them that he had just seen hanging from the limb of a tree a . . . . My neighbor has just received some peculiar visits. There came one after another a doctor, a lawyer, and a minister. What is going on at my neighbor's? Such answers as a dead person is hanging, my neighbor is dying, are correct. Fifteen Years. 54. Writes correctly the opposite of seventeen out of twenty given words. Use such words as good, outside, tall, quick, loud. 55. Can imagine the hands of a clock at any given hour transposed and tell what time it would then be. 524 DISEASES OF INFANTS AND CHILDREN. 56. Can interpret pictures, in addition to enumerating and describing the objects in them. Over Fifteen Years. 57. Distinguishes between abstract terms of similar sound and meaning, such as pleasure, welfare, event, and prevent. 58. Can give the difference between the president of a republic and a king. 59. Can imagine and draw the new form produced by joining transposed pieces of a diagonally divided rectangular card. 60. Imagines and draws the result of cutting triangular forms of twice-folded paper. Fold a square paper twice, allowing the person to see it done, and then cut a small equi- lateral triangle with its base on the middle of the closed edge. Have the person draw the paper as it will look when un- folded. 61. Can give the central thought of a selection read to him. For this purpose the following is used : " Many opinions have been given on the value of life. Some call it good ; others call it bad. It would be more just to say that it is mediocre ; but on the one hand, our happiness is never so great as we would have it and, on the other hand, our misfortunes are never so great as others would have them. It is this mediocricity of life which prevents it from being radically unjust." This method of testing the intelligence of children is very valuable, particularly for determining what should be done in regard to a child's schooling. The test is not as simple as it looks, and accurate results can only be obtained after considerable practice. The child should be examined alone, and should not be criticized or instructed at the time of the examination. The results of the examination should be re- corded at the time made. A child has the intelligence at that age all the tests that he succeeds in passing. After deter- mining the age for which a child passes all the tests a year is added to the intelligence age if he has succeeded in passing five additional tests belonging to superior age groups. Two MEDICAL INSPECTION OF SCHOOL CHILDREN. 525 years are added if he has passed ten such tests, three years if he has passed fifteen, etc. Thus, a child passed five tests for the seventh year, and also three for the eighth and two for the ninth, add one year for the five tests. These tests are for average children. Those from the better-class homes will generally show a higher intellectual development. The same examination should not be made too frequently, and the child should not be coached in giving correct answers. It must be remembered that this scale is one which must be used with common sense, and the examination must be made in accord- ance with certain restrictions, and where it is to be used Binet and Simon's original work may be consulted to great ad- vantage. 1 1 U A Method of Measuring the Development of the Intelligence of Young Children," Binet and Simon, translated by Clara Harrison Town, published by the Courier Co., Lincoln, 111. ; " A Syllabus for the Clinical Examination of Children," by Huey, published by Warwick and York, Baltimore, Md. ; " Manual of Mental and Physical Tests," by Whipple, published by Warwick and York, Baltimore, Md. ; "The Conservation of the Child," by Arthur Holmes, Lippincott Company, Philadelphia, Pa. It should be remembered that in early examination the child may not answer because it is frightened, or it may vol- untarily remain mute and motionless, especially children of three and four. A too hasty conclusion should not be formed as to the child's mental condition, and it should be remem- bered that at best the estimate is only approximate. The child may show a retardation in its development, but this is not to be taken as an evidence of feeblemindedness, unless there is a retardation of three years or of two years for the child under nine, and due allowance must be made for the advantages which a child may or may not have had. It may be remembered that enumeration of objects normal to about three years of age, that about seven the child begins to de- scribe objects, while interpretation of pictures or events gen- erally is not noted until about fifteen. 526 DISEASES OF INFANTS AND CHILDREN. SAMPLE PAMPHLET OF INFORMATION FOR DIS- TRIBUTION AMONG THE POOR IN SUMMER. 9 Nurse the baby, mother's milk is the best of all foods. Do not wean the baby in hot weather. Remember that ten bottle babies die to one that is breast- fed. One-third of the deaths of infants and young children occur during the hot summer months. Heat kills the baby chiefly by spoiling the milk given it. Nurse the baby regularly, not often er than two hours dur- ing the day and four hours at night. After three months of age do not nurse oftener than every three hours. No night feedings are necessary after five months. Do not nurse the baby every time it cries. If you cannot nurse your baby, consult your doctor before giving it the bottle. Fresh Air. — Give the baby fresh air day and night. Keep the windows open all day and all night. Keep the baby out of doors as much as you can. The out-door air is better for the baby than that of the house. The air in the squares and parks is better than that of the streets. Keep the rooms clean. Do not let garbage, slop, or dirty clothes stand about the room. Sleep. — Do not let the baby sleep in the same bed with any other person. Keep the baby quiet, and let it sleep as much as it will. Do not handle the baby too much ; let it alone. Bathing. — Bathe the baby every day. In very hot weather sponge the baby several times a day to keep it clean and cool. Wash the baby whenever the diapers are changed. Clothing. — The baby feels the heat as much or more than you. In hot weather take off most of the baby's clothing. INFORMATION FOR POOR IX SUMMER 527 If it becomes cold the clothing can easily be put back. If the baby has fever, take some of the clothing off, but do not put more on. A babv with fever will not catch cold. Diapers. — Wash the diaper as soon as it is soiled, and dry in the open air. Do not use a diaper a second time before washing it. Water. — In hot weather the baby needs a little more water an 1 not so much food. Give a few teaspoonfuls of pure, boiled water several times a day. Summer diarrhea is caused by spoiled milk or other food, bad air, dirt, and too much clothing, too much handling, too little sleep, too little water. If the baby vomits or has loose bowels, stop all food and give plain, boiled water until you have seen your doctor. Do not drus: the baby. If your babv is sick send for a doctor or take it to a hospital or dispensary. Do not ask your neighbor's advice about your baby, ask your doctor. The Bottle-fed Baby. — The Bottles. — Use a common round-bottomed bottle ; boil or scald it each time before put- ting the baby's milk in it. The Xipples. — Use plain black-rubber nipples. Boil them once a day. Wash the nipples before and after each feeding. TYnen not in use, keep the nipples iu a covered glass filled with water in which you have put a pinch of baking soda or borax. Xever use a nipple with a tube to it. Tlie Mill:. — Get only the best milk for the baby. Better pay more for milk and save doctor's bills and possibly funeral expenses. It costs less to buy a baby good milk for a year than to bury it. The best milk is bottled at the dairy and delivered in bottles. Milk sold from the can is apt to be dirty and unfit for use. Milk in summer from an open can in a shop is never fit to give a baby. Milk from a herd is better than milk from one cow. To Keep Milk. — Take it in as soon as delivered. As 528 DISEASES OF INFANTS AND CHILDREN. soon as possible mix the baby's milk. Place this in clean bottles and stopper with raw cotton. Keep the milk cold — on ice if possible. If you have no ice, wrap a cloth wrung out in cold water about the bottles. If you have difficulty in keeping milk, bring it to a boil as soon as it is delivered to you. Keep the things for the baby's milk separate. Keep the things clean. Scald them with boiling water before using. ' if it is not kept cold ; if it is not kept covered ; ^ 1 if it has been put in dirty bottles or cans ; if it is measured in dirty cans ; . if it gets dust in it. DIRECTIONS TO MOTHERS OF MENTALLY DEFECTIVE CHILDREN. The improvement will be slow, and no one can tell how much it will be, but much of it will depend on teaching. The child should have as much out-door life as possible, and should have the food and clothing looked after. Teach the child to do some simple thing, and then when he can do that, something else. Do not try to teach too much at one time, nor too difficult things. Eventually aim to teach the child to dress and undress itself, to keep itself clean, to control the bladder and bowels, to avoid disagreeable habits of all kinds. Give the child simple toys, as blocks of different shapes, sizes, and colors, and later various kindergarten games. Encourage as much as possible, and don't let other chil- dren tease or discourage the child. Remember not to lose your temper with the child. If possible, get a teacher of the feeble-minded to tell you how to train and educate the child. Remember that all of these things require the greatest amount of patience. INFORMATION FOR POOR IN SUMMER. 529 An Inexpensive Home-made Refrigerator. — Dr. Alfred Hess, of New York [Journal of the American Medical Asso- ciation, July 25, 1908, p. 317), has devised an efficient and Fig. 175. — Vertical section of home-made milk refrigerator : S, sawdust, excelsior, or other cheap non-conductor of heat ; T, cylinder of tin or galvanized iron ; C. can in which is placed the milk-jar. M. surrounded by broken ice, I ; N, newspapers nailed to lid of case. (Hess, in Journal of American Medical Association.) cheap refrigerator, which may be made as follows : An ordi- nary packing case, measuring at least 13x18x11 inches, should have a substantial layer of sawdust placed in the Fig.176. —Horizontal section of home-made milk refrigerator : M, milk container ; I, broken ice ; C, can for holding ice ; T, tin or galvanized iron cylinder to prevent sawdust, S, from falling into space Avben can is removed for purpose of emptying water, i Hess, in Journal of American Medical Association.) bottom. On this set a tin can, eight inches in diameter, and tall enough to hold a quart milk bottle, and around this place 34 530 DISEASES OF INFANTS AND CHILDREN. a cylinder of tin a little larger in diameter than the can. The cylinder is then surrounded by sawdust, the lid of the can is left free, and the ice-box is completed by nailing about fifty layers of newspapers to the lid of the case. Excelsior may be substituted for sawdust if desired. If the case is shallow, several layers of newspapers may be placed in the bottom of it. A little soda may be put in the can every day to prevent rusting. This refrigerator will keep two quart bottles or four eight-ounce feeding-bottles. If it is desired to keep more bottles, a tin can, 8| inches in diameter, with a slightly larger case, will hold the wire frame usually used as a bottle-con- tainer. The use of such refrigerators is a great help in the homes of the poor, and the total cost is only from 25 to 50 cents. LITERATURE. 531 PEDIATRIC LITERATURE. It is important that the student know how to use the information which has been collected by others and which is preserved in medical literature. Nowadays there is in almost every medical center one or more well-equipped medical libraries. In most of these there are trained librarians who can assist the student in finding just what he wants. It frequently happens, however, that the student is thrown on his own resources, and the following hints may be of value how to proceed in looking up the literature on any given topic. To find the older literature consult the Index Catalogue of the Surgeon-General's Library. This work was begun in 1880, and the first series, in sixteen volumes, completed in 1895. In 1896 the second series was started, and up to date (1907) ten volumes have been issued. This valuable work will be found in every good working library. It con- tains a very complete list of books and monographs, as well as numerous references to journal articles. To find the more recent literature, there are several meth- ods of procedure. One of the quickest is to consult some known article which contains a list of references. In most instances the articles referred to in the footnotes of this manual contain more or less complete bibliographies. By referring to the journals mentioned other references will usually be found. The most certain method is to use the Index Jledicus. This is a publication which gives a classified list of all medical publications, and is of the greatest value. It was published by the United States Government, from the Surgeon-General's Library, from 1879 until April, 1899. Congress failed to make an appropriation for it, and the pub- lication ceased. In 1900 the French undertook a work on similar lines — Bihliographia Medica. Three volumes of this were issued. The Carnegie Institution started a second series of the Index Medicus in 1903, and the French journal was discontinued. The Bibliograpkia Medica is arranged in the same way as the Index Medicus, and a knowledge of 532 DISEASES OF INFANTS AND CHILDREN French is not absolutely essential to enable one to find the references. It is not, however, very complete in American journal articles. The Index Medicus has a very complete index for the bound volumes, both of subjects and of authors. By making a list of references in each volume a complete bibliography of any subject may easily be prepared. The current numbers are not indexed separately, but the subjects are so classified as to facilitate finding all the articles mentioned. Information on any topic may be quickly and easily found by consulting the various text-books and monographs, espe- cially the larger works on pediatrics. Of these latter there is one in English, Keating' s Cyclopedia of the Diseases of Children, in five volumes. There is a very complete work in German in a number of volumes — Gerhardt's Handbuch der Kinderheilkunde. In French there is the excellent five-vol- ume Traite des maladies des enfants, edited by Grancher and Comby, the second edition of which has just been issued. The work of Barthez and Sannee is a perfect treasure-house of information, but is available only to those who read French. The more important journals on the diseases of children are The Archives of Pediatrics and Pediatrics, in America ; The British Journal of Diseases of Children, in England ; Archiv fur Kinderheilkunde, Jahrbuch fur Kinderheilkunde, Centralblatt fur Kinderheilkunde, Monatschrift fur Kinderheil- kunde, and Der Kinderarzt, printed in German ; Archives de medecine des enfants and Journal de clinique et de therapeutique infantile, in French ; and La Pediatria, in Italian. INDEX. Abdomen, palpation of, 46 Abdominal muscles, 152 absence of, 152 pain, 41 Abscess, alveolar, 131 of brain, 330 of liver, 180 peritonsillar, 139 retro-esophageal, 142 retropharyngeal, 140 from Pott's disease, 141 idiopathic, 141 Absence, congenital, of abdominal muscles, 152 Acetonuria, 258 Achondroplasia, 350 Acid intoxication, 119 urine, drugs to render, 498 Acquired syphilis, 440 Acute arthritis, 462 ascending paralysis, 360 hydrocephalus, 432 infectious diseases, 370 wasting paralysis, 419 yellow atrophy, 180 Addison's disease, 251 Adenia, 246 Adenitis, acute, 248 chronic, 249 syphilitic, 250 tuberculous, 435 Adenoids, 184 facial expression in, 37 in school children, 510 Adenoma of umbilicus, 68 Adherent prepuce, 271 Adolescent rachitis, 123 Adrenals, 251 hemorrhage into, 251 Air, fresh, 482 for baby in summer, 526 hunger, 120 Airing, 21 Alabaster cachexia, 266 Alalia, 315 Albumin milk, 93 Albuminuria, cyclic, 255 functional, 255 physiologic, 255 Alcohol, 485 Alopecia areata, 286 Alphabet, Wyllie's physiologic, 316 Alteratives, 488 Alveolar abscess, 131 Amaurosis, 39 Amaurotic family idiocy, 341 Amebic colitis, 164 Ammonia, aromatic spirit of, 496 Ammonium acetate, 493 chlorid, 494 Amyloid degeneration of intes- tines, 163 of kidney, 266 liver, 179 spleen, 252 Amyotrophic lateral sclerosis, 362 Anaemia infantum pseudoleu- caemica, 241 Anatomic peculiarities, 20 Anemia, lymphatic, 246 pernicious, 238 secondary, 239 splenic, 241 Anesthetics, 483 Aneurysm, 230 Anginoid scarlet fever, 373 Angioneurotic edema, 47, 320 Ankylostomiasis, 455 Antacids, 496 Anterior poliomyelitis, 419 Anthelmintics, 496 Antimalarial remedies, 499 Antimony and potassium tartrate, 494 533 534 INDEX. Antipyretic drugs, 483 Antipyretics, 481 Antirheumatic remedies, 497 Antiseptics, urogenital, 498 Antispasmodics for whooping- cough, 498 Anuria, 258 Anus, fissure of, 175 irritation of, 175 prolapse of, 174 Aortic insufficiency, 227 regurgitation, 227 stenosis, 226 Aphasia, functional, 316 Aphthae, Bednar's, 132 Aphthous stomatitis, 133 Appendicitis, 168 Arching, high, of palate, 40 Arms, pain in, 42 Arnold sterilizer, 96 Aromatic spirit of ammonia, 496 water, 490 Aromatic spirit of ammonia, 496 waters, 490 Arsenic, 488 Arterial hypoplasia, 230 Arthritis, acute, of infants, 462 associated with hemophilia, 470 deformans, 461 gonorrheal, 468 meningococcal, 469 pneumococcal, 470 tuberculous, 463, 469 Articular ostitis of hip, tubercu- lous, 465 of knee, tuberculous, 468 Artificial feeding, 76 respiration, Laborde's method, 52 Schultze's method, 51, 52 Ascaris lumbricoides, 172, 173 Ascites, 177 chlyous, 178 Asphyxia, 50 Aspirin, 497 Asthenic bulbar paralysis, 337 Asthma, 197 thymic, 250 Astringents, 496 Asylums, infant, feeding in, 106 Asymmetry of chest, 34 Ataxia, 300 Ataxia, cerebellar hereditary, 359 Friedreich's, 358 hereditary, 358 Atelectasis, congenital, 52 Atheroma, 230 Athetoid movements, 309 Athetosis, 309 Athrepsia, 115 Atomizer, steam, 188 Atrophies of nervous origin, 360 Atrophy, acute yellow, 180 peroneal muscular, 365 progressive central muscular, 360 neuritic muscular, 365 simple, 115 Atropin, 487 Aura, 303 Auvard incubator, 35 Bacillus coli communis therapy, 507 Back, 31 Backhaus' milk, 94 Backwardness, 316 Balanitis, 272 Balsam of tolu, 494 Baner's method, 91 Barlow's disease, 124 Barrel-shaped chest, 33 Basedow's disease, 320 Basham's mixture, 493 Basilar meningitis, 432 Bath, bran, 503 cold, 481 evaporating, 482 hot, 503 hot-air, 503 mustard, 504 salt, 503 soda, 503 starch, 503 temperature of, 18 Bathing, 17 of baby in summer, 526 Bean, soy, 94 Bednar's aphthse, 132 Belladonna, 487 Bell's palsy, 368 Bifid palate, 130 tongue, 130 Bile, flow of, interference with, 49 INDEX. 535 Bile-ducts, malformations of, 54 Binet and Simon's scale for measur- ing intelligence, 518-525 Birth palsies, 323 Bismuth, 496 Bitter wine of iron, 488 Black measles, 379 stools, 107, 108 Blackish-brown stools, 108 Bladder, 31 calculi in, 274 diseases of, 274 exstrophy of, 271 spasm of, 274 training of, 19 Bleeder's disease, 242 Blind children, training of, 26 Blindness, 39 word, congenital, 26, 39 Blood in infancy and childhood, 231 in stools, 49 in urine, 256 Blood-cells, red, 235 nucleated, 231 number of, 231 white, 231, 235 abnormal, 233 Blood-changes in congenital cyan- osis, 237 in diphtheria, 236 in disease, 236 in meningitis, 237 in pneumonia, 236 in scarlet fever, 236 in whooping-cough, 237 significance of, 235 Blood-dust, 235 Blood-plates, 234 Blood-vessels, diseases of, 230 Boils, 283 Bones, diseases of, 471 Bothriocephalus latus, 172 Bottle, nursing, hygienic, 95 Bottle-fed baby, care of, in sum- mer, 527 Bottle-feeding, 76 beginning, 94 Bottles, care of, in summer, 527 Bowels, inflammation of, 161 training of, 19 Brain, abscess of, 330 Brain, inflammation of, 326 malformations of, 320 tumor of, 331 water on, 331, 432 Bran bath, 503 Breast, pigeon, 34 Breast-feeding, 69 Breast-pump, 70 Breasts, 29 Breath, shortness of, in school children, 515 Breck feeder for premature and weak infants, 35 Bright's disease, acute, 261 Bromids, 485 Bromipin, 485 Bromoform, 498 Bronchi, diseases of, 193 Bronchial lymph-nodes, tubercu- losis of, 436 Bronchiectasis, 195 Bronchitis, 193 acute catarrhal, 193 capillary, 202 chronic, 195 fibrinous, 195 tuberculous, 432 Bronchopneumonia, 199 acute, congestive form, 202 chronic, 208 secondary, 202 Buhl's disease, 62 Bulging of anterior fontanel, 38 Buttermilk, 93 Cachectic thrombosis, 330 Calculi, renal, 269 vesical, 274 Calmette's test for tuberculosis, 427 Calomel, 491 Caloric needs of infants, 79 Fraley's method of determin- ing, 80 value of modified milk, deter- mination of, 79 Camphor, 486 Camphorated oil, 503 Cancrum oris, 135 Capillary bronchitis, 202 Carcinoma of stomach, 151 536 INDEX. Care of cord, 17 of eyes, 17 of genital organs, 19 of mouth, 18 of nervous system, 20 of newborn, 17 of skin, 19 of teeth, 18 Caries of spine, 463 Carrier, disease, 370 Carron oil, 501 Cascara sagrada, 492 Castor oil, 491 Catarrh, chronic gastric, 148 nasal, 183 Catarrhal appendicitis, 169 bronchitis, acute, 193 croup, 187 fever, acute, 424 jaundice, 153 laryngitis, acute, 189 pneumonia, 199 spasm of larynx, 187 stomatitis, 133 Cathartics, 491 Cells, mast, 233, 236 Cephalhematoma, 63 Cerebellar hereditary ataxia, 359 Cerebral infantile paralysis, 334 paralysis, 323 tumors, 331 Cerebrospinal fever, 327, 413 Cerium oxalate, 491 Cervical opisthotonos, 311 Cestodes, 171 Chalk mixture, 496 Chapin's milk-dipper, 83 Charcot-Marie atrophy, 365 Charcot's disease, 362 Cheesy pneumonia, 429 Chest, 25 asymmetry of, 34 barrel-shaped, 33 contracted, 34 deformities of, 33 flattened, 34 funnel-shaped, 34 Chicken-pox, 385 in school-children, 515 Childhood, anatomic peculiarities of , 20 physiologic peculiarities of, 20 Children, examination of, 36 Chills, 43 Chloral hydrate, 485 Chlorosis, 237 Cholera infantum, 157, 159 Chorea, 307 hereditary, 312 Huntington's, 312 in school children, 512 Sydenham's, 307 Chvostek's sign, 299 Chylous ascites, 178 Circulation, 214 Circumscribed edema, acute, 47 Cirrhosis of liver, 180 Citrate of magnesia, 492 Clark's rule for dosage, 477 Cleft palate, 129 Cleidocranial dystosis, 352 Climate, changes in, 482 Closure of anterior fontanel, 38 delay in, 38 of fontanels, 22 of sutures, 22 Clothing, 18 for baby in summer, 526 Clubbing of fingers, 48 Cod-liver oil, 487 Cold bath, 481 in head, 182 pack, 481 sponge, 481 Colic, 110 intestinal, 165 Colitis, amebic, 164 Colles' law, 441 Colon, dilatation of, 170 hypertrophy of, 170 irrigation of, 501 Colostrum, 70 Coma, 297 diabetic, 127 Comfort of child, 483 Composition of cows' milk, 77 Compression myelitis, 357 Condensed milk, 93 Congenital atelectasis, 52 heart disease, 217 myotonia, 310 stenosis of pylorus, 150 syphilis, 441 Congestion, acute, of liver, 179 INDEX. 537 Congestion of kidney, 260, 261 of spleen, 252 Conjunctival test for tuberculosis, 427 Constipation, chronic, 166 Contracted pupils, 39 ( 'nnvulsions, 301 Convulsive tic, 313 Cord, care of, 17 Corrosive esophagitis, 143 Coryza, 182 Cough in school children, 514 mixtures, 493 nervous, 197 reflex, 197 Counterirritants, 503 Cowling's rule for dosage, 477 Cow-pox, 388 Cows' milk, composition of, 77 Craniotabes, 38 Cranium, natiform, 25 Cream of tartar, 493 Creole's method of preventing oph- thalmia neonatorum, 56 Creeping pneumonia, 207 Creosotal, 495 Creosote, 495 Cretinism, 346 Croup, catarrhal, 187 false, 187 kettle, 188 spasmodic, 187 tent, 187 true, 190 Croupous pneumonia, 205 tonsillitis, 137 Cry, 41 hydrocephalic, 41 Cryptorchidism, 271 Cutaneous test for tuberculosis, 427 Cvanosis,congenital, blood-changes in, 237 Cyclic albuminuria, 255 vomiting, 144 Cyst, omental, 178 Cystitis, 268, 275 Cystopyelitis, 268 Cysts, hydatid, of liver, 180 Dactylitis, 48 Day terrors, 314 Deaf and dumb children, early t raining of, 27 Deaf-mutism, 354 Deafness, 40 Death, sudden, 49 Defective children, mentally, 528 Defects, physical, in school chil- dren, 513 Deficient children, morally, 345 Deformities of chest, 33 of hands, 48 of rectum, 152 of tongue, 130 Degeneration, amyloid, of intes- tines, 163 of kidney, 266 fatty, of newborn, 62 stigmata of, 353 Delicate infants, 34 Delirium, 296 Dentition, difficult, 131 Depression of anterior fontanel, 38 Deprivation, idiocy by, 339 Dermatitis venenata, 280 Dermatomycosis tricophytina, 290 Desquamation, epithelial, of tongue, 130 Development, muscular, 25 of intelligence of children, meas- uring, 518-525 Developmental paralysis, 352 Diabetes insipidus, 259 meUitus, 126 Diabetic coma, 127 Diaceturia, 258 Diapers, care of, 527 Diaphoretics, 493 Diaphragmatic hernia, 66 Diarrhea, 154 drugs useful in, 496 facial expression in, 38 summer, 157 Diarrheal diseases, infectious, 157 Diathesis, hemorrhagic, 242 Diet, forbidden, 101 of school children, 102 two and one-half to six years, 100 Dietetic errors, 108 Difficult detention, 131 Digestants, 491 Digit alin, Merck's, 486 Digitalis, 487 538 INDEX. Dilatation of colon, 170 of stomach, 149 Dilated pupils, 39 Diphtheria, 396 blood-changes in, 237 danger after exposure to, 516 in school children, 510, 515 intubation in, 407 laryngeal obstruction in, treat- ment, 406 return to school after, 517 tracheotomy in, 409 Diphtheritic paralysis, 368 Diplegia, spastic, 334 Discharge, nasal, acute, 40 Disease carrier, 370 Diseases of bladder, 274 of blood-vessels, 230 of bones, 471 of bronchi, 193 of ductless glands, 246 of intestines, 152 of joints, 461 of kidneys, 259 of larynx, 187 of liver, 179 of lungs, 193 of mouth, 128 of nervous system, 296 of newborn, 50 of nutrition, 114 of pharynx, 128 of rectum, 174 of skin, 277 of spinal cord, 355 of stomach, 144 of thymus gland, 250 of tonsils, 137 of uvula, 132 pyogenic, 54 Disposition, change in, 296 Diuretics, 492 Diuretin, 493 Diverticulum, Meckel's, 152 tumor, 68 Dizziness, 297 Dosage, 476 table of, 478-480 Dover's powder, 494 Drowsiness, 297 in school children, 514 Drug eruptions, 293 Duchenne-Aran type of muscular atrophy, 362 Duchenne's dystrophy, 363 Ductless glands, diseases of, 246 Dumb and deaf children, early training of, 27 Duotal, 495 Dwarfism, 351 Dysentery, 161 chronic, 162 Dyspnea, 46 Dystosis, cleidocranial, 362 Dystrophia adiposogenitalis, 253 Dystrophy, progressive muscular, 362 Ears, 40 examination of, in school chil- dren, 509 Ecthyma, 285 Eczema, 278 in school children, 510 Edema, 47, 68 angioneurotic, 47, 320 circumscribed, acute, 47 general, 47 of face, 47 of glottis, 190 Effervescing draughts, 490 Effusions, pleural, 46 Electrical reactions, 300 Elongated uvula, 132 Emaciation in school children, 515 Embolism, 230 Emphysema, 209 Empyema, 212 Encephalocele, 321 Endocarditis, 222 acute, 222 malignant, 224 ulcerative, 224 Enema, 502 Enlarged thyroid, 320 Enlargement of spleen, 252 Enteric fever, 409 Enteritis, 161 Enterocolitis, 161 Enuresis, 274 Eosinophils, 233 Eosinophilia, 236 Eosinophilic myelocytes, 234 INDEX. 539 Epidemic cerebrospinal meningitis, 413 hemoglobinuria, 62 parotitis, 394 pneumococcic infections, 425 roseola, 381 Epilepsy, 303 in school children, 513 Jacksonian, 303 psychic, 303 Epileptic idiocy, 339 Epiphysitis, acute, 462 Epispadias, 271 Epithelial desquamation of tongue, 130 pearls, 40 Epsom salts, 491 Erb-Goldflam syndrome, 337 Erb's dystrophy, 363 paralysis, 324 Ergot, 498 Errors, dietetic, 108 Eruption of permanent teeth, 28 of temporary (milk) teeth, 27 Eruptions, drug, 293 Erythema infectiosum, 384 Erythrocytes, 235 nucleated, 231 number of, 231 Escharotics, 501 Esophagitis, 142 corrosive, 143 Esophagus, inflammation of, 142 malformations of, 143 Essential paralysis of children, 419 Estraus Materna Graduate, 87 Euquinin, 499 Evaporating bath, 482 Examination of nervous system 296 of school children, 508 of sick children, 36 of stools, 48 Exercise, 20 Exophthalmic goiter, 320 Exostoses, multiple, 471 Expectorants, 493 Exstrophy of bladder, 271 Eyes, care of, 17 examination of, in school chil- dren, 508 running, in school children, 514 Face, edema of, 47 flushing of, in school children, 514 swelling of, in school children, 514 tapir, 362 Facial expression, 37 in adenoids, 37 in diarrhea, 38 in meningitis, 38 in nephritis, 38 in pneumonia, 38 in vomiting, 38 paralysis, 368 of newborn, 326 Factors in infant feeding, 106 Falling sickness, 303 False croup, 187 membrane, 398 meningocele, 322 Family jaundice, chronic, 180 Farinaceous gruels, 93 Fat of milk, 78 Fatty degeneration of newborn, 62 liver, 179 Favus, 291 in school children, 514 Feces. See Stools. Feeble-mindedness, 337 Feeding, artificial, 76 bottle-, 76 beginning, 94 by stomach-tube, 111 in infant asylums, 106 laboratory, 80 mixed, 76 nasal, 113 of delicate infants, 34 of infants, 69 of premature infants, 34 of sick infants, 109 second-year, 94 Ferrosomatose, 488 Fetal myxedema, 350 rickets, 350 Fever, inanition, 68 Fibrinous bronchitis, 195 Fingers, clubbing of, 48 Fish-skin disease, 277 Fissure of anus, 175 Floating spleen, 253 540 INDEX. Flushing of face in school children, 514 Follicular stomatitis, vesicular, 133 tonsillitis, 137 Fontanel, anterior, bulging of, 38 closure of, 38 delay in, 38 depression of, 38 examination of, 38 systolic murmur over, 38 tension of, 38 Fontanels, closure of, 22 Food intoxications, 118 Foreign bodies in larynx, 191 Fourth disease, 387 Fraley's method of determining caloric needs of infants, 80 Freeman's pasteurizer, 96 Frenum, ulcer of, 131 Fresh air, 482 for baby in summer, 526 Friedreich's ataxia, 358 Frohlich's syndrome, 253 Functional albuminuria, 255 aphasia, 316 heart disorders, 229 murmurs, 229 Funnel-shaped chest, 34 Furunculosis, 283 Gall-stones, 180 Gangrene, 292 of lung, 209 Gangrenous appendicitis, 169 stomatitis, 135 vulvitis, 275 Gartner's milk, 94 Gastralgia, 145 Gastric catarrh, chronic, 148 indigestion, acute, 146 chronic, 148 Gastritis, acute, 147 chronic, 148 Gastroduodenitis, 153 Gastro-enteritis, acute, 157 Gaucher' s disease, 253 Gavage, 111 Genetous idiocy, 338 Genital organs, 271, 272 care of, 19 malformations of, 271 German measles, 381 danger after exposure to, 516 return to school after, 517 Giant purpura, 244 urticaria, 47 Gigantoblasts, 231 Glands, lachrymal, 29 salivary, 29 sebaceous, 29 sweat, 29 thymus, 31 Glomerulonephritis, 262 Glossitis, 130 Glosso-labial-laryngeal paralysis, 362 Glottis, edema of, 190 Glycosuria, 256 Goiter, exophthalmic, 320 Gonococcus vaccines, 506 Gonorrheal arthritis, 468 Graduate, Materna, 86 Grand mal, 303 Granuloma of umbilicus, 67 Graves' disease, 320 Green sickness, 237 stools, 108 Ground itch, 455 Growth, rate of, in height, 23 Gruels, farinaceous, 93 malted, 92 Guaiacol, 495 Habit spasm, 309 in school children, 512 Habits, injurious, 319 Hand, trident, 351 Hands, 48 deformities of, 48 shape of, 48 swelling of, in school children, 514 Harelip, 128 Harrison's sulcus, 34 Head, retraction of, 311 shape of, 25 size of, 25 Headache, 313 Hearing, 27 Heart, 214, 215 disease, congenital, 217 disorders, functional, 229 INDEX. 541 Heat-rash, 281 Height, 22, 23 Hematemesis, 151 Hematoma of sternomastoid, 64 Hematuria, 256 Hemic murmurs, 229 Hemiplegia, 334 Hemoglobin, 231, 235 Hemoglobinuria, 256 epidemic, 62 Hcmopericardium, 221 Hemophilia, 242 arthritis associated with, 470 Hemorrhage from stomach, 151 into adrenals, 251 of newborn, 63 spontaneous, 64 traumatic, 63 visceral, 64 Hemorrhagic diathesis, 242 disease of newborn, 64 purpura, 244 Hemorrhoids, 175 Henoch's purpura, 245 Hepatitis, syphilitic, 54 Hereditary ataxia, 358 chorea, 312 syphilis, 441 late, 443 Hernia, diaphragmatic, 66 umbilical, 67 Heroin, 495 Herpes of vulva, 272 Herpetic stomatitis, 135 Hexamethylenamin, 498 Hiccough, 310 High-grade imbeciles, 345 Hip- joint disease, 465 Hippus, 39 Hives, 285 Hodgkin's disease, 246 Holt's percentage milk method of modifying milk, 86 table as guide in breast-feeding, 73 Hook-worm disease, 455 Horseshoe kidney, 259 Hot bath, 503 pack, 503 Hot-air bath, 503 Hunch back, 464 Hunger, air-, 120 Huntington's chorea, 312 Hutchinson's teeth, 448 Hydatid cysts of liver, 180 Hydrencephalocele, 321, 322 Hydrocele, 272 Hydrocephalic cry, 41 idiocy, 338 Hydrocephalus, 332, 333 acute, 432 Hydronephrosis, 270 Hydropericardium, 221 Hygiene, school, 508 Hygienic nursing bottle, 92 Hymenolepis nana, 172 Hyoscyamus, 487 Hyperemia of kidney, 260, 261 Hyperpyrexia, 45 Hypertrophic interstitial neuritis, 365 Hvpertrophv, chronic, of tonsils, 140 congenital, of tongue, 130 of colon, 170 Hypoplasia, arterial, 230 Hypospadias, 271 Hypostatic pneumonia, 207 Hysteria, 312 in school children, 513 Ice-bags, 481 Ichthyol, 501 Ichthyosis, congenital, 277 Icterus, 53, 179 catarrhal, 153 chronic family, 180 Idiocy, 337 amaurotic family, 341 by deprivation, 339 epileptic, 339 genetous, 338 hydrocephalic, 338 inflammatory, 339 microcephalic, 338 Mongolian, 339 paralytic, 339 Idioglossia, 316 Ileocolitis, acute, 161 chronic, 162 Imbecility, 337 high-grade, 345 Imperial drink, 493 542 INDEX. Impetigo contagiosa, 283 in school children, 514 Inanition, 114 fever, 68 Incontinence of feces, 176 of urine, 274 Incubator, Auvard, 35 Indicanuria, 257 Indigestion, acute gastric, 146 intestinal, 155 chronic gastric, 148 intestinal, 164 Infancy, anatomic peculiarities of, 20 physiologic peculiarities of, 20 Infant asylums, feeding in, 106 feeding, 69 other factors in, 106 Infantile cerebral paralysis, 334 myxedema, 346 spinal paralysis, 419 Infantilism, 349 Infants, caloric needs of, 79 delicate, 34 feeding of sick, 109 premature, 34 stools, 106 Infarctions, uric-acid, 260 Infections, acute, 54 epidemic pneumococcic, 425 septic, 54 Infectious diarrheal diseases, 157 diseases, 370 in school children, 515 danger after exposure, 516 return to school after, 517 transmission of, 370 Inflammation, local, remedies for, 501 of bowels, 161 of brain, 326 of esophagus, 142 of kidney, 261 of lungs, 205 Inflammatory idiocy, 339 thrombosis, 330 Influenza, 424 Inhalations, 505 Injurious habits, 319 Insanity, 352 Insufficiency, aortic, 227 mitral, 225 Insufficiency, tricuspid, 227 Intelligence, development of, meas- uring, 518-525 Interstitial pneumonia, chronic, 208 Intertrigo, 278 Intestinal colic, 165 indigestion, acute, 155 chronic, 164 intoxication, acute, 157 obstruction, 65 worms, 171 Intestines, 31 amyloid degeneration of, 163 diseases of, 152 malformations of, 152 tuberculosis of, 437 Intoxication, acid, 119 acute, intestinal, 157 food, 118 Intubation in diphtheria, 407 Intussusception, 167 Iodin, 489 Iodoglycerin, 489 Ipecacuanha, 493 Iron, 488 Irrigation of colon, 501 Irritability, 295 Irritation of anus, 175 Itch, 289 ground, 455 Jacksonian epilepsy, 303 Jaundice, 53, 179 catarrhal, 153 chronic family, 180 Joints, congenital syphilis of, 470 diseases of, 461 Juvenile general paralysis, 352 myxedema, 346 Keratoma diffusum, 277 ■ Kernig's sign, 298 Kidney, amyloid degeneration of, 267 calculi in, 269 congestion of, 260, 261 diseases of, 259 horseshoe, 259 hyperemia of, 260, 261 INDEX. 543 Kidney, inflammation of, 261 lardaceous, 266 malformations of, 259 malpositions of, 259 new growths in, 267 sarcoma of, 267 tuberculosis of, 440 waxy, 266 Kink cough, 390 Knee, inner side, pain in, 41 Knee-jerk, 297 Koch's old tuberculin, 507 Koplik's spots in measles, 377 La grippe, 424 Laboratory feeding, 80 Laborde's method of artificial respiration, 52 Lachrymal glands, 29 Ladd's table, 91 Lalling, 315 Landouzy-Dejerine dystrophy, 363 Landry's paralysis, 360, 420 Lardaceous kidney, 266 Laryngeal defects, 318 monotony, 318 obstruction in diphtheria, treat- ment, 406 stridor, congenital, 192 Laryngismus stridulus, 306 Laryngitis, acute catarrhal, 189 chronic, 190 membranous, 190 spasmodic, 187 syphilitic, 191 tuberculous, 190 Larynx, catarrhal spasm of, 187 diseases of, 187 foreign bodies in, 191 papilloma of, 191 tumors of, 191 Lassar's paste, 500 Late hereditary syphilis, 448 Law, Colles', 441 Warner's, of coincident develop- ment, 343 Legs, pain in, 42 swelling of, in school children, 514 Leichtenstern's phenomena, 416 Leukemia, 240 Leukocytes, 231, 235 abnormal, 233 degenerated, 234 frequency of various forms, 235 mononuclear, 231 polymorphonuclear neutrophilic, 233 Leukocythemia, 240 Leukocytosis, 235 mixed, 240 Leukopenia, 236 Lice in school children, 514 Lichen tropicus, 281 Licorice, 495 Liniments, 504 Lip reflex of newborn, 299 Liquor ammonii acetatis, 493 Lisping, 315 Literature, pediatric, 531 Lithuria, 257 Liver, 31 abscess of, 180 acute congestion of, 179 yellow atrophy, 180 amyloid. 179 cirrhosis of, 180 diseases of, 179 fatty, 179 hydatid cysts of, 180 Lobar pneumonia, 205 Lobular pneumonia, 199 Loss of weight, 109 Lousiness, 288 Lumbar puncture, 46, 417 Lung, diseases of, 193 fever, 205 gangrene of, 209 inflammation of, 205 Lymphadenoma, 246 of stomach, 151 Lymphatic anemia, 246 Lymphatism, 247 Lymphocytes, 231, 235 Lymphocytosis, 235 Lymph-nodes, 42 bronchial, tuberculosis of, 436 mesenteric, tuberculosis of, 439 tuberculosis of, 435 Macroglossia, 129 Magnesia, 491 544 INDEX. Magnesia, citrate of, 492 milk of, 491 sulphate of, 491 Maladie bronzee, 62 Malaria, 451 Malformations of bile-ducts, 54 of brain, 320 of esophagus, 143 of genital organs, 271 of intestines, 152 of kidney, 259 of spinal cord, 355 Malignant endocarditis, 224 scarlet fever, 373 Malnutrition, 117 Malpositions of kidney, 259 Malted gruels, 90 Manna, 492 Marasmus, 115 Massage, 482 Mast cells, 233, 236 Mastitis, 66 Masturbation, 319 Materna glass, 89 graduate, 87 Maynard Ladd's table, 91 Measles, 375 danger after exposure to, 516 German, 381 danger after exposure to, 516 return to school after, 517 in school children, 510, 515 return to school after, 517 Meckel's diverticulum, 152 Meconium, 70 Megaloblasts, 231 Megalocytes, 231 Membranous laryngitis, 190 rhinitis, 184 Meningitis, acute, 327 basilar, 432 blood-changes in, 237 chronic basilar, 328 epidemic, 413 facial expression in, 38 posterior basic, 328 spinal, 356 tuberculous, 432 Meningocele, 321, 355 false, 322 Meningococcal arthritis, 468 Meningococcus vaccines, 506 Meningomyelocele, 355 Mental development of children, measuring, 518-525 Mentally defective children, 528 school children, 511 Merck's digitalin, 486 Mercurial teeth, 29 Mercury, 488 Mesenteric lymph-nodes, tuber- culosis of, 439 Microcephalic idiocy, 338 Microcytes, 231 Miliaria, 281 Milk, albumin, 93 Backhaus', 94 care of, in summer, 527 condensed, 93 cows', composition of, 77 crust, 279, 282 Gartner's, 94 modification, 80 modified, caloric value, deter- mination of, 79 of magnesia, 491 preparation of, 96 prescriptions, 81 reaction of, 79 technic of modifying, 95 teeth, eruption of, 28 tests for, 74 Milk-dipper, Chapin's, 83 Minor symptoms, treatment of, 483 Mitral insufficiency, 225 regurgitation, 225 stenosis, 226 Mixed feeding, 76 Modification of milk, 80 Modified milk, caloric value, de- termination of, 79 Mongolian idiocy, 339 Mononuclear leukocytes, 231 Moorehouse's method of deter- mining caloric value of modified milk, 80 Morally deficient, 345 Morbus coxarius, 465 maculosus Werlhofii, 244 Moro's test for tuberculosis, 428 Mouth, care of, 18 diseases of, 128 Mucous polypus of umbilicus, 68 INDEX. 545 Mucus in stools, 48 Muguet, 133 Multiple exostoses, 471 neuritis, 366 Mumps, 394 danger after exposure to, 516 in school children, 516 return to school after, 517 Murmur, systolic, over anterior fontanel, 38 Murmurs, functional, 229 hemic, 229 Muscles, 46 abdominal, congenital absence of, 152 Muscular atrophies, 360 atrophy, peroneal, 365 progressive neuritic, 365 development, 25 dystrophies, 362 pseudohypertrophy, 363 Mustard bath, 504 pack, 504 plaster, 503 Myasthenia gravis, 337 Myatonia, 46 congenita, 46 Myelitis, 356 compression, 357 Myelocytes, 233, 236 eosinophilic, 234 non-granular, 234 Myocarditis, 228 Myotonia, congenital, 310 Mvxedema, fetal, 350 fruste, 348 infantile or juvenile, 346 Nasal catarrh, chronic, 183 diphtheria, 401 discharge, acute, 40 feeding, 113 speech, 315 sprays, 505 washes, 505 Natiform cranium, 25 Neck, swelling of, in school chil- dren, 515 Nematodes, 173 Nephritis, acute, 261 chronic, 264 35 Nephritis, desquamative, 261 diffuse, 261, 262 facial expression in, 38 parenchymatous, 261, 262 tubular, acute, 261 Nervous cough, 197 diseases in school children, 512 system, care of, 20 diseases of, 295 examination of, 295 Nervousness in school children, 513 Neuritis, hypertrophic interstitial, 365 multiple, 366 Newborn, care of, 17 diseases of, 50 fatty degeneration of, 62 lip reflex of, 300 puerperal fever of, 54 sepsis of, 54 Night terrors, 314 Nipples, care of, in summer, 527 Nodding spasm, 309, 310 Nodes, lymph-, 42 Noma, 135, 273 Normoblasts, 231 Nose, examination of, in school children, 510 irritating discharge from, in school children, 514 running, in school children, 514 Nucleated red cells, 231 Nursery, 21 Nursing, good, 483 bottle, hygienic, 95 Nutrition, diseases of, 114 Nystagmus, 39, 309 Oak rash, 280 Obstruction of intestine, 65 Oleoresin of male fern, 496 Omental cyst, 178 Ophthalmia neonatorum, 56 Ophthalmoscopic examination, 39 Opiates, 484 Opisthotonos, cervical, 311 Opium, 484 Osteogenesis imperfecta, 471 Osteomyelitis, acute, 471 Ostitis, tuberculous, 463 546 INDEX. Ostitis, tuberculous, articular, of hip, 465 of knee, 468 Otitis, 294 Oxyuris vermicularis, 173 Pachymeningitis, 326 Pack, cold, 481 hot, 503 mustard, 504 Pads, sucking, 40 Pain, 41 abdominal, 41 in arms, 42 in both sides of body, 42 in inner side of knee, 41 in legs, 42 in thigh, 41 pleuritic, 41 Palate, 40 bifid, 130 cleft, 129 high-arching of, 40 Paleness in school children, 515 Palpation of abdomen, 46 Pamphlet, sample, of information for distribution among poor in summer, 526 Papilloma of larynx, 191 Paralysis, acute ascending, 360 wasting, 419 asthenic bulbar, 337 BelTs, 368 birth, 323 cerebral, 323, 334 developmental, 352 diphtheritic, 368 Erb's, 324 essential, of children, 419 facial, 368 of newborn, 326 glosso-labial-laryngeal, 362 in school children, 513 juvenile general, 352 Landry's, 360, 420 of arm, 324 pressure, of spinal cord, 357 pseudohypertrophic, 363 spinal, 324 infantile, 419 Paralytic idiocy, 339 Paraplegia, 284 Paraplegia, Pott's, 357 Parasitic ointment, 501 Parotitis, epidemic, 394 Parry's disease, 320 Pasteurizer, Freeman's, 96 Pavor nocturnus, 314 Pearls, epithelial, 40 Pediatric literature, 531 Pediculosis, 288 Pellagra, 473 Pelletierin tannate, 496 Pemphigus, 60 syphilitic, 61 traumatic, 61 Pepsin, 491 Pericarditis, 219 chronic adherent, 222 Perinephritis, 270 Perisplenitis, 253 Peritonitis, 176 acute, 176 chronic, 177 tuberculous, 437 Peritonsillar abscess, 139 Perleche, 128 Pernicious anemia, 238 Peroneal muscular atrophy, 365 Pertussis, 390. See also Whoop- ing-cough. Petit mal, 302 Pharyngitis, acute, 142 Pharynx, diseases of, 128 Phimosis, 271 Phlebitis, sinus, 330 Phlegmonous tonsillitis, 139 Photophobia, 296 Phthiriasis, 288 Physical defects in school children, 513 Physiologic albuminuria, 255 peculiarities, 20 Pick's paste, 500 Pigeon breast, 34 Pinworm, 173 Plantar reflex, 298 Pleural effusions, 46 Pleurisy, 210 Pleuritic pains, 41 Pleuropneumonia, 208 Pneumococcal arthritis, 470 Pneumococcic infections, epidemic, 425 INDEX. 547 Pneumonia, 198 blood-changes in, 236 bronchopneumonia, 199 catarrhal, 199 cheesy, 429 chronic interstitial, 208 creeping, 207 croupous, 205 facial expression in, 38 hypostatic, 207 lobar, 205 lobular, 199 prolonged, 207 white, 441 Pneumopericardium, 222 Poikilocytes, 231 Poison-ivy rash, 280 Poliomyelitis, anterior, 419 chronic anterior, 362 Polychromasia, 231 Polymorphonuclear neutrophilic leukocytes, 233 Polynuclears, 233 Polypus, mucous, of umbilicus, 68 Polyuria, 259 Porrigo favosa, 291 Position, 42 Potassium acetate, 493 bitartrate, 493 chlorate, 489 Pott's disease, 463 retropharyngeal abscess from, 141 paraplegia, 357 Premature infants, 34 Preparation of milk, 96 Prepuce, adherent, 271 Prescriptions, milk, 81 Pressure paralysis of spinal cord, 357 Prickly heat, 281 Proctitis, 175 Progressive central muscular atro- phy, 360 muscular dystrophy, 362 neuritic muscular atrophy, 365 Prolapse of anus, 174 Prolonged pneumonia, 207 Proteins of milk, 77 Pseudohypertrophic paralysis, 363 Pseudohypertrophy, muscular, 363 Pseudoleukemia, 241, 246 Pseudoparalysis, 300 Psychic epilepsy, 303 Puerperal fever of newborn, 54 Pulse, 46 Pump, breast-, 70 Puncture, lumbar, 46, 417 Pupils, 39 contracted, 39 dilated, 39 inequality of, 39 Purpura, 243 fulminans, 245, 251 giant, 244 hemorrhagica, 244 Henoch's, 245 rheumatica, 244 Purpuric diseases, 244 Pus in urine, 257 Pyelitis, 267 Pyemia, 54 Pylorus, congenital stenosis of, 150 Pyogenic diseases, 54 Pyuria, 257 Quiet, 482 Quinin, 499 Quinsy, 139 Rachitis, 120 adolescent, 123 Reaction, electrical, 300 of milk, 79 of stools, 107 Rectum, deformities of, 152 diseases of, 174 Red cells, 235 nucleated, 231 number of, 231 gum, 281 stools, 107 Reduced iron, 488 Reflex cough, 197 lip, of newborn, 300 plantar, 298 skin, 297 Refrigerator, home-made, 529- Regurgitation, aortic, 227 mitral, 225 tricuspid, 227 Remedies for local inflammations, 501 548 INDEX. Remedies for skin diseases, 499 Renal calculi, 269 Respiration, 46 artificial, Laborde's method, 52 Schultze's method, 51, 52 Respiratory organs, tuberculosis of, 429 system, 181 Rest in bed, 482 Retraction of head, 311 Retro-esophageal abscess, 142 Retropharyngeal abscess, 140 from Pott's disease, 141 idiopathic, 141 Rheumatic purpura, 244 Rheumatism, 457 acute, 470 Rhinitis, acute, 182 chronic, 183 membranous, 184 syphilitic, 184 Rhubarb, 492 Rickets, 120 fetal, 350 Rickety rosary, 121 Riga's disease, 131 Rigors, 43 Ringworm, 290 in school children, 514 Rosary, rickety, 121 Roseola, epidemic, 381 Rotary spasm, 309 Rotheln, 381 Roundworm, 173 Rubella, 381 morbilliforme, 382 scarlatiniforme, 382 Running eyes in school children, 514 nose in school children, 514 Sago spleen, 252 Saint Vitus' dance, 307 Salicylic acid, 497 Salipyrin, 498 Salivary glands, 29 Salol, 498 Salophen, 498 Salt bath, 503 rheum, 278 solution, subcutaneous injection, 505 Salts of milk, 78 Salvarsan in congenital syphilis, 446 intramuscular injection, sites for, 447 Santonin, 496 Sarcoma of kidney, 267 of stomach, 151 Scabies, 289 in school children, 514 Scalp, seborrhea of, 282 Scapula, wing, in progressive mus- cular atrophy, 363, 364 Scarlatina, 371 Scarlet fever, 371 anginoid, 373 blood-changes in, 236 danger after exposure to, 516 in school children, 510, 515 malignant, 373 return to school after, 517 Schonlein's disease, 244 School children, diet of, 102 medical inspection of, 508 hygiene, 508 Schultze's method of artificial respiration, 51, 52 Sclerema, 68 Sclerosis, amyotrophic lateral, 362 Scorbutus, 124 Scurvy, 124 Seatworm, 173 Sebaceous glands, 29 Seborrhea of scalp, 282 Second year, feeding in, 97 Senega, 494 Senna, 492 Senses, special, 26 Sepsis of newborn, 54 Septic infections, 54 thrombosis, 330 Septicemia, 54 Shape of hand, 48 of head, 25 Shortness of breath in school children, 515 Sight, 26 Sign, Chvostek's, 299 Kernig's, 298 Simple atrophy, 115 Singultus, 310 Sinus phlebitis, 330 INDEX. 549 Sinus thrombosis, 330 Size of head, 25 Skm, 43 care of, 19 diseases, 277 in school children, 514 remedies for, 499 eruptions in school children, 514 reflexes, 297 Sleep, 20 disorders of, 314 for baby in summer, 526 Sleeplessness, 42 Sleep-walking, 314 Small-pox, danger after exposure to, 516 return to school after, 517 Smell, 27 Soda bath, 503 Sodiotheobromin salicylate, 493 Sodium bicarbonate, 496 citrate, 94 salicylate, 497 Somnambulism, 314 Somnifacients, 485 Soy bean, 94 Spasm, catarrhal, of larynx, 187 habit, 309 in school children, 512 nodding, 309, 310 rotary, 309 vesical, 274 Spasmodic affections, 309 croup, 187 laryngitis, 187 Spasmus nutans, 310 Spastic diplegia, 334 Special senses, 26 Speech, 27 disturbances, 315, 316 nasal, 315 Spice bag, 504 Spina bifida, 355 Spinal cord, diseases of, 355 malformations of, 355 pressure paralysis of, 357 tumors of, 358 meningitis, 356 paralysis, 324 infantile, 419 Spine, 31 caries of, 463 Spirit of mindererus, 493 Spleen, 251 amyloid, 252 congestion of, 252 enlargement of, 252 floating, 253 new growths of, 253 sago, 252 Splenic anemia, 241 Splenitis, 253 Splenomegaly, primary, 253 Spondylitis deformans, 462 Sponge, cold, 481 Spontaneous hemorrhage, 64 Sprays, nasal, 505 Sprue, 133 Sputum, 41 Squills, 494 Stammering, 315 Staphylococcus vaccines, 506 Starch bath, 503 Starr's table, 91, 92 Stationary weight, 110 Status epilepticus, 304 lymphaticus, 247 thymicus, 247 Steam atomizer, 188 Stenosis, aortic, 226 congenital, of pylorus, 150 mitral, 226 Sterilizer, Arnold, 96 Sternomastoid, hematoma of, 64 Stigmata of degeneration, 352 Still's disease, 461 Stimulants, 485 Stomach, 31 carcinoma of, 151 dilatation of, 149 diseases of, 144 hemorrhage from, 151 lymphadenoma of, 151 sarcoma of, 151 tumors of, 151 ulcer of, 151 washing, 501 Stomachics, 490 Stomach-tube, feeding by, 111 Stomatitis, aphthous, 133 catarrhal, 133 gangrenous, 135 herpetic, 133 ulcerative, 134 550 INDEX. Stomatitis, vesicular follicular, 133 Stools, black, 107, 108 blackish-brown, 108 blood in, 49 examination of, 48 green, 108 incontinence of, 176 infants, 106 mucus in, 48 reaction of, 107 red, 107 white, 49, 107 Strabismus, 39 Streptococcus vaccines, 506 Stridor, congenital laryngeal, 192 Strophulus, 281 Strychnin, 486 Stupes, turpentine, 504 Stuttering, 315, 316 Subcutaneous injection of salt solution, 505 Sucking ringers, 319 pads, 40 Sudden death, 49 Sugar in urine, 257 of milk, 78 Sulcus, Harrison's, 34 Sulphate of magnesia, 491 Sulphonal, 485 Summer complaint, 157 diarrhea, 157 Suppurative appendicitis, 169 synovitis, acute, 462 Sutures, closure of, 22 Swallowing, tongue, 131 Sweat glands, 29 Swelling of face, hands, or legs in school children, 514 of neck in school children, 515 white, 468 Sydenham's chorea, 307 Syndrome, Erb-Goldflam, 337 Frohlich's, 253 Synovitis, acute, suppurative, 462 Syphilis, 440 acquired, 440 congenital, 441 of joints, 470 hereditary, 441 late, 448 Syphilitic adenitis, 250 hepatitis, 54 Syphilitic laryngitis, 191 pemphigus, 61 rhinitis, 184 Syringomyelia, 358 Syringomyelocele, 355 Syrup of cinchona alkaloids, 499 Systolic murmur over anterior fon- tanel, 38 Tabes mesenterica, 439 Table, Ladd's, 89 of dosage, 478-480 Starr's, 91, 92 Tache cerebrale, 43, 400, 415 Taenia cucumerina, 172 eUiptica, 172 flava punctata, 172 mediocanellata, 171 saginata, 171 solium, 172 Taka-diastase, 491 Tannin, 497 Tapeworms, 171 Tapir face, 363 Tartar emetic, 494 Taste, 27 Technic of modifying milk, 95 Teeth, 28 care of, 18 Hutchinson's, 448 in school children, 511 mercurial, 29 Temperature, 43-45 of bath, 18 Temporary (milk) teeth, eruption of, 28 teeth, care of, 18 Tension of anterior fontanel, 38 Tent, croup, 187 Terpin hydrate, 494 Testicles, 31 undescended, 271 Tests, tuberculin, 427 Tetanus, 58, 59 Tetany, 305 Tetter, 278 Therapeutics, 476 Thigh, pain in, 41 Thomsen's disease, 310 Thorax. See Chest. Throat, examination of, in school children, 510 INDEX. 551 Thrombosis, 230 cachectic, 330 inflammatory, 330 of sinuses, 330 septic, 330 Thrush, 133 Thymic asthma, 250 Thymus, 31 diseases of, 250 Thyroid, enlarged, 320 Tic, 313 convulsive, 313 Tinea circinata, 290 favosa, 291 tonsurans, 291 tricophytina, 290 Tongue, bifid, 130 congenital hypertrophy of, 130 deformities of, 130 epithelial desquamation of, 130 swallowing, 131 Tongue-tie, 130 Tonics, 487 Tonsillitis, chronic, 140 croupous, 137 follicular, 137 in school children, 510 phlegmonous, 139 ulceromembranous, 137 Tonsils, chronic hypertrophy of, 130 diseases of, 137 Top-milk method, 83 Torticollis, 311 Touch, 27 Tracheotomy in diphtheria, 407 Training bladder, 19 bowels, 19 early, of deaf and dumb children, 27 of blind children, 26 Transmission of infectious diseases, 370 Traumatic hemorrhage, 63 pemphigus, 61 Tremor, 300 Tricophytosis, 290 Tricuspid insufficiency, 227 Trident hand, 351 Trional, 485 True croup, 190 Tuber culin injections in diagnosis, 427 Tuberculin injections in treat- ment, 507 tests, 427 value of, 428 Tuberculosis, 425 acute miliary, 428 Calmette's test for, 427 Moro's test for, 428 of bronchial lymph-nodes, 436 of intestines, 437 of kidney, 440 of lymph-nodes, 435 of mesenteric lymph-nodes, 439 of respiratory organs, 429 tuberculin in treatment, 507 von Pirquet's test for, 427 Wolff-Eisner test for, 427 Tuberculous adenitis, 435 arthritis, 463, 469 articular ostitis of hip, 465 of knee, 468 bronchitis, 432 laryngitis, 190 meningitis, 432 ostitis, 463 peritonitis, 448 Tumors, diverticulum, 68 of brain, 331 of larynx, 191 of spinal cord, 358 of stomach, 151 Turpentine stupes, 504 Typhoid fever, 409 danger after exposure to, 516 vaccines, 506 Typhus abdominalis, 409 Ulcer of frenum, 131 of stomach, 151 Ulcerative endocarditis, 224 stomatitis, 134 Ulceromembranous tonsillitis, 137 Umbilical cord, care of, 17 hernia, 67 Umbilicus, adenoma of, 68 granuloma of, 67 lesions of, 67 mucous polypus of, 68 Uncinariasis, 455 Undescended testicle, 271 Urethan, 485 552 INDEX. Urethritis, 272 Uric acid infarctions, 260 Urine, blood in, 256 character of, 254 collecting, 254 diminution of, 258 drugs to render acid, 498 in diabetes, 127 incontinence of, 274 pus in, 257 quantity of, 254 sugar in, 256 Urogenital antiseptics, 498 Urotropin, 498 Urticaria, 285 giant, 47 Uvula, diseases of, 132 elongated, 132 Uvulitis, 132 Vaccination, 19, 388 Vaccine therapy, 506 Vaccines, 506 autogenous, 506 bacillus coli communis, 507 gonococcus, 506 meningococcus, 506 staphylococcus, 506 stock, 506 streptococcus, 506 typhoid, 506 Vaccinia, 388 Valvular disease, chronic, 224 Varicella, 385 danger after exposure to, 516 gangrenosa, 387 return to school after, 517 Vasomotor stimulant, 498 Vernix caseosa, 29 Veronal, 485 Vertigo, 297 Vesical calculi, 274 Vesicular follicular stomatitis, 133 Vincent and Bellot's reaction in cerebrospinal meningitis, 417 Vincent's disease, 137 Visceral hemorrhage, 64 Volumen acutum pulmonum, 209 Vomiting, 110, 144 cyclic, 144 facial expression in, 38 in school children, 514 Von Pirquet's test for tuberculosis, 427 Vulva, herpes of, 273 Vulvitis, gangrenous, 273 Vulvovaginitis, 272 Warner's law of coincident de- velopment, 343 Washes, nasal, 505 Wasting disease, 115 paralysis, acute, 419 Water for baby in summer, 527 on brain, 332, 432 Waters, aromatic, 490 Waxy kidney, 266 Weight, 21, 24 loss of, 109 stationary, 110 Werlhoff's disease, 244 Wet-nursing, 75 Wetting the bed, 274 White blood-cells, 231, 235 abnormal, 233 pneumonia, 441 stools, 49, 107 swelling, 468 Whooping-cough, 390 antispasmodics for, 498 blood-changes in, 237 danger after exposure to, 516 in school children, 516 return to school after, 517 Whytt's disease, 432 Winckel's disease, 62 Wing scapula in progressive mus- cular atrophy, 363, 364 Wolff-Eisner test for tuberculosis, 427 Word-blindness, congenital, 26, 39 Worms, intestinal, 171 Wry-neck, 311 Wyllie's physiologic alphabet, 316 Xeroderma, 277 SAUNDERS' BOOKS on Practice, Pharmacy, Materia Medica, Thera- peutics, Pharmacology, and the Allied Sciences W. B. SAUNDERS COMPANY West Washington Square Philadelphia 9, Henrietta Street Covent Garden, London Our Handsome Complete Catalogue will be Sent You on Request D&stedo's Materia Medica, Pharmacology, Therapeutics, and Prescription lW riting By W. A. Bastedo, M. D., Associate in Pharmacology and Therapeutics at Columbia University. Octavo of 602 pages, illustrated. Cloth, $3.50 net. THREE PRINTINGS IN SIX MONTHS Dr. Bastedo' s new work has the distinct advantage of presenting the subjects from both the laboratory and the clinical sides. Dr. Bastedo for manv years devoted his entire time to laboratory work. Now, however, he is strictly a clinical man. He gives you the practical, daily application of that information he gleaned at first hand in the laboratory — facts you can use in your bedside practice. Because of this early laboratory training you are assured that his book is correct according to laboratory standards. 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An- ders, M.D., Ph.D., LL. D., Professor of the Theory and Prac- tice of Medicine and of Clinical Medicine, and L. Napoleon Boston, M. D., Professor of Physical Diagnosis, Medico-Chirur- gical College, Philadelphia. Octavo of 1248 pages, with 466 illustrations. Cloth, $6.00 net. JUST OUT— NEW (2d) EDITION This new work is designed expressly for the general practitioner. The methods given are practical and especially adapted for quick reference. The diagnostic methods are presented in a forceful, definite way by men who have had wide experience at the bedside and in the clinical laboratory. The Medical Record "The association in its authorship of a celebrated clinician and a well-known labora- tory worker is most fortunate. It must long occupy a pre-eminent position." PRACTICE OF MEDICINE II Ward's Bedside Hematology Bedside Hematology. By Gordon R. Ward, M. D., Fellow of the Royal Society of Medicine, London, England. Octavo of 394 pages, illustrated. Cloth, $3.50 net. INCLUDING VACCINES AND SERUMS Dr. Ward's work is designed to be of service to the man in general prac- tice. It gives you the exact technic for obtaining the blood for examination, the making of smears, making the blood-count, finding coagulation time, etc. Then it takes up each disease, giving you the general pathology, etiology, bearings of age and sex, onset, symptomatology, course, clinical varieties, complications, diagnosis, and treatment (drug, diet, rest, vaccines and serums, jr-ray, operations, etc.). There is a special chapter devoted to the medical treatment of hemorrhage, giving you the exact doses of the various drugs in- dicated and the methods of their administration, the serum treatment, trans- fusion, etc. Another chapter is devoted to the value of blood findings in surgical diagnosis, pointing out their value in differentiating benign from malignant growths, infectious from other diseases, appendicitis from typhoid fever. Smith's What to Eat & Why What to Eat and Why. By G. Carroll Smith, M.D., Boston. 1 2mo of 312 pages. Cloth, $2.50 net. FOR THE PRACTITIONER With this book you no longer need send your patients to a specialist to be dieted — you will be able to prescribe the suitable diet yourself, just as you do other forms of therapy. Dr. Smith gives "the why" of each statement he makes. It is this knowing why which gives you confidence in the book, which makes you feel that Dr. Smith knows. Slade's Physical Examination & Diagnostic Anatomy Physical Examination and Diagnostic Anatomy.— By Charles B. Slade, M.D., Chief of Clinic in General Medicine, University and Bellevue Hospital Medical College. i2mo of 146 pages, illustrated. Cloth, $1.25 net. 12 SAUNDERS' BOONS ON Stevens' Therapeutics Fifth Edition A Text-Book of Modern Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Physical Diagnosis in the University of Pennsylvania. Octavo of 675 pages. Cloth, #3.50 net. Dr. Stevens' Therapeutics is one of the most successful works on the subject ever published. In this new edition the work has undergone a very thorough revision, and now represents the very latest advances. The Medical Record, New York " Among the numerous treatises on this most important branch of medical practice, this by Dr. Stevens has ranked with the best." Butler's Materia Medica Sixth Edition A Text-Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor and Head of the Department of Therapeutics and Professor of Preventive and Clinical Medicine, Chicago College of Medicine and Surgery, Medical Department Valpariso University. Octavo of 702 pages, illustrated. Cloth, #4.00 net; Half Morocco, $5.50 net. For this sixth edition Dr. Butler has entirely remodeled his work, a great part hav- ing been rewritten All obsolete matter has been eliminated, and special attention has been given to the toxicologic and therapeutic effects of the newer compounds. Medical Record, New York " Nothing has been omitted by the author which, in his judgment, would add to the completeness of the text." Sollmann's Pharmacology Second Edition A Text-Book of Pharmacology. By Torald Sollmann, M.D., Professor of Pharmacology and Materia Medica, Western Reserve Uni- versity. Octavo of 1070 pages, illustrated. Cloth, $4.00 net. The author bases the study of therapeutics on systematic knowledge of the nature and properties of drugs, and thus brings out forcibly the intimate relation between pharmacology and practical medicine. J. F. Fotheringham, M.D., Trinity Medical College, Toronto. "The work certainly occupies ground not covered in so concise, useful, and scien- tific a manner by any other text I have read on the subjects embraced." Amy's Pharmacy Principles of Pharmacy. By Henry V. Arny, Ph. G., Ph. D., Professor of Pharmacy, New York College of Pharmacy. Octavo of 1175 pages, with 246 illustrations. Cloth. $5.00 net. George Reimann, Ph. G., Secretary of the New York State Board 0/ Pharmacy. " I would say that the book is certainly a great help to the student, and I think it ought to be in the hands of every person who is contemplating the study of pharmacy. THERAPEUTICS AND MATERIA MEDICA 13 Hinsdale's Hydrotherapy Hydrotherapy : A Treatise on Hydrotherapy in General ; Its Application to Special Affections ; the Technic or Processes Employed, and the Use of Waters Internally. By Guy Hinsdale, M. D., Fellow of the Royal Society of Medicine of Great Britain. Octavo of 466 pages, illustrated. Cloth, $3. 50 net. The Medical Record " We cannot conceive of a work more useful to the general practitioner than this, nor one to which he would resort more frequently for reference and guidance in his daily work." Kelly's Cyclopedia of American Medical Biography Cyclopedia of American Medical Biography. By How- ard A. Kelly, M. D., Johns Hopkins University. Two octavos of 525 pages each, with portraits. Per set: Cloth, $10.00 net; Half Morocco, $13.00 net. Dr. Kelly, in these two handsome volumes, presents concise, yet com- plete biographies of those men and women who have contributed note wor- thily to the advancement of medicine in America. Dr. Kelly's reputation for painstaking care assures accuracy of statement. There are about one thousand biographies included. Swan's Prescription-writing and Formulary Prescription-writing and Formulary. By John M. Swan, M.D., Director Glen Springs Sanitarium, Watkins, N. Y. I2mo of 185 pages. Flexible cloth, $1.25 net. Stewart's Pocket Therapeutics and Dose- book New (4th) Edition Pocket Therapeutics and Dose-book. By Morse Stewart, Jr., M.D. 32mo of 263 pages. Cloth, $1.00 net. Bohm and Painter's Massage Massage. By Max Bohm, M. D., of Berlin, Germany. Edited, with an Introduction, by Charles F. Painter, M. D., Professor of Orthopedic Surgery at Tufts College Medical School, Boston. Octavo of 91 pages, with 97 practical illustrations. Cloth, $1.75 net « 14 SAUNDERS' BOOKS ON GET Amo*»Ir^n THE NEW THE BEST AlllcnCan STANDARD Illustrated Dictionary The Ne w (7th) Edition , Reset The American Illustrated Medical Dictionary. By W. A. Newman Dorland, M. D., Editor of "The American Pocket Medical Dictionary." Octavo of 1 107 pages. Flexible leather, $4.50 net; with thumb index, $5.00 net. OVER 5000 NEW WORDS Howard A. Kelly, M. D., Johns Hopkins University , Baltimore. " Dr. Dorland's dictionary is admirable. It is so well gotten up and of such conve- nient size. No errors have been found in my use of it." Thornton's Dose-Book Fourth Edition Dose-Book and Manual of Prescription-Writing. By E. Q. Thornton, M. D., Assistant Professor of Materia Medica, Jefferson Medical College, Philadelphia. Post-octavo, 392 pages, illustrated. Flexible leather, $2.00 net. " It will afford me much pleasure to recommend the book to my classes, who often fail to find such information in- their other text-books." — C. H. Miller, M.D., Professor of Pharmacology, Northwestern University Medical School, Chicago. Lusk On Nutrition Second Edition Elements of the Science of Nutrition. By Graham Lusk, Ph.D., Professor of Physiology in Cornell University Medical School. Octavo of 402 pages. Cloth, $3.00 net. " I shall recommend it highly. It is a comfort to have such a discussion of the subject." — Lewellvs F. Bakkeh, M. D., Professor of the Principles and Practice of Medicine, Johns Hopkins University. Hatcher and Sollmann's Materia Medica A Text-Book of Materia Medica : including Laboratory Exer- cises in the Histologic and Chemic Examination of Drugs. By Robert A. Hatcher, Ph. G., M. D. ; and Torald Sollmann, M. D. 12010 of 411 pages. Flexible leather, $2.00 net. Bridge on Tuberculosis Tuberculosis. By Norman Bridge, A. M., M. D. i2mo of 302 pages, illustrated, Cloth, $1.50 net. MATERIA MEDICA AND THERAPEUTICS. 15 American Pocket Dictionary New (8thj Edition The American Pocket Mkdicai. Dictionary. Edited by W. A. Newman Dorlanu M.D. Flexible leather, with gold edges, $1.00 net ; with thumb index, $1.25 net. Pusey and Caldwell on X-Rays Second Edition The Practical Application of the Rontgen Rays in Thera- peutics and Diagnosis. By William Allen Pusey, A. M., M. D., and Eugene W. Caldwell, B. S. Octavo of 625 pages, with 200 illustrations. Cloth, $5.00 net. Cohen and Eshner's Diagnosis. Second Revised Edition Essentials of Diagnosis. By S. Solis-Cohen, M. D., and A. A. Eshner, M. 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D. , Professor of Clinical Medicine. Philadelphia Polyclinic. Octavo of 715 pages. Cloth, $4.00 net. Boston's Clinical Diagnosis Second Edition Clinical Diagnosis. By Laboratory Methods. By L. Napoleon Boston, A. M., M. D., Adjunct Professor of Medicine, Medico- Chirurgical College, 1 hiladelphia. Octavo of 563 pages, with 330 illus- trations, many in colors. Cloth, S4.00 net. Arnold's Medical Diet Charts Medical Diet Charts. Prepared by H. D. Arnold, M. D., Professor of Clinical Medicine, Tufts Medical College, Boston. Single charts, 5 cents; 50 charts, $2.00 net; 500 charts, £18.00 net; iooo charts, $30.00 net. 16 SAUNDERS' BOOKS ON PRACTICE, Etc. Saunders' Pocket Formulary Ninth Edition Saunders' Pocket Medical Formulary. By William M. Powell, M. D. Containing 1900 formulas from the best-known authorities. In flexible leather, with side index, wallet, and flap. $1.75 net. Jakob and Eshner's Internal Medicine and Diagnosis Atlas and Epitome of Internal Medicine and Clinical Diag- nosis. By Dr. Chr. Jakob, of Erlangen. Edited, with additions, by A. A. Eshner, M. D. 182 colored figures on 68 plates, 64 text-cuts, 259 pages of text. Cloth, $3.00 net. In Saunders 1 Hand- Atlas Series. Lockwood's Practice of Medicine Revised^nd^niarged A Manual of the Practice of Medicine. By Geo. Roe Lock- wood, M. D., Attending Physician to the Bellevue Hospital, New York City. Octavo, 847 pages, illustrated. Cloth, $4.00 net. Fenwick's Dyspepsia Dyspepsia. By William Soltau Fenwick, M. D., of London. Octavo of 485 pages, illustrated. Cloth, $3.00 net. Jelliffe's Pharmacognosy An Introduction to Pharmacognosy. By Smith Ely Jelliffe, Ph. D., M. D., Columbia University, New York. Octavo of 265 pages, illustrated. Cloth, $2.50 net. Stevens' Practice of Medicine Ninth Edition A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Professor of Therapeutics and Clinical Medicine, Woman's Medical College, Philadelphia. i2mo, 573 pages, illustrated. Flexible leather, $2.50 net. Camac's Epoch=Making Contributions Epoch-making Contributions to Medicine and Surgery. By C. N. B. Camac, M. D., of New York City. Octavo of 450 pages, with portraits. Artistically bound, #4.00 net. Todd's Clinical Diagnosis Second Edition Clinical Diagnosis. By Tames Campbell Todd, M.D.. Professor of Pathology, University of Colorado, Denver. i2mo of 455 pages, illustrated. Cloth, $2.25 net. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE k! C28I1 140) Ml 00 3 . • 'K* ^ ^e>J? Va ^ :