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ESSENTIALS OF THE DISEASES OF CHILDREN, ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS PREPARED ESPECIALLY FOR STUDENTS OF MEDICINE. BY WILLIAM M. POWELL, M.D., PHYSICIAN TO THE CLINIC FOR THE DISEASES OF CHILDREN IN THE HOSPITAL OP THE UNIVERSITY OF PENNSYLVANIA ; EXAMINING PHYSICIAN TO THE CHILDREN'S SEASHORE HOUSE FOR INVALID CHILDREN, AT ATLANTIC CITY, N, J,; FORMERLY INSTRUCTOR IN PHYSICAL DIAGNOSIS IN THE MEDICAL DEPARTMENT OF ■ THE UNIVERSITY OF PENNSYLVANIA, AND CHIEF OF THE MEDICAL CLINIC OF THE PHILADELPHIA POLYCLINIC. PHILADELPHIA; W. B. S AUN DE ES, 913 Walnut Srteet. 1890. Entered according to Act of Congress in the year 1890, by W. B. SAUNDERS, In the Office of the Librarian of Congress, at Washington. COLLINS PRINTINQ HOUSE, 705 JAYKE 6TKEET. TO LOUIS STAEE, M.D., OF PHILADELPHIA, AS A SINCERE TRIBUTE OF ADMIRATION AND REGARD SWS ioofe IS DEDICATED BY HIS ASSISTANT, THE AUTHOR. (iii) PREFACE. In presenting The Essentials of the Diseases of Children the author wishes to state that the substance- matter has been chiefly drawn from the works of Eustace Smith of London; J. Lewis Smith of New York; Edward Ellis of New Zealand; J. E. Goodhart's American Edition, by Louis Starr of Philadelphia; Diseases of the Digestive Organs by Louis Starr^ and Meigs and Pepper's Diseases of Children. Being a work of necessarily limited scope, the subject has been discussed mainly from its symptomatic and therapeutical standpoints, the questions of diet, general hygiene, and nursing, while receiving their place, being less fully considered than in the various books devoted to these important branches. In covering the provinces of symptomatology and therapeutics an effort has been made to bring the book thoroughly abreast of the times. W. M. POWELL. 2205 Pine St., Philadelphia. September 1, 1890. (V) CONTENTS. Introduction 17 Part I. Dentition ...... 25 Part II. Diseases of the mouth and throat . . 28 Part III. Diseases of the stomach and intestines . 43 Part IV. Diseases of the liver .... 74 Part V, Diseases of the peritoneum ... 81 Part VI. Acute infectious diseases ... 85 Part VII. General diseases not infectious . .110 Part VIII. The diathetic diseases . . '. .118 Part IX. Diseases of the spleen and blood . . 124 Part X. Diseases of the nervous system . . 130 Part XI. Diseases of the organs of respiration . 157 Part XII. Diseases of the heart .... 186 Part XIII. Diseases of the genito-uri nary organs . 193 Part XIV. Diseases of the skin .... 200 (vii) ESSEx^TIALS OF DISEASES OF CHILDREN. Introduction. Medical Examination. When is the best time to examine a child ? While it is sleeping. Why? In order that the pulse may be counted, the breathing, state of the skin, and general posture noted. What other points should be noticed before arousing it ? The attitude, the posture, if natural ; the color of the face, whether flushed or pale ; the lips, if pale or tinted ; the skin, if dry or moist ; the general expression, if natural or painful ; the presence or absence of moaning, starting, grinding of the teeth ; the movements of the nostrils, if quiet or working strongly; the eyes if closed, partly closed, or staring should be carefully observed. The respirations should be counted ; the condition of the fontanelle must be carefully examined, if closed or open, if pulsating greatly, if distended or retracted ; the pulse should be taken, the size and shape of the head should be noted, if large, and whether the veins are full. What should be noticed after the child is aroused ? The expression of the face ; whether it is fretful or languid ; excited or quiet ; if it has dark circles under the eyes ; the color and shape of the face, and the presence or absence of snuffling. 2 18 ESSENTIALS OF DISEASES OF CHILDREN. How long should a perfectly healthy infant sleep 1 At least eighteen out of the twenty-four hours. It is useful in fixing the period of the commencement of an illness to inquire when the child was first sleepless. What next should be dene ? The child should be stripped near the fire and out of the way of any draught. How should the healthy skin appear? It should be mottled, not flabby ; the limbs should move freely. What other important points should be noted? The joints should be carefully examined, whether large, small, or swollen. Eruptions should be looked for about the anus, and the penis carefully examined for adhesions or phimo- sis, etc. What is the number of respirations in a healthy child ? They range as follows : — From two months to two years the average is 35 per minute. Under one year the respirations vary from 40 to 50 per minute. From the second to the twelfth year about 18 per minute. When is the best time to look at the tongue? While the child is crying, if the child is quiet the under lip may be gently pressed by the physician's finger and it will protrude it. How shall we examine the throat? By placing the child on the nurse's lap with its head resting against her breast and gently depressing the tongue with a small spoon or tongue depressor, at times force may have to be used, but if the child is old enough to understand, a little coax- ing and kindness will generally suffice. INTRODUCTION. 19 How should the gums be examined? By placing the child's head between your knees and allow- ing its body to remain in the nurse's lap, thus you have perfect control over the child's head should lancing be required. How and when should auscultation be practised ? Always before percussion, as the latter usually excites the child. The back of the chest is the most important part to auscultate in a child. If it is found free from the physical signs of pneumonia, bronchitis, etc., we may presume that the front of the chest is the same, although if the child be quiet it is best to auscultate both posteriorly and anteriorly. How should percussion be practised? By a light tap with one or two fingers of the right hand upon a finger of the left placed fiat upon the chest. How should the abdomen be examined? By palpation with the warmed hand. In this way enlarge- ments of the spleen or liver are detected and other abdominal tumors. In what position should the child be placed during the palpa- tion? Upon its back, if possible, with its knees flexed so as to relax the abdominal muscles, but this is often impossible, then the next plan is to have the child placed on the nurse's lap in a sitting posture and slip the warmed hand beneath the clothes. Describe the expression of countenance indicative of disease. The upper part of the face is chiefly affected in diseases of the brain causing the brow to knit, the forehead to contract, and the eyes to roll. What diseases affect the middle portion of the face ? Cardiac and lung affections, the nostrils are sharp or dis- tended, the lips are pale or even bluish in color, and dark rings are under the eyes. 20 ESSENTIALS OF DISEASES OF CHILDREN. What diseases affect the lower portion of the face? Abdominal troubles, the cheeks are changed in color, even sunken, the mouth is drawn, the lips livid or pale. What other important signs should be noticed ? Redness or pallor, ptosis, unequal dilatation of the pupils, etc. What gestures usually point to disease of the brain ? Hands constantly to the head, pulling at the hair, rolling or burying head in the pillow. What gestures signify abdominal disease? The legs are drawn up, the face is anxious and sunken, the child picks at the bed-clothes. What gestures point to dyspnoea ? Child tears at its throat or puts its hand in its mouth, espe- cially in diphtheria and croup, when false membranes are form- ino;. What is the character of the cry in pneumonia and capillary bronchitis ? Labored, as if half suffocated. In croup? Brassy and metallic, with crowing inspirations. In cerebral disease ? Sharp, shrill, and solitary, i. e., the so-called " cri hydro- c^phalique.^^ In marasmus and tubercular meningitis ? Moaning and wailing are usually present. What does obstinate and long-continued crying usually denote ? Either earache or hunger. When are the tears and saliva usually secreted? About the third or fourth month. What does squinting of the eyes in acute illness denote? Either reflex irritation, paralysis or convulsions. INTRODUCTION. 21 What do small pupils usually denote ? They occur in active congestion, opium poisoning, and in sleep. Give the chief indications obtained from observation of the tongue. A furred tongue with spots of curd over its surface indicates dyspepsia and intestinal irritation. A red, hot, and dry tongue would point to an inflammation of the mouth, stomach, etc. A pale flabby tongue, marked at the edges with the teeth, denotes great debility. A heavy white fur is usually indicative of fever. Yellow fur, of liver and stomach trouble. Brown fur, a low typhoid condition. Strawberry tongue, scarlatina. Fecal Evacuations. Describe the stools of a healthy infant. They vary in color from a light to a greenish-yellow, and are of the consistency of mixed mustard. The reaction is acid, odor sour. How many stools should a healthy child have in the twenty- four hours ? For the first few weeks three ; from then on to the second year two. What does the presence of curds denote in the stools ? Indigestion. Describe the stools in intestinal catarrh. They are scanty, lumpy, dark in color, and mixed with mucus. What do clay-colored movements denote? An inactive liver. 22 ESSENTIALS OF DISEASES OF CHILDREN. What does a stool composed of blood, clots, and shreds of mucous membrane indicate? Intestinal infiammation, typhoid fever, dysentery, and tuber- cular disease. What is the Spinach stool ? ' It is a green evacuation commonly found in acuto and sub- acute diarrhoea in infants. M. Hayem believes the green color is produced by a particular bacillus which he considers conta- gious. What is the oily matter found in stools due to? Probably to defective action of the liver, pancreas, and intestinal glands. The fatty matters of the food are not pro- perly emulsified, and, therefore, not absorbed. What does the presence of mucus indicate ? Acute diarrhoea or mucous disease. Vomiting. How may vomiting be classified ? Inlo three groups : — The vomiting of nurslings, The vomiting of older children, Reflex vomiting. Describe the vomiting of nurslings. It is caused by the shape of the stomach being less curved than in the adult. It is not a sign of disease, and it is especi- ally found in children that have been nursed by an abundant breast. This vomiting is easily distinguished from that de- pending upon disease, as milk alone is ejected, although it may. be slightly curdled. Describe the vomiting of older children. This is commonly due to indigestion. Sudden vomiting in a child of previously good health would point to the onset of INTRODUCTION. 23 some acute disease, particularly scarlet fever. Occasionally in girls it is the development of symptoms well known in young adult females as the outcome of hysteria. Describe reflex vomiting. It may be due to meningitis, or tumor of the brain, chronic disease of the lungs, pertussis, dentition, or worms. The Pulse. What is the pulse beat of a healthy infant ? It ranges from 90 to 140 beats per minute. It is quicker in the female than in the male after the seventh year. It is much slower during sleep. Tlie following valuable table of the pulse is given by Miiller. At birth 130-140 1st year 115-130 2d " 100-115 3d " 90-100 7th " 85-90 14th " 80-85 The Temperature. What is the normal temperature of a healthy infant ? At twenty-four hours after birth the average temperature is 100.4° Fahr., at forty-eight hours after about 98.6° Fahr. After tliis it fluctuates between 98° Fahr. and 99.5° Fahr. How should the temperature be taken ? Never trust to your hand, but always use a fever thermo- meter. In young infants it is best taken in the rectum or groin ; in older children the mouth or axilla may be used. What is the weight of a new-born child? Seven pounds ; the extremes are from lour to eleven pounds. 24 ESSENTIALS OF DISEASES OF CHILDREN. "What is the average length of a new-born child ? Nineteen inches and a fraction over ; the extremes are from sixteen to twenty-two inches. What are the chief anatomical peculiarities of the new-born child? It has a small stomach ; its intestinal action is more rapid ; its power of generating heat is small ; its heart, brain, and liver are large. How should the dosage be proportioned for children? The proportionate dose for any age under adult life is repre- sented by the number of the following birthday, divided by twenty-four, i. e., for one year ^^ = J^, for two years 25 = i and so on. DENTITION. 25 PART I. Dentition. State the number of milk teeth. Twenty. Name them. Two lower and four upper central incisors, two lower lateral incisors, four anterior molars, four canines, and four posterior molars. In what order are they cut ? The two lower central incisors from the fourth to the seventh month; the four upper incisors from the eighth to the tenth month ; the two lower lateral incisors and the four anterior molars from tlie twelfth to the fifteenth month ; the four canines from the eighteenth to the twenty-fourth month, and the poste- rior molars from the twentieth to the thirtieth month. What is the infant's condition during dentition? It is usually the cause of many ailments, such as fever, vomiting, diarrhoea, indigestion, convulsions, etc. How should they be treated ? The child's general health should be most carefully looked into, the bowels regulated, the diet cautiously looked after, and the gums lanced over the advancing teeth when hot and swollen. The diarrhoea of teething is natural, and without it is very excessive it should not be treated. If it causes griping and is offensive the best remedy is a teaspoonful of castor oil, which will clear away any undigested food. Never use astrin- gents in these cases. The fever should be treated with one- half drop doses of tr. aconite, any suspicious twitching must be controlled with bromide of potassium. 26 ESSENTIALS OP^ DISEASES OF CHILDREN. State the number of permanent teeth. Thirty-two. Name them. Four central incisors of upper and lower jaw ; four lateral incisors, four first bicuspids, four canines, four second bicuspids, four first molars, four second naolars, and the four third molars. In what order are they cut ? The two central incisors of the lower jaw from the sixth to the eighth year. The two central incisors of the upper jaw from the seventh to the eighth year. The four lateral incisors from the eighth to the ninth year. The four first bicuspids from the ninth to the tenth year. The four canines from the tenth to tlie eleventh year. The four second bicuspids from the twelfth to the thirteenth year. These replace the temporary teeth ; those which are devel- oped de novo appear thus : — The four first molars from the sixth to the seventh year. The four second molars from the twelfth to the thirteenth year. The four third molars from the seventeenth to the twenty- first year. How is the general health during second dentition ? Not quite up to par, although the child may apparently look well he will complain of feeling tired. Dr. Louis Starr has frequently seen cervical adenitis due to the eruption of the fifth year molars, which quickly subsided when the swollen gums were lanced. How should the child be treated ? By a careful diet, plenty of fresh air and out-door exercise, and if appetite be poor the following tonic may be given : — DENTITION. 27 ;^. Tr. Nucis Vomicae Ti^xxiv-xxxvi. Elix. Calicayse q. s. ad f^iij. — M. Sig. Teaspoonful in water three times a day after eating. (For a child from 6 to 8 years of age.) The gums should be examined frequently, and if found swollen and tense be lanced freely. 28 ESSENTIALS OF DISEASES OF CHILDREN. PART II. Diseases of the Mouth and Throat. Stomatitis. Name the several forms of stomatitis. Catarrhal stomatitis. Aphthous stomatitis. Ulcerative stomatitis. Parasitic stomatitis. Gangrenous stomatitis. Describe catarrhal stomatitis. It consists of a simple hyperaemia of the mucous membrane of the mouth, accompanied by redness and swelling. The in- flammation varies in extent and degree. It may be limited to small, circumscribed points of the membrane, or extend over large patches involving the entire surface. In severe cases the mucous glands of the lips and cheeks are involved, and become enlarged. The disease may be primary or secondary. What are the causes of the primary form ? Any food or liquid that is irritating ; teething, improper care of the child's mouth ; exposure to cold and wet ; bad hygiene, and the administration of certain drugs, as mercury, iodine, and arsenic. What are the causes of the secondary form ? The secondary form usually occurs during the course of one of the eruptive fevers, and any disordered conditions of the stomach, especially those attended by acid eructations. At what age does it usually occur ? Although not limited to any particular age the disease usu- ally occurs during dentition. DISEASES OF THE MOUTH AND THROAT. 29 What are the symptoms ? The lips are unusually full and red, the skin at the angles of the mouth is excoriated from dribbling saliva. The mucous membrane of the mouth shows either a punctated, patchy, or diffuse redness, and is much swollen and tender to the touch. The mouth at first is dry, but soon the salivary flow is increased, which becomes acid in reaction, and at times viscid and flocculent. The mucous glands of the cheeks and lips project as pearly white nodules. The tongue is either red and smooth with enlarged fungiform papillae, or covered with a ■white frosting through which the papillae project in red points. Sucking and eating are painful. The child is restless, the skin hot, anorexia depending upon the local tenderness, and con- stipation are the general symptoms of the primary form. The symptoms of the secondary form depend upon the origi- nating disease ; the local symptoms remain the same. What is the duration of the disease ? The course of the disease rarely lasts longer than a week. What is the treatment ? After removing the exciting cause, the mouth at first should be carefully washed with pure water ; the gums should be lanced if hot and swollen. The mouth should be washed with one of the following solutions and the bowels kept freely opened by appropriate drugs : — ^. Potass. Chlorat. gr. x. Listerine 5ij- Aquse q. s. ad f §j. — M. Sig. Mouth-wash. ^. Potass. lodid. gr. iij. Glycerinse 5ij* AqujE Rosse q. s. ad §j. — M. Slg. Use locally. Salicylic acid, one j)art (dissolved in alcohol) to 250 parts of water is said to ease the pain. 30 ESSENTIALS OF DISEASES OF CIIILDIiEN. Aphthous Stomatitis. Describe this form. In this disease a number of small ulcers appear upon the inflamed and swollen mucous membrane of the lips, tongue, gums, and cheeks. They are round or oval, slightly depressed. Their color in the centre is a yellowish-white surrounded by a band of deep redness. They may run together and form large ulcers. The disease may occur at any age. What are the causes? Insufficient or improper food ; ill-ventilated houses ; chronic disease of the digestive tract, scrofula, etc. What are the symptoms? The previous day the child is restless and fretful, the mouth is hot and tender, the tongue heavily coated, the salivary flow is greatly increased, and the ulcers form. What is the course of the disease? The ulcers last from three to twelve days in mild cases ; in severe cases the pharynx, hard and soft palate may be involved. What is the treatment? First, regulate the diet and give a moderate dose of calomel, which may be followed by a course of pepsin, with dilute muriatic acid, if there be much gastric trouble. Locally a wash of chlorate of potash or borax may be used (gr. x to f Jj) every hour or two. Should the ulcers be obstinate in healing they may be touched once daily with a strong solution of nitrate of silver, or even W'ith a point of lunar caustic. Ulcerative Stomatitis. Describe this form. It is usually seen in children between the ages of three and eight years, and never before the commencement of dentition. DISEASES OF THE MOUTH AND THROAT. 31 Unlike the other forms just mentioned, the ulceration is a rapidly-spreading one. The lower jaw is said to be more frequently affected than the upper. The mucous membrane becomes red and swollen ; the gums are tender and bleed on the slightest touch; the edges of the gums in contact with the teeth turn a dirty yellowish gray, soften, and break down ; the teeth are loosened, and sometimes the periosteum is de- stroyed and necrosis takes place. What are the causes? Insufficient or bad food; cold, damp, or badly-ventilated houses. It may follow any of the eruptive fevers, dysentery, and scrofula. The presence of decaying teeth, and the careless administration of drugs — such as mercury, lead, and phos- phorus — often excite it. What are the symptoms? The mouth is hot and dry, tongue coated, and the breath very offensive ; the saliva becomes streaked with blood, and is very profuse ; mastication is the cause of much pain ; the sub- maxillary and lymphatic glands of the neck are generally swollen, and the face may be oedematous. The child is much debilitated, fretful, and sleepless. The ulceration usually ap- pears on the external surface of the lower gum, at first spread- ing to the upper gum, the edges of the tongue, and lastly on the cheeks. The ulcers are of a dirty gray color, depressed with red, swollen edges. What is the diagnosis? The general appearance of the gums before ulceration com- mences, the character of the ulcers, the odor of tlie breath, distinguish this disease from any others of the mouth. What is the prognosis? It is usually good. Should necrosis of the jaw occur the duration is much prolonged, but recovery is generally the rule; 32 ESSENTIALS OF DISEASES OF CHILDREN. intercurrent noma, however, often leads to the death of the child. What is the treatment? First improve the sanitary surroundings ; secure cleanliness, fresh air, and sunlight ; a diet of animal broths and milk may be given. Chlorate of potash, either alone or with dilute muriatic acid, should be administered. J^. Potass. Chlorat. gr. xlviij. Acid. Muriat. dil. f 5j- Sjrupi f^ss. Aquae q. s. ad f ^iij- — M« Sio-. Teaspoonful diluted every two hours for a child three years old. (Star?-.) The following wash is recommended by the same author : — ;^. Potass. Chlorat. gr. Ixxx. Acid. Carbol. gr. ij. Glycerinse f^j. Aquae q. s. ad f^viij. — M. Sig. Thoroughly apply to ulcers twice daily, and use as mouth-wash. When the ulceration covers much surface it should be swabbed by the physician with a saturated solution of perman- ganate of potassium daily; half a teaspoonful of Condy's fluid to a pint of water should also be used as a mouth-wash. Loose teeth ought not be disturbed without they retard the heal- in c^ of the sores. After the ulcers have healed the local treatment may be discontinued, and the child put on tonics, stimulants, etc. Thrush (Parasitic Stomatitis.) Describe the condition of the mouth. The mucous membrane of the mouth is covered with small white flakes, resembling minute pieces of curd. They are most abundant in the buccal mucous membrane, the tongue and DISEASES OF THE MOUTH AND THKOAT. 33 fauces ; occasionally they extend to other parts of the digestive tract, namely, the oesophagus, stomach, and intestines. -These spots are due to the development of a vegetable parasite, the o'idium albicans. "What are the causes? Improper food, bad hygiene, dirty nursing-bottles, tips, etc. It never attacks infants nursed at the breast. What is the pathological anatomy? Before the flakes appear the mucous membrane of the mouth is purplish-red in color, the secretion is acid in reaction ; the latter shows under the microscope many spores, oval in shape, sharply outlined, and hanging together in twos and threes; some white points appear on the buccal mucous membrane, which rapidly increase in extent and number ; about the third day these coalesce and form white flakes ; during the first few days they adhere firmly to the mucous membrane, after- wards they become loose and can easily be wiped off. The fungus grows only upon squamous epithelium. "What are the symptoms? The mucous membrane of the mouth is dry, tender, slightly swollen, and red ; the child is fretful and restless, the stools are usually loose and yellow in color. In twenty-four hours the thrush patches appear, first on the buccal mucous mem- brane, finally reaching the lips, tongue, and palate. When the patches appear there is increased fretfulness, much pain on sucking, occasional vomiting, and the passage of greenish stools. In from six to twelve days from the beginning of the disease the patches become loose and are removed by suitable applications and the act of sucking ; the mucous membrane is left red and free from ulceration, and soon returns to its normal condition. In the secondary form a previous history of some gastro-intestinal trouble is usually obtained. The pre- liminary catarrh of the mouth is very marked, the mucous 3 oi ESSENTIALS OF DISEASES OF CHILDKEN. membrane being intensely red and shining ; the patches are much -thicker, and adhere more firmly than in the primary form ; when they are removed or fall off they are quickly re- placed by others up to the termination of the case in death. There may be either occasional or constant vomiting, obstinate diarrhcea, the stools' being acid, and green in color; distended abdomen, colic, etc. ; the skin becomes pale and flabby, the anterior fontanelle sinks, and the child has scarcely enough strength to cry, and death from atrophy soon follows. What is the diagnosis? When the curd is wiped away the mucous membrane is found in its normal condition, a characteristic distinction of this disease. Aphthous stomatitis slightly resembles thrush, but the differentiation is made by noting that the yellowish- white spots of the former are depressed below the surface of the mucous membrane and are bounded by dark -red borders. Microscopic examination is always a positive test, and the presence or absence of the parasite decides the question. "What is the prognosis 1 The primary form usually ends in recovery. The secondary form is unfavorable. What is the treatment ? Wash out the child's mouth after each meal. See that the nursing-bottles, tips, etc., are kept absolutely clean. The diet should be carefully regulated as regards quantity and quality of the food, and the intervals of feeding, etc. The local treatment consists of keeping the mouth perfectly clean by washing it every hour with warm water, using a soft rag wrapped around the finger, after which one of the following washes may be applied either with a camel's-hair brush or clean piece of rag, which should be destroyed after using. I^. Grlycer'. Boracis §j. Sig. Use locally. DISEASES OF THE MOUTH AND THROAT. 35 ^.. Potass. Chloral. 5ss. Grlycerinse, Listerine, aa ^ss. Aquse q. s. ad i'^ij. — M. Sig. Use locally. ]^. Sodii Salicylat, Sodii Borat., aa gr. x. Acid. Carbol. gr. j. Grlycerinse 5ij- Aquse Rosse q. s. ad f fj. — M. Sig. Use locally. (Starr.) In secondary thrush the same treatment is applicable. Appropriate drugs should be employed to check the vomiting and diarrhoea, maintain the strength, and improve the diges- tive pow^ers. Gangrenous Stomatitis or Noma. Describe this disease. The affection usually commences with fetor of the breath followed by a free flow of saliva, which is very offensive. On examination a hard red, shining swelling is seen upon one cheek, not painful, but very tense. Inside the mouth at a point corresponding to the swelling a large excavated and ragged ulcer is seen covered with a brown slough, from which a putrid discharge oozes. This ulcer is phagedgenic in char- acter, it involves the gums, teeth, and destroys tissues. Necrosis of the jaw and perforation of the cheek may occur; deglutition is not generally interfered with. What are the causes ? It is always secondary, following severe maladies, such as small-pox, scarlet fever, measles, wliooping-cough, ulcerative stomatitis, and tuberculosis. It occurs between the ages of two and twelve years. Girls are said to be more susceptible than boys. It is not contagious. B6 ESSENTIALS OF DISEASES OF CHILDREN. What are the symptoms ? At the onset there are few constitutional symptoms, and the child rarely complains of pain. As the ulcer spreads constitu- tional depression sets in. The face becomes pale, the pulse frequent, 120 to 150 beats to the minute ; the mouth is held partly open, the tongue and teeth are covered with sordes ; the breath is fetid, and there is a large flow of offensive saliva of a brownish color streaked with blood. The appetite usually remains good and the bowels are inclined to be loose. Per- foration of the cheek may occur at any time between the third and tenth day. The gangrene may invade the lips, the ala of the nose on the affected side, and the cheeks as far as the lower eyelids. The gums and periosteum of the jaws are destroyed, and necrosis of the jaw, and looseness of the teeth occur. What is the dis gnosis ? In cases of noma, where the ulceration precedes the gan- grene, it may be mistaken for ulcerative stomatitis although in the former, around the ulcer where the gangrene commences, the tissues are very much thickened and indurated ; while the latter begins with a submucous deposit of fibrin attended with little thickeningr and induration. In ulcerative stomatitis the skin over the affected part is normal in appearance, in noma it is tense and shining. It may be mistaken for malignant pustule although this disease is rarely found in children. The pustule always begins on the skin, while noma is primarily a disease of the mucous membrane. What is the prognosis ? Very unfavorable — 75 per cent, of the cases die. Death may occur at any time between the third and fourteenth day. If recovery takes place the patient is disfigured by scars, loss of teeth, and probably portions of the maxillary bone. DISEASES OF THE MOUTH AND THROAT. 37 What is the treatment ? Have the sick room thoroughly ventilated, keep up the general health with nourishing food, stimulants, tonics, etc. Early cau- terization should be employed with the hot iron, nitric, sul- phuric or muriatic acid. All sloughs should be carefully removed. The gangrenous point should be swabbed with a solution of permanganate or chlorate of potash, carbolic acid or chlorinated lime. Druitt strongly advocates minute doses of chlorate of potassium. The interior of the cheek may be smeared with an ointment of vaseline and iodoform, or oil of eucalyptus. If the child cannot swallow he must be fed through a flexible catheter introduced into the stomach through a nostril or by nutrient enema. Acute Pharyngitis. What is the definition? An acute inflammation of the mucous membrane covering the tonsils, pharynx, and soft palate. It may be primary or secondary. What are the causes? The cause of the primar}' form is usually due to exposure of cold, impaired health, insufficient clothing, bad food, etc. The disease is not contagious. The secondary form accompanies the eruptive fevers, bron- chitis, and pneumonia. What are the symptoms? Fever, thirst, loss of appetite. The temperature may rise to 102° or 104° F. ; the pulse runs from 130 to 140 beats to the minute ; the throat is dry and voice husky, accompanied by pain on swallowing. On examination the tonsils, uvula, and pharynx are found to be red, and may be partially covered with a whitish mucus. The lymphatic glands at the angles of 38 ESSENTIALS OF DISEASES OF CHILDREN. the jaw are slightly enlarged and tender ; the breath is foul, and the tongue heavily coated with a white fur. What is the diagnosis? Inspection reveals the presence of inflammation. Care should be taken not to confound the patches of mucus with diphtheritic membrane. The former can be easily wiped away. What is the treatment ? Mild cases require little treatment. By the use of cam- phorated oil, externally, and a laxative the inflammation soon subsides. Tincture of aconite may be given for the fever, or the solution of the citrate of potassium ; after the fever has subsided the following may be used : — IJ:. Tr. Ferri Clilor. TTj^xxiv. Potass. Chloral, gr. xxiv. Sjr. Zingiber f^j. Aquae q. s. ad f'^iij. — M. Sig. Teaspoonful every two liours for a child of two years. Tiie throat should be wrapped with flannel, moistened with equal parts of turpentine and olive oil, and may be painted with a weak solution of nitrate of silver (gr. v to foj)* if the child be old enough it is well to let him gargle his throat with a weak solution of the chlorate of potassium (x-xv gr. to f ij). The diet should consist of milk for the first day, and after the fever subsides animal broths, such as beef tea, mutton or chicken broth. When convalescence begins a stronger diet may be allowed and a suitable tonic , administered, such as Huxham's tincture, elixir of calisaya, and tincture of nux vomica. Acute Tonsillitis. What is the definition? An acute inflammation of the tonsils, not of frequent occur- rence in infancy, rarely occurring before the age of five years. DISEASES OF THE MOUTH AND THROAT. 39 What are the symptoms? First, those of a cold with rigors, fever, flushed face, husky voice ; the child complains of headache, pain on swallowing ; the temperature rises quickly to 100° or even 103° F. ; the tongue is furred, the tonsils are swollen and red, and may be covered with small, yellow patches, resembling diphtheritic membrane ; the uvula and pharynx are generally swollen, and often (Edematous, difficulty of swallowing increases, and there is expectoration of thick mucus ; pain is complained of along the course of the Eustachian tube to the ear during the act of swallowing. The inflammation in children usually terminates in resolution or hypertrophy of the tonsils, rather than in actual suppuration as in adults. What is the diagnosis? Acute tonsillitis is most likely to be mistaken for diphtheria and scarlatinous angina. From the "former it may be told by the more acute and sthenic character of the symptoms ; by the slightness of the swelling of the glands at the angles of the jaw, and by the absence of pseudo-membranous exudation. From the latter it may be distinguished by the lower temperature, less frequent pulse, and the absence of the eruption. What is the treatment? It is often possible to abort an attack by painting the tonsils with a strong: solution of nitrate of silver and administering- a brisk purgative. If the child is able to swallow, quinine should be administered ; if not, suppositories of the same should be used. The fever may be diminished with the tincture of aconite in drop doses. The throat should be treated with one of the following prescriptions : — ^. Potass. Chlorat. gr. xxiv. Tr. Ferri Chlor. nxxxiv. Syr. Zingiber, f ^j. Aquae q. s. ad f ^iij. — M. Sig. Toasijooiiful every two hours lor a child of two years. 40 ESSENTIALS OF DISEASES OF CHILDREN. If the cliild be old enough to allow local applications to the tonsils, the following will be found very useful : — I^. Tr. Ferri Chlor. f5iss. Glycerinse f^j. — M. Sig. Use locally every two or three hours. Or, R. Argent. Nitrat. gr. v. Aqnse Rosse f^]. — M. Sig. Touch tonsils once or twice daily. A gargle of chlorate of potassium may be used with advan- tage, provided the child is able to perform the act properly. Flaxseed poultices must be applied to the neck to encourage suppuration ; the bowels should be kept open. When the abscess has broken, the mouth should be frequently washed witli some weak antiseptic solution ; the general health of the patient should be carefully looked after ; the diet consisting of milk guarded with limewater, animal broths free from fat, and stimulants. Hypertrophy of the Tonsils. Describe this disease. It is slow in its development. The disease is rarely recog- nized before the third or fourth year, although its commence- ment in early infancy is quite possible. What are the causes? Constant attacks of tonsillitis, and the irritation attending dentition. What are the symptoms? Loud snoring during sleep, a thick voice, and constant snuffling. On inspection the tonsils are found to be very much enlarged and project. The mucous membrane covering them is usually pale. The follicular orifices are found to be open DISEASES OF THE MOUTH AND THROAT. 41 and very distinct, and may show the yellowish-white points of retained secretion. In some cases the glands are so large tijat they meet and obstruct the throat, causing a constant hacking cough with labored breathing, difRculty of hearing due to pressure upon the orifices of the Eustachian tubes. What is the treatment? Moderate enlargerlient will usually disappear when puberty is passed. The syrup of the iodide of iron must be employed in combination with cod-liver oil ; the tonsils should be painted once daily with one of the following lotions : — ^. Tr. Ferri Chlor. f 5j. Glycerinse f^ss. — M. Sig. R. Ammon. lodid. gr. x-53S. Glycerinse f§j. — M. Sig. Apply every night with brush. ( Waring.} ;^. Liq. Ferri Perchlorid. f 3^s-5j. Gljceringe f^j. — M. Sig. Paint over tonsils once or twice daily. {Mackenzie.) T^. Liq. Iodine Comp. f 5ij" Glycerinse q. s. ad f ^j. — M, Sig. Paint once daily. {Starr.) In marked hypertrophy Dr. Starr employs with good results the solid nitrate of silver every other day. In making this application the caustic should be pointed and passed into the follicles of each gland, and then applied over the whole mucous surface. Should the above method fail excision must be resorted to. Retro-pharyngeal Abscess. What is the definition? A collection of pus formed in the cellular tissue between the posterior wall of the pharynx and the vertebral column. 42 ESSENTIALS OF DISEASES OF CHILDREN. What are the causes ? Direct injury ; disease of the cervical vertebrae ; severe chilling of the body ; scarlatina, and it very frequently arises idiopathically. What are the symptoms? Difficulty of swallowing and breathing ; stiffness of the neck ; difficult articulation. The dyspncea is often alarming when the patient is lying down, which is readily eased by rising to a sitting posture. On inspection the swelling can usually be seen occupying the middle of the pharynx pressing forward the uvula and soft palate. What is the diagnosis ? The presence of the tumor at the back part of the throat, difficulty of breathing and swallowing, stiflfhess of the neck and fulness at the angles of the jaw. What is the prognosis ? Usually favorable if early recognized and not complicated with cervical caries. What is the treatment ? When the seat of the abscess is high up it should be opened with a bistoury, the blade being guarded with adhesive plaster allowing only an eighth or quarter of an inch of the point to protrude. If the abscess is low down it is safer to use a trocar and canula. Light pressure must be made on the tumor with the jBnger for a few days to aid the evacuation of the pus. The general health should be maintained by suitable tonics and nutritious food. DISEASES OF THE STOMACH AND INTESTINES. 43 PART III. Diseases of the Stomach and Intestines. Acute Gastric Catarrh. What is the definition ? An acute catarrhal inflammation of the mucous membrane of the stomach rarely seen in breast-fed infants. What are the causes ? Dentition, exposure, badly ventilated houses, improper or too much food, and general feebleness of constitution. It may also follow the administration of certain drugs in emetic doses, as antimony, ipecacuanha and sulphate of copper. What are the symptoms ? The attack comes on in infants usually after a change of diet. In older children after an indigestible meal. The child has a hot dry skin, loss of appetite, sleeplessness, great thirst, if old enough complains of headache and a slight pain in the abdomi- nal region. These symptoms are followed by vomiting of curdled milk or whatever food remaining in the stomach that is imperfectly digested. Should repeated emesis occur, as it frequently does, there may be painful retching and a little bile stained mucus expelled ; the breath has a disagreeable, sour odor. The tongue is heavily coated with a yellowish-white fur; there is fever ranging from 100° to 102° F., and the pulse beats from 110 to 120 to the minute. There may be tenderness on pressure in the epigastric region, and the bowels are usually confined. These symptoms may continue from one to two days. The attack may suddenly terminate with several loose stools, the fever gradually subsiding, the tongue clearing and the appetite retur'^ing. 44 ESSENTIALS OF DISEASES OF CHILDREN. What is the diagnosis ? The history of the causation, the general character and odor of the vomit, the condition of the tongue, slight fever, course of the attack, and epigastric tenderness. What is the treatment ? The child should be kept perfectly quiet. Relieve thirst by administering small pieces of cracked ice. Do not give any food until the stomach is settled. Should the vomiting be obstinate, apply a weak mustard plaster to the epigastrium just long enough to redden the skin, and give iced limewater every ten or fifteen minutes or the following mixture : — ^. Liq. Calcis, Aquse Cinnamomi aa f §iss. — M. Sig. One or two teaspoonfuls, according to the age, every 15 or 20 minutes, as necessary. (Starr.) The subcarbonate of bismuth may be used either in powders or in mixture with a few drops of brandy. In exceptional cases in older children where there is headache, fever, abdominal pain, and nausea without vomiting, emesis should be induced by draughts of warm water or the syrup of ipecacuanha. When vomiting has entirely disappeared food must be given, at first, in very small quantities, that is, not more than one ounce of milk with a half ounce of lime or barley water. After the stomach is able to tolerate this, weak broths may be given. The bowels should be freely opened by a mercurial, followed by a saline laxative. The diet should be watched carefully for three or four days, and pepsin and bi- carbonate of soda powders administered after each meal. Chronic Gastric Catarrh. What is the definition ? A chronic catarrhal inflammation of the stomach occurring between the third and seventh month. Breast-fed infants are rarely affected. DISEASES OF THE STOMACH AND INTESTINES. 45 What are the causes ? Unsuitable food, over-crowding, filth, too early weaning, in- sufficient clothing, bad ventilation, unclean milk-cans, foul nursing-bottles and rubber tips, allowing the infant to eat ordi- nary table food. What are the symptoms ? Vomiting of curdled milk stained by bile, occurring at irreg- ular intervals. The character of the vomit soon chang-es and a clear watery fluid with fragments of food is ejected. There may be eructations of sour fetid gas. The temperature is normal, the skin is harsh, and the trunk and arms may be covered with an eruption of strophulus. The lips are red and dry, and the tongue is coated with a heavy fur. The mouth is dry, and the thirst is increased. The bowels are constipated, and the evacuations are accompanied by great straining consistkig of small hard lumps, occasionally covered with mucus. At times moderate diarrhoea is present. The abdomen is dis- tended and tender, the child loses flesh, the anterior fontanelle becomes sunken, the face is pinched, and the eyes sunken. The child may remain in this condition for several months with periods of slight improvement. The vomiting now becomes more constant, the milk instead of being curdled is in the same state as swallowed. The body wastes rapidly, and the skin hangs in loose folds about the limbs. The child is fretful and the abdomen becomes retracted. The pulse becomes weak and frequent, and the temperature falls below normal. The breath iias a sour odor, the saliva, perspiration, and urine are acid in reaction. The patient lies utterly exhausted in a half con- scious condition. What is the diagnosis? The long course of the disease, the obstinate vomiting of sour liquid, and the emaciated condition of the body. 46 ESSENTIALS OF DISEASES OF CHILDREN. What is the prognosis? Very unfavorable under the best circurastances. The attack may last from two to six months. What is the treatment ? The first step is a careful regulation of the diet. Milk should be given cold guarded with lime or barley water in tea- spoonful doses to be gradually increased as the stomach becomes more retentive. If the child has been weaned it is well to try a return to the breast. The clothing and hygiene should next be attended to. Tlie patient should wear a flannel binder, and woollen garments next to the skin, extra heavy worsted stockings should be worn to keep the feet warm. The child must be kept in a room of a temperature of 68° or 70° F., and napkins or bedclothing containing vomited matter should be immediately removed. A spice plaster or hot flaxseed poultice should be worn over the abdomen to relieve pain, or the part may be rubbed with turpentine and olive oil, and if the feet become cold they should be well rubbed with tlie latter and hot bottles kept in contact with them. At the beginning, should the child's strength warrant it, an emetic of ipecacuanha should be given to clear the stomach of its acid contents. To check the vomiting Fowler's solution (Liq. Potass, arsenit.), should be administered one-half drop three times a day for a child three months old. Should this fail, the wine of ipecacuanha, one drop every tw'o or three hours, or the tincture of nux vomica in half drop doses may be given three times a day, or minute doses of calomel. For the prostration stimulants must be given. Whiskey should be administered every two or three hours in ten or fifteen drop doses. During convalescence bitter tonics may be employed, such as tincture of nux vomica, elixir of calisaya, etc. DISEASES OF THE STOMACH AND INTESTINES. 47 Ulcer of the Stomach. What is the definition? An ulcer involving the mucous membrane of the stomach, occasionally occurring in new-born infants, but rarely seen afterward. It may occur either as a single ulcer, with a tendency to perforation as in adults, or as small erosions which cover the surface of the mucous membrane and assume the appearance of lacerated follicles. What are the causes ? In older cliildren the same as in adults, namely, privation, fatigue, disease of the lung, heart, kidneys or liver and tlie irritation of food. In new-born infants the circulatory dis- turbances which ensue somewhat suddenly at birth, the sudden arrest of the placental stream, the slow development of the pulmonary circulation, often associated with partial atelectasis which predisposes to venous congestion in the abdominal viscera and gives much ground to the belief that congestion and probably ecchymosis are at the root of the ulceration. What are the symptoms? Vomiting of blood is the most important symptom. Should a healthy child vomit blood within a few hours after birth it may have a gastric ulcer. In older children the symptoms are the same as in adults — pain in the epigastrium, vomitinor, etc. What is the treatment ? In infants the bleeding often proves fatal before any treat- ment is available. The child may be given cold alum whey and some castor oil, which by opening the bowels may relieve any local plethora that might be present. In older children the treatment is the same as for adults, and the reader is referred to works on general practice. 48 ESSENTIALS OF DISEASES OP CHILDREN. Vomiting. How may vomitings be divided? Into three classes, namely, the vomiting of nurslings, the vomiting of older children, and reflex vomiting. Describe the vomiting of nurslings. It is perfectly physiological, showing that the stomach is full. It usually occurs immediately after nursing, and the milk is unchanged. Should it continue, however, the little patient must be carefully watched, as it may become increas- ingly frequent, the vomit being more copious and the intervals of ejection shorter, till finally no food is retained. What is the treatment? If it be due to undigested food an emetic should be given, consisting of a teaspoonful of the wine of ipecacuanha ; the bowels should be opened by the use of calomel (gr. l), or castor oil, one teaspoonful ; a mixture of equal parts lime and cinnamon water may be used ; bismuth, bicarbonate of sodium, calomel, etc., will be found useful. The diet should be carefully looked into, as this trouble is usually found in artificially-fed infants. Describe the vomiting in older children. This is usually due to indigestion. Sudden vomiting in a child of previous good health should suggest the possibility of an onset of some acute disease — as scarlet fever. Describe reflex vomiting. It may be due to meningitis, tumor of the brain, pertussis, chronic lung disease, dentition, and worms. Describe the vomiting of brain disease. It is erratic in its occurrence. The tongue is perfectly clean, and there are no gastro-intestinal symptoms ; the usual evidences of cerebral disease are present — such as headache, DISEASES OF THE STOMACH AND INTESTINES. 49 impaired muscular power, diminished acuteness of vision, and intermittent action of the pulse. What is the treatment? Same as for simple vomiting, and treating symptoms as they arise. Flatulence and Colic. Describe these disorders. They are among the most frequent digestive troubles in infancy. What are the symptoms? Soon after food is taken the child becomes restless, kicks its legs about and cries ; the stomach is rigid, the face pale, and the vomiting of curds may occur. As the meal is digested the pain ceases. What is the treatment? Should.it be due to indigestible food, the milk must be diluted with an alkali — such as limewater, or bicarbonate of sodium, or by the addition of properly-made barley water. Of the drugs, any of the aromatic waters may be employed. Soda mint in hot water is usually successful in relieving the flatu- lence. When the pain is very severe twenty or more drops of brandy may be given in hot water, and a linseed meal poultice applied to the abdomen. If the bowels are confined a tea- spoonful of castor oil should be administered. Constipation. How may constipation be divided? Into two classes, namely, constipation of infancy, and con- stipation in older children. What are the causes of the former class ? Feebleness in the muscular expulsive power of the intestines, 4 50 ESSENTIALS OF DISEASES OF CHILDREN, in the material it contains, or both ; malformations about the anus — as fissure. It is more frequent among hand-fed babies than those nursed at the breast. It is commonly due to the use of cows' milk containing a large percentage of casein, starchy foods, etc. What is the treatment? If the child be nursed at the breast it may be treated through the mother's milk ; but this plan is rarely satisfactory. For the child castor oil is an old-time remedy, and really quite efficient for temporary constipation. Should the constipation become chronic small doses of fluid magnesia may be given three or four times daily, or sulphate of magnesium in five grain doses, the bitter taste being properly disguised in a suitable syrup. Manna is a useful drug, and is best adminis- tered by dissolving a bit the size of a pea in the nursing-bottle, or it may be given in the following way : — I^. Mannse Opt. 5.1' Syr. Simp, f ^=s. Aquae Cinnam. q. s. ad f ^j* Sig. Teaspoonful three times a day. Or, I^. Tr. Aloes et Myrrh ^j. Sig. One to three drops in sweetened water two or three times daily, according to age. Or, ^. Mannae Opt., Magnessii Garb, aa 5j' Ex. Sennse fl. f Siij* Syr. Zingiberis f§j. Aquae q. s. ad f ^iij. Sig. One or two teaspoonfuls three times a day for a child of two years. {Goodhart and Starr.) The diet should be carefully regulated, and the lower bowel be encouraged to expel its contents by enema, or suppository DISEASES OF THE STOMACH AND INTESTINES. 51 of soap or glycerine. Oat-meal water may be used to^ dilute the milk instead of the plain at least twice during the day, and friction should be applied to the abdomen night and morning, rubbing in a teaspoonful of warm olive oil. An enema may be given every morning, or even twice a day if necessary, consisting of soap and water. Glycerine ei.ema is highly recommended, one-half teaspoonful with two tea- spoonfuls of water should be given to a child of six months. At times the constipation is associated with much flatulence and pain, then a teaspoonful of fluid magnesia may be admin- istered with a little sweet spirits of nitre and sulphate of mag- nesium. If associated with heartburn, which causes the child to cry with pain or make faces and have hiccoughs, the follow- ing is used by Dr. Eustace Smith : — 5. Sodii Bicarb. 5)' Tr. Nucis Vomicse "nx^j' Tr. Cardamomi Comp., Syr. Simp, aa f 5ij' Aquse Chloroform (Br. P.) f §3S. Aquse q. s. ad f ^ij. Sig. One teaspoonful every six hours. Aloes powdered and dissolved in milk is recommended, also drop doses of fluid extract of cascara sagrada or tincture of podophyllin. What are the causes of constipation in older children? Indigestion, improper food, diseases of the stomach and liver, syphilis, malaria, etc. More common in girls than in boys. What are the symptoms ? The little patients are found to be rather fretful without any definite symptoms of disease ; their appetites are capricious, the breath generally very offlensive. The abdomen is large and tumid, the distention being marked. 52 ESSENTIALS OF DISEASES OF CHILDREN. What is the treatment ? Regular habits must be insisted upon. The child should be taken to the closet a certain hour each day. The juice of an orange or an alkaline water must be given before breakfast, or stewed prunes, and figs, as a dessert. Should these simple remedies fail to relieve the trouble, one of the following pre- scriptions will be found useful : — R. Ex. Belladonnae gr. A. Pil. Aloes et Myrrh, gr. ix. 01. Carl gtt. ij. M. et ft. pil. No. vi. Sig. One pill at bedtime for a child of six years. ( Goodhart and Slarr.') R. Ex. Cascarge Sagrad. Fl. f ^j. Sig. Three drops three times a day, to be increased as necessary for a child of five years. R. Pulv. Glycyrrhizse Comp. §j. Sig. Cofl"eespoonful at bedtime for a child of six or seven. R. Tr. Aloes et Myrrh, f 5iij' Syr. Zingiber, f ^ss. A quae q. s. ad f ^ij. — M. Sig. Teaspoonful two or three times daily for a child of six years. R. Ex. Belladonnse gr. j. Grlycerinse f^j. Vini Ferri Amar. q. s. ad f §iij. — M. Sig. Teaspoonful three times a day at the age of six years. (^Goodhart and Starr.) Cheadle's formula of twenty to forty grains each of the sul- phate of soda and sulphate of magnesia is highly indorsed. Constipation associated with sickness sliould always be care- fully investigated, and the possible existence of intussusception, peritonitis, and brain disease should be remembered. When constipation is obstinate from birth, the rectum should be carefully examined. Constipation in young children is not unfrequently associated with small fissures about the anus, DISEASES OF THE STOMACH AND INTESTINES. 53 causing severe pain during tlie act of defecation, and in some cases the pain is so intense that the sphincter contracts tightly and prevents any expulsive etFort. The treatment in such cases would be to keep the bowels slightly relaxed, to prevent any stretching of the parts, to keep the fissure and lower inch of the rectum well anointed with the following ointment : — ^. Ungt. Plumbi Carbonat. 5J« Uiigt. Hydrarg., Ungt. Zinci Oxidi aa 5ij- — M« Sig. Apply two or three times a day. If a dry dressing is preferred, equal parts of lycopodium and calomel, or oxide of zinc and calomel may be dusted over the part. In some cases it may be necessary to paint it with nitrate of silver, or even stretch it forcibly with the fingers, which is usually successful. Simple Diarrhoea. What are the synonyms ? Muco-enteritis, catarrhal enteritis. What is the definition? Frequent evacuations from the bowels of a thin watery character without tenesmus. What are the causes ? Unfavorable hygienic conditions, impure milk, summer heat in a crowded city, dentition, improper food, and overfeeding. What are the symptoms ? The onset may come on with vomiting and purging or with apparently little disturbance of the general health. Tliere is pallor, slight fretfulness, restlessness, and usually a rise in temperature. The mouth is generally dry and the child thirsty ; the tongue will be found much redder than natural, and the 54 ESSENTIALS OF DISEASES OF CHILDREN. papillae prominent. The motions are of a liquid consistency, and usually green or a yellowish color with a very offensive odor. What is the treatment? Careful attention should be given to the diet, and at the beginning of an attack it is well to use a gentle laxative as castor-oil to clear out the intestinal canal before the adminis- tration of astringents, then one of the following prescriptions will be found useful : — ^. Bismuth Subcarb. 5ss-5iss. Spt. Mjristicse ll\,xx. Spt. Vini Gal. f5iss 5h*j. Syr. Acacise f ^iss. Aquae Cmnam. q. s. ad f fiij. — M. Sig. (Shake well.) Teaspoonful every two hours. Or, 1^. Magnesise Sulphat. 5j' Tr. Opii Deed oral. gtt. xij. Syr. Simp. f^ss. Aquae Ciiinam. q. s. ad f ^iss. — M. Sig. Teaspoonful every two hours for a child of one or two years. (Meigs and Pepper.) Or, 5. Tr. Opii Deod. lT|.vj. Bismuth Subcarb. gr. Ixxij. Syr. Acacise f ^ss. Mist. Cretse q. s. ad f ^iij- — M. Sig. Teaspoonful every two hours. Should the stools remain green and slimy a course of minute doses of calomel will be useful. ^.. Hydrarg. Chlor. Mit. gr. j. Saccli. Lact. gr. xij. Pulv. Aromat. gr. vj. M. et ft. chart. No. xii. Sig. One powder every two hours. DISEASES OF THE STOMACH AND INTESTINES. 55 Entero-colitis. What are the synonyms? Febrile diarrlioea, summer diarrhcEa, *' summer complaint," inflammatory diarrhoea. What is the definition? A catarrhal inflammation of the lower portion of the small intestines and the upper portion of the large, characterized by diarrhcea, nausea, vomiting, pain, swelling of the abdomen, and emaciation. What are the causes ? Residence in large cities, bad hygienic surroundings, over- crowding, decomposing organic matter, high temperature. The disease is very rare in winter ; usually begins about the first of June, and disappears in the early part of September. Hand- fed babies are more prone to it. Impure food, sour milk, fari- naceous preparations in excess, over-ripe fruit, etc. It usually occurs between the sixth and eighteenth months of life, after the second year the attacks are less common. What are the anatomical lesions? There is hyperaemia of the mucous membrane of the ileum and colon, probably more marked about the ileo-caecal valve and in the sigmoid flexure. The intestinal glands are enlarged, and the Peyer's patches tumid, elevated, and punctured. The peritoneum over the inflamed glands is injected, and the mesen- teric glands are enlarged. The stomach may at times be normal, or the seat of catarrh, the mucous membrane being thickened and inflamed. If the disease assumes a chronic form, the glands break down and superficial oval ulcers are formed. What are the symptoms ? The attack is generally preceded by disturbed sleep, restless- 56 ESSENTIALS OF DISEASES OF CHILDREN. ness, eructations of a sour-smelling liquid, which in some cases is very offensive, an increase in the number of stools, with a decrease of their consistency. In one or two days diarrhoea and vomiting begin ; the latter is very obstinate, and the ejections consisting of sour, undigested food. Describe the stools. They may average from six to twenty or even more in the twenty-four hours. They may be semi-solid, of a yellowish color, with a fecal odor ; or liquid, green in color, acid in reaction ; or they may contain quantities of mucus and blood ; or towards the end be almost serous and Yerj offensive. What other symptoms shoiild be looked fori The tongue is dry and coated, red at the tip and edges, appetite poor, increased thirst, and distention of the abdomen. The skin is hot and dry. The pulse is weak and may run up to 120 or even 140 to the minute. The urine is high colored, scanty, and passed at long intervals. As the disease progresses the face becomes pale, the eyes are sunken and dull, the fontanelle is depressed, there is great emaciation. The buttocks and inner surface of the thighs become reddened from the acid stools and concentrated urine. What is the diagnosis ? The fever, vomiting, the number and appearance of the stools, the age of the child, the season of the year, the locality and general surroundings make the diagnosis of entero-colitis quite easy. What is the prognosis ? The outlook is usually bad, although a large proportion of cases recover under proper treatment. It is much more fatal among the children of the poor who are unable to have a proper plan of treatment carried out. The disease may prove fatal in a few days. DISEA.SES OF THE STOMACH AND INTESTINES. 57 What is the treatment ? First remove the cause. The child should be taken to the country or sea-coast at once ; if this is impracticable it should be kept in public squares where there is a free circulation of air. The heat of the day must be passed in some cool spot. The child should be allowed to lie in a clean cool bed and not fondled too much. The clothing should be as thin as possible, but it must not be forgotten that flannel should always be worn next to the skin. In the beginning of the attack the body must be care- fully sponged with water at 80° F., and gently dried. The diet must be carefully regulated, the quantity as well as the quality. Cracked ice may be given, and where water is used it should always be filtered or boiled. Should the child be hand-fed great stress should be laid upon the care of the milk, the nursing-bottles and tips. If vomiting occurs all food must be discontinued for at least twelve hours, and the thirst quenched by the use of thin barley gruel, Vichy water, etc., always given cold. In bottle-fed children it is well to stop the use of milk entirely and give chicken or mutton broth (free from fat), wine whey, beef juice (expressed from a rump steak). Mellin's food with barley gruel or raw scraped beef. The first step in the medical treatment is* to empty the bowels, and for this purpose there is nothing better than plain castor oil or the following emulsion of the same : — ^. Emul. Ricini, 50 % f§j. Sig. Teaspoon ful for a child of one year. Should the stomach reject this, an enema may be substi- tuted. This should consist of water that has been previously boiled and when used the temperature must be 65° or 70° F., about one pint for a child of six months, and double the quantity for a child of two years. The injection is best given slowly with a fountain syringe. 58 ESSENTIALS OF DISEASES OF CHILDREN. To abort decomposition and restore a healthy action to the intestines, calomel, salicylate of sodium or naphthalin may be given. ^. Hydrarg. Clilor. Mil. gr. j. Bismuth Subnit. gr. xxxvi-3j. M. et ft. chart. No. xii. Sig. One powder every two hours. ^. Sodii Salicylat. gr. xxiv-lxxij. Aquae Clnnam. f^iij. — M. Sig. Teaspoonful every two hours. 1^. Naphthalin gr. xii-5j. Sacch. Lact. gr. xii-5ss. M. et ft. chart. No. xii. Sig. One powder every three hours. The bichloride of mercury may be given in doses of yj^ to jAq of a grain, but it usually causes vomiting even in these minute doses. The following will be found a very valuable formula. ^. Bismuth Salicylat. gr. xxiv-lxxij. Syr. Acacise f^j. Aquae Cinnam. q. s. ad f ^iij. — M. Sig. Teaspoonful every three hours. Counter- irritation over the abdomen is useful either by the use of weak mustard or the ordinary spice plasters. Alcohol should be used when indicated to support the system, and during convalescence tonics are required, such as the elixir of calisaya, etc. Cholera Infantum. What is the synonym ? " Summer complaint." What is the definition ? An acute catarrhal inflammation of the mucous membrane DISEASES OF THE STOMACH AND INTESTINES. 59 of the stomach and intestines, occurring usually during the first dentition ; characterized by severe vomiting and purging, colicky pains, and prostration. What are the causes ? The same as entero-colitis. It may occur at any age under two years, but is most frequent between the sixth and the twelfth months. What are the anatomical lesions ? The gastro-intestinal mucous membrane is very much con- gested, thickened and softened, and the glands are enlarged. The sympathetic system is much disturbed. What are the symptoms ? The onset is always sudden ; the first symptom is the appearance of large watery evacuations which are often so serous that they do not stain the napkin, or they may be of a greenish-yellow or a dirty brown fluid. The first mentioned are usually odorless, but the others have an offensive smell which is not easily forgotten. The number of motions vary from ten to thirty in the twenty-four hours. Next, the stomach becomes irritable, everything is vomited immediately after being taken, and there is severe retching ; the appetite is lost, the thirst intense, the tongue dry and pasty, the abdomen flabby. There is much restlessness, and the tempera- ture may reach 105°, or even 108° F. ; the pulse is weak, the breathing irregular, urine almost suppressed ; in a few hours the face becomes pale, the eyes are dull and sunken, and the lips parted ; the fat of the body seems to melt away, the muscles become flabby, the skin is dry and hangs in loose folds. Next, there is rapid collapse, cold breath, uncountable pulse, irregular breathing, suppression of urine, and at last death. The attack often proves fatal in from twenty-four to forty- eisht hours. 60 ESSENTIALS OF DISEASES OF CHILDREN. What is the diagnosis? The character and odor of the stools, the frequent vomiting, intense thirst, high temperature, rapid emaciation, collapse, irregular breathing, etc. This disease is said to resemble sunstroke. What is the prognosis? Very unfavorable. The child should be removed to the country or seashore at once, as this offers about the only chance for recovery. What is the treatment? Owing to the great strain upon the system from frequent evacuations and vomiting, food should be given to replace the waste. The first indications for medical treatment should be to arrest the vomiting and purging, for which the following may be given : — ^:. Bismuth Subnit. 5ss-3iss. Spt. Myristicse rr^xx. Spt. Vini Gal. f 5iij. Syr. Acaciae §iss. Aquse Cinnam. q. s. ad f ^iij. — M. Sig. Teaspoonful every two hours. If this fails, broken doses of calomel with a few grains of subnitrate of bismuth will be found useful. ^. Hydrarg. Chlor. Mit. gr. ^. Bismuth Subnit. gr. xxxvj. M. et ft. chart. No. xii. *• Sig. One powder every hour or two. Or, ^. Liq. Calcis, Aquse Cinnam. aa §j. — M. Sig. Teaspoonful when required. The child should be allowed to suck ice constantly, and DISEASES OP THE STOMACH AND INTESTINES. 61 drink cool, filtered water. To check the purging astringents and opium should be used. Sulphuric acid is often of value. 5" Acid. Sulphuric. Aromat. nxxxiv. Liq. Morphiae Sulphat. t'5j. Elix. Curacoffi f^i]. Aquae q. s. ad f §iij. — M. Sig. Teaspoonful every three hours for a child one year old. {Goodhart and Starr.') An enema of two or three drops of laudanum suspended in starch-water may be given every third hour. Monti highly indorses intestinal irrigation by means of copious enemata of from one to three pints of warm or cool water, allowed to flow from an ordinary fountain syringe into the bowel. Mustard plasters should be applied to the abdomen several times in the twenty-four hours, or a spice plaster, or flax-meal poultice constantly worn, renewing every two hours. The body should be sponged night and morning with tepid water. The child must be kept in a large well- ventilated room, and on a cool, clean bed, if possible, and not held in the lap ; the clothing and diapers should be kept clean, and the clothes thoroughly aired before putting on. Stimulants should be given at the start ; from five to twenty drops of good rye whiskey should be given every two hours in a little limewater or Vichy. In the state of collapse the bodily temperature must be kept up by the use of hot bottles, flannels, etc. In this stage a mustard bath will be found valuable. Chronic Diarrhcea. What are the synonyms? Chronic intestinal catarrh ; chronic entero-colitis. What are the causes? Neglect among children of the poor, filth, series of attacks of 62 ESSENTIALS OF DISEASES OF CHILDREN. simple diarrhoea, lack of cleanliness. Usually occurs in infants from six to twenty-four months, and frequently in older child- ren. In children of the well-to-do it generally results from improper feeding. What are the symptoms? Tlie stools at tirst may be abundant although their character is not abnormal ; then they may gradually become pale in color and thinner in consistency ; the child loses flesh ; the stools become lumpy, with at first a small quantity of mucus ; in the later stages they are more frequent, and the amount of mucus is increased ; their color may be of a dirty brown water containing green particles, which is commonly known as the spinach stool. The child continues to waste rapidly ; the skin is dark and dry, hanging in folds upon the frame ; the face is wrinkled, and much resembles that of an old man ; the cry is weak, the tongue red and dry, and the abdomen usually distended. If the diarrhoea is not checked, the child gradually becomes more feeble, and sinks into a semi-comatose state; the temperature falls below normal, the extremities be- come cold, and the child may succumb to exhaustion, or pro- bably convulsions. What is the morbid anatomy ? The coats of the stomach and intestines are atrophied, pale and thin. The mucous membrane of the lower part of the small intestine is covered with black specks which are due to altered blood pigment deposited round the ulceration of the solitary glands and follicles. There may be more or less super- ficial erosion of the mucous membrane, and the mesenteric glands are swollen. What is the diagnosis ? Chronic diarrhoea is liable to be mistaken for tuberculosis of the intestines. If it begins soon after birth and there be a history of bad feeding, exposure, neglect, with no constant DISEASES OF THE STOMACH AND INTESTINES. G3 elevation of temperature, the affection is probably chronic diarrhoea. Tuberculous diarrhoea usually occurs after the third year, it is attended by pyrexia and enlarged mesenteric glands. There is tenderness on pressure in the right iliac fossa, and the abdominal wall is tense over this region. The evacuations are intensely fetid, brown and liquid when voided, but if left standing a dark sediment settles, composed of flocculent matter with small clots of blood and masses of mucus and pus. What is the prognosis ? Grave, in children under the age of two years, and when it occurs in syphilitic, rachitic, or feeble children. What is the treatment ? Tlie hygienic surroundings should be carefully attended to and the child kept perfectly clean. The diet should be liquid and carefully regulated. The following prescription will be found useful for a child of ten years : — ^. Ferri Sulphat. gr. viij. Magnesii Sulphat. 5.1- Acid. Sulphur, dil. f 50"- Syr. Zingiber, f^ss. Aquse Cari q. s. ad ffiv. — M. Sig. Teaspoonful in water three times a day. {Goodhart and Starr.) In older children prolapsus ani often occurs ; this should be relieved by strapping the buttocks together or using an enema of sulphate of iron (5j Oss), a third part to be used every morning. Any of the following prescriptions will be found useful: — ]^. Tr. Kramerise, Tr. Opii Camph. aa 5ij- Mist. Cretae q. s. ad f §ij. — M. Sig. Teaspoonful every two hours for a child of two years. 64 ESSENTIALS OF DISEASES OF CHILDREN. ^. Acid. Sulphuric, dil. f 5J-3iss. Liq. Morphise Sulphat. f 5ij-3iiss. Spt. Vini Gallici f 3"J-5''''' Syr. Zingiber, f gss. Aquse q. s. ad f ^iij. — M. Sig. Teaspoonful three or four times a day for a child of two or three years. ^.. Acid. Gallici, gr. x. Vini Opii v\v. Alcohol f5iss. Aquae Chloroform q. s. ad f ^iss. — M. Sig. Teaspoonful three times a day. Nitrate of silver is valuable when the diarrhoea is very obstinate and if aphthae appear in the mouth, the following is a very useful formula : — ^. Argenti Nitratis gr. j. Syr. Acacise §ij. Aquse Cinnam. q. s. ad f ^iij. — M. Sig. Teaspoonful every two hours for a child of two years. Stimulants should be given to relieve the prostration, whiskey being the best in doses of about ten drops every two hours. Astringent enemata may be used. Nitrate of silver, one grain to five ounces of water is highly recommended by Trousseau, but Goodhart and Starr prefer equal parts of an infusion of ipecacuanha and decoction of starch. When improvement sets in, strong tonics must be employed to build up the strength. Dysentery, What are the synonyms ? Bloody flux. Ulcerative colitis. What is the definition? An acute inflammation of the mucous membrane of the DISEASES OF THE STOMACH AND INTESTINES. 65 large intestines, characterized by fever, tenesmus, and frequent stools composed largely of mucus and blood. What are the causes ? Excessive heat, exposure to cold, and bad food. There are two forms, namely the sporadic and epidemic. Tlie epidemic form is said to be both infectious and contagious. The disease is more common in boys than in girls, and usually occurs in the second or third years of life. What are the symptoms ? The attack is ushered in with nausea, vomiting, fever, and acute abdominal pain. The stools are numerous and small in quantity, ranging from four to forty in the twenty-four hours, and are voided with much straining and discomfort. At first they contain fecal matter, but as the disease progresses they are composed entirely of mucus and blood mixed in a dirty yellowish fluid most offensive to the odor. There is restless- ness, sleeplessness, and rapid emaciation. The tongue is red and dry, covered in the centre with a dark coating. There is fever and intense thirst. The abdomen is much distended and painful on pressure over the region of the colon. As the attack progresses tenesmus occurs without the pas- sage of stools, and often causes prolapse of the rectum. The fever is replaced by a coolness of the surface. Tlie face becomes pinched, the cheeks sunken, and death may either take place from exhaustion or be preceded by slight convulsions. In grave cases the attack lasts from one to three days ; in favorable cases about two weeks. What is the diagnosis? High fever, tenesmus, tenderness of the abdomen, and the number and character of the stools. What is the prognosis? Favorable in the sporadic form and when there is only a 5 G6 ESSENTIALS OF DISEASES OF CHILDREN. sliglit elevation of temperature and a few stools. On the other hand, if the fever be high, and frequent evacuations containing much mucus and blood, great tenesmus ; when there is a ten- dency to collapse, the prognosis is grave. What is the treatment? The child must be put to bed in a well-ventilated room, and given only liquid diet. Small pieces of ice may be allowed to be sucked to relieve the intense thirst ; the abdomen should be kept covered with a flax-meal or mush poultice, changed every two hours. If the patient is seen early it is well to clean out the intes- tines by small doses of castor oil with laudanum (fifteen drops of castor oil with one drop of laudanum, every two or three hours, for a child of three years). After this has been given for twenty-four hours any of the following formulae will be found useful : — ^. Pulv. Ipecac. Comp. gr. vj. Bismuth. Subcarb. 5J' Pulv. Aromat. gr. vj. M. et ft. chart. No. xii. Sig. One powder every three hours. (Starr.) This should be followed by an enema of laudanum — gtt. iij to ^ss of tepid water every four hours. If this should fail use the followine, a. ]m:., m:. r>. Professor of Surgery and Clinical Surgei-y in the Unirersity of Mich- igan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Home, Italy; Late Surgeon JetTerson Medical College, etc. Thirty fine Lithographic plates in colors and 175 Wood cuts in the text. Post 8vo, over four hundred pages, cloth or oilcloth for the dia- eecting-room, $2.00. Medical sheep, $2.50. IN PREPARATION. DISEASES OF WOMEN, BY HEr^RY J. GS^ARRIOXJES., A.M!., 3Z.T>. Professor of Obstetrics in the New York Post-Graduate Medical School and Hospital; Gynaecologist to St. Mark's Hospital In New York City; Gynaecologist to the German Dispensaiy in the City of New York ; Consulting Obstetrician to the New York Infant Asylum ; Obstetric Surgeon to the New York Maternity Hospital: Fellow of the American Gynaecological Society; Fellow of the New York Academy of Medicine; President of the German Medical Society of the City of New York, etc., etc. READY SHORTLY. DISEASES OF THE EYE. BY OEO, E. De SCHW^EIIVITZ, M!. I>. Ophthalmic Surgeon to Children's Hospital and to the Philadelphia Hospital ; Ophthalmologist to the Orthopaedic Hospital and Intirmary for Nervous Diseases, etc. I N PREPARATION. A NEW UNABRIDGED DICTIONARY OF MEDICINE AND' ACCESSORY SCIENCE, BY JOHN M. KEATING, M. D., (Univ. of Pa.), FELLOW COLLEGE OF PHYSICIANS OF PHILADELPHIA ; VISITING OBSTE- TRICIAN TO THE PHILADELPHIA HOSPITAL, AND LECTURER ON DISEASES OF WOMEN AND CHILDREN; GYNAECOLOGIST TO ST. JOSEPH'S HOSPITAL ; SURGEON TO THE MATERNITY HOS- PITAL, ETC. ; EDITOR " CYCLOPEDIA OF DISEASES OF CHILDREN"; AUTHOR OF "MATERNITY — INFANCY — CHILDHOOD," ETC. AND HENRY HAMILTON, AUTHOR OF " A NEW TRANSLATION OF VIRGIL'S ENEID INTO ENGLISH RHYME" ; CO-AUTHOR OF "SAUNDERS' MEDICAL LEXICON," ETC. A voluminous and exhaustive hand-book of Medical, Surgical and Scientific Terminology, containing concise explanations of the various terms used in medicine and the allied sciences, with Accent- uation, Etymology, etc. The work, when completed, will form a handsome Royal 8vo. volume of some looo pages, beautifully printed from new type on paper especially manufactured for this purpose; it will contain the most recent additions to scientific nomenclature, important tables, etc., under the most convenient system of arrange- ment — the whole forming the most complete, reliable and valuable dictionary in the market. Indispensible alike to the Student and Practitioner, not only for occasional reference, but for daily use. SAUNDERS' QUESTION-GOMPENDS. Ji. OPINIONS OF THE PRESS. Extract from Medical Brief, St. Louis, May^ 1890. Semple's Legal Medicine Toxicology and Hygiene. "A fair sample of Saunders' valuable conipends for the student and practitioner. It is hand- somely printed and illustrated, and concise and clear in its teachings." Extract from Southern Practitioner, April, 1890. Stelwagon's Disease of the Skin. "The subject is as tersely and briefly considered as is compatible with learners, and as a means of refreshing the memory or permanently fixing therein the most important facts of Derma- tology, it will till an important place with students of'mediclne." Extract from Medical and Surgical Reporter, April.^ 1890, Craigin's Essentials of Gynfecology. "This is a most excellent addition to this series of question compends^ and properly used will be of great assist- ance to the student in preparing for examination. Dr. Craigin is to be congratu- lated upon having produced in compact form the Essentials of Gynaecology. The style is concise, and, at the same time the sentences are well rounded. This rejiders the book far more easy to i-ead than most compends and adds dis- tinctly to its value." Extract from the New York Medical Journal, May, 1890. Stelwagon's Diseases of the Skin. "We are indebted to Philadelphia. for another excellent book on Dematology. The little book now before us is well entitled "Essentials of Dermatology," and admirably answers the i>urpose for which it is written. The experience of the reviewer has taught him that just such a book Is needed. SVe are pleased with the handsome appearance of the book, with its clear type and good paper, and would specially com- mend the woodcuts that illustrate the text." Extract from Journal of Cutaneous and Getiito-Urinary Diseases, May 1890. " An examination of the manuals before lis cannot fall to convince one that the authors have done their work in a satisfactory manner. "Dr. Stelwagon's Essentials of Diseases of the Skin is an admirable com- pend of our knowledge of Dermatology. The author's experience as a teacher has enaljled him to formulate questions covering all essential points, while the answers are comprehensive with sufficient accuracy of detail to be thoroughly intelligible. Of especial value and comj)leteness is the therapeutical part of the work. "Dr. Wolff in the Ex;ami nation of the Urine, has given an account of the normal and pathological constituents of the urine and a resume of the I'ecent and inost improved methods for its chemical and microscopical examination. The iniportance of a knowledge of urinology and urinalysis to the student ot derma- tology and genito-urinai-y diseases cannot too strongly be insisted on." "Dr. Craigin in his Essentials of Gynaecology embraces many morbid con- ditions of much interest to the specialist in cutaneous and genito-urinary dis- eases, as the skin diseases alfccting the vulva, new growths of the vulva, the arious forms of vulvitis, vaginitis ui-ethritis, endometritis, salpingitis, ovarttis, 'Ic, which occur as .segueke of gonorrhceal inflammation." Extract frotn Boston Medical and Surgical Journal, May i, 1890. "Craigin's Gynaecology, a little book that does contain the essentials of gynse- cology and may be recrim rmMuied f-o 1 he h\ ndont as a safe and useful guide to him in liis studies.''^ SAUNDERS' QUESTION-GOMPENDS. OPINIONS OF THE PRESS. Extract from London Lancet, July 6tli, 1889. £ar£ka St^nAcni^ that *^ COLUMBIA UNIVERSITY se ^ 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. and its ai DATE BORROWED m u" m re eL li! icL Oi DATE DUE DATE BORROWED DATE DUE ^ogy sion - All .s to '1lled are Qore )ook and and 300k ader and g to Intly book V csc'f^; SAUNDERS' QUESTION-GOMPENDS. OPINIONS OF THE PRESS. tvrmT'TT June. 1889. fi nitei RJ48 3 chiJ> a Powell ] i? P87 he in- to' en- " Wolff's CnKMiSTUV. — A littlo bofik tlutt exj)l:iJnH, clearly and simply, the most difficult [fointrt in Medical Cln-iMist,ry, ho U);it ihU n^orj mi'k/D^^ ]jo*iAiKf^^nMC\fit^ify&.r of a medical student's elfortfi."