rW^yf?^^ R3^S K&3 College of ^Ijpjiiciang aniJ ^urgeong %ihvaxv 'r 1^^^^^ '^ MEDICAI ^'^ .^. LIBRARV I'TY 4" r \ 1 / / / / / / 1 1 / 25 3,000 75 50 25 2,900 75 50 25 / / / / / / / \ / \ / \ / \ / \ / \ / ' \ 1 6 \ / \ / \ / \ / \ / / / 1 / / \ / / ' / / f / / 1 / / / \ / \ / J \ / ^ / 1 Normal curve of weight during tbe first ten days of life. (Budin.) physician must take into account not only the infant itself, but con- ditions of heredity and surroundings. There is absolutely no unvary- ing picture of a normal child. There are limits of variation, and these the physician should endeavor to master. 24 INFANCY AND CHILDHOOD. Body-weight. — During the first two or three days following the birth of the infant there is a loss of body-weight. Usually this loss amounts to from 150 to 200 grammes, or 5 to 6^ ounces (Fig. 1). It is even greater in some infants. The passage of meconium and urine, the exhalations from the skin and lungs, and the small amount of nourishment taken by the infant account for this loss. As nursing begins the weight increases until the seventh day, when the infant, under normal conditions, will have regained its original weight. On Fig. 2. MONTHS 2 3 4 5 6 7 S 9 10 11 12 1 DAYS 1 ' 1 WEEKS 1 1 _ 123456759 tl 12 15 W I is eo 1 =- 1 SS S2 je 4jD le / - - _ '= ,-' ^ -4 .'_ I 3 ^^- - - 12 ' - - 4 :..:_:.:_ ;:-_::_^ . _. _,2- IGirls. 61.6 156.4 106.7 48.5 21.5 54.6 6.0 15.3 9.5 23.8 2.6 6.5 Table of Weight, Length, Head Circumference, and Girth of Chest from Birth to the End of the Fourth Year. Age. Birth . . . 6 months 12 months 2 years . . 3 years . . 4 years . . Sex. /Bovs. IGirls. /Boys. IGirls. /Boys. IGirls. /Bovs. IGirls. / Boys. IGirls. /Boys. iGirls. Length. In. 19.7 19.3 25.4 25.0 29.5 28.7 33.8 32.9 37.0 36.3 39.3 38.8 Cm. 50.0 49.0 64.8 63.6 73.8 73.2 84.5 82.8 92.6 90.7 98.2 97.0 Weight. Lbs. Kilos. 7.4 7.1 16.0 15.5 21.5 21.0 30.3 29.2 34.9 33.1 37.9 36.3 7.2 7.0 9.8 9.5 13.8 13.3 15.9 15.0 17.2 16.5 Head circum. Chest girth. In. Cm. In. Cm. 13.8 35.1 12.6 32.0 13.1 33.4 11.8 30.0 16.0 40.5 15.7 39.9 16.4 41.7 15.2 38.6 17.8 45.3 17.8 45.1 18.2 46.3 19.0 48.3 19.3 49.0 20.0 50.8 18.0 45.6 18.0 48.0 19.3 49,0 20.1 51.1 19.0 48.4 19.8 50.5 19.7 50.3 20.7 52.8 19.5 49.6 20.5 52.2 Pulse. — Its Rapidity. — The following is the rapidity of the pulse at the various ages of infancy and childhood given by Bednar : Beats per minute. Foetus 108 to 160 First two minutes of life 72 to 94 Fourth minute of life 140 to 208 Eighth day to second month 96 to 130 Second month to twenty-first month 96 to 120 Second to fifth year 92 to 108 Fifth to eighth year 84 to 100 Eighth to twelfth year 76 to 96 The pulse-respiration ratio in infants is as 3 or 5 to 1. The respiration in these little subjects being 30 to 32 a minute, the ratio of the respiration to pulse will be as 1 to 4 in infancy; 1 to 5 or 6 30 INFANCY AND CHILDHOOD. in tlie second year. Turning, crying, coughing, or any excitement will increase the pulse-beat 15 to 30 a minute. During sleep the pulse varies from 15 to 20 beats per minute. After the third month the pulse is more rapid in girls than in boys. Rhythm of the Pulse.- — The rhythm of the pulse has been the sub- ject of much investigation by various observers; the following are the main peculiarities of the normal pulse : (a) In infants and children the pulse is normally arrhythmic or irregular, both in regard to time intervals and its relation to what is known as the respiratory curve in sphyginographic tracing. (&) Dicrotism is a normal characteristic of the pulse in infancy and childhood. The irregularity of the pulse in some infants and children is not very marked; in others this irregularity becomes more apparent under the influence of undue excitement. Dicrotism, although very evident and due to the great arterial elasticity in normal children (Landois), is never as marked as in children who are the subjects of cardiac disease, pertussis (heart strain), or acute infection (typhoid fever). On the whole, it may be said in regard to the pulse, that it is more subject to variability as a result of slight influences than that of the adult. Body-temperature. — The temperature of the newborn infant will vary from 36.9° to 38.4° C. (98.4°-101.1° F.). The latter is excep- tional. According to the studies of Lachs, the average temperature of the newborn infant varies from 37.5° to 37.9° C. (99.5°-100.2° F.). After the first bath the body-temperature falls 1.7° to 2.5° F, Two hours after the first bath the temperature begins to rise, and reaches its initial height within twenty-four hours, or sometimes later. Li premature or weakly infants the temperature does not reach its original height for fully three days, and in some instances it may never reach the original height. The body-temperature of infants shows slight fluctuations during the day which are quite normal. The maximum temperature in most cases is reached at midday or during the afternoon ; the mini- mum, during the morning and evening. The daily fluctuations vary from 0.1° to 0.3° F. The daily fluctuations of temperature are more regular and uniform in the breast-fed infant as compared to the bottle-fed infant (Marfan). During sleep the temperature may sink from 0.3° to 0.5° F, (Alix and Vierordt). In a general way we may say that in infants and children any rectal temperature ranging from 99.3° to 100° F. is normal. Crying, excitement, or exercise will raise the temperature in infants and children from one-half to several degrees. I have seen an instance of a boy, seven years of age, with a normal temperature, observed throughout the course of two or more years, of 100.5° F. at TEE NOBMAL INFANT AND CHILD. 31 midday, which would rise 1° F. in the rectum after five minutes' exercise. This boy was otherwise in perfect health. The following table of body-temperatures (rectal) is the result of the investigations of Lachs, Vierordt, and Alix : Newborn infant 37.n° to 37.9° C. (99.5°-100.2° R). 5-16 months 37.4° to 37.9° C. 99.3°-100.2° R). 20 months-4 years 37.5° to 37.9° C. (99.5°-100.2° R). 5-9 years 37.6° to 37.8° C. (99.6°-100.1° R). Heat Calories.- — Children, according to Vierordt, produce more heat calories, per kilo of body-weight, in the twenty-four hours than do adults; thus, in children there are 130,681 calories per kilo produced as compared to the adult, where we find 39,640 calories. If, on the other hand, we accept the investigations of Rubner, in which the calories are calculated per square metre of body-surface, the infant does not use up any more calories than the adult: 1050 to 1200 as compared with 1300. The infant, for its size, therefore gives off more heat from the body-surface, and is therefore more sensitive to loss of heat than the adult. Urine. — Physical Characteristics. — The urine up to the eighth day of life is dark in color, contains epithelial cells, leucocytes, and uric acid crystals. After the eighth day the urine is a limpid, clear, colorless fluid. The urine of artificially fed infants is somewhat darker than that of breast-fed infants, and especially is this so in any disturbance of the functions of the intestine. If there is j aundice the urine may contain biliary pigment. The urine has a resinous odor, as in the adult. The specific gravity during the first three days of life ranges from 1010 to 1012 ; after the tenth day, when the infant has partaken of liquid food, the specific gravity falls to 1003 or 1004. It frequently happens that the newborn infant does not pass urine on the first or even the second day of life. This is" sometimes misinterpreted as due to some obstruction, either in the ureters or external genitals. From the second to the tenth day the infant voids urine two to three times in the course of the twenty-four hours. Ruge and Robin found that at the third month the infant voids urine ten to eleven times in the twenty-four hours, passing 400 to 500 grammes in that time; at the fifth month, 400 to 500 grammes daily ; from the second to the third year, 500 to 600 grammes; from the third to the fifth year, 750 grammes; and from the seventh to the tenth year, 1200 grammes daily (Parrot and Robin). The following table gives not only the quantity of urine passed during early infancy and childhood, but shows the difference in amounts passed by the breast-fed and the artificially fed infant. 32 INFANCY AND CHILDHOOD. It will be seen that, owing to the larger gross quantity of fluids taken into the body by the artificially fed infant, the amount of urine passed is greater than that of the breast-fed infant. The amount of urine is also dependent on the composition of the food. Camerer has shown that, as a rule, every 100 grammes of liquid food will yield 68 grammes of urine. Daily Quantity of Urine (Reusing), Breast. Bottle. Specific gravity. 1st day 8.4 35.8 1010 2d 3d 4th 5th 7th 8th 26.8 71.0 1010 40.9 135.8 1010 60.8 187.0 1010 liy.l 283.0 1005 157.0 325.0 1005 208.0 406.0 1005 30th-150th day ^^^lEreast 1012 150th-325th" 425/^^^^'^ ^^^^ 2d year 675 1012 3d-5th " 600-1200 1010-1012 6th " 1295 1012 10th " 1866 1010 The infant passes five or six times as much urine per kilo of body-weight as the adult; the child, three or four times as much. Urea.^ — Urea is excreted in greater quantities by the artificially fed infant and the infant fed by a wet-nurse than by infants fed at the mother's breast. Reusing found that in the infant at the mother's breast the amount of urea increases from the first to the third day, when it is highest. The reason of the diminished excretion of urea at this period lies in the fact that there is an insufiiciency of food Daily Amount of Urea. Breast-fed. Bottle-fed. 1st dav 0.06 0.33 2d "' • 0.26 0.40 3d " 0.52 0.67 4th " 0.50 0.55 5th " 0.78 0.65 6th " 0.79 0.61 7th " 0.81 0.88 30th-150th day 0.94 2d year 9.87 .3d-5th " 13.9 10th " 20.4 during the first days of life. The tissues of the body are burnt up in the processes of metabolism, hence there is a diminution of weight. Inasmuch as the body is rich in fat, this is burnt first and nitrogen is saved. As a result, the nitrogen excretion in the first days is less than it is later, when sufficient food makes up for the loss of body- TRE NORMAL INFANT AND CHILD. 33 weight. Added to this fact of insufficiency of food, there is a paucity of fluid nourishment during the first days, causing a retention in the body of the end-products of metabolic processes. After the first few days in the newborn infant, as in all cases of starvation, there is an increase of nitrogen excreted until by means of increased food metab- olism attains its equilibrium and urea is excreted in normal quantities. Albumin. — Albumin is found in the urine, according to Flens- burg, in 40 per cent, of newborn infants. He attributes its pres- ence to the existence of uric acid infarction in the kidney at this time. Other authors contend that albumin is not present normally in the urine of infants, but if the mother has during labor suffered from eclampsia, the urine of the newborn infant may contain albumin and casts. Czerny regards the whole question of albuminuria in the newborn as suh judice, inasmuch as in the cases investigated, including those of Flensburg, no mention has been made of or con- sideration given to disturbances of the functions of the intestine or other abnormal conditions which might have been present at that time, and he is inclined to believe that if such consideration were given, it would be found that the appearance of albumin in the urine of infants is in some way connected with the disturbances of the func- tions of the intestine. Indican. — Indican is not present in the urine of the healthy breast- fed infant; whereas it is found in traces in the urine of artificially fed infants, even in the absence of any disease. It is especially con- stant in the urine of infants suffering with gastro-enteritis, and may be present in the urine of infants suffering from a number of mal- adies, especially forms of suppuration. It is present in the urine of infants suffering from tuberculosis, but is not pathognomonic of that affection (Zamfiresco). Acetone. — Acetone is present in small quantities in the normal urine of infants and children, and is found also increased in quan- tity in the case of fevers, such as the exanthemata, or pneumonia. The amount of acetone increases in proportion to the height of the fever. It disappears or diminishes to the normal quantity with the disappearance of the fever. It is enormously increased in the urine of children during a seizure of eclampsia. It is not, however, the cause of the eclamptic seizure, as has been supposed. The cause of acetonuria is not clear. It is due neither to the hindrance of respi- ration nor to fermentation in the stomach or intestine ; but is prob- ably due to splitting up of the nitrogenous substances of the body, inasmuch as it is increased by a nitrogenous diet, and may be caused to disappear by an exclusively carbohydrate diet (Hammarsten). Diacetic Acid. — Diacetic acid is not a physiological constituent of the urine, but occurs chiefly under the same abnormal conditions as 3 34 INFANCY AND CHILDHOOD. acetone. There are cases in which acetone but no diacetic acid ap- pears in the urine. Diacetic acid is often found in the urine of children suffering from fever, such as the exanthemata. Inasmuch as diacetic acid is readily decomposed into acetone, it is probably an intermediate product in the oxidation of ^-oxybutyric acid in the organism. Acetone, diacetic acid, and ^S-oxybutyric acid stand in close relationship to one another. Urobilin. — Urobilin is absent from the urine of the breast-fed infant, but is found in traces in the urine of artificially fed infants (Giarre and Czerny). Dextrose.- — Dextrose is found in traces in the urine of infants, as it is in that of adults. Dextrose is not found in the urine of healthy infants, and only appears in the urine of infants suffering from gastro-intestinal disturbances who at the same time may be taking food rich in glucose or maltose (Koplik). Casts. — Hyaline and epithelial casts may be found in small num- bers in the urine of the newborn infant. Uric Acid Infarction. — Virchow has described these infarctions in the kidneys of newborn infants. They consist of red or brownish- red structures, which on section of the kidney are seen to be depos- ited in the pyramids of the organ, stretching from the papilla of the pyramid halfway, rarely extending to the border of the medullary portion of the organ. They exist in the kidneys of the newborn infant, reach the height of formation on the second, and are not found after the sixth day. In the newborn infant there is a hyper- leucocytosis, which is more pronounced in those cases in which the cord has been tied late. The quantity of uric acid in the urine of the newborn is much greater than it is later. In the tubules of the kidney there is an accumulation, especially in the tubuli contorti, of a hyaline sub- stance which is the result of cell production. In this hyaline sub- stance are deposited crystals of uric acid, and it is in this way that the infarctions are formed. The increased uric acid is in some way connected with the hyperleucocytosis above mentioned ; the leucocytes are disintegrated and uric acid thus produced. It has not been ex- plained, however, why there is an increased elimination of uric acid with resulting infarctions at this period and not later in infancy. MENTAL AND PHYSICAL DEVELOPMENT OF THE INFANT. It is not our purpose to enter into every detail of the development of the senses of the infant, for this would scarcely be called for in this section. On the other hand, there are certain important facts which are of great utility to the physician in his daily clinical work. MENTAL AND PHYSICAL DEVELOPMENT OF INFANT. 3o Sight.— On the second day the eyes are sensitive to light. On the twenty-first the eye will follow a light ; and at the beginning of the second month the infant will notice bright colors. At the third month the infant will recognize a familiar face. At the sixth month the infant will definitely recognize its parents apart from strangers. Hearing. — A newborn infant is deaf. This is due, it is snpposed,. to the blocking up of the Eustachian tubes with mucus. On the fourth day there are evidences of hearing, which develop from this time to the fifth week, when loud talking or noises in the room dis- turb the infant. At the sixth month the infant will recogTiize noises as to their varying tone. Taste. — The sense of taste is not fully developed until the sixth month. From the fourth day, however, an infant will show a prefer- ence for sweetened, " as compared to unsweetened, dilutions of milk. Feelings of Pleasure. — An infant will show decided pleasure at the sight of playthings at the fifth month, but can hardly be said to take an intelligent interest in any object before this time. Power to Hold the Head Upright. — The newborn infant cannot hold its head upright, and when held in arms the head will sway from side to side. The power to hold the head upright is not fully developed until the fourth or fifth month. This is important clinic- ally in connection with certain diseases, such as amaurotic idiocy, the development of which is attended with a loss of power to hold the head upright. Sitting. — The infant will make the first attempt to sit up at the fourteenth week ; but is unable to sit upright without assistance until the forty-second week. Standing. — The first attempt to stand without support is made by the infant at the tenth month. In the eleventh month the infant may not only stand, but even stamp its foot. Walking and standing- are delayed by rachitis. In such cases the infant may even cry if placed on its feet, on account of the pain such children experience in the bones. Crawling and Walking. — The infant will crawl on all fours in the fifth month. Attempts to walk begin at various periods, some infants being more precocious in this respect than others. The ear- liest attempts to walk are made in the tenth month. At the four- teenth month an infant will walk if held by the hand. It will stand alongside a chair in the fifteenth month, and in the seventeenth month a child will walk unsupported. Laughing. — An infant two months of age may be caused to laugh in a purely reflex fashion by gentle titillation at the corners of the mouth or on the chin. An intelligent laugh, however, is not observed until the sixth month. 36 INFANCY AND CHILDHOOD. Kissing. — Kissing involves the act and the understanding thereof, and these are seen combined only quite early in childhood — the twenty-third month. Memory. — True memory is observed first in the tenth month, when the infant will recognize the face of the parent after a short absence. In the twenty-first month the child will recognize its parents after a protracted absence. Speech. — On the forty-third day the infant may articulate unin- telligible sounds. At the fourteenth month it will be able to say mamma and papa; and at the end of the second year the child attempts the formation of simple sentences. In a general way, it may be said that the infant will show signs of intelligence, includ- ing sight, hearing, and vocal effort, at about the seventh month, and will first attempt to walk at the tenth month. There will be, of course, a wide variation in different infants in the development of the senses ; and yet we will always recogTiize as pathological the vacant stare, a total lack of utterance, an indifference to bright objects, and an inability to stand on the mother's knee, or to hold the head upright at the seventh month, especially if other abnor- malities, such as protruding tongue, are present. METHODS OF EXAMINATION. History Taking. — History taking is an art which may well be cultivated by the physician, for in a detailed history are often found the clues to an obscure case. The mother or nurse of the infant or child is the best observer of his various conditions, and the physician should not lightly reject any facts given to him by an anxious mother. The physician should not approach his patient with any pre- conceived notion of the malady, but should allow the disease to unfold itself with all its symptomatology; he should also have a definite routine of examination. Maternal History. — The details of maternal history are exceed- ingly important, especially as regards miscarriages or difficulties in labor. The difficulties in feeding of other children; the details of their illnesses ; the presence of disease in any collateral branch of the family, especially any nervous disorders, are extremely important. The occurrence of a similar affection in other children of the same family are of moment; and in older children the various steps of development of the senses, snch as sight, hearing, speech, and walk- ing, are, in nervous affections, of pertinent moment. In an infant the history of feeding in all its details is quite essential. The condition of the bowels, the presence or absence of vomiting, and in older children the history of dentition are of col- METHODS OF EXAMINATION. 37 lateral interest. A previous history of scarlet fever, measles or diphtiieria may have a bearing on some nephritic affection in the patient, and pains in bones and joints, as well as muscular pains may explain cardiac murmurs. The mother very frequently ventures in- formation as to previous operations on the tonsils, or adenoids, which may be of use as a guide in the case. Parental History. — The details of the parental history as regards the occurrence of tuberculosis, rheumatism, or nervous disorders are of importance. The tendency of other children in the family to eclampsia are facts of value. Having elicited the details of the previous history the physician proceeds to obtain the minutiae of the present illness. His routine will vary essentially as to whether his patient is an infant or child of advanced age. In an infant the feed- ing in all its details, and its successes and failures are of great im- portance. In older children these facts though essential are only of collateral interest. Onset of Illness. — This is of import, especially as to whether the onset was abrupt or acute or slow and insidious. In the great ma- jority of cases an illness in infants begins with fever, chill, cyano- sis, or vomiting. One of these symptoms may be present to the exclusion of the others, or they may all be present, or the illness may be ushered in with a convulsion. The condition of the patient immediately following the initial symptom constitutes the initial stage of the illness. Fever or unconsciousness may follow a chill or convulsion, or the patient may after the initial symptom develop an eruption, cough, dyspnoea, or pain. The fever may subside in a few hours, and the temperature return to normal, with a subsequent rise, preceded by a chill, cyanosis, or a second convulsion. Older children may complain of pain, as adults do. In the case of an infant, pain in the chest or abdomen may be indicated by an increase in the number of respirations or a sighing or moaning with each effort at respiration. The vomiting of the initial stage of the illness may not be repeated, or it may recur and form a leading feature. The nature of the vomited matter is important. It may have an acid reaction or odor, or may consist of stomach contents mingled with biliary pigment. It may be streaked with blood. In serious continued vomiting it may assume a fecal character. Vomiting may occur with the ingestion of food or independently of it. The amount of the stomach contents and especially whether this seems to those in charge of the infant more or less than the amount taken in at the individual nursing should be noted. The condition of the bowels is of importance. The movements may be numerous but of normal consistency and odor, or thev mav 38 INFANCY AND CHILDHOOD. be diarrhoeal and liave abnormal features. The movements may be accompanied by tenesmus or prolapse of the gut. The urine of sick infants is sometimes not passed for hours. The mother will make a note of this fact. The character of the urine is next to be ascertained. Its passage may be painful. The urine may stain the diaper yellow (jaundice) or red (lithiasis) ; it may contain blood. Older children may be required to pass the urine. The quantity is more easily estimated in older children than in infants. With the latter we should be cautious in drawing conclusions as to the daily amount. In taking a history as above, it is essential, while eliciting the main features of an illness, not to inquire concerning unimpor- tant details. The main features of the history should be grasped and completed in all their minutiae. Taking the Status Praesens. — It often happens that the infant or child is asleep during the first portion of the visit. Under that con- dition the respirations and pulse, with the character of each, can be noted. The posture during sleep, the expression of the face and its contour, the position and behavior of the extremities during rest, are of the greatest import. Respiration during rest is more instruc- tive than in a condition of unrest and wakefulness. The patient should be completely undressed for examination. This is done as a routine procedure even in cases of apparently mild illness. Any eruption on the skin is thus forced upon the attention of the physician. The Skin. — The condition of the skin is noted in a general way, the absence or presence of an eruption, general form of the body and its gross nutrition, the shape of the chest, contour of the abdomen and extremities as to their conformity, as well as the power in the muscles and their contour. The weight of an infant is of essential importance, especially where feeding is concerned. The Head. — The examination of the head should begin with ob- servation of its size, whether normal or abnormally small or large. The general shape of the head and condition of the bones are of importance in reference to the presence or absence of rachitis and areas of craniotabes. The manner in which the head is held is noted, as bearing on the presence of torticollis. In Pott's disease the head is held rigidly on the spine, and in older children supported with the hands. Some infants, for instance, amaurotic idiots and those suffering from birth-paralyses or diptheritic paralysis, are unable to hold the head upright. In forms of meningitis the head is re- tracted or held rigidly. The fontanelles may be normal, tense, as in meningitis or hemorrhage, depressed, or abnormally prominent ; they may be closed prematurely, as in microcephalus, or open beyond the normal period. The presence of tumors underneath the scalp, such METHODS OF EXAMINATION. 39 as cephalohsematoma, should be noted. The condition of the lymph- nodes posterior and anterior to the border of the sternomastoid muscle is of clinical importance. The Face. — The expression of the face in a condition of rest, and also when the infant or child cries, may enlighten us as to the presence or absence of paralyses. These may be localized, involving the muscles of one organ, such as the eye, or the v^hole side or both sides of the face may be affected. When the infant is asleep the mouth is normally closed and the infant breathes through the nose, the tongue being applied to the roof of the mouth. In so-called mouth-breathing the mouth remains open during sleep and the tongue is observed to lie at the floor of the buccal cavity. Respiratory Disorders. — In abnormal states, as adenoids, the breath- ing may be noisy; the cry may be peculiar, as described under retropharyngeal abscess; the lips may be cyanosed or the seat of rhagades or eruptions, such as herpes ; the symmetry of the face may be lost, as in parotiditis or adenitis, in v^^hich there is a swelling of one or both sides of the face. Cardiac Disease. — Cardiac disease in advanced stages gives a sad and anxious expression to the countenance, with exophthalmus or dilated pupils. Facial Paralysis. — Facial paralysis, either partial or complete, causes a characteristic facial expression. If the infant cries, or the child is made to smile, one side of the face remains immobile. Even in rest the angle of the mouth may be drawn toward the unaffected side of the face, as in tuberculous meningitis. Nuclear Palsy. — ^In nuclear palsy of the congenital variety de- scribed by Moebius and Schap ringer (pleuroplegia) both sides of the face are immobile, and the face has a mask-like expression. There are no folds in the face either in the acts of laughing or crying. Basedow's Disease.- — Basedow's Disease gives a peculiar expres- sion to the face, caused by the prominent eyeballs, which is pathog- nomonic of this disease. Hydrocephalus.^ — Hydrocephalus likewise lends a peculiar expres- sion to the face. The forehead is protuberant and overhanging. The eyeballs are forced downward, and the sclera are seen. The face proper is small as compared to that part of the head above the eyes. This is due to the large size of the cranium. Rachitis. — Rachitis at times causes a characteristic facial expres- sion which is likely to be confounded with that due to hydrocephalus. In some rachitic infants the eyes are prominent and the sclera is quite apparent. The orbital plates of the frontal bone being thin, the weight of the brain depresses the eyeball to a very slight degree. Exhausting Diseases. — Exhausting diseases, such as diarrhoea, 40 INFANCY AND CHILDHOOD. cause prominence of the eyes, giving a very characteristic exj^ression — the so-called hydrencephaloid of older v^riters. Congenital Syphilis. — Congenital sy^Dhilis in some cases causes a deformity of the nose, which is present at birth. The result is a peculiar angular deformity of the normal nasal curve. Looked at sideways, the bony septum is depressed ; the cartilaginous septum is still intact. An acute angle between the two results. This is similar to what is seen in destructive forms of syphilis later in life. The facial expression is characteristic of the disease. Palpebral Fissure. — The angle of the palpebral fissure is altered in conditions such as Mongolian idiocy. In this affection it is slightly oblique. In paralyses of the ocular muscles the palpebral fissure itself may be wider in one eye than in the other. In such cases, one pupil may be wider than the other (Horner's symptom). The pres- ence or absence of conjunctivitis, keratitis, nystagmus, paralyses of the orbital muscles, the condition of the pupils, are all points of im- portance in determining the status pr^esens. In diseases of the brain or its coverings an ophthalmoscopic examination of the fundus oculi should be made. Sight. — In partial or total blindness, not only do the patients fail to notice objects placed in front of them, but there is in addition a vacant facial expression or stare. If the blindness is total, the finger will be suffered to approach the eye so as to touch the cornea. Some infants have a tendency to hold the head to one side. This may be due to defective vision or to weakness or spasm of the muscles of the neck. In cases of defective vision the head assumes a normal position if the eyes are not focused on any object. As soon, how- ever, as an effort is made to accommodate, the head is inclined so as to bring the planes of vision of the eyes in accord. Photophobia. — Photophobia is an aversion to light, and is due to a spasm of the ocular sphincter in diseases of the conjunctiva or cornea (conjunctivitis, corneal ulcer). Nystagmus. — N^ystagmus is a series of involuntary nioveinents of the eyeball, due to inefficiency of certain muscles, and is met with in conditions of corneal opacity, congenital cataract, albinism, infantile amblyopia, spasms, nutation or head-nodding, and in nervous states, such as amaurotic idiocy. In weakly rachitic infants nystagmus may be exhibited around a horizontal or vertical axis of the eyeball, or it may show itself in a rotary oscillation of the globe. It is made manifest in infants by causing them to focus some bright object, held slightly above and to one side of the head. The Chest. — ^ Position of the Patient. — An infant should be so held for examination that the examiner and the patient may be at ease. Being undressed, with the thorax exposed, the infant is first held by METHODS OF EXAMINATION. 41 the attendant with the head looking over her shoulder, in which position the arms instinctively clasp her neck (Fig. 3). The patient so placed does not see the examiner. The spine should be straight, so that in percussing the sound is obtained on both sides under the same conditions. To examine the chest anteriorly, the infant is held looking forward, the anterior aspect of the thorax facing the examiner. If it is able to sit up, it may be examined in the sitting posture, both anteriorly and posteriorly. Fig. 3. Method of holding the infant for the examination of the posterior portion of the chest and lungs. With older children it is best to make an examination with the patient sitting upon a table or chair in a position convenient to the examiner. If confined to bed, the child must be examined in bed. As a rule, however, it is preferable to have the patient taken out of bed into the light. Infants and children sometimes try to grasp the instruments of the examiner ; gentle suasion will reassure them, force is never necessary. Instruments Used. — Stethoscope. — A stethoscope is absolutely es- 42 INFANCY AND CEILDEOOD. sential to the proper examinatiou. of the chest of an infant or child. This method is called mediate examination. We can by its means assure ourselves that the whole area of the chest has been carefully investigated. Examination by the ear — the immediate method — is uncertain. A small area of bronchopneumonia may easily escape detection in infants and children of tender age, in whom the axillgs and lateral regions of the chest should be carefully searched. Direct application of the ear to the chest is resented by infants and children, and is not a convenient procedure for the physician. With the stethoscope he can follow the movements of the body of a restless patient. The best form of stethoscope to employ is the binaural. The instrument devised by the author (Fig. 4) has given him the most Fig. 4. Author's form of stethoscope. (Archives Ped._, November, 1899.) uniform- results. A larger stethoscope, such as that employed for examination of the adult chest, does not differentiate the variety of sounds as well as this small instrument, and may cause pain to a restless infant, inasmuch as the chest-piece must be held too rigidly and is likely to press painfully against the chest-wall. Tape-measure. — A steel tape-measure, marked off into inches and centimetres, is convenient for detecting inequalities in the size of the sides of the chest. Methods of Procedure.- — Inspection. — ^We learn by inspection the shape of the chest and the character of the respiratory movements : also, the aspect of the cardiac area, the pulsation of the apex of the heart, its force and situation. Respiration in infants and children up to the age of ten years is of the abdominal or diaphragmatic type. The rapidity may be counted by noting the movements of the chest or by watching the rise and fall of the epigastric region in the recumbent patient. The Cardiac Area. — In some infants and children the cardiac area may be quite prominent in the absence of any cardiac dis- ease. In rachitic infants and children this part of the chest wall may conform to the shape of the heart. There remains even in the METHODS OF EXAMINATION. 43 later childhood of rachitic patients a very slight rotimditj or fulness of the precordial region. If the chest-wall is quite thin, the precor- dial region may normally present a wave of pulsation. All these signs may be exaggerated in disease of the heart. The apex-beat is normally distinguishable. Its force and area may be increased or diminished in disease. The apex-beat may be displaced upward and outward, or inward toward the median line (conditions of effu- sion in pericardium or pleura). Palpation. — Palpation, by laying the palmar surface of the hands on the chest, is hardly to be attempted with young infants and children. In these subjects the chest is so small that this method cannot mark out areas of fremitus or absence of the same. To deterniine its presence, it is more satisfactory to use the internal border of the hand, generally the right. The hand is held horizon- tally, the internal border pressing firmly against the chest-wall. Thus the slightest variations in vibration of the chest-wall can be detected. We begin above at the upper border of the chest and pass dovmward, comparing both sides. If the infant or child cries, so much the better. If we wish to ascertain the presence of fremitus in a baby, we may even cause it to cry. An excusable procedure is to press gently the cheeks of the infant with the thumb and index finger in a teasing manner; the infant will resent this by crying. Older children may be asked to count or induced to talk. In infants and children fremitus is not so marked or useful a sign as in the adult. ISTormally, it diminishes in intensity toward the base of the lung. In some children it is detected in the lower part of the thorax only by careful examination. It is normally well marked along the axillary line; it is most marked along the mid-regions of the chest between the scapulae behind. Anything which separates the lung from the chest-wall will diminish or extinguish fremitus. Solidification of lung tissue will cause better conduction and increase it. Percussion.- — It is not advantageous to use a pleximeter in ex- amining infants and children. The index finger of the left hand is laid horizontally on the chest with firm pressure. The skin or chest-wall and finger are thus made one medium. Percussion is performed by making a hammer of the middle finger of the right hand. The force used should come from the wrist; the forearm should be inmiobile. The stroke is expended upon the middle phalanx of the finger on the chest-wall, and should be of a tapping character, similar to that used in striking the keys of a typewriter ; there should not be a pushing motion. The force should not be great. A force equal to that necessary in the examination of the adult chest would set in vibration all the neighboring chest and abdominal organs and cavities, and would not bring out the delicate 44 INFANCY AND CHILDHOOD. distinctions of sounds necessary to diagnosis. Moreover, to some rachitic infants and young children a forcible stroke is distinctly painful. The Abdomen. — The abdomen of an infant or child is best ex- amined with the patient lying on a bed or a table covered with a soft blanket. The mother's or nurse's knees are not so satisfactory a sur- face for this purpose. The patient should be completely undressed. Inspection.^ — Inspection should include the examination of the skin as to color, presence or absence of an eruption, oedema, and of the abdomen as abnormally rotund or relaxed. In the latter condition we may sometimes make out the coils of intestine. Peristalsis should be noted especially in cases of persistent vomiting, obstruction of the intestine, or stenosis of the pylorus. In diseases which exhaust the strength of the patient we distinguish between relaxed and retracted abdominal walls. A retracted abdominal wall may be tense and incurvated — the so-called boat-shaped abdomen ; this is seen in menin- gitis. In some rare forms of septic peritonitis the abdomen may be retracted. The pain of a colicky attack will cause the abdominal walls to be tense although not retracted. In intussusception the coils of intestine or even the intestinal tumor may be seen on the surface. Ascites distends the abdomen, and when marked the rotundity is characteristic, and the skin is tense and shining. Peritonitis. — Peritonitis causes tympanitic distention. In per- foration of the intestine in typhoid fever or appendicitis the tympa- nites is accompanied at an early stage, as in the adult, by disappear- ance of the liver dulness. This sign will aid us more if the liver dulness and flatness have been determined accurately in advance of any complications. Free Fluid. — The presence of free fluid of an inflammatory na- ture may be determined by percussing for dulness in the flanks with a change to tympanitic resonance in the same situation on a change of position as in the adult. Tumors.- — Abdominal tumors give an uneven contour to the ab- domen. Such tumors are met in diseases of the spleen or kidney, enlargements of the liver, congenital renal cysts, ovarian tumors, or hydatid cysts. Palpation. — ^We palpate for pain, general or localized, and to determine the size and position of the abdominal organs; for tumor whether of or behind the peritoneum, tumors of the liver, kidney, or spleen; enlarged glands behind the peritoneum in the neighboi'hood of the mesentery of the small intestine ; polypi in the lumen of the intestine ; tumors due to appendicitis or intussusception. In palpating, we follow a certain routine, and palpate in the region of the spleen, then over the liver, and finally in the right inguinal region (appendicitis). METHODS OF EXAMINATION. 45 Ascites. — The signs are the same as in the adult. Tympanitis. — Tympanitis gives the same signs as in the adult. In newly born infants there is in rare cases a congenital weakness of the walls of the intestine. Any disturbance of the intestinal tract results in immense distention, which may be distressing to the patient, ifon-inflammatory is distinguished from inflammatory distention (peritonitis) by the absence of prostration or fever and the absence of free fluid in the abdominal cavity. There is another form of distention which precedes death in severe pneumonia or gastro- enteritis. Simple tympanitic distention is seen in rachitic children, in whom the lower part of the chest is narrowed and the abdomen uniformly protuberant ; in these children the distention is apparently increased by the forward curvature of the spine. Percussion gives a uniformly tympanitic note all over the abdominal area, except where fteces change the note into a dulness. There is no pain or only slight general tenderness. Pain. — Children may locate the pain felt in pneumonia, pleurisy, or pericarditis in the abdomen. The pain in these cases may be referred to the upper part of the abdomen. The patient may com- plain of pain radiating to the right inguinal region, and thus in lobar pneumonia of the lower portion of the right lung mislead the ex- aminer into a consideration of the existence of appendicitis. In diffuse peritonitis the pain is general, but in localized disease of the vermiform appendix the limitation of pain can be made out even in young subjects. If we suspect appendicitis, it is best to examine every part of the abdomen for pain before approaching the right inguinal region. In connection with pain and its significance, we may emphasize the fact that if the abdomen is relaxed (not retracted), showing the grooves due to the muscular parts of the abdomen — the bellies of the recti muscles, the incurvation of the abdomen just below the border of the ribs — we may assume the absence of tympanites. In such cases peritonitis is rarely present. Pain, which has no definite localization in an abdomen relaxed as above described, may be con- sidered as of no serious import. The condition of the abdomen in intussusception is described in the chapter treating of that subject. Polypoid tumors in the lumen of the ascending or descending colon may sometimes be distinctly felt in the relaxed abdomen to one side of the umbilicus. Floating kidney in children has been recently described by Comby. The methods of examination in forms of kidney tumor or displacements of this organ are described in the chapter devoted to those subjects. 46 INFANCY AND CHILDHOOD. Rectal Exploration,- — This is always carried out in the recumbent position. Bv rectal examination we may establish the presence of an abscess in the right inguinal region or of great swelling of the appendix in cases in which it is bound down by adhesions below the brim of the pelvis or of ischiorectal abscess. Eectal exploration is resorted to in all eases in which we are led to suspect the presence of an intussusception. In tuberculous peritonitis also, enlarged lymph-nodes may be felt through the walls of the rectum. Kidney and ovarian tumors can in some cases be felt through the rectum. It is not necessary to cause pain in the above procedure. On the contrary, rude examination only obscures the case. We should seek every opportunity to become familiar with the normal condi tions externally and per rectum, especially in the vicinity of the right inguinal region in order to be able to diagnose abnormal states. The Joints. — Affections of the joints are among the most frequent diseases of infancy and childhood. The method of examination of the joints should be familiar to every physician. If a mother states that her baby cries when it is bathed or diapered, we should examine the joints. In the newborn infant especially this holds true. If there is any limitation of motion, or should the extremities be limp, the joints should be inspected. In older children a sudden limp or intermittent obscure pain in a joint should receive attention at once. Position.^ — To examine the joints, the patient should be completely undressed, and placed on a table. The spontaneous movements of the limbs are first observed before any manipulation of them is attempted. We may thus observe that one limb is favored by the infant, limitation of motion may exist, or there may be a marked swelling of one joint. The shoulder, elbow, knee, ankle, and other joints are systematically examined. This can be done in quite a short time if we make it a routine of every physical examination. In examining a joint we should not forget that when inflamed, it is very painful if not gently handled, and that any rude procedure, in addition to causing pain, may injure the joint. The joint is inspected as to whether it is swollen, or has its normal form, or shows too plainly the prominences of the bones entering into its formation. Palpation will tell whether the temperature of the surrounding tissues is raised, whether there is fluid in the joint or whether the tissues about it are infiltrated. We also examine by mild pressure with the fingers the region of the junction of the epiphysis and diaphysis for tenderness. Motility.- — Motility is tested by flexing, extending, rotating, ab- ducting, and adducting. During such an examination we also note muscular spasm. Joint-crepitus. — Joint-crepitus is a peculiar crackling, rubbing METHODS OF EXAMINATION. 47 sensation found frequently in the joints of infants and children. It is detected by placing the palmar surface of the hand upon the joint and moving the extremity which enters into its formation. It has been found by the writer in children who complained of no definite joint-symptoms. It may, under these conditions, be present in many joints of the same patient. Some infants and children are " loose- jointed," that is, they possess a facility in causing subluxation of their joints and spontaneously reducing this subluxation with a snapping sound. Faint crepitus is found in children who have had an attack of rheumatism. Most Common Affections. — The most common affections to look for about the joints are simple luxations; syphilitic disease; osteomyelitis of a septic or infectious nature; scurvy of the joints or epiphyses in the vicinity of the joint; rheumatism, simple acute or chronic, and gonorrhoeal ; tuberculous joints, especially the hip ; paralyses (deltoid) of muscles about a joint; deformities, as in congenital coxa vara. The Spine. — Anatomy. — ^^The spinal column of the newborn infant is practically devoid of natural fixed curves. Fehling found that there was an almost imperceptible curve backward (kyphosis) in the dorsal region and a slight lordosis in the lower lumbar region. The latter curve was more marked when the extremities of the infant were extended. The fixed cuves seen in the cervical dorsal and lumbar regions later in life begin to form in the first year. They are fully fixed by the seventh year. Method of Examination. — The purpose of examination is princi- pally to discover abnormal curvatures and to test the pliability of the vertebral column. In other words, we examine for rigidity due to disease (Pott's). The patient is undressed and caused to stand erect. The index finger is passed down the vertebral spinous proc- esses, and the lines of these processes are marked out. Any ab- normal curve is thus made apparent. Painful areas are detected by pressure or tapping along the spinous processes. If deformity is present, it is important to decide whether this is permanent and combined with muscular spasm (Pott's) or due to rachitis. For this purpose the patient is placed on the examining table face down- ward. The examiner grasps both lower extremities at the ankles (Fig. 5). The palmar surface of the left hand is laid firmly on the junction of the cervical and dorsal spine. The extremities are now raised and hyperextended with the right hand. If the spine is supple and normal, it will curve backward as the pelvis is raised toward the vertical. If there is deformity due to Pott's disease, this will persist. Deformity due to rachitis will disappear under this manipulation. In hip disease, if the left hand is laid on the lumbar region and the above hyperextension gently carried out, first 48 INFANCY AND CHILDHOOD. flexing the legs back at a right angle and then lifting them vertically, a distinct spasm of the muscles is felt (psoas spasm) (Fig. 6). Spinal rigidity is also made apparent by causing the child to pick up some object from the floor. Under conditions of disease the patient will hold the spine rigid in picking up the object. The hips Fig. 5. Method of testing mobility and pliability of the spine. ^,J34,yitjy^, and knees are bent, but not the spine. To test the rigidity at the out- set of a meningitis, the head is raised as the patient lies recumbent. In meningitis the rigidity is such that the whole trunk can be raised by placing the palm underneath the occiput and gently raising the head. Fig. 6. ^_2)'Yti'ir Method of testing for psoas spasm. METHODS OF EXAMINATION. 49 Muscular Apparatus and Nervous System. — Form. — Atrophy. — Atrophy of muscle is seen in any disease whicli affects tlie trophic centres of muscle in the cord. Such diseases are poliomyelitis, and neuritis following traumatism, diphtheria, measles, or any infectious disease. Atrophy is seen in joint-affections, especially about the hip. In the latter case, not only disuse, but a true reflex trophic disturb- ance is the cause of the atrophy. Hypertroyhy. — Hypertrophy of muscle is seen in cases of iso- lated congenital hypertrophy of one limb, and also in pseudohyper- trophic paralysis. In all cases of change of volume of a muscle we compare the affected limb with that of the opposite side if the disease is unilateral. The diseased limb is measured in its circumference and compared with the corresponding healthy limb. Reflexes. ^ — Patellar lieflex. — We shall take up only that aspect of the subject which should concern the practitioner in his examination of infants and children. The minutiae of electrical muscle and nerve reactions may be gleaned from works treating of such matters- in detail. The most common deep reflex is that of the patellar tendon. It is obtained by placing the infant in a recumbent position, supporting the thigh by placing the left hand beneath it, and raising it above the level of the body. When the muscles are relaxed, tap the patellar tendon sharply with the middle finger of the right hand. The procedure is similar to that employed in percussion of the chest. Both limbs are examined in the same manner. Children who can sit are placed on a table with their lower extremities dependent. When the attention of the patient is fixed upon some object the tendon is tapped sharply. A percussion-hammer is not necessary. In diseases of the gray matter and of the posterior columns of the cord with trophic disturbance of the nerves (poliomyelitis, neu- ritis, Landry's paralysis, diphtheritic paralysis) the patellar reflex is diminished or absent. In brain tumor and in affections of the lateral columns of the cord (multiple sclerosis, spastic disease) the reflex is increased. The reflex is unimpaired in cerebral palsy, Friedreich's ataxia, and in cases of idiocy. Bahinski's Reflex. — Babinski's reflex is a plantar phenomenon found in some forms of meningitis (tuberculous), and in diseases in which there is irritation or involvement of the pyramidal tracts. On irritating the plantar surface of the foot with the tip of the index finger there is a vigorous hyperextension of the great toe with spread- ing of the adjacent toes. Morse has shown that this reflex cannot be relied upon in children under two years of age. I have had abundant opportunity to confirm this observation. As a differential diagnostic 4 50 ' INFANCY AND CHILDHOOD. sign, the Babinski reflex is of little value, although I have observed it to be present more frequently in the tuberculous forms of meningitis than in the pyogenic varieties. Kernig's Symptom. — Kernig's symptom is the flexion of the leg on the thigh when the thigh is flexed at right angles to the trunk, and is found in children suffering from any form of meningitis, and in diseases such as pneumonia or typhoid fever with cerebral symi^toms or so-called' meningism. The sign has the same characteristics as in the adult. In infants under one year the tendency to flex the leg on the thigh is normal. In these subjects, therefore, the presence or absence of this sign possesses no significance. G-ait or Walk. — The child is undressed, so that the feet and toes are exposed, and is caused to walk to and fro in front of the physician. The gait in disease may be ataxic, spastic, paretic, or wabbling. Ataxic Gait. — Ataxic gait is seen in children suffering from Friedreich's ataxia, or from tumor involving the motor centres for the lower extremities. The gait is uncertain ; patients walk as if inebriated, with the feet wide apart. Incoordination of movement is characteristic of all these cases. We must in all cases distinguish between simple muscular weakness, as in pseudohypertrophic paraly- sis, and convalescence from acute disease, such as fevers, and a weak- ness combined with a palpable defect in the power of coordinate action. In cases of cerebral disease, as a rule, there is lack of coordi- nation elsewhere, as in the muscles of the upper extremities. In these cases the coordination is tested in older children by telling the patient to close the eyes, and directing him to touch the tip of the nose with the index finger of the right hand several times in succes- sion. In cases of ataxia there will be great uncertainty in carrying out this manoeuvre. In diphtheritic paralysis there may be combined with a real weakness, ataxia or incoordinate movement. If we remember that in these cases there is a neuritis, with consequent atrophy of muscle and loss of reflex, we shall not commit the error of overlooking the paralysis in our desire to account for the condi- tion present as a simple muscular weakness the result of the illness. In these cases there may also be paralyses of the trunk muscles, causing inability to assume the upright posture. In ataxia caused by cerebral tumor there is in certain cases a crossed hemiplegia (pons tumor), with foot-clonus and paralysis of ocular muscles, which aid in the diagnosis. Cerebellar Tituljation. — In cerebellar tumor, which is the variety most common in children, there are at the outset, in most cases, disturbances of the gait or ataxia. Th(> patients walk in an uncer- tain manner, generally staggering to one side. In severe forms of this disease the patients will fall to one side if not protected. • The MANAGEMENT AND HYGIENE OF NORMAL INFANT. 51 cases thus far recorded all show early involvement of the optic, auditory, and other cranial nerves, abducens paralysis, with symp- toms of vertigo. Spastic Walk. — This walk is so characteristic as not to be easily mistaken for anything else. It is found in all forms of spastic paraplegia, congenital or acquired. There is not only actual spasm, but also weakness of muscle. There are other phenomena of nervous disturbance, such as increased patellar reflex and foot-clonus. The patient seems to drag the legs in walking. Each extremity is brought rigidly forward, the toes scraping the ground. The muscles may or may not be well nourished. Electrical contractility may or may not be increased. The children may walk cross-legged (Gowers). At first there is inability to walk; later in childhood locomotion is pos- sible. In certain forms the spasm of the extremities is so great as to keep them in constant extension at the knee ; flexion in these cases can only be attained with great expenditure of force. In infants and children who cannot walk and are the subject's of spastic paraplegia the characteristic position of the lower extremi- ties may be made aj^parent by supporting the patient on the feef. In all of these cases, as soon as the toes touch the ground the reflex produces the characteristic extension of the limbs, with the toes or ball of the foot on the ground and the heel raised. In very young infants who are the subjects of amaurotic idiocy the spastic phenomena are sometimes very marked. In these cases there are other symptoms, such as amaurosis and inability to hold the head upright, the presence of the Tay-Kingdon spot in the fundus of the eye, to aid in the diagnosis. Limping Gait. — Joint-affections cause simply a limping gait ; a study of the joint, as described elsewhere, will aid the diagnosis. Infantile Paralysis. — Infantile paralysis, or cerebral palsy, at the outset causes a characteristic dragging of the extremity if the paraly- sis is not complete. Infants in whom there is a complete loss of power in one or both lower extremities give a history as follows : The infant may have been able to walk or stand ; the attack suddenly de^ prives it of the power of motion. There is a limp extremity on one or the other side, with rapid atrophy of muscle and loss of reflex. In cerebral palsy there is no atrophy and the tendon reflex is present. The methods of examining the mouth and special organs will be considered in the chapters devoted to them. MANAGEMENT AND HYGIENE OF THE NORMAL INFANT. Taking the Infant from the Mother at Birth. — As soon as the infant is born and pulsation in the cord has ceased, the cord is tied 52 ' INFANCY AND CHILDHOOD. and the physician places the newborn in the care of the nurse. The tying of the umbilical cord should be performed rapidly, and the nurse, for this purpose, should have at hand a piece of sterilized tape or broad binding-silk and scissors which have been boiled in water and then carefully wrapped in a clean towel. It is not necessary to use silk which has been soaked in antiseptic solutions, such as car- bolic acid, for the infant is peculiarly susceptible to these drugs. I have seen an infant whose cord was tied with silk saturated with a very strong solution of carbolic acid who, within a few hours after birth, showed signs of the action of the drug. The sterilized tape and scissors should be in readiness for the physician, as searching for the tape or scissors causes an inexcusable delay. A warmed piece of soft blanket is wrapped about the infant at once. As is well known, the infant at birth cries lustily ; nature intends that it should be so at this time in order that the lungs may be filled with air. Umbilical Cord. — Tying of the Cord. — The physician should tie the cord, as has been stated, with a piece of sterilized tape or broad binding-silk, about an inch or an inch and a half from the body, after the pulsation of the cord has ceased, unless some feature in connection with labor indicates a more rapid procedure. After the initial bath the cord is inspected to see that the first ligature is still intact. Ahl- feld, after having placed the primary ligature, reties the cord close to the abdominal wall, though this seems to be unnecessary. If the ligature is still in place and there is no hemorrhage, the stump of the cord and the surrounding tissues are washed with strong alcohol, and a sterilized dry gauze pad with inclosed absorbent cotton is folded over the umbilical stump. This is held in place with a clean body- binder. The first dressing is not removed until the stump of the cord has fallen off and the umbilicus has healed, unless there is some in- dication for its renewal, such as the soiling of the dressing by the urine of the infant (Ahlfeld). Another method of dressing the cord is to form a pad of absorb- ent gauze four or five layers thick, about three inches square, cutting a small opening in the centre. The stump of the cord is passed through this opening and the gauze folded over the stump. The dressing is secured with an ordinary body-binder. This dressing, also, is not disturbed unless it is soiled by the urine of the infant. Stump of the Cord. — The stump of the umbilical cord dries up and falls off from the sixth to the tenth day. It may fall off as early as the third or as late as the fourteenth day. In premature or weakly infants this process is delayed. Even in healthy infants a delay may occur which has no pathological sig-nificance. When the stump of the cord drops off there remains a flat, granulating surface, which cicatrizes, and after a time takes on the appearance of the MANAGEMENT AND HYGIENE OF NORMAL INFANT. O'S neighboring skin. Occasionally, however, the site of the stump takes the form of a small pea-like body, sometimes having a thin pedicle. This is made up of granulation tissue and has been called fungus of the umbilicus. It will be discussed elsewhere, l^ormally there should be no protrusion of the umbilicus, even when the baby cries. The drying or mummification of the stump of the umbilical cord is a purely physical process, and depends more or less on the dryness of the dressing on the stump of the cord. When the stump of the cord remains dry, but few bacteria are found in the tissues ; if, how- ever, as in very exceptional cases, moist gangrene of the stump takes place, staphylococci and streptococci in large numbers appear in the stump and the immediate vicinity. The stump of the cord is thrown off by a sort of reactionary inflammation at the point of juncture of the amnion sheath of the cord and the skin. A few hours after birth the capillary network in this vicinity is seen to become congested. The amnion first separates, then the arteries, and finally the vein, leaving a granulating base at the umbilicus. Bathing.— First Bath. — The question has been much debated as to whether an infant should be bathed immediately after birth or whether the body should be simply anointed with vaseline or olive oil, wiped off, and not bathed until the stump of the cord has fallen off Whatever objection there is to bathing premature infants, this cannot hold with infants at full term. The bath is cleansing. The lochial discharge of the mother if allowed to remain in contact with the skin is apt to decompose, and a source of infection is at once presented. The most convenient form of bath-tub for the infant, if it can be obtained, is that constructed of rubber sheeting. It obviates placing under the infant any blankets, as must be done in a bath-tub made of metal. These bath-tubs are constructed so as to have a certain con- venient height from the floor. They hold heat better than the metal bath-tub. The temperature of the room in which the newborn infant is bathed should be 70° to 72° F. The bath-tub should be situated, if possible, near an open fire, to insure warmth. At birth the infant is covered with a white substance, the vernix caseosa, which must be carefully removed, and to this end the body is anointed with vaseline or olive oil, the latter being preferable to vaseline, which may irritate the skin. When the infant is anointed it should be exposed part by part only, in order to guard against rapid reduction of body-temperature, and care should be taken not to dis- place the ligature or roughly handle the stump of the cord, lest hemorrhage result. The first bath is, therefore, a scientific function ; it cleanses and protects the infant from present and future auto- infection. The water in which the infant is bathed should be boiled. 54 INFANCY AND CHILDHOOD. in order to destroy any extraneous source of infection, for, as will be seen later, the bath-water has been the cause of ei3idemics among the newborn, especially in hospital service. In private practice this danger does not obtain to the same extent as in institutions. The infant should be bathed rapidly, and at the same time in a painstaking and gentle manner. The water of the bath should be 100° F., and some additional warm water should be at hand in order that the temperature of the bath water may be maintained at this point. The infant is placed in the bath, rapidly washed with glycerin soap, and lifted out and placed in a warm blanket. The depth of the water in the tub should be just enough to cover the body. The head is supported above the water by the disengaged hand of the nurse. The infant cannot slip out of the arms of the nurse. While in the bath, the infant is constantly but gently rubbed, and when taken from the bath should not be blue or in the least chilled. Drying the infant is best performed on the knees of the nurse, part by part, so as not to expose the infant's whole body at one time. The cord is dressed as above described and the binder applied. All clothing, including the binder of the newborn infant, should be made of soft flannel or pure wool, Daily Bath. — There has been some discussion as to whether an infant should be bathed daily, after the first bath, before the separa- tion or falling off of the stump of the umbilical cord. It has been demonstrated that infants who are not bathed in the first week lose less in weight than those who are bathed. It is best, therefore, in order to avoid infection of the umbilical wound, to favor mummifica- tion of the cord, as well as to conserve the weight of the infant, not to give a full bath, after the first bath detailed above, until the umbilical wound has healed and the stump of the cord has separated. When this has taken place the infant is bathed daily ; up to that time it is washed twice daily, with a view to cleanliness. If the dressing on the umbilical stump has become soiled with urine, or otherwise, it is changed ; but unless this indication exists the first dressing is left undisturbed. The best time for the bath is in the forenoon, one hour after nursing. The temperature of the water of the infant's bath should not be below 99° or 100° F. during the first ten days; 95° F. dur- ing the first month of infancy; and 90° F. after the sixth month. It has been proposed — on grounds which are somewhat obscure and not founded on physiological facts — to harden the infant by means of a gradual reduction of the temperature of the bath-water until, even with an infant below one year, the bath-water is quite cool. Such a procedure does not harden the infant ; on the contrary, it has been shown tliat it is directly detrimental to his growth and well- MANAGEMENT AND HYGIENE OF NOEMAL INFANT. 55 being. Delicate infants, even those born at full term, may by such a process of hardening contract a bronchitis, or even some more dangerous affection of the lung. The details of the daily bath are much the same as those de- scribed with the newborn infant. The use of a sponge in bathing is not cleanly or desirable. A soft piece of linen or muslin or so- called washcloth is much to be preferred, as it can be easily cleansed and boiled. After the bath the infant is taken from the water and placed in a soft, warm blanket or bath robe, carefully dried and powdered. Powder is applied to the axillae, groins, buttocks — where surfaces come in contact. The general surface of the body is not powdered unless some indication exists. Premature Infants, and Infants who are Under Weight. — Infants born prematurely or those who weigh six pounds or less, even though born at full time, should not be bathed as above described, but are best washed part by part with warm water once a day until the weight has reached the normal limits. These puny infants are par- ticularly susceptible to reduction of temperature. In fact, the rectal temperature in such infants is always low, and any bath, even a warm one, will reduce the temperature still more and may result in serious chilling of the body. Hardening. — It will be seen from what I have said that I do not believe in the so-called hardening process as applied to children. I have seen children, whose mothers took a pride in bathing them with cold water, who remained pale, stunted in growth, nervous, even with a flabby musculature, notwithstanding a daily regimen of cold water which Avas intended to have a tonic effect, both on the general nervous system and physical development of the child. I have rarely found, at least in this climate, that any other temperature for bathing was indicated but that which has been mentioned above. A very excel- lent guide as to the proper effect of any form of bathing on an infant is the so-called reaction in and immediately after the infant is taken out of the bath. In the bath and after bathing the infant should be warm on the surface and present a ruddy appearance. If during or after a bath the infant is cyanosed and the surface of the body is cool, we will conclude that the bath, at whatever temperature it is given, is not adapted to the infant. Eyes.- — In a maternity service, where numbers of women are de- livered and there is danger of one infant being infected by another, it is customary to instil into each eye at birth a drop of a 2 per cent, solution of nitrate of silver. This is done as a prophylactic measure against gonorrhoeal ophthalmia, a disease which has been proved to be a great etiological factor in the causation of blindness. In private practice, however, this is scarcely necessary (see Oph- 56 INFANCY AND CHILDHOOD. thalmia J^eonatorum), especially if we are acquainted with the con- dition of the mother and no vaginal discharge has been present pre- vious to labor. If, however, there has been a vaginal discharge before labor, it is well either to apply the Crede method and instil a drop of a 2 per cent, solution of nitrate of silver into the eye, or to carry out the prophylactic measure of Kaltenbach, described in the section on Blennorrhoeal Ophthalmia. The eyes during infancy need no attention other than that cus- tomary in the adult — cleanliness. Any slight discharge from the eye indicates a conjunctivitis. The nearer this conjunctivitis occurs to birth, the more we should be on guard for detection of a gonor- rhoeal process. It is always wise, therefore, as soon as any secre- tion of pus is detected in the eyes of the newborn infant, to examine this pus for microorganisms of a specific nature. Any swelling of the conjunctiva or the lids should put us on our guard against gon- orrhoea! infection. Method of Taking the Body-temperature of the Infant. — The temperature of infants and children is always taken in the rec- tum ; but if the child is above five years of age we may, under certain conditions, take an axillary temperature. Some children are terri- fied at the sight of a thermometer ; others have an innate mod- esty, which it is the duty of the physician to respect, and which precludes the taking of a rectal temperature. If the indication is not pressing, therefore, an axillary temperature may be taken in older children in the same manner as in the adult. It is well in dealing with children to teach the parents how to use the thermometer. In this way each child may have its o^vn thermometer, whether it is used in the rectum, the axilla, or the mouth. This is not only convenient for the physician, but is entirely proper, especially as applied to children, for thermometers cannot be thoroughly disinfected, and it is certainly objectionable for a phy- sician to go from one little patient to another, introducing the same thermometer into the rectum. In introducing the thermometer into the rectum, the infant or child should be laid on the side. The bulb of the themiometer is anointed with vaseline or olive oil, the buttocks are gently sep- arated with the fingers of the left hand, and with the right hand the bulb of the thermometer is carefully insinuated into the rectum. The infant or child is continued on the side for three minutes.' Some thermometers register the temperature in less time. The thermometer is then removed, and after reading the register the physician should carefully cleanse the thermometer, before proceeding further, with a piece of cotton first, then with a fresh piece of cotton moistened with ether and then alcohol, and finally with a 1: 2000 solution of cor- MANAGEMENT AND HYGIENE OF NOBMAL INFANT. 57 rosive sublimate or a 0.5 per cent, solution of formalin. In private practice this paraphernalia is not always at hand, and the physician can see at once the utility of teaching the parents to have a thermom- eter in the house for the use of the child rather than that he should imperfectly cleanse his own thermometer and use it on another pa- tient. In children's hospitals this question of individual thermom- eters is of great importance, and no children's service can be con- ducted without danger of infections arising unless each patient has his or her own thermometer. Temperatures should be taken in mild cases of illness and in convalescence three times daily; in protracted and serious illness, such as pneumonia or typhoid fever, every three hours throughout the twenty-four. Diapers. — The diaper should be made of an absorbent material, such as well-washed soft muslin or linen, and should be about two yards square. It is first folded in the middle, then in three-cornered fashion, refolded, and thus applied to the infant. A diaper should not be covered with a rubber protection except during travel, inas- much as under these conditions the diaper becomes, if moistened, a species of poultice and intertrigo results, as well as eczematous erup- tions of the buttocks. Diapers should be applied warm and dry. A moist diaper will sooner or later cause a skin eruption. A diaper moistened with urine should not be dried and used again on the in- fant, for by this method the salts of the urine are crystallized in the meshes of the diaper fabric and will irritate the skin. Diapers when soiled should be placed in a covered utensil sold in the shops for this purpose. Before washing the diaper the excess of faeces should be removed. Diapers should be boiled in plain water, as soda in the water may irritate the buttocks, and should be washed by hand, not with the mandril, otherwise the fffices and discharges cannot be removed thoroughly. After a movement the child is dried gently with a piece of soft linen, sponges not being used, carefully powdered, and a new diaper applied. Diapers, if soiled, should not be put into a disinfecting solution. On the contrary, there is a positive objection to this, as diapers permeated with drugs may cause irritation of the skin of the buttocks. After changing the diapers, the nurse's hands and finger- nails should be cleansed with brush and file. This toilet of the hands and finger-nails is very important, even with breast-fed in- fants, since the neglect of this function will result in a contamina- tion of the breast nipple or food with fsecal bacteria. Even the infant's own faeces may cause serious intestinal disturbance if rein- troduced in the above manner into the stomach and intestine. Care of the Genitalia.— The care of the genitalia in male and 58 INFANCY AND CHILDHOOD. female infants is qnite important, and it is surprising to see how such a simple matter is neglected by the mother and nurse. In female infants and children during the bath the labia should be washed, gently separated, and the parts beneath laved with water. After the bath these parts should be carefully dried, but not powdered. It is a very common practice to powder the parts beneath the labia majora in female infants. This custom causes considerable irritation around the introitus vaginae, as a result of the powders settling on the parts. If these parts are not powdered, but simply dried after the bath, they will remain in a normal condition, and an accumulation of smegma will be avoided. In male infants the prepuce should be retracted daily and the parts bathed with ordinary water. In this way accumulation of smegma, and balanitis will be prevented. It is not necessary to use medicated solutions, such as boric acid, for this purpose. In boys the scrotum, buttocks, and adjacent parts should be powdered. Play; Fondling. — It must not be forgotten that the average in- fant's stomach is easily upset, and that any kind of pressure on the abdomen is often a very effective way of emptying the stomach. After feeding, therefore, the infant should lie quietly in its crib and not be handled or fondled. Unless this rule is followed, vomiting after nursing will quite frequently occur. It should be remembered that too much play is apt to tire an infant as much as it would an adult. Infants who are played with and fondled to excess are tired, restless, irritable, and sometimes do not sleep. There is no rule to be applied, but moderation is to be followed in these things as in all others concerning the infant's pleasure. Children should not be allowed too much intercourse with adults, as this is also apt to have a deleterious effect. Children should play with children. Adults should limit their play and contact with children as much as possible. Sleep. — An infant in perfect health spends most of the time in sleep when it is not nursing. Unless its attention is engaged by others, it will not play in the early months of infancy. After nursing, an infant falls asleep, generally on the breast. Therefore, if an infant cries or is restless after nursing, there is something at fault. Older children should slee]) in the afternoon for one hour, after the midday meal. This should be especially insisted upon with children who have a nervous temperament. If such children do not attain an early habit of sleep in the afternoon they will be restless at night, and finally develop symptoms of neurasthenia. Bed. — The best bed for the newborn infant is one in the form of a bassinet. The infant certainly should not sleep in the bed with the MANAGEMENT AND HYGIENE OF NOBMAL INFANT. 59 mother or nurse, for, aside from the clanger of so-called overlying, the infant is liable to become infected with the discharges of the mother; and in a breast-fed infant there is always a temptation to give the breast to the child at night whenever it is restless. Bad habits therefore result. Aside from this, an infant will be restless unless trained to sleep in its own bed. The mattress of the bed should consist of a hair cushion pro- tected by a rubber draw-sheet. Over this is placed a bed-pad, and over this the bed-sheet. After the fourth month an infant may be placed in a crib. For restless children cribs are made with high sides, so that they may not fall out. Rocking bassinets or cribs are undesirable. An infant accustomed to a rocking-crib or cradle will not fall asleep unless rocked, and the mother or nurse becomes a slave to the crib. If a baby in early infancy cries without any apparent cause just as it is placed in the crib from ,the mother's or nurse's arms, it is best not to take it up immediately, for, unless this habit is broken in early infancy, an infant will refuse to be pacified unless taken up several times in the twenty-four hours. The physician may be consulted concerning the pillow for the infant, as to whether it should be made of hair or down-feathers. It is well for the young practitioner to know that a pillow made of the finest curled hair is really more comfortable than a down-pillow. When placed under the infant's head, the pillow should reach well beneath the shoulders, so that the head and shoulders are supported together. The custom of not using the pillow for the infant allows the head to come in direct contact with the mattress, a very uncom- fortable position, and one which inevitably results with careless mothers or nurses in a slight erosion at the back of the head, over the occiput. So-called pacifiers made of rubber or muslin should never be used in the nursery. They are undesirable and unnecessary, and if not used will not be in demand. Nursery. — The temperature of the room in which the infant passes its days should be carefully maintained at from 68° to 70° F. Variations in the tenifterature of the room not only chill the infant, but interfere with its growth and nutrition. Drafts are reprehen- sible. The air of the room should have no odor, and we should ventilate indirectly from another room which is warmed. Incense should never be used to cover up an odor. The nursery should be well lighted, as well as capable of ventilation. An open fireplace aids the ventilation considerably, and in damp weather dries and warms the atmosphere as well as ventilates the room. The floor of the nursery should be made of hard wood or painted and covered with rugs. Carpets are not hygienic. They must be 60 • INFANCY AND CHILDHOOD. swept in situ; whereas rugs can be taken out, dusted, and aired. The crib should be protected from the open window by means of a screen. During infancy, up to the twelfth month, the temperature of the nursery, both day and night, should be kept at the same point. There is no reason why the temperature should be lower at night than during the day, as is customary in the sleeping-room of the adult. When the infant is in the open air, the nursery should be thoroughly ventilated for at least an hour a day. With premature children, however, we must be more careful and keep the temperature at a slightly higher point than the above. Or, if we have the room at 70° F., such children should be aided in maintaining the body- warmth by means of warm bottles placed underneath the blankets in the crib, but not necessarily close to the body. Open Air. — The infant may be taken into the open air three weeks after birth in the summer season and four weeks after during the winter, early spring, and fall. I have consistently advised that four weeks after birth, if the weather is not too cold, the newborn infant may be allowed an outdoor airing. I have seen no bad results follow from this advice. If the weather is exceedingly cold, com- mon sense would dictate that an infant should be kept indoors. A daily open-air exposure is always allowable in good weather, provided the infant be warmly clad, especially in the winter time, so as to run no danger of chilling. If an infant shows a tendency to be easily chilled when taken into the open, warm bottles should be placed under- neath the covers of the baby carriage. Infants should be protected from the direct rays of the sun, inasmuch as they burn and tan very readily. Tanning of the skin, or sunburn, is not necessary to the health of the infant. A physician will frequently be asked whether sleeping in the open air is injurious to the infant. It certainly is not, provided the infant is well pro- tected in the manner described above. Some infants fall asleep immediately on coming into the open. We could scarcely keep such infants awake, and nature simply indicates to us in this way that the open air is a tonic to the general nervous system. In large cities, both in summer and winter, the face should be protected by a veil when the infants are taken into the open. In the country this is especially necessary if mosquitoes and flies are in the vicinity. Children who are running about should not wear short stockings if the locality is infested with mosquitoes or insects. There is nothing particularly hygienic in the custom of wearing short stockings, and it exposes the children to the danger of infection, not only by mosquitoes (malaria), but by dangerous insects, such as spiders. Clothing. — The clothing of the infant should consist of a chemise of wool next the skin. Over this there should be a loose garment. MANAGEMENT AND HYGIENE OF NORMAL INFANT. 61 either wool or flannel, reaching from the shoulder to below the feet, and sufficiently long to allow it to be folded upward. Garments should not restrict the chest in the old-fashioned way. The chemise should be made of gauze weight in summer and slightly heavier in the winter. Some infants cannot tolerate the contact of wool with the skin, because it causes an eruption of sudamina ; in such cases it is well to place between the skin and the woolen garment a fine-linen chemise. Body-'binder. — It is customary to provide the newborn infant with a body-binder made of soft, white, thin Shaker flannel, five inches wide and sufiiciently long to pass two or three times around the body. It should be secured with strings, and not with pins, nor should it be sewed on the body. It is useful at first in retaining the dressing of the cord in place, and later on in supporting the umbilicus during straining or crying. The binder is discarded when the infant first makes attempts to stand. This usually occurs at the seventh month. The binder then loses its utility, inasmuch as the umbilical opening is naturally closed and supported by the muscular action of the recti muscles. It is customary, however, to substitute for the binder, when it is discarded, a so-called knitted flannel band, sold in the shops for this purpose. Skin.' — The precautions which should be observed in drying the skin after the bath have already been mentioned. Dusting-powders that contain perfume should be avoided. Dusting-powder is applied with a puff of absorbent cotton in preference to a powder-puff. This absorbent cotton can be thrown away and a new pledget used at each dressing. To prevent caking, any excess of powder should be removed. If the skin is subject to sudamina in the summer, a handful of bran is added to the water, or, what is preferable, the bran is put into a gauze bag, moistened and expressed in the water of the bath until the water becomes turbid. Salt water irritates the skin of these infants and should not be used. Mouth. — It was formerly customary to wash the mouth of the infant thoroughly either after each feeding in bottle-fed infants, or two or three times daily in breast-fed infants. There is really no scientific indication for doing this if the rubber nursing nipples and the bottles used for artificially fed infants are kept scrupulously clean; and the mother's or nurse's breast nipple with the breast-fed infant be cleansed with a solution of boric acid before and after each nursing. Sprue or stomatitis will thus be avoided. Before the eruption of the teeth, the natural secretions of the mouth are quite sufficient to keep the mouth clean. The nurse should not introduce the finger into the mouth of the infant, either to cleanse it or otherwise, under ordinary circum- 62 INFANCY AND CHILDHOOD. stances. I have seen stomatitis, both simple and gonorrhoeal, more commonly Bednar's aphthae, cansed by the introduction of the finger into the mouth for the purpose of cleansing the same. After the teeth have appeared they may be kept clean by washing once a day with cotton moistened with boric acid solution. The best time is in the morning, after the bath ; the mouth of the infant is carefully washed with a piece of absorbent cotton wrapped around a toothpick and moistened with boric acid solution. 'No force should be used, and no hard pressure exerted against the roof of the mouth especially, as in this way ulceration may result. In order to avoid the introduction of sprue into the mouth, the bottle nipples should be boiled once a day for ten minutes in a soda solution, and cleansed carefully with hot water after each nursing. In the intervals of nursing the rubber nipples are best kept either in a glass-covered jar or in a piece of absorbent gauze. It is well not to keep them in a solution of boric acid, as this is apt to become contaminated. It has been maintained by some that washing the mouth of the infant nursing at the breast is prophylactic against infection of the breast by bacteria of the infant's mouth. Aside from the fact that the bacteria which exist in the mouth of the newborn and young infant, before the eruption of teeth, are not pathogenic, no one has proved that they are capable of causing breast abscess. Epstein has shown conclusively that washing the mouth of infants is pro- ductive of infectious ulcerations of the mucous membrane of the buccal cavity, as well as the means by which extraneous infections, such as gonorrhoea and sprue are engrafted on the mucous membrane. In the newborn the production of buccal ulcerations as a result of a too diligent toilet of the mouth is not without great danger. It has been long acknowledged that bacteria may gain access to the circulation through these ulcerations and thus cause general sepsis. THE ADMINISTRATION OF DRUGS AND OTHER METHODS OF THERAPY. Medicinal Treatment. — CUiildren should receive drugs in an agreeable form, although some may take nauseous drugs with ap- parent indifference. Bulky mixtures or drugs which are apt to upset the stomach should not be prescribed. The author has seen a severe enterocolitis set up by a cough mixture containing antimony. Drugs should not be administered in pill form to infants or children. Tab- lets are a ready means of administering certain drugs. They can be crushed and given in a teaspoonful of some indifferent fluid. Powders are also easily taken. They are put in a spoon, some fluid added to TEE ADMINISTRATION OF DEVGS. 63 form a mixture, which is then administered. Quinine is given either in syrup of yerba santa or in chocolate powder and water; or the child is given a piece of chocolate to eat, and the quinine is then ad- ministered. A child should never be forced to take a medicine. Much harm is done in this way. Certain drugs, such as opium in the form of the simple tincture or morphine, should be given with great caution to children under the age of two years. Atropine, of late advocated in cholera infantum, should be given cautiously to infants and young children. They bear this drug badly. Jaboraudi is badly borne, as is also apomorphine. Camphor is a very good cardiac stimulant. It is useful in collapse, but must be given cautiously in cases in which there is diarrhoea. In the latter disease the camphor is apt to irritate the stomach and gut. The coal-tar series, such as antipyrin, antifebrin, and phenacetin, are powerful depressants. In those cases of fever in which it is not possible to give baths to lower the temperature we are sometimes forced to administer these drugs. It is then well to combine them with small doses of caffeine. If a child or an infant refuses to take a drug, it may be put in a teaspoon, the spoon held horizontally to the lips, and when the mouth is opened the spoon carried far back into the mouth and tilted. The spoon is held in the mouth until the act of swallowing, which must inevitably take place, is completed ; the spoon is then withdrawn. If this manoeuvre is thus carried out, the fluid will not be rejected. Holding the nostril closed, and thus forcing the child to open the mouth, is bad practice. Patience and suasion can accom- plish as much in most cases. Digitalis is not given continuously, but is administered for two or three days, and when the pulse begins to show signs of lessened frequency its administration is susj)ended. iVlcohol is well borne by children. I do not hesitate to administer it in cases of nephritis if the heart is weak. In the gastro-enteritis of nurslings the stomach is intolerant of alcohol. It should not be given except in very severe cases accompanied by great prostration, as the vomiting is apt to be aggravated. Antipyretics. — Much has been written concerning antipyresis and antipyretics in the treatment of the diseases of infancy and child- hood. The young practitioner can feel assured that high tempera- tures are well borne by infants and children. A temperature of 106.5° F. (41.3° C.) in an adult, although of short duration, would cause great alarm, and rightly so. On the other hand, such a tem- perature in an infant or child does not necessarily threaten life, nor is it incompatible with recovery. A convulsion is in some children the direct result of a rise, of temperature. Such a convulsion will not 64 INFANCY AND CHILDHOOD. necessarily lead to others nor to epilepsy. The heart and kidneys bear long-continued high temperature well in comparison with those of the adult. The most trivial causes will cause a rise of a degree or two in the temperature of an infant or a child. Taking all these idiosyncrasies into consideration, it may easily be understood by the student and practitioner why it is essential that methods of therapy should be modified before they can be applied to infants and children. A reduction of temperature from 104° to 102° F., even if it can be accomplished by a coal-tar derivative, does not cure the patient. Some diseases, such as measles, scarlet fever, pneumonia, and a number of others, run a course of high and low temperatures extending over a certain space of time. If an infant or child is attacked with convulsions following every acute rise of temperature, the parents should be warned of this fact. In these cases, as soon as a rise of temperature is noted, it should be com- bated by every means in our power. Reduction of temperature in such children at the outset of a disease is of the highest utility. It saves the nervous system from the shock of a convulsion. Hydro- therapy is, in such cases, the safest and most satisfactory antipyretic measure at our disposal. Dosage. — The dosage of drugs for infants and children has re- ceived much attention. In practice we judge more by the action of a remedy than the quantity administered. The initial dose should be small. Infants under a year receive /4oth of the adult dose, and at the age of one year %oth of the adult dose is safe. At the fifth year /^th, and at the tenth year % the adult dose is the rule. These figures are not absolute. ISTitroglycerin if given in doses of less than /45oth of a grain has scarcely any effect on children five years of age. On the other hand, strychnine may be safely given in quantities of /^snth of a grain to infants, and Msoth of a grain to children two to three years of age. It will be seen that if the hard-and-fast rule of division of doses according to age were followed, these drugs would necessarily be given in much smaller dose, and their action would be correspond- ingly inefficient. Hypodermic Administration. — Hypodermic administration of drugs to infants and children presents nothing peculiar, as compared with the same method applied to adults. Hydrotherapy. — The practice of hydrotherapy as applied to the adult must be somewhat modified before it can be carried out with the infant or the child. The reason for this is that the infant or child does not react so readily and cannot bear sudden changes of tempera- ture so well as the adult. The Sponge Bath. — A rubber sheet is placed on the crib, and over this one layer of a small blanket; the patient is then placed nude TEE ADMINISTEATION OF DEUGS. 65 on this blanket and covered with another blanket. There is thus no undue exposure. A small basin of water at 80° to 85° F., with a dash of alcohol, is now brought alongside of the crib. With a small sponge or piece of soft folded linen the parts of the patient are sponged; first one arm, then the other, then the trunk, and finally the lower extremities. As each part is exposed, the rest of the body is kept covered. This procedure is repeated until the body has been sponged for five or ten minutes. This method of hydrotherapy is especially suitable in acute rises of temperature of short duration and in mild cases of continued fever in which the temj)erature does not rise high. Cold Chest Compress.^ — Three layers of linen are cut so that they will envelop the trunk from the clavicles to the umbilicus. The gen- eral shape should be that of a shirt deprived of arms and open at the sides. On the outside of this linen compress there should be a compress of Shaker flannel cut in a similar manner. The compress of linen is moistened with water at 80° to 85° F. With robust children the water may be 70° F. The compress is wrung out and applied so that the neck, shoulders, and chest are covered as with a shirt. The flannel is now applied to the outside. The compress is moistened every hour with water at 70° to 85° F. and re-covered with the flannel. Cold Pack. — The cold pack is not so useful in the treatment of the febrile conditions of childhood. The method is similar to that fol- lowed with the adult, with the exception that the sheet is moistened with water at 80° to 85° F. In other cases the patient, after being wrapped in such a sheet, is rubbed by the attendant with ice on the outside of the sheet. The Full Bath. — The full bath, as advocated by Brand, is seldom carried out in the treatment of children. Children struggle against the bath, and if the temperature is too low, they become so depressed that it is difficult to rouse them. I therefore place children with typhoid fever, pneumonia, or scarlet fever in a bath at 100° to 105° F., and lower the temperature to 80° or 85° F., applying friction to the body constantly. After five or ten minutes the patients are taken out of the bath and rubbed dry. Warm-water bottles are applied to the hands and feet. In conditions of delirium and coma with a high temperature, in which the heart is weak, I have given baths at a temperature of 105^ to 108° F. The cases in which these baths are indicated are those in which any application of cold water causes cyanosis and collapse. I have seen infants suffering from bronchopneumonia, with high temperatures, in a condition resembling a rigor after a 5 66 INFANCY AND CHILDHOOD. bath at 85° F. With these infants the warm bath acts as a cardiac stimulant and is a sedative to the nervous system. Hypodermoclysis. — Hypodermoclysis is the introduction into the subcutaneons tissue of either a 0.6 percent, salt solution or the normal salt solution of Cantani (sodium chloride, 4 parts; sodium carbo- nate, 3 j^arts; water, 1000 parts). It is indicated in infants suffer- ing from cholera infantum and in other exhausting states. ]\[onti, who was the first to apply this mode of therapj^ to the infant, injects 100 to 200 c.c. at a time. Epstein showed that smaller quantities — 10 to 40 c.c. — are more beneficial and more quickly absorbed. Ex- perience teaches that large quantities of fluid injected subcutaneously cause extensive blood extravasations in exhausted infants and much subsequent pain. The solutions used should be freshly prepared and sterilized. Welch has reported cases of infection with Bacillus aerogenes capsulatus following hypodermoclysis. I have had one case, although every precaution was taken to avoid infection. A large antitoxin syringe, holding 30 c.c, is used. It should be carefully sterilized. Or a fountain syringe may be employed, and the solution introduced through a needle attached to the tubing of the syringe. From 20 to 30 c.c. of the solution is injected two or three times daily into the subcutaneous tissue of the lumbar region or abdomen. Monti injects into the subcutaneous tissue of the abdomen. Mas- sage should not be performed after injection, as it is very painful and causes hemorrhages. The puncture wound is covered with a piece of sterile gauze. The main point is to inject small quantities of the solution at intervals of from four to six hours, and watch the effect. The action is that of a stimulant to the heart and the processes of resorption. Epstein showed that within a few hours after injection of salt solution the proportion of haemoglobin and red blood-cells were reduced. As salt solution has a dissolving effect on the red blood-cells, the injection of large quantities of the solu- tion may be harmful. SyTinging of the Nose Instruments. — The best form of syringe for this purpose is an olive-tipped glass syringe. Some forms are made with a soft-rubber tip. The tip should be blunt, lest the nares be injured (Fig. 7). Fig. 7. , Nasal syringe. Correct shape. The solution used is generally a normal salt solution. Method, — The patient is wrapped in a sheet or blanket, and held iij the lap of a nurse, who holds a pus basin beneath the chin. The TRE ADMINISTBATION OF DBUGS. 67 operator stands behind the patient. The syringe is held horizontally to the floor of the nares and the solution slowly injected into the nostril (Fig. 8). If successfully performed, the procedure results in the solution's coming out of the other nostril. There is no danger in the manoeuvre if carefully carried out. If the infant is too weak, the nares may be syringed with the patient in bed in the FiG. 8. ^^eyief^ Method of syringing the nose in the upright posture. recumbent posture. The nurse stands at one side, and the head is placed on the side, the pus basin beneath the nose, as shown in Fig. 9. A rubber fountain-syringe may be used in the same manner. Here also the position of the syringe is horizontal to the floor of the nares. The syringe should be thoroughly boiled before and after using. An old syringe should never be used, no matter how carefully it has been sterilized. 68 INFANCY AND CHILDHOOD. Vapor Spray ; Calomel Inhalations in Acute Laryngeal Disease. — With infants and children the spray is not so useful an agent as steam vapor impregnated with balsams or turpentine, and combined at times with inhalations of the fumes of sublimed calomel. The spray cannot, as a rule, be used locally except with the most tractable children. With infants its use is not feasible. The vapor of steam impregnated with balsams or turpentine is very useful in all forms of acute laryngitis in which there is no bronchitis. I dispense with steam vapor if bronchitis is present. The mode of application in catarrhal or membranous croup is as follows : The crib is covered with a sheet suspended from four upright poles fastened to the corners of the crib. A tent is thus formed. The croup kettle is placed at one side of the crib, in such a Fig. 9. Method of syringing the nose in the recumbent posture. manner that the steam vapor escapes into the improvised tent. The vapor is medicated by placing in the kettle a teaspoonful of turpentine or thymol. This will be readily vaporized. ISTo special apparatus has any advantage over the ordinary croup kettle. If calomel sub- limations are to be given, they should be combined with the steam vapor. Ten grains of calomel are placed in a spoon held over an ordinary candle, and the fumes led under the tent, the air of which is impregnated with steam vapor. The special devices sold for the sublimation of calomel may be used, but possess no advantage over the method described above (Fig. 10). Calomel sublimations are ex- ceedingly irritating, but they relieve the patient very promptly. They may be continued for forty-eight hours at intervals of two hours, without fear of salivation. TEE ADMINISTBATION OF DKUGS. 69 Stomach Washing. — One of the most valuable additions to our therapeutic armament within recent years is stomach washing in case of the nursing infant. ISTo improvement has been made upon the method as first proposed by Epstein. The cases in which it is indi- cated are mentioned in another part of this work. The procedure is easiest of application to nurslings in whom there are no teeth or in whom very few teeth have erupted. With these subjects there is no danger of the catheter's being bitten, and there is no necessity of using a gag. With older children, however, a gag must be used when stomach washing is attempted. The Denhardt gag of the O'Dwyer set of intubating instruments is most suitable for this purpose. Fig. 10. Sublimer for calomel inhalation. Indications. — Washing out the stomach is principally indicated in the acute gastro-enteritis of the summer months. It is not bottle- fed infants alone that are attacked, but even breast-fed infants may be thus affected. The winter months also furnish their quota of these cases. One vomiting spell, as it is called, does not require attention. If, however, on suspension of the bottle or breast, vomit- ing continues and becomes uncontrollable, we proceed to stomach irrigation. Another indication is the so-called chronic dyspeptic vomiting. Those who advocate this method of treatment in these cases forget that, above all, the food is at fault, and must be regulated and modified. I do not favor washing the stomach in these cases. One washing is, as a rule, sufficient. I have rarely had to repeat it. If vomiting persists after the first washing, it is well to look for other conditions than gastro-enteritis, such as intussuscep- tion, as the cause of the vomiting. Stomach washing is also a favorite 70 INFANCY AND CHILDHOOD. mode of treatment in cases of persistent vomiting due to spasm or stenosis of the pylorus. Acute drug poisoning or ingestion of any irritating fluid is quickly relieved by stomach washing. I have washed out many children who had been given an overdose of paregoric, or who had taken Paris green, turpentine, or other drug. If, as sometimes happens, a child accidentally swallows a caustic alkali, we should not introduce the tube into the oesophagus or stomach. Method.' — A four-ounce funnel, a piece of rubber tubing two and a half feet long, and a ISTo. 14 rubber catheter are the instruments Fig. 11. Apparatus for washing out the stomach. necessary. The rubber tubing is attached to the funnel, and by means of a piece of glass tubing to the catheter, as in Fig. 11. About a quart of normal saline solution is needed. The temperature of the water should be at least 100° F. The operator needs one assistant. The infant is completely undressed, and is then wrapped in a blanket, the diaper having first been applied. The hands are tucked in with safety-pins. The infant having been laid recumbent on a table, the operator, standing on the right, introduces his left index < TRE ADMINISTRATION OF DBUGS. 71 finger into the mouth and depresses the tongue (Plate I.)- The catheter, moistened with water, is now introduced and passed back- ward. With gentle urging the catheter passes easily into the oesopha- gus. There is no likelihood of the catheter's passing into the larynx and trachea. About six inches of the catheter are introduced. The funnel is depressed and the stomach contents are first allowed to flow out. The funnel is then raised about two feet above the patient, and the assistant slowly pours the saline solution into the funnel, the fluid flowing into the stomach. Before the funnel is completely emptied, it is lowered and the stomach contents siphoned out. This operation is repeated several times, until the water returns quite clear. If during the stomach washing the fluid should be ejected from the stomach in the act of vomiting, it will easily flow out of the mouth if the infant is recumbent. There is not the slightest danger of aspiration of the fluid into the trachea. I think the recumbent position is superior to the sitting posture advocated by some clinicians. A young infant is unable to sit up of its ovni accord. The introduction of the tube is not so easy for the infant in the sitting posture as in the recumbent position. The tube being intro- duced, the stomach contents sometimes refuse to flow out because mucus and food particles obstruct the lumen of the catheter. In such cases the catheter is withdrawn, and washed out. The catheter is then pinched with the fingers in such a manner that some of the water or washing solution remains in the catheter. It is then intro- duced into the stomach. In this way the catheter, being filled with fluid, mucus and food cannot obstruct the lumen of the tube before siphonage is begun. Fluid can then readily be introduced into the stomach. These difficulties occur in cases in which there is a large amount of mucus in the stomach. The finger should always be retained in the mouth. By grasping the catheter with the thumb and index finger of the right hand, prying open the mouth at the same time, we prevent pressure on the catheter during the washing. If the infant has upper and lower incisors, the catheter must be held at one side of the mouth and the mouth kept open by means of the index finger held in the angle of the mouth. The method described above has been followed by me for years. I have never had an accident. Gavage. — Gavage is a method of forced feeding by means of the stomach-tube. I have practised this method of feeding infants and older children suffering from pneumonia or typhoid fever, who were delirious or unconscious. It is also a method which has been pro- posed in cases of uncontrollable vomiting and I have utilized it in patients suffering with spasm of the pylorus. The method of procedure is similar to that used in stomach wash- 72 ■ INFANCY AND CHILDHOOD. ing. It is best uot to introduce the catheter through the nose, but to keep the mouth open with some device. If the catheter is passed through the nose, no food shoukl be introduced into the funnel until we are sure the feeding-tube is in the stomach. With older children a tube passed through the nose may pass into the larynx. If it has done so, a hissing sound will be heard. Aphonia will also be present. In infants and young children the glottis is small, and a full-sized catheter will not readily pass into it. After the tube is in the stomach the prescribed amount of liquid food is introduced and the tube rapidly withdraAvn. The feeding may be repeated every four to six hours. Rectal Enemata; Irrigation; Enteroclysis. — The bulk of an or- dinary enema, introduced in order to empty the bowel, should be from 2 to 4 ounces. A Davidson's bulb syringe should not be used. A jSTo. 16 or No. 18 catheter is attached to the nozzle of an ordinary four-ounce hard-rubber syringe. The infant or child is placed on its side, with a rubber sheet under the buttock. The tip of the catheter is oiled and passed well within the anal ring. The catheter is then attached to the nozzle of the syringe containing the fluid to be injected, and the fluid is gently thrown into the rectum. An enema commonly used is soap-water, with the addition of a tablespoonful of castor oil or glycerin. The high rectal enema, irrigation, or enteroclysis, is given in all forms of summer diarrhoea, dysentery, and in typhoid fever. It is also indicated in cases in which there are symptoms of collapse, in exhausting diseases, in nephritis, and after operations. It was for- merly a method employed to reduce an intussusception in its early stages but is not now in vogue. In diarrhcea, the object of the high rectal enema is twofold — to clear out the faces from the lower bowel, and to supply fluid to the depleted circulating blood, thereby stimulating the heart. The latter is the main object in practising enteroclysis in states of exhaustion and after operations. In sup- pression of urine we aim to supply fluid to the kidneys and stimu- late the circulation. According to Kemp, the high rectal enema is one of our most useful diuretics. The solution employed is the Cantani saline solution (sodium carbonate, 3.0; sodium chloride, 4.0; water, 1000). At least a quart is injected. The temperature of the solution for simple wash- ing of the gut, as in diarrhoea, should be that of the body. In nephritis or colkpse the temperature should be at least 108° to 110° F. (42.2° to 43.3° C). The instrument employed may be a bag fountain syringe, of a quart capacity, to which is attached a small calibre soft-rubber rectal tube or a catheter, or the rubber tubing and catheter may be attached to a six-ouuco 2;lass funnel. ^ .<*<- 03 3 TBE ADMIN I ST EAT I ON OF DBUGS. 73 The patient is completely undressed and laid on a table on the side, with the knees flexed and the buttocks near the edge. A rubber sheet placed underneath the buttocks leads into a pail, so that the returning water will drain off (Plate II.)- Tlie buttocks are placed slightly higher than the trunk. The catheter or rectal tube is oiled and introduced two or three inches into the rectum, the water allowed to flow, and the tube passed higher up. Sometimes there is an obstruction to the passage of the tube, and then it is necessary to introduce the finger cautiously into the rectum alongside of the tube and guide it past the upper sigmoid ring. The tube may thus be passed from six to eight inches into the gut. It is seldom necessary to introduce it higher, as the water will find its way into the colon. About a pint or more of water is then allowed to flow into the gut. It is not necessary to compress the anus around the catheter to prevent the escape of the fluid. Some of the fluid may escape along- side the catheter. In some forms of exhausting diarrhoea a portion of the saline solution should be left in the gut after it has been well irrigated, in order to stimulate the heart and supply fluid to the circulation. Two irrigations may be necessary in the twenty-four hours, rarely more. In typhoid fever one low irrigation is given daily. In some subjects, if the irrigations are continued too long, hypersemia of the mucous membrane results. Clinically, this is manifested by a continuance or increase of mucus in the washings, and also by the occasional presence of blood. In such cases the enemata should be suspended. In nephritis complicating scarlet fever, rectal irrigation is one of the recognized methods of stimulating the secretion of the kidney, which result, according to Kemp, begins twenty minutes after the fluid is introduced into the gut. With adults the Kernp tube is used, but with children, who are difiicult to keep quiet, continuous irrigation is not feasible. In these cases high enteroclysis is given in the ordinary manner, as much of the solution as possible being retained in the rectum. This procedure may be repeated two or three times daily. In giving ordinary enteroclysis the bag of the fountain syringe or funnel should not be held more than three feet above the body of the patient, lest the pressure be too great. About a pint of fluid at a time is allowed to flow into the gut ; the catheter is then disconnected, and the contents of the gut allowed to flow out. A stimulating enema is given after an operation, or when symp- toms of collapse appear in any acute illness. Only small quantities of solution are allowed to flow into the rectum. A formula in use in my wards is the following: 74 INFANCY AND CHILDEOOD. Whiskey 3j. Caffeine gr. *. Tint, digital gtt. ij. Sol. sodium chloride (0.6 per cent.) ^J- Temperature, 102°-10.5° F. Xutritive enemata are used when for any reason, such as uncon- trollable vomiting, the stomach must be given complete rest. Soma- tose solution, of one teaspoonful of somatose dissolved in eight ounces of cold water, is given lukewarm Sij at a time, every four hours. Or, ext. pancreatis, gr. v ; sod. bicarb., gr. ij ; water §iv ; milk, oxvj ; with or without the addition of an egg. Give Bij or §iij. These enemata should be given slowly and high up, and in small quantities at a time. Tor constipation in cases in which faeces have become impacted and are in the form of hard scybala the following is excellent : Olive oil 3ij. Glycerin 5j- This should be injected to be followed after a few hours by an ordi- nary enema of soap-water. In cases of cardiac disease with uncontrollable vomiting, digitalis is administered with excellent results by the rectum. The requisite dose of infusion is placed in simple water up to the bulk of two ounces and is then introduced high in the rectum. This may be repeated three times daily for days. Lumbar Puncture. — Lumbar puncture was first practised by Quincke. It is to-day one of the most useful adjuncts to the methods of diagnosis in acute and chronic forms of cerebral and spinal dis- ease. Its future usefulness as a therapeutic measure is not clearly established, but will probably lie in relieving symptoms due to pres- sure, removing the excess of inflammatory exudate in the various forms of meningitis, and introducing sera and curative agents into the subarachnoid space. The Normal Cere'brospinal Fluid. — Normal cerebrospinal fluid is a clear colorless fluid having a slightly alkaline or neutral reaction. Its specific gravity varies from 1007 to 1009. It contains from 0.05 to 0.1 per cent, of albumin (Quincke, Rieken, Pfaundler), and be- cause of the presence of sugar (0.05 per cent.) has a slightly re- ducing action on copper. It does not coagulate spontaneously. If centrifiiged, a microscopic sediment of a few endothelial cells and small mononuclear cells and lymphocytes may be obtained. The cerebrospinal fluid is normally under a pressure of from 5 to 20 millimetres of mercury or 40 to 150 mm. of water. The pressure in infants is lower than that in children. The causes of the variations of pressure and the nature of the conditions under which they occur THE ADMINISTBATION OF DEUGS. 75 have not as yet been determined. Kespiration causes a deviation of fully 6 millimetres of mercury in the manometer column. Abnormal Conditions. — The cerebrospinal fluid will in pathological states vary in respect to specific gravity, composition, appearance, and in the amount of sediment contained. The pressure in the sub- arachnoid and cerebrospinal spaces v^^ill also vary in different forms of disease. It is increased in inflammatory states, hydrocephalus, hemorrhage, tumors of the brain, abscess, acute alcoholism, eclampsia and epilepsy. Specific Gravity. — -The specific gravity in tuberculous meningitis varies from 1003 to 1011 (Lenhartz), in cerebrospinal meningitis from 1005 to 1012 (Pfaundler). Gross Appearances. — The gross appearances of the fluid obtained by lumbar puncture may be changed by the admixture of blood. Blood may come from the puncture wound or may have been in the canal previous to puncture as a result of a hemorrhagic pachymenin- gitis or of some form of cerebrospinal meningitis, traumatism, or apoplexy with rupture into the ventricles. The wounding of veins either in the tissues or in the cauda equina may cause an admixture of blood. The quantity of blood may be just sufficient to tinge the fluid or the blood may be almost pure. It is not possible to determine whether the admixture of blood is or is not the result of accidental puncture of a vessel unless, as in pachymeningitis or traumatism, light is throv^i on the matter by the history of the case and the presence of blood on repeated puncture. The accidental admixture of blood is unfortunate, since it obscures the microscopical diagnosis. The hemorrhage into the spinal canal as a result of the operation of lumbar puncture is never alarming or of serious import. Tuberculous Meningitis. — Tuberculous meningitis changes the gross appearance of the fluid obtained by lumbar puncture. The fluid may be quite clear, exceptionally cloudy, opalescent, or in rare cases purulent. As a rule, however, it is clear in the early stages of the disease and cloudy in the later period. If the test-tube is held in a strong light, there may be seen, in a clear or cloudy fluid, myriads of highly refracting particles resembling the motes in a sunbeam (Moser, Bernheim, Pfaundler). The appearance is quite character- istic. It was first explained by Lichtheim, as the result of spontaneous coagulation. If a test-tube of the fluid obtained by lumbar puncture is placed in the upright position in an ice-box, there is found after twenty-four hours, a fully formed cobweb-like, funnel-shaped coagu- lum, beginning a little below the surface of the fluid and extending downward, the broader part of the funnel being above. According to Pfaundler, this coagulum is of diagnostic import. I have relied on its appearance in fluid which was not contaminated with blood, 76 INFANCY AND CHILDHOOD. and found it of great value. The formation of the coagulum begins after the fluid has stood for two hours, and is fully completed by the following day. It is usually found from eight to twelve days before death. Suppurative Meningitis. — In this form of meningitis, the fluid obtained by lumbar puncture is purulent, opalescent, grayish-white, grayish-yellow, or brovmish (hemorrhagic). Exceptional cases give a clear fluid. There may be a spontaneous coagulum resembling that seen in tuberculous meningitis. Epidemic and Sporadic Cerebrospinal Meningitis. — In the early stage of this disease, the fluid may be quite clear with suspended microscopic sediment. It may also be cloudy or thick, creamy or bloody. It may at first be clear, and later in the disease become purulent (Councilman). Chronic Hydrocephalus. — This gives a clear fluid with no sus- pended particles visible to the eye, although microscopically there may be leucocytes. Pfaundler in one of his cases obtained a fluid which was cloudy because of the admixture of leucocytes. Brain Tumors. — Tumor of the brain gives a clear fluid. I have had such cases. Sediment. — This feature will be fully discussed under the sec- tions devoted to tuberculous meningitis and cerebrospinal meningitis. Cytology. — The cytology of the fluid in an acute inflammation is as a rule polynuclear, whereas in a chronic process there is an excess of lymphocytes. Organic disease of the meninges such as syphilis will cause a lymphocytosis. Pathological fluids contain small mono- nuclear lymphocytes, polynuclear leucocytes, transitional forms, large lymphocytes (mononuclears) with basophile granulations, so-called plasma-cells, and finally endothelial cells. In addition to cellular elements the fluid may contain bacteria. These will be discussed under the various diseases. Here we may simply mention the pres- ence of the pus organisms. Staphylococci, Streptococci of various varieties, Pneumococci, Typhoid bacilli, Coli bacilli, Streptococcus mucosus, Tetanus bacillus. Influenza bacillus. Bacterium lactis aerogenes. Bacterium coli immobilatus and capsulatus, Saccharomyces glanders, Meningococci, and Tubercle bacilli. In fact almost any form of bacteria, as well as protozoan bodies, such as trypanosomes, have been found in the cerebrospinal fluid. Pressure. — The pressure under which the cerebrospinal fluid is retained in the subarachnoid space and in the spinal canal is in- creased in the various forms of meningitis. This is especially true of tuberculous meningitis, in which the pressure may reach 110 mm. of mercury. In this disease the pressure increases from the initial period to that of pressure symptoms, and diminishes toward the close TEE ADMINISTRATION OF DBUGS. 77 of the disease — the stage of paralysis. Ventricular involvement gives the highest pressure figures. The following figures are taken from Pf aundler's tables : First stage 48 m.m. of mercury. Stage of pressure 52 m.m. " " Stage of paralysis 24 m.m. " " In suppurative meningitis, the pressure varies froni 10 to 37 m.m. of mercury ; in cerebrospinal meningitis, from 24 to 50 m.m. ; in hydrocephalus, from 6 to 60 m.m. ; in tumor of the brain, from 3 to 52 m.m. (Quincke, Slawyk, Pfaundler). The presence of an increased amount of albumin in pathological states has been noted by Wentworth, Quincke, and Pfaundler. In tuberculous meningitis it may reach 0.3 per cent. ; in purulent menin- gitis, 0.6 per cent. The Operation of Lumbar Puncture.^ — Instrument. — The instrument consists of a trocar and canula such as is employed in tapping cavi- ties. The best form of instrument is that devised by Quincke (Fig. 12). The canula should be at least one millimetre in diameter. In order to de- termine the pressure, the manometer is used. This consists of a piece of ordinary glass tubing with an attachment of soft rubber tubing. The manom- eter is useful to determine the millimetres of fluid as indicative of pressure in the ventricles and subarachnoid space. In infants a rough way of estimating the pres- sure is through the tenseness of the anterior fonta- nelle, and in all children the force with which the first few drops of fluid escape from the canula. Indications for Lumbar Puncture. — Lumbar punc- ture is performed for diagnostic and therapeutic purposes in all cases in which there are symptoms which very closely simulate meningitis, or in which we think meningitis is actually present. I have also performed lumbar puncture re- cently for the relief of symptoms of so-called men- iiigism, knowing that no meningitis was present. Lumbar puncture is performed as a therapeutic procedure in cases of meningism, to relieve pressure, or at times in the condition of status epilepticus ; in all forms of meningitis ; and as a therapeutic procedure in chronic hydrocephalus. It has recently been advanced by the otologists as exceedingly useful in cases where meningitis is suspected as an extension from inflammation of the ear structures. The Quincke needle for lumbar puncture. 78 INFANCY AND CHILDHOOD. The decision to perform lumbar puncture in private practice is not alwavs easy on account of the dread with which the laity regard all procedures of this nature. In pneumonia where there may be a suspicion of pneumococcus meningitis and where there are signs of increased cerebral pressure as evinced by cerebral symptoms, the persistence of such symptoms may justify the physician in performing lumbar puncture. Indefinite cerebral symptoms such as headache, restlessness, and convulsions of a general or transitory nature are not indications for lumbar puncture. On the other hand, even very mild cases of meningitis, with indefi- nite sopor, muscular weakness, delayed reflexes at the knee, marked emaciation, and fever without even marked rigidity of the neck, may justify the procedure of lumbar puncture on the ground that if a meningitis is present we should endeavor to give the patient the benefit of the therapeutic serum as early as possible. Formerly it was the custom to refrain from puncture in doubtful cases ; to-day we prefer to puncture in these cases for reasons before mentioned. Cases with meningeal symptoms in which there is the history of a blow are proper subjects for puncture, since it may be necessary to exclude either meningitis or abscess of the brain. More detailed discussion of puncture for all forms of meningitis and hydrocephalus will be taken up in chapters devoted to those subjects. Place of Puncture. — The puncture is made in the space between the third and fourth or the fourth and fifth lumbar vertebrse. This point is obtained by palpating the crests of the ilium ; an imaginary tangent to these crests strikes the fourth space. The space above this imaginary line will, as a rule, be found to be the third space. Puncturing the canal in the space between the sacrum and coccyx or in the lower sacral space offers no advantages either anatomically or from a diagnostic standpoint. Method. — General anaesthesia is necessary only in strong muscu- lar individuals to reduce resistance. Children who can be held do not need anaesthesia local or general. The back of the patient is carefully scrubbed with green soap, then washed with alcohol and ether, and finally with sublimate. The patient is laid on either side according to the convenience of the operator. The spine is curved so that the spinous processes may be distinctly seen and palpated (Plate III.). ISTo considerable pressure should be brought to bear on the neck, since in cerebrospinal meningitis or in the basilar form of meningitis in which there is opisthotonos, serious injury to the neck may be caused. The spine is curved from the shoulders and < Oh s- a > < Oh G _0 ♦J 03 S- a O TEE ADMINISTEATION OF DEUGS. 79 pelvis. The needle, having been previonsly boiled, is introduced in the median line betv^^een the spinous processes at right angles to a tan- gent to the spine (Plate IV.). When it is in the canal, it is perceived that there is a lack of resistance, and that the point of the instrnnient is free. The canula is v^ithdrawn and the first drops canght in a sterilized test-tube. A second test-tube is substituted for the first after a few drops of fluid have been allowed to flow out, and from 10 to 50 c.c. of fluid are withdrawn, the amount varying vdth the pres- sure. If the fluid flows drop by drop, 20 c.c. are sufiicient for diag- nostic purposes and also to relieve the pressure. If there is opistho- tonos and the fluid does not flow well at first, cautious straightening of the neck will facilitate the outfiow. In infants the fontanelle is a good guide in gauging the pressure. As soon as a few cubic centi- metres of the fluid have been withdrawn, the fontanelle will be felt to be considerably flattened and relaxed or even depressed. If determination of pressure is desirable, the manometer tubing should be immediately attached as soon as the obturator to the canula is withdrawn, care being taken not to allow any of the fluid to es- cape, for this would invalidate the determination of pressure. The manometer is held at right angles to the spine in an upward direc- tion as the patient lies recumbent. The fluid from the spinal canal will rise in the manometer to the point where the glass is crooked ; it must not be allowed to flow over the curve ; the measurement is then taken of the height of the column of liquid. After this is done the manometer tube is lowered and the fluid is allowed to escape. In ordinary lumbar puncture the determination of pressure is not necessary. Heubner has withdrawn 100 c.c, but the removal of such large quantities is unnecessary and may be followed by hyperpyrexia and collapse. I rarely withdraw more than 30 to 50 c.c. If there is a dry tap, the canula should be withdrawn and a second attempt made on the following day. A dry tap may be caused by a flbrin clot or by the falling of the cauda equina in front of the opening of the canula. The fluid may be viscid and refuse to flow. In that case the fluid should not be aspirated with a syringe, since in the experi- mental laboratory this method has been proved to be hazardous. After puncture, the canula is rapidly withdrawn and the wound dressed with sterile gauze. Dangers of Lumbar Puncture. — Lumbar puncture if carried out as above indicated is rarely followed by ill effects or death. But there are enough cases of fatal issue during or after the lumbar puncture in the literature to make us mindful of the fact that in exceptional cases, esi^ecially when patients have been ill for some time, and in cases of tumor of the brain, such an issue is always possible. Therefore if lumbar puncture is performed in cases where there 80 INFANCY AND CHILDHOOD. Fig. 13. are reasons to assume the existence of a cerebral tumor, those inter- ested should be warned of the possibility of an untoward issue. Introduction of Fluids Containing Drugs or Sera Into the Spinal Canal. - — ISTow that cerebrospinal meningitis is treated with sera by the so- called sub-dural method, it becomes necessary aftar the withdrawal of the fluid in cases of meningitis to introduce the therajieutie serum into the canal. As a rule we introduce in quantity' as much as we have withdrawn from the patient. It is cus- tomary in some quarters to attach a syringe con- taining the therapeutic serum or fluid to the canula of the puncture needle, and thus slowly inject the fluid into the canal. This is not as desirable a procedure as using a so-calkd Quincke funnel for this purpose. The Quincke funnel consists of a small glass test-tube, drawn out into a funnel- shaped point, which is attached to a piece of tubing (Fig. 13). As soon as the fluid has escaped to the desired amount from the spinal canal, the tubing is attached to the tip of the canula, and the funnel being filled with the therapeutic agent, is somewhat depressed below the level of the opening in the canal in order to allow the air which may have been in the tubing to escape. The canula is then raised slightl}'', and it will be observed that the fluid will flow quite freely into the spinal canal. The 23atient remains in the recumbent position during the operation, as has been indicated in the paragraph on technique. All fluid introduced into the spinal canal should have been previously warmed carefully to the temperature of the body, and should be intro- duced slowly. Eapid introduction of the fluid will cause, in exceptional cases, collapse and especially This has ha])pened twice in the author's experience, though no fatal issue resulted. It has not occurred with the use of ihe funnel. QuiiiL-ke funnel, tub- ing ;m(l needle at- tachert for introduc- ing serum or fluids . . . » . . into the subarachnoid if a syriuge IS uscd ccssation of respiration space. ./ o SECTION II. NUTRITION AND INFANT-FEEDING. PRINCIPLES UNDERLYING THE PROCESSES OF NUTRITION. There is no division of jDediatrics which exceeds in importance that of infant-feeding. In fact the subject of infant-feeding is not only difficult to master, but requires thorough study and experience to carry it to a successful issue. The practitioner, therefore, will find that it is absolutely necessary for him to understand the prin- ciples underlying the art of infant-feeding, in order to attain any success in practice in this field. Though great advances have been made in the study of infant-feeding in the past decade, we cannot say that the art of applying certain principles of nutrition to the feeding of infants has attained its highest perfection. We cannot explain why one infant will thrive, whereas another, fed according to the same method, will fail to thrive and lose ground. To a certain extent the subject of infant-feeding is still empirical, although it may be said that empiricism is gradually but surely dis- appearing from this field of pediatrics. It is the exceptional infant which to-day refuses to thrive, and puzzles the most brilliant master of the art, but the vast majority of children can certainly be fed according to principles well established and laid out at the disposal of the general practitioner. If we study these principles of nutrition closely we shall see that they must to a certain extent conform to what is known to take place not only in the body of the infant, but also in that of the adult. There are certain exceptions which must be made as regards the infant, on account of its rapidly growing organism and the fact that the cells of the body are not only being replaced rapidly, but the tissues at the same time are undergoing rapid increment. As that of the adult, the body of the infant and child is constantly suffering a loss of its principal elements, consisting of water, albumin, fat, and mineral salts. This loss will vary within wide limits, accord- ing to the needs of each individual subject. The infant body must take in sufficient nourishment not only to make up for the constant loss and destruction of cell life, but also for the increase and growth of the body and development of various tissues, in this respect dif- fering; from the adult. The loss of nitrosjenous substances and fat must be made up by equivalents in the food ; at the same time in the 6 81 82 - NUTEITION AND INFANT FEEDING. infant and child enough must be furnished to allow for the rapid increase of weight and the growth of tissue throughout the body. There are other substances, such as collogen, chondrogen, keratin, mucin, and lecithin, which are needed in the infant's economy as well as in that of the adult, and these are excreted by the infant and child as in the adult. If fat and albumin are taken in sufficient quantity into the system, the loss in these substances is compensated for by the splitting up of the nitrogenous and fatty elements of the food. It will enlighten the student to familiarize himself with the role played by the various food elements in replacing the loss of tissue in the economy. These primary food elements are principally water, mineral salts (inorganic and ash residue), proteids, or albumin, fat, and carbohydrates. Water. — Water plays by far the principal role in the composition of the body. The tissues of the body contain from 66 to 70 per cent, of water in the newborn infant and. child, as compared with 64 per cent, in the adult. It exists in this high percentage in most of the organs of the body, with the exception of the bones, cartilage, teeth, and fatty tissue. The remaining organs, if these be excluded, will contain 78 per cent, of water. Water is not only essential to the adult body, but is a very important element of nutrition in in- fants. We see this exemplified in disease, especially when the drain on the system is great and the loss of fluids of the body is consider- able, as in cholera infantum, or in intestinal disease, acute and chronic. Infants show the drain of water from the economy very rapidly, and our treatment in disease is directed in a great many instances to supplying the loss of water caused by the diseased con- dition. The circulation of the blood and lymph depends on the pres- ence of a fixed percentage of water; in the former case 78 per cent., in the latter 96 per cent, of these tissues is composed of water. Di- gestion, both in the adult and the child, must have for its successful completion a certain amount of water element. Muscular and nerve force are greatly dependent on water and are regulated by it. The body excretes water through the urine, the fseces, the lungs, the skin, and the amount excreted varies widely, not only in the adult, but in the infaut and child. It is not our aim here to enter into any specific details of the role played by water in the economy, but from what has been said it can be seen that inasmuch as fully 86 per cent, of the breast-fed infant's food consists of water, nature has put great store by this element of foodstuff which is taken into the infant's body daily. Moreover, water given in disease will sometimes maintain life, but it cannot maintain the proper nutrition of the body without the PEINCIPLES UNDEEL¥ING PBOCESSES OF NUTRITION. 83 addition of other elements of food. This is seen in the treatment of gastro-enteritis. We may tide over a critical period in the disease by the administration of water exclusively, without endangering life through starvation. During this period, however, the nitrogenous waste of the body is not replaced by any equivalent article of food, and though we may continue on a water diet for a little while, it becomes imperative after a time to add other substances to the food. Mineral Salts. — Mineral salts exist in most of the tissues of the body and in all organized tissue which, when burnt, leaves an ash residue. Sodium, potassium, lime, magnesium, and phosphorus, with a trace of iron, are the principal mineral substances found in the body. Just as water is necessary to the maintenance of the nutrition of the body, so are the mineral salts. The actual growth of the child in the first six months amounts to 150 to 300 grammes; in the fol- lowing six months, 100 to 200 grammes per week. In the second year the body-weight is increased by 50 to 100 grammes per week, and from this time on the increase declines. The skeleton in the first year increases fully 2.2 pounds, or one kilo, in weight, and the earthy phosphates being an important element in the composition of the bones, 3.5 grammes of phosphate of calcium are used every week during the first year by the skeleton. This great demand of the skeleton for lime salts is met by the food of the infant — the milk — much better and in a more assimi- lable state than by any food taken by the adult subject. The muscles also need a certain amount of lime salts, and a dearth of mineral salts becomes evident much more quickly in the infant and child than it does in the adult. We see this exemplified in artificially fed infants, whose food (cows' milk) is not as well assimilated as is the mother's milk by the naturally fed infant. Whereas 800 c.c. of mother's milk contain 1.2 grammes of potassium phosphate, 0.2 grammes of lime phosphate, 0.6 grammes of sodium chlorid, and 2.5 milligrammes of iron, and these are completely assimilated by the infant, the same salts in cows' milk are excreted to a great extent by the intestine (Bunge), and for this reason, in part, rachitis and disturbances of nutrition of the bones are very common in artificially fed infants. Proteids. — ISText to water, according to Munk, the most important constituents of the body are the proteids ; they make up 10 per cent. of the tissues. The proteids in the food not only replace the general nitrogenous loss of cell tissue in the body, but with other substances, the so-called proteid-saving elements of the food, such as fat, add to the general nitrogenous store in the body. ISTitrogenous cell waste can be replaced only by the proteids of the food. Growth of body is accomplished by the proper supply of albumin in the food. Other 84 ' NUTBITIOX AND IN FAN I FEEDING. substances, such as fat. added to the albuminous substances of the food may replace nitrogenous waste in the body; increase of weight or growth can be accomplished only by the proteid elements of the food. The bone tissue, cartilage, tendon, connective tissue, need pro- teids also, as has been stated above, to replace the waste and accom- ]3lish the growth of these tissues. The breast-fed infant obtains in its food a casein and also, in small quantities, lactalbumin. From these the body forms not only the nitrogenous cell elements, but mucin, chondrin, glutin, elastin, keratin, which are derivatives of albumin, and whose mode of formation is still obscure (Munk). Fats. — Animal fats are composed of varying proportions of olein, palmitin, and stearin. Their presence in the body varies, within certain limits, from 9 to 23 per cent, of the body-weight. Fat is found in the body in the form of fat-deposits. It is deposited under- neath the skin, in the muscle, in the nerve tissue, around the various organs of the body. It plays an important role in the maintenance of the warmth of the body and exerts a non-conducting role, pre- venting radiation. As a food it cannot replace the proteids. Fat combined with proteid substances in the food may, however, act as a nitrogenous-saving substance. Thus, in muscular work the body needs a great amount of fat. If combined with the proteidb, nitrog- enous waste is saved and fat is burnt up in doing the muscular work, and it may even, if taken in sufficient quantities, cause an accumu- lation of fat in the body. To cause gTowth in nitrogenous tissue, however, the presence of a sufficient amount of proteid in the food is absolutely necessary. Thus, while fat and albumin may replace waste caused by muscular action, both in the fatty and nitrogenous tissues of the body, fat cannot add to the nitrogenous gi'owth of cell tissue. The infant and child obtain the fatty elements of the food in the milk. Whereas 97.5 per cent, of the fat in mother's milk is assimi- lated, only 93.5 per cent, of the fat of the cows' milk is assimilated by the infant. The artificially fed infant, therefore, is deprived of an important food element to the extent indicated, and in many cases assimilation of fats in the artificially fed infant is even much more imperfect in practice than is indicated by the percentage named. For in some infants, if the fat in the cows' milk is increased beyond a certain percentage, symptoms of intestinal indigestion manifest themselves in a so-calk^d fat diarrhoea. In other infants the difficul- ties of fat assimilation are shown in inordinate constipation and anaemia, especially if the percentage of fat in the food is in excess of 4 per cent. Such infants must be fed on a limited amount of fat because of the difficulty of assimilation of fat of cows' milk. METABOLISM IN THE NUBSING INFANT. 85 Carbohydrates. — According to Munk, carbohydrates exist in various tissues of the body, most abundantly in the liver, in the form of glycogen and grape sugar ; in the human milk, in the form of milk sugar, 3^ to 9 per cent., in the muscles, in the form of glycogen, 0.3 to 0.9 per cent., with some grape sugar. The blood and lymph con- tain a small quantity of grape sugar (0.1-0.15 per cent.). We find glycogen in all growing tissues, and the formation of glycogen seems to be a function of the young cell. The infant obtains its carbohydrates for the most part from the milk, where they exist in the form of milk sugar. Milk sugar as contained both in human and in cows' milk is assimilated by the infant completely, so that in this respect the infant is not deprived in artificial feeding of any food element. Carbohydrates play much the same role in the economy as do the fats in saving nitrogenous waste. Whereas we can make up to a certain extent nitrogenous waste by the addition of fats and carbohydrates to the food, the nitrogenous substances of the body themselves can be reproduced only by nitrogenous proteid substances. It is self-evident, therefore, that in infant-feeding, though we may produce fat by carbohydrates, saving to a certain extent nitrogenous waste, we cannot do this for any leng-th of time without producing an actual proteid starvation unless we supply with the carbohydrates and the fat a certain amount of proteids. We see this well illustrated in substitute infant-feeding in cases of difficult proteid digestion. We can aid digestion of the proteids by the addition of carbohydrates. We can even cause the formation and deposit of fat to a gTeat extent by the addition to the food of car- bohydrates. We can save nitrogenous cell waste by the addition of carbohydrates to the food. If we continue this mode of feeding for any length of time we can see clinically the effects of the dearth of proteids on the economy. The infants after a period of time do not increase in weight, the tissues of the body suffer in nutrition, and anaemia appears. We then must supply with the carbohydrates an increased amount of proteids. METABOLISM IN THE NURSING INFANT. The principles of metabolism and nutrition which have been established in the adult apply in a general way to the nursing infant. In the adult the food supplies the waste and maintains body-heat and energy, but in the infant it must also furnish, in addition to these, the material for body-growth. The main physiological character- istic, therefore, of infancy and childhood is that it is a period of growth, and the younger the infant the gTeater the growth. 86 ' NUTRITION AND INFANT FEEDING. Milk, the food of the breast-fed infant, contains all the necessary food elements to maintain nutrition, produce energy, warmth, and to aid in cell-growth. In considering metabolic processes in the infant we express the energy and warmth-producing equivalents of the food introduced into the body by the term calories. A calorie is the heat produced by raising 1 kilogi'am of water, 1° C, and is the unit of heat. In the infant there is a deficit, as in the adult, of 10 per cent, between the raw calories (food) introduced into the body and the actual number of calories produced. In other words, all the food is not absorbed. We do not know as yet how much to allow in estimating the number of caloric equivalents for the excreta, urea, carbonic-acid gas, and water. With the above defects yet to be eluci- dated by further investigations, we can present the following facts : A breast-fed infant, three months of age, weighs 5 kilos, takes 800 c.c. of breast milk in the twenty-four hours, and increases 0.25 to 0.35 grammes a day. A litre of human milk contains: casein 16 grammes, fat 35 grammes, milk sugar 65 grammes. The adult, on the other hand, takes daily 1.7 of proteids, 0.85 of fat, 7.5 of carbohydrates per kilo of body-weight. The nursing infant, there- fore, takes per kilo of body-weight twice as much proteids and three times as much fat as the adult, the milk sugar being converted into fat values. In the adult the ratio of proteid to other food substances is as 1 to 5 in the food ; whereas in the infant taking human milk the ratio is as 1 to 6, and with cows' milk, 1 to 3. According to Rubner, the value of 1 gramme of proteid sub- stance of the milk is 4.4 calories, 1 gramme of milk sugar, 3.9 calor- ies, and 1 gramme of fat, 9.2 calories. One litre of human milk is equal to 650 calories, and 1 litre of cows' milk to 700 calories. An infant three months of age, therefore, drinking 800 grammes of breast milk would take in 500 calories daily, and if it weighed 5 kilogrammes it would be taking 100 calories per kilogramme of body- weight a day. Bonnoit found by experiment that an infant pro- duced 80 calories per kilogramme of body-weight in twenty-four hours, and if we deduct 10 per cent, from the raw caloric equivalent of the food we would have almost as many calories introduced into the body as the body produced. The need of 100 calories per kilogramme remains constant during the first year of life, diminishes slightly in the second year, with the following exceptions : During the first ten days the infant uses up only 40 to 50 calories, and the increase of weight is accomplished mostly by the watery substances of the food. Rulmer and Heubner found that of the 100 calories used up by the infant, 20 were util- ized to supply body-waste and 80 were burned up to produce heat. Therefore the necessary hcat-])ro(liu'ing calories are much higher in METABOLISM IN TEE NUESING INFANT. 87 the infant as compared to the adult, as are also the number of calories necessary to increase body-weight. This greater need on the part of the infant is explained by Eubner by the fact that in proportion to their body-weight, infants present a greater surface area than do adults, and therefore lose much more heat in a given time than adults. Therefore the extent of loss of heat is dependent on the extent of surface exposed, and allowing for this and not calculating the needs of the organism by weight, we find that both the child and the adult need the same number of calories. The following shows the number of calories produced by the various constituents of the food in the adult and in the infant. Of 100 calories in the food taken in by the adult, proteids pro- duce 19, fats 30, carbohydrates 51. Of 100 calories in the milk taken by the infant, proteids produce 18, fat 53, carbohydrates 29. In the infant, therefore, the fat is the chief heat producer. It is also nitrogen-saving, inasmuch as the latter is used for cell-growth. After the first year growth is not so active and less fat is needed, and this constituent is replaced by carbohydrates. The following table illustrates this : Weight- Age, kilogrammes. 3 davs 3.0 6 "■ 3.2 4 months 6.0 Ij years 9.0 2i " " 10.0 11 " 23.4 Adult 70.0 Mineral Salts. — The infant in its milk takes more mineral salts into the body than the adult, kilo for kilo of body-weight. They are utilized in the growth of the infant. Excreta. — Much is to be learned as to how much should be allowed to the excreta in calculating the necessary calories used up by the infant organism. By the excreta we mean urea, water, and carbonic acid gas. Rubner and Heubner have shown that an infant in the first six months excretes less urea than the adult. In the second half year the infant excretes more urea than the adult, and this increases until the tenth year. In proportion to its weight the infant takes more nitrogenous substance into the body than it excretes in the form of urea. During the first six months, the growth of the infant being most active, this is markedly so, and the nitrogen is retained to a greater extent in the system during the first six months of infancy. Michael has found that the nitrogen excreted in the fseces and urine and the proteids of the food retained in the body were one-fourth of the whole increase of weio-ht in the newborn infant. Proteids. Fats. Carbohydrates. 2.4 2.8 2.9 3.7 4.3 4.4 3.8 4.5 4.6 4.4 4.0 8.9 3.6 2.7 15.0 2.8 2.0 11.4 1.7 0.85 7.5 88 NUTRITION AND INFANT FEEDING. Water, — Kubner and Heubuer found that of 530 grammes of water taken by the ten-weeks-old child into the body, 505.5 grammes were excreted, and of this quantity more than half was excreted in the form of urine. Carbonic Acid Gas (COo). — Voit, Pettenkofer, Forster, and Mensi have shown that from birth to the tenth year of life the child excretes one and a half to two and a half times as much carbonic acid gas as the adult, and this is practically furnished by the fats. Eubner, Heubner, and Bendix, however, have shown that a breast-fed infant weighing 5 kilos (11 pounds) exhales per square metre of hody- surface less CO2 than the adult. Munk thinks that the proteids are utilized in the organism to form carbonic acid gas. The principal facts, therefore, adduced in regard to the breast-fed infant in connection with metabolism are that the infant in the course of the first six months needs for the production of warmth, potential energy, and increase of weight 100 calories per kilo of body-weight. Eighty of these calories are util- ized for warmth and energy and 20 for increase of cell-growth. If, therefore, an infant takes only 80 calories into its body, its weight will remain stationary. If it takes less, it will have to utilize its own tissues in order to live, and emaciation will result. Metabolism in the Bottle-fed Infant. — What has been said of the nursling at the breast applies in a general way to the bottle-fed infant, with the exception that Rubner and Heubner have shown that an artificially fed infant needs 120 calories instead of 100 per kilo of body-weight to maintain warmth, energy, and increase in weight. They explain the need of the additional 20 calories taken into its body by the bottle-fed infant by the necessity of extra work on the part of the intestine in digesting cows' milk. It is of interest that the infant, notwithstanding the fact that cows' milk is so entirely different in its composition from human milk, can utilize this food in the production of caloric energy. The artificially fed infant must transform a proteid foreign to the body to one of a nature similar to that of human milk. The utilization by the infant of cows' milk is not perfect, for we have the following differences between the breast- and bottle-fed infant, which are apparent on the surface. The increase of weight is irregular in the bottle-fed infant as compared to the regular increase in the breast-fed infant. The daily fluctuations of temperature in the bottle-fed infant are irregular as compared to the fluctuations in the breast-fed infant. The bottle- fed infant, as a rule, is an ansemic child; the breast-fed infant the contrary. The bottle-fed infant may become rachitic even from birth. It is thought to be more susceptible to infection, less resistant to the inroads of disease. It is deprived of the enzymes and alexins IRE FOOD OF TEE INFANT. ' 89 present in the imman milk. Therefore the metabolic processes in the infant fed upon the bottle and those on the breast must necessarily diifer, and in this respect our scientific data are still incomplete. Human milk cannot be completely replaced bv any form of animal milk. THE FOOD OF THE INFANT. The study of infant feeding naturally divides itself into the con- sideration of the infants fed at the breast by the natural method and those fed with some substitute for the breast, such as cows' milk or infant foods, or dilutions of the same. Human-breast Milk. — Colostrum. — From the third or fourth month of pregnancy the human breast begins to show signs of func- tionating and secretes a yellowish-white, thick, sticky fluid called colostrum. As the period of pregnancy approaches the seventh month the secretion of colostrum becomes more active, and its phys- ical properties are those of a thin, grayish-yellow fluid which exudes from the breast-nipple under slight pressure. Physical Properties.- — Colostrum differs from the normal milk secretion in being of a light-yellowish or grayish-yellow color. It is markedly alkaline in reaction. It is rich in fats and proteids, poor in casein, in that the albumin exists in relatively gTeater quantity. The composition of the colostrum varies from time to time until the period approaches when it is replaced gradually by the normal milk secretion. This occurs about twelve days after birth in a normally functionating breast. At this time colostrum, as such, should have disappeared (Plate V.). The average composition of colostrum, according to Camerer and Soldner, is as follows : Water 86.70 Proteids 3.07 Fat 3.34 Milk sugar 5.27 Ash 0.40 It has a speciflc gravity of 1.040 to 1.060. Microscopically colos- trum, in addition to fat-globules, leucocytes, pavement epithelium, granules of casein and phosphates, contains the so-called colostrum corpuscles and the crescent-shaped bodies of Lourie. The fat-globules have similar physical properties to the fat-globules of the milk, and, as in human milk, they are found associated with the crescent-shaped bodies of Lourie, to be described (Fig. 14). The colostrum corpuscle is a spherical body four or five times larger than the milk-globule, and measuring 13 /a to 40 /^ in diameter. It contains fat in the granular and globular state. The colostrum 90 XUTFITIOX AXD INFANT FEEDING. corpuscle is looked iij)oii by some as a degenerated leucocyte (Czerny). The coloring-matter of. colostrum is contained in the colostruna cor- puscle. These colostrum corpuscles are the distinguishing feature of colostrum as compared to milk, and so long as they are present in the milk to any appreciable extent it cannot be considered as fit, in every sense, for continued infant-feeding. If lactation^ for one reason or another, is interrupted, the colostrum corpuscles reappear in the milk. When lactation is again established these corpuscles should disappear from the secretion. Should colostrum persist for Fig. 14. Colostrum corpuscles and crescents of Lourie. (Marfan.) too long a period in the breast, the infant, as a rule, does not thrive. It can thus be seen that from the twelfth day or thereabout after delivery of the infant, the milk which takes the place of the so-called colostrum should contain either no colostrum corpuscles at all or in a vanishing quantity. In addition to the colostrum corpuscle, colostrum contains an interesting crescent-shaped body, described in connection with human milk, which is seen adherent to the external border of the fat-globule. Some of these colostrum crescents may present an intimation of a nucleus. They have been described by Lourie, and can be seen by extracting the fat from the colostnini and staining with methylene blue or thionine. Milk.' — Milk may appear in the breasts the fifth, sixth or tenth day after delivery. In exceptiDiial (-a.-^es I have seen the milk de- layed as late as the third week; or it may diminish after having ai)]>eared and then increase after a few weeks. Our knowledge of the cheiiiisiry of liniii;iii milk is still incom- TEE FOOD OF THE INFANT. 91 plete and lacking in many essentials which would aid the physician in his work. Older analyses of human-breast milk give the gross amount of proteids, and Hoppe-Seyler suggested that the casein of human milk, or for that matter cows' milk, should be determined aside from the total quantity of proteids. Therefore the older analyses which deal with the total amount of proteids under the heading of casein are not as useful to us to-day as the more modern analyses which distinguish between the casein and other proteids in the milk. The great importance of this point will become more apparent when we study the composition of cows' milk and attempt to modify it to conform to the theoretical composition of human milk. C omposition. — The composition of breast milk varies not only in different women and the same woman at various periods of lactation, but in the same woman at different times of the day. The result is that various analyses differ with each other in a sense, but at the same time agree within certain limits. The student can appreciate these discrepancies by studying analyses of milk given by a number of authors. Whereas there are differences in proteids, these differences have certain limitations. Konig's analysis, as modified by White and Ladd gives the fol- lowing composition of human milk and cows' milk : Cow. Human. Caseinogen 2.88 0.59 Whey proteids 0.53 1.25 3^ T84 The casein in cows' milk comprises five-sixths of the proteids; in human milk, two-sixths of the total amount. We should bear this important fact in mind in reading the following tables compiled from Camerer and Soldner, showing the composition of human milk : Ether ext. Milk- „ „i -j fat. sugar. Proteids. Colostrum 5.0 4.5 3.5 Milk, fifth day 2.3 6.7 1.6 Milk, ninth day 3.4 6.7 1.4 Milk, first month 2.6 7.3 1.1 Second and third months 2.4 to 1.9 7.5 0.9 Backhaus gives the following table of average composition (in 100 parts) of human milk: Water .-88.20 Proteids .... . | 0-75 casein. 1 1.00 albumin (whey proteids). Fat 3.50 Sugar 6.20 Ash ... 0.25 On comparing these figures with those of Konig, White, and Sugar. Fat. 4.20- 7.60 0.70-9.00 5.90- 7.80 2.70-4.60 5.35- 7.95 1.31-7.61 5.20-10.90 1.60-9.46 92 . NUTBITION AND INFANT FEEDING. Ladd, it Avill be seen that White and Ladd include all the proteids exclusive of casein under the name of whey proteids. The whey proteids are principally lactalbumin and lactoglobulin. The above analyses tend to show that one examination of any breast milk gives but incomplete information as to its constant quali- ties; it will only tell us the composition of that one specimen of milk. In a general way we can speak of averages, and these we shall try to elucidate under the various headings. In order to appre- ciate the wide variations in the percentages of the proteids, sugar, and fats present at the different periods of lactation, it is further necessary to study the following analyses of leading authorities : Proteids. Pfeiffer 1.049-3.04 Johanessen and Wang . . 0.900-1.30 V. and J. Adiiance .... 0.230-2.60 Schlossmann 0.560-3.40 Compared with human milk, the following table of animal milk is instructive (Konig) : Human. Cow. Goat. Ass. Water 89.6 87.7 87.3 89.6 Casein 1.4 3.0 3.0 0.7 Albumin 0.6 0.4 0.5 16 Fat 3.1 3.7 3.9 1.6 Sugar 5.0 4.5 4.4 6.0 Ash 0.3 0.7 0.8 0.5 Proteids. — There are four albuminous bodies or proteids in hu- man milk. The most important is the casein, which is in a class by itself. The other group of proteid bodies includes the soluble albu- mins or whey proteids (lactalbumin), globulin, and opalisin. The casein of human milk comprises two-sixths of the total amount of proteids ; whereas in cows' milk it comprises five-sixths of the pro- teids. This is an exceedingly important distinction between the two milks. The casein of human milk is, according to reaction, a differ- ent casein from that of the milk of the lower animals. Szontagh and Wrobelewski contend that whereas the casein of human milk does not yield pseudonuclein on pepsin digestion, it is not a nucleo-albumin, and hence differs widely from the casein of cows' milk. Human milk, as stated, is not only poorer in casein than cows' milk, but the casein is less in proportionate combination with the remaining pro- teids and lactalbumin. This in part explains the more flocculent nature of the casein coagulum in human milk. The casein of human milk is derived from the protoplasm of the cells of the mammary gland. It is set free from the cells of the mammary gland in which the fat is formed. In addition to the proteids human milk contains lecithin, 0.58 per cent. (Burrow) ; iron, 3.52 to 7.21 mg. to the litre (Jolles and Friedjung). PLATE V FIG. 1 FIG. 3 FIG. 4 Microscopic Appearance of Woman's Milk. Fig. 1, — Normal milk, showing the preponderance of medium-sized fat-globules. Fig. 2. — Poor milk. Preponderance of large fat-globules and a paucity of fat. Fig. 3.— Poor milk, a paucity of fat and an almost granular state of the fat- globules. Fig. 4.— Colostrum of later pregnancy. Figs. 1, 2 and 3 from Fleischman. Fig. 4 from Marfan. TRE FOOD OF TEE INFANT. 93 Fats. — The fat of human milk is contained in the so-called fat- globules. On placing a drop of human milk under the microscope, the fat-globule is seen as a highly refracting, spherical body. The globule varies in measurement from 0.001 mm. to 0.02 mm. in diameter (Plate V.), as compared to 0.0016 to 0.01 mm. the size of the fat-globule of cows' milk. It is therefore larger than that of cows' milk. The fat of human milk is a yellowish-white mass, when separated resembling butter, with the specific gravity of 0.966. It melts at 34° C, and is solid at 20.2° C. It contains butyric, caproic, capric, myristic, palmitic, stearic, and oleic acids. It is j)oor in volatile fatty acids. The non-volatile fatty acids consist of fully 50 per cent, oleic acid, while the palmitic and myristic acids exist in greater quantity than the stearic acid. In addition to the casein and fat we have the water, 89.6 per cent. Moreover, human milk contains nucleon, 0.124 per cent.; lecithin, 0.58 per cent. ; iron, 3.52 to 7.21 mg. to the litre. If milk is stained with carbol thionine or methylene blue there are seen, as in the colostrum, crescent-shaped bodies which are adher- ent to the outer border of the fat-globule. They are not nucleolar or remains of nuclei, but are portions of the mammary epithelium which have adhered to the milk-globule at the time of its expulsion from the cell (Lourie). Mineral Salts in the Milk. — Human milk contains a number of salts, among which are calcium phosphates, potassium, magnesium, iron, alum, calcium and sodium chlorides, sodium carbonate, traces of fluorine and silicium. The most important of these salts are the tribasic calcium phosphates, part of which are held in solution, an- other part exists in a colloid state, the remaining portion being in suspension, and is seen under the microscope as minute dust-like particles in the milk, /4ooo mm. in diameter (Duclaux). The tri- basic calcium phosphate is insoluble in water, but in the milk is held in solution by the presence of the alkaline citrates. Salts in the milk. Human milk. Cows' milk (Soldner). Natrium chloride 1.35 0.962 Calcium chloride 0.70 0.870 Calcium phosphate 2.50 1.477 Natrium phosphate 0.40 Magnesium phosphate 0.50 0.336 Carbonate of soda Fluorite calcium trace. Potassium citrate 0.495 Magnesium citrate 0.367 Calcium citmte 2.133 Iron phosphate 0.01 Reaction. — The reaction of human milk depends on the presence of the contained salts. It is amphoteric, alkaline to litmus and acid 94 NUTRITION AND INFANT FEEDING. to plieuolphthalin. The actual quantity of sodium and potassium varies, the sodium being more abundant than the potassium at the beginning of lactation (De Lange). In other words, the reaction of human milk is amphoteric. Specific Gravity. — The specific gravity ranges from 1.028 to 1.034, being lower in poorly nourished women. Bacteria in the Breast Milk. — A woman in good health will show bacteria in the breast milk. They are found in the galactiferous ducts of the breast nipple. After expressing the first drops of milk and flushing the ducts, it is found that the after-coming milk is free from bacteria. The bacteria found in the breast milk belong prin- cipally to the Staphylococcus albus class but the Staphylococcus pyogenes aureus and some forms of Streptococcus have also been found by Kohn and ISTeuman. These bacteria have no ill-effect on the infant, and the attempt to trace dj^speptic disturbances to them is not supported by clinical facts. Enzymes and Alexins of Human Milk. — According to the latest in- vestigations, the proteids of human milk contain certain derivatives of the living cell. I^ot much is known about them as yet, but their presence proves beyond a doubt that human milk is a substance essentially different from the milk of other animals. Moreover, their presence in the milk and the presence of other substances in animal milk proves that all milk is a living product and not a dead substance. The enzymes are the soluble ferments in human milk, the most important of which is the so-called amylase, first described by Bechamp and subsequentl}^ by Moro. It is capable of converting starch into sugar in the same manner as does the secretion of the parotid gland ; in other words, it exerts a diastatic action on starch. Amylase is not found either in cows' or sheep's milk. It is destroyed by heat, and human milk heated above a certain temperature loses its amylolytic properties. This ferment is present, though to a much less degree, in dogs' and asses' milk. It is supposed to be derived from and is a product of the glandular tissue of the mammary gland, and is not primarily present in the blood. The reason of its presence in human milk is not quite understood, inasmuch as the infant reared exclusively on breast milk does not receive any starchy sub- stances in its food. Marfan isolated another ferment in the milk, called lipase, which is capable of splitting monobutyrin into butyric acid and glycerin. This lipase is present to a slight extent in cows' milk. Human milk contains also a ferment capable of Sjilitting salol into phenol and salic,ylic acid, and a substance capable of coagulating fibrin, inasmuch as a minnto (inantitv of hnman milk added to hvdrocele THE FOOD OF THE INFANT. 95 1 fluid causes its immediate coagulation (Moro and Hamburger). This substance is not present in cows' or goats' milk. Moreover, human milk, as also the milk of animals, possesses certain vital specific properties. Bordet, Moro, and others have shown that if human milk, cows', goats' or any other animal milk be injected into the peritoneal cavity of an animal, the serum of that animal in very high dilutions is capable of coagulating the milk of the animal whose milk was injected into its body. Human milk contains so-called alexins — that is, bactericidal and globulicidal substances — and Moro has shown that the serum of the blood of the breast-fed infant is more bactericidal than the serum of the blood of the infant fed upon cows' milk. Amount of Breast Milk Consumed by the Infant in Twenty-four Hours. — Camerer has collated and analyzed the results obtained by Ahlfeld, Pfeiifer, Weigelin, and Hahner as to the quantity of breast milk taken daily by an infant. These figures were obtained by weighing an infant from the earliest period before and after nursing. Camerer gives us the following table, the amounts being indicated in cubic centimetres : Day. 1st. ^ 3d 4th. oth. 6th, 7th. 10th. 14th. 30 130 240 290 330 365 400 450 500 Amount of Milk Taken. Middle 2d week. 4th week. 7th week. 10th week. 20th week Minimum. . . 210 380 520 600 700 Medium ... 440 580 770 800 900 Maximum . . .540 810 1040 1170 1150 The amount of breast milk consumed by the infant at each nurs- ing must vary with the frequency with which the infant is placed at the breast. If the infant is placed at the breast five times in twenty- four hours the mean quantity of milk taken at each feeding is quite large as is seen by consulting Ahlfeld's figures. Thus an infant at the breast 1 month old consumes • . . . . 104 ccm. 2 months 3 4 5 6 7 163 173 212 212 214 217 These figures are within the limits of stomach capacities given by Pfaundler and in excess of those of Fleischman, Holt, and Eotch. If the infant nurses at more frequent intervals than Ahlfeld's baby. 96 NUTBITION AND INFANT FEEDING. the quantity of milk ingested at each nursing will be less than the above figures. It is noteworthy that on the first day of life the infant observed by Camerer nursed three times, and seven times in twenty-four hours from the second to the fourteenth day. Each nursing occupied a mean of about twenty to twenty-five minutes. These data are of value in the artificial feeding of infants. The quantity of milk secreted by the human breast may increase up to the ninth week of lactation, and remain stationary from this time to the period of weaning ; or the amount of milk secreted daily may increase from the earliest period to that of weaning, when it is at its height (Czerny). Changes in the Composition of Milk, — Daily Changes. — ^Milk may vary in composition in the course of twenty-four hours in the same nurse, both in the total amount of proteids and fats, to the extent of 1 per cent, or more. Schlichter has found that the changes occur at various times in the day. The composition of the milk in the nursing woman at different hours of the day may be seen in the following table by Schlichter : Nurse A. Casein. Fat. Proteids. Sugar. Morning 1.10 0.80 1.69 7.11 Noon 1.10 1.88 2.16 6.92 Night .... 3.16 1.95 6.83 Nurse B. Morning 0.55 3.77 1.19 5.37 Noon 0.77 3.90 1.91 6.15 Night 0.71 3.73 1.26 6.19 Nurse C. Morning 0.55 3.61 0.19 6.18 Noon 0.83 4.21 1.08 6.24 Night 0.41 3.60 1.16 6.47 Gregor has shown that the variation in the color and consistence of the stools of infants can be accounted for by the variation in the gross amount of fats in human milk at different times of the day and from day to day. Influence of Foods on Breast Milk.^ — A diet rich in nitrogenous substances increases the quantity of the milk and the percentage of fats and proteids. A diet rich in fat may increase the percentage of fat in the milk. On the other hand, it is not always possible to increase the casein in the milk l)y means of diet if the milk is poor in this constituent (Konig). Starvation lessens the quantity of the milk and the proportion of the casein to the other proteid bodies in the milk in the same manner as does a poor dietary (Decaisne). If we enlarge the diet we improve the milk. Beer and malt liquors increase the quantity of the milk and the percentage of its fat-con- stituents (Konig). TRE FOOD OF THE INFANT. 97 In trying to improve tlie milk of the human breast we should not resort to too much experimentation, for a good milk will some- times be made unfit for the infant by placing the nurse or the mother on a diet to which she is unaccustomed. On the other hand, I have seen the milk retain its colostrum characteristics through the fact that the mother did not follow out the dietary to which she was accustomed previous to delivery and did not take her usual exer- cise. Women accustomed to a wholesome, moderate dietary will, if fed liberally with fats and carbohydrates, secrete a milk rich in fats and poor in proteids ; such a milk will at once disagree with the infant (Konig"). If a nurse has been on an insufficient diet, the diet should be increased in a general way. She should have a moderate allowance of meat, partake sparingly or not at all of tea, coffee or beer, and have sufficient exercise. If with these changed conditions the milk does not improve both in quantity or quality we should not hesitate to replace the nurse by another ; or if the mother is nursing the infant, to aid the breast with artificial food. This is preferable if the mother is nursing to taking the infant away from the breast. Drugs and Foreign Substances in the Milk. — Iodine and salicylic acid may pass from the blood into the milk of the human breast. Iodine may even cause iodism in the nursing infant when the nurse is taking any appreciable amount of iodide of potassium (Koplik). Iodine is eliminated in combination with the casein of the milk. As to the appearance of other substances, such as drugs, in the human milk if taken in medicinal doses by the mother or nurse much is to be learned, for very little is actually known. Opium is not eliminated if taken in ordinary doses, though atro- pine may, if taken by the nurse, be eliminated in the milk and cause dilatation of the pupil in the infant. Alcohol taken in limited amounts, as is customary at the table, is not found as alcohol in breast milk ; but if larger quantities are taken, from two-tenths to six-tenths of 1 per cent, of alcohol may be found in the milk. Passage of Bacteria of the Infectious Diseases Into the Breast Milk. — The extent to which bacteria of the various diseases may pass into the milk of the infected woman is still a matter of question. Under the heading, Contra-indications Against jN'ursing the Infant, this matter has been discussed in part. It has been proved that the toxins, antitoxins, and agglutinins of the infectious diseases, such as typhoid fever and diphtheria, may pass into the milk of the nursing woman suffering from these diseases. The bacillary infection of the milk, however, is quite a different matter, concerning which much is to be learned. In local tuberculous infection of the mammae it can well be understood that bacilli may gain direct access to the milk 7 98 - NUTRITION AND INFANT FEEDING. through infections foci of the galactiferons dncts. It is still qnestioii- able whether milk from a gland free from local foci, thongh coming from a woman affected with tuberculosis, mav contain tubercle bacilli. In typhoid fever and diphtheria the bacilli may appear in the milk of a woman suffering from severe systemic invasion of the bacilli of either of these diseases, but, as a rule, this is not the case. In pneu- monia we can scarcely apply to the human subject the results obtained in the lower animals, for in the former the disease is rarely an in- vasion of the blood to the extent seen in the lower animals. Thus, cases such as those published by Bozzolo, in which pneumococci were found in the milk of a woman suffering from severe pneumonia and endocarditis, are exceptional. Toxins, Antitoxins, and Agglutinins. — Tetanus toxins and antitoxins may pass into breast milk, and in certain animals, such as mice, this milk may confer immunity on the nursling (Ehrlich, Brieger). Diphtheria toxin and antitoxin may be eliminated in the breast milk. Ehrlich and Wassermann found that goats immunized against diphtheria could confer this immunity through the milk. Roux and Martin confirmed this observation in the cow. It has also been proved that the breast milk of women convalescent from typhoid fever pos- sessed agglutinating properties on the Eberth bacillus similar to that of the blood (Achard, Bensaude), and that this agglutinating prop- erty could be transferred to the blood of the infant nursing this milk (Landouzy, Griffon, and Casteigne). In passing from the blood into the breast milk the agglutinating substance is much weakened, like- wise more so when transferred from the milk to the blood of the nursing infant. The above facts would seem to indicate that the question as to whether the breast milk of a mother or nurse suffering from any disease is fit for the nursling is not an indifferent one. The passage of toxins, antitoxins, and agglutinins into the milk should, with reser- vations mentioned elsewhere, forbid the use of any breast milk coming from a mother or nurse the victim of active acute or chronic disease. Menstruation, — The effect of the function of menstruation on breast milk is still a matter of discussion. Rotch has found some variations at this period, not only in the percentage of the fat, but in the proteids, from that which existed before menstruation. Other authors think the greatest variations will be found in the fats (Ben- dix). I am inclined, however, from my own experience to believe that variations in breast milk during menstruation are exceptional, for the great majority of infants do not show at this time any dis- turbances of the functions of the gut. An exception to this may prob- ably be the first menstruation of lactation. Infants at this time may have green movements and slight colicky ]iains which persist until THE FOOD OF TEE INFANT. 99 menstruation is established in the mother, when all functional disturb- ances of the gut disappear and the children do not seem to be dis- turbed by the recurrence of the function. In fact, if we study the tables of the analyses made before and during menstruation and sub- sequent to this period we shall see that the variations are no greater than those which occur from day to day when menstruation is absent. Pregnancy. — The question is frequently asked, '' Has pregnancy any effect on the quality or quantity of the milk, and may an infant nurse the breast of a pregnant woman ? " Having conducted a very large dispensary class in diseases of infancy and childhood for fifteen years, I not infrequently saw infants nursed at the breast of pregnant mothers. Such infants did not seem to suffer ; some of them, in fact, being beautiful babies. Examination of these mothers showed them to be pregnant from four to; six months. The milk secretion was not markedly changed in amount. This corresponds to what has been established by Poirier, who found that of 100 pregnant mothers who nursed their infants, 72 infants showed no change in their general well-being, while 20 showed disturbances necessitating immediate weaning. Eight infants showed slight intes- tinal disturbances. The question may be justly asked whether a; like proportion of cases might not be met with necessitating weaiiing among mothers not pregnant and nursing their babies. Pregnancy may diminish the amount of milk, but in the majority of cases no change occurs. It is just, however, unless extraordinary indications to the contrary exist, that a mother should not be asked to nurse her baby while pregnant with another. Such an infant should be weaned from the breast. Methods of Analysis of Human Milk. — In the section treating of the examination of breast milk it was shown that with experience it is possible to decide in a general way as to the quality of the milk without chemical analysis. Emergencies, however, arise which may necessitate more careful examination of the milk in order to account for some disturbing symptom in the infant. After thriving for a few weeks the infant may, without apparent cause, cease to gain in weight, or the movements may be abnormal, or there may be colic. Under these conditions it is certainly an advantage to be able to de- termine the composition of the milk, since a chemist is not always at hand. Conrad, a physician in Bern, has devised some instruments which are easily manipulated and are within the reach of every physician. His article, published in 1880, is still unsurpassed in clearness of detail. The milk to be used in all analyses is that ob- tained in the mid-period of nursing. Specific Gravity. — To ascertain the specific gravity, Conrad re- 100 NUTBITIOX AND IXFANT FEEDING. Fig. M -^^^- ^^- duced the size of Qiievenne's lacto- densimeter so that it could be uti- lized for taking the specific gravity of small quantities of mother's milk (Fig. 16), The specific gravity is taken at 15° C. The scale runs from 1020 to 1050. Fat.^ — Conrad estimated the fat by first calculating the cream layer. This he determined by means of a gTaduated glass cylinder devised by Bouchardat, Quevenne, and Cheva- lier. This cylinder he reduced in size. The method is so unreliable that it is merely mentioned in pass- Of greater reliability is the ]\Iarchand tube, reduced in size by Conrad. The set consists of two of these tubes. Each tube analyzes 5 c.c. of milk (Fig. 15). Five c.c. of milk are poured into the tube, and then 5 c.c. of ether. These are well shaken after a drop of ofiicinal caustic soda solution has been added. Absolute alcohol is then added up to the A mark. The whole is again shaken and placed in water at 35 '^^ to 40" C. for ten or fifteen minutes. The fat separates above, and is read off. A percentage table accompanies the instrument. This instrument is not accurate. There is a variation of from 0.2 to 0.5 per cent, or more. Two analy- ses are made at the same time for the sake of accuracy; hence the two tubes. Lewi's Metliod. — More accurate than Conrad's is the method worked out in mv clinic by Lewi. This is really an adaptation to breast milk of the Babcock sulphuric acid method, as modified l)y Leifman and Beam. The apparatus needed comprises a reduced Babcock bottle, a Conruds lactobutyr- ometer. Conrad's lactoden- simeter. THE FOOD OF THE INFANT. 101 pipette for measuring the milk and acid, and a smaller 1 c.c. pipette accurately divided into cubic ^k (see Figs. ir. 17. 3.93 Fig. 18. Fifi. 19. ^4 £^3 millimetres 18, 19). The pipette is filled to - the meniscus (this represents 2.92 c.c. of mother's milk) and introduced carefully into the body of the bottle, so that the long thin pipette comes down into the body of the bot- tle. The pipette is cleansed, and refilled to the meniscus with chemically pure sul- phuric acid ; the pipette is in- troduced as before. This pre- caution is taken in inserting the pipette so that at this stage no ebullition shall occur in the neck of the bottle, and so invalidate the result. ]^ext, fill the 1 c.c, pipette up to the sixth marking with a mixture of equal parts cf fusel oil and concentrated hydrochloric acid ; add this to the milk and sulphuric acid and fill the bottle with equal parts of sulphuric acid and water. The bottle is placed in an aluminum re- ceiver and adjusted to the centrifuge. The specimens are revolved one and a half to two minutes, and the read- ing is then taken. This method, if carefully carried out, gives very little error, and is practically equal to the Soxhlet quantitative fat estimation. It can be ap- plied to cows' as well as to human milk. The following table shows the error in the various methods as compared with accurate chemical determination: ^0 — J^ Instruments employed in the estimation of fat in milli. Lewi's method. 102 NUTRITION AND INFANT FEEDING. Soxhlet (chemical). Reduced centrifuge. Marchand. Feser. Specimen 1 4.4 per cent. 4.4 per cent. 3.48 per cent. 5.00 per cent. II. . i 2.4 2.3 2.56 2.37 " III. 1 1.1 « 1.1 1.44 " 1.25 IV. 1 3.9 3.8 3.17 3.25 VI. : 4.6 4.7 2.35 3.80 VII. ! 2.3 2.3 3.99 2.20 " A^II. ! 4.4 4.2 " 3.68 4.20 " VIII. , 4.7 " 4.6 3.60 " The Proteids. — To possess clinical value in the determination of the proteids, a method must differentiate between the amount of casein and that of the other proteids, such as lactalbumin and lacto- globulin. This is possible only by careful and exhaustive quanti- tative chemical analyses. The methods at our disposal which are practicable in the physician's office determine only the gross proteids. The gross proteids may be normal in amount, and the casein or caseinogen be deficient. Such milk would not be nutritious. This was demonstrated years ago in sick and starving women (Decaisne). The following is the method of Woodward for determining the total proteids: Two ''milk burettes" (Fig. 20), each containing Fig. 20. Milk burette of Woodward. 5 c.c. of milk, are allowed to stand overnight in a warm place (100° F., 38° C). Thej are then cooled. The milk is drawn off into two Eshbach tubes, and 10 c.c. of the Esbach solution added. The tubes are then shaken, put into a centrifuge, and rotated until the reading is constant. This method was perfected in the Pepper Laboratory, Philadelphia. The author has utilized this method, and found it satisfactory. Cows' Milk. — Composition. — Of 700 analyses, Konig gives the following as the average composition of cows' milk for 100 parts : Water, 87.2; casein, 2.88; albumin (lactalbumin), 0.51; fat, 3.68; sugar, 4.90. Cows' milk has a .specific gravity of from 1.028 to 1.034. It is amphoteric in reaction, but is relatively more acid than human milk. Fresh cows' milk does not coagulate on boiling, but heat causes a skin of casein and lime salts to form on the surface of the milk. Tf allowed to stand at the temperature of the room, lactic acid TEE FOOD OF TEE INFANT. 103 is formed in cows' milk as a result of bacterial growth and splitting of the milk sugar and coagulation or curdling of the casein occurs when the milk is heated ; after a while, an excess of acid being formed, spontaneous separation of the casein will occur. Fat. — Fat is contained in cows' milk, as in human milk, in the form of fat-globules, which are held in suspension in the serous part of the milk by an envelope of albumin. There is no doubt that the milk-globules contain all the fat of the milk. The fat-globules are smaller than those of human milk. It is uncertain whether the fat- globules contain any protein substances. Proteids. — The casein of cows' milk is a nucleo-albumin, con- tains phosphorus and coagulates when heated, as also by the addition of acids and rennet. The amount of casein in cows' milk is not only relatively but absolutely greater than in human milk ; and in describing human milk it was stated that the casein forms five- sixths of the total proteids in the cows' milk ; whereas in human milk the casein forms two-sixths of the total proteids. This one fact is of far-reaching importance. Simple dilutions of cows' milk still leave it with a greater propor- tion of casein, as compared to the other proteids in the milk, than that which exists in human milk. Though we may dilute cows' milk so as to reduce the proteids to the relative proportion in which they exist in human milk, we cannot do this without at the same time reducing its nutritive value ; that is, we fail to get the quantity of digestible proteids in the milk, although the proteids may exist in the same proportion in our mixture. In other words, the proteids of the cows' milk are not so completely assimilated by the infant as are those of human milk. Again, the casein of cows' milk is precipitated or coagulates very early with the aid of acid and salts ; that of human milk quite late or not at all. In the human stomach, therefore, cows' milk will not take up as much acid of the gastric juice without coagu- lating as will human milk and the coagula occur in large masses. We can readily see in this another disadvantage in the use of cows' milk as an infant food. Human milk, on the other hand, takes up a large amount of the acid of the gastric juice and coagulates in very fine flocculi. This finer mode of coagulation accounts partly for the more complete assimilation of human milk by the infant. It was formerly thought that the casein of human and cows' milk were chemically identical. Later study, however, shows that the casein of human milk, in contradistinction to that of cows' milk, is not a nucleo-albumin (Szontagh). Human milk is richer in nucleon and lecithin than cows' milk and contains more combined phosphorus than cows' milk in the nucleon. It can be seen from this that the contention of Hoppe-Seyler, Hammarsten, and Wrobe- 104 ' NUTRITION AND INFANT FEEDING. lewski, tiiat the two caseins are essentially different, is well founded. ISTot only is the casein of cows' milk a substance sui generis, but its digestion in the intestine of the infant is accomplished with great loss. Moreover, it has been shown that the salts of cows' milk, especially those of lime and potassium, are not well assimilated by the infant gut, fully 34 per cent, of these salts being excreted by the put; whereas only 10 per cent, of these salts are found in the fseces of the infant fed at the breast. These facts are of great importance in comparing the two modes of feeding infants — that of the breast and the bottle. The prevalence of bone disturbances of the severer type in artificially fed infants is thus partly explained by the loss of the salts of lime and potassium, these being important to bone nutrition and growth. The increase of weight in artificially fed infants also gives us an insight into the physiological processes in such infants. The quantity of milk, as before stated, necessary to maintain nutrition is greater in the case of the bottle-fed infant than in that fed on the breast. There is always a danger of overfeeding an infant which is bottle-fed. The increase of weight is not as regular in the bottle-fed infant as it is in the breast-fed infant. The following will show at a glance the differences in the assimila- tion of the various elements of cows' milk as compared to human milk by the infant gut (Uffelmann) : Cows' Milk Human Milk. Proteids 98.7 per cent. 99.5 per cent. Fats 93.5 " 97.5 " Salts 66.2 " 90.0 Sugar 100.0 " 100.0 " Ash 92.0 " 97.0 " According to Forster, an infant four months of age taking 1215 c.c. of cows' milk excreted three-fourths of the lime salts in the fseces. Bacteria in Cows' Milk. — Pasteurization; Sterilization.- — By in- sisting on strict cleanliness of the cows' udder, the hands of the milkman, and the utensil in which the milk is collected, it is pos- sible to obtain a milk tolerably free from bacteria. In commerce, however, this is manifestly impracticable. Milk collected with the greatest care contains bacteria, and if these appear to the extent of only 9000 to the cubic centimetre at the time of milking, enough will have developed under favorable conditions to cause such an increase within twenty-four hours at an ordinary temperature as to bring this number up to 5,600,000 to the cubic centimetre (Miquel). Soxhlet has shown that in order to inhibit the growth of these bac- teria in the milk, it must be kept at a very low temperature, and in summer weather practically in contact with ice. THE FOOD OF TEE INFANT. 105 The most important bacteria fomicl in milk are the Bacterium lactis aerogenes, the Bacillus mesentericus vulgatus (the potato ba- cillus), and the Bacillus subtilis. Cows' milk may contain also streptococci which come from the udder of the animal, and any pathogenic bacteria, such as the pneumococcus, typhoid bacillus, diphtheria bacillus, the germs of scarlet fever, measles, or tubercu- losis, cows' milk being an excellent culture medium for the growth of germs of all infectious disease. The habitat of the bacteria of cows' milk is first the teat of the udder. The milk ducts in the teats are of considerable size and residual milk decomposes in them. The entrance of bacteria into these ducts, such as the Bacterium lactis aerogenes, the hay bacillus, the potato bacillus (Bacillus mesentericus vulgatus), is favored by the habits of the animal and uncleanliness in the stalls in which the animal is kept. Uncleanly utensils in which the milk is collected are a source of contamination. Infected Cows' Milk as a Cause of Epidemics,- — Typhoid Fever. — Cows' milk is unquestionably an excellent medium for the growth of bacteria and is most readily infected ; thus, epidemics of typhoid fever have been traced to infected milk. Such milk becomes infected either in the dairy, where the fever may be prevalent among the dairy- men, or through dairy utensils which have been cleansed with in- fected water. Dysentery. — Dysentery may be caused by drinking infected milk (Klein). Diphtheria. — The Klebs-Loffler bacillus grows quite well in cows' milk, which may consequently be the means of readily spreading the disease; thus, school epidemics have been traced to infected milk. Scarlet Fever. — -Scarlet fever has been conveyed by cows' milk infected by those contaminated with the disease (Kober, Freeman). Cholera Asiatica. — Cholera Asiatica may be conveyed through milk diluted with infected water or milk handled by a cholera- infected individual. Tuberculosis. — It is not the place here to discuss the transmission of tuberculosis to the human subject by means of the milk of a tuberculous cow. This matter is secondary to the more immediate question as to the prevalence of tuberculosis in the infant and child as a result of the ingestion of infected cows' milk. That this mode of acquiring tuberculosis is exceedingly rare will be acceded to by most observers, and published epidemics or isolated cases of tuber- culosis in children, caused by infected cows' milk, lack the evidences of absolute certainty as to etiology. Aside from tuberculosis, it is generally granted that suppurative disease of the udder of the cow may cause serious digestive disturb- 106 ' NUTEITION AND INFANT FEEDING. ances in the infant by infecting the milk. In fact, certain forms of stomatitis are traced by some (Forcheimer) to snch a source. Milk Acidity. — If milk is not cooled immediately after milking, and kept cool, it soon shows a marked increase in acid reaction. This is due to the growth of the Bacterium lactis aerogenes, which not only turns the milk acid, but in doing so produces toxins which are of considerable danger when introduced into the stomach and gut of the nursing infant. Without entering further into details, we may say that cows' milk intended for infant-feeding should be obtained from a herd of healthy animals, preferably of the Holstein type. Mixed milk is to be preferred to the milk from one cow, for the reason that any infectious element introduced into the milk coming from a large herd of animals is so diluted as to be less dangerous to the individual infant than the milk containing infectious matter coming in a concentrated form from one animal. The milk should be carefully collected in utensils which have been thoroughly cleansed and sterilized with steam. The infant should obtain the milk as soon as possible after the milking; cer- tainly within twenty-four hours. Having been modified and put up for the infant's use, the food should be presented to the infant in divided portions, each of which is sufficient for a nursing. In large cities, where the milk does not come direct from the dairy to the infant, it is still thought advisable to subject the milk to various forms of sterilization or heating, in order that the con- tained bacteria may, for the most part, be destroyed, and that it may remain fit for feeding the infant for fully twenty-four hours. In places where the milk can be obtained direct from the dairy, and where we are certain that the collection of the milk has been carried out with care, we may do away with the heating process, especially in the winter time. In the summer, however, some form of sterilization is necessary. Under the term sterilization the author includes both Pasteuriza- tion and sterilization. Pasteurization. — Pasteurization is to-day the process most in vogue for the preservation of infant food, and also to destroy, for the most part, any deleterious bacteria contained in the milk. It was first per- fected by Pasteur, and therefore bears his name. The milk is sub- jected, in a suitable apparatus, to a temperature of 65° C. (149° F.) for a variable length of time, generally half an hour, and then rapidly cooled to SO'^ C. (68° F.). The most practical apparatus for this purpose was devised by Freeman, and is sold in the shops as the Freeman Pasteurizer (Fig. 21). If properly carried out with this apparatus, the method destroys all pathogenic germs which may be present in the milk, and also a large percentage of the other bacteria TRE FOOD OF THE INFANT. 107 of the milk, including most of the Bacterium lactis aerogenes, but does not destroy any sporulated bacteria, such as the Bacillus mesen- tericus vulgatus. Sterilization. — Sterilization is the process of heating milk to 212° F., or 100° C. This may be done by means of the Arnold Steam Sterilizer (Fig. 23), or by simply placing the milk in properly corked bottles in boiling water. As a rule, the milk is heated for twenty minutes, when it is considered sterilized. The milk should then be rapidly cooled, as in the process of Pasteurization, for by this process the fat of the milk will not separate. Sterilization is best performed by the above processes, but the ordinary sterilizers will not render the Fig. 21. Fig. 22. Fig. 23. Freeman Pasteurizer Arnold Steam Sterilizer. milk absolutely sterile. It will not destroy any sporulated bacteria, but will destroy the Bacterivim lactis aerogenes and all pathogenic germs. Milk which contains sporulated bacteria, such as the potato bacillus (Bacillus mesentericus vulgatus), may after a short time undergo a change due to the proliferation and action of the sporulated bacteria, which have not been destroyed by sterilization under ordi- nary atmospheric pressure. This consists in a splitting up of the casein and a so-called peptonization of the milk. This change begins after a few days, and when complete renders the milk alkaline in reaction and sweetish in taste. Milk, unless it has been sterilized under two atmospheres of pressure and at a temperature above that obtainable in the household sterilizer, is never completely sterile. Milk which has undergone the above peptonization is unfit for infant-feeding. Disadvantages of Sterilization as Compared with Pasteurization. — In describing sterilization and Pasteurization of milk, it has been 108 NUTBITION AND INFANT FEEDING. intimated that sterilization has its disadvantages, and these are, in short, that the lactalbnniin of the milk is coagulated to a slight degree ; the casein is changed, so that it is not as absorbable; the fats are liquefied, so that in sterilized mixtures they may be seen on the sur- face in the form of an oily layer ; and the lime salts are converted into unabsorbable com^Dounds, so that infants taking sterilized milk lose these salts for the economy. They do not get the necessary bone pabulum. This would account in part, if true, for the prevalence of scurvy in infants who take sterilized milk as an exclusive food for too long a period of time (Cronheim and Miiller). Though sterilization was at first a great step in advance, in- asmuch as the process presented to the nursing infant the possi- bility of obtaining its food in a wholesome condition hours after its preparation, even in the hottest weather, there developed certain disadvantages in connection with its prolonged use. It has been noted, partly owing to the increased use of sterilized milk and partly to the fact that bottle-feeding has become much more general to-day than formerly, that infants who take sterilized milk to a certain extent do not thrive as well as infants who obtain either a mixed diet or a food not so thoroughly cooked. The result has been a de- cided increase in the number of scurvy cases, undoubtedly due to the changes in the food. Aside from the danger of scurvy, a certain proportion of infants who do not develop scurvy and who are fed exclusively on sterilized milk remain stationary in weight, although the stools of such infants may be normal in appearance. Again, infants who are taking sterilized milk develop in a certain proportion of cases inordinate constipation, and this in itself is a very troublesome feature. In looking for another method of preserv- ing the infant food, at least here in America, Pasteurization was next taken up. It was found, however, that the heating of the lactalbumin even to a temperature of 70° C. had its disadvantages, in that a certain amount of lactalbumin was coagulated. Still, the dis- advantages of Pasteurization are less, as compared to those of sterili- zation, and it was at once apparent that if Pasteurization could be applied as a method of preservation of infant food, it would be a step in advance. The author at first advocated the heating of milk for infant-feeding at a lower temperature, a temperature subsequently taken up by Monti, of Vienna, of 180° F. At this temperature milk will keep twenty-four hours even in warm weather, with ordinary care, without turning sour. Even this temperature was found exces- sive, and Freeman advocated a still lower one for Pasteurization, and devised an instrument for carrying out this process, which to-day is in general use. Coincident with the agitation against sterilization, and even Pas- TRE FOOD OF TEE INFANT. 109 teurization of milk, the dairy methods have been so improved to-day that the time of Pasteurization can be reduced, and in midwinter, in large cities, the milk can be obtained in such purity as to be given raw- to the infant. The whole question, therefore, of the preservation of milk has resolved itself into obtaining a milk as free from impurities and as recently from the dairy as possible. Thus, if we are certain of the cleanliness of our milk and the care with which it is handled. Pasteurization can be followed out as a method of preservation of the infant's food, even in the summer time ; but such Pasteurized milk, no matter how clean the original milk when received from the dairy, must be kept carefully on ice in order to prevent its turning sour. Among the poor in large cities, however. Pasteurization is not safe in midsummer, and where large numbers of infants are fed from laboratories careful sterilization offers the best safeguard against in- fantile summer diarrhoea. In the fall and winter. Pasteurization, in large cities, is quite sufficient to preserve the infant food ; and, as has been stated, in winter we may even, if we are sure of the source of our milk and its recency from the dairy, give raw milk to infants. Sterilization and Pasteurization, therefore, are simply methods of preservation of infant food, and have nothing intrinsic in themselves as regards the problems connected with infant-feeding. Experimental Study of the Assimilation of Sterilized, Pasteurized and Raw Milk. Nitrogen taken Nitrogen remaining in milk. in feces. Grammes. Per cent. First infant — Pasteurized milk 10.9209 4.6 Sterilized milk 13.7449 4.9 Raw milk 5.3914 3.4 Second infant — Boiled milk 32.643 4.5 Sterilized milk 30.969 4.3 The table given above shows the comparative digestibility of raw, Pasteurized, and sterilized milk (Koplik), as indicated by the per- centage of nitrogen remaining in the fseces of the infant. These experiments were performed by feeding the same infant with raw and heated milk. The results showed that, although the differences are slight, they are in favor of milk subjected to little or no heat. Doane and Price have confirmed these results by experiments on the calf. What Shall the Practitioner do in Regard to Sterilization and Pasteuri- zation? — If the patient has access to a milk which is only twelve hours from the dairy we may simply Pasteurize this milk both sum- mer and winter, and in the summer-time it should be carefully kept on ice. During the winter we may give such a milk raw if obtained 110 NVTRiriON AND INFANT FEEDING. from a mixed herd of cattle. Raw milk from a limited herd is dan- gerous, inasmuch as the dilution is not great enough to eliminate impurities from sick cows, should there be such, in a small herd. The practitioner should therefore advocate a mixed milk from a large herd as the best safeguard against infection of the infant. The dairy should be kept scrupulously clean, as should also the animals, and the milk kept in clean utensils, in order that the above ideas may prove beneficial to infants. If the infant's milk (modified) is to be carried any distance during the summer, sterilization is a safeguard for a short period of time. Raw Milk in Infant-Feeding.- — With the improved methods of dairy hygiene and care exercised in most cities in the collection of milk intended for infant-feeding, the milk contains less bacteria and reaches the infant much earlier to-day than formerly. The result of this, at least in IS^ew York, where it is possible to obtain milk within twelve to twenty-four hours of the milking-time, has been that the milk is of a very low acidity and bacterial content. The ques- tion arises whether we may not give such milk, modified properly, in a raw state to the infant. For even Pasteurization, it must be admitted, tends to change the ingredients of the milk to such an extent as to compromise their nutritive value. The author in practice Pasteurizes the infant's milk in the winter- time, and in many cases gives the milk in the raw state. In the summer, however, in large cities, where the icing of milk may have been imperfect, it is safest to sterilize the milk during the heated term. This is only for a period, at most, of three months. An infant taking sterilized milk under proper conditions during the heated term is not injured by such a food, and is protected from an attack of gastro-enteritis, for it is not possible, even though great care be exercised, to prevent an occasional bottle of milk from in- creasing in acidity. The result of such a change might be an- attack of diarrhoea which would endanger life. In the fall, wanter, and early spring the practitioner, if he is certain the milk is of good quality and has been collected in a careful and cleanly manner, need not do more than Pasteurize the milk. If he is absolutely certain of the source and freshness of the milk he may even give it raw. There are certain infants Avho have an idiosyncrasy against the taking of raw milk. The acidity cannot be rectified by lime-water, and the result is that such infants will have loose movements or even diar- rhtt'a. These cases are exceptional, of course, but they must be borne in mind. In exceptional cases the author has seen even Pasteurized milk disagree in the same manner with the infant. Moreover, we know now that the administration of heated milk, especially sterilized milk, over too long a period will cause bone dis- TEE FOOD OF THE INFANT. Ill FiCx. 24. turbances, and it is certainly unwise to give, at least at the present day, sterilized milk to infants in the cooler seasons of the year. Even with the administration of Pasteurized milk for any length of time, it is well at about the fourth to the sixth month of infancy to give several times daily a small quantity of diluted orange-juice. In this way the ill effects of heated milk are counteracted, and the infant is supplied with those salts and acids which are lacking in the Pasteur- ized and sterilized fluid. Frozen Milk. — The process of freezing is deleterious to cows^ milk, inasmuch as it breaks up the original fat-emulsion, and milk when thawed does not present the normal appearance under the micro- scope. The individual fat-globules are seen to be angular, and in- stead of presenting a spherical refracting body, the globule presents concentric rings, showing that in some way the cold has acted on the fat. Such milk, if given to an infant, will at times disagree and cause greenish diarrha?al movements, sometimes vomiting. More- over, in midwinter it is very common for children who have pre- viously been quite regular in their bowel evacuations, with movements of normal consistence and appearance, to become constipated as a result of the ingestion of milk which has been frozen and then thawed. It seems that the fat of the milk undergoes some change which interferes with its hitherto cathartic action on the bowels. As a result, these infants will have hard, constipated movements ; or the movements may be partly constipated or partly of normal consistence. In such cases the physician will have no other resource but to advise patience until the milk can be delivered in an unfrozen condi- tion. Nursing Bottle. — The best form of bottle is the so-called Freeman bottle (Pig. 24), which has very little neck, a wide mouth, not much shoulder to the neck, so that it may be easily cleansed. For newborn infants there is now constructed a very small bottle of the same model with a capacity of three ounces, the idea being that when milk is given in a small bottle, the heat is retained during nursing much better than when a small quantity of milk is contained in a large bottle. In the latter case the milk is chilled before the termination of the feeding. When filled the bottles are corked with non-absorbent cotton. They are corked loosely, so that the steam may escape. If the cotton is j ammed tightly into the bottle, the cork will blow out in the heating. After nursing, the bottles are filled with a solution of washing soda and allowed to stand a few hours, and then washed externally and inter- Nursing bottle of the Freeman model. 112 NUTRITION AND INFANT FEEDING. ually aud drained dry. Any residue of milk remaining after nursing should not be utilized for another nursing. The cleansing of the bottle is carried out with a so-called bottle brush. E'ipples should be boiled once daily for ten minutes, and washed with' hot water after each nursing. It is well to have several nipples carefully sterilized in the early morning and kept in a clean jar, rather than in a solution of boric acid. If the nipples are kept in boric acid the latter is apt to become contaminated, as also the nipples. Before feeding, the bottle of milk is warmed to a temperature of about 100° to 105° F. (40.5° C), so that the milk may not chill the stomach of the infant and thereby suspend the digestive process. Dr. Sobel has constructed a bottle-warmer, by means of which the milk may be heated to exactly the same temperature at every nurs- ing. This is sold under the inventor's name in the shops. FOOD PREPARATIONS. Peptonized Milk. — With the perfection of our methods of the modifications of cows' milk, either in the laboratory or at home, the use of peptonizing agents as an aid to digestion of the casein of the milk has become more and more limited. On the other hand, it cannot be denied that the addition of peptonizing substances in safe quantities to the milk intended for the infant has a great advantage in certain cases of difficult casein digestion. As a rule, the infant will not take kindly to completely peptonized milk. It has a bitter taste, which cannot be overcome by the addition of sugar or any other agent to the milk. We are thus compelled, at least in the author's experience, to introduce the peptonizing agent into the milk in such a manner as not to change the taste of the food. The best method, therefore, of peptonizing the milk for infant-feeding is the so-called cold method. This is done as follows: The milk is modi- fied, either at home or in the laboratory, in the ordinary way. Just before giving to the infant, if the amount is from four to six ounces at each feeding, one-fifth of a peptonizing tube is added to the mix- ture, which is then well shaken and placed in lukewarm water for two and a half minutes, and then given to the infant. Such a milk will not have a perceptibly bitter taste. Another method of peptonizing milk for infant-feeding is to employ the so-called peptogenic milk powder for this purpose sold in the shops. A bottle of modified milk containing four or eight ounces of the mixture is fortified with about an eighth of a measure of peptogenic milk powder just before feeding, heated for seven minutes in lukewarm water, and then given to the infant. Infants FOOD PBEPABATIONS. 113 may be kept on this food for montlis, and then when the digestion and powers of assimilation have improved, the peptonization may be gradually omitted. The author has seen no ill effects from this method of giving peptonized foods. He feels, however, that at various intervals during the feeding of such infants, attempts should be made to omit the peptonizing ingredients from the mixture, in order to see whether the infant cannot thrive without them. The indications for the use of peptonizing infant food will be given under the heading of Difficult Digestion. Condensed Milk. — Condensed milk is very frequently employed to feed infants through the whole of the nursing period, and while it cannot be denied that some good results are thus obtained, con- densed milk, pure and simple, for the majority of infants is not available. Many infants will cease to increase in weight under its continued use; others will develop rachitis and scurvy. Condensed milk is sold in the shops in hermetically sealed cans, with or without the addition of sugar. The sugar is used to pre- serve the milk, and is generally cane-sugar. Condensed milk is poor in fats, although with the dilutions customary in infant-feeding, the proteids are not only low, but are in a more absorbable state than in most infant foods. Condensed milk also contains a very large pro- portion of sugar, both milk- and cane-sugar, and this, as has been pointed out under the heading of ISTutrition, is one of the most easily absorbable foods for the infant. An infant successfully fed on condensed milk will show a large deposit of fat. It may have a very good color, but a critical eye will invariably discover evidences of faulty metabolism, such as rachitis. Condensed milk is sometimes of great value in cases of gastro- enteritis, in which the digestion of ordinary modifications of cows' milk seem to be unsuccessful. It should only be used, however, in these cases to tide over a critical period. Condensed milk may be used fortified with cream, and under such conditions the cream is well assimilated. In traveling, also, if good milk is not available, infants who have been fed on carefully prepared mixtures may tide over a period of a few days on dilutions of condensed milk. The following composition of condensed milk is given by Konig : Water. Proteid. Fat. Sugar. Ash. Condensed milk without ^g^^g ^^^^ ^^ ^^ j3 gg j 99 cane-sugar J With the addition of cane- 1 26.44 10.47 10.07 14.16 2.00 sugar 38. 80 per cent. . J In order to prepare condensed milk for infant-feeding, the milk is diluted ten to twelve times for infants below three months of age, 114 NUTBITION AND INFANT FEEDING. and five to six times for older infants. In the cases of gastro-enteritic disturbance above mentioned, when the assimilation of cows' milk is difiicult in the period following subsidence of symptoms, dilutions of condensed milk, with the cautious addition of raw cream or top milk, are borne better than modifications of cows' milk. This method of feeding should be resorted to only after a demonstration of the failure of milk modifications, and should only be preliminary to feeding with fresh cows' milk. Barley-water. — Barley-water is one of the most useful adjuvants either to modified milk mixtures or as an exclusive food for a short time in cases of gastro-enteritic disturbances. The proper preparation of barley-water has been the subject of much study. The simplest method of preparing barley-water is that which utilizes the so-called Robinson's Patent Barley. A heaping teaspoonful of Kobinson's Patent Barley is suspended in a pint of cold water until the lumps have disappeared. The mixture is then placed in a small saucepan over a gas-stove fire, and stirred constantly for fifteen to twenty min- utes while boiling. The more the barley-water is boiled, the more thoroughly the barley is dissolved and dextrinized. After boiling, the loss of bulk is made up to the original quantity by the addition of water. The use of the so-called dextrinized barley instead cf Robin- son's Patent Barley offers in certain cases advantages to which refer- ence will be made later on. Dextrinized barley is sold in the shops as such. It is made up of barley-pearls ground and heated for a long period of time according to the formula of J. Lewis Smith. The composition of Robinson's Patent Barley is given by Konig as follows : Water 10.10 Proteids 5.13 Fats 0.97 N.-free extractives (carbohydrates) 81.87 Ash 1.93 It will be seen by a study of its composition that carbohydrates enter into it very largely. Fats and proteids are present in very small quantities. It is therefore unavailable as an exclusive food. Oatmeal Gruel. — Oatmeal is utilized in the same manner as bar- ley to dilute milk. It is made up in the form of a gruel. Two or three teaspoonfuls of oatmeal are boiled in a pint of water for three hours in a double boiler and then strained. This decoction, made up in the same manner as the barley, is utilized to dilute milk when barley has a constipating tendency. The composition of oatmeal, according to Munk, is as follows : FOOD PBEPABATIONS. 115 Water 10.1 Proteids 14.7 Fat 5.9 Carbohydrates 64.7 Eaw fibre 2.4 Ash 2.2 Arrowroot Gruel. — Arrowroot gruel has been used from time immemorial to dilute milk, especially in cases of summer diarrhoea. Dr. Merei is mentioned hj Routh as having first suggested the use of this cereal for diluting milk. A teaspoonful or two of the arrowroot is added to a pint of water and boiled in the same manner as starch and oatmeal, strained, and the decoction used as a diluent with milk. The composition of arrowroot, according to Konig, is as follows : Water 16.50 Proteids 0.88 Fat 0.10 Carbohydrates 81.16 Eaw fibre 0.05 Ash 0.19 Beef -juice. — The principal beef-juices are Valentine's, the prep- aration called Puro, Bovinine, Brand's, Wyeth's, Armour's, and Bur- goyne's preparations of beef-juices. Beef-juices contain little protein and much extractive matter, so that the nutritive value is very low. There are some of these beef -juices, such as Bovinine, which are manufactured from blood rather than beef-fibre. In such a case the Composition of Beef-juices. Valen- tine's.i Puro.2 Bovin- ine.s Brand.* Wyeth.s Armour.e ^ Bur-, W^ater Proteids Extractives .... Mineral matter . . Per cent. 51.21 9.65 11.16 10.84 Per cent. 36.60 30.33 19.16 9.79 Per cent. 81.09 13.98 3.40 1.02 Per cent. 59.15 15.45 16.55 8.85 Per cent. 44.87 1 38.01 17.12 Per cent. 74.10 r 8.30 t 9.54 7.51 Per cent. 49.51 13.00 8.10 14.20 extractives are few and the proteids low; they are more in use than the other preparations. In order to take enough of these beef -juices to equal a teaspoonful of scraped meat in nutritive value, more must be taken than could be borne by the average stomach in illness (Hutchison). They are not, therefore, available as exclusive articles of diet for any length of time, and young children especialJy, whose ^ Analysis by Dr. Candy. ^ Fresenius (Leyden's Handbuch der Ernahrungstherapie). *Food and Sanitation, Dec. 23, 1893 (Analysis by Chittenden). * Analysis by Dr. Candy (unpublished). ^ The Lancet Analysis (quoted by the makers). ^Analysis by Dr. Attfield (supplied by the makers). ^ Analysis by Dr. Candy. 116 NUTBITION AND INFANT FEEDING. palates are capricious, will rebel against most of these preparations, though they mav prefer those which contain less salt than others. They are useful, therefore, only as articles of diet twice or three times in the twenty-four hours, and furnish ingTcdients in the shape of water and salts and very little protein to the body. Peptone Preparations. — By peptone preparations are meant such preparations as Somatose, Carnrick's Peptonoids, Fairchild's Pano- peptone, and others. By referring to the table the reader will see that there are quite a number of preparations on the market. Of Showing the Composition of Peptone Preparations. Preparation. Water. Soluble pro- teids (chiefly albumoses). Extractives and other non- proteid or- ganic matter. Mineral matter. Per cent. Per cent. Per cent. Per cent. Somatose 9.20 80.00 6.70 Carnrick's peptonoids . . 5.40 24.00 65.40 (mainly sugar) 5.20 Koch's peptone 40.16 34.78 15.93 6.89 Liebig's peptone^ .... 31.90 33.40 24.60 9.90 Brand's beef-peptone . . 84.60 7.00 L40 Denaever's peptone . . . 78.4.5 12.15 4.32 2.54 Darbv's fluid meat ^ . . . 25.71 30.60 30.18 13.50 Armoui-'s wine of peptone^" 83.00 3.00 12.90 1.10 Fairchild's panopeptone" 81.00 6.00 13.00 (largely sugar) 1.00 Peptonized milk ^^ .... 87.50 1.76 10.04 (= sugar, fat, and unaltered proteid) 0.70 Liquid peptonoids ^^ (Arlington Co.) .... 5.25 12.63 0.95 the peptonized foods in a ready form, the most concentrated by far is Somatose, which contains 80 per cent, of albumoses; whereas other preparations contain, as will be seen by reference to the table, very little proteid matter, and are, therefore, of very slight nutritive value. Somatose, however, though containing as it does the greatest amount of proteid matter, cannot be taken in large quantities for any length of time without causing diarrhoea, and in this respect it is imavailable as an exclusive form of food. In feeding infants and children I find it is of the greatest value in those cases in which it is necessary to give the stomach absolute rest and to feed per rectum. For such cases the Somatose is prepared as follows: A teaspoonful * Leyden 's Handbuch der Ernabrungstherapie. 'Ibid. See also von Noorden, Therapeutische Monatshefte, June, 1892. " Horton Smith's Journal of Physiology, vol. xii., p. 42, 1891, and Leyden 's Handbuch. " Maker 's analysis. '*Horton Smith (loc. eit.). " Maker 's analj'sis also contains 14.94 per cent, of alcohol by weight. FOOD PBEPABATIONS. 117 of Somatose is dissolved in eight ounces of cold water. Two ounces of this solution is given carefully per rectum, care being observed to pass the catheter above the second sphincter, in order that the food may not be rejected. This may be repeated every few hours. Thus given, a rectal enema is absorbed for the most part, and in some cases it may be mingled with milk part for part, the nutritive properties being thus increased. Butter Milk. — Butter milk was first proposed as an infant food by Ballot in 1865 and recently revived and perfected as a substitute for the breast milk by Teixeira de Mattos. According to the latter it is prepared as follows: A litre of butter milk (commercial) is mixed with a level tablespoonful of rice, wheat or any cereal flour and stirred constantly over a low flame for 25 minutes. During this time it is brought to a boil three times after having added two to three tablespoonfuls of cane or beet sugar. The advantages of such a mixture for sick infants is that it has a very low fat and a very high proteid content. Inasmuch as the mixture has been boiled and some advise that bicarbonate of soda be added to a point of alkalinity, the acidity of the butter milk and its supposed bacterial nature have nothing to do with its favorable effects. It is an uncertain food to use, as some butter milks are distinctly dangerous and their prepa- ration has not yet been so perfected that we can avoid this danger. Kumyss. — Kumyss has the following composition (Konig) : Water 90.44 Alcohol 1.91 Lactic acid 0.91 Milk sugar 1.77 Proteid 2.44 Fat 1.46 Ash 0.42 Originally kumyss was made from mares' or camels' milk by the addition of a ferment indigenous to Tartary, called kefir. To-day kumyss is manufactured from cows' milk by the addition of ordinary yeast-fungus, and contains, as will be seen by reference to the table, a certain amount of alcohol and lactic acid. I have never succeeded, even for a short period of time, in feeding infants on kumyss with any amount of satisfaction. It is only available in illness of older children with capricious palates. Its use, therefore, is exceedingly limited. The same may be said of Matzoon. Beef -extracts. — Beef -extracts are open to the same objections as beef-juices, in that they contain for the most part extractives and are not intended for prolonged periods of use. There are prepara- tions, such as Bovril's, which contain meat-fibre, but which must be given in such concentrated form to obtain the necessary nutriment 118 NUTRITION AND INFANT FEEDING. as to cause diarrhoea. Beef-extracts, on account of the warmth and contained salts, are supposed, when administered, to stimulate the appetite. A teaspoonful of Bovril's is equal to 8 grammes of lean meat, and therefore must be given in very large quantities, as stated above, in order to obtain any amount of nutrition. Beef-broth. — Beef-broth has a composition of proteids 0.4, fat 0.6, salts 1.2, and extractives 1.2. With the extractives beef-broth contains creatin, xanthin, and hypoxanthin. One pound of meat is cut up, placed in one pint of water, and allowed to stand for four or five hours. It is then cooked over a slow fire for one hour. After cooling, the fat is skimmed off. This makes a very agreeable beef -broth. Table Showing the Composition of Beef-extracts} Liebig's extract.2 Bovril.3 Bovril for invalids.* Armour's extract.5 Brand's essence. 6 Vejos.f Water Proteids .... Gelatin Extractives . . . Mineral matter . Ether extract, etc Per cent. 18.3 }"{ 30.0 23.6 18.6 Per cent. 44.40 16.94 20.32 18.32 Per cent. 21.82 21.42 39.60 17.16 Per cent. 15.55 8.73 2.16 43.23 25.91 4.12 Per cent. 87.17 5.40 5.03 1.01 1.39 Per cent. 25.02 19.35 21.02 14.07 17.09 (Carbo- hydrate). In addition to the above, beef-broth contains phosphate of cal- cium, earthy phosphates, sodium chloride, oxide of iron ; the nutrition obtained from it depends mostly on the salts, especially of calcium combined with those of the phosphorus. Acorn Cocoa. — Acorn cocoa is a preparation made in Germany, and may be obtained on sale in the shops. The author has found it of especial use in cases of diarrhoea and intestinal disease in which it is advisable to suspend the use of milk. It may be given for some days. Children, however, object to its taste, and for this reason it is not applicable in every case. It contains fat, nitrogenous matter, and tannic acid. A teaspoonful of the cocoa is dissolved in eight ounces of water, and the preparation is given warm in much the same manner as milk. ^ Hutchison, The Lancet, 1902. ^ Analysis by Tankard. ^Analysis by Stiitzer (quoted by Voit, Miinchener medicinische Woehenschrift, No. 9, 1897). * Analysis supplied by the company. "Food and Sanitation, Dee. 16, 1893. 'Analysis by Dr. Candy (unpublished). ' The Lancet, April 16, 1898, p. 1060. N. B. — " Vejos " is a purely vegetable product, but is included in this table for convenience. ARTIFICIAL INFANT FOODS. 119 Stohlwerck's acorn cocoa has tlie following composition : Water (Fresenius, Konig) 5.28 Proteids 14.06 Fat 14.42 Sugar 25.15 Tannates 1.96 Extractives 23.39 ARTIFICIAL INFANT FOODS. Infant foods have been the subject of much investigation on the part of the profession. Scientifically the physician is correct when he maintains that children cannot be brought up, as a rule, on the exclusive use of any infant food. The infant foods present to the practitioner either dried milk, a cereal in combination with it or alone, with or without the addition of a malt preparation of some kind. It is quite evident, therefore, that there are several serious objections to them as exclusive articles of diet for a great length of time. The principal objection is that they are dried or heated food substances. In a majority of cases this is a dangerous article to use for a prolonged period in infancy and childhood without combining it with some fresh article of diet, such as cows' milk. Again, many of the infant foods contain nothing but a dry, care- fully prepared cereal. , It is evident that this alone cannot be given as an exclusive article of diet to an infant. It may be administered for a short time, as will be pointed out in the article on Infant- feeding; but it cannot be given for any prolonged period without giving rise to those very symptoms which we all fear referable to the bones and the circulatory system; evidence of disturbed nutrition, such as rachitis and scurvy. We may divide infant foods roughly into three groups : The first group, such as AUenbury's, Horlick's, Carnrick's, and ISTestle's Food, contain cows' milk desiccated, combined with some cereal and sugar. These foods are intended as an exclusive diet for infants, and against these the scientist objects principally. They are foods which cannot be applied as an exclusive food, and which if given over a prolonged period are open to the objections stated above. The second group of infant foods are possibly the most useful, and are those which contain some form of malted carbohydrate. The carbohydrates are in soluble form and the food may be regarded as a desiccated malt extract. Some of these preparations also contain diastase, and by combining the food with cows' milk or by the addi- tion of some carbohydrate to the milk we can obtain a combination which is not only digestible for the infant, but may be of great 120 NUTRITION AND INFANT FEEDING. nutritive value for a short period of time. In this group belong Melliu's Food, Loeflund's Malt Soup, the latter being nothing more nor less than the Liebig Malt Extract combined with potassium carbonate. The third group of infant foods are those vrhich are constructed of a pure cereal, and in this group are Eidge's Food, Imperial Granum, Eobinson's Patent Barley, and others. This last group may simply be considered as very carefully prepared cereals. They apply in those cases of intestinal disorder in which it is desirable for a short period of time to exclude milk completely. These foods, including condensed milk previously mentioned, Composition of Infant Foods} Food. o 1 ^ General description and remarks. ^ S Dried human m.ilk . Per Per Per Per cent. cent. cent. cent. 12.20 26.40 52.40 Geocp I. Allenbury No. 1 . . . 5.70 (For children before the age of three months.) Allenbury No. 2 . . . 3.90 (For children from the age of three to six months.) Horlick's malted milk 3.70 Camrick'B soluble food 5.50 Nestl^'s milk food Manhu infant food , 5.50 8.86 GEorp II.— Oasj A Mellin's food 6.30 OoM B. Savory & Moore's food 4.50 9.70 14.00 9.20 12.30 13.80 3.00 13.60 2.50 ILOO 4.80 8.70 5.60 7.90 trace 10.30 1.40 1 10.20 1.20 9.20 1.00 66.85 72.10 76.80 76.20 77.40 75.90 82.00 83.20 79.50 82.80 Per I cent. 2.10 The standard of composition to which I artificial substances should con- form. 3.75 Desiccated cows" milk from which the excess of casein has been re- moved, and a certain proportion of soluble vegetable albumin, milk, sugar and cream added. No starch present. 3^ Resembles the above, but contains some malted flour in addition. No starch present. 2.70 A mixture of desiccated milk (hO per cent.', wheat flour (26i.i per cent.), barley malt (2Z per cent.), and bi- carbonate of soda 1% per cent.i. Contains no unaltered starch when mixed. 2.20 A mixture of desiccated milk (STVi per cent. I, malted wheat flour (37i^ per cent. 1, and milk-sugar (25 per cent. I. When prepared accordinn to directions the casein is partially digested, but a considerable amount of unchanged starch is left. 1.30 A mixture of desiccated Swiss milk, baked wheat flour, and cane-sugar (30 per cent). More than a third of the total amount of carbohy- drate is in the form of starch. 1.00 A mixture of desiccated milk and malted cereals. When prepared according to directions contain.'^ a good deal of unaltered starch. 3.80 A completely malted food. All the carbohydrates in a soluble form. May be regarded as a desiccated malt extract. 0.60 Composed of wheat flour with the I addition of malt. 0.80 A mixture of wheat flour and pan- I creatic extract. 0.50 I A mixture of wheat flour and malt. When prepared according to direc- tions it still contains some unal- ' tered starch. ^Bobert Hutchinson, Lancet, 1902. (Abbreviated by the author). ABTIFICIAL INFANT FOODS. 121 Composition of Infant Foods [Continued). Food. ■6 ?2 General description and remarks. 1 2 ss i^ Group 11.— Class B Per Per Per Per Per (Continued). cent. cent, cent. cent. cent. Diastased farina . . . 8.30 7.60 1.30 81.70 1.10 A malted farinaceous food. When prepared according to the direc- tions, practically all the starch is converted into soluble forms. Coomb's malted food 7.90 12.10 2.80 76.80 0.40 A malted farinaceous food. Nutroa food 6.80 15.90 10.30 66.00 1.00 A mixture of cereals with the addi- tion of a certain proportion of pea- nut flour, from which the some- what bitter taste of the food and its Group III. high proportion of fat are derived. Ridge's food 7.90 9.20 1.00 81.20 0.70 A baked flour, containing only 3 per cent, of soluble carbohydrates, the remainder being starch. Neave's food 6.50 10.50 1.00 80.40 1.60 Resembles the above. Frame food diet . . . 5.00 13.40 1.20 79.40 1.00 A thoroughly baked flour to which have been added cane-sugar and some extract of bran. Opmus food 10.90 9.10 1.00 78.60 0.40 A granulated wheat food. "Falona" 7.00 8.40 8.50 79.90 1.20 A mixture of cereals (oats, barley, and wheat), with a ground fat- containing bean. Robinson's groats . . 10.40 11.30 1.60 75.00 1.70 Ground oats from which the husk has been removed. Robinson's pat. barley 10.10 5.10 0.90 82.00 1.90 Ground pearl barley, poor in every element except starch and mineral matter. Chapman's whole flour 8.40 9.40 2.00 79.30 0.90 A finely ground whole-wheat flour. Scott's oat flour . . . 5.80 9.77 5.00 78.20 1.30 A fine oat flour. Addenda. Imperial granum . . 9.23 14.00 1.04 75.34 0.39 (Classified under Group III.) Eskay's food 8.58 5.82 1.16 89.02 1.30 (Classified under Group I.) show a deficiency of fat and an excess of carbohydrates. On this ground alone their prolonged nse is objectionable. The proteids present are either in the form of dried, heated proteids of cows' milk, one of the most indigestible forms of proteid substances that can be given to the infant, or in the nature of vegetable substances which are foreign to the infant dietary. Condensed milk also contains such an excess of sugar as to cause acid dyspepsia ; although preparations of condensed milk are made up, as has been stated, without sugar. In the treatment of enteritis, both of the acute and subacute type, it is essential in very young infants to give temporarily some form of food which does not contain milk in any form. Although an ordi- nary cereal may be used in these cases, a more agreeable form is one of the infant foods, and especially Imperial Granum, This, made up to the consistence of ordinary barley-water, may be administered in cases of ileocolitis for quite a length of time, and will not be rejected by the infant or young child. At the period of weaning — the ninth month — cereals may be added to the milk, in the form of an infant food, such as Ridge's Food, Imperial Granum, or barley. In such cases the barley or 122 NUTRITION AND INFANT FEEDING. infant food is well borne. It must not be forgotten also that in the malted foods, wben added to the milk, we are giving a form of sugar, malt-sugar, one of the most digestible carbohydrates. The objection raised to the combination of malted foods, starchy cereals, and milk, that the infant is not capable of digesting starch, does not obtain fully in practice. We find, as will be shown in case of the dextrinized gruels, that large quantities of carbohydrate and flour may be given to infants, and their digestion will not only be normal, but they will thrive and increase in weight very rapidly; whereas, under an ordinary milk diet they have remained atrophic. MATERNAL NURSING. The ideal food for the infant is the milk of the mother s breast. Under our social conditions, the mother who can nurse her child from birth to the period of weaning is an exception to the rule, not because most mothers do not wish to nurse their infants. On the contrary, the author has found them very anxious to perform this function, but the average mother to-day has not the physical develop- ment that fits her to nurse the child. The result is that she cannot furnish sufiicient milk, or that the milk is not of the quality requisite for successful nursing. Some mothers will have a sufficiency of so-called milk. The infants, however, do not gain in weight, are puny, have attacks of colic, and the symptoms indicate that the food is at fault. Examination shows that in such women true milk secre- tion is rarely established; the milk remains in the colostrum stage. Some physicians think that if the infant cannot have the benefit of the maternal breast a wet-nurse is the alternative. If with the wet-nurse we had simply to consider the fitness of the food, this would be true. If the maternal breast is not at our disposal, the next best and the safest thing for the race is a substitute for the breast, for many reasons, some of which we will try briefly to indicate. In the first place, it is not moral nor conducive to the future good of the race to ask a mother (the wet-nurse) to put aside her own child and to deprive it of the breast for the sake of a strange child. Second. ISFo matter how healthy a wet-nurse may be at the time of examination, we have no assurance that such a wet-nurse will remain healthy, or that some diathesis not apparent at the time of examination may not be transmitted to the infant (Czerny). We thus take a healthy infant, place it at a breast, and feed it with milk concerning the ultimate influence of which we are utterly in the dark. The author is inclined to believe that so far as human milk is con- cerned, certain tendencies may be conveyed from the nurse to the MATEBNAL NUBSING. 123 infant which will crop out later in life. Bj this he refers rather to scrofulous tendencies, lymphatic tendencies, tendencies connected with diseases of the blood-forming organs. Third. The introduction of a stranger into the household is a cause of great disturbance to that household, and also one of concern to the physician. The idea that a child brought up at the breast is better fitted for the struggle for existence may be true ; on the other hand, the difficulties, at least in this country, of obtaining, fit wet- nurses for children are so great that it would be well, if the mother cannot nurse the infant, to place it on a substitute in the form of bottle-feeding, unless this is not feasible. Of course, in all this we do not include those exceptional infants which cannot be fed artificially. Such cases occur, and must be placed upon the breast. Finally, if the mother can furnish two or three nursings daily, it is well not to take the child off the breast entirely, but to institute what is known as mixed feeding. In some cases this is a very satis- factory method of feeding the infant. Contraindications to Maternal Nursing. — A mother may suffer from syphilis or skin eruptions or may have a deficiency of milk and under certain conditions may still be allowed to nurse her infant. A ivet-nurse should be free from all constitutional and psychical taint to nurse an infant. Syphilis can be communicated to the wet-nurse by the infant, or to the infant by the wet-nurse through luetic lesions of the nipple. A syphilitic infant, therefore, must not be allowed to nurse the breast of a woman who is free from syphilis ; and we should be very careful not to place a child free from syphilis on the breast of a wet-nurse without previous careful examination as to the presence of syphilis in the nurse. A mother, on the other hand, who has syphilis can nurse her infant without danger of communicating syphilis to the infant if the mother has been exposed to and contracted the disease up to a period of two months before the delivery of the child. An infant congenitally syphilitic may nurse its mother without commu- nicating the disease to the mother. These facts have been well estab- lished, and have been commented on in the chapter on Syphilis. Should the mother have contracted syphilis subsequent to the birth of her infant, and should she have been nursing the infant, it would be wise to take the infant away from the breast, for such a mother may communicate the syphilis to the infant in the same manner as a syphilitic wet-nurse. Tuberculosis in the mother, even in its milder manifestations, is a contraindication to her nursing her infant. Though the manner in which the toxins of the tubercle bacillus or the bacillus itself pass 124 NUTBITIOX AND INFANT FEEDING. into the breast milk, if sucli be the case at all, is still a matter of study, sve can well understand ho"«' the mother, weakened by the inroads of such a disease as tuberculosis, would be further seriously injured and weakened by nursing her child. The close contact of mother and nursling, furthermore, might favor the infection of the infant in other ways than by the milk alone. On the other hand, an old focus of tuberculosis, such as a healed pleurisy or coxitis long healed, in a vigorous mother would not contraindicate nursing should the secretion of milk be abundant and should the function not make inroads upon her health. Active symptoms of Bright's disease, such as general anasarca and other signs of serious involvement of the kidney, would preclude a mother's nursing her infant, not only because such a function would weaken her, but because, metabolism being profoundly disturbed, the breast milk would be unfit for the maintenance of the nutrition of the infant. Advanced disease of the heart would also unfit a woman for nursing her infant. On the other hand, a slight albuminuria not giving any objective or subjective symptoms should not interfere with the desire of the mother to nurse her offspring. Advanced and active disease of the liver would in the same manner as the above diseases contraindicate nursing. Organic nervous disease with paralysis, severe neuroses, insanity, hysteria, epilepsy, neurasthenia of a marked type, when present in the mother, contraindicate the nursing of the infant. Aside from the disturbances said to be caused in the infant nursing the breast of a person the subject of hysterical or epileptic attacks, we would scarcely care to trust such a sufferer with the care of an infant. On the other hand, slight nervous tendencies in the mother should not contraindicate the nursing of the infant, for in such a case we would open the way for the deprivation of the breast to a large number of infants, and give an easy avenue of escape to some from the responsi- bilities of maternity. The severe forms of anaemia, leukaemia, ma- lignant disease, such as carcinoma and sarcoma, the presence of a very miarked goitre vrith active symptoms, may be mentioned as con- traindications to the nursing of an infant. The acute contagious diseases, the exanthemata, erysipelas, pneu- monia, bronchopneumonia, pleurisy, acute rheumatism, typhus and typhoid fever, diphtheria, are all contraindications to nursing the infant. I have seen mothers suffering from erysipelas nurse their infants without infecting them. This should not be the rule, how- ever. In a case of diphtheria the danger to the infant of infection is much greater than would be counterbalanced by the benefits to be attained from continuance at the breast. The milk of a woman suf- PLATE VI FIG. 1 Form of the Breasts of a Wet-nurse >A^ith Abundant Milk of Good Quality. (After Sehliehter ) FIG. 2 Form of the Breasts of a ^A/■et-nurse whose Milk is Deficient in Quantity and Quality. (After sehiichter.) MATEBNAL NUBSING. 125 fering from a severe pneumonia with a high febrile curve cannot be all that is desired for the infant, and the process of nursing with the accompanying physical and mental disturbance might react against the mother. Selection of a Wet-nurse. — It is not necessary that the wet- nurse should have been recently delivered. A newborn baby may be given the breast of a nurse whose baby is from one to two months of age. In fact, her milk is preferable to that of a nurse who has just been confined. For, apart from the uncertainty as to whether the milk will agree with the baby, the milk after a few weeks attains a uniform composition, and is more likely to agree with the baby than milk from the breast of a woman recently confined. I prefer to place the newborn infant on a breast at least three weeks old. The method of examining a wet-nurse as to her fitness begins with ascertaining the history of her own baby. It should sleep well in the intervals of nursing, be free from colic, and have normal move- ments. The baby should be completely undressed for examination. It should be at least tolerably well nourished. There should be no eruption on the skin, no copper-colored intertrigo, no snuffles, no pig- mented spots, and no rhagades around the mouth or anus. The skin of the palms of the hands or the soles of the feet should not be fissured or hard or present suspicious pigmentation. The head should not have an idiotic, microcephalic conformity. The wet-nurse should be below the age of thirty. Old multiparse do not, as a rule, furnish good milk. The shape of the breast is important. The pear-shaped, elongated, hanging breast furnishes more milk than the firm, round breast of virgin shape (Plate VI.). The nipple should be about one centimetre long and three-fourths of a centimetre in diameter. The baby can easily grasp such a nipple and draw it into the mouth. A flat nipple, or a nipple with fissures, or a nipple surrounded by eczema is not desirable in a nurse, and may even be dangerous to an infant. The nurse is next directed to undress, and her body is examined for traces of any eruption which may be specific. Pigmented macules should arouse suspicion, as also enlarged cervical or epitrochlear lymph-nodes. The lungs, especially the apices, are examined for bronchitis or tuberculosis. The nurse is rejected if there be the slightest evidence of apical involvement. The teeth should not be carious to such an extent as to preclude the possibility of their being kept clean. The presence of a foetid ozsena is highly objectionable, apart from the offensive odor. Such cases may be latently tuber- culous. The woman should be mentally sound. The wet-nurse is then examined as to the presence of venereal disease by inspection of the introitus vaginse and the anus. The mucous membrane of the mouth should be examined for evidences of syphilis. Search is 126 NUTRITION AND INFANT FEEDING. made for mucous patches and suspicious cicatrices. After having examined both child and mother in the manner detailed, we are in a position to recommend the nurse if the milk is satisfactory. The physician should have at hand in his office means by which he can at once decide upon the desirability of a wet-nurse. He must not at the beginning be driven to the necessity of a milk analysis. He decides first as to the quantity and then as to the quality of the milk. As a rule, a wet-nurse comes to the physician insufficiently fed and in a frame of mind far from tranquil. If despite these con- ditions the milk possess the qualities desired, he may at once venture to place the baby at her breast. If the milk does not agree with the baby after a fair trial, future conduct will be guided by certain developments, both in the quantity and quality of the milk and the condition of the infant. Quantity of the Milk. — The physician grasps the breast in the palm of his right hand and gently but firmly attempts to express the milk. The milk should with gentle pressure flow freely from the ducts. A drop is caught on the nail of the thumb. This time- honored nail-test is not to be despised. A drop of good milk will retain its bluish-white tint. This test will bring out the color of the milk, whether too watery, yellow, or white, to the experienced eye. The nurse is then directed to pump by gentle pressure a quan- tity of milk into a long, narrow beaker glass. If the breast has not been nursed within an hour, there should be no difficulty in obtaining at least an ounce of milk in this way. With this quantity we can at once decide on the efficiency of a nurse. The milk should have a bluish-white tinge. Any trace of yellow or green when a test-tube of the milk is held in the light, is abnormal. Milk may be very abundant but of a dirty white tinge ; some specimens separate almost instantly upon withdrawal into a yellowish oily layer on top and a serous liquid below. Any such abnormalities in the milk should cause the rejection of an applicant. If the breasts, history, and physical examination are satisfactory, and the quantity and physical characteristics of a nurse's milk are good, we may recommend her without making a chemical examination of the milk. Such an examination is impracticable for the practitioner with the means at his disposal. Even if carried out, it may be unfair to the nurse. At the examining visit the proportion of proteids and fats may be below what it will adjust itself to in a day or two when the wet-nurse is rested and housed in her new home. More nutritious diet will greatly change the composition of the milk. There are, however, conditions which may require an examination of the milk at a sub- sequent period. In such a case the methods detailed elsewhere may be resorted to. MATERNAL NUESING. 127 The Beginning- of Nursing. — Once having determined to place the infant at the breast, the question arises, When should this func- tion be begun ? Immediately after birth the mother is tired and so is the infant. They have both gone thought a critical period. It is well to let them rest for some hours. If the infant sleeps, and awakens only to be changed as to its diaper, we should not hasten to feed it. The author follows the rule that the infant be given a little water at intervals from the first six hours until the beginning of the next day after birth, and then the mother, having been thor- oughly rested, the child is put at the breast, even though there are but a few drops of colostrum in the breast. The first day after birth the infant should be fed at intervals of three hours. At this time there will be very little in the breast, but the stimulation of the breast by nursing will cause an increased secretion of milk, so that by the second day nursing may be inaugu- rated at regular intervals of two hours. After this the intervals of nursing are so apportioned that the newborn infant during the first week will obtain the breast from nine to ten times in the twenty-four hours ; the second week, eight or nine times in the twenty-four hours ; and in the fourth week, eight times in the twenty-four hours. After this the intervals of nursing will be much the same as they are in artificial feeding. We give the breast at intervals, generally of two and a half hours, so that the last nursing is at 11 p. m. After the first month the infant should sleep until five or six o'clock in the morning, when it obtains the first nursing. Then from the second to the sixth month seven nursings in the twenty-four hours are suffi- cient. The nursing should be so arranged that the mother and child may have complete rest of five hours between 12 p. m. and 5 a. m. The number of times an infant should nurse at the breast is in the large majority of cases a matter of training and habit, especially with the breast-fed infant. Czerny, following, Ahlf eld advises placing the baby at the breast on the average of five times in the twenty-four hours. With care and patience this can be done. The practitioner, however, will meet a number of mothers who will nurse their offspring more frequently, and the above gives the limit of such nursings. In frequent nursing the infant receives less at each feeding than in the nursings at longer intervals. Care of the Breast. — The care of the breast really begins before the birth of the infant. About the seventh month of pregnancy colos- trum appears in the breast. At this time it can be seen in some cases to exude from the nipple. Unless care is taken at this time we will have a fissuration of the breast nipple, due to the action on the epi- thelium of the skin of the drops of colostrum which are allowed to collect and decompose on the nipple. The result is that at birth 128 • NUTBITION AND INFANT FEEDING. the mother may have sufficient milk in the breast, but be unable to nurse the child on account of the presence of these fissures, I advise, therefore, that at this time of pregnancy the nipples be kept scrupulously clean and washed twice a day with a dilute solution of alum water or some antiseptic wash. In this way the decomposition of colostrum on the nipple is avoided, and the nipple is strengthened by the slight massage of washing. If the nipple is not well devel- oped, this is the time also to attempt its development. This is done by drawing out the nipple twice a day, either with the clean fingers or by means of suction. A small clay pipe may be used for this pur- pose, and the future mother may draw out the nipple by means of suction with this simple instrument. I am certain if this hygiene of the nipple is pursued that fissures of the nipple will be less frequent. Fissured Nipples.- — Ordinarily, if the nipple of the breast is kept dry and clean, it will not fissure and eczema will not occur. Fissures, however, sometimes occur even when great care has been taken to prevent them. Fissures or rhagades appear in about one-half of the nursing women. They are present either on the summit of the nipple or at its base. In the latter situation they are in the form of linear or circular ulcers. If fissures of the nipple are painful, the infant should not nurse the breast directly, but through a shield which protects the nipple, the best form being the Davidson shield. The fissure is painted once daily with a 10 per cent, solution of nitrate of silver. If there is a discharge of visible pus from the fissure, or if the breast nipple has a point of suppuration ever so small, the breast should not be nursed, for by so doing the mother may develop abscess of the breast or the infant may contract an infectious diarrhoea. Physicians insist on placing infants at the breast immediately after delivery, for two reasons: first, because it is said that suction at the breast favors contraction of the uterus. Whether with this function there is contraction of the uterus has not been proved. Again, it is said that at this time suction will favor the flow of milk. Milk with colostrum does not appear to an appreciable amount in the breast, if not previously present, before twenty-four to seventy- two hours or even eight days after delivery. If, as has been pointed out, the breast is nursed too frequently, the traumatism caused by a vigorous infant will give rise to erosions of the nipple, and thus fissures. An excellent nursing breast may be ruined by over-zealous efforts on the part of the physician. Fissures once present, if unyielding to the methods detailed above, must be allowed to heal by giving the breast perfect rest. Some women will nurse an infant at the breast, the nipples of which are the seat of fissuration, without pain, caking, or inconvenience. In other women caking will take MATERNAL NURSING. - 129 place, with intense pain on nursing, and lymphangitis and abscess result. In all such cases of pain, lymphangitis, and caking nursing is best suspended, the infant being placed temporarily on the bottle. The breasts are supported, the fissures painted daily with silver, and if caking is present the breasts are emptied carefully with the pump and massage of the breasts performed. If after the breasts become soft and the fissures are entirely healed there is still a little milk in the breast, the infant may be put again at such a breast, and if the organ is in a normal state the stimulation of suction will start a proper milk secretion. I have done this in a case in which the breasts had been at rest for three weeks after delivery, with excellent results. The milk returned in abundance, without unnecessary trau- matism to the breast, the infant nursing only three times daily at first. We should never expose a mother to the danger of abscess of the breast by persistent attempts at nursing fissured nipples. Caking of the Breast.- — After the birth of the infant, the breast should be closely watched to prevent the so-called caking of the milk. If the infant is not strong and does not nurse well, there will be a residual amount of milk in the breast. After nursing, this milk should be pumped off with a. breast-pump. The most satisfactory breast-pump is one with a glass bell and a rubber bulb. Pumping the breast at first, when the milk is forming, will prevent caking and rapidly regulate the secretion to the normal amount. On the other hand, if a fissure of the nipple is present, caking is more apt to occur, on account of the pain attendant on emptying the breast, either by nursing or by means of the breast-pump. We should be exceed- ingly cautious in these cases to examine the breast repeatedly in order that areas of caking may not escape us. If caking occurs, the breast should be rubbed or massage per- formed three times daily. The hands of the nurse are carefully washed and anointed with some sterilized oil. The breast is grasped in the palms of both hands, one above and the other beneath. The breast is then gently subjected to firm pressure with a vermicular motion. This massage is kept up for five or ten minutes. Nursing the Infant. — The infant should nurse about twenty minutes and then fall asleep at the breast. The nipple is washed with a solution of boric acid before and after each nursing, and is covered in the intervals of nursing with a small piece of absorbent gauze folded several times. In this way the nipple does not come in contact with the clothing, and any exuding milk is caught on the gauze, which is replaced by a clean piece whenever necessary. The infant while nursing should lie in the arms of the mother or the nurse. The nurse grasps her breast just behind the base of the nipple with the index and ring fingers; the thumb should be used 9 130 NUTBITION AND INFANT FEEDING. to exert pressure on the breast and thus regulate the flow of milk. In this way the infant is prevented from drawing the nipple too far into the mouth. The habit of moistening the breast with saliva or a few drops of milk is reprehensible. The infant's mouth will fur- nish all the moisture needed. Signs of Efficient Breast-feeding.— An infant nursed at the breast is thriving if it has a good color, if its weight increases in regular ratio, if it sleeps between the nursings, and the stools are normal in color. It may be said in this place that, as to the stools, they will vary even in the most thriving infant, both in color and consistence, from time to time. An infant who is otherwise in good health and is not suffering from any disturbance of the gut will have from time to time slightly fluid, yellow movements ; at other times the movements may contain a few whitish curds ; and at other periods, even the most thriving breast-fed infants may show in the stools greenish discolored particles. If the infant shows no other signs of disturbance and is in good spirits, these changes in the color and consistence of the movements should not give us concern ; they are dependent on the varying composition of the breast-milk. If the milk contains on certain days more fat than usual, the movements may be softer and more frequent than customary. If the proteids are increased in quantity they may even show a greenish tinge. These conditions, however, must be infrequent and should not carry with them disturbances, such as colic, restlessness, or stationary weight. I have seen infants who were thriving, in that they had a very good color and their weight increased, but they suffered from inordi- nate colic, and examination of the breast milk showed, even at the second month of infancy, quite a number of colostrum corpuscles. After certain hygienic hints were carried out by the mother, these colostrum corpuscles disappeared from the milk, the colic abated, and the infant returned to a normal condition. Disturbances, there- fore, of the gut are not always an indication for the cessation of maternal breast-nursing. Signs of IneflBcient Breast-feeding. — An infant is not thriving on the breast milk if its weight remains stationary for any length of time. For this reason infants should be weighed once a week at first, and after the second month at least twice a month. At the first indication of stationary weight an infant should be weighed every three days, in order to see whether there is any increase under new conditions. If the weight continues stationary the milk should be examined. It may be deficient in quantity to such an extent as to no longer satisfy the child. In that case the infant will be ob- served to nurse the breast for a long time, or it may nurse the breast MATERNAL NURSING. 131 a short time and then relinquish the nipple and cry ; or it may cry in the intervals of nursing. All these are signs of inefficient feed- ing. In such cases the breast should be examined just before a regular nursing, in order to estimate the quantity of milk in the breast. The infant should be weighed, then given the breast, and weighed after nursing is completed. The breast is also examined after nursing. In this systematic way we can estimate the amount of milk taken by the infant at that particular nursing. The movements of infants fed on an inefficient breast as to the quantity of milk are dry, constipated, and small. The author has seen the character of the stools improve upon increasing the quantity of food, either from the breast or by supplementing the breast with the bottle. In some cases the infant cries and has colic, the move- ments are passed with much flatus, and are uneven in consistence, lumpy here and there, with green discoloration. In such a case the quantity of the milk may be sufficient, but its quality is not up to the requisite standard. The nurse's milk should be examined not only chemically, but microscopically. A single chemical examina- tion of the milk, as has been stated, gives no definite information. The milk, therefore, of the morning and evening nursings should be examined. It may again be emphasized that colic alone or combined with slight variations in color and consistence of the infant's stools is not a justification for the suspension of nursing. An infant may gain in weight, have good color, and still have inordinate colic. With patience and hygienic exercise on the part of the nurse colicky attacks will ultimately grow less frequent, and many infants who suffered colic at first will, as the second month approaches, cease to have colic as soon as the milk has definitely assumed a uniformly normal composition. Infants who thus have suffered colic at the second or third month after birth will cease to be inconvenienced and will thrive from this time forward. If an infant at the breast fails to increase in weight, and at the same time suffers from inordinate colic, has green, curdy movements or a slight tendency to diarrhoea, it becomes a very important ques- tion as to whether it is not better to take such a child from the breast entirely, and to place it either on another breast or a substi- tute for the breast. An examination of the breast milk will aid us, as has been intimated elsewhere. If this breast milk reveals to any marked degree elements such as colostrum corpuscles and fails to show the characteristics of normal breast milk, we will still be more anxious to take such an infant from the breast. In fact, a con- tinuation of an infant at such a breast is sometimes not devoid of danger. In one case the continued attacks of colic, accompanied by 132 NUTRITION AND INFANT FEEDING. fLuid movements, with green curds from birtli, resulted ultimately in an attack of intussusception. This occurred in an infant five months of age. After the operation the infant was placed on the mother's breast again, and had a return of the former symptoms — constant colic, green curdy movements, alternating at times with slight diar- rhoea. It was taken off the breast immediately, placed on an artificial substitute, and throve. MIXED FEEDING. Mixed feeding is the administration of the breast, supplemented by the bottle containing some substitute for the milk lacking in the breast. Infants who are nursed on an inefficient breast as regards quantity of milk should be carefully weighed, and the quantity of milk in the breast estimated for the twenty-four hours. This may be done by weighing the infant before and after each nursing, or can be roughly estimated by simply observing the amount of milk that can be pumped off from both breasts combined two hours after •a feeding. Having measured the milk, we can estimate within cer- tain limits the amount of milk which such a breast would yield in twenty-four hours. If there is sufficient milk in the breast for even two nursings, the mother should not be denied the pleasure of nursing her infant. We should not hastily reject such a breast as worthless, for two feedings of breast milk will be a great aid to the infant, both in the development of bone and the other tissues of the body. If two nursings exist in the breast, we would give the bottle six times in the twenty-four hours to an infant below the age of three months, and five times in the twenty-four hours to an older infant. In feeding on the bottle in combination with the breast, we should begin as we do in the newborn, with a low percentage of fats and proteids. Having accustomed the infant to the bottle, we should gradually work up to the normal percentage of fats and proteids, as will be shown in the chapter on the Feeding of Infants. The details as to the construction of the food are the same as those followed out with the infant fed upon the bottle exclusively. Care should be exercised in these cases to avoid overfeeding. Mothers are especially prone to overfeed infants, having an idea that a fat baby is a healthy one ; but if it is explained to the mother that fat does not mean health, overfeeding may be avoided. This is especially true of mixed feeding; such infants are apt to be overfed and to be overweight, for the mother who has two nursings of the breast will be apt to consider this of very little moment and attempt to feed on the bottle, as if the infant had nothing from the breast at its disposal. The result is that such infants frequently suffer from overflow vomiting. In many cases this overflow vomiting does not ARTIFICIAL FEEDING OF INFANTS. 133 seem to disturb the infant to any appreciable degree. It should be avoided, however, for such vomiting may at any time become a matter of serious moment. ARTIFICIAL FEEDING OF INFANTS. Artificial feeding of infants is the substitution for the breast milk of some one of the foods considered in the previous pages. Although attempts have been made to rear infants artificially on asses' or goats' milk, the experiment has failed, and cows' milk is universally utilized as a substitute for the mother's breast in artificial infant-feeding. Before cows' milk can be given to the infant as a food it must be modified, that is, the fats, proteids and sugar must be rearranged and diluted into an easily assimilable mixture. There are two methods now well recognized of modifying cows' milk for infant-feeding. One of these methods is the so-called labora- tory method of infant-feeding. The laboratory method or Botch's method of infant-feeding attempts to recombine the fat, proteids, and sugar of milk not only in proportions which conform to what is found in human milk, but to attempt to find out, by the frequent changing of these constituents, what is best adapted to each infant. Rotch and his school contend that what is good for or adapted to one infant may not be suitable for another. In his own words : " What is one infant's food may be another's poison." The Eotch method of infant-feeding has now had a very extensive and thorough trial. Its successes and failures will be considered later on. The difficult cases of infant-feeding baffle the most skilful efforts at modifying cows' milk. It is fallacious to assume that the proteids and fats of cows' milk can be assimilated without change in the economy. The old methods of infant-feeding considered simply the dilution of the whole milk two or three times, either with simple water or with some decoction of a cereal, either barley or arrowroot. In the first month the milk was diluted one in three ; in the second month, one in two ; in the third month, two in three, etc. These simple methods continued in use until Biedert, in Germany, and Meigs, in the United States, attempted to proportion the casein, fat, and sugar so as to make the mixture approach the composition of human milk. Biedert called his food a cream mixture. It was made in the same general way as Meigs' mixture. There was a low percentage of proteids, and a fat percentage corresponding to what is found in human milk. The proteids in Meigs' mixture ranged from 1.2 to 1.5 per cent. In Biedert's mixture the proteids existed to the extent of 1 per cent., fat 2 to 2.5 per cent., sugar 4 per cent. Meigs' mixture contains 3.5 per cent, of fat and 6 per cent, of sugar. 134 NUTRITION AND INFANT FEEDING. Biedert's Mixture. — Biedert took 50 ounces of milk, or 1.5 litres, and allowed it to stand one hour. The cream taken off the top of this milk contained 10 per cent, of fat. The amount of cream was 8 ounces. In other words, the top 8 ounces off 50 ounces of milk was a 10 per cent, top cream. It will be seen from this that his top milk method is identical with that now in vogue in this country. With this he constructed the following formulae. Number of mixture. Cream (10 per cent.). Water. Milk-sugar. Milk. Casein. Fat. Sugar. Litre. Litre. Grammes. Litre. Per cent. Per cent. Per cent. I. i 1 18 (= 1.0 2.5 5.) II. i f 18 tV (= 1.4 2.6 5.) III. i 3 s 18 i . ( = 1.5 2.6 5.) IV. i s s 18 i (= 1.8 2.8 5.) V. i 3. 18 8 (= 2.1 2.3 5.) VI. 1 4 12 1 2 (= 2.3 2.4 5.) If we compare these formulae with Meigs' mixture, we find that Meigs contended that the infant needed through its whole nursing period practically one formula. Meigs therefore had : 1. A 16-ounce top milk [7 to 8 per cent, of fat]. 2. A solution of milk-sugar, 15 per cent. 3. A solution of lime-water. He combined them as follows : !3 ounces of top milk. 3 ounces of sugar solution. 2 ounces of lime-water. This, according to our present methods, would give approximately a mixture of 3 per cent, of fat, 1.3 per cent, of proteids, 6 per cent, of sugar, which is also what Meigs strove for, with the exception that in some milks, as has been shown, more fat would be obtained than that given above, which is calculated from an average milk. With some milks Meigs obtained 4.7 per cent, of fat. To be more concise, Meigs designed the above method to obtain : Water 87.6^. Fat 4.7 Casein 1.1 iMeigs' artificial food. Sugar 6.2 Salts 0.2 J It will be seen from the standpoint of to-day that both these men were pioneers of percentage feeding. It may be mentioned here that ABTIFICIAL FEEDING OF INFANTS. 135 the method of Escherich is based on an attempt to calculate with rough dilutions of milk the amount of albumin necessary for the daily maintenance of nutrition. So far as the author knows, the Escherich method is little in vogue in America. The other two methods of modifying milk, which calculate the gross amount of calories necessary to maintain nutrition for infants, are the Huebner-Hoifman and the Soxhlet method. They have en- deavored to construct a chemical mixture with the aid of cows' milk which is equal to the raw nutritive calories in mother's milk. In both these methods the milk is diluted with an equal amount of water. Huebner-Hoifman uses as a diluent a 6 per cent, solution of milk sugar whereas Soxhlet uses a 9 per cent, solution. The addition of sugar of milk is intended to take the place of fats, which are de- ficient in these mixtures. Sugar of milk, according to Soxhlet, has a caloric value equal to that of the fat deficit. If it is desirable to feed a great number of infants in a public laboratory, I can say from actual experience that these mixtures are of the greatest utility, inasmuch as they can be easily prepared, and certainly the greater number of infants thrive on them. It is almost impossible in a laboratory intended for the use of the poor of a great city to give each child a percentage mixture. In other words, the feeding en masse is an entirely different problem from the feed- ing in private practice. Infants from the first to the third month do not thrive as well on the Huebner-Hoffman and Soxhlet mixtures as they do on modifi- cations obtainable by the home method, which will be described. In other words, infants below the third month get in these mixtures an excess of proteids and deficiency of fat. The Meigs' mixture is more applicable to these cases. The Rotch Method.- — The method of Rotch has as its pivotal point the fact that all infants cannot be fed on the same mixture, and, taking the composition of human milk as a working basis, each infant should be considered as a separate problem in constructing a formula which within certain limits would be most suitable to its needs. Rotch therefore separates the milk from the cream by means of a separator or by gravity, and working with skimmed milk and cream containing 16 or 20 per cent, of fat and a dilution of milk-sugar, the constituents of the milk are rearranged. By this method an infant can be fed on a mixture of 1.5 per cent, of proteids, 3 per cent, of fat, and 6 per cent, of sugar; or 1.5 per cent, of proteids, 2.5 per cent, of fat, and 6 per cent, of sugar, or any percentage of proteids, fat, and sugar that we may desire to give. Rotch also contends that an infant which may not thrive on 1.2 per cent, of proteids might do so on 1.5 per cent. The proportion of fat may be reduced or increased 136 NUTRITION AND INFANT FEEDING. as needed in the individual case. In other words, the physician should consider his percentage formula in feeding the infant, just as he prescribes a certain strength of a drug. To obtain these percentages a laboratory is needed, and to-day laboratories for supplying these mixtures to be used in the percent- age feeding of infants are to be found in large cities. Though theoretically this method of reconstructing the milk would seem on the surface to be the most rational, it has certain inherent defects. These defects are much the same as those of the older methods. 1. By simply rearranging the proteids, fat, and sugars we do not change the proportionate relationship which the casein or caseinogen bears to the lactalbumin and other proteids of the milk, and we do not in any way change the foreign nature of these to the human economy. 2. With the exception of a few limited facts and formulae we have no data which, with our present knowledge, will enable us to know in every case when to increase or to diminish the proteids and also the fats. 3. The process of separating the cream from the milk by ma- chinery destroys the original delicacy of the fat-emulsion in the milk. The infant does not assimilate these mixtures in every case as well as those which are constructed from milk which has not been manipu- lated to the extent that laboratory milk has. In order to utilize the Rotch method by means of the laboratory, the physician has simply to prescribe the percentages that he re- quires on a slip made out for the purpose and furnished by these laboratories. It is needless to say that unless a physician is satis- fied to follow a routine common to all his cases, instead of trying to understand the needs of each infant, he is certain to meet cases which even the most accurate modifications of the laboratory will not cause to thrive. In other words, the laboratory alone will not enable the physician to feed infants successfully. To do this he must know not only the percentages required at certain ages from constructed formulae, but must study the digestion of each child, its movements, and try to analyze whether certain elements of the milk such as the fats are in excess or in diminished quantity. It may be said that in practice children can get along on a very few fixed formulse. An infant which will not thrive on these formulae within certain limits will not thrive on any percentage modification of cows' milk, no matter how we may rearrange the percentages of its in- gredients. Principles Underlying the Rotch Method of Percentage Feeding. — As has been intimated, we must distinguish very carefully between infants who are quite normal and those suffering from intestinal dis- AETIFICIAL FEEDING OF INFANTS. 137 turbances in feeding them with cows' milk. The healthy infant needs but very few changes of formulae throughout its infant life. The first fact to be ascertained is whether the infant is capable of digesting cows' milk at all. If such is the case, by a careful be- ginning and modification of milk we can carry the infant along on very few formulae, possibly three or four, through its period of infancy. Proteid. — The total amount of proteids in the cows'-milk mix- tures must be very low for the newborn infant, certainly not to exceed 1 per cent, during the first week. After this the proteids are increased or kept at this point until the third month, when they are increased to about 1.5 per cent., and we may increase them until the ninth month. For vigorous infants of heavy weight we may increase the proteids at the sixth month to 2 per cent. Fats.— The fats in the first days after 'birth should be low — from 1.5 to 2 per cent. After the second week to the third month we may give from 2.5 to 3 or 3.5 per cent, of fat; rarely more than this. The reason for this is that during this period the infant will not digest more fat. Infants who are getting a larger amount of fat than the percentage indicated will, as the nurse puts it, frequently " spit up " curds between the feedings. All the movements will be frequent, soft, and in some cases even of an oily consistence or soapy in look and constipated. In other words, infants who are taking a greater proportion of fat than that indicated will have a mild fat- diarrhoea, which may at any time become more severe and give rise to considerable concern. From the third month to the termination of infancy the fats may range from 3 to 3.5 or even 4 per cent. ; never more than this. Infants who are taking high percentage fat mixtures will increase in weight, up to a certain point apparently thriving, and then will be noted to become pale, with constipated, dry, formed movements. Sugar. — In modifying milk the sugars are placed in the mix- ture at a uniform percentage of 6 per cent. It is rare for us to be called upon to alter this percentage to any considerable extent. Too much sugar will cause in some cases fermentation in the gut, result- ing in the production of gas. The children may thrive for a time on an excess of sugar ; but in all these cases, sooner or later, a point is reached at which the sugar is no longer tolerated in large percent- ages. It is therefore unwise to give a larger percentage of sugar than that indicated. Salts. — The salts of the cows' milk are scarcely considered in modifications. We know very little to-day about the fate of the salts in the cows' milk — how much of them are absorbed and exactly how much rejected by the intestine. It has been intimated in an- other paragraph that the heating of the milk causes a complete loss 138 NUTBIIION AND INFANT FEEDING. to the economy of the salts present in cows' milk ; but inasmuch as the heating of milk is coming more and more into disuse, and more pro- nounced efforts are being made to obtain a pure milk which can be administered with as little heating as possible, we have still to learn the fate of the salts in sterilized. Pasteurized, or raw milk, and the indications for adding equivalents of soluble salts to the milk for the feeding of infants. A Schedule of Percentages Adapted to Infants of Various Ages. Age. Proteids. Fat. Sugar. Premature infants . One to seven days Seven to fourteen days Fourteen to thirty days One to three months Three to six months Six to nine months Nine to twelve months Per cent. 0.33 0.50 0.80 1.00 1.25 1.50 1.50 to 2.00 3.05 Per cent. 1.00 1.50 2.50 3.00 3.75 3.00 to 4.00 3.00 to 4.00 4.00 Per cent. 5 to 6 5 to 6 5 to 6 5 to 6 5 to 6 5 to 6 5 to 6 5 to 6 Number of Nursings, with the Quantity of Milk Necessary for the Infant. — The quantity of milk which should be given to the infant at each feeding from birth to the ninth month has been variously estimated. The capacity of the stoinach alone would be a crude and most unscientific standard, for this would not, in artificial feeding at least, follow nature's method with breast-feeding, for from birth the amount of milk furnished to the infant by the human breast daily does not always accord with the full capacity of the infant's stomach. It will be found that the quantity fed to the breast-fed infant is much below the stomach capacity if the infant is fed at frequent intervals, and, as has been shown in Ahlfeld's baby, equal to or even above it if nursed at long intervals. With artificial feeding, moreover, we know that there is a great waste in feeding infants upon cows' milk, and were an infant fed on exactly the same amounts of modified cows' milk as some of the breast-fed infants obtain from the breast, it would not increase regularly in weight and might even starve. The age of the infant, also, is not a guide, for what would be a suflBcient amount for one infant might not be sufiicient for an- other, or might be even an excess. In all cases the capacity of digestion must be taken into account, and also the development of the child. Some vigorous infants will take more food than other infants of the same age that are not as well developed physically. More rational is the method of arriving at the amount to be given at each feeding which takes into consideration not only the capacity ARTIFICIAL FEEDING OF INFANTS. 139 of the stomacli, but the age and the amount of primary food ele- ments necessary to maintain nutrition and to increase body-weight of the infant at various ages. If we calculate the amount of albumin or proteids or fat necessary per kilogramme of the body- weight to maintain nutrition, we shall have the more scientific method of determining the quantity of milk to be taken daily by the infant. This method has been advocated by Huebner and Kubner and also Escherich. The difficulty of calculating what is known as the calories neces- sary to the maintenance of nutrition and body-weight — and by calories is meant the amount of albumin or proteids, fat, salts, and water mentioned above — is, that the physician cannot always have at his disposal a method by which these calculations can be made. In other words, they must rely on investigations made by others, and understand that the results as they are presented to us to-day in infant-feeding are based on actual calculations of the amount of calories necessary to the infant. It has been found that the nutrition of artificially fed infants cannot be maintained by an amount ol proteid of cows' milk equal to that taken in the breast milk. In other words, the proteid equivalent can be obtained, but other constituents, such as fat, would be at fault, as well as the daily quantity of food, were we to depend entirely upon the caloric method. The figures given to the student and physician to-day, therefore, are a combination of what has been found empirically to be needed, and what has been verified in the chemical laboratory to be absolutely necessary. Let the student therefore study the amount of breast milk consumed by the infant in the twenty-four hours, and compare these amounts with the amounts consumed by the bottle-fed infant in the same period of time. Number of Nursings Daily and Quantity of Each Feeding for the Artificially Fed Infant. — If we now attempt to apply the knowl- edge acquired in the study of the breast-fed infant to the artifi- cially fed infant we meet with the following obstacles : Cows' milk taken in the same quantities, as has been said, is not as completely used up by the gut as breast milk. There is much more waste, as has been shown by Knopfelmacher and Camerer. This waste is caused chiefly by the failure of the gut to assimilate completely the casein and the fat of the cows' milk. The stools, also, of bottle- fed infants are more numerous and of greater total bulk than those of breast-fed infants. In view of the lack of definite knowledge on all these points, the quantities of modified cows' milk which should be given at each feeding to the infant are still, as has been intimated, only approximate. The amount of calories necessary for the maintenance of nutrition and a definite increase of the body- 140 NUTRITION AND INFANT FEEDING. weight will be shown elsewhere, and the student may compare the tables given with the equivalent calories in the total amount of breast milk and cows' milk given to the breast-fed or artificially fed infant. He can therefore satisfy himself of this fact that the older authors, and even some of the most recent writers, underfeed their infants, if the food which they prescribe is strictly adhered to in quantity and composition; and such is the fact, for many of these infants I found by observation not only to be underweight, but in some cases they fail in complete assimilation of their foods. The physician must also understand, however, that only a few of these formulae and state- ments really epitomize the limit of our knowledge to-day, and future investigators must complete that knowledge. Table Showing the Number of Feedings and Quantities of Modified Milk to be Given to Artificially Fed Infants. Age. First day Second day Third day Fourth day Seventh day Second week Fourth week or first month . Two months Three months Four months Five months Six months Seven and eight months . . Nine months Number of feed- ings daily. 8-10 8-10 8-9 7 or 8 7 7 6 or 7 6 6 6 Quantity at eacli feeding. Co. Oz. 10 20 30 1 40 50 60 2 60 2 90 3 120 4 150 5 180 6 210 7 240 8 250 8^ Total to be given in 24 hours. C.c. 30 160 240 320 400 480 480 630-720 840 1050 1080-1260 1260 1440 1500 Oz. 1 5^ 8 lOf 13^ 16 16 21-24 28 35 36-42 42 48 50 The increase in the amount of milk from the seventh to the ninth month is not so apparent, since at this period we, as a rule, begin to feed cereals in addition to the milk. The above figures are not absolute, but only approximate. Some infants may require a half-ounce or more than the quantities indi- cated ; others will be satisfied with less nursings. In all these items an observant student of the infant will, guided by the observations of the nurse of the infant, discover the indications in each case for himself. Household Modification of Milk for Infant-feeding. — The accu- racy obtained in home modification is as well adapted to the feeding of infants as the laboratory percentages. The advantages of home modification of cows' milk for infant-feeding may be stated briefly as follows : The family and the physician can be independent of the modifier at the laboratory. The milk is manipulated as little as ARTIFICIAL FEEDING OF INFANTS. 141 possible. If the infant does not thrive, we can say definitely what is at fault. The home modification of milk for infant-feeding depends on the fact that in large cities, and in places where milk is obtainable from the dairy within a reasonable time, the milk can be separated by gravity into top milk or cream and skim milk, and this separation takes place in certain definite proportions. Meigs, Biedert, and Chapin showed that it is possible to construct from top milk per- centage mixtures, inasmuch as the top milk prepared in the manner to be described has an average constant percentage of fat, proteids, and sugar. QUART BOTTLE OF MILK BEFORE CREAM HAS RISEN Tig. 25. QUART BOTTLE OF MILK FAT IN different portions AFTER CREAM HAS RISEN removed from the top AND MIXED. GRAVITY CREAM CONTAINS m to 24,". FAT FAT 3^ TO 5j« PROTEIDS 3^T0 4i{ SUGAR 4^ TO 6^ FAT AND PROTEIDS ARE NEARLY EQUAL EXCEPT IN VERY RICH MILKS TOP 2 OZS. MIXED 24)< FAT REMAINING MILK OR SKIM MILK FAT .Zf, TO 1.Bi< PROTEIDS 3i«T0 4iS SUGAR 4^ TO 6^ ' 3 OZS. " 22.5je " ' 4 OZS. •' 2\Ai " 5 OZS. " 19.2!<" 6 OZS. " 16.8^" 7 OZS. " 8 OZS. " 9 OZS. " 10 OZS. " 1B.0;<" 13.3;S" 11.5:« " io.5;s " 12 OZS. " 9.0^" 14 OZS. " 7.8^" 16 OZS. " 7.0i«-' 18 OZS. " 6.3;J" 20 OZS. " B.0;2" 22 OZS. " 5.4:^ " 24 OZS. " B.0;8 *• 26 OZS. •• 4.7^ " 28 OZS. " 4.B^ " 30 OZS. " 4.3f, " ALL MIXED AM " Diagram illustrating the formation of top milks in quart bottles, so-called setting process. Modified from the diagrams of Chapin. Top Milk. — In this country the custom of delivering milk in so-called quart bottles is almost universal. The milk is placed in these bottles at the dairies, and when it reaches the consumer, it is set, as it is termed, into a top creamy layer above, and a milk poor in fat, so-called skim milk, below (Fig. 25). In the supernatant creamy fluid, or top milk, we find certain definite percentages of fat. In modifying milk in the home, the top 142 NUTBITION AND INFANT FEEDING. lajer as it separates from the milk is utilized as it is delivered in quart bottles. Chapin has found that if a number of milks deliv- ered in the citv homes are analyzed, the first 9 ounces from the top of the quart bottle of milk will contain all the way from 12 to 16 per cent, of fat, varying with the richness of the milk in fat. Twelve Per Cent. Top Milk. — If the original milk contains 4 per cent, of fat, the first 9 ounces will be what is known as a 12 per cent, top cream. If the milk is a very rich milk containing butter fat to the extent of 5 per cent., the top 9 ounces will contain 16 per cent., approximately, of fat. The proteids are quite constant in the top milk and are equal to those found in the skimmed milk. In other words, in milk rich in butter fats the top milk contains fat in proportion to the proteids of 3 to 1. If the milk is poor and only contains 3 per cent, of butter fat, the first 9 ounces will contain generally 9 per cent, of fat, and this milk will contain 3 per cent, of proteids, so that the percentage of fat to proteids still remains 3 to 1. It may be said at the start that the student would do well not to consider the thin milk as existent, for most milk, either in the city or throughout the country, contains at least 4 per cent, of butter fat. Seven Per Cent. Top Milk.^ — Another top milk to be considered is the so-called first 16 ounces taken from a quart of milk. If the milk is a rich milk and contains 5 per cent, of butter fat, the first 16 ounces will contain 9 per cent, of fat. If it contains 4 per cent, of butter fat, the first 16 ounces will contain 7 or 8 per cent, of fat. The fat in both of these instances is present in a proportion of 2 to 1, as com- pared to the proteids. The physician would do well to assume in making his modifications that he is dealing with a rich milk. In this way he will avoid giving mixtures which contain too much fat, which element gives the most trouble if present in too great quantity. If the student will therefore simply consider the top 9 and 16 ounces of rich milk, he will have sufiicient material for feeding the infant up to the ninth month of infancy. He should therefore try to per- fect himself in the methods of utilizing top milk in which the fat is present, as compared to the proteids, in the proportion of 3 to 1, and a more dilute top milk in which the fat is present, as compared to the proteids, in the proportion of 2 to 1. In feeding infants up to the third month it is convenient to use a top milk in which the fat is present, as compared to the proteids, in the proportion of 3 to 1. In other words, it is best to use the first 9 ounces of top milk, for by this method we can obtain, as will be shown by the tables, a smaller percentage of proteids and the requisite percentage of fat indicated in the earlier periods of infancy. From the third to the sixth month it is advisable to use a top milk in which the fat is present, as compared to the proteids, in the proportion of ARTIFICIAL FEEDING OF INFANTS. 143 2 to 1, for in this way we can obtain a larger percentage of proteids and more fat from one bottle of milk than we could if we use a smaller amount of richer top milk in which the fat is present, as compared to the proteids, in the proportion of 3 to 1, for in the latter case we shall be compelled to use 2 bottles of milk. This can more readily be understood by reading the subjoined tables indicating the percentages at the various ages. Chapin, for the purpose of obtaining the top milk, has devised a small dipper. The use of the dipper is convenient but not necessarily essential. If the top milk is poured off carefully, equal accuracy is obtainable without the use of the dipper. Top Milk Made at Home.^ — In cities milk is delivered in quart bottles, and in many places in the country this is also the case. But if the practitioner is living in a district where bottled milk is not sold or not obtainable, it is quite necessary that he should understand that there is no mystery about bottled milk. Any milk obtained shortly after milking and placed in a wide-necked bottle or utensil with a capacity of one quart will separate the top milk, or set, as it is called, in the manner previously described under the heading of Top Milk. This setting process takes place within four hours after the milk is placed in the utensil, so that, if the practitioner has not access to bottled milk, he can be accurate if he will obtain an ordinary quart utensil, such as a pitcher, and place the milk in the same as soon after the milking as possible, setting it aside for four to six hours, and then proceeding according to directions given. Such milk will show the separation into the skim milk and creamy layer, as described elsewhere. There should be no visible dirt or dark specks in the bottom of the bottle, for such milk is unwholesome and should not be given to the infant. The milk should have no peculiar odor, for no matter how carefully modified, such milk will be rejected by the infant. If mixed with equal portions of TO per cent, alcohol, milk when heated in a test-tube should not curdle. In other words, we should begin with a good, fresh, clean milk. The Home Preparation or Modification of Milk for Infant- feeding.- — In what follows it must not be forgotten that the formulse and statements are directed toward the management of distinctly nor- mal cases. We will consider the percentage modification of cows' milk in the household, presupposing that there are no difficulties in the way of complete assimilation by the infant. The Method of Calculating Percentages.^ — Taking the milk in quart bottles as a standard we know that in the first 9 ounces of top milk the ratio of fat to proteids is as 3 to 1, and in calculating any percentages, whether we fix on the proteids or on the fats as a method 144 NUTRITION AND INFANT FEEDING. of calculation makes very little difference, provided we remember this proportion. For example: If we calculate on a formula con- taining 3 per cent, of fat, and we desire to construct this formula with the first 9 ounces of top milk, the proteids in that formula will be 1 per cent. If we wish to give 0.25 per cent, proteids from the first 9 ounces of top milk, the fat must necessarily exist in a per- centage of 0.75. It is well, therefore, for the practitioner simply to fix in his mind what percentage of one or the other ingredient he desires to give to the infant, calculate upon that, and the fat or pro- teid will exist in that formula in the ratio indicated. The author, for convenience, fixes the amount of proteid which he wishes in his mixture, multiplies that by 3, to obtain the percentage of fat that would exist in that mixture, and proceeds in the following way : An infant at birth, for example, will receive 0.5 per cent, of proteids, its ■fats would be 1.5 per cent., if constructed from the first 9 ounces of top milk. Let us suppose, for example, that a 12 per cent, top milk is to be used, and that the total amount to be given in twenty-four hours is 8 ounces. We wish to reduce the percentage to 1.5. The question involved is, " How much of the 12 per cent, top milk must be used to make a 1.5 per cent. 8-ounce mixture?" The following mathe- matical statement simplifies the process : If of a 12 per cent, top milk you would use 8 ounces in twenty- four hours, to make a 1 per cent, top milk you would use xV of 8, equal f ounces. To make a 1.5 per cent, top milk you would use 1.5 times f , equal 1 ounce. One ounce, then, of a 12 per cent, top milk, diluted 7 times, will give an 8-ounce 1.5 per cent, mixture. How to Work Out the Above Percentages of Fat, Proteids, and Sugar. — Problem 1. — Let the physician take, for example, a premature infant. By referring to the schedules it is seen that such an infant should have 10 or 12 feedings in the twenty-four hours. The most assimilable mixture should have a strength of 0.33 per cent, proteids, 1 per cent, of fat, and 5 or 6 per cent, of sugar. Such an infant should have 12 feedings, each \ ounce, making a total of 6 ounces for the twenty-four hours. If a 12 per cent, top milk is utilized, inasmuch as the fat-percentage of our mixture is 1 and that of our top milk is 12, the total quantity in the twenty-four hours being 6 ounces, we need tV of 6, equal -J ounce of this 12 per cent, top milk, which must be diluted by 5-J- ounces of water or barley-water, as the case requires, in order to obtain a mixture of 6 ounces containing 1 per cent, of fat. In order to get the requisite percentage of sugar of milk which, when mingled with the diluent and the -2- ounce of top milk, will ARTIFICIAL FEEDING OF INFANTS. 145 approximate 5 per cent., 2 teaspoonfuls of sugar of milk should be dissolved in the diluent before adding the top milk. Problem 2. — The infant is one month old. Such an infant would assimilate best a mixture apj)roximating 1 per cent, of proteids, 3 per cent, of fat, and 5 per cent, of sugar. It would need 10 feedings in the twenty-four hours, each containing 2^ ounces, making a total quantity of 25 ounces. If the 9-ounce top milk is used (12 per cent, of fat) we would proceed as follows : The percentage of fat desired being 3, and the total daily quantity being 25 ounces, we would have to take \2, of 25, equal to ^\ ounces of 12 per cent, top milk, with 18f ounces of the diluent, which should contain 6 per cent., of milk- sugar, or Y teaspoonfuls. Problem S. — The infant is four months old, and it is desirable to construct its formula from the 16-ounce top milk (7 per cent, fat), ratio of fats to proteids 2 to 1. The percentages most adapted at this age would be 3 of fat, 1.5 of proteids, and 5 of sugar of milk. This infant should have 8 feedings in the twenty-four hours, each containing 5 ounces, a total of 40 ounces of food in the twenty-four hours. The percentage of fat being 3, that of the top milk Y, and the total amount of food being 40 ounces, there would be needed % of 40, equal to 17 ounces of top milk, with 23 ounces of the diluent, to which is added 6 per cent, of milk-sugar, or 9 teaspoonfuls. For the above formula it will be necessary to use 2 bottles of milk, taking 16 ounces off each, mixing them together, and of these 32 ounces to utilize 17. Problem Jf. — The infant is six months of age, and would need 7 feedings, of 7 ounces each, making a total of 49 ounces for the twenty- four hours. The formula most adapted in this case would be 3 per cent, of fat, 1.5 per cent, of proteids, and 5 per cent, of sugar of milk, utilizing the top 16 ounces of a bottle of milk, the percentage of fat in the formula being 3, that of the top milk 7, and the total amount of the food being 49 ounces, there would be needed % of 49, equal to 21 ounces of top milk ; 28 ounces of the diluent will be neces- sary, containing 5 per cent, of milk-sugar, or 9 teaspoonfuls. It will be necessary in this case, also, to utilize two quart bottles of milk to obtain 21 ounces of 16-ounce or 7 per cent, top milk. That is, 32 ounces of this top milk are obtained, and of these 21 ounces only are utilized. Problem 5. — The infant is nine months of age. In this case 6 feedings will be given in the twenty-four hours, each containing 8 ounces, making a total of 48 ounces. The formula most adapted to this age would be 4 per cent, of fat, 2 per cent, of proteids, and 5 per cent, of milk-sugar. The percentage of fat being 4 in the formula, that of the top milk 7, and the total quantity of food for the twenty- 10 146 ' NUTEITION AND INFANT FEEDING. four hoiTrs being 48 ounces, the physician -would need tr of 48, equal to 25 ounces of 7 per cent, or 16-ounce top milk, 23 ounces of the diluent, and enough sugar of milk to make a 5 per cent, solution. Problem 6. — An infant six months of age, for therapeutical rea- sons, is to be put on a formula containing 1.5 per cent, of fat, 0.5 per cent, of proteids, and 5 per cent, of sugar. Here the percentage of fats to the proteids is as 3 to 1, therefore it will be convenient to use the top milk containing 10 to 12 per cent, of fat and 3.5 per cent, of proteids. It is desired to give the infant 7 feedings of 7 ounces each, making a total of 49 ounces. The percentage of fat being 1.5 in the formula, and that of the top milk being 12, the total quantity for the twenty-four hours being 49 ounces, the physician would need 1.5 —^ — of 49, equal to 6^ ounces of top milk, 42|- ounces of the diluent. In order to get a 5 per cent, solution of the milk-sugar there would be needed in this case 5 per cent, of 42 ounces, equal to 18 teaspoonfuls of the milk-sugar. It frequently happens with infants above three months of age taking a modification of the 16-ounce top milk that constipation will set in, and we wish to increase the fats in order that the movements may be less constipated. In order to do this we must obtain, a top milk which is richer in fat than the top milk we are giving. To illustrate: The infant who is taking a third dilution of the 16-ouuce top milk will be taking approximately 2.5 per cent, of fat, 1.2 to 1.5 per cent, of proteids. If we wish to increase the fats to 4 or 3.5 per cent, and retain the proteids we are administering to the infant, it will be impossible to do this with the 16-ounce top milk, for any dilution of this milk will vary the proteids. We are therefore com- pelled to resort to the utilization for such an infant of the 9-ounce top milk, which contains an average of 10 to 12 per cent, of fat. By diluting this one-third we would get about 3.5 to 4 per cent, of fat and still retain the same percentage of proteids as in our original mixture. An infant four months of age, taking eight bottles, 5 ounces each, would need 40 ounces for its daily mixture. TTe would therefore be compelled to use, in order to obtain the 9-ounce top milk, 2 quarts of milk, from each of which 9 ounces would be taken, making 18 ounces of top milk. This, after being thoroughly mixed, would be utilized to the extent of 13 ounces for our mixture, giving 27 ounces of the diluent, whatever that may be, we would have a formula of 3.5 per cent, fat, 1.3 to 1.5 per cent, proteids. It should be understood that the percentages of fats given in these tables are only approximate, for there is no milk which will yield an absolute fixed percentage of fat in the top milk obtained by gravity, without variation, from day to day. The proteids, however, are ARTIFICIAL FEEDING OF INFANTS. 147 more constant in percentage; but even here in modificatioiL we can only obtain approximate accuracy. Though these tables contain 8 modifications each, some of them differing but ^ of 1. per cent, either in the fats or the proteids, such minutiae are not really needed or even Formulce constructed with top 9-ounce milk, having an average composition of 12 per cent, fat, 3.5 per cent, proteids, 4 per cent, sugar. Possible combinations. Fat. Proteid. Su gar. 1.00 per cent. 0.33 pe r cent. 5 pel • cent. 1.50 " 0.50 5 2.00 " 0.66 5 2.50 " 0.83 5 3.00 " 1.00 5 3.50 " 1.20 5 4.00 " 1.33 5 4.50 " 1.50 5 Formulce constructed with top IQ-ounce milk, having an average composition of 7 per cent, fat, 3.5 per cent, proteids, 4 per cent, sugar. Fats to proteids 2 to 1. Possible combinations. Fat. 1.00 per cent. 1.50 2.00 2.50 3.00 3.50 4.00 Proteid. Sugar. 0.50 per cent. 5 per cent. 0.75 " 5 1.00 " 5 1.25 " 5 1.50 " 5 1.75 " 5 2.00 " 5 Whole milk having an average composition of 4 per cent, fat, 3.5 per cent, proteids, 4 per cent, sugar. Fats to proteids S to 7. Pos- sible combinations. Fat. Proteid. Sugar. 1.00 per cent. 0.85 per cent. 5 per cent. 1.50 1.32 " 5 2.00 1.60 " 5 " 2.50 2.15 " 5 3.00 2.60 " 5 3.50 3.00 " 5 " 4.00 3.50 " 5 possible in practice. It will be found best to master 3 or 4 modifica- tions of top milk, constructed either from the 9-ounce top milk or the 16-ounce top milk, and utilize these in general practice. For exam- ple: The infant who is taking 1 per cent, of fat and 1.33 per cent, of proteids may do just as well on 1.2 per cent, of fat and 1.50 per cent, of proteids. For all practical purposes, therefore, formulae which contain 1.5, 2.5, and 3.5 per cent, of fat will be as available in practice as formulae containing 1, 2, and 3 per cent, of fat. Referring to the proteid percentages, it will be seen that certain 148 NUTRITION AND INFANT FEEDING. of them are in heavy-faced type. Both in the laboratory and at home it is impossible to obtain an accuracy which will assure the physician that he is administering to his patient 0.66 and not 0.5 per cent, of proteids, or some intermediate figure ; nor can he be certain that his mixture, even if prepared at the laboratory, contains 1.23 or 1.33 per cent, of proteids, rather than some slightly higher or lower figure. The reason for this is that the proteids of cows' milk, like the fats, must vary from day to day, and thus no absolute fixed average per- centage of proteids can be counted on. Konig, in an analysis of several hundreds of milks obtained from a number of herds of cows, shows that the proteid percentages in milk vary, not only at different seasons of the year, but at times of the day, and also with different kinds of fodder. It is therefore illogical to attempt the working out of minutise of percentages varying from 0.2 to 0.3, when the original milk has not a fixed average percentage. To obtain accuracy within the difference between 0.2 to 0.3 per cent, would necessitate a chemical analysis of the milk before each modifi- cation is made, a manifestly impracticable procedure, especially as regards the proteids in the milk. The author has gone into these matters to show that the elaborate tables given by some are, on careful analysis, impracticable. It is well, therefore, for the physician to feel assured that with the proteids, as with the fats, approximate formulae with averages of 0.25, 0.5, 1, 1.5, 2, and 2.5 per cent, of proteids are as effective in practice as minute fractional percentages, if such were attainable. Too High Fat-percentages and Their Remedy. — If Problem 4 is studied it will be seen that 2 bottles of milk must be utilized in order to obtain the requisite 21 ounces of top milk, and if this is so for the sixth month, more of this top milk will be required for the seventh and eighth months. Some infants will not thrive on such a large amount of fat. In the summer especially they will spit uj), and have several loose movements dail}^ Or they become anremic and constipated, with dry, soapy movements. In the face of such difficulties I follow the plan of using only 1 bottle of milk ; and, if after the fifth month (Problem 3) more than 16 ounces of top milk are required, I take these off the top of the bottle, adding the rest as diluent. Thus, at the sixth month, 21 ounces off the top of a quart of milk to 28 ounces of diluent. At the seventh month, 23 ounces off the top of a quart of milk to the required amount of diluent. At the eighth month, 25 ounces off the top of a quart of milk to the required amount of diluent. The amount of diluent is calculated as in the foi'iiici' tables. By this iiictliod of simply increasing the amount of milk taken off the top of one <|iiai't of milk after the sixth month, we arrive at a ARTIFICIAL FEEDING OF INFANTS. 149 point (the tenth or eleventh month) when the infant is taking a full quart of milk with diluent daily. This method, which is exceedingly simple, and which in summer particularly does away with the danger of excess of fats, has served me well. If this method is pursued, the strict calculation of percentages of fats and proteids is necessarily abandoned. Problem 7. — Let us suppose that for certain reasons top milk cannot be obtained, or the milk obtainable is whole milk and the peojDle are not sufficiently intelligent to construct top-milk mixtures. In the table of possible combinations with whole milk there is a most available formula : Two per cent, of fat; 1.6 per cent, of proteids. Whole milk having a strength of 4 per cent, of fat. 7 feedings are needed. 7 ounces each. 49 ounces in the whole mess. Percentage of fat needed, 2, divided by 4 per cent, in the whole milk will result as follows : 2 sy AQ i ^^ ounces of milk, ^ ^ (2.5 ounces of diluent. Problem 8. — Taking the same infant with the same 49-ounce mixture to construct the formula : Three per cent, of fat ; 2.6 per cent, of proteids. We would need : .T .q r 37 ounces of milk, ^ ^ \ 12 ounces of diluent. Diluents. — Very little has been said thus far as to diluents in modifying cows' milk. The principal function of diluents is to dilute or cut up the casein of the milk, and at the same time dilute the fat to such a degree as to make both these ingredients more digest- ible in the infant stomach. As diluents used in modifying cows' milk, a solution of milk-sugar of definite strength, barley-gruel, or whey is used. Solution of milk-sugar should be 5 or 6 per cent, strength. Milk- sugar chemically pure is sold in the shops as such, and it is dissolved in water which has been filtered and boiled or in distilled water. As to barley-water, the preparation of which is detailed in full elsewhere, it should be remembered that the milk-sugar is dissolved in the barley-water while it is being boiled, as in this way there is no residue. Reaction. — Lime-water is added to all milk mixtures in order not only to make them more alkaline, but to aid, as has been shown, in the digestion of the casein by delaying coagiilation of casein in the stomach and favoring the passage of the milk or stomach contents 150 ' NUTRITION AND INFANT FEEDING. into the intestine. The food should contain, according to Meigs and Eotch, from one-twentieth to one-twenty-fifth of its bulk of lime-water. Lime-water is made by adding about an ounce of unslacked lime to half a gallon of boiled or distilled water, shaking well, and then allowing it to stand until the supernatant liquid is clear. It is then ready for use. Lime-water is best added to the food just before giving to the infant. Thus, to an 8-ounce mixture are added 3 teaspoonfuls of lime-water. I generally advise the omission of the lime-water after the sixth month of infancy. When is a Bottle-fed Infant Thriving? — It may be said that a bottle-fed infant is thriving if it increases regularly in weight, wakes up betimes to nurse the bottle, does not suffer from colic, and has movements of uniform consistence and color. It should not " spit up," as it is said, to an inordinate degree. There should be no rejec- tion of food after the bottle has been given, thus showing that the quantity has been accurately gauged. The color of the infant should be good. The young infant should sleep most of the time, except when nursing or engaged in play. Older infants should have a happy, contented expression of the face. We do not consider an infant with a very large deposit of fat as necessarily a healthy one. On the other hand, another of exactly the average weight may be much healthier than the infant who is over- weight. Thus, the physician will have to draw conclusions from various data of color, weight, development, and well-being of the child as to whether it is thriving on the food mixture. Physicians should not be afraid to leave well enough alone with the artificially fed infant, and, if the gain during some weeks is not up to the standard, should not be discouraged, in view of the fact that the succeeding week may show the average gain. Bottle-fed infants gain irregularly ; sometimes for a week may appear to have gained but very little, an ounce or two. The succeeding week may show a marked recuperation and gain in weight above the average. The physician imbued with the principles of percentage feeding also should not be too hasty to change percentages, but should en- deavor to content himself with a minimum number of changes. In this way the parents of the infant will be impressed with the fact that the artificially fed infant is not taking, even at the best, a perfect food, but only one which must make up the deficiencies caused by the lack of the mother's milk. Among the disturbances from which apparently normal infants suffer, and by this we refer to infants who are thriving, are, first, constipation. The physician will see an infant on one mixture have two movements daily, perfect in color and consistence ; whereas ARTIFICIAL FEEDING OF INFANTS. 151 ^ 1^^ (V oS > o d 7^ d S d S " lO a c3 lO f d d ^;>d r^tj > d d 3 10 a ^d *^d 10 o «d _o —id > d > d >'~' >^p Xo ^S ^^ Ss H§ Mco ?.g S? xS m3 an^ MO CM jmcs in CM MCO JIOCO -BO CO BO TJI BO^ into BO in Boin BOt~ JMtO CO ^ ^ t^ c3 lO CI to to to o in IH " SB 3 o CO tH fr-« ^ M Oi CM CM C4 CJ ^ g CO 1 .! io 10 to o O o > o > o > t4 o o o > o o >-• o .1 c iS to M io j53 s s lO 10 K5 w lO ;? BO ;? d •^o •r^ O d d >o ■rHd •So d >d Kg to CO lOO) JtO -g^ m^ M^ *3 00 WPl BO 1-1 IKitJI iW-^ BOC- Mt^ BOOO BOOO -<*' o Mi ^J ^ 1 ^ ^ ^ ^ ^J ^ -fcj ^ +J ^J ^ ^J ■♦j ■*-> c c j5 C Ci •^ CJ c fl a d ^ fl C2 c c ss ss ss ss ss g- gs gs gS g" g=^ . Fh tri . t-l . (-( . i-* . ^ . tn . (H . t^ ^ . iH . f-l . ^ . (H . t. &-S N 0) N a) N 0) N 0) N tU N N o O C o p. o o. O P< O ft O ft O ft O ft O ft O ft O ft O ft o ft O ft o ft &H CI C<1 cnoi 0)C-4 CnC;! oc^ 0 tOI> toi~ toc~ to t^ to I> >. . a >, =^■2 . N =^N c5 o d (4 "[n "^N «?« o o =^N ::^ CJ o o o o o - o CJ o CJ o CJ o CJ O CJ O OrH oo O'X oo oo oo oco o o etc OrH OCC om OCJ O CM O 00 O rH CO "^ CM>H CMi-H OrH CO d 'S' Cl to-* S^ -^Ti* oin ^3 O o o o CO 00 00 00 1 1 s CO 00 00 I> i> i> t> to to to 3 Q Oi Mh Cfi c3 o to to to to o to o to to to to to . /— '^— , • cS m 09 >. >. 03 o A ^ a ^ 2 m sa § 03 c3 13 -d a o o 03 2 03 ■a o 03 -a /a _'5 -a c 0) 0) D O D o c a o o a j3 S O a O c o a CD > o a E cc H flH S m CO fe fe H H fe E in 152 NUTRITION AND INFANT FEEDING. another infant on the same mixtnre will be inordinately constipated, and movements hard, having the form and consistence of scybala. He will thus learn to account for this constipation on various grounds. A certain percentage of newborn infants are apt to be constipated, and this constipation is due to an inherent inertia of the g-ut, and also a lack of secretion of the normal lubricating fluids of the gut. In these cases also we may find a tendency to constipation inherited from the mother. Given an infant with constipation, there are various modes of rendering this symptom a matter of less care to the physician, as well as to those in charge of the infant. If the food is heated, it is well either to omit this process or to reduce the heating to a mini- mum. We should endeavor not to give constipated infants steril- ized food; but rather, in the winter and fall, Pasteurized or raw food. In some cases it is necessary to diminish the amount of fat in the mixture, and in this place we should caution the physi- cian to go very slowly in increasing the fats. If the fats are in- creased we should never, especially with the newborn or young infant, give more than 3 to 4 per cent, of fat. In many cases 4 per cent, of fat will be followed by other symptoms fully as annoying as con- stipation. I refer to the so-called spitting or rejection of part of the food after nursing. This consists in the bringing up of a number of curds in the intervals between feedings. These curds, as a rule, have a sour odor and are accompanied by eructations of gas. In such cases it is best to reduce the amount of fat, for in very young infants an irritation of the stomach to any marked degree, as evidenced by the rejection of a part of the food in the spitting of curds, may result in serious vomiting, a symptom much more to be feared than the con- stipation. However, in the administration of top milk we very often find, especially with the newborn (and by newborn I refer to infants below three months of age), that a fourth dilution of top milk replac- ing a third dilution will often remedy the constipation. Spitting. — Spitting, or rejection of part of the food after nursing to any extent, may become an annoying symptom, and the physician should try his best to remedy it, although the infant may apparently be thriving. A breast-fed infant may spit to quite a degree and not cause us any uneasiness; but it is otherwise with an artificially fed infant. Such a condition may lead to serious enteric disturbances, necessitating a suspension of the food entirely; or the spitting may be due in some cases to an excess of fat, and we should try with such infants, even though thriving, to reduce the fat gradually until we arrive at a point at which the spitting is less evident, at the same time retaining the percentage of proteids in the mixture. Colic. — Bottle-fed infants who are apparently thriving and at ABTIFICIAL FEEDING OF INFANTS. 1 53 times quite contented will have one or two attacks of colic in the twenty-four hours. In a breast-fed infant we may have a number of colicky attacks. The breast-fed child may thrive, the movements may not show much change from the normal, and the physician in these cases is not disturbed ; on the other hand, in an artificially fed infant an excessive degree of colic is a cause of uneasiness, not only to the family, but to the physician, for it indicates that the digestion of the infant does not proceed along physiological lines. It has been stated that one or two attacks of colic daily are not inconsistent with perfect health in the infant, if the movements are of normal con- sistence and color. On the other hand, any excess of colic, combined with a disturbance of the consistence and color of the movements, the appearance of curd particles or white curds in the movements, or a yellow movement containing too much fluid, mixed with white curds, is a signal for a change in the percentages of fats of the mixture. We should not, however, reduce them to too low a figure. Less than 1 per cent, of fats for an infant from three to six months of age will result in a diminished gain in the weight of that infant, although the infant may be thoroughly comfortable. On the other hand, some infants at the age of six to nine months may digest 2 or more per cent, of fats, so that working between these limits the physician will have to find out the amount of fats that can be completely digested by the infant, always bearing in mind never to allow the proteids to reach too low a percentage, else not only diminished gain in weight will result, but also other disturbances of nutrition which we wish to avoid. Fat-diarrhcea. — The physician, while increasing the proportion of fat in his mixture, the infant thriving at the same time, will find that the movements will at times become fluid, though yellow in color ; and at other times will be more consistent and of the same color. With some infants the movements will become of an oily consistence. In such extreme cases there will also be uneasiness with the move- ments, and colicky attacks. Movements which are normal in color, contain no curds, whose consistence is of an oily character, indicate that the fats are in excess of the necessary quantity. Such infants may even gain in weight on this excessive amount of fat. The food should be suspended in these cases for a few hours, and the mixture administered with a diminished amount of fat. Such infants will do well on low percentages; whereas other infants of the same age will take more fat and still give no evidences of fat-diarrhoea. Greenish Movements. — Bottle-fed infants, apparently thriving Vill have at times movements which contain green residue and white curds, and this will be followed by a movement which is perfectly normal in color and consistence. This may be repeated at intervals 154 NUTRITION AND INFANT FEEDING. of a week, and I am accustomed to lay no stress on such, an occur- rence. On the other hand, if such green movements occur frequently and are accompanied hy colicky pains, it indicates that the milk is not digested. Such infants can scarcely be included in the normal category; they are simply mentioned here, and the subject will be taken up in another section. Disturbances on the Boundary Line between the Normal and the Abnormal. — Vomiting. — Some mothers will tell the physician that the child vomits a certain amount of its food once or twice daily and does not seem to be very much disturbed by it. If such an infant in- creases in weight, looks well, and has movements of normal consis- tence there is very little indication for our interference, except, perhaps, to reduce slightly the amount of food administered at each nursing. The cases, however, which puzzle the physician are those which vomit 2 or 3 times daily, and which do not increase in weight in a physiological ratio. Such infants increase slightly in weight at first, and after a time cease to increase. We have then to deal with an abnormal condition. Too Low a Percentage of Proteids. — It has been mentioned that the physician should be cautious not to reduce the percentage of proteids beyond a certain limit. If he does, the child will not only fail to increase in weight, but the development of the child will be below the normal, and we may even incur the danger of scurvy, pro- nounced rachitis, and other evidences of disturbed nutrition. Too Low a Percentage of Fats. — Too low a percentage of fats will also result in disturbed nutrition to the infant. By this we refer to a percentage of 1.5 of fat for an infant five months of age. If such a percentage of fat is continued for two or three months, the infant will cease to increase in weight and will develop those disturbances of nutrition already mentioned. Assimilation of the Food Without Increase in Weight. — It is not in- frequent, especially in the newborn, to find infants who completely assimilate the mixture we administer to them. They sleep well, are not disturbed by colic, the movements may be constipated or of normal consistence and color, and still the infant fails to increase in weight. These are the bafiling cases. An increase in the percentages for the newborn infant, or in the quantity of the mixture, can be made within certain limits. If we overstep the bounds, the mixture will disagree with the infant and cause symptoms which will necessitate a tem- porary suspension of the food. When Shall the Food be Peptonized? — It has been mentioned elsewhere by the author that in peptonizing the food he makes use of only one method — the cold method — for the reason that most infants will not object to the taste of the food when this method is employed. ARTIFICIAL FEEDING OF INFANTS. 155 The cases in which an attempt should be made to peptonize the food are as follows : The newborn infant is placed upon a percentage mix- ture. It suffers from constant colic, sleeps very little, has move- ments which are green, mixed with curds; on the whole the infant remains stationary in weight or the increase is very slight. In these cases most satisfactory results are sometimes obtained by peptonizing the food in the following way : Just before the food is administered a third or a quarter of a so-called peptonizing tube is added to the milk; it is well shaken and heated for two minutes. With this exposure to warmth there is very little development of the bitter taste in the milk. It is then given to the infant. It is sur- prising to see what an immediate change occurs in the general con- dition of the infant. The child will sleep, the pain and colicky attacks disappear, the movements become yellow in color and normal in consistence; the increase of weight will begin and continue along physiological lines. The physician must not expect, however, that this result will follow in every case. It is to be supposed that before any attempt is made at peptonizing the mixture the physician has made every effort to find the correct proportions for his particular patient, and having satisfied himself that there is a difiiculty in the digestion, he may proceed to peptonize the milk, but not under any any other conditions. Whey Method of Modification of Cows' Milk.— This method is really very old. In Routh's " Infant-feeding " we have the whey method, similar to that which is practised to-day, described by Mr. Lobb. This gentleman, in a brochure on hygiene, read before the Harveian Society, gave the details of preparing a " compound resem- bling human milk," and this mode of modification of cows' milk as devised by Professor Falkland. Recently the method has been taken up by Vigier, and elaborated by Monti, of Vienna, in 1897. Botch has advocated this method of diluting milk for feeding infants with difficult digestion. Whey has a composition, according to Konig of — - Proteid 0.8 per cent. Fat 0.2 " Sugar . 4.7 |' Lactic acid 0.3 " Salts 0.6 " The proteid contained in whey includes the lactalbumin of the milk and lactoprotein. The salts are potassium, sodium, lime, and mag- nesium, with iron in combination with chlorine, phosphorus, and sul- phuric acid. Whey is made by adding 1 part of rennet to 200 parts of milk at a temperature of 35° to 40° C. (95° to 104° F.), or a tablespoon- 156 ' NUTRITION AND INFANT FEEDING. ful of the rennet sold in the shops may be added, roughly speaking, to a quart of milk, allowed to stand, mixing thoroughly until the milk separates into a liquid and a curd portion. The curd is then broken up thoroughly and the whole is strained through cheese- cloth. About 20 ounces of whey may be thus obtained from a quart of milk. The rennin of the rennet is still existent in the whey, and must be destroyed before the whey can be mixed either with milk or cream for the purpose of modification. In order to do this the whey must be heated to the temperature of 165° F., at least — that is, Pasteurized — for thirty minutes. Older authors advo- cated bringing the whey to a boil. Whey, as such, without the addition of cream or milk, is exceedingly useful in feeding infants who are suffering from enteric catarrh. It contains, as is seen, the liquid proteid substances of the milk, with salts and water. An infant can be kept on such a diet for several days without the danger of being starved. It has certain advantages over albumin- water, which will be described later. It is acid in reaction, and may be sweetened with sugar if the children object to taking it. The principle of its introduction into infant-feeding, combined with certain percentages of cream, is founded on the fact that, when we modify cream or milk to make it conform to the formula as found in human milk, we are still dealing with a casein which is not present in proportion to the lactalbumin as it is in human milk. By thus separating the liquid proteids from the casein and recom- bining them this disparity of percentage is overcome. The proportion, as has been stated before, of the casein or case- inogen to the remaining proteids of cows' milk — the lactalbumin and lactoglobulin — is five-sixths of casein to one-sixth of lactalbu- min and lactoglobulin, as compared to human milk, which contains two sixths of caseinogen and four-sixths of lactalbumin and lacto- globulin. In the whey we obtain all the absorbable proteids; and if we use cream, which is highly concentrated, for fat-proportions and skim milk to obtain the caseinogen, we can make a mixture which both relatively and actually contains the same proportions of caseinogen, lactalbumin, and lactoglobulin as human milk. It must be said at the start, however, that the preparation of milk modified by the whey method is carried out with the greatest difficulty at home ; and even when constructed at the laboratory the method has not yet been perfected to such an extent as to be entirely devoid of objection. It very frequently happens that unless the whey is thor- oughly and most carefully Pasteurized, the modified milk curdles when heated. It is very difficult thus to prepare the whey mixture. It has not come into vogue for the reason that the physicians have not yet accustomed themselves to the theory of preparing these solutions. SHALL THE PHYSICIAN BESOBT TO INFANT FOODS ^ 157 It is also found that the manipulation to which the milk is subjected is open to the same objections that ordinarily obtain with modified milk as prepared at the laboratory. Children, for some reason not yet explained, do not thrive as well on these carefully prepared mixtures as they do on mixtures prepared in the ordinary way. White and Ladd have reduced casein in these mixtures so that, with concentrated cream, skim milk, and whey, they obtain mixtures in which caseinogen and casein, as stated, bear the same proportions relatively to the lactalbumin and lactoglobulin as it does in the human milk ; that is, with a total proteid percentage of 1.25, two- thirds are whey proteids and one-third caseinogen. The following table shows a few of the combinations of caseinogen and lactalbumin obtainable from the laboratory : Fat. Caseinogen. Lactalbumin. Sugar. 1.00 per cent. 0.25 per cent. 0.25 per cent. 4 to 7 per cent. 1.50 " 0.25 " 0.75 " 4 to 7 2.00 " 0.50 " 0.75 " 4 to 7 2.50 " 0.50 " 0.75 " 4 to 7 3.00 or 3.50 " 0.50 " 0.75 " 4 to 7 SHALL THE PHYSICIAN RESORT TO INFANT FOODS? Under the heading of Infant Foods have been indicated the con- ditions under which these foods may be utilized. iSTo conditions there laid down presuppose that any infant food may be used as an exclusive diet for the infant. Infant foods are only either a tem- porary makeshift — where milk for some reason must be excluded from the dietary — or they may be added to milk to aid its assimila- tion. In the first set belong the infant foods which have been indi- cated under the heading devoted to this subject, such as Imperial Granum or the carefully prepared cereals. These foods are used in forms of dyspepsia or intestinal disease to tide over a critical period. To the second class belong the infant foods of the malted varieties, such as Mellin's Food, which are added to the milk to aid its assimi- lation. In other words, we utilize the diastase or malted sugar to aid in the digestion of the proteids of the milk. Barley-gruels and How to Utilize Them. — Some physicians ob- ject to the addition of barley-gruel in any strength to the milk intended for the normal infant, on the ground that the gut of the infant is not prepared for the assimilation of starchy food, and we find authorities who deprecate the use of barley-gruel for the new- born infant, on the ground that it is difficult of digestion. We find others who deprecate the use of barley-gruel under all conditions other than actual disease. The author's experience does not carrv out 158 NUTBITION AND INFANT FEEDING. the assertion that harley-gruel is not well borne by the newborn infant. On the contrary, some of the most successful cases of infant-feeding are those of newborn infants whose percentage mixture contained as a basis a thin barley-gTuel. These cases are especially those new- bom infants with whom the digestion of the fats is very difficult. The barley-gruel for these infants is as follows: A heaping tea- spoonful of Eobinson's Patent Barley is allowed to a pint of water. This is dissolved, then stirred over a gas-flame, brought to a boil, and kept at this temperature for fully ten minutes. While the barley- gruel is boiling, the amount of milk-sugar requisite for the infant's mixture is added. The gruel is then allowed to cool, and the top cream is added in the requisite percentage quantity. If prepared in this way we will have greater success than with a barley-gruel only momentarily heated to the boiling-point. Milk mixtures prepared in this way have a consistence of thin gruel and are quite well borne, not only by the newborn infant, but throughout the nursing period. The use of so-called dextrinized barley in the making of the gruel, on the other hand, is not well borne by younger infants, inasmuch as there is a greater residue and the solution is not as complete as with the ordinary Eobinson's Patent Barley. Dextrinized barley is rather indicated from the third month to the later periods of infancy, and even when this gruel is not as well borne by some infants as the ordinary barley-gruel above indicated. There is no question in my mind that the addition of a barley-gruel to a milk mixture aids in the assimilation of the curd of the milk. This can be well seen when an infant taking such a mixture spits up a small quantity after feeding. The curd thus rejected is very finely divided, and closely resembles the curd of mother's milk. Dextrinized Gruels as Infant Food. — Jacobi was the first in this country to advocate the addition of a cereal decoction to milk in di- lutions to aid the digestion of the casein in the cows' milk. From this has developed the addition of dextrinized gruels to cows' milk, with the same end in view. Chapin, in this country, and Keller, in Germany, advocate this method of infant-feeding. So far as the Chapin method is concerned, it consists principally in dextrinizing a thin gruel of barley or flour by means of a diastase preparation (Cereo), adding this to the milk, and administering it in this fashion to the infant. Chapin advocates the administration of dextrinized gruels in combination with milk in percentage dilutions both for healthy and sick infants. The author cannot see the necessity for dextrinizing any dilution of milk for the normal infant. Keller has advocated the use of these gruels with sick infants. SHALL THE PHYSICIAN BESORT TO INFANT FOODS? 159 especially of the marantic type, and in this respect the author's experience carries out the contention of Keller, that much can be accomplished by the use of these dextrinized gruels. The majority of pediatrists use no other diluent than water for the milk of normal infants. In the present method some form of diastase, either pure or combined with malt extract, is added to the cereal dilution. Chapin takes a tablespoonful of flour, adds this to 1^ pints of water, and boils the mixture for fifteen minutes. He then adds a teaspoonful of a solution of diastase (so-called Cereo) to the mixture, the gruel be- comes thin, and is then considered dextrinized. In this form it is added to the milk as a diluent in the requisite quantity. Keller utilizes the formula of Liebig in making a malt extract. To this malt extract potassium carbonate is added as an animal salt. One hundred grammes of this malt extract are added to 500 c.c. of water, or 1 pint, and dissolved. This is solution l^o. 1. He then suspends 50 grammes of wheat flour in 500 c.c. of milk, so that the solution is quite uniform. He then strains the milk and flour through cheesecloth. The solution of malt extract and that of the milk and flour are mixed together, put into a common vessel, and stirred con- stantly over a slow fire. After about twenty minutes of stirring the whole mixture is brought to a boil to stop all processes of digestion. The mixture is now put up in bottles, each containing about 6 ounces, corked, and kept cool. This mixture contains dextrinized cereal and malt-sugar in addition to the milk. The Liebig malt extract utilized by Keller is composed of maltose, 57 per cent. ; dextrine, 12,4 per cent. Wheat contains 66.8 per cent, of starch, 7.5 per cent, of dextrine, and a small amount of dextrose. By the action of the ferments in the malt extracts — principally diastase — the starches are converted into sugars. By this method a number of easily assim- ilable substances are introduced into the economy. The action of these processes on the casein coagulation seems favorable to its assimilation. The acid intoxication of intestinal origin said to be present in these infants, is neutralized. Ammonia, which is an index of dis- turbed intestinal metabolism, diminishes and finally disappears from the urine. It should be borne in mind, however, that in feeding in- fants of the marantic type on dextrinized gruel or any over-cooked food, there is great danger of the development of scurvy. We cannot therefore feed these infants for any length of time on these foods, for not only do they develop scorbutic symptoms, but after a while cease to increase in weight, or remain stationary, become anemic, and are then in as bad a condition as they were at first. 160 ' NUTRITION AND INFANT FEEDING. FOOD OF BREAST-FED OR BOTTLE-FED INFANTS AFTER THE SIXTH MONTH. It has been shown by Camerer and Rotch that the secretion of breast milk reaches its highest limits, both in quality and quantity, during the first six months of lactation. In many cases the quantity of milk diminishes, as also its quality. If the infant gains steadily in weight after the sixth month, no additional food is indicated. If, however, the increase of weight is not satisfactory, we may at this period begin with the daily administration of one or two bottles of modified cows' milk, in addition to the breast, continued until the infant is completely weaned. On the eruption of the incisor teeth, at the seventh month, the infant is allowed a cereal, in the shape of pre- pared barley, as a pap, with cracker or rusk of bread once or twice a day. If the infant is inclined to be constipated, the barley is omitted. The same procedure is followed as to cereals with bottle- fed infants after the seventh or eighth month. FEEDING FROM THE NINTH TO THE TWELFTH MONTH. Breast-fed Infants. — Weaning. — It is not advisable to attempt weaning at the outset of the summer, even though we may be com- pelled to keep the infant at the breast a few months longer than usual. If the infant is ^^artially weaned — that is, on a mixed feed- ing of breast and bottle — it should not be deprived of the breast entirely during the summer season. The reason for this is quite evident. During the summer a bottle-fed infant is very likely to be upset should anything happen to the milk. We would therefore be compelled to suspend the feeding with the bottle, proceed without milk for a few days, and then gradually return to the milk diet. In doing this our task will be less difficult if we have even a scantily secreted breast milk at our disposal. Convalescence from a dys- ]Deptic attack will be much more rapid if return is made cautiously to breast milk than to a substitute feeding. It takes about eight weeks to wean an infant completely. Sudden weaning of an infant from the breast is not only inadvisable, but in some cases attended with the greatest difficulties. If the infant has had the benefit of one or two additional bottles daily from the sixth month, the task of weaning is comparatively simple. If, however, the infant has been kept on the breast exclusively until the ninth month, when weaning is attempted certain difficulties will at once appear. The infant will not take the bottle if there is a breast at its disposal. The only way out of the difficulty is to deprive the infant at certain times of the day of the breast, and thus starve it into taking the bottle. This requires moral courage on the part of the mother an 1-^ CD 1i O < 3 3' r+ -J JO CQ CD O JO «3 JO '0 W a; c-t- CD CD <5 CD 3 3^ 2 1 o CD o" Cfi >-* cq' CD 0- c-t- 3' "S rr ^ 5- t-t- JO (D- ^- CD 3" CD 3 in c^. ^-' CQ D o o" i CD 1: 1, JO i '3' 3 CD CD CQ CD JO Cfi ^ 3 C W T] r+ 3 CD, CD (D cd" I-* r+ 5' 3 ■5 CD 3" CQ cd" CD CD 0= "s 2_ w b! n' CD c CD cQ_ ^ H P- 3" CD CQ S M CD c-"- ^• o' 3_ cT ?r ?r D cq" r+ 3 in- CD CD Q ti "^ K-* T c-t- 3" JO JO D CD JO _ •y 13 tfi (D ;5 CQ P- JO 3 CD (D CD cT ^ v; Jfl CQ CD h— g> c-*- 3 "0 5' CQ O 2. 5' <; w o o 3 < CD 3" 3" a r > W INFANTILE SCOEBUTUS OB SCURVY. 257 One or both of the lower extremities lies as if paralyzed. If an attempt is made to move them, the infant appears to feel pain. The limb is swollen in the course of the shaft or in the vicinity of the knee or ankle, the swelling extending up the shaft (Plate XIII.), The ribs are apparently tender. There may be one or two subcu- taneous ecchymoses on the surface of the body. If there are teeth, the gums, especially those of the upper jaw, are swollen into cushion- like formations. These bleed easily and may partly conceal the teeth. If there are no teeth, the gums may appear normal, or the free bor- der, especially of those of the upper jaw, may have a bluish, swollen appearance, which may be very slight or quite marked. There may be a small hemorrhage into the sac of the tooth which may not yet have erupted. The infants may have a capricious appetite, may take little of the bottle or may nurse ravenously. The very severe cases have, as a rule, been allowed to run on for months in the belief that the infants were suffering either from rheu- matism or dropsy. For some time before coming under treatment, the infant has cried when diapered or when the shoes or stockings were put on; later it becomes pale and loses ground. The appetite is poor. The thighs and the ankles begin to swell. The child does not move the extremities, which are swollen to twice or three times the original circumference. Ecchymoses appear on the surface of the swellings of the legs and thighs. Parts of the skin acquire a bluish-green, bruised appearance. Deformity occurs in the thigh, especially at the junction of the diaphysis with the head of the bones. This is due to infracture or loosening of the epiphyses at the epiphy- seal line. The costochondral junction of the ribs is much swollen. There is a distinct series of very large swellings in this locality which are due to hemorrhage into the line of juncture of the rib and carti- lage. Ecchymoses and sugillation appear about the orbit. The face and eyes have an (Edematous, hydrsemic appearance. The gums may not be at all affected, but if the infant has teeth there may be spongi- ness and bluish discoloration of the gums. When the infant is examined, the pain produced by the procedure causes it to shriek with agony. The ribs are painful to the touch. The swellings on the thigh are uniformly fusiform, and, as a rule, hard and not fluctuating. The abdomen is tense and tympanitic. There may be some bleeding from the nose, but not necessarily from the bowel. In other cases there are not only hemorrhages from the bowels, but also from the kidney, in the form of hsematuria. There may be albumin and casts in the urine, or these may be absent. Of especial interest are those cases in which hsematuria is the only marked objective symptom of the disease. Such cases as I have seen were in excellent physical condition, of good weight and color, 17 258 DISEASES DUE TO DISTUBBANCES OF NUTBITION. and still for a period of days or weeks have voided urine which con- tains blood, but no casts. Careful examination will reveal a tender- ness of the tibiae, or a just perceivable swelling of the gums or a very narrow blue line along the gums. I have recently seen a number of cases of scorbutus in which the main symptom was the appearance of blood in the stools, simulating a dysentery. In another case, that of a child twenty-two months of age, the first symptom of scorbutus was a sharp hemorrhage from the bowel. This hemorrhage was repeated, but was not as profuse as the initial one. A careful examination in this case revealed a slight tenderness of the tibiae and a tendency to ecchymoses following the least traumatism. Fig. 33. ILLHESS 21 22 23 24 25 26 27 1 HOUR 3 6|9 12 ,\e\,n 3 6 J9|:2 3 s » 12 3 6 9 12 3le 9 12 3 s|9Jl2 3 8 9 112 8 6 9 12 3 6 9 12 3 6 9 12 3 a 9 12 3 6|9 12 3 s 9 12 103° -^l02' X < ^101 •- 100° 99° 1 1 ^ ^ / ' \ A / \ *^Y " /V — V. — .^ _ J _ _ , _ _ _ _ -A J _ _ _ _ _ _ n — \ — I — ; -; — i — \ — ^'^ -- — — 1 — — r- — -^ 1- n - - -^ - - J^ "^ / ■ ^ l^ i ' PULSE ® y ii f.'?, + SsSS tliSjSS g 1 1 s § 2 2 = = 2 2 2 2 s 2 s a 2 2 s a resp: g SjS S g|SS »,'i-,- 3 1 e g s e p g S ? « S P "" p g s 3 S ? S s s Temperature-curve of a case of scorbutus in an infant seven months of age. Resorp- tion fever. The chart shows the very high number of respirations as compared to the pulse. Cause of high respirations probably pain and extreme ansemia. The curve taken from the start of treatment. The pulse is, as a rule, not increased in frequency. In one case without complicating pneumonia, in which I found the respirations enormously increased, I reached the conclusion that this increase was due to the pain and extreme anaemia. In severe cases there may be slight temperature (Fig. 33), due to resorptive fever caused by the immense extravasations of blood. The hemorrhages in the skin may be localized in the form of minute petechia or there may be ecchymotic blotches of considerable size. The latter may appear over the swellings along the bones. The fractures or infractions were present in only 9 cases of the set collected by the American Pediatric Society. The gums were generally affected in infants with teeth, and were swollen and spongy in 24 cases in which there were no teeth. They may be normal in severe cases if there were no teeth, and swollen in mild ones. The symptoms in older children resemble those of adults. In one case in a child over two years of age the surgeons of a dental clinic had INFANTILE SCOBBUTUS OS SCUEVY. 259 been consulted for an uncontrollable bleeding of the gums. The child had ceased to walk on account of pains in the lower extremities, which had been interpreted as rheumatic. In older children the gums are affected, and the hemorrhages take the form of petechise and blotches, appearing in crops over the surface of the body as in the adult. They have joint-pains and malaise. Prognosis. — The disease in infants and children gives a very good prognosis if recognized and treated in time. Most cases recover. The fatal cases are those in institutions or elsewhere in which the diagnosis has not been made or in which death has been caused by some intercurrent affection, such as cerebral hemorrhage, diarrhoea, or pneumonia. In 379 cases collected by the American Pediatric Society the mortality was 8 per cent. It would seem to-day that with improved methods this figure should be much lower. Duration.^ — There is no fixed duration. Much depends on an early diagnosis. Even if the disease has existed months before a diagnosis is made, the patient may still recover. The great danger is that a hemorrhage may occur in the cerebrum or that the infant may contract an intercurrent affection through exhaustion. If allowed to continue without treatment, the disease may cause exhausting intes- tinal hemorrhages or hemorrhage of great extent elsewhere, Math con- sequent anaemia and death. Diagnosis. — The diagnosis of infantile scurvy presents no diflicul- ties. The pains in the extremities, the paralytic phenomena, the swelling of the gums, the swelling in the vicinity of the joints of the limbs, or along the shafts of the bones, the swellings on the ribs, and the ecchymoses in the skin and about the eye, are all characteristic. The pareses of the upper extremity are frequently mistaken for those due to syphilis. The history, and the absence of syphilitic eruptions will aid in diagnosis. In the presence of a hsematuria in an artifi- cially-fed infant, where other causal elements fail we should always think of the possibility of scurvy. In cases of prolonged enteric catarrh, in which the infants are emaciated and pass pure blood with the movements, scurvy should be thought of. I have seen a case of scurvy with hemorrhages from the bowel mistaken for intussuscep- tion, and operated under this mistaken diagnosis. Treatment. — The treatment of infantile scurvy is simple and sat- isfactory. The infant is given fresh milk properly modified. The milk should be given raw, and in summer should be kept well packed in ice. In addition, orange-juice and lemonade are given in the course of the day. An infant seven months old should have 2 ounces of lemonade and one ounce of orange-juice in twenty-four hours, given every two hours after each nursing. Some authors advise the giving of beef-juice, but it is necessary only when fruit juices are not toler- 260 DISEASES DUE TO DISTURBANCES OF NUTRITION. ated. After two weeks the quantity of fruit juice should be reduced, but a small quantity of orange-juice should be given daily for some time. Medicines are not indicated except for the anaemia, which is best treated by doses of half a drop of Fowler's solution given three times daily, or by some easily assimilable peptonate of iron. MARASMUS OR INFANTILE ATROPHY. (Athrepsia (Parrot).) Definition. — Infantile atrophy or marasmus is a condition due to a distinct disturbance of nutrition traceable to the food of the infant in the absence of any infectious or bacterial agent. Occurrence. — It is seen in infants both of the wealthy class and among the poor. In both cases the infants have been improperly fed and in breast-fed infants the same results follow as in bottle-fed infants if the breast-milk is inefficient. Secondarily it may follow any disease of the gut or complicate syphilis or prematurity, but these cases are not properly included under the heading of primary atrophy. Etiology. — The cause of atrophy is now quite well understood. It is not the result of any infection but is the cumulative result of the inefficiency of the food in sustaining the nutrition. The elements of the food to which in past years most attention and study have been directed, especially in bottle-fed infants, are the fats, proteids, and carbohydrates or sugar. Formerly the proteids of cows' milk were thought to work great injury to the infant and those who did not thrive and finally developed the symptom complex of atrophy were thought to have fallen victims to the great difficulty of assimilation of the proteids. The casein of cows' milk, it was argued, coagulated in the stomach in thick leathery curds and the energy expended by the stomach and intestine in assimilating and especially preparing these curds for assimilation wore out the infant and appropriated energy to the loss of body-weight. Heubner and Rubner especially were active in maintaining this theory. To-day we are not so certain that this is really so or that the casein of cows' milk is so much more difficult of digestion than that of mother's milk. Some maintain (Meyer) that the difficulty lies, not in the rough curding of the casein of cows' milk, but in the inability of some infants to convert the foreign proteid of cows' milk into a proteid which is similar to that of breast-milk and therefore ready for assimilation. Eotch, Holt, and others still maintain that the difficulty is in the way of complete assimilation of the casein of cows' milk, while, on the other hand, Jacobi, Escherich, Czerny hold other elements of the milk responsible for the difficult assimilation of cows' milk. Czerny goes so far as to challenge any evidence as to MARASMUS OB INFANTILE ATEOPHT. 261 the fact that casein of cows' milk is difficult of digestion even by the youngest infant. The Fats. — Jacobi was among the first to point out that the fats of cows' milk were the main difficulty in the complete assimilation of cows' milk and still maintains that malnutrition is brought about in some infants by too great fat percentages. Czerny has for years gradually worked out methods of feeding which are based on the con- viction that the fats in the cows' milk are exceedingly noxious to some infants. Czerny and Keller have shown that the fats cause excessive production of acids in the intestine, an acidosis. In these disturbed conditions of nutrition, resulting in atrophy, ammonia in large amounts is excreted in the urine instead of urea. The formation of ammonia entails a drain on the economy, hence the emaciation. Excess of fats in the food favors the production and over-production of acids in the gut. There is no question of infection for the condi- tions above are produced in the face of utmost cleanliness and a germ- free or practically bacterial-free food. Cereals and Carbohydrates. — As to the injury done to infants by cereals and carbohydrates as an exclusive diet, there can be but one opinion. The newborn infants, though they bear cereals, as barley, well when combined in dilute solutions witTi milk, do not bear them well, exclusively. This is seen in many cases of marasmus in which the infants from the start were fed on some infant food which in the main was a refined cereal or a cereal combined with some form of sugar. Such foods seem to agree with the infants at first, but after a while they develop symptoms which become cumulative and result in injury to the infant nutrition. Condensed milk, made up largely of carbohydrate or that with a low proteid, tends to bring about the symptoms which show a severe disturbance of nutrition. Morbid Anatomy. — It must be kept in mind that whatever is found post mortem in the form of an infection is an after-effect of the reduced physical condition of the infant and is secondary to the main condition which is one of progressive failure of nutrition. The body is much emaciated; the skin hangs in folds on the extremities, and presents hemorrhages or petechise. The lungs may show atelectatic areas or may be the seat of bronchopneumonia. The heart is small and the muscle-fibre pale. In many cases the stomach is dilated and the mucous membrane pale. The small intestine shows few changes. The Peyer's patches may be slightly raised and show the so-called shaven-beard appearance. The follicles of the colon may be slightly prominent. The microscopical changes in the gut are not characteristic. In some places the follicles are the seat of catarrhal inflammation. Both in the stomach and the intestines there are patches where there is an absence of glandular tissue; in its place 262 DISEASES DVE TO DISTUBBANCES OF NUTRITION. Fig. 34. is a newlj formed connective tissue composed of round and spindle- shaped cells. The villi of the gut have disappeared. The whole mucosa is thinner than is normal (Baginsky). On the other hand, these changes may not be marked. Heuhner thinks that these changes in the gut described by Ba- ginsky are postmortem artifacts and are not the result of the disease. The liver is fatty and may be enlarged. The spleen is small. The kidneys may be pale, especially in the cortex, and may be the seat of parenchymatous degeneration. The lymph-nodes of the mesentery may be enlarged. Symptoms. — The symptoms of infantile atrophy are rather cumu- lative and begin to show themselves after a time of feeding which may not have been so discouraging at first. The infant may. have, been premature or of fine normal development at birth. Whether on the breast or bottle the signs of disturbance are much the same. They begin with slight marks of trouble. The color of the infant fails at first ; there are slight dyspeptic dis- turbances, such as sjDitting up, or colic and restlessness ; and then the first serious sign that inroads are being made on the economy is met with in the stationary weight. With the occurrence of this stationary weight, the stools are either constipated, dry and soapy in consistency, or they may be soft and curdy. The infants cry incessantly and have a ravenous appetite which is not appeased by more food. The greater amount of food which is given under the mistaken idea that they are hungry does not nourish the infants and added to the serious symptom of stationary weight we finally have loss of weight. The condition is now progressive. The muscles and tissues lose their physiological tone, the fat disappears and the skin hangs loose on the extremities, the face is thin and the infant has an old, senile appearance, the chest is emaciated, the ribs show, and the fonta- nelles are depressed. Over the buccinator muscle is a small cushion of fat. the so-called " sucking pads," which persist when all other Vertical section of the head of a child two months of age, showing the sucking pads (S. C). Symington. MARASMUS OR INFANTILE ATROPHY. 263 facial fat has disappeared. This gives the cheeks a peculiarly puffed look. At this stage infections are apt to add to the seriousness of the situation. Furuncles, intertrigo of the buttocks, erosions of all kinds, or sprue, are apt to make their appearance favored by the least neglect. The buttocks are much emaciated and the tuber ischii show prominently. The heart is v^eak and in the last stages the muscular sound is scarcely audible. The patients become an easy prey to gastro-intestinal infection with resultant diarrhoea which may close the scene. The temperature if no infection be present may be normal or subnormal. The infants in many cases finally lose all desire for food. Others drink with avidity, but do not assimilate the food taken. If untreated, these infants emaciate until they are reduced to skin and bones. They grow exceedingly weak, and die with some intercurrent infection, such as pneumonia, tuberculosis, or infectious disease. Treatment. — In the treatment of infantile atrophy lie all the problems which have confronted the physician in infant feeding. If the student or practitioner desires to attain great success he must approach each individual case and study what element in the feed- ing is at fault. As a rule he well find that the infant has been fed haphazard or with frequent changes of formulae without any par- ticular direction, or that there has been a too continued effort to make the infant's digestion conform to a food in the face of bad results ; or that the infant has been fed on some infant food. If the infant has been fed on cows' milk, either the quantity has been too great in the aggregate or the quality too strong as it is called. If the infant has been receiving too concentrated a mixture, the first step is dilu- tion. In mild cases this alone will work quite well. Too great a dilution is not effective, however, because if the fat is at fault and the milk is diluted too much, the proteids are reduced. Even if we finally find a mixture which affords certain relief to the symptoms, the infant does not increase in weight because something is lacking. In such cases the addition of cereal will solve the difficulty and an increase of weight will result. Quite often this is ineffective so that in addition to the cereal some carbohydrate, such as the malted foods, must be added. In such cases Keller has devised a modification of the old Liebig formula by which the cereal and malted sugar are added to the milk. He has called this malt soup. In other cases we find that where fats are not borne well the butter milk described elsewhere has given excellent results because it is a fat-free food rich in proteids containing also a cereal and carbo- hydrate (cane-sugar). As it is still difficult to obtain a reliable butter milk and an account of the great danger attending the use of some of its forms, this method of feeding atrophic infants has been abandoned for the present. 264 DISEASES DUE TO DISTUBBANCES OF NUTRITION. It will tlius be seen that the management of these cases presup- poses study of the needs of each particular individual. If the first few attempts to feed such infants do not result in palpable progress there should be no dangerous delay and experimentation, but the infants should be given the human breast as soon as possible. No infant is too old to place at the breast. With patience and care most infants, even if past the first period of infancy, may be taught to take the breast. The result at first is sometimes discouraging, as the increase in weight is not always commensurate with the expecta- tion, but when it once begins it is nothing short of marvellous how an infant reduced to skin and bones will in a short time fully double its weight. With the feeding, the general hygiene of the infant should receive attention. Daily baths with sea-salt and open-air life are especially indicated. In infantile atrophy the medical and mechanical treatment are of less importance than the selection of proper food. For this reason we should not seek to multiply remedies. The movements of the bowels in some cases have an exceedingly fetid odor. The treatment is begnin with the administration of brisk cathartics, such as castor oil. The bowel is then washed out once a day until the character of the movements has improved. If there is a tendency to diarrhoea, tannigen, with or without bismuth, may be given three or four times daily. If there is any great amount of gas generated in the stomach, a very small dose of dilute hydrochloric acid and pepsin should be given daily after a feeding. SECTION V. THE SPECIFIC INFECTIOUS DISEASES. THE EXANTHEMATA. The exanthemata, scarlet fever, measles, Eotheln, varicella, and variola, are acute specific infectious diseases, characterized by an eruption on the skin, the so-called exanthema or rash. They form a distinct group. The poison or infectious element originates in the body of the patient. The nature of this poison is unknown. Though suspected to be bacterial, the essential cause in any of the exanthemata has not been isolated. We do know, however, that the acute exan- themata are conveyed from one person to another by direct contact or through the medium of the atmosphere. In this respect they differ essentially from such diseases as typhoid fever, or even syphilis, in which the morbific agent must be introduced into the body. They are therefore not only communicable but contagious in the true sense of the term. Most people are susceptible to some of the exanthemata, such as measles and smallpox. On the other hand, not every one exposed to contagion will contract scarlet fever or varicella. Few persons are attacked twice by the same exanthematic affection, but there are exceptions to this rule. An attack of one disease, such as measles, does not confer immunity from an attack of another, such as scarlet fever. The exanthemata occur either endemically or epidemically. Each has a well-defined period of incubation — that is to say, an interval between the time of the exposure to contagion and the onset of char- acteristic symptoms. In the different exanthemata this interval varies within wide limits. The period of incubation seems to be more accurately determined in measles than in the other exanthemata. It is well established that two of the exanthemata may occur at the same time in the same subject. This is not a point in favor of the identity of the essential cause of the exanthemata. On the contrary, it is an accepted fact that each of the exanthemata is distinct in itself, and that each disease has its specific essential cause. SCARLET FEVER. Scarlet fever is an acute infectious disease with a characteristic rash or exanthema. It is highly contagious. Etiology. — It has not as yet been established whether the infec- 265 266 THE SPECIFIC INFECTIOUS DISEASES. tious agent is a micro-organism, although streptococci have been isolated from the secretions and scales in the desquamative period, l^either do we know whether there is an organism, a protozoan, in the circulating blood. Mallorj, Duval and Field have described cer- tain protozoa-like bodies in the lymph-spaces of the skin. Field regards them as being derived from the protoplasm of degenerated epithelial cells. The atmosphere about the patient seems in most cases to be the zone of contagion. The nearer a person has been to the patient the more likely is he to convey the disease to a third person. Articles of clothing may retain the infection for months. Scales from the skin of the patient, dried secretions, the urine if nephritis exists, and faeces are also mediums of infection. The longer the physician remains near the patient the more likely is he to convey the disease. This mode of infection occurs. Osier records his belief in having carried infection to a patient. Foodstuffs handled by those suffering from the disease or by those who have been near patients may convey the disease. This is especially the case with milk, which is said to have been the cause of epidemics in England. The poison of scarlet fever seems to pervade the ward or sick-room for a long time. Whether this period extends over two years, as recorded by Murchison, is a matter not yet settled. We do not yet know how the poison obtains entrance to the body. The discharge from a scarlatinal otitis is said to be capable of communicating the disease. Susceptibility. — All children exposed to infection do not contract the disease. It is less contagious than measles.' On the other hand, although a person may be expoi>ed once and escape, he is not neces- sarily immune to future exposures. A nurse attended many cases for me before contracting the disease. As a rule, one attack of scarlet fever protects a person from subsequent attacks. The literature records cases of well-observed second and third attacks. The author has seen cases of a second attack. We should, however, be cautious in accepting reports of repeated attacks. Rotheln may have been mistaken for scarlet fever. Occurrence. — Scarlet fever occurs at any age, and in all countries, being endemic in K'orth America and Europe. It is most prevalent in autumn and winter (September to February) . It remains endemic wherever introduced. Sporadic cases occur. It may occur sporad- ically for years and not become epidemic. Epidemics of scarlet fever are less frequent than those of measles. It occurs also in epi- demics. In epidemics only 38 per cent, of the population are affected. There is therefore an immunity of the majority (Jiir- gensen, on the Faroe Epidemics). As a rule, fully 56 per cent, of those exposed before the twentieth year contract the disease. SCAELET FEVEE. 267 Incubation. — According to the German authorities, scarlet fever has an incubation period of from eight to eleven days. English authors (Murchison) fix the period at from three to six days. The vast majority of cases develop v^^ithin a period of from three to five days after exposure. If eleven days elapse v^ithout the appearance of symptoms, we may with reasonable certainty say that the danger of infection is passed. Cases of thirty days' incubation are recorded, and the author had a case in his practice in which a physician con- veyed the disease, the boy being attacked three weeks after his visit. In all such prolonged periods of incubation, however, there is a proba- bility of a more recent exposure. The contagion is active during the period of incubation and during the eruptive and desquamative stages. The consensus of opinion is that the contagion diminishes in the desquamative stage. In America desquamation is considered a bar to the mingling of convalescents with those who are well. In England patients are discharged from the hospitals before the desquamation is over. We should exercise great caution in allowing convalescents to mingle with the healthy, especially if there is a residual otitis or adenitis or any purulent focus, for such pus is considered capable of conveying the disease. Strange to say, there are no positive data on this point. Contagion will be treated more fully under Prophylaxis. Immunity.- — Although there is no absolute immunity at any age, scarlet fever attacks nursing infants lees frequently than older chil- dren. We have no positive data as to transmission of the affection in utero. Cases are recorded in which the newly born infant has been attacked, but some authors are inclined to look on such cases with doubt. In certain sets of cases the affection takes on a virulent form, in which all the members of a family attacked will have complica- tions, septic or otherwise, of a fatal character. All had septic malig- nant fever. There may in such cases be an element of mixed infec- tion (Henoch). Symptomatology. — Scarlet fever does not present uniform symp- toms. A general description of the disease can hardly be given without misleading the student. During an epidemic or during the prevalence of scarlet fever, there are a number of cases of angina in which no exanthema of scarlet fever is seen. This is especially so with those whose duties keep them near scarlet fever patients. There is no doubt that such anginal cases are capable of conveying the dis- ease to others. A case of this kind has come under the author's notice. A nurse suffering from an angina went from a scarlet fever case to a healthy child. Although the nurse had taken all external precautions she conveyed the disease to the child. This raises the question of scarlet fever sine exanthema. Let us say that scarlet fever poison can cause a specific angina capable of conveying the dis- 268 TEE SPECIFIC INFECTIOUS DISEASES. ease to the healthy. Certain forms of exanthema of scarlet fever are very evanescent, and in anginal cases may escape observation. Period of Incubation. — The period of incubation has no fixed symptomatology. In many cases the symptoms begin with the ap- pearance of the eruption. The children play about; they have a slight angina, but do not complain. This is apt to be the case with children who are sufferers from chronic catarrh, enlarged tonsils, or adenoids. In other cases the invasion of the disease is a stormy one. There may be an initial convulsion j)receded by a sharp rise in tem- perature. Examination in such cases may show, previous to the appearance of the eruption, a marked angina or a membranous deposit on the tonsils, but nothing more. Other children suffer from a ton- silitis of moderate severity, a marked febrile movement, and, what is characteristic, attacks of anorexia and vomiting. A chill, followed Fig 35 DAY OF DISEASE 1 2 3 4 j 5 6 1 1 106° : "4^ W- -H i W\ Se \ ± + iifi g — ^ ifl||#tt h Hi HI = 3 1 10i° O 103' I 2 102° g 101° 100° 99° 98° -H-t- ■ -^ == ^=^- P V m ^ i=i^=H t-±iJ P 1 — — ;--J ^ t^ 17 liz ^ = =F ^ m^i ™ IZ EE +h- 1 -:J /: 5 b U i E: g:g| M EE EE I H T^ / j z ^ _E -r 1 bz zn W :: EE 1 nMNN ^ —4. -rh- d - S 3 W+tj4 ^ik-£ ™ i E -HH hi- tVv' s^_ -r— - 1 PULSE 2 2 o ^ S O L-S o o o 53 s s Moderately severe scarlet fever ; female child four years of age. Observed from the outset. Normal course. by fever and vomiting, ushers in a large number of scarlatinal anginas. Occasionally the symptoms of invasions are so mild and evanescent as to escape the notice of even watchful parents. These are the eases in which the first symptom to attract attention belongs to a later period of the disease or to some of the complications. There are thus all degTees in the severity of the symptoms of the period of invasion, varying with the susceptibility of the subject and the virulence of the epidemic. General Course of the Disease. — An attack of scarlet fever takes a certain general course. After the initial symptoms of vomiting and abrupt onset of fever twelve to thirty-six hours elapse, when an erup- tion or rash appears on the skin; this eruption, though characteristic, varies greatly in intensity, mode of spreading, and distribution. The SCARLET FEVER. 269 fever is now very High; the eruption spreads and becomes more intense and general (Fig. 35). At the greatest intensity of the erup- tion or florescence the fever is highest. In typical cases of scarlet fever the eruption reaches its full development and runs its course within two to six days. At the end of this time it fades, and desqua- mation begins. The fever subsides gTadually, leaving the patient convalescent. The period of invasion is not so sharply defined as in measles, nor is the stage of eruption so distinct and uniform as in that disease. The length of the period of desquamation in both measles and. scarlet fever varies. The malignant cases may at first appear mild. The children are taken with vomiting and a moderately high fever, and the eruption Fig. 36. SHiL 1 2 3 4 1 HOUR 3 6 9 12 3 6 .1,2 sis.ab slejaliz 3 6 5 12 3 6 9 12 3 6 9 12 3 6 9 12 s 9 12 3 6 9 12 106° Eios" < o: iOi° H 103° 102° 101 ! - ^ A 1 s / \ r ' ■; i \ / ( / 1 / PULSE a S g a S- ^ 3 S 3 s s § 3 s s s S S s RESP. s s. s s g s S ^ s ?, s S s s % ^ .5 S s J Malignant scarlet fever ; ursemic symptoms from outset. Boy, six years. Sopor increasing to coma ; bloody urine. Involuntary passage of urine and faeces. Death in three days after onset of symptoms. appears. While the eruption is spreading, however, the patients become stupid, and within a few hours after the appearance of the exanthema pass into a state of coma. The urine is diminished in quantity or supj)ressed, and contains blood, albumin, and casts. The temperature remains elevated (Fig. 36). The pulse is rapid and at times thready. These patients remain comatose and die within a few days (three or four) of the onset of the symptoms. In other malig- nant cases the affection of the throat and adjacent lymph-nodes is a leading factor in the septic phenomena, while the kidneys show very little participation in the general toxaemia. Such patients will show necrotic pseudomembranous inflammation in the fauces after the eruption is fully developed. The glands of the neck are involved. The temperature ranges from 103° to 105° F. (39.4° to 40.5° C), with daily remissions. The patients have a sallow, septic appearance, and are stupid and irritable. The exanthema fades slightly after 270 IRE SPECIFIC INFECTIOUS DISEASES. having been in efflorescence. Tlie Ijmph-nodes in the neck enlarge to great size. These patients maj die in the second week from gen- eral toxaemia. Between the normal course and these malignant forms there are all degrees of severity and mildness in this affection. Surgical Scarlet or Infection of Wounds with Scarlet Fever. — ■ Maunder and Murchison called attention to the fact that patients with wounds are prone to contract scarlet fever more readily than others. Hermann has recently reported several cases. It is of in- terest that burns are apt to be followed by an outbreak of scarlet fever. Leiner has described such cases and I have seen a number and observed very active and extensive desquamation follow the fading of the erup- tion as well as complicating nephritis. The Angina. — The angina of scarlet fever is limited to the pillars of the fauces, the uvula, the tonsils, and retropharynx. The angina may be simply a slight redness of the fauces and very slight swelling of both tonsils. The lymph-nodes at the angle of the jaw may be very slightly enlarged. The tonsils may be so greatly enlarged as to close the opening of the fauces. This is likely to be the case if there has been antecedent hypertrophy of the tonsils. ISTo mem- branous deposit may be seen, yet there may be a distinct lacunar form of tonsillitis. The lymph-nodes at the angle of the jaw may be much larger than in the milder anginal cases. The swelling of the lymph-nodes may involve the connective tissue about them in a phlegmonous mass. This is especially so in the severe septic forms of scarlatinal angina of the streptococcus variety. Membranous Angina. — Membrane spreading to the pillars of the fauces may be present on one or both tonsils. This condition was formerly called scarlatinal diphtheria. In the vast number of cases of scarlet fever — in fact, in all the uncomplicated cases — this mem- brane is not a true diphtheria like the diphtheria of Loffler. It is a streptococcus membrane (diphtheroid), caused by the streptococcus of pseudomembranous formations. This membrane may involve the posterior pharynx and nares, and spread downward into the larynx and trachea. True diphtheria of Loffler occurs in those cases of scarlet fever which have been exposed to the infection of diphtheria at or about the time of the outbreak of the scarlet fever or at some period during the course of the disease. The membrane in these cases will show, on examination, the Bacillus diphtherise of Loffler. These cases of true di])htheria complicating scarlet fever are exceptional. The pseudodiphthoria is usually caused by a streptococcus of the scarlatinous variety. In some forms of scarlet fever this pseudo- membranous inflammation of the tonsils becomes a primary factor in the disease at an early period before the full development of the erup- tion. This process involves the lymph-nodes and the whole connective 8CABLET FEVEB. 27 1 tissue of the neck below the jaw in a necrotic streptococcus inflamma- tion. In many cases a true streptococcsemia may result from the entrance of the streptococci into the circulation. In other cases the patient may have passed through a mild eruptive stage and on the tenth to the fourteenth day a severe pseudomembranous tonsillitis makes its appearance with marked glandular enlargements and high fever. Some of these cases are also complicated with a severe nephritis. Retropharyngeal abscess, mediastinal burrowing abscess, abscess pointing on the external portion of the neck, or empyema, may result from the necrotic tonsillar affection by extension through the lymph-nodes. Secondarily, a general systemic infection may result in such cases. The mucous membrane of the mouth presents nothing character- istic in the great majority of cases of scarlet fever. The buccal mucous membrane is pale, and of a normal hue at first; the soft palate may present a few red, irregularly shaped spots or red streaked areas, or these may be absent. Later in the course of the disease a stomatitis may appear. This is more likely to occur in the so-called septic case. In these the superficial epithelium is removed; the mucous membrane has a dry, red, beefy appearance. The lips are fissured and bleed easily. The tongue in most cases of scarlet fever is furred at the outset, and may present a slightly reddened appearance at the borders and tip. In some cases there is the so-called characteristic strawberry tongue. This appearance is caused by an undue prominence and erection of the papillge of the tongue, especially at the tip. The tip is red, and with the prominent papillse gives the appearance of a strawberry or of the tongue of the lower animals (cat). In many cases the tongue later becomes denuded of epithelium and shows the erected papillse on the dorsum ; in others it becomes dry and fissured. The latter condition is seen in the toxic cases. The Exanthema. — The exanthema of scarlet fever, though very characteristic in appearance, varies more than in any of the other exanthemata in mode of appearance, distribution, spreading, and in duration. In the mild cases the eruption is sometimes so evanescent as to escape notice. In other cases it appears only on certain parts of the surface. It may be very discrete in form and punctate. Usually it first appears on the upper part of the chest about the clavi- cles, spreads down the chest, and around upon the back. At this time it is also seen on the neck, beneath the jaw, behind the ears, and on the temples. It consists of a minute, delicately punctate rose-colored rash. The punctate appearance is the distingaiishing feature of the erup- tion. At the outset this punctate character is best observed on the 272 TEE SPECIFIC INFECTIOUS DISEASES. chest, abdomen, and the nates. If the eruption has in places become confluent, the skin shows a uniform redness. In such cases the punc- tate character of the rash can best be discovered by studying the skin from a distance in bright daylight. It will then be made out dis- tinctly in those places in which the rash is most recent. A favorite method is to undress the patient and study the lower abdomen, the thighs, and nates. In the early cases the punctate character of the rash is apparent on the neck and behind the ears. The appearance of the face at the outset of the disease is charac- teristic. There is a pallor about the mouth and alse nasi, while the cheeks are flushed with a flame-like erythema. The eyes may be injected. The cheeks do not show the characteristic punctate rash, although flushed either from the fever or intense dermatitis, which involves the whole surface. The eruption spreads from above down- ward, involving the arms and forearms, hands, and lower extremities. It retains the punctate character wherever it spreads, but loses this characteristic after it has been out for a short time and become con- fluent. When confluent the rash causes the skin to appear uniformly red and swollen. In some places, especially the extensor surface of the hands and forearms, the eruption is blotchy and erythema- tous. The skin is roughened in patches by the erection of the papillae. In other cases, and especially in those occurring in summer, the skin is studded with myriads of minute vesicles, or, again, the skin may present minute pustules. There is pruritus in the cases in which the dermatitis is severe. The rash of scarlet fever attains its full devel- opment at the end of two or three days. It is then said to be in efilorescence. It remains out a variable length of time, in some cases six days. In other cases the eruption may develop fully in two days and then fade. Cases in which the rash is visible for only twenty- four hours are not uncommon. The appearance of a fading scarlet fever rash is very character- istic if it has involved the whole surface. The skin is dotted here and there by raised papillae, and appears as if irregularly and lightly daubed with rouge. Even a fading rash may be easily diagnosed by an experienced observer. In mild cases the rash may disappear within twelve hours, leaving no vestige of its presence. In other cases the rash appears only on the lower part of the abdomen and upper part of the thighs. The eruption on the lower part of the extensor surface of the forearms, and also on that of the legs, is apt to assume a blotchy, roseola-like appearance. Such cases have been mistaken for measles. Abscesses or furuncles, multiple or single, may involve the skin. In rare cases gangrenous processes have been recorded. A secondary infection may be assumed in all of these cases. SCARLET FEVEB. 273 The Fever. — In the first few hours there is a rapid rise of the temperature to 104° or 105.8° F. (40° or41° C). It remains high with morning remissions until the eruption on the surface reaches its full development. With the fading of the eruption the temperature falls, and within six days, if the case is uncomplicated and typical, becomes subnormal. The patient may show a subnormal temperature for a few days, after which it may rise to the normal. In some cases the temperature may rise very rapidly, reaching its highest point within a few hours. It may then fall to the normal rapidly, though the eruption be still present. Wunderlich and Henoch record cases of profuse exanthema with a mild febrile course or practically afebrile curve, 101° F. (38.4° C), falling rapidly to 100.4° F. "(38° C.) within twenty-four hours. In those cases in which there are complication's either in the throat, ear, joints (rheumatism), or serous cavities, the temperature- curve will be influenced accordingly and will continue for days at a low range, 102° to 103°, with daily remissions. In other cases, evening remissions may occur instead of morning ones. After the fading of the eruption the fever may continue for days, 100.4° to 102.2° F. (38° to 39° C), in the absence of any complication. After days or weeks of absence of temperature there may occur a distinct rise and a species of relapse similar to that seen in typhoid fever. This is probably due to a form of secondary streptococcus infection. During the height of the eruption the temperature may reach 107° F. (41.6° C), although in mild cases it may not be over 103° F. (39.4° C). In cases of septic infection, especially of the lymph-nodes, or in streptococcus diphtheria, with infection of the lymph-nodes, the temperature-curve will be of a remittent character, falling and rising once or twice in twenty-four hours, and may retain this character throughout the affection. Uraemia or any affection of the pleura, lungs, or heart will be ushered in by a rise of temperature even if it has returned to the normal. If a complication occurs early in the disease, the temperature will fail to drop to normal with the fading of the eruption (Fig. 34). Incases of otitis persisting through the stage of desquamation there will sometimes be an evening rise, although the ears are discharging freely. In such cases the bone may be involved (mastoid disease). In severe, malignant forms in which symptoms of profound sepsis, such as coma or stupor, are present from the outset, the temperature remains persistently high (105.6° F., 40.8° C), remitting a degree toward morning. The temperature remains high until the fatal issue (see Fig. 36). Desquamation.- — The period of desquamation begins as soon as the exanthema commences to fade. Generally speaking, since the exanthema first appears on the upper part of the chest and neck we 18 274 THE SPECIFIC INFECTIOUS DISEASES. should expect desquamation to begin there. It may be in fine, branny scales, such as are seen in measles ; or else, as is most common, the skin peels in larger particles. The hands and feet show the largest scales, and complete casts of the hands and feet are sometimes shed. I have seen the nails shed completely twelve weeks after the attack. The desquamation may be scarcely perceptible. In some cases only certain parts of the extremities, such as the toes or inner portion of the thighs, show desquamation. It is, however, always present. Desquamation in itself is not a pathognomonic symptom of scarlet fever. It occurs in forms of dermatitis which bear no relationship to the disease. It is still a subject of debate whether cases of angina without an exanthema may desquamate. Henoch is inclined to think Fig. 37. DAY OF DISEASE ■ 2 3 4 5 e 7 s 9 10 11 12 13 14 15 1 HOUR ^ 11 ^ ■^■^ .. ^ -'r-i =b J\2i -Sr^ »b 7^ Js Js »;2 ^'s »':2 »:2 »<- ^ »Ij: =h »b » 2 - 3 •^ -a = a »2 105° < 103" "'. 102' I Wl' ^ 100'" 99' -I °'' h ■S -1 ^=F = = 3 1= =1 i 1 11 ^-~ \. IS / # :s 5- ;: ^^ :'r 7 1"^ y ^^ xv i ■r ^, i^^ -1 ;"^ -Sr i-7 i B = = h -;* 5^;" s;| ^:^ ;& v ;:\ A, H-- ^ = EE -:/ \i A \ \ A ;- 0-": - ":7 = i J V V -;v ^ i,A -i- ri i : if.^ S!-^ -i ;-^ = = I^ i- ':-- V^ -v^ \'\ /^ \ 'N r ~3. S r- /N ,-j /^5 PULSE g s -r S'^ s 2 21 £'S 5 £ 3,S 22 sbs S\ 2 "H' -i!^ s 2,3 gl 8; e §i g RESP. 1 a s s . .|. s s + + s S S:? ^1^ .1. °\ S| H s\s s s|s 5 H + s h s H as 3 URINE 3 74 1 J3 5^ 'H 12 ^H M »^ 5 34 3 30 5 33 5 31 J !i 3^5« sJiJi Jj 34 Scarlet fever, moderate severity, in a boy six years of age. Stiows tlie delay in the drop of the temperature due to complicating otitis of the right ear at the outset of the period of desquamation. this possible. We should remember that an evanescent, slightly marked exanthema may escape the notice of even the most careful observer. The duration of desquamation is variable. There are cases in which a secondary desquamation occurs after the primary one has run its course. The severity of desquamation has no relation to the intensity of the exanthema. Some very marked cases of scarlatina desquamate less than those in which the eruption has been faintly marked. The average duration of desquamation is six weeks (Kellogg). The Nose. — The close relationship of the nasal passages to the pharynx facilitates the invasion of bacteria from the throat. The nasal passages become affected simultaneously with the severe angina. There is a severe catarrhal or pseudomembranous inflammation of the mucous membrane. In the so-called septic cases there may be an ichorous discharge from the nostrils. There will be in such cases erosions, and sometimes fetor, with the discharge of necrotic tissue through the nasal passages. Necrosis of the cartilaginous and bony SCABLET FEVEB. 275 structures may result. In other forms there is a pseudomembranous deposit around the opening of the nostrils extending up into the nasal passages. Casts of the nasal passages may be expelled. The mem- brane may leave a bleeding surface. Ear. — Duel found the ears affected in 20 per cent, of the cases of scarlet fever. Generally both ears are diseased. Deafness is frequently a result of otitis. Ten per cent, of those who suffer from deaf-mutism can trace their affliction to scarlet fever. Usually the ears become affected in the third week, although they may be involved at the outset of desquamation. The affection of the ears is ushered in by a rise of temperature and manifestations of pain (Fig. 38). Occasionally tinnitus and deafness are initial symptoms. There Fig. 38, S;i°H '*'»» 1" 1' 18 1"» ••() -Jl •_>2 •>■[ 21 H0UR_^^^2"-».:-« - . i^.^„™JJ2„^o.fi„,. 2„«,p™ 2- -" 1 -"" =H 1 I-"! "" - -™,.,_-,,..,.,[;„,„j:^ 104° -J- -[4- -)- ^ M^- --J-J -^ _ J_ ' ( ^.oM--J-t-MlliS^Z^^----Z ^V^ ''IiS-SS : li02°EEEEEEE.rCl^^^'li-^- Z- ' ' 4. 1 /L-LIjJ-L ^ : ^Zm^x!^ ^^'' 1:1/7^^2^ A ''\J"' ^.^^Mm -^^^^^^ru^V^S^ ^ .^^^^^ h4_^13:u.^S ^ZJt ± - — "S /' ' 1 - ^ r 1 ■ -: - = ""^-'--" " i" '" "" ------- .. - --__-__---. RESP. ^S«'SSS5iSl5S^iS^SgS5|i?SS?SSSS'3Sj'J'?^S'S???SSSS?,^S^?..S.SSSSSSSSSSSSSSSSSSSSSSS Female child, two and a half years of age. A mild form of scarlet fever complicated In the second week by an otitis. may be convulsions or even cerebral symptoms. The onset of ear trouble may be insidious, and not suspected until the purulent dis- charge makes its appearance. If there are premonitory symptoms, they may precede the perforation by one to three days. Ear compli- cations in scarlet fever are always of serious moment. Meningitis, •sinus thrombosis, and abscess of the brain are among the more serious results, and may result long after the fever has run its course. The onset of otitis usually occurs during the period of desquamation. The patient may be up and about. There is still some redness of the throat, with swelling of the lymph-nodes. There is a sudden rise of temperature to 103° or 104° F. (39.4° or 40° C). The child begins to vomit food and has headache. At night the child starts from sleep and cries as if in pain. Children do not always locate the pain in the ear. The reason is that the pain occurs before the child is quite awake. The sleep is restless. The muscles of the face and hands twitch in sleep. These symptoms may at times abate. The temperature may fall to the normal and then rise sharply. Any of these symptoms should direct attention to the ear. 276 TRE SPECIFIC INFECTIOUS DISEASES. The mastoid may become the seat of inflammation in the fifth or sixth week. The ears may have been discharging very freely. The child is not, however, free from fever. At times during' the day the patient complains of frontal headache, is drowsy, and the temperature shows a rise to 102° or 103° F. (38.5° or 39.9° C). There is ten- derness behind the ear or in front of the auditory meatus. There may be a slight blush above and behind the pinna. In these cases the mastoid may be the seat of suppuration. There are forms of otitis which occur on the eighth day of the disease. The temperature does not fall to the normal. The patient has begun to desquamate, but the temperature remains elevated a degree or more and takes fully three or four days longer to fall to 99° F. (3Y.2° C.) in the rectum than in an uncomplicated case. At the eleventh day of the disease pain is complained of. The drumhead is found to be bulging. An insidious serous otitis media is in progress. The Eye. — Conjunctivitis may appear in some cases of scarlet fever as a result of a mixed infection. The lachrymal duct is the canal through which such infection travels. Conjunctivitis in cases of gangrenous pharyngitis and rhinitis may lead to panophthalmitis and destruction of the eye. Lymph-nodes. — The lymph-nodes in various parts of the body enlarge in scarlet fever. Those situated at the back of the neck behind the posterior border of the sternomastoid muscle may enlarge some days before the appearance of the exanthema. At the time of the appearance of the eruption we may find that the lymph-nodes in the axilla, inguinal region, and those at the angle of the jaw, are enlarged. In other cases the lymph-nodes, except those at the angle of the jaw, may not be perceptibly enlarged. In some cases the lymph-nodes at the angle of the jaw may enlarge at the end of the second week, with a distinct rise of temperature to 104° F. (40° C.) or more, as a result of reinfection through the tonsils and pharynx. The con- nective tissue of the neck beneath the body of the jaw is involved in the inflammation of the nodes. In such cases the swelling has an appearance similar to that seen in angina Ludovici. In severe mixed infection the tissues of the neck may become gangrenous. As a result of such severe gangrenous inflammation, phlebitis erosion into the veins and arteries with fatal hemorrhage may result. Retropharyn- geal abscess or retropharyngeal adenitis is a sequence of infection of the lymph-nodes. The retropharyngeal abscess in such cases is not as benign as that occurring independently of scarlet fever. In the latter the abscess is apt to involve a chain of retropharyngeal nodes. Multiple burrowing abscesses result. The nodes of the mediastinum may be affected, causing empyema or pericarditis. The mediastinal abscess may cause death by pressure on the trachea, or by eroding the trachea, burst into it and cause death through suffocation. SCARLET FEVER. Ill The Mouth. — Stomatitis always occurs in severe scarlet fever. It may be simply a mild catarrhal process. If there is a pseudomem- branous formation on the tonsils, this pseudomembrane may spread to the mucous membrane of the soft palate, and the buccal mucous membrane may also become affected. The tongue is dry and fissured ; the lips are dry, fissured, and bleed easily. There may be a discharge of necrotic tissue from the mouth. The soft palate, tonsils, and pharynx may be fused into a necrotic mass, emitting an offensive odor. Joints. — The joints become inflamed in from 2 to 6 per cent, of the cases of scarlet fever. This affection of the joints has been called Fig. 39. DAY OF , ILLNESS 3 4 i. G 7 8 •J 10 11 12 13 11 15 Hi 17 18 1 19 1 or :g ; A i n ^ t IjjHi - ii A /^N J 1^ t f S'' ■ i i /i \ f- -^ ^J ; |^:i &:i '\ /; i v^>^ V v)^^ / \'^ K-^- s| H, f: :\ : N ^ A A ^ ":s£ = - / \ -: \ 5 \ ^ ^n/;k -is ^ " = ; ' ';! i : s-t 5 ^ ^?E - 99- '^-^ • , i_ __ _i_ ^ _i ^_ ^ ^ _ -^ _ ^ ■ = = PULSE S T 3| S| I i, T. 5 "s ~ •;s. '^ e 3~~ w ~ g T <; s B s i. :5 =, 3, r \- s; 3" P2 ? RESP. S S |3 i S! g| s if N g |. V \- \- i ^ ^ ^ I" i i ..1^ h 1 1 SS|S! i ± ^ 1 i 1 js^ t Boy five years of age, observed from the outset of the disease. Scarlet fever with joint- complications. No cardiac involvement. Recovery. scarlatinal rheumatism. The joint-affection may, in exceptional cases, precede the exanthema. It appears, as a rule, in the second or third week of the disease (Fig. 39), and is therefore one of the manifestations seen during desquamation. There may be pain in several articulations. In other cases swelling may occur, with effu- sion of serum into the joints. These cases retrograde. There may be a complicating endocarditis. In other cases there is suppuration of the joint. An arthritis with streptococci in the joint-effusion results. The streptococci invade the joint through the epiphyses of the bone, and produce a streptococcus osteomyelitis with suppuration of the adjacent joints (Lannelongue, Achard, Koplik, Van Arsdale). As a rule, suppuration occurs in only one joint. Cases in which several joints are affected are generally septic, streptococci having gained access to -the general circulation through a necrotic focus in the throat or pharynx. Such cases are fatal. There are metastases in the lungs, kidneys, pleura, and pericardium, with hemorrhages in the skin and enlargement of the spleen. Periarticular abscesses rarely occur (Henoch). The prognosis is serious in all suppura- tive cases. The Kidneys. — In scarlet fever, as in most infectious diseases, there may be a mild form of nephritis in the earlier stages. There are a small amount of albumin and a few hyaline casts in the urine. This nephritis is of little significance, and has nothing in common 278 THE SPECIFIC INFECTIOUS DISEASES. with the severer form which occurs later in the disease. The severe form of nephritis begins as a rule in the third week. It has been known to appear in the sixth week. The frequency of this compli- cation varies in different epidemics. In some, only a small number of cases are affected (5 per cent.). In other epidemics fully 70 per cent, of the cases are thus complicated. Its occurrence cannot always be predicted from the severity of the disease. The mildest cases may develop severe nephritis. The diphtheritic forms of angina are more likely to be complicated with or followed by nephritis. On the other hand, the severest forms of scarlet fever may run their course without marked nephritis. Sorensen has shown that at autopsy the most marked changes may be found in the kidneys, although no clinical signs of the affection have been manifested during life. In 50 per cent, of the autopsies upon scarlet fever patients Friedlander found changes in the kidneys. It was formerly thought that exposure played an etiological role in this affection, but this view has been abandoned. l^ephritis may develop in cases which have been very carefully guarded from exposure from the outset. Although the symptoms will be detailed elsewhere, it may be here stated that the first symptom is a slight oedema about the eyes and face which spreads to the rest of the body, involving the trunk and extremities, the hands and dorsum of the feet, and the scrotum. In some cases the cedema is not marked, in others the anasarca is extreme. The serous cavities may become the seat of effusion, and there may be hydrothorax, hydropericardium, or ascites. The urine also shows changes very early. The quantity dimin- ishes very rapidly, or it may be completely suppressed. The urine shows the presence of albumin, rarely more than 0.5 per cent. It may be highly colored or smoky, or may be distinctly red in color, owing to the large amount of blood and blood-pigment contained. The urine in cases of partial or complete suppression generally con- tains a large amount of albumin, blood, hyaline, epithelium, and blood-casts, renal epithelium, and leucocytes. The specific gravity may at first be high, 1.030 ; later, when diuresis is inaugurated, it may fall to 1.006. All cases do not run a course with anasarca. There are cases without this symptom. The invasion of the affection is sometimes marked either by a rise of temperature or convulsions. The prognosis is good in spite of the very alarming symptoms, such as convulsions and coma, which are seen in some cases. This nephritis usually runs its course in from four to six weeks, leaving the kidneys intact. Sometimes the nephritis apparently subsides, but albuminuria of a very mild or intermittent form persists for months. In fact, many of the so-called cases of paroxysmal albumi- nuria are probably due to unobserved scarlatinal nephritis. Finally, SC ABLET FEVEB. 279 there are cases in which the anasarca recurs at long intervals as a result of chronic diffuse nephritis. Vrcemia. — Ursemia commonly sets in with a diminution in the whole quantity of urine passed daily. It may supervene without any distinct change in the quantity or quality of the urinary excre- tion (Henoch). In these cases the changes in the urine follow the appearance of the ursemic symptoms. Ursemia may also appear not- withstanding the passage of an increased amount of urine. The latter mode of onset in ursemia is very uncommon. The early symptoms are vomiting, headache, and slight twitching of the facial muscles. These may subside with the abatement of the nephritis. We may have, however, eclampsia as the first symptom, with tonic or clonic convulsions, unconsciousness, and coma with temporary absence of the reflexes. The respirations are increased, and in most cases the temperature rises. The pulse is small and the skin dry. The convulsions may subside, but the coma may continue. The eclamptic seizures may be repeated. The ursemia may subside, and after a very protracted interval reappear with a repetition of the above phenomena. Mania, melancholia, and aphasia may ensue. Amaurosis without changes in the retina is a more common con- dition. The retinitis of Bright's disease is absent in scarlet fever. Litten found a swollen condition of the papilla. Amaurosis may persist in the intervals between the convulsions. The heart action immediately preceding the convulsions is slow. The pulse may be as low as 40 per minute. During the convulsions the heart action is increased. The respirations may be 60 and the pulse 200 (Jlirgensen). The temperature may be 100.4°-103° F. (38°-39.5° C), rarely 10r.6° F. (42° C), with an initial chill (Jiirgensen). Ursemia may set in at any time while the kidney is aifected. The iJear^.— Myocarditis of an acute infectious character is likely to supervene in septic cases of scarlet fever. The changes in the myocardium may also be secondary to changes in the pericardium and endocardium. Endocarditis of the cardiac walls is more frequent than that of the valves. For this reason murmurs should be carefully observed. ]^o conclusions as to their valvular origin can be reached until long after convalescence. Especially is this true of murmurs which are heard over the base of the heart and pulmonic orifice. Endocarditis is uncommon, but is more frequent in this disease than in diphtheria or typhoid fever. Pericarditis is rare. Muscle murmur is often mistaken for it. If present, pericarditis is usually of the dry fibrinous or serofibrinous variety. It is rarely purulent, except in cases of marked purulent involvement of other organs and cavities, notably the pleura. 280 THE SPECIFIC INFECTIOUS DISEASES. Dilatation of an acute character may supervene early in severe cases. In such cases v^e may have tachycardia or bradycardia. There may be cyanosis. Sudden death is very rare in scarlet fever. Friedlander has shown that in scarlet fever with marked nephritis and uraemia, the consequent increased arterial tension results in dila- tation of the left ventricle, with slight hypertrophy. The weight of the heart is increased 40 per cent. The pulse may be slow and irregular. As the nephritis subsides the tension diminishes and the frequency of the pulse increases. Hypertrophy being the result of long-continued increased tension, can be demonstrated only in extreme cases. Dilatation is rarely so great as to cause death. Lungs. — The lungs may be affected by pneumonia, which is gen- erally of the bronchopneumonic type. Lobar pneumonia as a com- plication of scarlet fever is rare. Gangrene of the lung may occur in the severe septic cases. Pleura. — Pleuritis as a complication of scarlet fever usually appears in the middle of the second week. It is commonly of the serous variety, but the author has had many cases in which there was an empyema usually of the streptococcic variety. Flirbringer states that in 5 per cent, of the cases of pleurisy there is nephritis. The Blood. — There is a diminution of the haemoglobin, which is marked in cases in which nephritis is present. During convalescence the haemoglobin increases. Slight leukocytosis is also present in the course of the disease. Marked leucocytosis occurs with suppurative complications such as otitis, adenitis or empyema. There may be purpura and surface hemorrhages. Stomach and Intestine. — Vomiting has been mentioned as an early symptom in scarlet fever. It is sometimes repeated in the course of the disease if a cough due to any laryngeal or pulmonary complication exists. Diarrhoea is sometimes a serious corhplication. There may be a simple diarrhoea, in which an excessive number of movements may threaten the life of the patient early in the disease ; or, on the other hand, the diarrhoea may subside without serious results. The diarrhoea may take on a dysenteric or typhoidal type, with severe hemorrhages from the gut. There are some forms of diphtheria of the pharynx, stomach, and large intestine in the septic types of scarlet fever which have been described by Litten. Sequelae. — As sequelae to scarlet fever may be mentioned : Anaemia. — This may persist for some time. Glandular Swellings. — The lymph-nodes at the angle of the jaw are apt to remain enlarged long after convalescence. The tonsils may remain large. Tuberculosis. — Tuberculosis may follow scarlet fever. It cannot be said that there is any distinct connection between the two diseases. SCARLET FEVEB. 28 L Scarlet fever may leave the patient more susceptible to infection either of acute miliary or chronic tuberculosis. Nervous Diseases. — Chorea has been noted by Gerhardt to follow scarlet fever, as have also rheumatic joint-affections v^ith endocarditis. Facial paralysis may occur as the result of prolonged otitis. Psychoses, such as melancholia and mania, have been noted, similar to those foUov^ing typhoid fever or pneumonia. Otitis. — Otitis may remain with a permanent discharge and con- sequent deafness or mutism. Relapses or Second Attacks.- — There are no relapses in the true sense in scarlet fever, but instances occur in which after the primary eruption has faded a new and general scarlatinous rash appears. In others, the disease runs an exceedingly mild course, the rash is evanes- cent and lasts only a short time, and the temperature falls quickly to the normal. After ten to fourteen days, a rise of temperature occurs, the lymph-nodes at the angle of the jaw enlarge and the tonsils also enlarge and become covered with a pseudomembrane. The temperature is quite high. Albuminuria and nephritis of a severe type may appear at this time. Second and third attacks of scarlet fever are found recorded in the literature. I have not seen any in which I have personally diagnosed two attacks. The suspicion always is present that in these cases rotheln may have been diagnosed as scarlet fever. Diagnosis.- — The diagnosis of scarlet fever in most cases presents few difficulties; but there is no disease in which the symptoms are more indefinite at times. This is particularly so with patients who present an evanescent or partial exanthema and only slight febrile disturbance. In some cases the diagnosis must always remain in doubt. Under these conditions it is better to err on the safe side, and to take all precautions of isolation. The exanthema if partial or not very well marked is likely to be overlooked. The angina, which is the most constant symptom, may be mild. The temperature presents nothing typical as in typhoid fever. It is good practice in the presence of a localized exanthema of a punctate character on the thighs or lower abdomen or the upper part of the chest, with angina and a slight febrile movement, to consider the case as one of scarlet fever. In all cases of sore throat it is wise not to omit an inspection of the general surface. Although some authors have described the angina of scarlet fever as typical in color, the author has never found this sign of value. In some cases of scarlatinal angina the throat is intensely red ; in other cases it is of a pale-pink hue; in still others the throat is only slightly inflamed. Enanthema. — The enanthema is not of any service in making a diagnosis. The eruption on the soft and on the hard palate is not characteristic. 282 THE SPECIFIC INFECTIOUS DISEASES. Albumin. — Albumin in the urine is thought by some to be diag- nostic of scarlet fever. There may be marked and unmistakable symptoms of scarlet fever without albuminuria. A simple lacunar amygdalitis may be accompanied by albuminuria. Differential Diagnosis. — We must differentiate the eruption of scarlet fever from that of measles and rotheln, from drug eruptions, and those due to irritants. Measles. — In some forms of scarlet fever the eruption on the forearms has a blotchy appearance. ISTear the wrist-joint the author has seen it closely resemble the eruption of measles. In these cases the punctate character of the eruption elsewhere on the surface, and the presence of angina, will assist us, in the absence of any enan- thema on the buccal mucous membrane ('' Koplik's spots") (Plate XIV.), in coming to a conclusion. In measles the diffuse localization of the exanthema on the face, the conjunctivitis and bronchitis, will aid us. In scarlet fever parts of the face, such as the alse nasi and the region of the mouth, are free from eruption, while in measles these localities are affected by the exanthema. Rotheln. — Scarlet fever is most frequently mistaken for rotheln, and vice versa. In rotheln, when the eruption is punctate, it is invariably dis- crete. There is never the severe dermatitis vdth swelling of the skin found in scarlet fever. In rotheln the lymph-nodes are more constantly and generally swollen behind the sterno-mastoid, in the axillae and groin. The throat is but slightly reddened. Eotheln presents a normal temperature or at most a temperature at the outset of the eruption of 101°-102° F. (38.3°-38.8° C.) or even 103° F. (39.4° C), which rapidly subsides to the normal, although the exan- thema may be spreading. Drug Eruptioris. — Following the administration of quinine chil- dren develop an eruption which closely resembles that of scarlet fever. In the presence of an angina and fever it may be difficult to exclude scarlet fever. Antitoxin of diphtheria, antipyrin, and belladonna also cause a rash closely resembling that of scarlet fever. It is well in such cases to discontinue the drug, and after a few days, the erup- tion having disappeared, to administer it again. If the patient be susceptible, there will be a repetition of skin symptoms. Kerosene rubbed on the surface will cause a punctate eruption the exact coun- terpart of a scarlet fever eruption. Among the poor, with whom petroleum is popular as a general remedy, this should be borne in mind. If that has been the case, the skin will have a distinct odor of kerosene. Prognosis. — The prognosis in scarlet fever varies largely with the character of the epidemic and the prevalent type of the disease. In SCAELET FEVEB. 283 some epidemics in Kew York City the mortality has been exceed- ingly low — 2 to 4 per cent. (J. L. Smith), while in others it has been notably high. In England the mortality varies from 13 to 40 per cent. Personal idiosyncrasy will affect the prognosis. Some children develop malignant septic types of the disease although the prevailing epidemic is mild. Cases complicated with severe angina septic in character do badly from the outset. ISTephritis is a complication greatly to be feared. It may result in uraemia and death, or the acute may be followed by a chronic nephritis which may ultimately prove fatal. Otitis may cause serious and even fatal complications, such as brain abscess or sinus thrombosis. Affections of the endocardium or pleura may prove fatal. The prognosis of the so-called scarlatinal rheumatism is good. The joints, even if synovitis develops, retrograde as a rule to the normal in from two to three weeks. This may result even if high fever persists for some time during the joint-affection. In the pres- ence of joint-complications it is necessary to be on the lookout for endocarditis or pericarditis. The occurrence of the latter takes place, as a rule, in cases in which there are other signs of septic infection, such as pleuritis and even peritonitis. These are cases of mixed infection. If synovitis is complicated vdth such a serious inflamma- tion as pericarditis, the latter is very likely to be purulent and in that case the prognosis is grave. The patient cannot be said to be out of danger until the fourth week of the disease has passed without serious complications. A very high temperature at the outset is an element of danger, although not necessarily so. Septic cases with high temperature and pulse above 150 in the first week of the disease are always to be regarded with apprehension. Lotz shows that the mortality is greatest under the age of one year and between the first and second years. The lowest mortality according to statistics occurs between the tenth and the fifteenth years. Morbid Anatomy. — Skin. — The investigations of Preobrachensky and Pearce show that during the interval from the third day to the fourth week certain changes occur in the skin. These consist chiefly in an erythematous inflammation of the papillary layer, with hyper- semia, hemorrhages, and a diapedesis of erythrocytes and leucocytes. There is an oedematous infiltration of the connective tissue of the skin. The cells of the rete Malpighii show vacuolization. There is also an infiltration of the sudoriparous and sebaceous glands with small round cells. The epithelium of these glands desquamates and necroses. 284 THE SPECIFIC INFECTIOUS DISEASES. At the time of the eruption streptococci are found in the skin, espe- cially in the vesicles of the sudamina. The changes in the kidneys will be considered in the chapter on Diseases of the Kidney. Bacteriology. — The parasitic nature of scarlet fever is still a matter for study. Streptococci play a leading role in the disease. Micro-organisms have been described in the blood (Hallier, Klebs, Tschamer) . Others have seen plasmodium-like protozoa in the blood (Pfeiffer, Doehle). Pearce concludes that the bacteria vt^hich pro- duce secondary infections are the Streptococci, Staphylococci and Pneumococci in order of frequency as named. Streptococci have been found in the throat membranes (Loffler), in the joints (Litten, Heubner, Koplik, Van Arsdale), and in various viscera (Frankel, Freudenberg) . Streptococci have also been found in purulent foci of the joints and pleura (Raskin), and in the kid- neys, in cases which have succumbed to fatal nephritis (Babes). In septic forms of scarlet fever these streptococci exist in the circulating blood (Babes, Lenhartz, Peer). Streptococci have also been found in the cerebrospinal fluid and bone-marrow (Baginsky). Bacteriol- ogists, however, are not willing to assign to these streptococci anything but a secondary role, because they present no features which distin- guish them from ordinary Streptococcus pyogenes. Kurth found that some of the streptococci, the so-called conglomerate-forming strepto- cocci, were of a virulent type. The more important complications, such as pneumonia, otitis, adenitis, pleuritis, disease of the antrum of Highmore, abscess of the lung and kidney, endocarditis and inflam- mation of the sphenoidal sinuses are caused by Streptococci (Pearce). Bretonneau, Henoch, and Heubner have always distinguished the diphtheria of scarlet fever from true diphtheria. Sorensen describes the membranous formations of scarlet fever as milky, yellow, smeary deposits which cannot be peeled from the parts. The membrane seems to penetrate into the mucous surfaces. Ulcers form, and the tonsils, soft palate, uvula, and nasopharynx become a necrotic, slough- ing mass. Scarlatinal diphtheria is pre-eminently a septic inflam- matory process with high fever, swelling of the lymph-nodes, and suppurations in dift'erent parts of the body. If the larynx and trachea are affected, the bronchi rarely become involved. The con- trary is true of Lofller diphtheria. In the latter the membrane can be peeled from the surface of the mucous membrane. The membrane is rich in fibrin, and spreads more on the surface and not in the depths. True diphtheria is followed by paralyses. The lesions of the gastro-intestinal tract are degeneration with proliferation of epithelium and invasion of leucocytes. In the heart there is myocarditis with fatty degeneration, in the liver focal necrosis SCABLET FEVEE. 285 and leucocytic invasion. In the spleen there is endothelial prolifera- tion, abundant formation of plasma-cells and leucocytic invasion. The kidneys most frequently shov^ acute interstitial nephritis. The so-called plasma-cells of Councilman are found in the lymph-nodes, kidneys, spleen and tissues (Pearce). Prophylaxis. — The diagnosis of scarlet fever once made, the pa- tient should be isolated from the rest of the family. If several chil- dren are affected in the same family, these children should be sepa- rated and not placed in one room. Otherwise reinfections will occur. The clothes worn just prior to the illness should be sterilized in steam and then aired in the sun. Sufferers with angina who have been about the patient should not be allowed to come in contact with the healthy. All the children of the family should be kept from school. During the illness the bedclothes and linen of the patient should be put into a 1 : 5000 solution of mercuric chloride, prior to being boiled and dried and aired in the sun. The sick-room must be kept well ventilated. There is no advantage in keeping the temperature of the sick-chamber too low. The author has found a temperature of 68° F. (20° C.) comfortable for the patient and those about him. Sun- shine and fresh air are of more value than a room uncomfortably cool. If possible, it is well to spray with some simple cleansing solution morning and evening the throats of any children of the family who are not affected. The physician should take off his coat and vest and put on a linen robe of some kind before entering the sick-room. On his departure he should leave this robe outside the sick-room, or, better still, outside the window of an adjacent room. If the physician wears a beard, he should wash his face in a 1 : 2000 solution of mercuric chloride after leaving the patient. The hands should also be scrupulously disinfected. When he returns home he should make a complete change of clothing before visiting other patients. Carpets and superfluous furniture should be removed from the sick-room. The hanging of sheets wet with disinfectants in the door of the sick- room is not essential. Those about the sick should have no intercourse with the healthy, nor should they go through the house. Meals should be carried by others to some neutral spot. After convalescence the question of the disinfection of the sick- room and its occupation by others arises. It must be confessed that at present we are in possession of no absolutely sure method of dis- infecting a room after its occupancy by a scarlet fever patient. We may adopt one of two methods. The cracks and spaces in the win- dows and doors are closed with strips of paper glued over them. The disinfectants, preferably a large quantity of binoxide of manganese. 286 TRE SPECIFIC INFECTIOUS DISEASES. table salt, and sulphur, are placed in the centre of the room. The sulphur is then ignited and the doors sealed. Formalin is also effective. After twenty-four hours the room is opened and aired, and the floors and walls are scrubbed with 1 : 2000 corrosive subli- mate. In hospitals the scrubbing is sufficient. The floor and walls about the bed occupied by the patient are scrubbed, and also the bed. The mattresses are steamed in a sterilizer constructed for the purpose. In families it is best to destroy or burn all bedding of hair. Eugs may be aired and disinfected by steam at the establishments equipped for the purpose. How soon may a scarlet fever patient have intercourse with the healthy? We have no exact data on this important point. Some authors advise that after the termination of desquamation the patient be given a bath of 1 : 10,000 corrosive sublimate, and then allowed to mingle with the healthy. Others (Baginsky) advise prolonged isola- tion. It is not always practicable, nor indeed desirable, to isolate a patient for too long a period. Family considerations demand a return to the family circle as soon as possible. In these cases the course first mentioned is the most practicable. In cases which have exhibited a malignant septic form of the disease the author would advise pro- longed isolation after convalescence, for the safety of the other chil- dren. The urine of a scarlatinal case if there are even mild signs of nephritis, such as albumin and casts, is believed to be infectious. A recent otitic discharge is thought to be capable of conveying the scar- latinal poison. Treatment. — The treatment of scarlet fever is largely symptomatic. In an ordinary mild case there is little to do but to regulate the diet, and keep the nose and throat freed from excess of secretion. The diet should consist mostly of milk, matzoon, junket, malted milk, cream and water; later on farinaceous gruels, cream soups, bread, toast and milk. Water should be freely given at frequent intervals. The skin needs a little care. During desquamation it is anointed once a day with a 1 per cent, salicylic acid or boric acid ointment, to be stopped after the first week. If there is pruritus the following lotion, recommended by Kellogg, is useful : Calamine 3j 4.00 Zinc oxide 3 ss 2.00 Aqua rosae 5 j 30.00 Glycerin HI xv 1.00 The urine should be examined daily, for even in the mildest cases severe nephritis is apt to intervene. Vigilance should not be relaxed until after the fourth week. SCABLET FEVER. 287 The fever in simple cases needs only the mildest measures. We should remember that the tendency of the fever is to mount until the eruption is fully developed. It then naturally remits. Thus a tem- perature of 105° F. (40.5° C.) in an ordinary uncomplicated case may not last more than a few hours. In ordinary cases sponging with lukewarm water is efficacious. The aim is not so much to reduce the temperature as to support the nervous system and the heart. In private practice it is well not to resort at once to full baths simply because the temperature is above 104° F. (40° C). The reverse is true with temperatures which are persistently high for days. In such cases the author resorts to full baths. The patient is placed in a bath at 100° F. (37.'7° C), and the water cooled to 85° F. (29.4° C). With children it is well not to resort to lower tempera- tures. This is especially true in the asthenic forms of sepsis. The patients fail to react after the bath, and seem weakened by the exces- sive cold. The patients remain in the bath about five minutes, and are then taken out. In cases in which the temperature mounts above 105° F. (40.5° C.) we may employ the pack at a temperature of 70° F. (21.1° C), with much benefit if the reaction is good. The trunk pack may be repeated every one or two hours. The baths above described may be given every four hours. While the patients are in the bath reaction may be promoted by mild friction. Patients with scarlet fever, especially young children, do not bear baths below 75° F. (23.8° C.) well. The old theory that kidney complications are caused by cold baths is not proved. On the contrary, in uraemia Kussmaul lays much weight on the beneficial effects of cold packs where hot baths produce untoward symptoms (Baruch). Antipyretics. — Antipyretics are of little value in scarlet fever, and should not be used unless there is some special contraindication against hydrotherapy. Antipyretics of the coal-tar series especially weaken the heart in the toxaemia which accompanies scarlet fever. Heart. — The heart is supported in septic cases with high tempera- ture, in the same manner as in other diseases of a toxic nature. Alcohol (whiskey) is not given in mild cases. In considering its administration the kidneys should be taken into account. We wait until the temperature remains persistently high. At the third or fourth day a constant temperature of 105° F. (40.5° C.) which refuses to abate vdth treatment calls for the employment of alcohol vdth other remedies. For a child of from two to five years half a drachm to a drachm of alcohol every three hours is a sufficient dose. Alcohol and digitalis are probably our best cardiac remedies. Caf- feine and camphor may also be employed. Strychnine does not seem to do so well in cases in which there is an active myocarditis. Throat and Nose. — In inflammations of these passages we simply 288 TSE SPECIFIC INFECTIOUS DISEASES. keep the parts sprayed with an alkaline solution in order to remove excessive secretion. In this way the patient is made comfortable and the inflammation of the fauces kept within bounds. It is not always possible to spray the throats of the little ones. If there is nasal involvement, the passages may be kept clear by syringing with salt solution in the manner as described by Kellogg and in vogue at the Minturn Hospital, ISTew York. The patient, protected by a rubber sheet, is turned on one side with the cheek resting on the edge of a pus basin, and the head is lowered slightly by removing the pillow, (Infants are prepared as for intubation by wrapping them from the shoulders to the feet in a strong sheet fastened firmly at the shoulders, elbows, wrists, knees, and ankles.) A fountain or Davidson soft rubber bulb syringe is used. The straight tip of the syringe is introduced into the mouth in the median line and carried back to the base of the tongue, which is held down so as to expose the back of the throat. The solution is then directed with considerable force against the pharynx, or the part of the throat from which we wish to dislodge the membrane. When the mouth is filled, the tube is compressed with the finger, and the patient is allowed to expel the solution into the basin. This procedure is repeated until the treatment is finished. Strong antiseptic solu- tions or solutions of sublimate or peroxide of hydrogen are of little use if not harmful. Antitoxin of diphtheria is employed if true Loffler diphtheria coexists. In the streptococcic or most common form of pseudomembranous inflammation we have no remedy which acts directly on the inflammation. Antistreptococcic serum has not given encouraging results. In those cases of scarlet fever in which there is great obstruction of the nasal passages and enlargement of the tonsils, with spreading of diphtheritic membrane from the tonsil to the nasal pharynx and posterior nares, there is great difficulty in breathing. It is almost impossible in some cases to cleanse the nares on account of the accu- mulation of secretion and pseudomembrane. The patient lies in a semi-soporose state. The lymph-nodes at the angle of the jaw are greatly enlarged. This condition of affairs may set in from the very onset of the disease. In these cases the problem arises of relieving the difficulty of breathing. Any interference in a surgical way with the tonsil would be dangerous to the patient at this time. Two courses are open to us : We may intube the nostrils with a piece of soft-rubber catheter tubing, each nostril being intubed with a piece of soft-rubber catheter, extending backward toward the pos- terior wall of the nasal pharynx. !N"os. 10 to 12 are the most avail- able calibres of tubing. The pieces of rubber tubing are secured externally with safety-pins, being cut close to the external nares. SCABLET FEVEB. 289 Through these tubes the posterior nasal space can be cleansed by cautiously allowing some salt solution to run through the rubber tubing (l^orthrup). The relief in some cases is instantaneous; in others the amount of secretion is so great as to block up the rubber tubing. There is then no other resource but to remove the tubing and to instil in each nostril 3 to 5 drops of a 1 : 1000 solution of adrenalin chloride three or four times daily. The relief from this remedy is very great in some cases. I have seen the breathing re- lieved at once. At the same time, owing to the fact that adrenalin is a cardiac stimulant, the patient is rather supported as well as relieved by this remedy. Its effect should, however, be closely watched. We should be very cautious in these cases not to irrigate the nostrils either too often or too forcibly, on account of the danger of ear complications, but should try every measure before resorting to irrigation. ISTasal irrigation is carried out in a manner similar to that pursued in attacks of true diphtheria in the same situation. Lymph-nodes. — The lymph-nodes, especially in the region of the angle of the jaw, are, if swollen, treated with local cold applications, with inunction of ichthyol or unguentum Crede underneath the cold applications. This frequently affords much relief. Unless distinct fluctuation exists, we should avoid incision of the lymph-nodes of the neck. The author has seen these nodes incised at the beginning of the second week in septic cases, with very unsatisfactory results. Pus is not found in such cases, but only foci of necrosis, which are best left to nature until the patient regains strength. Later in the disease such nodes may suppurate and need incision. Nephritis. — The treatment of nephritis is elsewhere described in detail. The lines of procedure are indicated here. As a prophy- lactic against the occurrence of nephritis the early exhibition of urotropin in doses of three to five grains, three times daily, is con- sidered of great value. Headache, vomiting, and convulsions are treated with hot baths, and by the continuous irrigation of hot saline solution (Kemp) per rectum. The kidneys are apt to be affected from the outset in malignant cases. In these cases the Kemp treat- ment with saline enemata is most suitable. With young or intract- able children the continuous irrigation of Kemp cannot be carried out. In these cases a high rectal enema of normal saline solution is given twice daily or more often if necessary. If general anasarca is present, the patient is given two warm baths daily; or with aid of hot air diaphoresis may be facilitated by wrapping him in a blanket which has been moistened with hot water and then wrung dry. Digi- talis in the form of infusion is the most efficient remedy, combined with moderate doses of potassium acetate, tartrate, or citrate. Milk is the exclusive diet. 19 290 TEE SPECIFIC INFECTIOUS DISEASES. Complete suppression of urine, with blood and all the anatomical elements of severe inflammation of the kidney, will sometimes be followed by an increased amount of urine. In such cases the treat- ment just indicated will not be efficacious. The heart must be sup- ported, and watch kept for ursemic symptoms. Opium should be employed with extreme caution — best not at all in convulsions; chloroform inhalations with chloral per rectum are preferable. Saline enemata at 108° F. (42.2° C), diuretin, and nitroglycerin are appli- cable in those cases in which there is suppression of urine. Otitis. — Otitis is sometimes first indicated by spontaneous per- foration and purulent discharge. In other cases pain with a sharp rise of temperature will indicate inflammation of one or both ears. Paracentesis is best performed early, even if only slight redness of the drum is present. Later in the disease (fifth or sixth week) both ears may continue to discharge profusely, with an evening rise of temperature. In some cases the author has noted slight frontal head- ache and drowsiness toward evening. There may be only a slight redness over the mastoid of one or both ears. It is best not to tem- porize in such cases, but to advise opening the mastoid process to insure drainage and avoid sinus thrombosis or cerebral abscess. Complications in the lung, such as bronchopneumonia, are treated on general lines. The possibility of the occurrence of pleurisy should not be lost sight of. Extensive effusions must be aspirated. In all forms of pleurisy, even if the amount of fluid is not large, but per- sists, with a rise and fall of temperature, a needle should be intro- duced into the chest to determine the nature of the fluid. Pus should be evacuated from the pleura in the manner directed in the chapter on Empyema. Joints. — Joint-affections are best treated by immobilizing the affected articulations. The patient should be kept quiet, and sodium salicylate in liberal doses administered. If this is ineffectual after a few days, the joints should be wrapped in cotton moistened with oil of wintergreen, and sodium salicylate combined with sodium bicarbonate given in very liberal doses (aa grains iv (0.4) for a child of three or four years, four times daily). It synovitis occurs and the fever continues high, the joint should be aspirated under antiseptic precautions, in order to ascertain if pus is present. If this is the case, an incision with drainage is the proper remedy. Serum Treatment. — The serum treatment of scarlet fever by means of a polyvalent streptococcus serum has recently been favor- ably reported by Escherich, Moser, Bokai in Europe and Charlton in America. The difficulty of preparing such a serum has as yet pre- vented its general adoption. EOTHELN. 291 ROTHELN. (German Measles; Bubella; Trousseau's Eoseola.) Epidemics of this disease have been described by Forney, 1784; Heim, 1812; Hildebrand, 1832; and in recent times by Thomas Smith and Crozer Griffith. ■ It is an acnte infections disease, con- tagious from person to person, through the atmosphere, though not as highly so as measles. It may occur in the same person a number of times, and may attack those who have had measles. All children exposed do not develop the disease. Age. — The youngest patient in the author's experience was seven weeks old. The affection may occur at any age. The author has seen cases in adults. It occurs with the same frequency in both sexes. Prodromal Period. — There is a prodromal period, during which there may be a slight suffusion of the eyes, with swelling of the con- junctival fold at the inner canthus of the eye. In two cases observed by the author the lymph-nodes behind the border of the sternomastoid muscle were enlarged six days before the appearance of the exan- thema. There is no fever or constitutional disturbance. The period of incubation is placed by Thomas and Emminghaus at from fifteen to twenty days. Just prior to the eruption there are headache, nausea, and bronchial irritation (Forcheimer, Emminghaus). Symptoms. — Exanthema-. — The exanthema resembles that of mea- sles so closely that at the outset it is common for physicians to mis- take one for the other. It is also similar in that it is first noticed to appear faintly around the alas nasi and on the upper lips. The exan- thema appears first on the face, at the temporal regions, and on the cheeks. It is in some cases preceded by an erythematous blush dif- fused over the whole face (Emminghaus), which disappears in a few hours, leaving the true exanthema (pre-exanthematic erythema). The exanthema is papular, of a deep rose-red color, and distinctly arranged in crescentic outlines. This arrangement of the papules in circles and half circles can be made out where the eruption is spread- ing. On the face and neck it gives place to the blotchy appearance characteristic of measles. As a rule, the eruption remains discrete. (Edema of the skin is rarely present. The papules have been described as of two varieties — one the size of those in measles, and the other punctate (Thomas). The punctate papules have been seen by the author on the upper part of the chest, where the eruption is confluent. They are likely to be mistaken in these cases for the exanthema of scarlet fever. In some cases of Thomas and of the author the punctate papules only were present over the whole trunk. There is an absence of the intense dermatitis seen in scarlet fever, and the individual roseolar spots have the out- line above referred to. 292 THE SPECIFIC INFECTIOUS DISEASES. , " The exanthema, while fading on the face and chest, spreads slowly on the extremities, remaining discrete where it is spreading. It remains at its efflorescence on the face and trunk from a few hours to a day, when it begins to fade first from the face, and then from the trunk. A patient may present a perfectly normal skin twenty-four hours after the appearance of the eruption. Evidences of the erup- tion may remain on the trunk and skin for two or three days. The skin then may present bluish or brownish crescentic spots in place of the original exanthema, similar to what is seen in simple erythema. Four days after the eruption has appeared the skin in most cases will have a normal hue. There is no pigmentation or discoloration as in measles. Desquamation. — Desquamation is not always apparent. It is possible in exceptional cases to see a very slight desquamation on the upper part of the thorax or inner aspect of the thighs. The Eruption on the Mucous Membranes. — In rotheln the erup- tion on the mucous membranes does not resemble the exanthema of the skin. There is an eruption in the mouth, but it is not charac- teristic. There is a mild injection of the conjunctiva, a redness of the fauces, and perhaps a slight cough. Coryza, photophobia, and bronchitis are absent. The mild angina and the injection of the con- junctiva resemble what is seen in la grippe. Thomas and Emming- haus have described an irregular, spotted, streaked appearance, with small grayish miliary vesicles, on the soft and the hard palate. Ger- hardt has described a spotted hemorrhagic eruption on the palate, and Forcheimer an irregular macular rose-red eruption on the soft palate. ISTone of these is constant or characteristic of rotheln, but all are found in other affections. The buccal mucous membrane, however, is absolutely free from eruption of any kind, and in this fact we have a valuable diagnostic distinction between this disease and measles. In a small percentage of cases a few red stellate spots on the buccal mucous membrane have been seen by the author. In no case, how- ever, was the measles spot with its bluish-white central speck present. Temperature. — The temperature may at the outset be 99.8° F. (37.5° C.) in the rectum, and continue at this point throughout the disease. It may be 102° F. (38.8° C), rarely higher. The tem- perature is highest at the outset when the exanthema appears on the face (Fig. 40). It falls rapidly within a few hours by a sort of crisis. Meanwhile the eruption may spread to the lower extremities. Lymph-nodes. — The author has studied a number of cases with especial reference to the lymph-nodes. Before the appearance of the eruption the nodes behind the sternomastoid and angles of the jaw may be enlarged. At the time of appearance of the exanthema the nodes of the axilla, bicipital groove, and groin become enlarged to the EOTHELN. 293 size of a beau or larger. The nodes may remain enlarged for weeks after the eruption has disappeared. S'pleen, — The spleen is not enlarged. The Genitals. — In one case the injection of the vulvar mucous membrane caused temporary dysuria. Complications. — Kotheln is such a mild disease that complications are rare. Prognosis. — The patients recover rapidly. Diagnosis. — The diagnosis of rotheln should not present any diffi- culties. It is most likely to be confounded with measles, scarlet fever, and erythematous eruptions. Fig 40 . DAY OF MONTH 1 '- 3 4 DAY A.M. P.M. A.M. P.M. A.M. P.M. A.M. 101° X -100° > o - \ lU 1 UJ \ 3 / < \ L- \ '-' ^ O 1 o V ^ ^ 1- 99^ N u S UJ ■^ — ■ , ^ "N ^ S k ^ -^ PULSE 108 116 120 120 120 108 104 RESP. ■Zi ■i-i 34 'U 30 23 20 Temperature-curve of a case of rotheln in a boy six years of age. from the outset. Observed The symptoms are much milder, and there is an absence of the . specific buccal enanthema of measles. Measles does not, as a rule, present simultaneous lymph-node enlargements all over the body, such as are seen in rotheln. Scarlet fever presents a severe dermatitis, which is absent in rotheln. There is a marked angina of a progressive type, with high temperature. The general enlargement of lymph-nodes is not so useful a sign, since in scarlet fever the lymph-nodes of the neck may be enlarged at the angle of the jaw, or those in the axillae and in the groin may enlarge as the eruption develops. In scarlet fever there is a characteristic desquamation. Erythematous eruptions of the small papular type may resemble rotheln, but the characteristic crescentic outline of the rotheln roseola is absent. Treatment.^ — Isolation need not be rigid. Children are kept in- doors in summer until the eruption has disappeared and the tem- 294 TEE SPECIFIC INFECTIOUS DISEASES. perature is normal. In the winter months the patients are kept indoors one week from the onset of the disease. The angina rarely requires treatment. MEASLES. (Bubeola; MorMlli.) Measles is an acnte infectious disease distinguished hj a charac- teristic eruption or exanthema on the skin and enanthema on the mucous membrane of the mouth. It is highly contagious. The specific agent has not been isolated. Most people are susceptible to measles, and suffer from at least one attack. Infants up to the age of five months are not as susceptible as at a later period. IsTewborn infants have been infected by the mother, and the foetus has been infected in utero. The foetus in such cases may be expelled pre- maturely, and at birth is found covered with the exanthema; or, if the infection occurs at full term, the foetus may be expelled alive covered with the exanthema (Squire). The firstborn only is believed by Thomas to be immune for the period mentioned. The disease is very infrequent during the first year of life. Bartels calculates the occurrence at this time at 5 per cent, of the total number of cases. The author has seen measles in infants under five months of age. Measles is most frequent between the age of one and five years (Bartels, Henoch). It is prevalent in all countries of the globe; climate or meteorological conditions seem to have no influence upon its preva- lence either endemically or epidemically. Measles has a well-defined period of incubation, varying from thirteen to fifteen days (Van Panum). In calculating this period we include the time which elapses from exposure to the appearance of the eruption on the body. It will be seen later that this period includes the period of incubation proper, in which absolutely no symptoms, not even fever or malaise, are apparent, and the period of the enanthema on the mucous membrane. The enanthema, which may be accompanied by coryza of mild or severe type, may appear from the ninth to the tenth day after exposure, and lasts from three to five days. Thus while the coryza may be postponed several days or the enanthema may be present for a variable period, the two periods together have a duration of from thirteen to fifteen days. I have seen the enanthema fully five days before the exanthema, and have seen cases of this kind without any manifestations of coryza to sig- nalize the onset of the disease. It is erroneous, therefore, to calculate the period of incubation from the exposure to the onset of coryza, as the latter is variable as to the time of its appearance. One attack protects the individual from subsequent attacks. Au- MEASLES. 295 thentic cases of two attacks in the same individual have recently been recorded. By this is not meant a recrudescence of the exan- thema after it has once faded. This is also knov^m to occur ( Jlirgen- sen). Experiments have proved that measles is highly contagious in the catarrhal stage. Inoculations with the blood (Home) and nasal secretions (Mayr) have given positive results. The period of greatest contagion extends through the period of the exanthema. It diminishes as the exanthema fades, and is thought to disappear grad- ually during the period of desquamation. Thus though more general in its power to infect, the poison of measles has a shorter period of life than that of scarlet fever. The poison of the latter disease may retain its power of infection months after the disease has run its course. From what has been said, it will be understood that the infection of measles takes place in the vast majority of cases in the stage of the enanthema (incubation). At this time there may be no coryza. Infection occurs during the stage of desquamation (Baginsky). If ordinary caution is exercised, it is doubtful whether measles is ever carried by a healthy individual to a third person as scarlet fever is. Baginsky records an epidemic caused in this manner. The poison does not adhere to articles of furniture and wearing apparel with the same tenacity as that of scarlet fever. Symptoms. — The ordinary simple type of measles is that which runs its course without any complications or sequelae. There is a prodromal period, which includes the period of incubation before the appearance of the enanthema on the mucous membrane of the mouth. During this period it is well established that there are no clinical symptoms whatever — neither fever nor malaise. At the time of the appearance of the enanthema on the mucous membrane the patient begins to feel slightly ill. The symptoms may be only a headache or a slight disturbance of the stomach. The author had noted in some cases a rise of a degree or more in temperature toward evening. There are at this time slight injection of the eyes and general lassi- tude. Coryza is not pronounced. The patient during the first days of the enanthema, and by this is meant forty-eight to seventy-two hours before the appearance of the exanthema on the skin, presents few signs of illness. If, guided by the very faint redness at the inner canthus of the eyes, we look into the mouth, a few spots of a very characteristic eruption are seen on the buccal mucous membrane. This eruption is pathognomonic of the invasion of measles, and will be later de- scribed as the enanthema. After forty-eight to seventy-two hours, and in some cases a longer period, there are coryza, cough, and con- junctivitis. There is a slight febrile movement, varying in intensity in different cases. 296 THE SPECIFIC INFECTIOUS DISEASES. The exanthema now appears, and is first noticed at the temporal region of the face and the alfe nasi as a macular rose-red spotted erup- tion, which becomes papular later in the course of the disease. The face and scalp are now fully covered by the rose-red irregularly shaped papules, which next appear in rapid succession on the back of the hands, forearms, anterior part of the trunk, back, and lower extremi- ties. This order of the appearance of the exanthema is not always maintained. In some cases, as pointed out by Rehn, and verified by the author, the eruption may first appear on the back. It is, there- fore, advisable to examine the patient in a nude state. The eruptive stage of measles generally lasts three or four days, during which the patient has an exacerbation of all the sym^jtoms of the stage of invasion. There are intense photophobia, active coryza, and a croupy cough as a result of the invasion of the laryngeal mucous membrane by the enanthema. The bronchi are also affected, and there are symptoms of acute bronchitis. Even very mild cases of measles show laryngeal and bronchial involvement. At this stage the exanthema on the skin is general and profuse, and in places con- fluent. The patches of healthy skin are crescentic, owing to the pecu- liar conformation of the papules. In some mild cases the rash may be very diffuse, but in others discrete. In the mildest forms of measles the rash closely resembles in the latter respect that seen in rotheln. The fever reaches its height when the eruption on the skin is fully developed. If the mucous membrane is inspected at the height of the skin eruption, it will be seen that the enanthema becomes diifuse before the eruption of the skin is fully developed. The mucous mem- brane of the mouth is diffusely inflamed and studded with bluish- white specks which rapidly disappear or desquamate. The eruption on the skin persists for three or four days and then begins to fade. With disappearance of the eruption the general symptoms abate. The fever remits, and the temperature becomes normal by gradual morning remissions. The coryza, cough, and photophobia lessen, and the patient passes into the convalescent period. Desquamation begins when the pinkish hue of the eruption has disappeared. This stage continues until the last vestige of pigmented spots on the skin has disappeared. As a rule, it is completed two weeks after the exan- thema has made its appearance. Desquamation is never absent in measles (Crozer Griflith), but it may be difficult to detect its pres- ence. The epithelium is shed in the formof branny scales. Desqua- mation is best seen on the anterior part of the chest, shoulders, and inner surface of the thighs. In uncomplicated cases it is not attended by constitutional symptoms. The Temperature. — Measles presents no characteristic fever- MEASLES. 297 curve. The invasion is rarely signalized by a chill. There may be a slight sensation of chilliness. The prodromal period before the appearance of the enanthema is not marked by fever. The period of the enanthema presents a slight temperature with morning remis- sions to normal (Fig. 36). When the eruption appears on the skin the fever increases, and reaches its height after thirty-six hours, at the time of the full development of the eruption. The temperature continues high v^^ith morning or evening remissions for from one and a half to tw^o and a half days, and then subsides, and disappears in from twenty-four to thirty-six hours after desquamation has set in. The temperature may reach 104:°-105.8° F. (40°-41° C.) without complications. During the stage of desquamation the temperature is not elevated unless complication exists in the lung or elsewhere (Fig. 41). Fig. 41. S5nt°; 1 2 3 4 6 6 = 1 HOUR 3 li 9 12 ■' ti 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9|12 3 6 9 12 3 09 12 3 6 9 12 3 " 9 12 3 6 9 12 3 6 9 12 u 9 12 ' » 12 lOi 103 i 102 i- lUO 99° 10 N- \T H :ic - s / \ f 1 s / s \ r s ^ V s PULSE "O/llO n^ ^120 .0, ''iso no. Iso 11 110^ ^115 90^ io 1 Uncomplicated measles in a boy of five years. I have sketched the type of disease which is not complicated by serious affection of the viscera and which has no sequelae. On account of variations from the simple type just described, measles is one of the most dreaded diseases of infancy and childhood. In fatal cases occurring during the first two years of life the lung is generally involved (Henoch). The appearance of the eruption is ushered in with a convulsive seizure or a chill. The pneumonia appears as the eruption reaches its height, and within two weeks either proves fatal or else leaves the patient weakened or the subject of an empyema. The infection of the kidneys may be so severe as to prove speedily fatal, or there may be severe mastoid disease. On the other hand, there are cases of measles of a type so mild as to cause little constitutional disturbance. The fever is very mild and evanescent, and present only at the outbreak of the eruption, and 298 IRE SPECIFIC IXFECIIOrS DISEASES. even at this stage may be so slight as to escape notice. Jiirgensen records measles without fever. The Enanthema, — This is the eruption which appears on the mucous membrane of the mouth. It differs from the exanthema in respect to location. The enanthema appears in the mouth from three to five days before the appearance of the exanthema. It is accom- panied by redness of the pharynx, and of the anterior and posterior pillars of the fauces. The soft palate is studded with irregularly shaped rose-colored spots or streaks. The spots on the hard palate present small whitish, punctate, miliary vesicles. These spots are also found on the otherwise normally colored mucous membrane of the cheeks and on that opposite the gTims of the upper and lower molar teeth. They have been described by Flindt in these localities and on the palpebral conjunctiva. Filatow has described a desqua- mation of the epithelium of the mucous membrane of the lips and cheeks, in the form of minute whitish shreds (Slawyk). A complete series of studies of the enanthema of measles has been made, and there can, therefore, be no doubt of its existence. In 1896 I pub- lished a study of the enanthema on the buccal mucous membrane, and on the inner surface of the lips. In this study I showed that the enanthema on the hard and soft palate so frequently described since the publication of Rehn was not peculiar to measles. The spots of rose-colored papules or streaks with the superimposed miliary vesicles are found in rotheln, scarlet fever, and some cases of simple angina. The eruption on the buccal mucous membrane alone, however, pre- ceding the appearance of the exanthema on the skin by a period of from three to five days, is characteristic of the invasion of measles. It is pathognomonic of the disease, and occurs in no other known con- ditions. It is almost invariably present, observations having shown it to be absent in only a very small percentage of cases (Plate XIV.). On looking at the mucous membrane lining the cheeks (buccal) in strong sunlight, a very characteristic eruption of irregular stellate or round rose-colored spots is seen. In the centre of each spot there is a bluish-white speck. This appearance of a bluish-white speck on a rose-colored background is pathognomonic of the onset of measles. The speck is sometimes so minute that strong sunlight is necessary to render it visible. The number of specks at the outset may be less than half a dozen. In a short time they become more numerous, and the rose-colored spots become confluent, so that there are ditfusely red patches of buccal mucous membrane studded with bluish-while specks. The specks rarely or never become confluent; their color does not resemble that of sprue, nor are they as coarse as sprue accumulations. They are seen on the inner surface of the lips, and are sometimes well marked on the buccal mucous membrane adjacent to the aiims PLATE XIV FIG. 8. FIG. 4. The Pathognomonic Sign of Measles (Koplik's Spots). Fig. 1. The discrete measles spots on the buccal mucous membrane, showing the isolated rose-red spot, with the minute bluish-white centre, on the normally colored mucous membrane. Fig. 2. Shows the increased eruption of spots on the mucous membrane of the cheeks ; patches of pale pink interspersed among rose-red areas, the latter showing numerous pale bluish-white spots. Fig. 3. The appearance of the buccal mucous membrane when the measles spots coalesce and give a diffuse redness, with myriads of bluish-white specks. The exanthema is at this time fully developed. Fig. 4. Aphthous stomatitis sometimes mistaken for measles spots. Mucous membrane normal in color.' Minute ydlotv points are surrounded by a red area. Always discrete. MEASLES. 299 of the upper molar teeth. If the finger is passed over the mucous membrane, they are felt to be raised and firmly adherent. They can be rubbed off by force or picked oft" with forceps. As the exanthema spreads, the enanthema of the buccal mucous membrane becomes dif- fuse. When the exanthema is at its height and during efflorescence the eruption on the mucous membrane begins to lose its character- istics. The bluish-white specks are washed away by the buccal secre- tions and leave the mucous membrane diffusely reddened and raw. Fig. 42. DAY OF ILLNFSS 12 3 4 HOUR 3 6 9 12 3 6 9 12 3 6 9 12 3 9 12 3 6 9 12 3 fl 9 -- 3 9 12 3 6 9 12 107° o 106 105° il04° L. UJ ^103 < UJ Q. ^102° 1- 101° 100° o -*•- - ^ o UJ -O- ui < n! Q. o o- - ^ ^ tn Ui ^ V -J ^ ' •:£ _) "*■ j o rn / I / ■»■ UJ J \ / ^ > r' ^ / in ^ / rn o '\ / ui UJ k, , > ,^ s. -■ ^^ / / s / \ Hi / s -' / \ ^ s. y \ / \ \ / s / \ \ \ f y / \ / UJ \ / ^_ p \ / H z < 2 o i c5 i n n r> 2 rs § o -*< S C3 '^i 3 i ?s 3 3 3 iS RES P. 3 s a 3 s 8 5? h s " 'f -»■ o ^ "* o •^ -*< •a ,^ 3 3 I? 5! ■* ■^ -* Case of measles observed from the flrst appearance of the " Koplik spots " to the time of the outbreak of the exanthema, a period of fully four days. During this time it appears there was a gradually rising curve of temperature without any exanthema with a low leucocyte count. By referring to the temperature-curve, it will be seen that the appearance of the enanthema is accompanied before the outbreak of the skin eruption by fever of a low type (Fig- 42). There is also at this time a leucopenia ; a diazo reaction appears in the urine at the time of the outbreak of the exanthema. 300 THE SPECIFIC INFECTIOUS DISEASES. Exantliema. — The exanthema of measles is a characteristic erup- tion of rose-colored or purple-colored papules, varying in diameter from 1 millimetre to 1 centimetre, the average diameter being 2 milli- metres. They are irregularly circular, or longer in one diameter than another, or shaped like a half -moon. They arrange themselves crescentically. They are at first discrete, but soon become confl^^ent, so that large areas of skin are covered. Here and there are areas of normally colored skin. The discrete papules have a distinctly cres- centic arrangement. This is seen on the thorax and thighs. As a rule, the whole face is covered with the eruption, and the skin swollen. The eruption spreads from the face and head to the back of the neck, throat, upper part of the back, chest, and back of the hands and arms. The lower extremities become affected, as well as the palms of the hands and soles of the feet. As a rule, the eruption on the skin is papular; the papules may show at their summit miliary vesicles. They may become confluent and form patches. Hemorrhages may occur in and around the papules (Morbilli hsemorrhagica). In these cases petechise occur in the course of the exanthema, and persist into the period of desquamation. They should not be confounded with petechial eruptions or purpura, which may appear after the exan- thema has run its course. The exanthema in weakly children may be limited in its distribution and not characteristic. Henoch believes that many cases in which the exanthema does not develop in sequence, take a subsequent course which may. be severe. If therefore the ex- anthema should first appear on the back, instead of the face, and spread thence, complications may be expected. Although complica- tions occur with eruptions which are diffuse and very general, the severity of the eruption is no index as to the severity of the disease. When the exanthema fades, it leaves the skin studded with dirty brownish-colored spots, which have the arrangement of the original exanthema. These pigmented areas gradually fade, and when des- quamation is complete they disappear. Measles may run its course without the appearance of the exan- thema on the face. It may be ill-defined and limited to certain parts of the body. It may develop in full intensity and then suddenly fade within a few hours. This occurs in cases in which severe disturb- ances of the circulation alter the distribution of blood in the skin. In these cases there may be a complication of the lungs or heart, but the fading of the exanthema is not, as is thought by the laity, pri- marily the cause of any affection of the internal organs. Complications. — The Nose, Pharynx, and Larynx. — In very young infants severe inflammation of the mucous membrane of the nose and nasopharynx may lead to difficulties not only in breathing, but also in feeding. In these cases membrane rarely develops. If it does MEASLES. 301 appear, it takes the form of a pseudomembranous rhinitis, generally of a diphtheroid streptococcic nature. Its course then may be sub- acute. The larynx is sometimes severely affected, so that at the height of the exanthema the patient is troubled with a harassing, croupy cough. In some cases the patient becomes almost aphonic. If there is no obstruction to the breathing, this symptom, which causes great concern, disappears. The larynx may present a pseudomem- branous affection of a streptococcic nature. Gerhardt has shown that ulceration of the posterior laryngeal wall may ensue from traumatism to the larynx as a result of repeated fits of coughing. If these ulcera- tions cause swelling of the mucous membrane, obstruction to respira- tion may result. The bronchitis which is always present in such cases may cause obstruction of the finer bronchi. On account of inef- ficient respiratory effort atelectasis and pneumonia may result, with fatal issue. Diphtheria. — Diphtheria may complicate measles. It may pre- cede the eruption, or may develop at any time during the attack. In all such cases the patient has been exposed to a diphtheritic infection. A case in the author's hospital service had recovered from diphtheria two weeks previous to the attack of measles. Three days after the appearance of the exanthema the conjunctiva became covered with true diphtheritic membrane. The larynx then became involved, and stenosis set in within twenty-four hours after the appearance of the membrane on the conjunctiva. The exanthema in these cases is likely to fade rapidly or become hemorrhagic. Diphtheria complicated with measles is rapidly fatal, since the trachea and bronchi become involved. Fatal pneumonia supervenes. On the other hand, the author has seen a croupy cough with dyspnoea, set in three weeks after convales- cence from measles. Diphtheria bacilli were found in the pharynx. In this case no pseudomembrane on the pharynx was visible. It is not always possible to decide in a given case whether there is a simple swelling of the mucous membrane of the larynx or a pseudomem- branous process. In cases with severe laryngeal symptoms, if no membrane is visible, a culture of the secretions of the pharynx should be made. The temperature-curve does not aid us. Diphtheria may run its course with a low or a high temperature. The pulse is of little assistance in making a diagnosis. There is nothing in the nature of measles which predisposes toward diphtheritic infection. During convalescence persistent hoarseness or aphonia is not infre- quently seen without other disturbances. The voice gradually returns to the normal. Prudden and ISTorthrup, in a paper on diphtheria with fatal pneumonia, record three cases of fatal diphtheria complicating mea- sles. The diphtheria and subsequent pneumonia were of the strepto- 302 THE SPECIFIC IXFECTIOUS DISEASES. COCCUS variety. The three cases formed part of a series of seventeen cases of streptococcus diphtheria followed by pneumonia. Bronchitis; Bronchopneumonia; Atelectasis. — A very serious complication of measles is bronchitis, which may involve the capillary bronchi, causing atelectasis and bronchopneumonia. In the stage of efflorescence the bronchitis at times becomes severe. There are found on auscultation fine crepitant rales in addition to the very coarse mucous and sonorous rales. At the end of inspiration a fine crepi- tation is heard, similar to that present at the beginning of pneu- monia. There is also subcrepitation at the close of expiration. In these cases the constitutional symptoms are severe, if large areas of lung are involved. The dyspnoea is extreme. Although cyanosis may be present, no areas of consolidation are detected on physical examination. It is reasonable to infer that in all cases of severe inflammation of the smaller bronchi, areas of bronchopneumonia exist. Auscultation may reveal areas of lung in which the air enters imperfectly. An attack of coughing will open up the bronchi, when air again enters these areas (atelectasis). In young infants and children this form of bronchitis is a serious complication. As a rule, it leads to bronchopneumonia. The pneumonia which complicates measles, either in the eruptive stage or in the desquamative period, is anatomically usually of the bronchopneumonic type, although the lobar form may occur. The pneumonia is caused by an invasion of the lung tissue by streptococci from the bronchi. A bronchopneumonia may at first be difficult of detection. As a rule, however, it involves a lobe of the lung in a short time. The lower portions of the lung behind are usually first involved, although the upper lobes or middle lobe may in exceptional cases be first involved. When consolidation takes place, the area of lung involved may be as extensive as in lobar pneumonia. A pneu- monic process should be suspected if the temperature in the stage of desquamation does not fall to the normal. There is a distinct rise of temperature which varies in intensity, and remits in the morning to become higher in the evening. The cough becomes troublesome, and there is also dyspnoea. In such cases the temperature alone can- not be relied upon for a diagnosis. A careful physical examination will be of assistance. Under two years of age this form of broncho- pneumonia is very fatal. As a rule, pneumonia complicating measles terminates, if not in immediate recovery, in a bronchopneumonia which persists for weeks. The temperature may fall almost to the normal in the morning and in the evening rise a degree or more. In addition to the bronchopneumonia there may be pleurisy, with thick- ening of the pleura and purulent exudate. In some cases the upper lobe of the lung shows signs of unresolved pneumonia for weeks. MEASLES. ao^ Emaciation is progressive. All of these cases are not necessarily tuberculous. A tuberculous process may be engrafted on a non- tuberculous bronchopneumonia at any time by infection with tubercle bacilli. In measles there seems to be a predisposition to invasion of the lung by tubercle bacilli through the catarrhal and inflamed mucous membrane of the bronchi. We can reasonably hope for recovery in many of these cases of simple chronic bronchopneumonia. If tuber- culous glands, vi^hich have been dormant before the invasion of measles exist, they form focal points for the development of tuber- culosis of the lungs or meninges. Such cases are fatal. Autopsy will reveal recent lesions alongside of old tuberculous foci. The frequency of infection with tuberculosis varies in different localities. In some epidemics it occurs in 5 per cent, of the cases; in others, 16 per cent, or more are affected (Bartels, Jiirgensen). Fig. 43. DATE S 9 10 11 12 13 14 15 16 Fe 17 »ru 18 19 20 21 22 23 24 25 26 27 28 105° 104 1 102° ^ O ^ 101 1 100° *- 99° 98° 97° M EASL ES EN DOC MD\ IS / '\ / \, \ y s V y \ (\ S >. 1 \ \ V / v^ ^^ "A / \ % \y ^ PULSE 102 118 116 124 133 134 134 140 140 133 140 146 136 140 140 138 143 140 130 138 130 RESP. 34 32 34 43 60 63 56 63 60 60 54 50 70 68 60 56 54 50 52 60 50 Measles complicated with endocarditis in a boy six years of age. The Heart. — The endocardium is rarely affected in measles. If endocarditis does occur, it is usually an intercurrent affection in a rheumatic subject. Fig. 43 shows a temperature-curve from a case in which rheumatism preceded an attack of measles, and which in turn was followed by endocarditis. Myocarditis may be found in fatal cases of bronchopneumonia. In bronchopneumonia complicated with pleurisy, pericarditis may also be present (Baginsky). The Intestines. — In some epidemics diarrhoea is a frequent com- plication. The movements are numerous, and watery in character. When the large intestine is involved the stools contain blood and mucus, and tenesmus is present. The season of the year influences the intensity of the infection. In the warm months the diarrhoea may be of a severe type. In cases recorded by Henoch and Thomas, autopsy showed enlarged Peyer's patches and solitary follicles resem- bling those seen in typhoid fever. 'No cases of ulceration have been recorded. Jiirgensen is inclined to regard the diarrhoea a result 304 THE SPECIFIC IISFECTIOUS DISEASES. of infection of the intestinal mucons membrane. The enanthema appears in this locality early in the disease. The Kidneys. — In many cases of measles, albnmin and a few hyaline and epithelial casts are present in the urine. They are the result of a parenchymatous inflammation of the kidney, due to the poison of the disease, A severe nephritis, such as is common in scarlet fever, is rarely seen. I^ephritis is apt to occur in the severe cases complicated with bronchopneumonia. There may then be marked albuminuria, blood, and casts of all kinds in the urine, with suppression. On the other hand, nephritis in the stage of desqua- mation is uncommon. There is always in such cases suspicion that an infection coincident with scarlet fever may have been overlooked (Henoch). If diphtheria complicates measles, nephritis is likely to be present. The Bones and Joints. — The author has seen osteomyelitis with suppuration of the joints follow measles. Streptococci were found in the pus. In one case bronchopneumonia was an earlier complica- tion. These cases are rare. Lymph-nodes. — If the inflammation of the throat is severe, the lymph-nodes at the angle of the jaw and underneath the body of the jaw may be enlarged. Rarely, however, is the adenitis as severe as in scarlet fever. The glands or nodes in the axillae, bicipital groove, over the internal condyle of the elbow-joint, and in the groin may be enlarged to the same extent as in rotheln, as a result of the processes taking place in the skin. Severe infection of the gut may cause swelling of the mesenteric lymph-nodes, which, if not tuberculous, will retrograde after the disease has run its course. The Blood. — In measles as distinguished from scarlet fever an examination of the blood shows a subnormal number of leucocytes or a leucopenia. This condition of the blood is found in the initial stage of the disease, and persists well into the period of the exan- thema in uncomplicated cases, as is well shown in Fig. 39. The Nervous System. — It is rare to see convulsions usher in an attack of measles, even of a severe type. In anomalous forms of the disease complicated with pneumonia there may be cerebral symptoms similar to those seen in the latter affection. There may in some cases be a complicating cerebrospinal meningitis with purulent exudate. If tuberculosis is present, the meninges may be attacked, as in any tuberculous infection. French writers have observed neuritis follow- ing measles. The Eyes. — Following severe cases of measles, photophobia, spasm of the orbicularis, inflammation of the lachrymal duct, conjunctivitis, ulcerations of the cornea, and amaurosis may result. Hence, even in mild forms of tlic disease the eyes should be frequently inspected (Eversbusch). MEASLES. ;^>05 The Genitals. — The author has seen djsuria in cases in which the enanthema affected the mucous membrane of the vulva in girls. Henoch records cases of gangrene (noma) of the genital organs. The Mouth. — Inasmuch as the mucous membrane of the mouth is the seat of an active eruption, stomatitis is likely to be present, especially if through carelessness or traumatism the mucous mem- brane has become infected v^ith bacteria from without. In such cases aphthae may result. Children in unhygienic surroundings are likely to develop noma of the cheek if exposed to the infection. Pertussis. — Pertussis is an occasional complication of measles. A.S in diphtheritic infection, there must have been exposure to the contagion of both pertussis and measles, since etiologically the dis- eases have nothing in common. The danger in the coincident occur- rence of measles and pertussis is that bronchopneumonia is likely to develop, and prove a serious if not fatal complication. The Ear. — The external structures of the ear may be affected by oedema and swelling. The external auditory canal may become the seat of painful swelling and diffuse inflammation. Gangrene of the pinna has been noted (!N^ottingham, Bourdillot). The most common affection of the ear is otitis media catarrhalis. Of 33 cases of severe complicated measles, Tobeitz found otitis of this variety in 16. The frequency of otitis varies with different epidemics. The otitis makes its appearance in the period between the seventh and the twenty-sixth day following the development of the exanthema. Of 22 fatal cases of measles, otitis was found in 19, only Y of which presented symp- toms during life. The great majority of cases of otitis give no pro- nounced symptoms and end in resolution. These mild cases are the result of the action through the blood of the measles poison on the ear structures (hematogenic). The severe cases follow a mixed infec- tion through the pharynx and Eustachian tube. In the pus of acute or chronic otitis, with or without inflammation of the mastoid, the streptococcus, Staphylococcus pyogenes, and pyogenic diplococci have been found. The general course of otitis is not so severe as that of scarlet fever. In some epidemics the severe and fatal cases are more common than in others. Sequelae. — Any of the complications named above may pursue a chronic course. In this sense only are they sequelae. Chronic blepharitis, blennorrhoea, keratitis, otitis, catarrhal inflammation or ulceration with stenosis of the larynx, septic retropharyngeal abscess, and chronic bronchopneumonia may persist for weeks or months. Prognosis. — The prognosis in measles varies with the virulence of the epidemic, the resistance of the individual, and the age of the patient. The idea prevalent among the laity, that measles is a comparatively mild affection, is incorrect. In the cases treated in 20 306 THE SPECIFIC INFECTIOUS DISEASES. both dispensary and private practice, and at all periods of infancy and childhood, the mortality is 8 per cent. (Breyer). The mor- tality is greatest during the first year of life, and niay vary in different epidemics from 10 to 40 per cent. The lowest mortality seems to be between the fifth and eighth years — 6 per cent. (Bagin- sky). Hospital statistics are of little value to the general practi- tioner, as the class of cases treated in institutions give a high mortality- rate. The mortality in hospitals may be as high as 30 to 35 per cent. (Henoch, Fiirbringer). Diagnosis. — The diagnosis will in most cases present few difii- culties if the physician follows a fixed routine in the examination of the patient. The mode of onset, the coryza, the enanthema of the buccal mucous membrane, and the skin eruption are characteristic. If the physician will examine the inner surface of the cheeks and the buccal mucous membrane in every seemingly slight indisposition of children, he will in certain cases be able to predict an attack of measles far in advance of the appearance of the exanthema. In some cases the enanthema appears on the buccal mucous membrane before coryza is present. The inspection of the buccal mucous membrane thus becomes important as a prophylactic measure. Strong sunlight is essential for thorough inspection. Although the bluish-white spots on the rose-red background may sometimes be seen by artificial light, especially electric light, a diagnosis of measles should never be made at night. Cases of influenza closely resemble measles at the outset. These present the injected conjunctivae, cough, and rose-colored spots on the soft and the hard palate seen in measles. In la grippe, how- ever, the buccal mucous membrane is pale and presents absolutely no eruption. In one of the early grippe epidemics in ISTew York the children showed an ill-defined roseolar eruption on the surface, but the buccal eruption was never present. Rotheln. — Botheln in some cases resembles mild measles so closely that the author has often questioned whether so-called cases of mild measles without rise of temperature, described by authors, were not cases of rotheln. The difficulty in differentiation is increased if measles is prevalent at the same time. The absence of the buccal eruption is a crucial test. Schmid has also laid stress on this point. In some rare cases of rotheln there may be seen an isolated, rose-red' spot here and there on the buccal mucous membrane, but the bluish- white speck in the centre of these spots is never seen as in measles. Scarlet Fever. — Scarlet fever may at times closely resemble measles, especially in those forms in which the eruption on the face is evanescent. In scarlet fever the buccal mucous membrane has a normal hue. The author has seen scarlet fever complicated with measles. In these cases the scarlet eruption appeared first. Within MEASLES. 307 two or three days there was a general recrudescence of the exanthema, with the appearance all over the body of a roseola (the scarlet rash had faded somewhat), coryza, and the buccal eruption. In other cases the scarlet fever eruption on the back of the hands and forearms assumes the blotchy, papular roseolar form of the exanthema of measles. The author has seen a case of this kind in which an expert entertained the possibility of rotheln or measles. The buccal enan- thema was absent. The subsequent course of the case proved the diagnosis of scarlet fever to be correct. Typhoidal Roseola. — The roseola of typhoid is sometimes so abun- dant as to mislead the physician into mistaking it for the eruption of measles. Measles complicating typhoid at the end of the second week has come under the author's notice. In this case the buccal eruption was profuse. Drug Eruptions. — Antitoxin and drug eruptions may simulate a measles eruption, but the buccal mucous membrane never presents the enanthema. Syphilitic Roseola. — The roseola of syphilis frequently resembles that of measles so closely as to cause uncertainty in the diagnosis. Here the conjunctivse may be injected, and there may be a slight febrile disturbance (Sobel). The buccal mucous membrane is pale, and shows no eruption resembling that seen in measles. The diag-nosis of measles thus resolves itself into a recognition of the disease before and after the appearance of the skin eruption. Before the appearance of the eruption there is very little to guide us. Cough, coryza, and fever may accompany an influenza. In these cases the buccal eruption is of great diagnostic value. After the eruption appears, the question narrows itself to the differentiation of measles from rotheln or scarlet fever, and the recognition of the various forms of erythema, roseola, drug and antitoxin eruptions. Prophylaxis. — As soon as the physician has made the diagnosis of measles or suspects its presence, the patient should be isolated from other children of the family. Among the poor it is sometimes im- possible to do this. The members of the family not directly con- cerned in the care of the patient should be denied admittance to the sick-room. It is not necessary to cover the door of the room with cloths or sheets moistened with disinfectants. The physician before entering the room should take off his coat and put on some convenient linen gown or bath-robe, so as to completely cover his person. This robe should hang outside the door of the room, so as to be easily acces- sible. When not in use, it should be hung in the open air. If the physician wears a beard, he should wash it after leaving the patient, for if the patient coughs in the physician's face, he is likely to carry the infection in his beard to the next child visited. Should the measles be complicated with diphtheria, extra precaution is necessary. 308 THE SPECIFIC INFECTIOUS DISEASES. Treatment. — General. — A typical mild case of measles needs little medicinal treatment. We try to make the patient comfortable. The temperature of the room should be about 68°-Y0° F. (20°-21.1° C), if possible. The ventilation should be constant and attained by moans of opening doors and windows of rooms communicating with the sick-room. It is not necessary to darken the room very much; in fact, Bartels has shown that light and air are necessary to the comfort and well-being of the patient. The author has found that the ordinary yellow window-shade, if drawn over the windows, suffi- ciently excludes the actinic rays which are irritating to the eyes. In a typical case of measles a temperature of 104°— 104.5° F. (40° C.) may be ignored. It should be remembered that the fever continues only during the period of the eruption. With the fading of the exanthema the temperature becomes normal. It is only in cases in which there is a high temperature with delirium that medi- cation is called for. It is not uncommon to see children covered with an eruption and with a temperature of 104° F. (40° C.) playing in bed with their toys. The cough will sometimes need treatment. In such cases I am accustomed to prescribe TIX iv (0.25) of paregoric combined with TTX ij (0.12) of syrup of ipecacuanha, every three hours. If the patient is kept awake by the cough, a small dose of Dover's powder (grains j or ij) (0.06 or 0.12) or codeine (grain tV to 4) (0.006 to 0.008) at night will be sufficient. If the patient is very restless at night and we do not wish to give opiates, grains v (0.3) of trional will quiet a child of five years. Some young children can be put to sleep by a small dose of phenacetin (grainsij) (0.1). In a mild case, especially if there is pruritus or irritation of the skin, there is no objection to sponging the patient once a day with water at 100° F. (37.7° C), containing some alcohol or a pinch of sodium bicarbonate. The food should be light. Milk, broths, and, when the fever has defervesced, chicken, soft-boiled eggs, jelly, toasted bread, crackers, rusk {Zwiehack), and cereals in attractive form, with cocoa, comprise the diet list. Orange-juice or weak lemonade may be given in mod- eration. Water-ices may be given, if desired. As soon as desquamation has set in, I direct the body to be anointed every second day with an ointment of washed benzoinated lard combined with 5 per cent, of boric acid. The patient is allowed to get out of bed as soon as the temperature has fallen to normal, and is permitted to go out of doors three weeks after the outbreak of the eruption in the summer and four weeks in the winter months. Be- fore mingling with other children, the patient should be thoroughly washed with soap. It i s not necessary to put an antiseptic in the bath. The Treatment of Complications. — Bronchitis; Bronchopneumonia. MEASLES. 309 ■ — ^A severe inflammation of the finer bronchi is likely to cause as much fever, dyspnoea, cough, and restlessness as a primary broncho- pneumonia. The temperature then rises and continues elevated — 104°, even 105° F. (40°-40.5° C.) — with morning remissions. In these cases the temperature must be reduced, I never hesitate to utilize hydriatic measures. The most convenient mode of applying water is by means of compresses moistened with water at 80° F. (26.5° C). If the patient reacts well, the compresses may be applied at 67° F, (19.4° C.) ; if he becomes cold and cyanosed, at 105° F. (40° C). These warm compresses are at times very sooth- ing, causing the patient to drop into a quiet sleep. It should be remembered that the object of applying the compresses is not always to reduce temperature rapidly, but rather to stimulate the heart and support the patient. Douching the head with ice-cold water, as rec- ommended by some, is a very questionable practice. The use of the coal-tar antipyretics should be avoided. In lowering the temperature they act as depressants. In severe cases of bronchopneumonia aconite should not be used to lessen the rapidity of the pulse. Caffeine, cam- phor, strychnine, and digitalis in proper doses are more satisfactory. If a bronchopneumonia be prolonged into the convalescent stage, we should be on the alert for pleuritic eifusion. This is especially likely to occur if the pneumonia lasts longer than two weeks. In these cases the symptoms present are similar to those described under Pleurisy, and the treatment is carried out on the same principles. Laryngeal 8ympioms. — The laryngeal symptoms become harass- ing when there is much swelling or slight erosions of the laryngeal mucous membrane. In such cases an improvised tent should be erected over the crib or bed and filled with steam vapor saturated with thymol or turpentine. Older children can be persuaded to breathe the vapor generated in an open kettle. If symptoms of stenosis appear, it must at once be determined by culture whether a diph- theritic process, a streptococcic pseudomembranous formation, or a stenosis due to simple catarrhal oedema of the mucous membrane is present. Diphtheria.- — Antitoxin is indicated in diphtheria either of the conjunctiva, pharynx, or larynx. A large dose should be given at the outset, on account of the virulent nature of this affection as a complication of measles. We should not be too ready to intubate on the first appearance of stenotic symptoms. Many of these cases improve. The introduction of a tube into the inflamed larynx in measles is not without danger of causing ulcerations of a troublesome type after the measles has run its course. It is well to follow O'Dwyer's advice in such cases — withhold the tube as long as dan- gerous dyspnoea is absent. The use of apomorphine, tartar emetic, 310 TEE SPECIFIC INFECTIOUS DISEASES. or tiirpeth mineral, so popular with continental physicians, to expel membrane or secretion, is of doubtful value. The Ear. — Otitis should be suspected if there is restlessness and an intermittent course of temperature without apjDarent cause. Older children may indicate the seat of pain. In some cases it may be nec- essary to incise the tympanic membrane. The procedure affords relief from pain, and is without ill effects. Pus or a few drops of serum only may be evacuated. Diarrhoea.- — Diarrhoea requires the same treatment as a primary enteric catarrh. Eyes, Nose, and Mouth. — The care of the eyes, nose, and mouth should be conducted on general lines. If the secretion is excessive, the eyes may be bathed once a day with a lukewarm weak saline solu- tion. Unless the secretions are excessive, the nostrils should not be syringed or douched. If clots of mucus or pseudomembranous shreds form in plugs, they may be dislodged once a day by a nasal washing with a suitable hand syringe. The mouth should not be washed more than once a day. This should be done both for infants who are fed artificially and for older children. On account of the great vulner- ability of the mucous membrane in this disease the utmost gentleness should be exercised lest aphthous ulcerations develop. VARICELLA. (CMclcenpox; (Ger.) WindpocTcen.) Varicella is an acute infectious disease with a characteristic exanthematic eruption. It is distinct from vaccinia or variola, is an affection of childhood, occurring before the tenth year, rarely later, and is transmitted by direct contact and through the atmos- phere. It cannot always be conveyed by inoculation, as is the case with vaccinia or variola. It does not protect from vaccinia or variola. Varicella, vaccinia, and variola have been observed to attack the same patient successively at very short intervals. Few children escape after exposure, and one attack does not confer immunity. I have seen cases of second attacks. Varicella is an endemic disease, and rarely occurs epidemically. Incubation.^ — Varicella has a period of incubation during which competent observers have noted no disturbances (Henoch) ; others record malaise, coryza, and sore throat. The author is inclined to regard the prodromal period as free from symptoms. The period of incubation is usually fourteen days, but it may be protracted for nineteen days. Symptoms. — The symptoms consist of an exanthema, an enan- thcnia, fever, and slight malaise. There may be complications. VARICELLA. 311 Previous to the appearance of the exanthema there may be a slight febrile movement and malaise, which in children may pass unnoticed. In cases pursuing a normal course, a chill with a marked rise of tem- perature may precede the eruption by fully twelve hours. When the eruption appears the temperature gradually falls, unless another crop of papules appears, when there is another sharp rise of tem- perature. Sore throat and slight malaise may herald the eruption. There may be, as in measles and in varioloid, an erythema of the surface prior to the appearance of the exanthema. Exanthema.- — The exanthema consists of an eruption of roseolar papules varying in size from that of a pin's head to that of a split pea. They first appear on the forehead and face, and spread to the trunk. In some cases larger blotches appear, but these are of the nature of an erythema, which may precede the eruption of the roseola by a few hours. The roseolar papules have a characteristic violet- rose tint, are raised above the surface, and are sometimes hard to the touch. In a few hours the papule develops on its summit a vesicle, which rapidly fills with lymph. These vesicles become tense, and if the papule is irregular in shape cover the whole upper surface of the papule. In many places the vesicle at the stage of its efflorescence presents an umbilication which strongly resembles that seen in the vaccinia pock. The contents of the vesicle become cloudy and then yellow; the vesicle is surrounded by a dusky pink areola. In the course of a day or two the cycle is completed, and the vesicopustule begins to desiccate. A reddish-brown scab is developed. Many of the roseolar papules do not develop the vesicle and pus- tule. While one crop of papules is going through the cycle described above, others appear on various parts of the body. It is character- istic of varicella to have the surface covered with roseolar papules, papules with vesicles, and with pustules, in various stages of devel- opment. The papules, vesicles, or pustules may be few or very abundant. In some cases after the scab of the vesicle l^as fallen off a distinct scar is left, similar to that seen in vaccination, but much smaller ; it may persist for years. The skin between the papules and vesicopapules is normal in color. The soft palate and sometimes the hard palate may show a few isolated papules, vesicles or vesicopustules similar to those seen on the cutaneous surf ace (enanthema). In most cases there is an angina, an injection of the conjunctivae or even an enanthema on the ocular con- junctiva (Henoch). Thomas records varicella papules and pustules on the nasal and vulvar mucous membrane (Fig. 44). The temperature is in many cases little raised above the normal. In others it reaches 103° F. (39.4° 0.) at the outset of the affection. In rare cases 106.5° F. (41.3° C.) has been observed. As soon as 312 THE SPECIFIC INFECTIOUS DISEASES. the eruption is fully developed the temperature rapidly becomes nor- mal. The duration of the fever varies from one to three days. I have seen severe cases in which the high temperature persisted fully a week. The eruption was in these cases accompanied by secondary pustulation. Other Symptoms. — Many infants and children show little consti- tutional disturbance. In other cases there is lack of appetite with excessive irritability. In others, on account of the profuse eruption in the vulva and around the nates, there is annoying vesical tenesmus and even rectal tenesmus. The latter condition I have seen in a Pig. 44, DAY OF ILLNESS 1 2 3 4 5 6 HOUR ° o» = 2"'= = -,;,»=, "3 "" =»3 =,oo>2"o = 3" = o. u » o = g « o = cj =. .oog — f; - 103° - _J_ "~S -- o_ r \ ^ i \ yy ~ E ^ J J z ^^ t_ -I- = t-- — t—\ T •^ 102° - _J_ ^r- h-- - z\- -.--. I < ^ 101°- '\ - '- ^ S ■-% T==M~ - H 100° - 99° 1 '- '=-F — tA '■ \ 1 IW V > 1- ji ^p- C u - C ' t = ' x^ ■ '3 T PULSE 2 3 S % Is o 3 ^ S 2 ^ ^ g gg S3| s RESP. f. s;^ ■&■ "«• ■* SSS S S3? 3 l!S! 3;!,?; ?! URINE „ „c » „ x»s: - ~?^= „;„x .. o STOOL ' 1 1 1 1 It' ' Varicella temperature-curve showing successive rises due to a new eruption of papules and vesicles. Boy aged six years. child two and a half years of age, in whom there was a profuse erup- tion of vesicles in and around the introitus vaginae, on the nymphae, and around the anus. There is in some cases a recrudescence of the exanthema in various parts of the body, with rises of temperature. Complications. — Gangrene of the skin with sloughing of large areas has been noted by some observers (varicella gangrenosa). The conclusion is inevitable that in many of these cases there must have been a mixed infection. Erysipelas is also a complication. Nephritis. — In many cases there is albumin in the urine to the extent of a trace. Henoch has described six cases of varicella compli- cated with nephritis on the eighth to the fourteenth day after the appearance of the eruption. In these the eruption was profuse and accompanied by fever; there was oedema with albumin and casts in the urine. One case with fatty liver and moderate hypertrophy and dilatation of the left ventricle resulted fatally. Other authors have VARICELLA. 313 confirmed the observations of Henoch. I have seen slight albumi- nuria in some cases of varicella. Joint-dffections. — I have observed two cases of varicella with swelling, pain, and effusion in one or both knee-joints. In neither was there suppuration. Both cases retrograded, and in a few days the joints became normal. The whole picture simulated what is seen in some cases of scarlet fever. There was no endocarditis. Otitis. — Otitis may occur as a complication of severe cases. Pneumonia. — Pneumonia is an occasional complication (Fig. 45). Nervous System. — I have recently observed two cases in which after the exanthema had run its course, on the tenth or fourteenth day of the disease, the patients, both boys, seven and nine years of age, developed increasing sopor, with mild hydrocephalus, and paresis in all four extremities. In one case there was considerable difficulty in swallowing. There was after the first day no temperature above 100° in the rectum. The symptoms also at times included a restless Fig. 45. DAY OF MONTH S',J 30 Oct. 1 2 s 4 3 « : s 9 10 u 1-2 1.1 14 lo IG 1 105° 101° 103° 1 102° t 101° a 100° S 99° 98° 3i i|i *? ^ ^L: -:- "nr- r-^.r ' ^ s ^ 33 ^ ^ ^ ^l ^ ,'-J \ \- i A (^ nil' Vr /; K -~_: ^L. =^ 5, V :\1 \/ ^ V h \ - h i> K^ y\ '^ X < rr a (D o !Q_ D c+ P CD tJ c-t- •-^ c+ m 3" C CD t3 <; (D Cfi T 2D o' r+ •— ' CD (D CC Ui CD CD O 1-^ VACCINATION 317 extensive necrosis of tissue. This may affect the fasciae or muscular layers, causing large loss of tissue. Among the rarer complications of vaccination is a true septic infection. In these cases there is a history of mismanagement of the pustule, such as traumatism or the compression of the arm by a bandage. Infection which manifests itself in a remittent febrile curve occurs. In one case w^hich came under my notice a few pus-corpuscles appeared in the urine, the elbow- joint and other joints became painful and swollen, and suppuration in the joints resulted. These cases are fatal. There is a true osteo- myelitis of the heads of the bones, with formation of pus in the joints. In other cases the child may by scratching inoculate itself elsewhere, either on the arms or even lips and eyelids ; the latter condition has come to my notice. It forms a very painful and severe complica- tion. Erysipelas may set in early or late in the history of the vacci- nation. It may spread down the arm and forearm on the trunk and may endanger the life of the patient. In other cases there may be suppuration of lymph-nodes. In susceptible subjects a rebellious eczema may appear as a direct sequence of the vaccination. Among the complications may be mentioned axillary adenitis, hemorrhage into the pock (trauma), exuberant granulations, and keloid of the scar. Rosenau found that the dry points contain more bacteria than glycerinized vaccine. All vaccine contains pus-organ- isms. He thinks that properly prepared glycerin lymph is to be preferred to dry points. The same investigator examined a large number of samples of commercial vaccine and failed to find tetanus germs in them. It seems more likely that carelessness in dressing or handling, or faulty technique in performing the operation has been the means of introducing tetanus-spores, rather than that these should be present in the vaccine virus. Generalized Vaccinia. — This is a general eruption of vaccine pus- tules, which in rare cases appears from the third to the seventh day over the whole trunk and extremities. It is really a generalized cowpox, similar to the generalized eruption in the exanthema. D'Espine and Jeandin describe cases in which there can be no doubt of the absence of infection of the surface by the nails or otherwise. The prognosis in these cases is good; there are no severe symptoms, and the fever is slight. Vaccination Eruptions. — The eruptions which follow vaccination or occur while the pustule is still in course of development are of interest. Sobel has made an exhaustive study of these eruptions. Two per cent, of the vaccinations are followed by more or less gen- eralized eruptions. They appear while the local site of the vacci- nation is open or as late as eight weeks after the primary inoculation, but most often between the ninth and the fourteenth day after inocu- 318 TBE SPECIFIC INFECTIOUS DISEASES. lation. They have no relation to the size or severity of the local pustule, which may be normal. Among the types of eruptions are the erythematous, urticarial, papular, vesicular, pustular, morbilli- form, bullous, pemphigoid, and scarlatiniform. Auto-inoculation by scratching generally occurs an inch or tvsro from the original site, but it may occur elsewhere, as on the eyelid or conjunctiva. The most common type of generalized eruption is undoubtedly the urticarial in its various forms. These include wheals, papules, bullae and vesico- papules. The morbilliform are easily differentiated by the absence of fever and coryza and other signs of measles. The scarlatinal forms cause great uneasiness and elevation of temperature. These cases should be observed for urinary complications and subsequent desqua- mation, in order to exclude scarlet fever. Among the rarer types are the ecthymatous eruptions. Management. — The management of a normal case of vaccination is important. We should protect the vesicle from traumatism by m.eans of some simple contrivance, such as a shield. If the areola is angry looking and the redness and swelling severe, we may paint it once a day with compound tincture of benzoin. This is very soothing and protects the surface from friction. If complications occur, they should be treated on surgical principles. Above all, there should be no retention of pus by the dressing. Dressings which seal the vaccine pustule hermetically from the air cause retention, and are therefore dangerous. Sepsis as described above is not the result of vaccination, but of subsequent mismanagement. Revaccination. — Vaccination should be repeated after the lapse of ten years, and every five years thereafter. During an epidemic, every one who has not been revaccinated should be vaccinated. Im- munity to variola diminishes as we reach the termination of the first decade after the first vaccination. If the revaccination runs a typical course identical with that of the original vaccination, immunity is generally lasting. OTHEE SPECIFIC mFECTIOUS DISEASES. TYPHOID FEVER. (Abdominal Typhus; Ileotyphus.) Occurrence. — Of 222 cases of typhoid fever in my hospital service, 122 were of the male and 100 of the female sex. In 8 the age was under 2 years, the youngest being 13 months; in 42 between 2 and 5 years of age; and 9Y between the 5th and 10th years; and the remaining Y5 were among children up to the 14th year of life. Thus TYFEOID FEFEE. 319 20 per cent, of the patients were below the fifth year of age. It may be said that all these cases were diagnosed by modern methods, includ- ing the Widal agglutination test. Typhoid Fever and Pregnancy. — According to Etienne, quoted by Morse, the foetus in utero is born prematurely in 70 per cent, of the cases of typhoid fever in the mother. The causes of the abortion are much the same as those which obtain in pregnant women suffer- ing from any infectious disease. The high temperature, the toxins in the circulation of the mother, and the death of the fcetus, all con- tribute to cause miscarriage. Of 12 abortions, 9 were stillbirths, 2 lived four and 1 five days. Foetal Typhoid. — There are two sets of cases which prove that typhoid fever can be transmitted from the mother to the fcetus : First, those in which the mother, having been infected with typhoid fever, expels a foetus which may have lived some hours after birth and in whose organs the typhoid bacillus has been found, such as the cases of P. Ernst, Giglio, Lynch, and others. The second set of cases are those in which the blood and fluids of the foetus give the Widal reac- tion with bacillosis. Such is the case of Foster and Ballantyne. The mother of this foetus died of typhoid fever shortly after deliv- ery. The stomach contents and the serum of the peritoneal cavity gave a Widal reaction. The bacillus was found in the kidney, spleen, and intestinal contents, but not in the blood. Griffith's case was that of an infant apparently healthy, though jaundiced, at birth. When seven weeks old the blood of this infant gave the agglutination reaction. It is possible that in this case the agglutinating substance passed from the mother to the fcetus during the pregnancy without causing typhoid fever in the fcetus. Thus, the presence of the agglutination reaction is no proof of typhoid fever, as it may be transmitted through the placenta, and the foetus thus escape typhoid fever (Ballantyne). The anatomical changes found in the foetus affected by typhoid fever are not identical with those seen in the adult. This is due to the fact that the infection of the foetus is hsematogenous, which ex- plains the high foetal mortality. The spleen is sometimes though not always enlarged. The changes in the gut are not characteristic, being confined to a few enlarged follicles. The liver may be enlarged, and the kidney may show hemorrhages. Infantile Typhoid. — It has recently been contended that typhoid fever is rare in the infant or the child under two years of age. With the improved methods of laboratory diagnosis of typhoid fever we may shortly be in a position to determine the relative frequency of the disease in the newborn and the young infant. Typhoid fever certainly occurs under the age of two years. As Crozer Griffith has 320 TEE SPECIFIC INFECTIOUS DISEASES. pointed out, we should think of the j^ossibility of its presence in every case of continued remittent fever of the nursling not to be explained on other grounds. Of 331 cases, 9 under two years of age were diagnosed by Henoch as typhoid fever. Among others who report cases are Ollivier, l^oyes, ISTorthrup, and Bell. I have seen 8 cases under two years. One was in a bottle-fed infant which had so-called typhoid sepsis with meningitis and pyelitis. In this case there was typhoid bacillosis of the blood and all organs without intes- tinal lesions. In another case the infant was on the breast, the mother having typhoid fever. Blackader, in a recent series of 100 cases, met 4 under two years of age. Gerhardt reports a case in an infant twenty-five days old, and Blumer 1 in an infant five days old. These cases may be regarded as either congenital or post-natal typhoid. Morbid Anatomy. — It has been stated that when the foetus in utero is affected with typhoid fever the process is in the nature of a hsema- togenous infection, and that there are few if any characteristic ana- tomical changes. In young infants and children the changes in the gut so characteristic of adult cases are not always seen in their full development. The solitary follicles and Beyer's patches are enlarged, but ulcerations are seen only here and there, and seldom lead to per- foration (Monti). In a case of my own the typhoid bacilli were found in the blood and various organs, but there were no intestinal lesions. On the other hand, in older children the changes in the gut closely resemble those of the adult, as has been shown by Henoch. The mesenteric lymph-nodes, especially those in the vicinity of the ileocsecal valve, are enlarged. The remaining changes resemble those seen in the adult subject. ~ Sjnnptoms. — The invasion of the disease in young children is rarely with a chill. More frequently there are indefinite chilly sen- sations and mild general malaise. There are headache, pains in the limbs, vertigo, and in many cases vomiting. The symptoms of the period of invasion are so very indefinite in infants and very young children that cases sometimes escape diagnosis. In other cases, after a few days of malaise the cerebral symptoms become marked. The headache is augmented by delirium at night, especially in older children, and stupor is present. In younger chil- dren the period of invasion may simulate a pneumonia. In fact, these cases begin as pneumonia, and it is only on careful considera- tion of the clinical symptoms — the predominance in a few cases of cerebral symptoms or the enlarged spleen, and the presence of roseola later on, with the elevation of temperature — that we are led to think of typhoid fever. In some of these pneumonic cases there are none of the charac- teristic features of typhoid. There is no roseola, no splenic enlarge- TYPHOID FEVEE. 321 ment, no epistaxis, but there may be diarrboea. During an epidemic only the systematic examination of the blood for the Widal aggluti- nation reaction will reveal these cases. Such a case is the following : A child, five years of age, was admitted to my hospital service with an indefinite previous history. Temperature 104.6° F. (40.3° C), pulse 140, and respirations 30. There was apathy, also a broncho- pneumonia in the upper lobe of the left lung. This case gave a very positive Widal reaction early in the disease. The spleen became pal- pable four days after admission. In another case, of a child four years of age, signs of a lobar pneumonia of the upper lobe of the left lung were present without any roseola, enlarged spleen, diarrhoea, or abdominal symptoms. On the fifth day of the disease the Widal reaction became positive in a dilution of 1:50. This child died on the sixth day of the disease, with increasing signs of pneumonia and a positive Widal reaction of 1 : 350. Many of these cases of typhoid fever in older children become comatose after the first week. Such a case was admitted to my wards. The onset was with headache and fever. There was no vom- iting, epistaxis, or chill. The child became unconscious, with a tem- perature of 106° r. (41.1° C), rigidity of the muscles of the neck, increased reflexes, ankle-clonus, Kernig's symptom, and enlarged spleen. This case gave a positive reaction to the Widal test, and lumbar puncture failed to reveal anything characteristic in the fluid withdrawn. The invasion is not characteristic in infants. In exceptional cases (Blackader) a convulsion is the first symptom noted. In some cases there may be a simple continued fever, with diarrhoea, without other symptoms. In a case reported by Crozer Griffith the roseola and the enlarged spleen were present. The subsequent history of a case varies with the character of the infection. In the forms which have a slow, gradual onset the chil- dren remain for a time in good physical condition. During the first week the sensorium is clear, the tongue is coated, and the face color is good ; the spleen may be readily palpable, the roseola appears, and there may be diarrhoea or constipation. In some cases the iliac ten- derness is marked ; in others absent. It may not be possible to deter- mine the presence of ileocsecal tenderness in young children. The symptoms after the first week may be augmented by delirium at night; in older children this delirium, which has much the same character as in the adult, is also present during the day. Children from five to seven years of age are more likely to have the quiet form of delirium, while older children are noisy and try to get out of bed. The course of pneumonic cases is noteworthy. Resolution is tardy in those cases which recover. To the symptoms of pneumonia 21 322 TEE SPECIFIC INFECTIOUS DISEASES. are added after a time those of typhoid fever — roseola and enlarged spleen. The temperature-curve is not characteristic, and resembles that of the sustained remittent type (Fig. 46). In some cases pleurisy may be present. In the new^ly born infant to whom the fever has been conveyed in utero the picture of the disease is unlike that seen in older infants and children. The symptoms resemble those of sepsis of the new- born. Thus in the case published by Blumer the first symptom of the disease was an uncontrollable hemorrhage from the vagina. Before death this was supplemented by hemorrhages into the skin and from the gTims. The cases of typhoid fever in infancy thus far recorded by Morse, Fig. 46. iUN°ss 3 4 5 7 8 9 HOUR 3 G S12 3 6 a'12 3 912 3 6 9 12 3 6 9l2 3 6 91123 6 912 3 Ills 12 3 B a 12 3 6 912 3 6 9 12 3 6 S 1! 3 S S12 3 6 912 3 6 9jl2 3 6 9 12 o:io3° s LgJ : L.UJi^.^JL [LJ h-r^fn ^x- B Hith^^H#tttt n tiMHlfrH+[#M-H\H-Hii^ i02° = = = -=-z:z%:"r — 4S-^-^-±-ijt = "±^±-±:i± = =as^=i4t^ * : :ti__z^^± 101 L_L J 1 1 ^ IL _^ — 100 j:: T"-T- — ^ + 4-r- -^-!--T- ' ' -^r^ — ^4t=-tt=- PULSE s=s Sa SsSSbSSSss s SSISSsS S eSsS "ESP. s ss ss s § ? S! « sTs s s s 3 as ^n s s s s s sssss Typhoid fever which began as a lobar pneumonia in a girl four years of age. Consoli- dation of the lower lobe of the left lung ; death on the tenth day of the disease. Crozer Griffith, Blackader, and the author, may be divided into two classes : those in which there is a mild diarrhoea with distention of the abdomen, roseola, and enlarged spleen ; and those which present cere- bral symptoms. The latter develop coma. In one of my cases there were meningitism, a distended abdomen, rose spots, and enlarged spleen. In both forms there are severe and mild types. Cases in which the temperature rarely rises about 104° F. (40° C.) recover, while those with a higher temperature may be fatal. Roseola. — In children, as in the adult, the roseolar papules are seldom absent. In some cases their number is large, while in others they are few and widely scattered over the surface. They may appear in successive crops, and reappear in the relapse. Occasion- ally the roseola is preceded by a diffuse erythema closely resembling the scarlet fever eruption. The roseola may, as in the adult, appear TYPEOIB FEVEB. 32,' on the third, fifth, or tenth day, and may end of the second week, after which it gradually fades, leaving a pigmented area. The eruption is sometimes so profuse as to resemble the eruption of typhus. It may be profuse in cases in which the cerebral symptoms are marked. I have seen typhoid fever with severe cerebral symptoms, but with an eruption very sparse or entirely ab- sent at the height of the disease. In severe delirious cases, hemorrhagic areas appear on the bony prominence of the shoulders and extremities. Petechise are common. In protracted cases ex- tensive purpuric areas appear on the abdomen. These hemorrhagic cases are not necessarily fatal. Enlarged Spleen. — The enlarged spleen is the most common physical sign. At the o'utset of the disease it is not always easy to palpate the spleen. This is especially true of younger children. The enlarged spleen is present not only in older children, but also in cases of foetal typhoid fever. I have seen the enlargement persist for weeks after con- valescence. In one case the spleen could be distinctly felt below the border of the ribs for a long time after recovery. In some forms of relapse the spleen enlarges after having diminished to the normal size. Cases in which the spleen remains enlarged a long time are likely to have slight rises of tempera- ture of short duration. Typical relapses without enlargement of the spleen may occur. The fact that the spleen con- tinues enlarged after the temperature has become normal does not always indi- cate the approach of a relapse. Temperature. — An elevation of tem- perature in young children is usually even be delayed until the s ■ -f ■ ( s > u y n . '■ 7 5 /- "^ i ^ '' i' 15 < ~ — - ■p S < — f t- , > ■~~ g ^ 96 ■0 ■a M (. S , -^ ^L 3 ' 7 « \ ■-^ w < oc 89 ■0 s M - - = ;^ 001 85 -= — - 96 92 P — ■r=" ■ 96 12 . 06 85 1H 801 TZ •r OCT 92 . 1-1 ^' 96 \Z •«t< ^' ■ 001 t2 s 001 12 . ^' o 00 09 r: •a •/V <' Oil 92 f^ , — '' S6 92 r — - OZT 92 ".2 00 01 r' )•£ ■/J V ' 001 12 NC li ov 3H 1 /a m' — t 06 t2 3 < ^ szr 12 ■" > 201 92 2 S SOT 82 =1 =- ■ 811 82 « >- 021 OS =- 911 82 1H «: 5" ZTl 9£ ' ^ 031 82 O J 811 OS -2 — _, CSI 08 OS _ 9ST 08 — =. 001 12 cc = - OSl 92 ?■ BSl 12 - ^ \. -^ ffl __ >, --, OSl IS " ^ 911 12 ) Sll IS ^ / ' 001 12 —- 7 801 ^2 M t 801 12 ■■^ ; OOT IS « <' 96 12 ) 001 •12 - < 26 12 ^ 001 IS °| o o o o o c CaHVd") ■dW3X Ci o £ ^ 324 TRE SPECIFIC INFECTIOUS DISEASES. not noticed by those about the child during the first eight days. Children rarely complain of slight malaise, and a rise of a degree or even more above the normal may escape notice ; as a result, the impression is prevalent that the temperature during the first week does not follow the typical curve. The cases which I have observed sufiiciently early, and which were not complicated with pneumonia, showed during the first week the gradual rise seen in the adult (Fig. 47). This gradual daily rise of temperature is also seen in relapses. On each day the temperature at its highest point is higher than on the previous day. After the first week the temperature is likely to show a remittent curve with a sustained maximum point. After the second week the temperature may remit, gradually falling, or intermit ; frequently it remains high for weeks, with daily remissions. By the end of the second week it reaches 104° to 105° F. (40° to 40.5° C.) at its highest. In the course of the third, fourth, and fifth weeks it may range a degree lower, with remissions to 101° F. (38.3° C), not reaching the normal. If the case is protracted, the temperature may persist into the sixth week, running up as high as 106° F. (41.1° C), falling fully five degrees twice daily. In one case the tempera- ture did not become normal until the eighth week. Even at this late period there may be relapses. In many cases the temperature falls to the normal after six or seven weeks, or becomes subnormal, and then after an interval of a few days or a week rises and fluctuates a degree or more above the normal. This continues for a few days, the temperature remitting to the normal or near the normal. These post-typhoidal fluctuations are sometimes mistaken for i^elapses. They are rather to be attributed to inanition, or are the result of slight absorption from the gut. In a large number of cases the first sign of convalescence is a subnormal temperature. On the other hand, the temperature may be subnormal for a week or more and relapse follow (Fig. 49). It may be said that as a rule the first week of typhoid fever in children shows a gradual rise of temperature. The subsequent tem- perature is sustained, remitting two or more times daily. This curve may last one, two, or more weeks. In other words, there is no charac- teristic temperature-curve. In relapses the temperature rises grad- ually from day to day. Among the causes which may give rise to a slight temporary elevation of temperature is constipation. A lobar pneumonia or a bronchopneumonia will cause a persistence of the high temperature, as will also other conditions, such as otitis. The inverted type of temperature-curve is described by Henoch. The morning temperature is higher than the evening, or there may bo a rise at 3 a m. or 6 a. m., a fall in the forenoon, with a rise again TYFHOIB FEVER. 325 at noon, and a fall toward evening. Such a curve may be followed within a day or two by the usual fall in the morning and rise toward evening. These fluctuations occur at the height and at the decline of the disease. HemoiThages. — Hemorrhages from the bowel are not so common in children as in the adult. I have seen persistent hemorrhages in only 8 out of 222 cases. In one case there was post-typhoidal ulcer- ative colitis. The bowels may be constipated, normal, or diarrhoeal. The number of stools varies. In the majority of cases diarrhoea is absent. In some the temperature in convalescence may rise a degree or more for a day or two. In these cases there may be fecal accumu- lation due to incomplete evacuation of the gut. Fig. 48. OALV Of ILL'NESS •' C 7 8 10 11 12 13 1 14 1 105° 1 ---fc, r|--i--cJ- : 1 . ' ibH ±|lp 1^ "^ •,,»^j_ "'iT' ¥ w -^h[2fl,f2~j.|^2 101°:: — :- = : , 103°: : o: : : iiii) m ^ r' i \ ■ 11- 1 ■ ' ' ': ' ; ! : : ; : : ' , : ^ 101°::—:-:: S H 100°: uL- Wf- V -^ ' ■ ' ^ J!' V 7^ V' ¥ 1 ! MFit^ 99°: 'o- PULSE SSS, ;:_222::2;;22jSj2 J:ji ^ .. t',\ iX4- - ^ ': 1 1 ■ 1 ' ^ t t ^-.Mih -""1" iksslsi s.\s'^\^ s]s;s^ 353S Trr *f oSJ.'^S si^j^s S^35 "JT^ ,\z 4. sjsjs sssssis Typhoid fever of short duration in a boy siz years of age. Pain, — Sensitiveness in the ileocsecal region is very difiicult to determine in young children. In older children it is sometimes marked, and indicates ulcerative processes in that region or in the neighborhood of the appendix. Pain as a symptom in typhoid fever in the adult occurs in two- fifths of the cases observed by McCrae. In childhood it is not as common a symptom, inasmuch as young children are not apt to com- plain of pain. It is observed, however, though the exact percentage of cases cannot be stated, on account of the peculiarity of the subjects dealt with. In the adult abdominal pain in the course of typhoid fever is present in complicating pleurisy and pneumonia ; or it may be due to a distended bladder, the ingestion of solid food, vomiting, fsecal impaction, diarrhoea, appendicitis, peritonitis, cholecystitis, abscess of the liver, phlebitis of the abdominal veins, and hemorrhage. In childhood some of these conditions may be present, accom- panied by abdominal pain. In the cases observed by the author cholecystitis, appendicitis, perforating ulcers, peritonitis, impaction of fseces, and vomiting could be fixed on as a causal factor in the pro- duction of the pain. Pain not due to perforation, appendicitis or 326 THE SPECIFIC INFECTIOUS DISEASES. colecystitis, as a rule, is general in its location. It may be accom- panied by meteorism, or may be present with a retracted abdomen. I have seen it in some cases preceded by vomiting; in other cases no snch symptom was present. In childhood it is particularly notice- able that pain not due to perforation is unaccompanied by a rise of pulse, and certainly not by a rise of temperature. I have seen very severe abdominal pain, necessitating the administration of opiates, without the least disturbance of the pulse, respiration, or temperature. This latter condition is apt to occur in nervous, hypersesthetic chil- dren. The pain due to perforation will be described elsewhere. I have seen one case where intense pain was caused by a distended gall- bladder with cholecystitis, the diagnosis being confirmed at the oper- ating table. In this case the pain was distinctly localized, and there was temperature due to the hepatic condition. Otitis. — Otitis is not uncommon. I have seen several cases. Mastoiditis. — I have observed mastoiditis in 11 cases, 1 of which resulted fatally in the second week of the disease. Parotitis. — I observed parotitis in 4 cases. Tongue. — -The tongue of children with typhoid fever resembles that of the adult. It is at first coated, and is protruded in a tremu- lous manner; subsequently the epithelium is thrown off and the papillae become prominent. In some cases the tongue resembles the so-called strawberry tongue seen in scarlet fever. At the height of the disease it may become dry and fissured, and sordes may collect on the teeth. The lips become fissured and bleed easily. Nervous SymptoTns. — The nervous symptoms of older children resemble those of the adult. With younger children sopor is the rule and delirium is infrequent. Melancholia or depression is occasionally met with in convalescence, usually in girls of hysterical temperament. The Heart. — In a recent epidemic of typhoid many cases showed systolic apex-murmurs. These murmurs were loudest over the base, close to the sternum, or over the pulmonary orifice. Such murmurs are myocarditic. In one case there was a loud musical systolic murmur heard over the apex of the heart. It was also heard at the base of the heart. The murmur appeared early in the third week. There was also a pleuropericardial friction-sound. Post-mortem ex- amination revealed myocarditis and pleuropericardial adhesion. The Lungs. — The occurrence of lobar or bronchopneumonia late in the course of typhoid is serious. At this time the patient's powers of resistance are greatly diminished. Especially grave are the cases which show a sustained high temperature for two or three weeks, and then develop pneumonia. If with the pneumonia there are extensive henaorrhages under the skin at the situation of the bony prominences, the outlook is grave. In such a case I have seen a pneumonia involve the wliole lobe of the limg in consolidation within a few hours. TYPHOID FEVEE. 327 The Blood. — In children, as in the adult, the number of red blood- cells diminishes, and reaches the lowest point at the end of the febrile period. The hgemoglobin also is diminished. The leucocytes are di- minished from the outset until con- valescence, but increase after it is established. In one of my cases their number fell to 3500, and then rose to 12,400. In a case compli- cated with extensive ulceration in the gut and bronchopneumonia they numbered 30,000. In fatal cases complicated with lobar pneumonia I have found them as low as 4500. According to Thayer, the polynu- clear neutrophiles steadily diminish as convalescence approaches, while the mononuclear lymphocytes and eosinophiles increase. With the es- tablishment of convalescence blood conditions return to the normal. Relapses. — A relapse is a grad- ually ascending temperature-curve extending over a week or longer after the temperature has been normal for a time (Fig. 49). A relapse was noted in 7 of 46 cases of my last series. In all, it was mild and no serious results followed. • On the other hand, a prolonged low febrile curve causes great emacia- tion in children. Undue impor- tance has been attached to the con- dition of the spleen in these cases. The percentage of relapses varies with the nature of the prevailing epidemic. Blackader records 15 re- lapses in 100 cases, and Henoch 44 in 375 cases. Apparently relapses occur independently of the mode of treatment and diet. Complications and Sequelae. — Skin. — Subcutaneous abscesses may oc- cur, and onchyia is common. Ery- ^ 3 1 II 1 II niiii ini 1 o 1 1 11 ! i! ^\\\^ 1 III 1 2 ''" \ Mi 1 ■= . 1 : •^ « 2 ^.j . . . 1 ; o s ' 2 _-* 5(3 is o y OS 00 2 ! ; J ■ 11: o N 2 5. o 1 ^^_ 11 2 ^ 's , 2 ^ o y'''^ GO 2 ^ o 1 •< ■•^ 2 ■5^- 90 n o Z_ © 00 2 1 ' SO I 95 •= y. : 2 i ^ ^ -•It 80 o r" Sit 95 «5 2 •= *i- — -, 2 "■ — ^ o 1 ' / CO 2 *-~ II ■o ^ 2 ^it o ^ 2 / o u 2 H" o ZL ^ •s 2 , / o \^ 2 ' • ^"-- —SI •J / 2 ^ • o ^ 2 --^" •= Z o •* t* 2 > ^|| 2 *<-.^ o t ^8 95 O 2 T^ o «i 2 > o r' i 2 ^S- so 95 = 1 : ^4- 2 ^_^. = \ eot 95 2 ^ ; ' E •-= ^ 2 ^-^ - i| 86 9-. o 1 <_ i , « 2 S ^ ■o ' ; ' 2 ^ ~ i 1 1 i ! ■SI v:. i ! ' • g 2 77..^: -J ^^ t-6 9S 2 •»>\ 95 -i J 5tt 95 US 2 -— ^ ' i[ sot S5 -J ^ 2 1 ~ ■• — ' ' ' ' 1 o ill T^ +- TTTiniott 95 id 13 X CHHVd) 'dWiX D i 328 TBE SPECIFIC INFECTIOUS DISEASES. sipelas and parotitis are uncommon. (Edema may be confined to the scrotum, or during defervescence the whole surface of the body may be oedematous. In a case of scrotal oedema coming under my observa- tion there were no casts or albumin in the urine ; the leucocytes were diminished. Henoch attributes oedema to cardiac weakness rather than to nephritis. Diphtheria. — Diphtheria is a very serious complication. I have observed it in 2 cases. The Lungs. — Bronchitis is a frequent complication. In the later stages of the disease in younger children it is likely to develop into bronchopneumonia, especially in cases in which the course of the dis- ease has been protracted. Pneumonia may occur in older children at the outset or in course of the disease. Gangrene of the lung is mentioned by Henoch as a rare complication. Arthritis. — Arthritis is uncommon. Usually only one joint is affected. It occurs in the post-typhoidal period and runs a favorable course. Nervous System. — Among the nervous symptoms which compli- cate or follow typhoid fever are aphasia, amblyopia, ataxia of the lower extremities, paralyses of various sets of muscles, double ptosis, and hemiplegia. In hysterical children there may be a post-typhoidal melancholia. In others stupidity may persist for a time. Recovery usually takes place in all forms of paralysis, aphasia, and melan- cholia. The paralyses are possibly due to a neuritis of toxic origin, as is the case vdth the other infectious diseases or an encephalitis. Hemiplegia occurs only as a result of embolism (Henoch). I have seen cases of ataxia and marked melancholia. The children made an excellent recovery. In one case, a boy of four years, catalepsy was present for a period of five weeks after the temperature had become normal. Meningitis occurred in an infant of 13 months. Kidneys. — ISTephritis of a mild type may occur and persist long into convalescence. Pyuria occasionally occurs but is usually of no severity and requires no treatment. Perforation of the Intestine in Typhoid Fever. — The frequency of perforation of the intestine in children affected with typhoid fever, according to all available statistics, is 1.2 per cent, of all the cases. Of my own material of 222 cases there were 6 of perforation, in 5 of which the diagnosis was confirmed by operation (2.7 per cent.). In the adult subject the frequency is 1 to 2.5 per cent, of all cases. Therefore, in the severer forms of typhoid fever in children, perfora- tion of the intestine is almost as frequent as in the adult. Time. — Most cases of perforation occur in the third week, some TYPHOID FEVER. 329 in the second week and least frequent are those in the first week of the disease. One of my cases occurred in the sixth week. Symptoms. — Perforation may occur with a slow, insidious onset, or an acutely abrupt one. If there is active delirium of the low mut- tering type, it is impossible to fix the time of onset and the diagnosis becomes apparent only when peritonitis has made headway. In one of my cases in which the onset was insidious, the pain was com- plained of only six hours before the operation and yet it was found that peritonitis was then far advanced. In this case the day before the operation, the patient was somnolent, pale, and complained of anorexia. Vomiting appeared, followed by a drop in the tempera- ture, then pain and abdominal rigidity fully twelve hours after the onset, as subsequent history proved. In a case of brusque onset, the symptoms appeared in the forty-third day of the disease. The tem- perature had been normal since the fourth week of the disease. Pain localized around the umbilicus was the first abrupt symptom; with this there was abdominal tenderness, and distension with disappear- ance of the liver dulness. The temperature rose to 104°, the pulse from 104 to 128. In another case with abrupt onset, vomiting fol- lowed by pain and abdominal tenderness was the first symptom. Thus the symptoms and mode of onset make each case a matter of individual study. Pain may be preceded by a chill or vomiting. It may be slight, sharp or intense, or paroxysmal and may not reach its greatest inten- sity for 24 hours after the perforation. Delirious patients do not complain of pain. Abdominal tenderness, even to slight palpation, accompanies the pain, as does rigidity. Even slight rigidity is diag- nostic. Distention is present in most cases, though in some there may be retraction. If there is fluid in the peritoneal cavity this will be demonstrated by movable dulness in the flanks and indicates advanced peritonitis or peritoneal reaction. Disappearance of liver dulness with accompanying abdominal distention demonstrates the escape of intestinal gases into the free abdominal cavity. A sharp fall in the temperature followed by an equally sharp rise is very significant when present with other symptoms, for a fall of the temperature alone is not diagnostic. In addition to the symptoms just noted as marking the onset of perforation in typhoid fever, there is an increase in the number of leucocytes. This was true of all my cases. In one case the leuco- cytes mounted from 6000 to 7000 to 10,000 to the c.mm., and in another to 13,000 to the c.mm. With all of the above symptoms the respirations became rapid and shallow, due to the peritonitis. The 330 THE SPECIFIC INFECTIOUS DISEASES. prostration is evident even to collapse. Tlie patients lie prone and resent interference. Diagnosis. — The diagnosis of perforation of the intestine in typhoid fever must therefore rest on the advent in a patient, otherwise doing well, of pain preceded bj chill, vomiting or prostration, abdom- inal distention and tenderness with a drop in the temperature fol- lowed by a subsequent rise. A rise in the pulse and respirations, dis- appearance of liver dulness with subsequent appearance of fluid in the peritoneal cavity, leucocytosis and prostration. I have seen several cases in children who were operated on with the mistaken idea that there was a primary appendicitis. In these there was a typhoidal ulceration of the appendix without perforation. The pain which was referred to the appendix misled the physician. Prognosis. — The prognosis in intestinal perforation complicating typhoid fever in children varies with the time which has elapsed from the onset of the perforation to the treatment. Fitz has shown that if left alone 5 per cent, of the cases in adults recover. In chil- dren we have no corresponding statistics, except that of my 6 cases 1 recovered. This was an undoubted case of perforation in which the inflammation localized itself to the right iliac fossa. Elsberg has included my cases in statistics of 25 cases of typhoidal perforation in children with operative interference, in which the percentage of recovery was 64 per cent., as compared with 22.4 per cent, in the adult. The prognosis, therefore, in children, in mixed statistics, is apparently more favorable than in the adult. Duration of the Disease. — The duration of typhoid fever varies within wide limits. Henoch, in his tabulation of more than 200 cases, shows that the longest duration was seventy days ; the shortest seven to nine days. In my own cases the duration varied widely, if the rises in temperature were taken into account. The average dura- tion was four weeks and three days. The shortest case lasted ten days, and the longest lasted eleven weeks. Diagnosis. — Enough has been said to show that the diagnosis of typhoid fever in infancy and childhood is at times very difficult. With young children enteritis, pneumonia, meningitis, and even appendicitis may simulate typhoid fever in their onset. Cases which begin as a pneumonia are especially difficult of diagnosis. The cere- bral forms of typhoid fever may closely resemble meningitis. The history is very important. The onset of typhoid fever is gradual, the cerebral symptoms increasing in intensity as the disease progresses. An enlarged spleen and a few roseolar papules will be of service in making a diagnosis, but, on the other hand, an enlarged spleen is common to many conditions of infancy and childhood. In the most puzzling cases, such as those simulating enteritis of non-typhoidal nature, the roseola may at the outset be absent. T¥PEOID FEVEB. 331 111 a doubtful case the Widal agglutination blood-test should be made daily to clear up the diagnosis. In many cases this reaction is the only clue to the condition. During the prevalence of an epi- demic every case of pneumonia or doubtful meningitis or enteritis should be subjected to this test. Widal Agglutination Reaction. — The Widal agglutination reac- tion is of greater utility in rnaking a positive diagnosis of typhoid fever in children than in adults. The fact that an enlarged spleen may be due to various causes, such as rickets, the occurrence of fevers of a remittent or continued type, possibly due to otitis, enteritis, pneu- monia, and the prevalence of diarrhoea of all kinds in infants and children, tend to make the Widal test of inestimable value. In a paper based on 84 of my cases of typhoid fever in infants and children, Gershel found the reaction positive in 81. Three hun- dred and twenty-nine examinations in all were made. Thirteen per cent, of the tests were positive at the end of the seventh day, 63 per cent, on the fifteenth day, and 89 per cent, on the twenty-fifth day of the disease. The reaction was negative in only 3 cases which gave the clinical symptoms of typhoid fever. These figures corre- spond to those obtained by Blackader in a smaller number of cases. A negative reaction unless the examinations have been repeated over a leng-th of time is of no significance as excluding typhoid fever, whereas a positive reaction is absolutely pathognomonic of the dis- ease. In a few cases the reaction was not obtained until the close of the disease, when the temperature had been normal for some days. In another case of a child of three years, the reaction was not obtained until a relapse had occurred. Blood- cultures.- — If in a given case a blood-culture can be made, a positive culture of typhoid bacilli may be established, even before the Widal reaction is obtained. Blood-cultures are available in cases of negative Widal reactions. The Ehrlich Diazo Reaction in the Urine. — Thirty-three cases were exam.ined with reference to this reaction. The fifth day was the earliest day on which it was obtained. In the majority of cases the reaction was present from the seventh to the tenth day of the disease. The latest appearance was on the forty-seventh day from the outset of the disease. The reaction was absent in 15 per cent, of the cases. In all of the cases in which the Ehrlich reaction was obtained the Widal test was positive, and appeared in the first two weeks of the disease. The diazo reaction may appear before the Widal reaction, but in some cases the contrary is true. In conclusion, it may be said that in the presence of symptoms and signs of typhoid fever the diazo reaction is an aid to diagnosis, although not pathognomonic of the disease. 332 TKE SPECIFIC INFECTIOUS DISEASES. Of the clinical signs pointing to typhoid fever, the character of fever aids us but little. In the third week it may become intermit- tent, thus simulating malarial fever. In other cases the fever may be sustained with daily remissions until the fifth week. Typhoid fever with great ileocsecal tenderness and pain may closely simulate appendicitis. A continued fever of longer duration than a week, a tremulous tongue, facies, a pulse below 120, an enlarged spleen, and a few roseolar spots, will aid in the diagnosis. The diagnosis of typhoid fever must, therefore, be confirmed by the Widal reaction, except in a small percentage of cases. The pres- ence of roseola, enlarged spleen, facies, tremulous tongue, diarrhoea, and continued remittent fever are the clinical symptoms which should lead the physician to apply the test. Prognosis. — The prognosis of typhoid fever in infancy and child- hood is, as a rule, good. The mortality varies with the severity of the infection and the character of the epidemic. If the infection is severe, the complications will militate against recovery. Henoch, in 375 cases had a mortality of 14 per cent. ; Blackader, in 100 cases lost only 1 ; Crozer Grifiith had a mortality of 3, per cent. It is commonly supposed, and some authors lay stress on the fact, that the mortality of typhoid fever in children is lower than in the adult, and therefore the prognosis is better. This simple statement does not give us any idea as to the true mortality of typhoid fever in children. Some authors place the mortality in this disease as low as 4 or 5 per cent. This may be true of some statistics in certain epidemics. In a series of 222 hospital cases of my own of typhoid fever in children, ranging from thirteen months to thirteen years, the average mortality was 7.6 per cent. This would about express the average mortality of typhoid fever in children when epidemics of varying severity are taken into account. In this same material the mortality in one year was only 4 per cent., and in another as high as 16 per cent. It will be seen from this that hospital cases, from which all statistics are drawn, show that the mortality of typhoid fever in infants and children is much the same as in the adult cases. In 222 cases of typhoid fever there were 12 per cent, of relapses. In this we include only those cases in which there was a true relapse — that is, an average normal temperature for at least eight days pre- ceding the relapse. The average duration of the relapse was eleven days. The mortality in cases where there had been a relapse was nil. Treatment. — The treatment of mild cases of typhoid fever is purely symptomatic. There is little need for the administration of medi- cines. On the other hand, the severer cases are difficult to manage. This is especially true in the treatment of children, to whom it is not TYPHOID FEVER. 333 always possible to apply methods adopted with the adult. In cases in which delirium is present night and day bromides in large doses are efficacious. With older children they may prove useless, and morphine may then be necessary to meet the exigencies of the case. In the vast majority of cases milk, milk soups, and cereal soups form the basis of the diet. If there is progressive emaciation, one, two, or three raw eggs should be added to the milk daily. In other cases malted milk, junket, whey, or matzoon may vary the diet. It is well in protracted cases not to wait too long for a complete drop of temperature before resorting to other foods than milk. This is espe- cially true of cases extending over a period of seven or eight weeks, in which there is always a rise of temperature of half a degree or a degree above the normal for a few days, with a drop again to the normal or subnormal. In these cases there is a form of inanition fever, post-typhoidal in nature. Solid food should not be withheld too long lest the emaciation become extreme. After the fifth week we may in most cases allow the patient gruels containing cereals. After the temperature has fallen to the normal and remained there for four or five days, it is safe to return gradually to a full diet. It is doubtful if relapses occur as a result of too early feeding if this method is followed. In comatose states resort may be had to forced feeding. Alcohol. — Alcohol is not needed in mild cases. It is given in cases in which the pulse is weak and the temperature high. Delirium is no contraindication to its use, as it is in other affections. Heart. — The heart is stimulated by digitalis, strychnine, or cam- phor. If the heart has shown slight dilatation with a murmur devel- oping in the course of the disease, the patient should not be allowed out of bed too soon for fear that unfavorable symptoms may result. Hydrotherapy. — The temperature is controlled by hydrotherapy. The patient is placed in a bath at 100° F. (3Y.7° C), and the tem- perature of the water gradually reduced to 85° F. (29.4° C). With older children the temperature may be lowered still further. Chil- dren do not bear the classical Brand bath treatment well. The plunge bath is given three or four times daily whenever the tempera- ture is 103° F. (39.4° C.) or more. Should the child struggle very much against the administration of the bath, it is wiser to forego it and substitute sponging. If the sponging is not followed by good reaction, the use of water should be abandoned. In cases of delirium a bath once or twice daily at 105° F. (40.5° C.) has a quieting effect. The utmost gentleness must be observed while the patient is in the bath lest some latent abdominal complication may be aggravated. Hemorrhages. — Hemorrhages from the bowel are not frequent in children. They may occur early or late in the disease. In the latter 334 TEE SPECIFIC INFECTIOUS DISEASES. case they must be differentiated from hemorrhage due to enterocolitis of a post-tjphoidal character. In hemorrhage due to typhoidal ulcer an ice-bag is applied to the abdomen, and small doses of opium, pref- erably the deodorized tincture, are administered to control peristalsis. Ergot and digitalis are given internally in order to contract the blood- vessels if possible. Enemata should not be given. If the hemor- rhage becomes excessive, it is proper to give hot saline enemata, and to infuse normal saline solution under the skin or into the veins. Enteritis. — Enteritis of an ulcerative or pseudomembranous char- acter occurring as a complication of typhoid fever is treated in the same manner as the primary affection of the same nature. Perforation. — Perforation should be treated on surgical princi- ples. As with adults, those perforations v^hich occur late in the dis- ease, when the patient is in an exhausted and emaciated condition, give a less favorable prognosis than those which occur early. The surgical treatment will be more successful the sooner the diagnosis is established, for in those cases in which peritonitis has advanced to a marked degree the prognosis is fatal. The success of surgical treat- ment will also depend largely on the fact as to whether the perfora- tion is single or multiple. In one of my cases it was demonstrated at operation that no less than three ulcers had perforated, and there were as many more on the point of perforation, so that in this case simple sewing up of the ulcerated parts could scarcely have suc- ceeded in saving the patient, for in this very case a perforation after operation caused the death of the patient. In such cases the treat- ment of multiple perforations is a problem for the surgeon. In cases of doubt an exploratory operation for the presence or absence of a perforation is justifiable and even called for. Constipation. — In most cases of typhoid fever an enema will remove accumulated fi"eces from the lower bowel. Enemata are not given unless indicated. If the bowel contents are streaked with blood, enemata should be discontinued. In cases in which there is a slight rise of temperature during convalescence without apparent cause, grains v (0.3) hydrarg. cum creta should be given. Tympa- nites is treated as in the adult subject. The evacuations should be mixed with an equal volume of a solution of carbolic acid (1:20) as soon as passed. The hands of the nurse should be thoroughly cleansed after each movement. The patient's hands are cleansed daily, in order to avoid auto-infection. MALARIAL FEVER. (Paludism; Malaria; IntermiUcnt Fever.) Malarial fever is an acute infections disease due to the inocula- tion of the individual with the Plasmodium malaria?. It is common MALARIAL FEVEE. 335 in infants and young children, and is believed to occur in utero. Crandall has reported a case in which symptoms developed eighteen hours after birth, and in v^hich the plasmodium was found in the blood of the infant. Those who, like Moncorvo of Brazil, have oppor- tunities to observe malarial fever in young infants and children, find the greatest frequency under two years. The author has not met paludism as frequently in the nursing infant as in older children. The reason for this must lie in the fact that young infants are more protected from infection with veils, etc., than older children. One attack does not confer immunity to subsequent attacks ; on the con- trary, infants and children once the subject of paludal poisoning seem particularly liable to reinfection and relapses. The period of incubation varies from a few hours to weeks. In the tertian type it is believed to be from seven to fourteen days. In one of my cases the first chill appeared eleven days after the patient had left the malarious district. Etiology. — The essential cause of malarial fever is the same in infants and children as in the adult. It is an inoculation fever, and is conveyed to the human subject by a certain species of mosquito (Anopheles). The poison exists in the neighborhood of swamps and stagnant waters. The Parasite. — The plasmodium or protozoa of malaria circulates in the blood of infants and children, undergoing its cycle and sporu- lation in the same manner as in the adult. In one series of cases in infants and children that I studied, the tertian was the most preva- lent form of parasite. These cases occurred in ISTew York City and its vicinity. This has been the experience of other IsTew York City observers. One may assume that the blood will, as a rule, contain the parasite prevalent in a given locality. Several forms of parasites may exist in the blood of the same child, or there may be several generations of the same plasmodium. These may mature at different times, giving various types of fever in the same subject. In a tertian case, the fever may thus become quotidian, a second set of parasites causing a distinct chill and fever (paroxysm) on the day when the first generation is quiescent. We may have, as Mannaberg and others pointed out, simple and double tertians and quartans. But no combination of quartan parasites can simulate the simple tertian type. I have seen very few cases of quartan in children. They are uncom- mon in ISTew York City, but I have seen preparations of the quartan type which were found in the blood of children in the Southern States. As in adults, tertian paroxysms may occur every day, caused by two sets of parasites which mature at about the same time daily, or one set matures at a different hour than the set of the following day. In such a case paroxysms would occur at the same hour only every other 336 THE SPECIFIC INFECTIOUS DISEASES. day. Many children have a distinct severe paroxysm only every other day, but on the intervening day a careful examination v^ill detect a very low fever. This is probably due to a set of parasites which mature without producing marked chill or fever (abortive). The Blood.- — In recent tertian I have found young spores in abundance in the blood a few hours after the chill. In some speci- mens the spores were free. Between paroxysms in tertian cases the blood contains colorless oval plasmodia — the fully developed body — leucocytes having rods and pigment-granules and rarely, small round forms with flagellse (Koplik). In stained specimens (methyl-blue) young native forms are found in all stages up to fully developed protozoa. The red blood-cell containing the parasite is distinctly enlarged. I have found in the stained specimen as in the unstained ones, the sporula in free groups, bodies with flagellse, and erythro- cytes with stained granules. The half-moons are also found in chronic cases. The blood contains free granules, and peculiar shrunken, brassy-colored, red blood-cells. Monti found the specific gravity of the blood to be increased. Morljid. Anatomy. — Post-mortem examinations in cases of malarial fever in infants and children are exceedingly rare. Opportunity may be afforded when death occurs as the result of accident or of some other disease. Monti states that in fatal cases the spleen is enlarged ; the capsule is tense, and in places shows rupture. The pulp is dark red owing to pigment deposit (melanin). Old spleens show a dis- appearance of melanin and a deposit of yellow ochre pigment along the trabeculse. In chronic cases the connective tissue is increased, the liver is enlarged, and there is atrophy of the liver-cells. The parasites are found in the blood. The endothelium of the blood- vessels contains yellow and brown pigment. In exceptional cases there are melanin deposits. In acute cases the bone-marrow is the seat of melanin deposit; later this disappears, and the marrow is found to be yellow and fatty. The brain cortex in severe cases shows pigment deposit ; sometimes there are thromboses and hemorrhages. Symptoms. — Children living in malarious districts do not always manifest malarial poisoning by having paroxysms of chills and fever. The disease is masked under the form of a progressive anaemia, with accompanying enlargement of the spleen. These patients may de- velop symptoms in from a few days to a few weeks after leaving the malarious region. The onset of a paroxysm is usually marked by the appearance of chills. In young infants a distinct chill is not always present. They become cold and blue at a certain time each day. In older children the paroxysm is indicated by headache and a feeling of lassitude, which comes on at a certain time each day, or by a dis- MALARIAL FEVER. 337 tinct chill. In exceptional cases eclampsia or vomiting may usher in a paroxysm. In other cases there is no eclampsia, but the hands become cold, there is a feeling of faintness, and the child complains of being ill. Meanwhile there is a rise of temperature, during which there are muscular tremors of the extremities and a peculiar upward rolling of the eyes, indicating an impending convulsive seizure. The chill may occur during sleep. In one case the mother noticed that the child (three years of age) became pale during sleep, the hands and extremities became cool, and the pulse rapid. The febrile move- ment following the chill may be very slight, scarcely half a degree above the normal. In such cases the chill is not marked or is scarcely noticeable. This occurs in double tertian, in which one paroxysm is abortive. In most cases the fever is very high at first — so high that it is characteristic. A temperature of 106.5° F. (41.3° C.) is not uncommon, and is well borne. As a rule, the fever has a distinctly intermittent type. The temperature may rise after the initial chill and remain high for days, and then fall to the normal. In the simple form the fever lasts from four to twelve hours, and is followed by a critical perspiration, during which the temperature rapidly falls to the normal. In some cases the children appear free from symptoms in the interval between the paroxysms. Others suffer from headaches and a feeling of lassitude, and in infants there are gastric and intes- tinal disturbances. In protracted cases a distinct anaemia develops, with progressive enlargement of the spleen, l^ieuralgia of the periph- eral nerves has been noted in older children. During a paroxysm Monti noted polyuria, which persisted until the following day. The spleen enlarges rapidly, and in a short time may be felt as low down as the umbilicus. I have found the spleen markedly enlarged; in one case the organ was not palpable below the ribs, although a slight enlargement could be detected on percussion. The liver may be enlarged in chronic cases. In subacute forms chills are not present, but there is an irregular febrile movement, with progressive ansemia and splenic enlargement. Repeated Attacks or Relapses. — Children, as well as adults, may have repeated attacks of malarial fever. As a rule, however, these so-called independent attacks in children are relapses, due either to inefficient treatment or to the development of a new series of para- sites. Infants may have relapses. I have treated such eases until all anaemia and signs of active malarial poisoning had disappeared, and then administered arsenic for months, only to find a return of the symptoms after an interval of months. Diagnosis.- — -The diagnosis of malarial fever is based upon an examination of the blood. If a child suffers from pronounced 22 338 THE SPECIFIC INFECTIOUS DISEASES. ansemia, malaise, pains in the limbs, and enlarged spleen the blood should be carefully examined. Expert knowledge is always necessary for a definite diagnosis. It is surprising to note the large number of cases beginning with chills and presenting an intermittent fever curve and enlarged spleen, diagnosed as malarious, in which parasites cannot be detected in the blood. Many septic and inflammatory proc- esses in infants and children simulate malaria. Rachitis, syphilis, gastro-enteric catarrh, otitis, pneumonia, typhoid fever with relapses, have all been mistaken for malarial fever. The diagnosis rests on an examination of the blood in all cases in which chills and fever or any of the symptoms described coexist with enlargement of the spleen. Quinine should not be administered until the blood has been very carefully examined. In other words, malaria should be diagnosed or excluded before resorting to this remedy, which was formerly much in vogue as a diagnostic test. Its use before diagnosis can only result in uncertainty, since there are rises in temperature, not due to the paludism, which may be influenced by quinine. A very high tem- perature of an intermittent type, in connection with other physical signs, should cause the physician to consider the possibility of paludal poisoning. I have not seen cases of the pernicious type. They occur in the Southern States. Acker has published 2 cases of malarial fever in children, in which there were the initial cerebral symptoms of coma and con- vulsions. Coma in one case came on in paroxysms. In the interval the child was rational. The sestivo-autumnal parasite (pernicious) was found in the blood. Prognosis. — The prognosis of malarial fever in ISTew York City is very good. With proper treatment the patient should recover. I have never met a fatal case. They occur in districts in which the pernicious type of the disease is prevalent. Treatment. — If pjossible, the patient should be removed from the malarious district. The remedies employed in all cases are quinine and arsenic, or their derivatives. According to Golgi, quinine should be given before the paroxysm, and also in the intervals. The action of the drug is exerted directly upon the plasmodium. At this time segmentation of the parasite takes place in the blood, and most of the young parasites are free in the plasma. They then respond most quickly to quinine. Large doses should be given to infants and children, in order that the infec- tion may be destroyed quickly and completely. The soluble bisul- phate and muriate are suitable preparations. To an infant under one year of age grains ij (0.1) are given in a dose, repeated three times a day, the last dose being given from three to five hours before INFLUENZA. 339 a paroxysm. To children between two and five years of age grains iij to V (0.2 to 0.3) are giyen in the same manner. Some infants take quinine readily when it is suspended in powder form in milk or water ; others are given a piece of chocolate, and when the surface of the mouth is coated with the candy the drug is administered. Euquinine is a preparation tasteless and odorless, and is readily taken by children. It has the disadvantage of causing vomiting in some children. The dose is the same as that of quinine. The syrup of yerba santa is a good menstruum. In cases in which children cannot take quinine by mouth, Jacobi advises giving it per rectum, dissolv- ing the drug in a solution of tartaric acid. In the severe form of pernicious malarial fever of the tropics quinine is given by the hypo- dermic method. Infants- and children with chronic or subacute forms of malaria are likely to be constipated. Under these conditions I have found calomel more efficient in clearing the g-ut than castor oil. After the quinine treatment has been continued for some time the spleen will be observed to diminish in size and the paroxysms to dis- appear. If the anaemia persists, it is well, after diminishing the frequency of the dosage of quinine, to combine it with small doses of Fowler's solution. The arsenic must occasionally be temporarily discontinued, or the functions of the stomach will become deranged. Warburg's tincture does not seem to be very efficacious with children under five years of age, nor with older children, unless given in very large doses. Children do not develop cinchonism as quickly as adults, and the quinine may therefore be continued for a long time. Treat- ment should not be suspended until the spleen is no longer palpable and the angemia has disappeared. Quinine should then be continued in small doses at regular intervals. The preparations of cinchona, such as cinchonidia, cinchonidin, chinidin, etc., are not reliable. The following is Baccelli's formula for the subcutaneous use of quinine in pernicious intermittent fever: Quinin. nuiriat 15 grs. (1.0). Natrium chlorat 1 gr. (0.06). Aq. destillat 3iiss (10.0). INFLUENZA. {La Grippe; Acute Catarrhal Fever.) Influenza is a specific infectious disease chiefly afi^ecting the mucous membranes. It is highly contagious, although all individuals exposed do not contract the disease. It occurs in the form of pan- demics in which whole communities are affected. This pandemic form occurs less frequently in children than in adults, and is of 340 TEE SPECIFIC INFECTIOUS DISEASES. interest to the physician only when an epidemic prevails. The endemic form of influenza affects children more frequently than adults, and is the form which will be described, although in its symp- toms it closely resembles the epidemic form. The endemic form may occur at any season of the year. In large cities influenza is endemic, and appears to be more prevalent after rapid changes from lower to higher temperatures. Rapid fluctuations in the humidity of the atmosphere in winter also favor the development of the germs of this disease. In l^ew York City, midwinter and spring are the seasons when outbreaks of this affection occur. Influenza sometimes becomes epidemic in hospital services. I have recently had this experience and Holt has published a study of influenza pneumonia in institutions. Age. — Influenza may affect the newly born infant, A case of this kind is reported by Townsend in the Transactions of the Amer- ican Pediatric Society. The disease is most frequent between the ages of six months and five years. The younger the child, the more severe the affection. Mode of Infection. — Individuals are infected by coming into con- tact (contact infection) with others suffering with the disease. The germ is contained in the sputum and the nasal secretions; therefore poorly ventilated rooms and public conveyances and institutional con- ditions favor the transmission of the disease. Parents may transmit it to their children in the act of kissing, and wet-nurses who have la grippe are likely to infect the infant at the breast. Etiology. — The epidemic form of influenza has been studied by Pf eiffer and Kitasato. Pf eiffer isolated a bacillus from the bronchial mucous membrane, trachea, and lungs. This bacillus, which is now believed to be the essential cause of epidemic influenza, is exceed- ingly small, and two or three times as long as it is broad. It has rounded extremities, occurs in pairs and chains, does not stain by Gram's method, and in influenza, pneumonia, and encephalitis is found in enormous numbers in the lungs. It is called the Bacillus influenzae. It is still an open question whether it occurs in the blood. Although this bacillus has been found in sporadic cases of endemic influenza, competent observers, Luzzato among the latest, have found that in a large number of endemic cases of influenza the Pfeiffer bacillus is absent. In its place is found the Frankel diplococcus. This is thought to be the essential cause of an important group of cases of endemic and sporadic influenza in children — the so-called pneumococcus grippe. Predisposing elements in the etiology of endemic influenza are exposure to cold and a diminution of the strength of the individual. One attack does not protect the indi- vidnal from subsequent attacks. Incubation. — Influenza is believed to have an incubation period INFLUENZA. 341 of from twelve hours to three days. Endemic influenza occurs fre- quently in large cities and at times local epidemics of the disease are seen. Morbid Anatomy. — Inasmuch as influenza is rarely fatal, the pathological anatomy is imperfectly formulated. In fatal cases a general inflammatory condition of the mucous membrane of the nasal passages and of the larynx and trachea, is found. The surface of the lining membrane of the bronchi is reddened, covered with muco- pus, and the membrane itself is infiltrated with small round cells. There may be a diffuse inflammation of the smaller bronchi, with peribronchitis and inflammatory reaction. Areas of bronchopneu- monia or lobar pneumonia are found in the lungs. The heart is dilated and the seat of myocarditis. There may be endocarditis and the kidneys may present an acute nephritis. The pleurae are inflamed, and there may be serous or serofibrinous pleurisy or empyema. Among the other lesions are those due to the complications, otitis, meningitis, inflammation of the gastro-intestinal tract, and cerebro- spinal meningitis. Symptoms. — It has been customary to divide the symptomatology of endemic influenza as it occurs in children into clinical forms. According to my experience, there is no sharp dividing-line between the various forms of endemic influenza as seen in children. The gastro-intestinal, nervous, and pneumonic forms are frequently pres- ent in the same patient. Endemic grippe as it occurs in children in ISTew York City will be described, the epidemic or pandemic form being ignored. The most frequent form is the catarrhal of an acute and even subacute type. The infant or child may at the outset have a chill. Most frequently there is vomiting, and also fever, and pains in the head and limbs. There is a coryza, and in many cases a croupy, barking cough. The eyes are injected, the face is red and flushed, and the child presents an appearance resembling that of the first stage of measles. The mucous membrane of the throat is deeply injected and the tonsils inflamed and enlarged. The temperature is elevated ; in fact, at the outset it is as high in this disease as in malarial fever, 106.5° F. (41.3° C). The cough is sometimes incessant. The irritation in the throat is extreme, and vomiting after the coughing paroxysm may lead the physician to believe that he is dealing with whooping-cough. In young infants these symptoms may last for a day or two, during which the move- ments may become green and even diarrhoeal. This diarrhoea is sometimes so severe as to be a prominent feature of the disease. The prostration both in infants and children is marked. After two or three days the catarrhal condition of the upper air-passages subsides. 342 THE SPECIFIC INFECTIOUS DISEASES. Fig. 50. and the patient develops symptoms of an acute broncMtis of a severe t}73e. These forms of grippal bronchitis have at the outset a high febrile curve, and a fever persisting for days. The bronchitis affects the smallest bronchi. They may develop a bronchopneumonia in small areas. In other cases the bronchitis passes suddenly into a pneumonia without a preceding chill. The pneumonia of la grippe may be lobular or lobar in type. In the vast majority of cases the pneu- monia is of the pneumococcus variety. Esj)ecially severe are the cases of grippe which are ushered in with a chill, high fever and cerebral symptoms, such as sopor, delirium, and rigidity of the neck muscles. In many of these cases exami- nation of the chest reveals pneumonia. These cases are not so common among infants as among older children. Cases in which there is a cerebro- spinal infection in no way differ in symp- tomatology from cases of cerebrospinal meningitis due to the meningococcus or the pneumococcus. The endemic grip- pal forms of cerebrospinal meningitis may be caused by the influenza bacillus (Sanger). I have had six cases of cere- brospinal meningitis caused by the bacil- lus of influenza. The diagnosis was con- firmed by lumbar puncture and the culti- vation of the bacillus on media. The child at first complains of fatigue, and has a tendency to sleepiness, cries out and starts in its sleep, and suffers from intense headache. After a time vomiting with rigidity of the muscles of the neck sets in. These symptoms increase in intensity, sopor finally setting in with all the symptoms of a cerebrospinal meniugitis. These cerebral cases are rare. A common form of grippal attack is that in which all the symp- toms of nasopharyngeal inflammation are present. There is also mild bronchitis of the larger tubes. The temperature may fall to the normal in the morning or toward noon, but toward evening it rises from one-half a degree to three degrees above the normal. The child plays in the afebrile intervals. It may awake from sleep in a peevish, irritable mood, or may start in its sleep. These symp- toms may continue for a week or longer. In many of these cases there is serous or. purulent otitis media, or there may even be a M E M E M E ^ 101° of X < UJ i 100° < tr Q- S UJ DAY OF DISEASE PULSE RES P. DATE \ \ \ \ \ \ \ \ V \ \ > \ 3 4 5 106'^ 100"^ 106 X X X Feb. 2 3 4 Endemic influenza with bron- chitis in an infant seven months of age. INFLUENZA. ;43 mastoid inflammation from the outset. In other cases the patient has an intermittent or remittent fever. The fever, if a continued one, has morning or evening remissions. Examination of the heart may reveal an acute endocarditis, although marked symptoms of car- diac involvement may be absent. Symptoms referable to the kidney have received little attention in text-books. In endemic grippe there is almost always a slight Fig. 51. DAY M E M E M E M E M E M E M E M E 104° 103° hJ X z UJ n 1 103 < 111 UJ a. S UJ 1- 100° 99° , S N /\ ■v / \ N,/ / \ \ 1 \ \ \ \ \ \ \ \ L \ \ \ \ \ \ \ \ \ v, \ DAY OF DISEASE 1 2 3 4 5 6 7 8 PULSE X 103 /^^ ^^ 136'^ 150'^ W^ 120 RESP. X 38'^ 33^^ X y X X X DATE Feb. 2 3 4 6 6 1 8 9 Endemic influenza, lobar pneumonia of the lower lobe of the right lung. Child two and one-half years of age. trace of albumin in the urine, which, as a rule, disappears at con- valescence. Occasionally, there is a true nephritis, with casts, de- creased secretion, and blood. Such cases have been described by Freeman. Of grave import are the cases of nephritis in endemic grippe which at first show a trace of albumin and a few hyaline, 344 TEE SPECIFIC IXFECTIOrS DISEASES. epithelial, and blood-casts, witli a very small (microscopic) amount of blood in the urine. The urine is normal in amount. The con- dition is revealed only by the microscope. CEdema is absent. The child is at first pale, but this pallor disappears later. The trace of albiunin in the urine, hoTvever, with a few casts and blood-cells, per- sists for months. These cases may be mistaken for '" cyclic " albu- minuria. They are really nephritis of an insidious character follow- ing endemic grippe. I have seen cases of endemic grippe complicated with swelling of the parotid and submaxillary glands and of the lymph-nodes of the neck. Otitis media is a common complication of influenza in winter and spring. Such cases may run their course without complication or result in mastoiditis or sinus thrombosis. Duration. — The duration of endemic grippe is from two or three days to as many weeks. I have seen cases present a temperature- curve for three weeks, but have not met the cases of protracted dura- tion, with or without fever, described by Filatow. and would regard such cases as peculiar to the country of that author. Prognosis. — The prognosis of endemic grippe is favorable. If complications supervene, it varies with their nature. Diagnosis. — The diagnosis presents no difficulties. In some cases the nervous symptoms may cause the physician to suspect meningitis when pneumonia is present. A careful physical examination will dispel the doubt. Meningitis and pneumonia may be present in the same case. Otitis may supervene without the presence of marked symptoms referable to the ear. An aural examination should be made in all cases in which fever persists and physical examination of the lungs and other organs fails to reveal abnormal conditions. Treatment. — The treatment of influenza is simple. At the outset in the milder cases small doses of quinine are administered, to control the headache, restlessness, and fever. For the angina small doses of ferric chloride are given to infants every one to three hours. In older children, the throat is, in addition, sprayed two or three times daily with salt solution or a solution of boric acid. The fever is treated by sponging; packing or baths are rarely necessary. The bowels of infants are washed out with high enemata if diarrhoea sets in, and milk food is temporarily suspended. Pneumonia, if present, is treated as outlined in the section on that disease. Otitis should be treated by early incision of the drum-membrane, as even cases in which no pus, but only serum, is present are relieved by this procedure. With older children the use of phenacetin alone or in combination with monobromate of camphor is permissible if the head- ache and pains in the limbs are very troublesome. A grain of each GLANDULAR FEVER. 345 may be given once or twice daily for a short time. The prostration is best combated by the use of strychnine alone or combined with caffeine. Alcohol is not well borne in these cases, since it is likely to cause gastro-intestinal symptoms. In those cases in which there are meningeal symptoms lumbar puncture should be performed to determine the presence of meningitis. GLANDULAR FEVER. (Pfeiffer.) Glandular fever is a form of infection which manifests itself by an enlargement of the lymph-nodes of the neck, with accompanying enlargement of the liver and spleen, and an initial period of fever. It occurs from the second to the eighth year of life, but may occur in infancy. During an extensive epidemic J. P. West observed it in the nursing infant. Etiology. — The etiology is obscure. This disease is a species of infection or toxaemia. In some cases (West) there has been diarrhoea, in others constipation, and in most cases a slight injection of the naso- pharynx. It is possible that the infectious agent gains access to the lymph-channels through the gut or nasopharynx. This would account for the involvement of the mesenteric glands, as observed by Pfeiffer, and for the infection of the nodes of the neck through the thoracic duct. Symptoms. — After slight malaise, or even without prodromata, children are attacked with fever, restlessness, headache, vomiting, and pains in the limbs. After a few hours of these premonitory symp- toms, swelling of the cervical glands on one or both sides is noticed. These glandular swellings extend from beneath the body of the jaw along and beneath the upper third of the sterno-mastoid muscle. The lymph-nodes beneath the muscle are also affected. After one or two days these glands or nodes not only increase in size, but nodes at the back of the neck and in the supraclavicular region are also affected. In the cases recorded by West the axillary and inguinal lymph-nodes were also involved. The temperature at first ranges from 102° to 104° F. (38.8° to 40° C), but in from twenty-four to forty-eight hours it may fall by crisis. There is a slight redness of the pharynx or the color of the mucous membrane may be normal. There is pain on deglutition, and there may be a slight cough, but no distinct pul- monary affection. In both Pfeiffer's and West's cases the liver and spleen were enlarged. In the cases of Starck, Rauchfuss, and Pro- tossow these enlargements were not always present. Lymph-nodes. — The lymph-nodes may enlarge to the size of a pigeon's egg. The redness of the pharynx is disproportionate to the enlargement of the nodes (Rauchfuss), so that it is hardly permissible 346 THE SPECIFIC INFECTIOUS DISEASES. to speak of an anginal lymphadenitis, as in scarlet fever. In both Starck's and West's cases there was enlargement of the nodes, which were not painful, but sensitive to pressure. The swelling of the carotid lymph-nodes began, as a rule, after a few hours, was in most cases first visible on the left side of the neck, and reached its height from the second to the fourth day. The glands on the opposite side of the neck then became affected. The swelling rarely continues unilateral. It is uniform, as thick as an index-finger (West), and is composed of several nodes. There is a stiffness of the neck and also a sensation of choking. Suppuration is absent. There is in all cases a tenderness of the abdomen about the umbilicus, which, in Pfeiffer's opinion, indicates an infection of the mesenteric nodes. West found the mesenteric nodes enlarged in 37 cases. In ISTew York there have occurred every year in the winter months a large number of cases in which the symptoms were limited to en- largement of the lymph-nodes on either side of the neck at the angle of the jaw. Sometimes the nodes in the axilla were also enlarged. There was a high febrile movement for days and weeks. These cases resolved, leaving no further evidences of infection. I have regarded such cases as those of glandular fever. Diagnosis. — The disease is readily differentiated from mumps. In some epidemics the submaxillary glands were involved, but never the parotid. The appearance of the swelling of the lymph-nodes fi^rst on one side, and then on the other side of the neck is characteristic, and should be differentiated from the glandular swellings occurring with grippal affections or pneumonia. Heubner has reported cases in which there was a complicating nephritis. Duration. — The fever disappears after a few hours or may last two or three days. It may recur later. The glandular swellings, however, increase or persist nine to twenty-seven days, the average duration being sixteen days (West, Eauchfuss). Treatment. — As the affection has a tendency to spontaneous recov- ery, the treatment is purely symptomatic. MENINGITIS. Classification of the Different Forms of Meningitis.- — The simplest classification is that which divides meningitis into the primary and secondary forms. The primary form includes cerebrospinal menin- gitis of the epidemic type, or cerebrospinal fever, as also the sporadic forms of this disease, and, as a separate entity, the pneumococcus meningitis. In the secondary forms we have the tuberculous and pneumococcus meningitis, the latter being secondary to pneumonia, endocarditis, or injury of the cranial bones. Third, there are the MENINGITIS. 347 pyogenic forms of meningitis, due to staphylococci, streptococci or secondary either to the disease of the cranium or local infections. Fourth, there are the forms of meningitis secondary to typhoid fever, influenza, colon bacillus, diphtheria, gonorrhoea, syphilis, anthrax, actinomycosis. Fifth, in a separate rubric there is the so-called serous meningitis, which is recognized as a secondary form of dis- ease, due probably to streptococci or pyogenic organisms. It will be seen that this classification recognizes both the sporadic and the epidemic forms of the cerebrospinal fever as the same disease due to the same essential cause, the meningococcus of Weichselbaum. Barlow and Gee divide simple meningitis in infants and children, as to locality, first, into the vertical form, which is a leptomeningitis, and affects the vertex of the cerebrum, sometimes spreading toward the base, and often involving the cord ; and in the second class they include the so-called postero-basic forms of meningitis, in which the exudate is confined principally to the posterior part of the base of the brain. All forms of meningitis may be cerebrospinal as to distribution and it should be understood that the term cerebrospinal meningitis has been retained and when used refers more particularly to the men- ingococcus form. In constructing this section the author has utilized 114 cases of meningitis occurring in his hospital service. They were divided into the following groups: 68 were cases of the cerebrospinal form of meningitis of the epidemic type. Of the remaining cases, 35 were tuberculous forms of meningitis, 1 case a so-called staphylococcus meningitis, 1 case a primary pneumococcus meningitis, 3 cases strep- tococcus meningitis, and in 6 cases a bacillus corresponding to the influenza bacillus in cultural characteristics. The author will first consider cerebrospinal meningitis of the epi- demic, and sporadic type, and then will consider the so-called vertical meningitis and postero-basic meningitis of Barlow and Gee, serous meningitis, and finally tuberculous meningitis. Cerebrospinal Meningitis (Cerebrospinal Fever; Spotted Fever; Meningococcus meningitis; Petechial Fever; Malignant Purpuric Fever) .- — Cerebrospinal meningitis is an acute infectious disease, the characteristic lesion of which is an exudative inflammation of the pia mater of the brain and spinal cord. It occurs in epidemics, but may occur sporadically. Etiology. — Cerebrospinal meningitis, both in its epidemic and sporadic forms, is due to an infection by the Diplococcus meningitidis intracellularis of Leichtenstern, Weichselbaum, and Jager. This micro-organism is a diplococcus reminding one strongly in its form of the gonococcus. It is decolorized by the Gram stain. It is found 348 TBE SPECIFIC INFECTIOUS DISEASES. not only in the body of the pus-cell — hence its name — but in the exudate also outside of the pus-cell. Though the epidemic form of cerebrospinal meningitis is caused in the vast majority of cases by this micro-organism, there is another group of cases of the cerebrospinal type which is caused by the Diplo- coccus pneumoniae. This latter class of cases has been described by Xetter, Foa, and Bordoni-Uffreduzzi. These cases may occur epi- demically also, but are generally seen in combination with lobar or bronchopneumonia, or as a complication of otitis media. The form of affection discussed in this section is rather the sporadic and epi- demic type of cerebrospinal meningitis caused by the intracellular diplococcus above mentioned. In the epidemics of this disease so far observed, it is not unusual for several members of a family to be attacked. The rule, however, is the contrary. The cases in an epi- demic number several hundreds, the last epidemic in ISTew York amounting to somewhat over 1000 cases. The disease seems to have no marked tendency to spread. In large cities the epidemics occur in the spring of the year ; and, after the epidemic has run its course, sporadic cases are observed in the fall and winter months. Mode of Infection.— It has been a matter of great speculation as to how the infection is conveyed from person to person in this disease, if such does occur; and also as to the manner in which the micro- organism — the intracellular diplococcus — gains access to the circula- tion. Cases are observed here and there, and I have seen two such cases in the last epidemic, in which the disease is complicated by pneumonia, the meningitis and the pneumonia both being due to the intracellular diplococcus. These cases, however, are exceptional. It has been supposed that the micro-organism gains access to the circu- lation through lymph-spaces in the mucous membrane of the nose and conjunctivae. I have published one case in which the Diplococcus intracellularis was found in the secretion of the conjunctiva in a child suffering with the disease, in whom the meningitis had been preceded by a con- junctivitis. Wright has published a case in which the intracellular diplococcus was found in the nasal secretions of a person suffering from influenza symptoms, mild headache, fever, and constitutional disturbances, which might very well have been a mild form of cere- brospinal meningitis. A micrococcus, so-called Micrococcus catarrh- alis, is found in the normal secretions of the nose, and it has been mistaken time and again for the Diplococcus intracellularis. It has been intimated that the infection may gain access to the circulation through the respiratory organs. However these facts may be, they do not definitely establish how the infectious material gains PLATE XVI Cover-glass Stain of the Sedimented Fluid Obtained by Lumbar Puncture in Epidemic Cerebrospinal Meningitis. Polymorphonuelear cytology; -vacuolization of the leukocytes and lympho- cytes; peculiar conformation of the nuclei in cells; large cells resembling lym- phocytes; Diplocoecus meningitidis in the cell body of the leukocytes and also outside of the cell bodies in smaller numbers Jf' PLATE XVII -— >^i -'' "W' K ,r?s», 1. /• « ;>-:;r"-^^i.^^__ f / i=.i.^ .-<* y'^ %•- ' .J5 V" /•a". . _!i^- . .7'-:.;-, ' ''■^''■'': ' Kr. 4 Section of the Spinal Cord, showing the Exudate on the Surface, More Marked Posteriori y and Involving the Anterior and Posterior Nerve Roots. Epidemic cerebrospinal meningitis in an adult; death on the fifth day of the disease. PLATE XVII I f nk, The Exudate of the Early Stage and Inflanimatory Reaction in the Pia Mater. This shows: Swelling cells of the pia; fibrin in the exudate; the leu.koeytie invasion; new connective-tissue cells; nuclear division; large cells containing three or more leukocytes described by Councilnian, Mallory, and ^A/■ right. MENINGITIS. 349 access to the circulation, or whether the disease is conveyed from person to person. Occurrence.- — Cerebrospinal meningitis is distinctly a disease of young people. Eotch reports a case in an infant six days old. The youngest case of the epidemic type seen by me occurred in an infant ten weeks old. Of 111 cases reported by Councilman, 29 occurred in infants and children. Of a series of 70 cases of cerebrospinal meningitis reported by me, 47 per cent, were under two years of age; the youngest was four months of age, and 61 per cent, of the cases were under four years of age. The oldest child in my hos- pital service was fourteen years of age. Thus the average age was two years. Morbid Anatomy. — ^In certain sporadic cases of cerebrospinal meningitis of the epidemic type the clinical symptoms may have been very marked, and yet post-mortem examination fails to reveal any gross macroscopical lesions of the brain and j^ia mater. They appear to be normal. Under the microscope, however, a slight infiltration of the pia with pus and fibrin and a new growth of cells is seen. In other cases there is an extensive infiltration of the pia with serum, fibrin, and pus. The exudation is especially profuse at the base of the brain and on the posterior surface of the cord, more especially in those cases which will hereafter be described as postero-basic menin- gitis. The ventricles of the brain may be markedly distended with serum and even pus. Among the associated lesions found are sub- serous punctate hemorrhages of the endocardium; ecchymoses and petechise of the skin, hyaline and granular degeneration of muscle, multiple abscesses of the skin, suppuration of the joints, parenchy- matous degeneration of the heart, liver, and kidneys, and swelling of the lymph-nodes and spleen. In all the epidemic cases of the type referred to in this section the Diplococcus intracellularis is found in the exudate of the pia mater and cortex of the brain and in the fluid of the ventricles. Symptoms. — There are certain types of cerebrospinal meningitis which are seen both in the epidemic and sporadic forms of the disease. The malignant types are seen rather in the epidemic forms ; whereas the milder types are seen in the sporadic cases. Clinically, therefore, we may divide all cases of epidemic cerebrospinal meningitis into three forms : The first form is the malig-nant type of the disease, in which the children, in previous good health, are attacked and die within twenty-four or thirty-six hours of the onset of the disease. The following case, one of the first of the epidemic of 1904, is a characteristic example of this type: An infant twelve months old, nursed at the breast; perfectly formed, large, healthy, bright child, never previously affected by any illness, nursing, and bowels normal. 350 TSE SPECIFIC INFECTIOUS DISEASES. On the morning of the onset of the illness the child appeared drowsy and stupid, refused the breast, vomited once, hut was not feverish. In the evening the infant was still drowsy and listless ; the tempera- ture rose to 103° F. ; pulse 110 and weak. There was no peculiarity about the eyes, no stiffness of the muscles of the neck or body. Early on the morning of the next day the child awoke with a cry, and the mother discovered red spots on the cheeks; the face was slightly swollen; the eyes had a staring expression, and the child was appar- ently blind. A few hours later the entire face, hands, and body were covered with blotches of an ecchymotic character. The tissues of the extremities seemed to be hard to the touch and swollen. The buttocks and body appeared as if the child had been beaten. Petechise and ecchymosis involved the whole surface of the body. At this time the temperature was 101° F., pulse very weak, scarcely perceptible at the wrist, the lips blue, the reflexes abolished. There was no rigidity of the muscles of the neck. There was no Kernig symptom. The pupils were uneven and did not react ; there was a slight con- junctivitis. The breathing was weak and catchy. Death super- vened within a few hours. These cases are not unusual in epidemics, and here and there sporadic cases occur of this type. Another type of case is the more common form of the disease. A child in aj^parent health will suddenly complain of headache, fever, and begin to vomit. There may be a chill. The fever is generally high, the pulse rapid. The headache is very severe and is a constant leading symptom. There is also intense pain at the back of the neck, extending down the back. The child is irritable and restless, tossing about, intolerant of light and sound. Any interference and touch on examination of the surface of the body causes pain ; in other words, there is hyperesthesia. After a few hours rigidity of the muscles at the back of the neck appears, and this rigidity may increase to opisthotonos ; in some cases on the second day there may be repeated convulsions. When the disease is completely inaugurated the child lies in bed in a characteristic attitude, the lower extremities flexed, the arms flexed, the head slightly retracted. The children, for the most part, lie on the side. With the full onset of symptoms in some epidemics petechise appear with ecchymoses over the whole surface. These petechise vary in size from a pin-head to large blotches resembling hemorrhages due to traumatism. Ecchymoses are seen especially on the extensor surfaces of the lower extremities. The patients complain of constant headache, some are very restless, delirium sets in; the delirium may be of a mild or muttering type. In some cases there is no sleep, the patients toss here and there in the bed, and complain of constant pain in the head. The bowels may be constipated ; in some cases PLATE XIX Convexity of the Brain.. LLJiuomic cerebrospinal meningitis >Arith death on the fifth day of the disease. Purulent exudate. Fia 2 Lateral View of the Brain in the Same Case. o 0) c T5 ^. 3 cQ rfi O O H- ( O Ij C "3 w 2. 2^ w ■s 0) "ti 3 QO (D CO O 0) jr "* '-h yj Ti 03 U2 r-^ m' (■f) C"*" r u > X MENINGITIS. 351 there is diarrhcea. The urine may contain evidences of a nephritis. In other cases no such evidence is present. The amount of urme passed in some cases may be enormous; in other v^ords, there is polyuria. The spleen may be enlarged. The type of case just de- scribed corresponds to the mass of cases seen in an epidemic. A third type of this disease is more puzzling in its character ; it affects infants and young children in apparent health. Infants and children are noticed to have a constant rise of temperature; there may be vomiting; there is restlessness; if nursing, they refuse the breast. The fever after a few days takes an intermittent course, mounting as high as 104° and 105° F. at certain times of the day; falling to the normal or subnormal at others. In the intervals of freedom from temperature the children or infants v^ill play, and when the temperature rises they complain of headache (if old enough), become drowsy and irritable, refuse nourishment, and develop symp- toms which point toward meningeal inflammation, such as the Kernig symptom, rigidity of the back of the neck. In these cases the typical symptoms of meningitis are not always present. Delirium may not be constant or may not extend over the twenty-four hours. The rigidity of the neck may not be very marked, especially in young infants. The Kernig symptom in children, especially below two years of age, may not be evident. The most characteristic feature of these cases, it seems, is the prolonged temperature of an intermit- tent type, closely resembling malarial fever. In fact, many of these cases have been mistaken for malaria. There is a fourth type of case, which will be described under the heading of Postero-basic Meningitis, which is observed not only spo- radically, as has been remarked by Still, but also in epidemics. Mode of Onset. — In all the cases that I have had an opportunity to observe in my hospital and private practice, and in which the diag- nosis was confirmed by lumbar puncture, the main characteristic of the disease was its sudden onset. In only a small percentage of cases was there a doubtful history of sudden onset. In this respect the disease differs markedly from other forms of meningitis, especially those of the tuberculous type, in which the invasion is slow and insidious. From a study of the symptoms the onset may simulate an attack of gastro-enteritis in some children. Cerebral Symptoms. — If the fontanelle is not closed there is dis- tinct bulging or tenseness, even in the early stages of the disease, certainly before the fifth day. The patients suffer from delirium or coma, and in the milder cases headache is the principal symptom, and periods of consciousness alternate with those of stupor. Rigidity of the neck, either slight or marked, is present at one time or another in all cases, and opisthotonos is present in about TO per cent, of the cases (Plate XX.). 352 THE SPECIFIC INFECTIOUS DISEASES. According to Osier, neck rigidity or opisthotonos was not present in tlie adult form of primary pneiimococcus meningitis. In one case, however, of my own, of primary pneumococcus meningitis in a child, neck rigidity was present. There is hypersesthesia of the surface, and the patients cry out if the bed is jarred or the skin touched. In some cases there are recurrent rigors and convulsions, either uni- lateral or general. There may be facial paralysis and hemiplegia in the early or the later stages of the disease. Reflexes. — In the majority of cases of epidemic cerebrospinal meningitis the patellar reflex is present in the early stages of the disease, but it may disappear in the rapidly fatal or moribund cases. The so-called tache cerebrale of Trousseau is obtained in all cases. BabinsJci Reflex. — Babinski, a French neurologist, described the extension of the great toe and separation of the other toes on irrita- tion of the plantar surface of the foot as a characteristic sign of dis- ease of the pyramidal tracts or the lateral columns of the cord. In epidemics of cerebrospinal meningitis this phenomenon is obtained in only a small percentage of cases, in contradistinction to what is noted in the tuberculous form of meningitis, in which it is common, being obtained in 6 of 26 of my cases of tuberculous meningitis. The Babinski reflex is of very little value in children and infants below two years of age, for a phenomenon closely resembling it is obtained in perfectly normal individuals at this age (Fig. 83). Kernig Symptom. — The Kernig symptom — that is, an inability to extend the leg on the thigh when the latter is flexed on the trunk — is obtained at one time or another in all cases of cerebrospinal menin- gitis. In children below two years of age, however, this sign must be accepted with caution because of the natural tendency in infants and children of this age to contraction of the lower extremities, a variety of normal myotonia (Fig. 52). On the other hand, in cases of so-called cerebral symptoms complicating pneumonia and typhoid fever, the Kernig phenomenon may also be apparent, so that, although it is present in all cases of meningitis, it is not pathognomonic of the disease. It may be absent in eases of the malignant type in which there are collapse symptoms. Hyperwsthesia. — In the majority of cases of cerebrospinal menin- gitis, after the symptoms are fully established, the patients are irri- table, refuse to be comforted, start at the slightest sound, lie mostly on the side, the arms and lower extremities flexed, the body taking a crouching position. Any attempt to disturb the patients is met with resistance. The amount of hypersesthesia varies not only in the different epidemics, but in different types of the disease, but it is present in most cases, thus being in marked contrast to what is seen in the tuberculous form of meningitis, in which the children lie in a MENINGITIS. 353 stuporous condition, do not notice their surroundings, cannot be roused, and are not as irritable as in the epidemic cerebrospinal form. MacEwens Sign. — • MacEwen has shown that in children, in various forms of meningitis, percussion of the skull over the anterior horn of the ventricles will give a tympanitic note if the head is so held that the frontal or parietal bone may be percussed over the anterior horn of the ventricle. The patient is placed in the sitting posture, with the head inclined to one side, and percussion of the inferior frontal or parietal bone is carried out. The MacEwen sign is obtained in those cases of the cerebrospinal meningitis in which there is an accumulation of fluid in the ventri- cles, and was absent in only 2 cases of 13 studied with a view to Fig. 52. Kernig symptom in a case of cerebrospinal meningitis of the epidemic type. Female, nine years of age. obtaining this sign. It is more common in the tuberculous forms of meningitis. Facial Pares^is. — In epidemic cerebrospinal meningitis facial pa- ralysis may occur in the very severe cases at the outset of the disease, especially if the base of the brain is involved. Paralysis. — There may be paralysis not only of the facial mus- cles, but of the extremities on one or the other side, either at the outset of the disease or toward the close. Eyes. — There may be an initial conjunctivitis, keratitis, strabis- mus, contraction, dilatation, or inequality of the pupils ; neuritis of 23 354 THE SPECIFIC INFECTIOUS DISEASES. varying grades of the disk ; atrophy, and finally purulent choroiditis. There is no appreciable impairment of vision in some cases. In a fonr-months-old baby paralysis of the orbital muscles of one side appeared early in the disease.' A peculiar phenomenon has been observed by me and described by others referable to the pupils : If an attempt is made to bend the head forward as the patient lies in bed unconscious, the pupils will be observed to dilate (mydriasis). Contrary to the generally accepted opinion, we have found that expert examination of the fundus of the eye in cases of cerebrospinal meningitis of the epidemic type revealed few changes in the optic pupilla in the majority of cases. In some cases there was dilatation of the veins, or congestion without neuritis. In only one case was there descending neuritis. This corresponds very closely to what Barlow and Gee found to be true both of the vertical and postero- basic forms of meningitis. In a group of 26 cases of meningitis of the tuberculous variety, however, examined by an expert ophthalmol- ogist, some change was found in the fundus in fully 77 per cent, of the cases. This change consisted either of an optic neuritis or papil- litis, or the presence of tubercles in the choroid. Blood.— The leucocyte count in cases of cerebrospinal meningitis of the epidemic type ranges from 20,000 to 55,000 to the cubic milli- metre in 55 per cent, of the cases. There are cases, however, with a low leucocyte count of 11,00.0 to 12,000 to the cubic millimetre. This corresponds very closely to what was found by Osier to be true of the adult cases. In tuberculous forms of meningitis, however, of infants and children, in 40 per cent, of the cases there is a leucocyte count of 20,000 to 25,000 to the cubic millimetre, and in 60 per cent, of the cases the leucocyte count is below 20,000 to the cubic milli- metre. Rarely, however, does the leucocyte count exceed 24.000. In the fatal cases, in Avhich the lumbar puncture may yield a fluid markedly purulent, the leucocyte count may mount from 35,000 to 55,000 to the cubic millimetre. On the other hand, a fatal case with fluid obtained by lumbar puncture might show a leucocyte count not exceeding 23,200. Cases which have recovered may show in the course of the disease a leucocyte count of 14,000 to 28,000 to the cubic millimetre, and they may have mounted as high as 45,000. It cannot, therefore, be said that a prognosis as to recovery or fatal issue can be made from the leucocyte count alone in cerebrospinal meningitis. Pulse. — The pulse in cerebrospinal meningitis, as a rule, is rapid and irregular; but there are periods in which the pulse is slow, some- times 80 or even lower. This is not as common, however, as the rapid pulse. Respirations. — The respirations, as a rule, are shallow, increased MENINGITIS. 855 in frequency, and irregular in rhythm. In a few cases there may be Cheyne-Stokes respiration. In other cases Cheyne-Stokes respira- tion is not seen in the whole course of the disease ; as the fatal issue approaches, the respirations may cease before the heart ceases to beat. In the terminal stages the respirations sometimes fall to 10 a minute, and the pulse to 50, indicating the onset of general paralysis. Temperature. — There is no curve of temperature which is dis- tinctive of cerebrospinal meningitis. It may be said, however, that the temperature in many cases is of the intermittent variety, and for this reason these cases are frequently mistaken for malaria. In the intermittent type of temperature the remissions are very gTeat, some- times ranging eight degrees in twenty-four hours; that is, a tempera- ture which has been high will in a few hours fall to the subnormal to rise again. This is not uncommon and may extend over weeks. On Fig. 53. " ': Cerebrospinal meningitis. Female infant, eight months of age ; unconscious on admis- sion to hospital; fatal issue. (Meningococcus.) the other hand, the temj)erature may remain persistently high, espe- cially in the rapidly fatal cases of the malignant type. In the chronic cases the temperature may fall to and continue within normal limits for days or even weeks. In some cases, after the temperature has remained normal for days or weeks, there may be a so-called recrudescence of temperature of an intermittent type extending over a week or more. This does not preclude ultimate recovery. In one case in the recent epidemic the temperature con- tinued of the intermittent type, with the remissions mentioned above, for eight weeks, fell to the normal for a week, rose again, continued intermittent for a week, and finally fell to the normal and remained there. In this respect the temperature may even resemble typhoidal curves of the third or fourth week. 356 TRE SPECIFIC INFECTIOUS DISEASES. Spleen. — The spleen may be enlarged in some cases. Ear. — The ear may be the seat of otitis or mastoiditis. Deafness, especially where the base is involved, may supervene very early. Anterior' Fontanelle. — The anterior fontanelle in infants and children in whom the structure has not closed, may be tense or dis- tinctly bulging; and in those cases in which there is considerable accumulation of fluid the posterior fontanelle may reopen. Shin. — In many of my cases there has not been that prevalence of skin rash described by most authors. It has been only in the last epidemic of 1904 in which skin eruptions were prevalent. They included the roseola resembling that of typhoid fever. The roseola appears, as a rule, at the outset of the disease, and may recur in the Fig. 54. DAY OF „ ILLNESS " ' 8 25 26 27 ^11 f w f r a. : i_s\r «_ — =— E < 102 s- -•=- : .__ ^_..t- ^tJ- t ■^ -5^ X S r. '^ S 1 J ^»^ t- A ^ Ni -1 5 i Ij ^ o 5_ '^^ ^ A J -t 3 °= im ^ <;o ► i ^ J " 4 i 13 lui -*^ <>-e ^> \~f^ ^-t—6 * < -m4tmf-^rftt ffniJjM h / 1 S! 100 f ^ .1 ^ ^ 3—5 ^- 99'^ : 1 — ±;_=; s PULSE SSS o SsooS o < 5SS3S silsasl laSsiil 0^00030 RESP. SSS S SSScS S ; JSSSSa SSSSSSS SS;5S33^ S;5S!5S^3 Cerebrospinal meningitis. Female child, eight years of age ; temperature at two extremes of the illness. Recovery. (Meningococcus.) course of the disease. Purpuric spots extending over the general sur- face are common at the outset, as well as ecchymoses, and these may disappear within a few days, leaving absolutely no trace of their presence; or recurrent crops of ecchymoses and petechise may appear in the course of the disease. Herpes labialis varies in different epidemics as to its frequency, being absent in the majority of cases in some epidemics, and being frequent in others. Herpetic eruptions may occur elsewhere on the trunk or extremities. I have seen exten- sive herpes on the hand. One case has come to my notice in which the herpes were quite generally distributed over the trunk and extremities. Complications. — In some epidemics of cerebrospinal meningitis there are few complications. Those cases which recover do so with very little to show that the nervous system in any of its extent has been severely compromised. The eyesight is not injured, nor is there subsequent hydrocephalus in any cases. In other words, the recov- MENINGITIS. 357 eries when they occur are complete and satisfactory. This is espe- cially true of small epidemic outbreaks occurring over the course of years. In the recent epidemic of 1904, however, the complications were more frequent; joint complications were observed in 2 cases of a series of 30 ; blindness was not an uncommon complication, as also deafness. Recovery was incomplete, with hydrocephalus in several cases of a series of 30. Pneumonia was observed as a complication of cerebrospinal meningitis of the epidemic type in 2 fatal cases. Sequelae. — Recovery may take place without compromise of any of the senses or functions of the patient. Both in young and older children hydrocephalus, either of a mild or severe type, may super- vene in the course of the disease ; it may run a short course and the patient recover with a mild form of hydrocephalus, which in years gives rise to nervous symptoms, such as partial paresis or epileptic form of convulsions. Severe types of hydrocephalus lead in many cases to permanent idiocy or imbecility, with or without paralysis. In some cases blindness or deafness results as a direct cause of menin- gitis. Arthritis, which sometimes complicates the disease, has a ten- dency to get well and leave no marks of its presence. Many patients recover with so-called sensitive spines, or paresis of certain sets of muscles, which later in life becomes apparent. Optic neuritis or blindness occurring in the course of the disease very frequently retrogrades, and the patients, on recovery, bear nO' marks of any ocular lesion. Characteristics of the Fluid Obtained by Lumbar Puncture.^ — The fluid obtained by lumbar puncture in cases of meningitis, studied both as to cytology and bacteriology, is of particular interest as regards the possibility of making a diagnosis. The cytology of the fluid obtained in cerebrospinal meningitis shows a preponderance of the polynuclear leucocytes. In a small percentage of cases the mono- nuclear cells, contrary to the general belief, may be prevailing ele- ments, thus closely resembling what is seen in tuberculous meningitis. In chronic cases mononuclear leucocytes abound ; and in these cases, especially those of the basic type described by Still, the cytological picture resembles that of tuberculous meningitis. The fluid obtained by lumbar puncture in cerebrospinal meningitis may be quite clear, with scarcely any sediment, and may be markedly purulent, in this respect differing from the fluid obtained in tuberculous forms of meningitis, which is clear in at least TO per cent, of the cases. Bacteria. — In the vast majority of cases of cerebrospinal menin- gitis the Diplococcus meningitidis intracellularis of Weichselbaum was found at one time or another, either in leucocytes or outside of the leucocytes. In the chronic cases, however, there are times in which the Diplococcus intracellularis is not found. This is especially 358 ' THE SPECIFIC INFECTIOUS DISEASES. true of the posterior basic cases. In those cases in which the diplo- coccus has not been found during life in the fluid obtained by lumbar puncture, it may be discovered postmortem in the fluid obtained from the ventricles of the brain. I have recently punctured the brain ven- tricles of infants during life in cerebrospinal meningitis. The char- acteristics of the fluid are identical with those of the fluid obtained by lumbar puncture in the same cases. Course of the Disease. — The course of the disease after the symp- toms are fully developed in typical cases has been indicated in the first part of this article. The patient lies unconscious, the head is retracted, and in some cases the back arched. The delirium is con- stant, and the patients complain of headache. The neck is rigid; some patients complain also of j)ain in the course of the sciatic nerves. •When disturbed they cry out with pain. There may be rigors, during which the patients become cyanosed and the heart feeble. The respirations are shallow and irregular. If the case lasts over a, week the patients may refuse nourishment, and on this account marked emaciation sets in. In some cases the disease takes on an abortive type. After a period of headache, fever, vomiting, intervals of remission of all symptoms, including' temperature, alternate with intervals in which the temperature runs an intermittent course, with a return of the headache, stupor, and uneasiness, convalescence finally sets in, and the patients rapidly recover. Other cases result fatally in a few days. Some cases run a course of from eight to fifteen weeks, with the temperatures described, great emaciation, and finally make an incomplete recovery. Others attain a freedom from symptoms, but emaciation and paralysis persist, or even blindness and deafness, until an intercurrent affection ends the sufferings of the patient. As will be shown, there are few recoveries in children below two years of age. In other cases recovery takes place, but idiocy, hydrocephalus, blindness, or palsy may persist. Diagnosis. — Cerebrospinal meningitis must be difl'erentiated from tubfrculous meuiugitis, typhoid fever, and pneumonia with cerebral sym])toms. It is distinguished from tuberculous meningitis by the sudden onset, its continued or intermittent higher febrile movement, the early onset and marked rigidity of the neck and opisthotonos, and, as has been intimated, the higher leiicocytosis, and finally by the examination of the fluid obtained by lumbar puncture. Cerebro- spinal meningitis is distinguished from ty])hoi(l fever by the fact that in the latter disease there is a leucopenia and a constant enlargement of the spleen with Widal reaction. On the other hand, there may be cases of ty])li()i(l fever in wbicli llic cercljral symptoms are very MENINGITIS. 359 marked and in wbicli a meningitis may be present, due to an inva- sion of the meninges of the brain and cord by the typhoid bacillus. In this set of cases the diagnosis will be very difficult without the aid of a lumbar puncture. This latter procedure should be made in order to exclude the severer affection of cerebrospinal meningitis. A pneu- monia with cerebral symptoms will at the outset closely resemble a cerebrospinal meningitis, especially in very young children. Even if an examination of the lungs reveals a pneumonia during an epi- demic of meningitis, we cannot always exclude the latter disease without resort to a lumbar puncture, for cases of meningitis of the epidemic cerebrospinal type caused by the intracellular diplococcus are met in which pneumonia is present as a complication. On the other hand, pneumonia per se with cerebral symptoms does not, as a rule, give us the very niarked rigidity, opisthotonos, petechise, intense cephalalgia, and Kernig symptom seen in cerebrospinal meningitis. I have, however, met isolated cases, both of pneumonia and typhoid fever with cerebral symptoms, in which a Kernig symptom was obtained, as well as the so-called tache cerebrale of Trousseau, although these cases are certainly exceptional; in any doubtful case we should not hesitate, as has been said, to resort to lumbar puncture in order to clear up a given case. Prognosis. — The mortality of cerebrospinal meningitis varies largely with the severity of the infection and in different epidemics. In some epidemics the malignant cases seem to predominate; that is, those cases which die within a short time (from twenty-four hours to five days) after the onset of the disease. On the other hand, in small epilemics the mortality may not exceed 48 per cent. There are epidemics in which the mortality has risen as high as 90 per cent. Especially fatal are the postero-basic cases and those attended by malignant features at the very outset of the disease. The prognosis, unfortunately, cannot be predicted in cerebrospinal meningitis, either from the nature of the fluid obtained by lumbar puncture, or from the condition of the blood as reflected in the leucocyte count, or the range of the temperature. We can only say that it is especially fatal the younger the patients. We have records, however, of cases of cerebrospinal meningitis occurring in infants of five months and one year of age, substantiated by culture and lumbar puncture, in which recovery occurred. The prognosis has recently been much improved by the serum treatment of Flexner. In 400 cases collected by Flexner and Jobling treated by their serum, the mortality was lowest in cases treated in the first three days of the disease (11 to 13 per cent.), in cases from the second to the twentieth year; on the seventh day of the disease the mortality of injected cases ranged from 24 to 26 per cent. Below 360 THE SPECIFIC INFECTIOUS DISEASES. 2 years of age the mortality, when treated from the fourth to the seventh day, was 16 to 25 per cent., and 50 to 66 per cent, when treated later. Treatment. — Serum. — One of the greatest advances of modern medicine is, as with diphtheria, the serum treatment of cerebrospinal meningitis of the meningococcus type. Among the various sera which have been perfected and proj^osed, the Flexner serum is now by selec- tion the one utilized. Its action is bacteriolytic and therefore the great advantage in its use is the proposal by Flexner to inject this serum into the spinal canal and thus reach the bacteria directly. It has been found that after one or more injections the number of bacteria (meningococci) is gi'eatly reduced and the fluid withdrawn from the cerebrospinal canal contains either very few bacteria or none at all. It thus acts in a manner differently from the diphtheria serum which is injected subcutaneously and affects the disease through a contained antitoxin. It is well to remember that the Flexner serum is of virtue only in cases of the meningococcus variety. The serum should be used as soon as the symptoms of meningitis are apparent. A tentative lumbar puncture should be made as early as possible. Before lumbar puncture it is not always possible to diagnose the exact form of meningitis present. Therefore to avoid delay which may be harmful a so-called exploratory puncture is made at the start. If the fluid thus obtained is turbid an immediate injec- tion of serum is made and the cerebrospinal fluid examined. If men- ingococci are found the injection of serum is repeated until the symptoms indicate that the disease is under control and convalescence established. Before proceeding to puncture, every piece of apparatus necessary should be in readiness. The needle is carefully boiled, the tubing to be attached to the needle is sterilized, as also the funnel by which the serum is introduced into the canal. The serum having been care- fully warmed to the temperature of the body, the site of puncture is cleansed, the needle introduced, and the fluid of the subarachnoid space allowed to flow out. After withdrawal of 30 to 40 or more c.c. of fluid, 30 c.c. of the serum is allowed to flow slowly into the canal just evacuated. The syringe has long been discarded by me for the Quincke funnel. After all the serum has flowed into the canal the needle is withdrawn and the puncture sealed with a sterile gauze dressing. Flexner and Dunn advise the repetition for three succes- sive days of 30 c.c. of serum. In young infants this should be done on account of the dangerous nature of the disease. In older children it is well to study the symptoms closely and to repeat the injections on successive days as needed. In some cases I have found that two injections sufficed to bring about convalescence. MENINGITIS. 361 I have carried out the intracranial injection of serum in infants in whom the effect of the lumbar punctures was not apparent after the first few injections of serum and in whom basic symptoms were in evidence. Gushing and Knox first carried out these intracranial injections of serum in posterior basic cases. My experience with this method as yet is too limited to make any positive statements. In these cases the puncture-needle is entered with the infant in the recumbent posture, in the parieto-f rental angle of the anterior fontanelle to one side of the median line. The inferior angle is chosen. The fluid comes through the canula quite readily and the serum is introduced in the same manner as in lumbar puncture. Aseptic precautions as to shaving of the head aud site of the cranial puncture are very important, as the least oversight may lead to a meningoencephalitis due to a mixed infection. Lumbar Puncture.- — The symptoms calling for lumbar puncture are increased exudate in the subarachnoid space, with extreme rigid- ity, opisthotonos, coma, delirium, bulging fontanelle ; in young in- fants chills with subsequent rises of temperature are indications for a repetition of and introduction of serum by lumbar puncture. In those cases in which coma and delirium supervene at the very outset of the disease, lumbar puncture may be performed within twenty-four hours of the onset of symptoms. We should not hesitate after the first puncture to repeat the procedure within twenty-four hours, as indicated above, if symptoms either recur or remain stationary. In young infants and children especially repeated lumbar puncture seems to be called for by the very fact that in these subjects the con- tinued pressure and increase of fiuid in the subarachnoid space and in the ventricles of the brain increases the tendency to dilatation of the ventricles, a serious complication which may lead to collapse symptoms, sudden death, or ultimate chronic hydrocephalus. In those cases in which at the outset of the disease the head retraction is very marked, the lumbar puncture is sometimes unsatisfactory, inas- much as little fluid is withdrawn. In these cases the exudate at the base of the brain and the extreme retraction of the head may cut off the communication of the subarachnoid space and spinal cord with the ventricles of the brain. The canal of Majendie, through which this communication is sustained, is in these cases occluded. These are the cases in which ventricular puncture is suggested. Lumbar puncture alone is not curative. It relieves symptoms of headache and delirium. It removes a certain amount of purulent exudate which is a menace to the vital structures of the brain and cord, and is thus a method of drainage rather than a curative meas- ure. It may, in cases of sudden distention of the ventricles of the brain with fluid, avert death. 362 TKE SPECIFIC IXFECTIOrS DISEASES. The amount of fluid Tvitlidrawu at each puncture should be from 30 to 50 C.C., depending greatly on the extent of pressure present, as indicated hv the manner in Tvhich the fluid flows from the puncture cannula. If the fluid flows drop by drop, a small amount, 20 to 30 cc. is withdrawn. In some cases the fluid fairly spurts from the cannula, and in such cases 50 c.c. or more may be withdrawn. In other cases the exudate is so thick and purulent that it will not flow from the cannula except in large, thick drops at long intervals. We should not in these cases attach a syringe to the cannula and apply suction to the fluid, for in this way. it has been shown, hemorrhages may be caused in the spinal cord and the pia of the brain. Anses- thesia is not needed in young children but may be administered to older, boisterous children. As might be supposed, a number of modi- fications on the procedure of simple lumbar puncture have been proposed. General Treatment. — Aside from the serum treatment of cerebro- spinal meningitis the general conduct of the case is of utmost im- portance. Diet. — The maintenance of the nutrition of the patient is a most important element in these cases of meningitis. In those cases in which the patient is comatose and refuses to take nourishment by the mouth, it is a difficult problem to maintain the nutrition of the patient. In many cases nourishment must be given by the rectum, and in some must be introduced into the stomach by means of gavage. In the first case we frequently iind that after nourishing the patient by the rectum for a few days this viscus becomes intolerant and very little nourishment is retained. Peptonized milk and somatose in the form of enemata are the most available forms of nourishment by the rectum. Gavage does not meet our ideals as to nourishment of the patient, because there is resistance to this procedure on the part of the unfortunate sufferers. Thus, each individual case will be a problem to the physician ; some patients take food with avidity, and in these cases milk and broths are the principal forms of nourish- ment given. Drugs and Hydrotherapy . — The bowels of these patients are gen- erally constipated, and from time to time a cathartic must be given; the most preferable cathartics are the mercurials, calomel in dose of ^ to 2 grains, are given to clear the bowels. This may be repeated at intervals of forty-eight to seventy-two hours. Enemata do not seem to reach the majority of cases. The headache is very severe in a great number of cases, and no remedy that we know of completely relieves the symptom. Morphine given in moderate doses relieves some patients. In others this drug is not well borne, and the patients seem to become more stupid and the circulation weaker under its MENINGITIS. 363 continued use. The author has tried the various drugs of the coal- tar series. Pyramidon in doses of 5 to 7 grains, given at intervals of three to four hours, seems to have relieved a certain percentage of cases. The head is shaved and the ice-cap applied. Even this procedure is not well borne by some patients, and they strongly protest against it. It seems to increase the pain. The delirium is treated with liberal doses of mixed bromides of sodium, potassium, and ammonia. In some cases chloral in moderate dose is added to this mixture, and is well borne by the patient. It does not depress the circulation. The irregularity of the heart which is present in a large number of cases does not call for any active treatment. Alcoholic stimulants should be avoided if possible, as there seems to be no indication for their use. One of the principal modes of meeting restlessness, the occasional high temperature, the rigors and accompanying cardiac weakness, is the systematic use of warm baths. The patients are placed in a warm bath of a temperature of 105° to 107° F. three times in the twenty-four hours. Care should be taken to lift the patient gently from the bed into the bath. Massage should not be performed as in the ordinary bath given in pneumonia, while the patient is in the bath, inasmuch as this friction irritates and excites the patient and seems to cause a great deal of pain. - The duration of the bath should be from five to ten minutes. The time for giving it should be chosen when the temperature is on the rise, the irrita- bility of the patient at this time being greatest. If the heart should become very weak, camphor is indicated ; if possible, by the stomach. If this is not feasible, camphor, in the form of camphorated oil, should be given subcutaneously. Acute Lepto-meningitis (Vertical Meningitis). — In this form of meningitis the vertex or superior surface of the brain is affected ; the region of the cerebrospinal foramen may escape, but not necessarily so, and in some cases the base also may be affected. Occurrence. — It is found in the newborn and children as a com- plication of sepsis, erysipelas, pneumonia, influenza, diseases of the ethmoid and mastoid bones, perforation of the bones of the skull, or suppurations elsewhere, such as retropharyngeal abscess. Etiology. — The essential cause is an invasion of the tissues of the meninges of the brain by streptococci, pneumococci, the influenza and coli bacilli. These cases are sometimes diflicult of diagnosis, because in many of them the classical symptoms of meningitis are absent. In the early stages of the disease anatomically there is dryness and opacity of the pia hyperemia. Later, oedematous conditions of the pia 364 TEE SPECIFIC INFECTIOUS DISEASES. supervene with the formation of lymph and fibrin along the sulci and in the tissue of the pia mater and on its surface. Later, the puru- lent exudate may extend over the surface of the brain, involving not only the base of the brain, but also the spinal cord. In some cases the exudate does not penetrate the ventricles of the brain; in others inflammation extends into the ventricles. In this form of meningitis there are complications either primary or secondary, such as pneu- monia, empyema, pericarditis. Symptoms. — The diagnosis is difficult. The symptoms are often latent. Retraction of the head is very often absent, and ocular symp- toms are rarer ; in fact, the fundus in many cases is found to be normal. Vomiting is less frequent than in the basic forms of menin- gitis to be described, or in the cerebrospinal forms just described. Convulsions of a violent character may be present; they may be repeated throughout the disease, and are associated in some cases with high temperature ; in other cases they are absent. These convulsions may be epileptiform. Clonic spasms may be local at first, but, as a rule, they become bilateral and general. There may be, as in menin- gitis, tonic spasms. The duration of the disease is shorter than in posterior basic meningitis, may last from one to two days to as many weeks, and in exceptional cases may become chronic. In many cases it is impossible, unless a lumbar puncture is made, to differentiate these cases from tubercular meningitis. IsTor is it possible, if the exudate extends to the spinal cord and rigidity sets in, to differentiate a so-called vertical case from an ordinary cerebrospinal meningitis of the epidemic type unless a lumbar puncture is made. The differen- tiation, therefore, of these cases must depend on a continued observa- tion of the case and the performance of lumbar puncture. Posterior Basic Meningitis. — Posterior basic meningitis is so called because the inflammation affects the posterior part of the base of the brain and the structures in this location, and rarely spreads to the vertex of the brain, at most only affecting the tips of the temporo- sphenoidal lobes, and in some cases extending forward to the optic commissure. These cases were flrst described by Gee and Barlow, in the Bartholomeiv Hospital Reports of 1878, and subsequently by Still in 1898. Occurrence. — The affection occurs in infants and children below the age of two years, and is rarely seen in older children. I have seen exceptional cases in children of three and five years of age. Etiology. — These cases, according to Still, and confirmed by my own observations, are caused by a diplococcus which is identical with the diplococcus of Weichselbaum, Jager, and Leichtenstern, an intra- cellular diplococcus not staining with Gram's method. Although Still thought that these were only sporadic cases of the epidemic form PLATE XXI Posterior Basic Meningitis. (Gee, Barlow, and Still.) Author's ease. MENINGITIS. 365 of cerebrospinal meningitis, it can now be said that they are seen very frequently and in large numbers in epidemics of cerebrospinal menin- gitis, and may occur sporadically. Thej^ are only specific, inasmuch as they are a form of cerebrospinal meningitis as it occurs in younger children and infants. These cases divide themselves into those which are fatal after six weeks; those which die after three or four months with hydroceph- alus ; and those which recover. In the first set of cases anatomically we find pus and lymph at the base of the brain and extending down the cord. In the second set of cases there is simply thickening of the pia and arachnoid, with adhesions between the cerebellum and me- dulla. The inflammation may spread down the cord to a varying degree and upward along the lining membrane of the ventricles, and afterward along the base as far as the optic commissure. In the chronic cases there may be adhesions of the meninges either in the anterior part of the base of the brain or even on the vertex, showing that this has been slightly involved. The adhesions at the base may unite the medulla and cerebellum and obliterate the foramen of Magendie or the fourth ventricle. This results in accumulation of fluid in the ventricles with hydrocephalus. In some cases the ven- tricular fluid is clear; in others it contains flakes of fibrin and pus and meningococci. As has been shown, complications in this form are rare. Occa- sional arthritis is found. In some cases Still has found tuberculous foci of the viscera, which he considers accidental. In other cases the middle ear may contain mucopurulent secretion, but no evidence of the extension of the ear disease to the brain or meninges. Symptoms. — The onset, as in cerebrospinal meningitis, is abrupt and has the same symptomatology. The most characteristic symp- tom clinically of these cases is the retraction of the head. This supervenes early and continues until death or recovery of the patient. Convulsions, tonic or clonic, occur early in the disease, but are less frequent than in meningitis, involving the superior surface of the brain and cord. There are rigidity of the limbs and opisthotonos, and an increase and diminution of this rigidity, in the course of the disease, with tetanic contractures of the upper and lower extremities, as shown in the accompanying drawings. Vomiting is one of the first or early symptoms, and may occur throughout the disease. After the disease has lasted some time the eyes have a fixed stare; there may be strabismus or nystagmus ; the pupils are contracted, or later may be dilated. Optic neuritis is not common, though the patients may be blind. If the anterior fontanelle is still open, it bulges with the increasing hydrocephalus, and in some cases the posterior fon- tanelle, which may have been closed, is reopened, the sutures become 366 TSE SPECIFIC INFECTIOUS DISEASES. widely separated, and the children finally lay unconscious and per- form automatic movements with the facial muscles, mouth, and extremities. The rigidity and retraction in some cases are extreme; the opis- thotonos is very marked at times; at others the neck rigidity will relax, hut on the least irritation, either of friction or otherwise, the opisthotonos and tetanic spasms recur (Plate XXII.). Recovery may take place with retrograde of most or all of these symptoms, or imperfectly so with hydrocephalus. In some of these cases the tem- perature curve at first is high, and after the disease has lasted some time it may drop to the normal and remain there, or rise a degree above the normal, at times thus simulating tuberculous meningitis; or the temperature may be normal for periods of weeks and then sudt denly, without any apparent cause, show wide variations, with high temperatures during certain parts of the day and subnormal tempera- ture at others. Death may supervene suddenly without '^ause. Prognosis. — The prognosis is very bad. There are few recoverieiS, and in an ej^idemic most of these children die or develop an incurable hydrocephalus. Treatment. — The treatment at first is the same as that outlined in cerebrospinal meningitis; that is, an early use of the serum. In the chronic state the treatment is directed toward the relief of the hydrocephalus. As soon as this is established or evident, repeated lumbar puncture should be performed, in order to stay the increase of the fluid in the ventricles, and, if possible, effect a cure of the: hydrocephalus ; this is not always possible. In these cases the Flex-: ner serum is introduced into the ventricles of the brain, which are punctured through the anterior fontanelle. The contained exudate is withdrawn and the serum introduced. The operation is repeated on both ventricles in succession. So far the results have not been encouraging or conclusive. The treatment of the symptoms are the same as that laid down for cerebrospinal meningitis. Meningitis Serosa (Quincke) (Acute Internal Hydrocephalus}. — Meningitis serosa, or acute internal hydrocephalus, must not be confounded with tuberculous meningitis, which formerly was called acu.te internal hydrocephalus. Meningitis serosa was described in 1893 by Quincke. Four years later Bonninghaus reported some of these cases, and since then a number have been described in the literature. Occurrence and Definition.' — It is a comparatively rare disease, and occurs only between the ages of one and five years. In consists of a serous inflammation of the extra- and intra-cerebral pia mater, and as a consequence of this inflammation there is an inflammatory oedema in the subarachnoidal space, accompanied by acute internal M ^ c c -l-J "(f) a a o -> !1h Cfl :3 ■:, () 0) C) td n1 0) e, en cc C3 x; Tl ( J ^ f/i u H-J 05 c MENINGITIS. 367 hydrocephalus, or serous exudate in the ventricles of the brain. We have two forms of this condition: in one the brain and membranes are found to be the seat of inflammatory oedema, in which the exu- date in the ventricles is comparatively small in amount ; in the other, the more common form, there is a very large exudate in the ven- tricles, and the membranes of the brain and pia mater are but little affected. Etiology. — The etiology is not quite clear. Quincke insists that the condition may occur idiopathically, in a manner similar to an idiopathic pleurisy. Later authors are inclined to regard serous meningitis, however, as an infectious process, due to the invasions of staphylococci or streptococci, which are found in the ventricular fluid removed through lumbar puncture or postmortem. Some of these cases may follow a chronic hydrocephalus ; others may be traumatic or complicate an acute febrile disease, such as typhoid fever or pneumonia. Symptoms. — The symptoms are not always marked, and it is not always possible to recognize the disease with certainty. The differ- ential diagnosis from other forms of meningitis, such as the tuber- culous form, is made with the greatest difficulty. The disease may begin with varying symptoms. The children are peevish and restless ; they refuse to take nourishment. There may be constipation, dis- turbances of the process of digestion, and flnally vomiting, with con- tinued emaciation. The temperature in all cases thus far observed is raised but little above the normal; or, if raised to 103° F., rapidly falls again to the normal. The pulse may be normal or slightly in- creased in rapidity. A constant symptom in children below fourteen months is that the head increases in circumference, the sutures are forced apart, and the anterior fontanelle becomes tense and bulging. The cerebral syiuptoms consist mostly of sopor, uneasiness, strabis- mus, and nystagmus. Sooner or later convulsions appear, involving most of the musculature or gToups of muscles. In some cases an early optic neuritis has been observed. The course of the disease is a protracted one, inasmuch as the symptoms may extend over weeks or months, ending finally in death, preceded by an increasing cachexia. In those cases which have recovered, the circumference of the head has returned to its normal dimensions. Morbid Anatomy.- — The most striking lesions found post-mortem are a dilatation of the ventricles of the brain with an increased amount of intraventricular fluid, by which the surface of the brain is com- pressed and the convolutions flattened. The ependyma is swollen, thickened, and the surface granular. The choroid plexus is hyper- semic. The membranes of the brain may be dull and more or less 368 THE SPECIFIC INFECTIOUS DISEASES. hypersemic. In some rare cases, at the base of the brain a circum- scribed purulent meningitis has been described, which supports the view that serous meningitis may follow a localized condition of this character. A characteristic of serous meningitis is the cloudy swelling with proliferation and desquamation of the cells of the ependyma, and cellular infiltration of the brain substance beneath the ependyma with round cells, especially along the bloodvessels. In such cases there is really an ependymitis or meningitis ventricularis. Diagnosis. — The diagnosis of serous meningitis must be made from meningitis of other varieties, especially of the tuberculous or cerebrospinal type. The author is inclined to believe that during life a very careful exclusion of every possible infection is the first step toward the diagnosis. It is a well-known fact that forms of otitis media purulenta will cause cerebral symptoms and even an increase in the intraventricular fluid, and such otitis is apt to be overlooked, unless thought of at the time a diagnosis is made. The patient, there- fore, would run greater danger from such an accident, and would lose a chance of recovery if the diagnosis of otitis or mastoid disease were too long delayed. Optic neuritis, which I have seen in two cases, may be present in forms of meningitis of the cerebrospinal type, although Beck puts much stress on this phenomenon. Lumbar puncture will aid more in the diagnosis than any other procedure. The puncture fluid in cases of meningitis serosa thus far published contained no micro- organisms, is of low speciflc gravity, generally 1.007, contains 1 to 1.5 per cent, of albumin, and very few if any cellular elements beyond those of a few blood-corpuscles. On the other hand, a tuberculous meningitis would give a puncture fluid which, though it might in a certain percentage of cases be devoid of micro-organisms, would con- tain a number of mononuclear lymphocytes. In cerebrospinal men- ingitis the puncture fluid would contain micro-organisms unless the meningitis was of a chronic variety, in which form the micro-organisms might be absent. In cerebrospinal meningitis, however, a study of the puncture fluid would again aid us, inasmuch as it would show a preponderance of the polynuclear leucocytes. MUMPS. (Epidemic Parotitis.) Mumps is an infectious and contagious disease of the parotid gland, at times involving the other salivary glands as well as the testis or ovary. Etiology. — Parotitis is endemic in large cities, and frequently MUMPS. 369 becomes epidemic in schools and institutions where large numbers of children are congregated. It is most common among children of school age, because they are more exposed to infection than children at an earlier or later period of life. Girls and boys are attacked with the same frequency. It may occur in the newly born infant. The author has seen a case in an infant three weeks of age. The essential cause of mumps is unknown. Laveran and Catlin describe micrococci which they found in the blood and in the glandu- lar lymph of the parotid and testis. These micrococci were arranged Fig. 55. ^' Bilateral parotitis. in twos and fours, did not stain by the Gram method, and were 1 to 1.5 micromillimetres in diameter. Michaelis and Bein isolated an intracellular chain-forming diplococcus from Steno's duct. The theory thus far advanced is that these micro-organisms gain access to the parotid through the duct. The period of incubation, according to Rilliet and Lombard, may vary from seven to twenty-six days. Morbid Anatomy. — As the disease is rarely if ever fatal, oppor- tunities to determine the morbid conditions have been few. Virchow first described the condition of the gland as one of inflammatory serous and cellular infiltration of the intra-acinous and peri-acinous 24 370 THE SPECIFIC INFECTIOUS DISEASES. connective tissue. The outcome is resolution; induration rarely remains. Symptoms. — There is a prodromal period, during which the pa- tient is attacked with chilly sensations or a chill, and sometimes with vomiting. There is pain in the region of the ear, and also a ringing in the ears and deafness. There is also a'febrile movement, the tem- perature in some cases mounting to 104° F. (40"^ C). The tem- perature may be normal throughout the disease. There may be headache and loss of appetite. After these symptoms have lasted awhile, the face becomes swollen, as a rule on one side only (Fig. 55). Fig. 56. Parotitis involving tlie submaxillary glands, lateral view. Boy, four years of age. This swelling gives the face an uneven contour, and is the charac- teristic symptom. In older children it causes a feeling of tenseness and pain on mastication. Sometimes patients are averse to opening the mouth on account of the pain. In young infants there is drool- ing. In the majority of cases, after the swelling has lasted three or four days and is subsiding, the opposite side becomes affected. In addition to the swelling of the parotid there is also intumescence of the lymph-nodes of the neck at the angle of the jaw and of the node on the parotid gland in front of the ear. Frequent]}^ the sub- maxillary glands are also swollen, giving the whole face a rounded contour. In most cases the general condition of the patients is good MUMPS. 371 and there is very little discomfort. Other cases have considerable pain and constitutional disturbance. In all my cases there was dis- tinct angina and svv^elling of the tonsils. In a newly born baby there was swelling of the tissues underneath the jaw and about the larynx, with croupy breathing indicating cedema of the mucous membrane of the larynx. English writers have described cases in which the submaxillary glands alone were involved, the inflammation being strictly limited to the glands on both sides (Fig. 56). I have seen cases of this kind. Complications. — The testes and epididymis in boys and the ovaries and glands of Bartholini in girls may become affected. There may Fig. 57. Angiuiiia uT the parotid simulatiug mumps. be ardor urinpe and a urethral discharge. These complications are not so common as the text-books declare. Hydrocele may occur with the orchitis. I have seen a case of this kind in a very young infant. The urine may show a trace of albumin, or in very rare cases there may be blood in the urine. Endocarditis, pericarditis, rheumatism, and osteomyelitis have been reported as complications, but the author has never met such cases. Parotitis complicating pneumonia has been observed in a boy of six years, and in another case otitis and parotitis were present at the same time. In rare cases the breasts 372 THE SPECIFIC INFECTIOUS DISEASES. and lachrymal glands are affected. Parotitis may be a complication of typhoid fever, measles, varicella, and influenza. Course. — The disease is at its height in from three to six days, and runs its course in from seven to fourteen days. Mild cases may last only two days. Severe cases are rare. These present cerebral symp- toms and sveelling of the tissues about the neck simulating angina Ludovici, with considerable dyspnoea. Cases of recurrent mumps, continuing for from four to six weeks, are recorded. When suppura- tion occurs, it is probably the result of some mixed infection. Diagnosis. — The diagnosis is not difficult. Uncertainty as to whether the parotid is affected or not will be dispelled by drawing a line parallel with the lower border of the jaw; the parotid swelling will be above the line and the lymph-nodes of the neck below it (Fig. 57). In swelling of the mastoid region the ear is raised from the skull, while in parotid swelling, even if it occur behind the ear, that organ remains in its normal position. The swelling of parotitis never fluctuates, but is elastic in character. Prognosis.— The prognosis of mumps is good; the majority of cases recover without complications. If the kidneys, endocardium and pericardium are affected, the prognosis will be influenced by the course of these affections. I have never known parotitis to result fatally. Treatment. — The patients are isolated and kept in bed as long as symptoms are present. The parotid is anointed twice daily with warm oil of hyoscyamus and covered with cotton. The bowels should be regulated with a saline cathartic. The diet should be assimilable. The affection cannot be controlled by means of drugs. Pain and fever are treated on general principles. PERTUSSIS CONVULSIVA. ( Wlwoping-cougli.) Pertussis is an acute specific infectious disease, caused by a micro- organism, probably of the influenza group. It is characterized in the majority of cases by a spasmodic cough accompanied by a so- called whoop. Pertussis is not only infectious, but it is also contagious. It is propagated through the atmosphere in schools and public places, the air of which is contaminated with the specific agent of the disease. The micro-organism is thought to exist in the sputum and the secre- tions of the nasal and air-passages of the patient. The disease is especially contagious at the height of the attack. There is reason to believe that the cough of the first or catarrhal stage is highly con- PERTUSSIS CONVULSIVA. 373 tagious. The sputum in the stage of decline is also capable of convey- ing the disease to others, since it contains the specific micro-organism. Occurrence. — Pertussis prevails in all countries and climates. It is most frequent during the winter and spring months. It is always endemic in large cities, but, like scarlet fever, becomes at times so prevalent as to be epidemic. Pertussis is essentially a disease of infancy and childhood, but the individual is not exempt at any age. I have met it in the newly born infant. I have found the disease slightly more frequent in females than in males (1009 out of 1820 cases). Twenty-two cases occurred in infants between one and two months of age. The majority of cases (1343) occurred between the sixth month and the fifth year. The disease is most frequent be- tween the first and the second year (404) ; next most frequent between the sixth and twelfth month. After the fifth year the frequency diminishes up to the tenth year, after which the disease is very infre- quent. IsTot every one who is exposed contracts the disease. One attack does not necessarily confer immunity, but cases of second attack are rare. It has been observed that pertussis, measles, and influenza frequently follow one another in epidemic form. Incubation. — The incubation period is variously placed at from two to fourteen days. Etiology and. Bacteriology. — The essential cause of pertussis was believed by Deichler and Kurloff to be a protozoa-like body which they found in the sputum. Afanassjew and Szemetzchenko isolated a bacillus from the sputum. It occurred singly, in pairs or chains, and measured 0.6 to 2.2 micromillimetres in length. The more recent researches on the bacteriology of pertussis are those of Czape- lewski, Hensel, and Koplik. Czapelewski and Hensel described in 1897 a non-motile "pole bacterium" or bacillus resembling the in- fluenza bacillus. I at the same time described in the sputum a finely punctate, thin, minute bacillus, 0.8 to 1.7 micromillimetres in length, resembling the influenza bacillus, and staining like that or like the diphtheria bacillus. This bacillus was found recently by Luzatto in cases occurring in an epidemic of pertussis in the city of Graz. It is classified by him as belonging to the influenza group. Positive proof that this bacillus is the cause of pertussis is lacking, since the disease has not as yet been produced experimentally. Evidence simply points toward a bacillus of the influenza group constantly found in the sputum. Jochmann. and Krause and Bordet and Gengou have recently described a bacillus of the influenza group as etiological in pertussis. It is probable that all these micro-organisms are of the same class as those described above. Morbid Anatomy.- — Post-mortem examination reveals marked in- 374 THE SPECIFIC INFECTIOUS DISEASES. flammation of the nasal passages, bronchopiieumoiiia, and empyema or simple fibrinous or serous pleurisy. Emphysema as a result of rupture of the lung-tissues has been reported by ISTorthrup, who describes the lungs of an infant seven months old as being studded with cavities measuring one-half a centimetre to two centimetres in diameter. The lungs looked like parchment filled with bubbles. Hemorrhages in the eye, ear, and brain are a feature of the morbid anatomy of fatal cases. Symptoms. ^ — There is undoubtedly a period of incubation, but its length is undetermined, and it can only be said that, if the disease is due to the invasion of a micro-organism, some time must elapse between the invasion and appearance of symptoms. After the appear- ance of the symptoms there are three stages — the catarrhal, the spas- modic and the stage of decline. There is no sharp line of demarcation between these stages. Catarrhal Stage. — This stage in some children is characterized by a cough which is especially troublesome at night, and has sometimes a croupy character. The peculiar nature of the cough becomes apparent when after a few days it becomes more troublesome instead of subsiding. After four or five days it may be accompanied by A'omiting once or twice a day, especiall}^ if the paroxysm occurs after meals. Examination of the chest may fail to reveal bronchitis. This negative sign is of great value. As the case passes into the spasmodic stage it is noticed that the paroxysms of coughing last longer, and that the child becomes red ' in the face and expectorates a larger amount of mucus than in ordinary catarrhal conditions. This period of cough without a whoop may last five to twelve days. I have seen many cases in which the whoop was absent in the whole course of the affection. The child had what might be regarded as a severe spas- modic cough followed by vomiting. Fever is present as a rule only during the first few days. It may be remittent and slight. If bron- chitis complicates this stage of the disease, there may be a daily rise of one or more degrees in temperature. Usually toward the close of the catarrhal stage the incessant cough causes slight puffiness of the eyelids and slight oedema of the tissues of the face. Spasmodic Stage. — The spasmodic stage is distinguished by the presence of the characteristic whoop. The cough becomes of a more pronounced spasmodic type. The child has distinct paroxysms, which begin with an insjnration, followed by several expulsive explo- sive coughs, after which there is a deep, long-drawn inspiration, which is characterized by a loud crowing called the whoop. After one paroxysm has ended, it may be followed by a number of similar ones. When a paroxysm is impending the face assumes an anxious expres- sion, and the child runs to the nearest person or to some article of FEBTUSSIS CONVULSIVA. 375 furniture and grasps it with both hands. The paroxysm is some- times so severe that the child will fall prostrate or claw the air con- vulsively. In the severest and most dangerous type a convulsion supervenes. In moderately severe types of the disease the child's face is red or livid, the eyes bulge, and at the end of the paroxysm a quantity of tenacious mucoid or mucopurulent sputum is expecto- rated. In other cases there is vomiting at the end of the paroxysm. In the intervals the face is livid or pale, or the eyelids are puffy and the face oedematous. In some cases there are punctate hemorrhages on the face, especially about the eyes and temples. There may be chemosis of the conjunctivae as a result of the bursting of bloodvessels. At this period there is in the majority of cases an accompanying bronchitis, with slight rise of temperature during the day. At first the paroxysms occurring during the twenty-four hours may be few; in some cases they never become frequent, but as a rule they increase in number, so that the patient may have from twenty to one hundred in the twenty-four hours. This stage gradually declines, the number of paroxysms diminishing daily in number and severity. They may subside suddenly or gradually after from four to twelve weeks. The whoop may at times reappear. After the disappearance of the whoop a cough persists for days or even weeks, or it may entirely disappear and suddenly recur with the whoop. It is characteristic of the spas- modic period of the disease that the paroxysms should be more harass- ing at night than during the day. Other Sy7nptoms. — In all cases of pertussis, even in the absence of complications, there is a slight increase in the number of respira- tions. In cases of even moderate severity the heart impulse is weak, and in exceptional cases the area of superficial cardiac dulness is larger than normal, indicating dilatation of a moderate degree. The pulse is irregular in force and rhythm, and is distinctly more dicrotic than normal. In other words, there is a condition of heart-strain, which is evinced by dyspnoea (even in the absence of exertion), oedema of the face, and cyanosis. Kidneys. — In the majority of cases a trace of albumin is present in the urine; in others, a few hyaline casts. Blood in the urine is seen in rare cases. Blood. — Leucocytosis of the polynuclear type is usually jDresent in the second week of the disease. Complications. — One of the most common complications of per- tussis is bronchitis. It may be mild or severe. In the severer form the smaller bronchi are affected, with accompanying bronchopneu- monia (Fig. 58). The physical signs are the same as in simple bronchitis and pneumonia without pertussis. In some cases the bronchopneumonia pursues a subacute or persistent course. If reso- 376 TEE SPECIFIC INFECTIOUS DISEASES. liition takes place, other areas become consolidated. Emaciatioii is sometimes extreme. Emphysema is frequently present. Bursting of the air-vesicles may cause pneumothorax, or air may escape into the mediastinum and thence into the neck and into the subcutaneous tissue of the whole trunk. Hemorrhages. — During a paroxysm there may be epistaxis, con- junctival hemorrhage, bleeding from the ears, and petechige on the face and body. Nervous System. — Convulsions, either general or localized, may complicate pertussis. In the former case the outlook is grave, death taking place within twenty-four to forty-eight hours. Fig 58 ,UN£°SS 15 IC 17 18 lU 20 21 1 HOUR 3 6 .. 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 G 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6,9 12 3lC 9,12 3|6 9|l2 3 , 6 9 12 105° 101° ->103° I < -^102° '^lOl 100° 99° / f ' ^ f / ' 1 \ ^ \ / L- _ _ ._ _ _ -A-L -'[-- — -^ -f ^ ^ — — - - -^ -^ - — rr- -%- — r- ' i 1 1 ! 1 \ 1 A ' / Y \ ._ -^— r J ^, j — — — p- L - — ^— — ^ —t- ' — ; ~ p -^ -T- ^n^ f j 1 I 1 1 ] 1 ! ;_ ' _ _ ' • PULSE i = i" iTi" i ¥ f S. i 1 sY Eili 1112 5. = Sill il'SS S55S 1 i s s ,? s fS 2 -? 1 RESP. !S g sjeis 3 s 3 S s s SjS Si^S^S ?|Sj3;S "^i r\ S|S|S s S|S|R,5 S,3,3,S 1 )5,S s.,s.|..: . '5 = Pertussis ; disseminated bronchopneumonia in both lungs. Infant eight months of age. Fatal termination. Psychoses, such as melancholia and hallucinations, may compli- cate pertussis. Monoplegia, hemiplegia, or paraplegia, localized facial and oculomotor paralyses, sudden total blindness, deafness, cerebral hemorrhages, hemiansesthesia, and aphasia have been observed. Gastro-enteritis. — Gastro-enteritis of a fatal type may ensue. An attack of pertussis may favor the invasion of the tubercle bacillus. This may have been previously present in the bronchial lymph-nodes or elsewhere in the body, or it may be received into the body during the attack or afterward. In such cases tuberculosis of the lungs or other organs, such as the peritoneum, develops. Diagnosis. — If a cough fails to improve and is especially harassing at night, later in the disease becoming paroxysmal, if the face becomes livid during the paroxysm, if the patient vomits after coughing, per- tussis should be suspected and precautions taken to prevent its spread. As a rule, examination of the chest is negative in the first PERTUSSIS CONVULSIVA. 377 stage. Tlie absence of bronchitis and the presence of a cough of the character described are characteristic of pertussis. The presence of the whoop dispels all doubt. Infants who have the incisor teeth and older children may, after the pertussis has lasted for a week, develop an ulceration of the frenum of the tongue, which is called a dentition ulcer. It is caused by friction of the frsenum ling-use with the edges of the teeth during the act of coughing. These ulcerations are not diagnostic of the disease ; many cases do not show them, and on the other hand they frequently occur in coughs of other forms. Mortality and Prognosis.- — The mortality of pertussis is greatest during the first year of life (25 per cent., Voit). Between the first and the fifth year it is about 5 per cent., and from this time to the tenth year, 1 per cent. (Monti). The occurrence of pneumonia in children under two years of age adds largely to the mortality. Rachitis or marasmus will militate against recovery. Hygienic sur- roundings render the prognosis more favorable. Treatment. — Prophylaxis. — The patient should be isolated, and should sleep in a large, well-ventilated room. During the day the unoccupied sleeping-room may be filled for an hour with the vapor of formalin (set free by means of a small formalin lamp). The object is to destroy suspended germs. If two communicating rooms are available, they may be occupied alternately every twenty-four hours, the unoccupied room being fully ventilated in the interval. In this way reinfection may be avoided. In spring and summer, if the weather is favorable, the children should be constantly in the open air during the day. In large cities the mother is directed to take the child into the park. When in the open air the paroxysms are usually notably lessened. The child should be warmly clad in winter. Sea air seems to aggravate some cases and benefit others. Pine woods and moderately high altitudes are probably the most beneficial, for the patients are not exposed to the unfavorable climatic conditions peculiar to the seacoast. Kilmer, to allay vomiting and the severity of the paroxysms, has recently applied a knitted band stretching from the axillae to the pubes ; on this is sewn a width of silk elastic so as to tightly envelop the abdomen. I have seen patients quite comfortable with the appliance. Medicinal Treatment. — Medicinal treatment consists of inhala- tions, topical applications, and internal remedies. Simply to enum- erate all the remedies which have been proposed and used in pertussis, would take up the space of a monograph. Inhalation of ozone has been advocated by Caille. The remedy is expensive and the appa- ratus not readily procurable. Inhalation of a mixture of 20 per 378 TRE SPECIFIC INFECTIOUS DISEASES. cent, nitrous oxide and 80 per cent, oxygen is beneficial in cases in which the heart is weak. The inhalations are given with a cone for ten minutes twice daily. Insufflation of quinine or other drugs has not proved beneficial. The practice seemed to intensify the par- oxysms. Prior, Coggeshall, and others have proposed the application of solutions of cocaine, 4 per cent, to 10 per cent., to the nares and throat. I have had no experience with this method, nor with the local application of antitussin. If the cough is very troublesome, I first endeavor to control it with full doses of antipyrin combined with tincture of digitalis. The digitalis, in doses of a drop or two several times daily, supports the heart, as is shown by the rapid disappearance of the oedema and cyanosis after its administration. Antipyrin is given in doses of gTain j (0.06) for every year of age up to grains v (0.3) every three hours. If the cough is not perceptibly relieved by this remedy after forty-eight hours, I suspend its use, and give codeine in full doses every three hours. Codeine is to be preferred to morphine, which is advocated by Henoch. If vomiting is severe, the food is given in very small quantities in fluid form every few hours. By this method food is retained and absorbed, whereas a full meal is invariably rejected. The use of belladonna has not . impressed me favorably. In several cases it seemed to aggravate the cough by causing a dryness of the laryngeal mucous membrane. Bromoform I consider danger- ous and of questionable utility. Quinine in full doses three or four times daily is a favorite remedy with many. Vaccination and the injection of diphtheria serum have been proposed to abort the dis- ease. I have had no experience with the serum treatment. In a word, the treatment of pertussis consists in applying the rules of hygiene, in mitigating the cough with antipyrin or preferably codeine, and in supporting the heart with digitalis. The complications should be treated on the principles laid down in the sections on Bronchitis, Pneumonia, and Pleurisy. DIPHTHERIA. Diphtheria is a contagious febrile disease which affects the throat and air-passages. It is characterized by the formation of a pseudo- membrane on the parts affected. The disease manifests itself by a local lesion and general symptoms caused by the entrance of toxins and, at times, of bacteria into the blood and lymph. Age and Occurrence. — Although diphtheria is uncommon in the newly born infant, statistics of large numbers of cases show a certain percentage in these subjects; thus, of 547 cases reported by Monti, the newly born number 24, and in Baginsky's statistics several cases DIPHTHERIA. 379 are noted. The disease is more frequent from the first to the third month than from the third to the tenth month (Monti). The largest number of cases occur from the second to the sixth year (40 to 63 percent.) (Monti, Baginsky). According to Seitz, it is slightly more frequent among boys than girls. Strong as well as weakly children are attacked. Children who suffer from nervous affections, such as poliomyelitis, are more likely to contract the disease than others (Baginsky). All exposed to infection do not contract the disease, because some individuals are immune. Escherich and Fischl have proved that the blood of con- valescents contains antitoxic elements. Cases of several attacks in the same individual are not uncommon. Racial peculiarities have no influence. Diphtheria is prevalent in all parts of the world and epidemics occur at all seasons of the year. It is more common among the poorer classes, not on account of uncleanliness, but as a result of overcrowding. Contagion. — Diphtheria is contagious from person to person, and may be conveyed by any one who has been in the room occupied by a patient with the disease. Mild cases may give rise to fatal cases. The disease is infectious, spreading through families and schools, and may be conveyed through the medium of sputum, hands, toys, clothes, and in milk. Period of Incubation. — This has not been determined with any accuracy in diphtheria. Two to eight days, or an average incubation of three days, is laid down by most observers, but no accurate data are available on this important point. Some authors place twenty days as an extreme limit of incubation. This latter period is evi- dently only founded on surmise. Etiology. ^ — The essential cause of diphtheria is a bacillus, the Bacillus diphtherise, which was first noted in stained specimens by Klebs in 1882; Loffler first isolated and accurately described it in 1884. It is present in all cases of true diphtheria of Bretonneau. In the 3 per cent, of cases in which it is reported absent there is good reason to believe that failure to establish its presence was due to imperfect technique. The bacillus is non-motile, twice as thick and about as long as the tubercle bacillus, thickened at the extremities, has no spores, and in some forms has been described as branching. It is very resistant, adheres to clothes -and candy, and has been found in milk. It will retain vitality a long time in dried membrane (seventeen weeks), as has been shown by Eoux and Yersin. It has been detected nine weeks after the disappearance of the membrane from the throat. It is found present with other bacteria, principally staphylococci and streptococci, pneumococci. Bacillus coli commune, 380 TEE SPECIFIC INFECTIOUS DISEASES. pyocaneus, proteus, and sprue. It has been found by Roux and Yersin in the throats of perfectly healthy individuals, and may be present without the formation of a membrane. It has been shown that this bacillus forms toxins of very positive action. According to Sidney, the toxins of diphtheria may be divided into albuminoses and organic acids. The pseudobacillus of diphtheria was first isolated by Hoffman. In its growth and staining properties it is identical with the true diphtheria bacillus, but is not virulent to animals. Roux and Yersin regard it as a weakened diphtheria bacillus. Others believe that it Fig. 59. Fig. 60. l-«»*^ AS Vrf 'a* The Bacillus diphtheriiB (Klebs-Lcjffler). Fig. 59. — ^Pure culture, photomicrograph. Pig. 60\ — ^Pure c^ilture, photomicrograph. X 1000. X 1000. Shows the irregular beaded stain. bears no relation to the true bacillus. It is found associated with the true bacillus, and also in cases of diphtheria after this bacillus has disappeared from the throat (Koplik). Some authors have given the name pseudodiphtheria bacillus to another variety of bacilli, but this term should be strictly limited to the form described above. General Infection with the Bacillus Diplitherice alone and with Other Bacteria. — The bacillus of diphtheria was first demonstrated by Frosch (1895) in the heart's blood, liver, spleen, kidneys, and lymph-nodes. Since then, Kolisko, Paltauf, Schmorl, Booker, Coun- cilman, Mallory, and Wright have demonstratod its presence in the DIPHTHEBIA. 381 blood and internal organs in fatal cases of diphtheria. The work of Councilman and his pupils is the most recent and complete on this subject. They show that the bacillus may occur alone or in associa- tion with streptococci or staphylococci in the blood, lungs, liver, spleen, and kidney. It is more likely to be found alone in fatal cases of uncomplicated diphtheria. The mixed infections with streptococci and other bacteria occur in diseases, such as scarlet fever and measles, which may be complicated with diphtheria. The investigators just 1 and 3. Cultures of the pseudobacillus of diphtheria on agar, showing the diffuse character of the growth. 2. Growth of Bacillus diphtheriae (Klebs-Loffler) on the same medium. It is a delicate growth in colonies. mentioned found endocarditis, bronchopneumonia, empyema, mastoid disease, and thrombosis of the sinuses due to the diphtheria bacillus. The bacillus was found also in the pus of acute abscesses in various localities. Morbid Anatomy. — In fatal cases the membrane appears as a thick brownish or grayish-brown mass. It is sometimes present as a thin whitish pellicle, and occasionally is almost black. It may be friable or as resistant as cartilage, and may extend over the tonsils, palate, pharynx, base of tongue, epiglottis, and trachea. The areas 382 TBE SPECIFIC INFECTIOUS DISEASES. not covered by membrane are injected, and may be the seat of hem- orrhages. The tonsils are enlarged and blnish red. In the gan- grenous forms the tonsils, soft palate, and uvula may be converted into necrotic masses. The nasal j)assages may show membranous deposit. The epiglottis and vocal cords are thickened. The tracheal mucous membrane is hypersemic and swollen, there may be adherent membrane, or the pseudomembrane may be loose and curled up in the lumen of the trachea. The membrane itself has been described by Virchow as croupous and diphtheritic. Councilman is of the opinion that little is to be gained by adhering to the old classification of croupous and diph- theritic membranes. Baginsky also describes forms of diphtheria in which the membrane possessed both croupous and diphtheritic struc- tural characteristics. According to Councilman, the first step in the formation of the membrane is a degeneration and necrosis of epithe- lium, preceded by a proliferation of the nuclei of the cells. Detritus and hyaline masses result. An inflammatory exudate rich in fibrin is thrown out from the underlying tissue. ' The fibrin forms in part a reticulum enclosing cells and degenerated epithelium, and in part a hyaline reticulated membrane. The hyaline membrane is formed on surfaces which are covered with several layers of epithelial cells. Fibrinous membrane is formed on the surface and in the tissue. By constant accretions thick masses are formed. The membrane is never formed on an intact epithelium, but may extend over it. There is nothing specific in the diphtheritic membrane. The connective tissue and the bloodvessels beneath the membrane may be the seat of hyaline degeneration. The mucous glands are degenerated. The diphtheria bacilli are found growing in the necrotic tissue and in the exudation, never in the living tissue or in epithelium undergoing primary degenerative changes. In exceptional cases they may be found enclosed in pus-cells and necrotic epithelium. They are found in masses, and when deeply situated have been covered up b}^ later formation of membrane. Heart. — Councilman, Mallory, and Pearce have recently described the myocarditis sometimes complicating diphtheria. There is a fatty change in foci or in more diffuse areas in the muscle-fibre. In another form of myocarditis there are interstitial changes, consisting of focal collections of plasma and lymphoid cells, and the formation of new connective tissue, resulting in some cases in a fibrous myocarditis. These pathologic changes are due to the action of the diphtheria toxins on the heart-muscle. The Lungs. — Councilman states that the most common lesion in fatal cases is a bronchopneumonia, lobar pneumonia never being present. The process begins in an infeclion of the atria. The bac- DIPHTHERIA. 383 teria found in the lung, and which are present independently of the character of the lesion, are the pneumococcus (rarely), Streptococcus pyogenes, and the diphtheria bacillus. Marrow-cells are found in the capillaries, and' thrombi in the larger vessels. The lymphatics are dilated and contain fibrin and cells. Spleen. — The spleen macroscopically is normal; microscopically, the lymph-nodules are more prominent than is normal, and contain foci of epithelioid cells. The vessels are the seat of hyaline degen- eration, and in the later stages contain large numbers of plasma-cells. Some of the nodes may be the seat of necrosis and abscess. Liver. — The changes in this viscus are due to the action of toxins, and consist of parenchymatous degeneration and necroses, seen espe- cially in the centre of the lobules. There is slight hyaline degenera- tion of the capillaries. Kidneys. — There may be simple degeneration or acute nephritis. The severe forms of nephritis are found in the cases which are quickly fatal (Councilman). The interstitial and glomerular changes are more common in older children and in protracted cases. There is no specific form of nephritis in diphtheria, and all the changes are due to the action of toxins. Lymph-nodes. — The mesenteric lymph-nodes, the nodes at the angle of the jaw and in the retropharynx and oesophagus are enlarged, and may undergo necrotic changes (Flexner). Councilman, Mallory, and Pearce describe the changes in the lymph-nodes as being more marked in those nearest the lesion. There are congestion, hemor- rhages, and diffuse and circumscribed necrosis. In addition there is a formation of foci resembling miliary tubercles, and composed of epithelioid cells which undergo degeneration, forming granular detritus. Bacteria are not found in the nodes. The changes are due to the toxins. Nerves. — There are fibrillation, increase of the cells of the sheath of Schwann, fatty degeneration of the axis-cylinder, hemorrhages, and nodular degeneration of the nerve-sheaths. In the spine there are infiltration of the meninges, hemorrhages, and degeneration of the anterior horns. Degenerative oculomotor changes are present. There are dilatation and round-cell infiltration around the central canal of the cord. Stomach. — Diphtheritic membrane in the stomach occurring in cases of diphtheria has been described by Smirnow and Councilman. Of 220 cases reported by the latter, 5 showed the presence of mem- brane to a greater or less extent. The membrane either covered the whole surface or formed patches or streaks over the rugse. The mucous membrane was swollen, hypersemic, or hemorrhagic. The Middle Ear. — Of 144 cases reported by Councilman, Mai- 384 IRE SPECIFIC INFECTIOUS DISEASES. lory, and Pearce, 86 showed involvement of the middle ear on one or both sides ; in 7 the mastoid was affected. The inflammatory products were serum or pus. The organism most constantly present was the streptococcus, but the diphtheria bacillus has been found, as have also the staphylococcus and pneumococcus. The Blood. — The specific gravity is increased at the height of the disease. In mild cases it is not perceptibly changed ; in severe septic cases it may range from 1054 to 1060 (Baginsky). Haemoglobin is reduced only in severe cases of protracted course. Leucocytosis is not marked in mild cases, but in severe septic forms an increase of the white blood-cells has been observed by Felsenthal and Monti, In malignant cases there is a reduction in the number of red blood-cells (Ewing, Billings, Morse). Sjrmptoms. — Clinically, it is convenient to divide diphtheria into the purely local forms with few constitutional symptoms, the local forms with symptoms of marked toxaemia or septic forms, and the laryngeal forms. Purely Local Forms ivith Slight C otistitutioiial Disturbances. — In diphtheria sine membrana, cynanche contagiosa (Senator), or catarrhal diphtheria, there may be no formation of membrane, the fauces showing only an angina of varying severity. In some cases there is the picture of a follicular or lacunar amygdalitis. Macro- scopically there is nothing to show that the process is diphtheritic (Plate XXIII. ) . In other forms the membrane is present on the tonsils as specks or strips of exudate, or white or greenish pultaceous masses which may extend to the uvula, or there may be spots or extensive plaques on the posterior pharyngeal wall. In other mild cases the process is confined to a small necrotic excavated area in one or the other tonsil, as described by Henoch. In still other forms the mem- brane may cover both tonsils, and extend over the soft palate and pillars of the fauces. In these forms of localized diphtheria the nares are seldom involved. In these localized forms of diphtheria the infant or child may present few symptoms pointing to the throat affection. Unless the physician be systematic in his methods of examination, he may fail to inspect the throat at his first visit, and the diphtheria may thus escape detection. The nursling in this as in the non-diphtheritic affection, may refuse to take the breast. The movements are green- ish, and have an offensive odor, or may be diarrhceal. There are fever and restlessness. Inspection will reveal slight or marked swell- ing of the lymph-nodes at the angle of the jaw. The temperature may not be above 101° F. (38.3° C.) or may be as high as 105° F. (40.5° C). As a rule, it is not persistently high. The pulse is accelerated and the respirations slightly increased. PLATE XXIII 1. Tonsillar Diphtheria, ^A/^ith a small patch of membrane on the uvula. 2. Tonsillar Diphtheria, with a patch of membrane on the pillars of the fauces. 8. Acute Follicular Amygdalitis, which may be diphtheritic. DIPHTHEBIA. 385 The invasion of the disease is for the most part insidious in nurslings; rarely is there a chill or convulsion. The tonsils are en- larged, and show small specks or plaques of membrane on their sur- face. The uvula may be red and swollen, and there may be patches of membrane on the sides adjacent to the tonsils. There is sometimes a croupy cough. In purely local diphtheria, however, the larynx is not involved in the majority of cases. The urine may show a trace of albumin, and in some cases a few leucocytes, blood-cells, and a very few hyaline casts. In older children the signs of illness are more marked. They complain of pain on swallowing, and the tem- perature may at first be high. Toxsemic symptoms, such as pain in the joints, headache, pain in the back, and slight prostration, are present. Inspection of the throat may show the tonsils to be enlarged, and to present the appearances mentioned above. Other members of the family may complain of sore throat. I have reported cases in which children complained of but few symptoms and engaged in their customary play. Examination of their throats disclosed the presence of simple inflammatory redness and swelling of the tonsil, pharynx, and uvula. In these cases the diphtheria bacillus was detected in scrapings from the fauces. Membrane never developed, and yet they were cases of true diphtheria. The fever is not characteristic. The temperature may at first reach 104° F. (40° C.) or above, and gradually drops to the normal with subsidence of the symptoms. Otitis and suppuration of the sub- maxillary and retropharyngeal lymph-nodes may cause the tempera- ture to become remittent or intermittent. Septic Form of Diphtheria. — In the second clinical form of diphtheria there are in addition to the local symptoms present in the first form, constitutional symptoms of a severe or even septic type. The children at the outset appear very ill; the temperature is high, there is marked restlessness with a tendency to drowsiness, the face is flushed, and the breathing noisy or nasal. The infants refuse the breast or bottle, and older children complain of great pain in swal- lowing. In some cases the glands at the angle of the jaw are swollen, and the neck is more rotund than normal. Inspection of the throat shows the membrane on the tonsils, or on both uvula and tonsils. It spreads rapidly, the tonsils, soft palate, and pharynx being covered in one or two days. The membrane may break down, and masses of necrotic tissue be expectorated. In severer forms the membrane extends over the posterior nares, and gradually invades the nasal pas- sages. At first a slight nasal serous discharge is noticed, which in- creases in amount and becomes ichorous and tinged with blood; the anterior nares become eroded and are coated with a whitish or greenish membrane. In some cases the membrane involves the buccal mucous 25 386 TEE SPECIFIC IXFECTIOrS DISEASES. membrane. There is severe stomatitis, the lips are eroded, and the angles of the mouth may show rhagades covered with membrane. With the development of these symptoms the toxaemia increases ; the fever may be moderate, not exceeding 102° or 103" F. (38.8° or 39.4° C.) ; the pulse is rapid and feeble; the sensorium somewhat benumbed. The lymph-nodes at the angle of the jaw may be much enlarged, and the tissue underneath the jaw may be the seat of phleg- monous inflammation. The breath has a very fetid odor. The urine may reveal the presence of albumin, a slight amount of blood, and a few casts of the hyaline or epithelial type. The constitutional symptoms may diminish in severity, and with the subsidence of the local symptoms the appetite returns, the sen- sorium brightens, and recovery gradually takes place. On the other hand, if a fatal issue occurs, it results from heart paralysis, paralysis of the general nervous system and respiratory function, or extension of the diphtheritic process to the larynx, trachea, and lungs. If the diphtheria extends to the larynx, the voice becomes first husky, then croupy. The breathing is labored and of the laryngeal or croupy types, there is retraction of the suprasternal notch and epi- gastrium, the accessory muscles of respiration are drawn into play, and unless relieved the patient dies of suffocation.' Even if relieved, when the septic symptoms and toxaemia are severe the patient may succumb or the process may spread downward, and involve the trachea and lungs. In those cases in which there is cardiac paralysis, vom- iting and abdominal pain supervene. The patient is pale and the surface cool. Gallop rhythm sets in and the heart-sounds become indistinct. The expression is at first anxious, then apathetic ; the voice is scarcely audible; the patients no longer notice their sur- roundings. Death ensues from pulmonary cedema with symptoms of heart-failure. If the general nervous system is involved, paralysis of the soft palate sets in even after the membrane has disappeared from the tonsils and pharynx. The reflexes are absent, and the child is unable to sit upright. The act of swallowing not only becomes difficult, but fluids may find their way into the larynx and thence into the trachea, causing pneumonia ; or the paralysis may extend to the diaphragm, when the lethal issue is hastened by paralysis of the respiratory apparatus. The Malignant Septic Form. — This form has been partly de- scribed above. It is characterized not only by the malignancy of the local process, but by the severity of the toxsemic symptoms as well. It was formerly believed that these cases were due to mixed infections with streptococci and staphylococci, but it is now known that the Bacillus diphtheriae alone may cause all the symptoms. In these DIPETHEEIA. 387 cases not only the toxins, but the bacillus itself enters the circu- lation. The pharynx, tonsils, and nares are covered with a dirty brown or greenish membranous exudate. There is an ichorous dis- charge from the nares. The tonsils, pharynx, and lymph-nodes of the neck become necrotic. The membrane is discharged from the nose and mouth. The fetor of the breath is extreme, and the pros- tration correspondingly great. The larynx, trachea, and lungs may be involved in the diphtheritic process. The pulse is weak and rapid. The temperature may not be above the normal, and in some cases may be subnormal. Acute nephritis may be present. In some cases hemorrhage under the skin and from the nose, mouth, bowel, and even kidney, may precede death. A few cases recover, but in them the necrosis of tissue in the pharynx and larynx causes permanent defects and cicatricial con- tractures. Loss of the uvula and perforations of the soft palate may result from diphtheria in early life. Laryngeal Diphtheria. — Laryngeal diphtheria (croup) is the re- sult of the extension of a mild or severe tonsillar or pharyngeal diph- theria. There may be no preceding clinical manifestations. There are the rare cases of so-called ascending croup, whose existence has not been wholly disproved. Cases are seen in which the most careful inspection has failed to detect preceding disease of the pharynx, epi- glottis, or tonsils. Lastly, there is a class of cases which occurs during convalescence from pharyngeal or tonsillar diphtheria. The symptoms vary accordingly as the disease manifests itself first in the larynx or follows a localized tonsillar or pharyngeal diph- theria. In the latter case there may be slight redness of the tonsils or pharyngeal mucous membrane, or the parts above the larynx may show membranous deposits. In either case the laryngeal invasion is ushered in by croupy cough and stridulous or metallic breathing. The cough is harassing and persistent, and the stridor increases within twenty-four or forty-eight hours to such an extent as to be distinctly audible, and to give the impression that there is a mechanical obstruc- tion in the larynx. The breathing becomes labored, and there is retraction of the parts above the sternum and of the peripneumonic groove, especially at the epigastrium. In rachitic infants the sides of the chest and the epigastrium are markedly retracted at each descent of the diaphragm. With increasing obstruction the face assumes an anxious expression, the lips become cyanosed, and the surface cool. The pulse is rapid — 120 to 180. The fever may be high or low. The lividity of the face in the severer forms of dyspnoea gives place to pallor. The picture of laryngeal obstruction, with the stridulous breathing, increased respirations, and overaction of the accessory muscles of respiration, is so characteristic as to be significant to even 388 THE SPECIFIC IXFECTIOrS DISEASES. the inexperienced observer. During the paroxysms of coughing membranous casts are expelled from the larynx. The membrane may extend downward, involving the trachea and bronchi, casts of which may be expelled. The lungs may become involved, and in severe cases are the seat of a bronchopneumonia of streptococcic nature. With this there may be compensatory emphysema. The urine may show the existence of slight or extensive nephritis, or may be normal in every respect. Especially deceptive are those cases of membranous laryngeal diphtheria or croup whose onset closely resembles that of so-called catarrhal laryngitis. In these the symptoms may develop suddenly, and within twenty-four hours the patient presents all the symptoms of laryngeal obstruction (croup d'emblee of the French). Inspec- tion may show little variation from the normal appearances in the pharynx. We should be cautious not to assume that no membrane is present in the larynx. Cases have been recorded in which laryn- goscopic examination failed to show membrane in the larynx, but in which postmortem it was found beneath the cords and in the trachea. Course and Duration. — In the mildest and purely local forms the disease reaches its height in from two to four days; the temperature then drops to the normal and convalescence is established In the severe septic forms the membrane spreads from the tonsils to the pharynx, and the disease attains its full development in from five to eight days. The temperature falls by lysis or crisis, and convales- cence is established. If the case is very severe, the disease shows no tendency to limit itself, the toxsemia is extreme and the involvement of the lymph-nodes is very great. Death may enstte in from a week to fourteen days. In some very malignant cases death may ensue in from three to four days after the onset of the disease. The laryngeal diphtheritic croup reaches its full development as a rule early — within three days. The disease may then retrograde under treat- ment or may advance into the trachea and bronchi, and cause death in a variable length of time. Complications. — The complications include bronchopneumonia, pleuritis, gastro-enteritis. retropharyngeal abscess, suppuration or necrotic destruction of the lymph-nodes of the neck, nephritis, cardiac paralysis, early and late for post-diphtheritic) general paralysis, and diphtheria of the eyes, skin, and vulva. Bronchopneumonia and Pleuritis. — Bronchopneumonia is found in from 50 per cent. (Baginsky) to 80 per cent. (Talamon) of the autopsies on children who have died of diphtheria. It results from extension of the disease from the trachea into the smaller bronchi and alveoli of the lung, and is therefore always a true bronchopneumonia. DIPETHEBIA. 389 Through the investigations of Loffler, Flexner, ISTorthrup, and Prud- den, it has been proved that the diphtheria bacillus, the Streptococcus pyogenes, the Staphylococcus pyogenes, and the pneumococcus are the exciting causes of the pneumonia. In the pneumonia resulting from the diphtheritic or pseudodiphtheritic processes complicating scarlet fever and measles, Prudden and ISTorthrup have shov^n that the Strep- tococcus pyogenes is an active causal agent. The onset of a compli- cating pneumonia is generally indicated by an exacerbation of the dyspnoea, fever, and cough. The prostration is also more marked. Auscultation of the inferior lateral or posterior parts of the chest on one or both sides reveals the presence of bronchopneumonia; while resolution is taking place in one part of the lung, other areas are being involved. Thus an apparent improvement may be follow^ed by a rapid rise of temperature, increased dyspnoea, and rapid pulse. This form of bronchopneumonia may be complicated by pleuritis of a serous, serofibrinous, purulent, or hemorrhagic type. Gastro-enteritis. — In nurslings there is frequently a diarrhoea v^ith green stools and vomiting. In some cases these symptoms may become severe. Extension of the membrane into the oesophagus, stomach, and gut may take place, v^ith a fatal result. The cases of simple diarrhoea are directly due to the swallov^^ing of bacteria from the mouth and fauces. The diarrhoea may be so severe as to become one of the leading features of the disease. Retropharyngeal Abscess. — Retropharyngeal abscess occurs in the tonsillar and pharyngeal forms of diphtheria as a result of infection of the retropharyngeal lymph-nodes by streptococci. Nephritis. — ISTephritis may be absent, slight, or severe. Baginsky found it present in 42 per cent, of his cases. In the majority of cases of even mild diphtheria there is albuminuria ; in some the urine may, in addition, contain casts, blood-cells, renal epithelium, and leucocytes, shoM^ing grave lesions of the kidneys. The affection of the kidneys is brought about by the action of the toxins on the parenchyma of the kidney. ISTot only are toxins produced in the kidney substance, but bacilli have been found in the kidney and in the urine. A large percentage of the cases of nephritis are of the mild type. Here, as in scarlet fever, v^^e have cases in vs^hich there is nephritis with blood-casts and ursemic symptoms in the course of the disease, and cases in which there is total suppression. All are agreed that oedema and anasarca of the body are uncommon, even in the presence of severe nephritis. I have seen severe septic forms of pharyngeal diphtheria ushered in with vomiting and ursemic symptoms, such as headache and exhaustion, before the appearance of the membrane. These symptoms subsided when the membrane was fully formed, to be followed in a few days by complete suppres- o90 TRE SFECIFIC INFECTIOUS DISEASES. sion of urine after the disappearance of the membrane. In one of my cases the membrane had entirely disappeared from the throat and the patient was apparently convalescing when total suppression set in, continued for several days, followed by uremic convulsions and death. Heart Paralysis. — Of greatest clinical significance is the cardiac diphtheritic paralysis, which may become apparent either early in the disease or later on in convalescence. The early form may set in while the membrane is still visible in the throat. It occurs in the septic forms of the disease. These are the severe cases. The chil- dren show great prostration and apathy; the pulse is rapid and irregular ; the heart-sounds, especially the muscular sounds, are indis- tinct; the pulse is feeble and flickering; there are vomiting and abdominal pain. These symptoms may repeat themselves in attacks, until finally the patient dies with all the symptoms of collapse, such as cool ex- tremities and shallow respirations. In such cases there is, as a rule, a marked nephritis. In the late cases the symptoms of cardiac failure appear from the second week of the disease to the seventh week of the convalescence. The membrane has disapjieared from the throat. There may be no premonitory symptoms, or there may have been a slight blowing murmur at the apex. In their mildest form the heart symptoms appear in the second or third week. The heart becomes irregular, and the muscular sound is weak ; the pulse becomes small and either slow or rapid (tachycardia). There may be attacks of syncope, during which the patients vomit, complain of abdominal pain, and refuse medicine and nourishment. Sudden cardiac failure and death without symptoms, premonitory or otherwise, may occur in the period of convalescence. Mild forms of cardiac irregularity which do not eventually prove fatal are seen in the beginning of convalescence. There are forms of cardiac irregularity which may appear alarming at first and in which complete recovery results. Thus, as will be seen under the heading of Myocarditis, it is not uncommon in the convalescence, early or late, to observe the heart become irregular. This irregu- larity increases from day to day. In its most pronounced form I have observed it in a child three years of age, in whom the heart would contract two or three times, there would then be a pause, fol- lowed by a two or three or four contractions. The pulse vfiried from 80 to 96 during sleep, and 110 to 130 in the waking state. The compressibility of the pulse varies in these cases; the heart-beat is weak, or at times may be strong. The second sound will be accen- tuated at the pulmonary orifice. In these cases the child is apparently comfortable. There is no pericardial distress, pain. DIPHTHEEIA. 391 there maj be occasional sighing. The cardiac irregularity may per- sist for days, even weeks, and ultimate recovery result. It is not always in the severe cases of diphtheria that these symptoms of car- diac disturbance appear, but often in the apparently mild cases of short duration. The severe forms of cardiac paralysis set in with symptoms of the early cases. These symptoms may have been preceded by the milder symptoms of cardiac irregularity. There is slight albumi- nuria. Suddenly, while in apparent good health, the patients com- plain of dyspnoea and pain in the stomach. The lips become cyanosed and the extremities cool, the pulse thready, the heart impulse weak, the heart-sounds scarcely audible; the heart may be rapid or as slow as 40 to 50 beats per minute. Vomiting is repeated, and in some cases the liver is enlarged, as also the spleen. In all cases of diph- theritic myocarditis the enlargement of the liver and spleen with the increase of the pulse rate is a symptom of very serious moment, and, as a rule, a precursor of a fatal issue. The patients may survive one or two such attacks, only to succumb finally. In the early forms of cardiac paralysis there may be no gross lesions in the heart-muscle. In the later forms the lesions are more apparent. There are fatty parenchymatous changes. In other cases there may in addition be changes in the vagi. Diphtheritic Paralyses. — Paralyses are the result of the action of the toxins of the Bacillus diphtherise on the nerve-trunks and tissues of the general nervous system. The paralysis may occur in the course of the disease or during convalescence. When the paralysis occurs early, it affects the velum pendulum palati. In cases which result fatally the heart becomes affected, pneumonia caused by the passage of food into the larynx develops, or the paralysis may become general. In the latter case the symptoms are similar to those seen in the post- diphtheritic forms of paralysis. This form of paralysis manifests itself from the second to the sixth week after the onset of the disease. In mild forms, it may begin with a paralysis of the muscles of the soft palate, which remains localized. The child has a nasal tone of voice, and liquid food is regurgitated through the nose on swallowing. In severe cases there are in addition loss of the patellar reflexes, ataxic conditions, inability to sit upright or to stand, oculomotor paralysis, facial paralysis, pallor, weak heart, arrhythmia, loss of appetite, and albuminuria. Recovery may take place even when there is general involvement of the muscles. The great danger is extension of the paralysis to the diaphragm." Post-diphtheritic paralysis occurs in 5 to 7 per cent, of the cases of diphtheria, according to Baginsky, who reported 131 cases of paralysis in 2300 cases of diphtheria. The soft palate was 392 THE SPECIFIC INFECTIOUS DISEASES. most often affected. Among the other forms of paralysis are those of the facial and oculomotor nerves, the larynx (recurrent laryngeal), and lastly forms of ataxia. Antitoxin has little effect in preventing these paralyses. They occur as frequently after its administration as during the pre-antitoxin period. In the American Pediatric Society's tabulation 9.7 per cent, of the cases had paralysis; of these, 32 out of a total of 328 cases died of cardiac paralysis. Hemiplegic cerebral palsy may occur in diphtheria (Monti, Levi, Baginsky) . Disturbances of the Sensory Nerves. — Disturbances of the sensory nerves also occur in diphtheria, such as perversions of the senses of smell and taste ; also anaesthesia of the rectum. Psychical Derangements. — Psychical derangements such as mel- ancholia have been reported. Diphtheritic Ophthalmia. — True diphtheritic ophthalmia occurs both as an accompaniment of diphtheria of the fauces and as a pri- mary affection. There are two distinct forms of pseudomembranous affection of the eye. In the first, the Loffler bacillus is present, but in the second, or diphtheroid form, it is absent, and the streptococcus alone is found. Of the true diphtheritic form, one class of cases has a mild clinical course. In these the bacillus isolated resembles the pseudodiphtheria bacillus in not possessing virulent properties. In the other form of diphtheritic eye affection the membrane spreads rapidly and causes destruction of the eye. The dii)htheritic invasion is ushered in vrith redness and chemosis. The membrane appears first on the palpebral conjunctiva, and causes marked swelling of the lids. There is little seropurulent discharge. In the progressive form destruction and perforation of the cornea result. I have seen several cases in connection with fatal diphtheria complicating measles, and also cases in which there was no history of diphtheria in the patient or family. I have seen it occur as a primary affection in nurslings. According to Baginsky, diphtheritic ophthalmia occurs in 3 per cent, of the cases of diphtheria, and is most frequent from the second to the sixth year. Diphtheria of the Skin. — Diphtheria of the skin occurs when the specific bacillus finds lodgment in an abrasion or cut. The mem- brane spreads over the wound and encroaches on the surrounding skin. Diphtheria of the Vulva. — Diphtheria of the vulva is met with both as a primary affection and as a complication of true diph- theria elsewhere in the body. I have not found the Klebs-LofQer bacillus in a number of pseudomembranous inflammations of the vulva and vagina in infants. Some of these cases show the presence of true membrane ; others begin as aphthous ulceration and develop DIFRTHEBIA. 393 membrane later. These cases are benign. Tbe diphtheritic bacil- lary cases may be divided into two distinct classes according to their causation. The cases of one class show the Loffler bacillus, but are benign in course, although I have proved by animal experiment the presence of the bacillus of diphtheria in virulent form. In the other class of cases there is extensive destruction of tissue, and sometimes a fatal result. Cases of this class occur as a complication of diphtheria elsewhere in the body or in connection with the exanthemata. The symptoms of diphtheria of the vulva and vagina may be localized strictly to the parts, or there may, as in the severer forms, of Henoch, be constitutional symptoms of toxaemia. Locally, the dis- ease is characterized by the appearance of patches of membrane on the inner surface of the labia, clitoris, and introitus vaginge. The parts, especially the labia majora, are intensely swollen and (Edema- tous. In Henoch's cases there was gangrene or necrosis of neighbor- ing tissues. In my cases there was no complicating diphtheria of other parts. The cases occurred in infants and in children under two years. They were benign in course, although of bacillary type. Nasal Passages. — Councilman, Mallory, and Pearce call attention to the frequency of invasion of the accessory sinuses of the nose and antrum by the diphtheritic process. They found the antrum affected in 33 cases of 52 examined. Clinically, this affection is more com- mon than appears from these figures. This would account, according to these authors, for the persistence with which diphtheria bacilli continue in the nasal secretions after the throat lesions have disap- peared. The disease of the antrum may, as pointed out by Wolff, and recently by Mayer, persist after the diphtheria has run its course. Mayer classifies the symptoms as eversion of the lower lid, fistulous opening in the cheek from which pus exudes, and a fetid purulent discharge from the nose on the side of the face at which the fistula is situated. Other Complicatio7is, — Diphtheria in pertussis is a serious com- plication, since the resistance of the patient is generally much de- creased. Bronchopneumonia is especially to be feared. In tuber- culosis the patient usually dies as a direct result of the complication. In measles the diphtheritic process is a grave complication; it may invade the larynx and death may ensue from extension of the disease to the lungs. In typhoid fever the process causes death by invasion of the lungs. Exanthem.^ — Is there an exanthem characteristic of diphtheria ? I am inclined to view all eruptions which may occur in the course of this disease as purely accidental. They may be the result of reme- dies (antitoxin) administered or of some infection originating in the gut. Among these eruptions are the various forms of erythema and roseola. Erythema urticatum is often seen. 394 TRE SPECIFIC IXFECTIOUS DISEASES. Diagnosis. — The diagnosis of diphtheria must be considered in its clinical and bacteriological aspects. Clinically the characteristic and ever-present lesion is the membrane. This is seen on the tonsils, uvula, pillars of the fauces, and the posterior pharyngeal wall. Its color varies. In consistency it may vary from a thin pellicle or cloudy discoloration to a thick adherent, pultaceous or stringy mass. In a large proportion of cases the presence of the membrane and other characteristics are j)resumptive evidence of diphtheria. On the other hand, there are certain forms (not very frequent) of pseudo- membranous inflammation of the tonsils and fauces which are not truly diphtheritic; these are called pseudodiphtheria or diphtheroid. In these cases the Klebs-Loffler bacillus is not found, but strepto- cocci, staphylococci, and other bacteria are present. Some forms of diphtheria show at first only fibrinous specks on the tonsils ; in others there are small necrotic ulcerations on the tonsil, and in still others the diphtheria may simulate an acute catarrhal follicular amygdalitis or lacunar amygdalitis. These cases are not as infrequent as was formerly supposed. In- the pseudomembranous and other forms of inflammation of the throat above described a bacteriological test should always be made. It should be practised as a routine pro- cedure in all cases of angina. Cultures should be made in cases of laryngeal inflammation in which no membrane is visible in the fauces. If membrane be present in the fauces, and a culture fail to reveal the Klebs-Loffler bacillus, a second and even a third culture should be made. I have frequently established the presence of the specific bacillus in membrane in cases in which the first culture-test proved negative. It is not a reliable nor satisfactory method to spread membrane or secretion from the throat direct on a cover-glass, and decide from such a preparation the nature of the process. The technique of culture-tests is scarcely within the scope of this work. It is sufficient to state that growth can be obtained within four or five hours if the culture-tube is subjected to a temperature of 100.4° to 102.2^ F. (38° to 39° C.) in a small incubator. Other diseases, such as membranous forms of stomatitis, may simulate diph- theria. In these cases the culture test is the only positive mode of making a diagnosis. Certain forms of laryngismus stridulus resem- ble acute diphtheritic laryngitis, or a diphtheritic process may be present in the larynx in a rachitic infant subject to attacks of laryn- gismus. Cultures should be made in all such cases. In small towns and country districts the practitioner without the aid afforded by laboratories will often be thrown on his own resources in making a diagnosis. In such cases the following clinical symptoms may be considered fairly presumptive evidence of diphtheria: The presence of membrane on a tonsil and a small patch, streak, DIPHTHERIA. 395 or speck of membrane on the adjacent surface of the uvula or tip of the uvula ; a patch of membrane on the tonsil and an accompanying patch on the posterior pharyngeal wall; the presence of a croupy cough and stridulous breathing with small patches of membrane on the tonsil or epiglottis, are all of much diagnostic value. The presence of albumin in the urine is of little value in making a diag- nosis, as it may be present in non-diphtheritic affections and absent in diphtheria. Constitutional symptoms are only of corroborative value. It is well known that the most virulent forms of diphtheria may at first be manifested by few constitutional symptoms. The tempera- ture-curve is not characteristic. If a patient who at first suffers from a catarrhal tonsillitis or pharyngitis, shows within twenty-four hours minute patches of membrane either on the uvula or pharynx, it may reasonably be assumed that true diphtheria is present. An acute laryngeal inflammation, croupy cough, and stridulous breathing which not only persist beyond the first twenty-four hours or first night, but also become aggravated, justify a diagnosis of diphtheria of the larynx, although no membrane is visible in the throat. Gen- eral symptoms are of little diagnostic value. Rhinitis at first accom- panied by a serous and later by a fetid sanguinolent discharge, with glandular swellings in the neck, is diagnostic of diphtheria. Adenitis is frequently absent at the outset of tonsillar diphtheria, even when patches of membrane of some size are present. On the other hand, a simple catarrhal tonsillitis is often accompanied by marked adenitis. Paralysis of the soft palate, appearing in the course of a severe or mild pseudomembranous tonsillar, pharyngeal, or laryngeal inflam- mation, or after the affection has run its course, points strongly to true diphtheria, although cases of paralysis of the soft palate follow- ing diphtheroid have been reported. The color of the membrane, its detachability, and the fact that a bleeding surface is left after its removal, cannot be relied upon as aids to diagnosis, in view of the fact that interference with the membrane is not advisable. Aphthae with pseudomembrane over the vault of the hard palate, spreading to the gums and cheeks, are seen in newly born and older infants. These forms of pseudomembranous stomatitis are the result of traumatism inflicted by the infected fingers of the nurse or mother, and are limited to the parts on which they are first seen. Such septic membranes rarely spread unless the exciting causes are perpetrated. Herpes of the pillars of the fauces, so-called herpes of the tonsils, are often mistaken for diphtheritic patches. With a suitable light such an error should seldom be made. Following the ingestion of caustic alkali or the traumatism con- 396 TRE SPECIFIC INFECTIOUS DISEASES. sequent on washing or rubbing the mucous membrane, aphthous ulcerations, which closely simulate diphtheritic membranous patches, are prone to appear over the hamular process of the palate bone. The history of the case, the absence of diphtheria elsewhere, and the result of a culture test will exclude diphtheria. The patches of necrotic tissue seen on the tonsils, pillars of the fauces, and uvula following tonsillotomy and ablation of adenoids, and sometimes accompanied with paralysis, may mislead the observer and cause him to make a diagiiosis of true diphtheria. The membranous patches which appear on the tonsils of scarlet fever patients at the outset of the disease are for the most part diph- theroid. Unless the patient has been exposed to a double infection, which is infrequent in private practice, the patches of membrane which appear later in the disease are also of a diphtheroid nature. True diphtheria may coexist with scarlet fever (Baginsky, Escherich, Councilman), but does so in only a small number of cases. The appearance of a pseudomembranous exudate on the tonsils of a patient attacked with measles should be regarded as diphtheritic until the contrary has been proved. The laryngitis with croupy cough and breathing often complicating measles is not, as a rule, diphtheritic. Prognosis. — The prognosis and mortality vary with the age of the patient, the form and severity of the infection, and the extent to which organs other than the fauces and larynx are involved. Young infants, unless they come under observation early, give a high mor- tality rate. Septic forms of diphtheria are more fatal than those in which the process is a distinctly local affection. The mortality also varies with the nature of the epidemic. In Baginsky's statistics of 2Y11 cases, the mortality from the sixth to the twelfth month was 52 per cent. ; from the second to the third year, 37 per cent., decreasing to 8 per cent, in the tenth year. The death-rate is high in infants and children of delicate constitution and in those suffering from any form of dyscrasia. Treatment. — The treatment of diphtheria may be prophylactic, constitutional, and local. Prophylaxis. — The patient should be isolated as soon as the mem- branous deposit is detected. Other children of the family who have been in contact with the patient should at once be given immunizing doses of antitoxin, and the furniture of the sick-room, such as hang- ings and carpets, should bo removed, only the most necessary articles being retained. The room should be well ventilated. The nurse should not come in contact with other members of the family. All articles of clothing worn by the patient should be dipped in an anti- septic solution (corrosive sublimate, 1:2000) before removal from DIPHTEEBIA. 397 the sick-room. The physician, before entering the sick-room, should cover his head with a cap and wear a long coat or bath-robe, which should be hung outside the sick-room. If it is necessary for members of the family to enter the room, they should observe the same precau- tions, and on leaving the room they should gargle or rinse the mouth with some mild cleansing solution, preferably of boric acid. A throat culture should at once be made. The swab should be rubbed over the tonsils if they are the seat of exudate ; if the case is laryngeal, the swab is passed over the epiglottis and posterior pharyngeal wall. Utensils used in feeding the patient should not be used by others. The patient after convalescence should not mingle with other children until culture has proved the absence of the Bacillus diph- therise from the throat. Constitutional Treatment. — Constitutional treatment consists first in the administration of diphtheria antitoxin. It is not within the scope of this work to enter into the details of the theory of action of this agent, which is the outcome of the modern experimental method of the investigation of disease. Its place in the therapy of diphtheria is now assured. The mortality of diphtheria has been greatly reduced since its introduction. Baginsky gives the following figures, show- ing the mortality before and after the introduction of antitoxin : Age. Before. After. Two years 60.2 per cent. Two to four years 51.2 " Eight to ten years 28.8 " 25.8 per cent. 17.1 " 10 " Of 5794 cases in private practice collected by the American Pediatric Society, the total mortality was only 12.3 per cent. In the cases injected on the first day of the disease the mortality was 7.3 per cent. In the laryngeal form of diphtheria the results have been especially favorable. In 1704 cases operated and not operated there was a mortality of 21 per cent., of the intubated cases, 23 to 27 per cent., as against 60 to 70 per cent, before the introduction of antitoxin. Dosage. — The dosage varies with the age of the patient, the sever- ity of the infection, and the duration of the case before the beginning of treatment. Mild forms of local membranous affections of the tonsils and pharynx coming under observation on the first day should receive doses of antitoxin as follows: Up to one year, 1000 to 1500 units; one to two years, 2000 to 2500 units; two to five years, 2500 to 5000 units. If the disease has markedly progressed twenty-four hours after the first injection, the initial dose should be repeated. The severer forms of localized diphtheria with marked constitutional symptoms should receive initial doses half as large again or twice as large. Laryngeal forms should receive proportionately large doses. 398 TRE SPECIFIC INFECTIOUS DISEASES. Fully twice the above doses are given at the outset of the laryngeal symptoms. The American Pediatric Society recommends as an initial dose 1500 units for a child under two years, and 2000 units for one above that age. I employ 300 units for immunizing purposes in very young infants, and 500 units in older children. The immunizing power extends over a period of three weeks. It is best to give an initial dose of sufficient amount, so that a repeti- tion of the dose will not be necessary ; on the other hand, it is advis- able not to give an excessively large dose. The concentrated anti- toxins are preferable both on account of the diminished bulk and the infrequency with which skin- and joint-affections follow their injec- tion. Recently prepared antitoxin should be obtained, for it has been shown that this agent deteriorates with age (Abbott), and then no longer contains the original unit values. EiG. 62. f?£-a £:hmold, n. v. Antitoxin syringe with asbestos packing ; can be taken apart and sterilized. Time of Injection. — The antitoxin should be given as early in the course of the disease as possible. If membrane is present, no time should be lost in waiting for the result of the culture test, for if the disease is not true bacillary diphtheria no harm can result from the injection, while to wait may be hazardous to the patient. Mode of Injection. — The syringe with asbestos packing should be used for making injections. Such an instrument is easily cleansed and boiled. I find the back just above the buttock the most con- venient location in which to inject. The child can be easily held if this site is chosen. The parts should be carefully cleansed. The injection is given in the same manner as a hypodermic injection. The parts should not be rubbed after the injection. Effect of Injection. — There is a slight temporary rise of tempera- ture following the injection. It is thought to be due to the entrance into the blood of the additional toxin contained in the antitoxin. DIPHTEEBIA. 399 This rise is succeeded by a gradual or critical fall, which continues until the temperature is subnormal. The membrane ceases to spread and exfoliates. In some cases these phenomena may be delayed twenty-four hours. The next day the pulse drops, the prostration gives way to a clear sensorium and good heart action, and sometimes the children sit up in bed and play with toys. The glandular swell- ing also diminishes markedly. In laryngeal cases if there has been threatened stenosis, the symptoms retrograde. Fully one half retro- grade spontaneously. On the other hand, if the temperature persists high after twenty-four hours and the membrane continues to spread, the injection should be repeated, especially if the swelling of the lymph-nodes is marked and there are symptoms of septic infection. The effect of an injection of antitoxin on the blood is to diminish the number of leucocytes ; just prior to the fall of temperature there is a critical hyperleucocytosis (Ewing, Schlessinger). Albuminuria continues, but this is also the case not only when no antitoxin has been used, but also in almost any infectious disease in which bacteria or their toxins circulate in the blood. The eruptions which occur after the injection of antitoxin are of interest. At the site of the injection an abscess or phlegmon may form. This is the result of uncleanliness in technique or is due to some irritating substance in the antitoxin. A brawny erythema which gradually disappears may appear in a day or more at the site of injection. The injection may be rapidly followed by a painful eruption on the extremities, consisting of circumscribed violet colored spots, closely resembling erythema nodosum. The subcutaneous tis- sues are swollen, the joints are painful, and in addition there may be elevated temperature and a cardiac murmur. Herpes labialis and herpes nasalis, urticaria-like general eruptions, and morbilliform or scarlatiniform eruptions have followed injections. These eruptions appear from a few days to fourteen days after the injection. Conjunctival injection, tachycardia, and arrhythmia may be present. The acute symptoms described above subside in most cases within two or three days. Kidney irritation may follow the injection of large doses of anti- toxin. In many of the cases reported, however, the renal symptoms have not been due to the antitoxin alone, and the same may be said of the recorded cases of endocarditis following antitoxin injections. The introduction of antitoxin has by no means lessened the neces- sity of careful general management of a case by the physician. The temperature is controlled or modified by hydrotherapeutic procedures. Antipyretics of the coal-tar series should not be administered, as they weaken the heart. 400 TSE SPECIFIC INFECTIOUS DISEASES. If signs of cardiac paralysis of the early type set in, full doses of the cardiac remedies^ — digitalis (if the pulse is rapid), strychnine, caffein, camphor, and whiskey — are given. Of the remedies, digi- talis must be used cautiously, else the pulse will be seriously depressed. Strychnia and caffein are the best and most available remedies. In the cases of cardiac irregularity it is best not to multiply drug reme- dies, or the stomach will be upset and the general conditions be aggra- vated. To a child three years of age we may give Kso grain of strychnia every three hours ; whereas caffein is best used in the form Fig. 63. °LNE°ss 2 3 4 6 6 7 8 HOUR 3G9>2 309I2S69I2 3G9I2 369]2 369I2369 12 369|I2 3G9I2 36912369|2 369I2 369I2 3I>912 = V „ <, '<■ ■§ -* g >- 5 g^ lUO ^ ~ 5 Wq-o o ♦J 5 * S z o °tt3 J^^ §^< 1U4 £ : r i ,. E ^^3 * ^ -/u^i 5» \. ^ t. t #! ^ -1 .r3 %^(\•>. \ J^ -4 ^« u'^'^» t ,- » S^"^ ^ Z C2 a E ^ £ X,-.^ y- \^ )(-»--<-*» *^^ \ 3 5^ \ ms) w! o V 101 - /- t , 5^^ k \ "•"•■SE 3 Sssasiai^saaSliSSS^ 2IS SllslssSSSssSS Ss^Sss ° HESP. C* Tl Cl TI 71 CM C4 CI C-l -M Tl CI Tl (M C^ TO 7J M 71 w N-'- Z?/.-i^' Introduction of the tube into the chinlj of the glottis. Fig. 72. The index finger pushes the liead of the tube into place in the Uu'yux. Figs. 71, 72. — The operation of intubation of the larjmx. Position of child, operator and assistant. 406 THE SPECIFIC INFECTIOUS DISEASES. held upright in the arms of a nurse, so that the head of the patient is on a level convenient to the operator, v^ho stands facing the patient. An assistant standing behind the nurse steadies the head of the patient. The gag is introduced by depressing the tongue and jav^v^ith a tongue- depressor. The assistant steadies the gag as he holds the head tilted very slightly backward. The tube, threaded with a silk ligature, is with its introducer held firmly with the right hand. The index finger of the left hand is now introduced into the mouth to the root of the tongue and search made for the epiglottis. In young infants^ the Fig. 73. Method of hooking forward the epiglottis in intubation. epiglottis is short. The finger must be introduced quite deeply, feel- ing the arytenoid cartilages of the larynx, and is then drawn upward until the epiglottis is hooked forward. The index finger now holds the epiglottis (Fig. 73), and in a small larynx a skilled operator can also feel the arytenoids (Fig. 74). The tube is now introduced in the median line of the mouth along the palmar surface of the index finger (Fig. G9), and the finger guides the tube over the epiglottis ' Peculiarities of the Larynx. — Thomson anrl Turner have shown that the infan- tile form of larynx diiifers materially from that found later in life. At birth and in infants and young children the epiglottis is very small and gutter-shaped. The glottis is guarded above by the aryteno-epiglottie folds, which are closely approxi- mated to each other. Toward the tenth year the epiglottis becomes much flattened, the aryteno-epiglottie folds become widely separated, and the larynx assumes the adult type. It is important to remember these points in the operation of intubation. DIPHTHEBIA. 407 and into the chink of the glottis and prevents its slipping into the oesophagus (Fig. 70). ■ The instrument should always be kept in the median line. The index finger holding the epiglottis should be held well to the angle of the mouth, so as to obtain plenty of room. 'No force should be used, else false passages will be made. If the first attempt at introduction does not succeed, we should not persist too long, but remove the intro- ducer rapidly and give the larynx a few moments to recover its action, and then try again. As the tube passes into the chink of the glottis the handle of the introducer is elevated, as in Fig. 71, causing the end of the instrument to lie against the base of the tongue. The tube is released, the introducer and obturator withdrawn, and the index finger gently presses the head (Fig. 72) of the tube into the larynx. The gag is withdrawn, and the silken thread passed over the ear of Fig. 74. ^W'ry^' ^- The infantile larynx. Its development into the adult type at the age of nine years. 1. Infant, three months of age. 2. Child, three and a half years of age. 3. Boy, nine years of age. Enlargement upward of the epiglottis and shaping of the arytenoid cartilages. (Thomson and Turner, British Medical Journal, December 1, 1900.) the patient and fixed back of the ear with a piece of rubber plaster. Some operators remove the thread after ten minutes. The advan- tages of leaving the thread are that, should the tube be coughed up in the absence of the physician, it can be recovered by the nurse. In extubating, it is an aid in removing the tube. JSTo ansesthetic is required, and ordinary assistance only is neces- sary. The air passing into the bronchi is moistened in its passage through the natural passages. The danger that food particles may pass into the larynx has been exaggerated. The detachment of mem- brane in front of the tube is very infrequent. Should it happen, and the membrane not be expelled on removal of the tube, tracheotomy is admissible if asphyxia is imminent. It sometimes happens that the tube is expelled many times after introduction. It should be reintro- duced or a larger tube employed. 408 TEE SPECIFIC INFECTIOUS DISEASES. If the operator has chosen to leave the silken cord of the tube in situ, it should be passed through the space between the first molar and bicuspid tooth, to avoid its being gradually bitten through. Should it be bitten through, the finger is introduced into the mouth to the top of the tube and the thread with- drawn, while the tube is kept in the larynx with the finger. The tube is allowed to remain from twenty-four hours to five days. Since the introduction of antitoxin the tube is taken out much sooner than was formerly the practice. If there is marked improvement in two or three days, removal of the tube should be attempted and the effect of such a procedure on the breathing should be observed. Both in the 'New York and Boston hospitals many operators prefer the recumbent to the upright position in introducing the tube. The patient is easily intubed in bed or on the table in the prone position. Extubation. — The patient is placed in the same position as for intubation. The left index finger is passed into the mouth and search made for the epiglottis, the tip of the finger resting on the arytenoids. The extractor is passed along the palmar side of the finger and is guided into the opening in the tube by the tip of the finger. Extuba- tion is more difficult than intubation. The extractor should be regu- lated by means of a small screw, so that the blades do not open too far. This is to guard against injury to the soft parts of the larjaix should the opening of the tube not be entered. Dangers. — The dangers of intubation include detachment of mem- brane during introduction, laceration of the parts, the formation of false passages, and asphyxia. The first rarely occurs unless force is used. The second can only occur as a result of rough and unskilled efforts at intubation. The third occurs only following prolonged efforts at introduction of the tube. Even a skilful operator may pass the tube into the ventricle of the larynx. jSTorthru^D has published a case in which there was a false pocket above the cords which prevented the entrance of the tube into the larynx. In other cases there is what is described by O'Dwyer as subglottic stenosis. ISTorthrup thinks that this is due to swelling of the mucous membrane at the level of the cricoid cartilage. In these cases introduction of the tube is very difficult. The operator may be compelled to use force to push the tube past the stenosis or a smaller tube may be employed. While the tube is being worn, it may become obstructed by membrane. This is indicated by a return of the croupy cough, a snarling, flapping sound, and obstruction to ex]nration. To obviate these difficulties, O'Dwyer has had short tubes con- structed without a retaining flange. These tubes have a. special intro- ducer. The largest size for the age is chosen, and the tube forced into the larynx. These tubes should be used oidy by skilled opera- DIPETHEEIA. 409 Fig. 75. tors. The tubes are allowed to remain but a short time in the larynx. Other complications are the formation of granulations or ulcerations around the lower end of the tube if it is too long, and at the cricoid cartilage if it is too large. The former condition is not serious ; the latter may destroy the cartilage. Granulations may form about the head of the tube. In this case tubes with built-up heads are used to press on the granulations, thus causing them to atrophy (Fig. 75). Feeding. — Feeding the patient after intro- duction of the tube requires care. Most infants will nurse with the tube in the larynx. In some there is considerable difficulty in swallowing. The patient is taken in the lap of the nurse and fed with the head held a little lower than the body. Fluids thus cannot enter the trachea and cause pneumonia. Treatment of the Complications Bronchopneu- moiiia. — The treatment of the bronchopneumonia which complicates diphtheria is similar to that employed in the treatment of a primary affection. The question of the further administration of antitoxin always rises in these cases. I give it in full doses, since it is known that the Bacillus diphtherige is the causative factor. Gastro-enteritis. — The gastro-enteritis which complicates diphtheria it apt to prove very serious the same treatment as a primary gastro-enteritis. DipJitJieria of the Vulva. — Both the severe and the mild cases of diphtheria of the vulva or of the vulva and vagina should be treated with antitoxin. In some of the mild forms of undoubted bacillary origin which I have seen, the membrane was easily removable. In these cases, contrary to the practice in the tonsillar cases, I remove the membrane with a spud wrapped with cotton. The bleeding sur- face left after removal is painted with a 10 per cent, solution of silver nitrate once daily. I have cured cases by this method alone. If there are extensive swelling, necrosis, and gangrene, this method will be of no avail, and antitoxin should be given in full doses, and re- peated according to indications. Paralyses. — The treatment of diphtheritic and especially post- diphtheritic paralyses is at present largely empirical. The symptoms appear with the degenerations in full progress. Of all the remedies recommended. Fowler's solution in tonic doses has seemed to give the best results. I have seen patients recover when given arsenic, nutritious food, and abundant fresh air. Hypodermic injections of strychnine are of questionable value. Electricity is of value as Built-up tubes. It should receive 410 THE SPECIFIC INFECTIOUS DISEASES. an adjuvant to massage of the muscles only in general paralysis. It is questionable whether in some cases it is not capable of doing great harm by tiring nerve and muscle. I find that patients do very well with hydrotherapy and massage. In these cases the last reaction to reappear is the patellar reflex. Diphtheroid (Pseudodiphtheria; False Diphtheria). — The term diphtheroid includes all pseudomembranous formations not caused by the Klebs-Loffler bacillus. It was first proposed in 1860 by Boussage, and has recently been adopted by Weigert, Escherich, Heubner, and Behring. Occurrence. — This form of pseudomembranous formation is most frequently met with in the exanthemata, especially scarlet fever and measles. In the former it is a common complication. It is also met in other conditions, and fevers such as typhoid, and may occur as a primary affection. Etiology. — The cases met in the exanthemata were first described by Prudden, who believed that the process was due to a streptococcus, the Streptococcus diphtherise. Since then, the occurrence of the streptococci has been confirmed, but there have also been added to this group of pseudomembranous inflammations cases in which the pseudomembrane is caused by a diplococcus, the so-called Roux coccus. The pneumococcus (Jaccoud and Menetrier) may also cause a pseu- domembranous angina. The Bacterium coli and the gonococcus (the latter in newly born infants) may cause a membranous formation in the mouth and throat. The Staphylococcus pyogenes aureus is also found in these diphtheroid membranes. By far the most important group is that first mentioned, the pseu- domembranous or diphtheroid inflammation caused by the Strepto- coccus pyogenes, which is none other than that isolated by Prudden. These cases are characterized by their favorable course; while the mortality in diphtheria varies from 20 to 35 per cent., according to the age of the patient, the virulence of the epidemic, and the early administration of antitoxin, the mortality of the diphtheroid cases ranges from 3 to 5 per cent. (Park, Baginsky). Symptoms and Course. — The pseudomembrane occurs on the ton- sils, pharynx, and larynx. There are adenopathy and fever. The prostration and constitutional disturbance are much less than in true diphtheria. Membranes and casts of the larynx and trachea may be expelled. Suppuration of the lymph-nodes may also occur. In many of these cases there is a complicating bronchopneumonia of the strep- tococcus type (Prudden and !N"orthrup), which usually results fatally. Diagnosis. — It is not possible to make a diagnosis of diphtheroid from the gross appearance of the membrane. The culture-test is the only reliable method of determining the nature of a pseudomembra- SCBOFULA OB SCBOFULOSIS. 411 nous exudate. If the first culture gives a negative result, a second one should be made. Treatment. — Clinically the treatment is much the same as in true diphtheria. The administration of antitoxin should not he delayed until the nature of the exudate is determined. It is then discon- tinued. An exception to this rule may be made in the scarlatinal form of diphtheroid, in which it is safe to wait for the result of the culture-test, unless it is known that the patient has been exposed to diphtheritic infection. In such a case antitoxin should be adminis- tered. In laryngeal obstruction the indications for treatment are the same as in true diphtheria. SCROFULA OR SCROFULOSIS. The tendency in some quarters is to ignore the existence of scrofu- losis as a clinical entity and to rank all these and allied conditions under the rubric of general tuberculosis, Bayle and Laennec first described this condition. Definition. — Scrofula is a form of infantile tuberculosis engrafted on a lymphatic constitution, manifesting itself in superficial catarrh and infections of the skin, enlargement of the lymph-nodes, and inflammations of the joints and bones. Forms.- — There the two forms of scrofulosis : a. The tuberculous form, which is practically identical with cutaneous, lymphatic, and bone tuberculosis. h. The mixed form, in which both the tubercle bacillus and the pyogenic bacteria are found in the lesions and products of inflam- mation. The second form may not show the effects to as great an extent as the first form of the so-called tuberculo-toxic action of the toxins of the tubercle bacillus on the skin, mucous membranes and lymph- nodes. Occurrence. — Scrofulosis is almost exclusively a disease of child- hood and youth, and is rarely seen after the twentieth year. Henoch and Birch-Hirschfeld state that the majority of cases occur between the third and the fifteenth year. Females are more frequently affected than males. Ruhl found it to be most common between the sixth and the tenth year. Etiology. — In considering the etiology of scrofulosis, it should be borne in mind that at the period of life during which the disease occurs the lymph-nodes are not structurally fully developed. On account of this condition and of deficiencies of other tissues such as the skin and mucous membranes, bacteria obtain easy access through the skin, mucous membranes, and lymph-vessels even when there is no breach of continuity of surface (Cornet). 412 TSE SPECIFIC IXFECTIOrS DISEASES. It is also true that certain individuals, especially those of a lymphatic tendency once infected, show a predisposition to affections of the mucous membranes and other tissues. The essential causes of scrof ulosis are the tubercle bacillus and the pyogenic bacteria just mentioned. These bacteria are present in ill-ventilated rooms occupied by phthisical patients. Scrofulous in- fection may be traced to parents, brothers, sisters, nurses, and play- mates. Dried sputum is a prolific source of infection. Infection is favored by any solution of continuity of the skin or mucous mem- branes, and also by hyper^emia or oedema of these tissues. The predisposing factors are social conditions, unhygienic sur- roundings, moist dark dwellings, uncleanliness, improper or insuffi- cient food, and lack of fresh air and exercise. The overcrowding in the poorer quarters of cities affords abundant opportunities for infec- tion. Any weakening of the system by infectious diseases, such as measles, pertussis, scarlet fever, diphtheria, rachitis, struma, cretin- ism, and erysipelas, may be the starting-point for infection. Trau- matism or frostbite favors the entrance of bacteria. Morbid Anatomy. — The mucous membranes are the seat of hyper- aemia and thickening. There are increased secretion and activity of the glands, also desquamation of epithelium, and excretion of serum and blood-elements from the surface of the membrane. Adenoids. enlarged tonsils, bronchitis, intestinal and vaginal catarrh, are the most common of the lesions of the mucous membrane. Skiyi. — There are eczema, thickening of the epidermis, and trans- udation of serum and elements of the blood (erythrocytes and leuco- cytes). Ecthymatous eruptions are common. There may be lupus. Cornea. — The cornea shows conjunctivitis and phlyctenulse. Lymph-nodes. - — The lymph-nodes show hyperplasia, which is scarcely noticeable in the early stages. They subsequently enlarge to form tumor masses, which may soften as a result of suppuration or may retrograde to the normal. The nodes in almost any part of the body may be involved. They are enlarged to a greater or less degree, and are infiltrated with tubercle. On section they show either simple caseation or mixed infection. The latter is the case if pyogenic infection is combined with the tuberculous form. Xodes which are the seat of cheesy degeneration may soften and break down, forming cold abscesses. These may open externally oi into the bronchi, bloodvessels, pericar- dium, or peritoneum. Joints and Bones.— In the bones the tuberculous invasion gives rise to fungus or dry caries. Several such foci may be present in the same bone. These foci may heal and years afterward become inflamed as a result of traumatism or infectious disease. SCBOFVLA OB SCBOFULOSIS. 413 The fingers, toes, and extremities of the long bones are thickened as the result of periosteal inflammation. The ends of the hones are the seat of tuberculous osteomyelitis. The joints may be involved. At first there is serous exudate without perforation into the joint of the tuberculous foci. Later there are thickening of the synovial membranes and seropurulent exudate into the joint-cavity, with destruction of the cartilages and heads of the bones. Symptoms. — General Clinical Picture.- — The patient is anaemic, but not necessarily emaciated ; on the contrary, there is a very good panniculus of fat in the majority of cases. The face of some of these subjects presents an eczematous or lupoid eruption. The lips are thick; the conjunctivae may be injected, and there may be blepharitis or phlyctenula of the cornea. Snuffles and nasal catarrh or ozsena are present. The majority of the patients are mouth-breathers, and suffer from adenoids and enlarged tonsils. In some there is chronic otitis with an offensive discharge. There is a fulness about the neck due to enlarged lymph-nodes. The body may present skin eruptions in the form of ecthyma or varieties of eczema. The general surface is in other cases free from eruption, is pale, and has a transparent, marble-like appearance, showing the blue veins underneath. Many of these patients give a history of chronic bronchitis. In others the remains of old suppurations of the lymph-nodes about the neck are seen in the form of livid cicatrices. If the long bones of the extremi- ties have been affected, the surface of the skin shows either old or recent bone sinuses. The symptoms in most cases develop first on the skin and mucous membranes; the lymph-nodes then enlarge, the bones and joints are next involved, and finally, if the case does not progress favorably, amyloid degeneration of the different organs and emaciation develop as a result of prolonged suppuration. In all cases the changes in the lymph-nocles play a leading part, and are characteristic. The 8hin. — In the unmixed tuberculous form lupus is the most common skin lesion; in another form there is the so-called scrofu- loderma of Besnier. Lichen scrofulosorum, with the characteristic enlargement of the lymph-nodes, is another form of skin eruption. In the second form eczematous and acneform eruptions are present. In such cases the skin is thickened as a result of chronic inflamma- tions. There are suppurating rhagades around the eyes, mouth, and anus, and ecthymatous eruptions may be present on the trunk and extremities. A form of scrofulous ecthyma, made up of purple, painful nodules resembling erythema nodosum, has been described by Hutchinson. Hebra has described a prurigo of the scrofulous subject. Mucous Membranes. — There are ulcerations and chronic catarrh 414 THE SPECIFIC IXFECIIOUS DISEASES. of the uasal and bronchial mncous membranes, and in some cases ozsena of an atrophic character. These patients have adenoids and enlarged tonsils. The tonsils are favorite seats of infection. In other cases the posterior nasal and pharyngeal catarrh leads to retro- pharyngeal abscess, or caries of the spine may cause abscess forma- tions in the retropharynx. The Ears. — As a result of the catarrh of the nasopharynx chronic otitis may develop. When otitis follows any of the exanthemata in a patient with scrofulous tendencies, it pursues a chronic painless course. Such an otitis may tend to tuberculous disease of the mas- toid with sinus thrombosis, or even to tuberculous meningitis. There is pain only when there is a mixed pyogenic infection. The Eye. — Chronic eczema of the lids, blepharitis, phlyctenula of the cornea, and keratitis fasciculosa are seen. The phlyctenulse do not yield readily to treatment. Hypopyon of the anterior chamber may also be present. Trachoma is in some instances of a tuberculous origin. Lupus of the conjunctiva is sometimes present. Lymph-nodes. — The tuberculous and tuberculo-pyogenic forms of enlargement of the lymph-nodes are at the outset similar. The pyo- genic varieties are associated with enlarged tonsils and adenoids. The skin over the enlarged nodes may remain normal for months or years, or in both the tuberculous and pyogenic varieties it may become adherent, red, inflamed, and break down. The lymph-nodes discharge, leaving suppurating cicatricial openings. Clinically, infections of the scalp lead to enlargement of the lymph-nodes of the neck and retromaxillary region. Those of the cornea, iris, and ear tend to enlarged preauricular nodes and to enlarged nodes of the submaxillary region. Infections of the mouth and tonsil cause enlarged nodes at the angle of the jaw and beneath it. Otitis with mastoid disease causes enlargement of the node on the point of the mastoid. The lymphatics of the gums and lips are con- nected with the nodes of the submaxillary region and angle of the jaw. Affections of the nose will cause enlargement of the glands of the neck (Jacobi). Lesions of the fingers Avill result in enlargement of the cubital and axillary nodes. Infection of a circumcision wound or balanitis will cause enlargement of the inguinal lymph-nodes, as will also infections of the foot and knee. The lymph-nodes in direct line are always involved ; distant ones are never infected unless there is infection of the intermediate nodes. It was formerly believed that the bronchial nodes were particularly subject to infection. Any special susceptibility to infection shown by these nodes is due to their location, infectious material being fre- quently present in their vicinity. Cornet found the bronchial nodes affected in 103 out of 126 cases SCBOFULA OB SCBOFULOSIS. 415 of tuberculous disease occurring before the completion of the fifteenth year. These observations confirm the statement of Henoch, that the bronchial nodes are affected in the majority of cases of tuberculous disease. Becker, Barthez and Rilliet, Henoch, and JSTorthrup have described the enlargement of bronchial nodes. According to Henoch, they may, even if tuberculous, be enlarged without involving the lung tissue. By pressing on the vagi they may cause rapidity of pulse, and if on the recurrent laryngeal may give rise to spasmodic dyspnoea or to a croupy cough. Pressure on the oesophagus may cause dys- phagia ; pressure on the trachea may cause inspiratory dyspnoea ; and pressure on the pulmonary veins, hypersemia of the lungs. Henoch and Baginsky doubt the possibility of diagnosing these enlarged nodes even with the help of all these symptoms. Fig. 76. Tuberculosis of the proximal phalanx of the index finger in a scrofulous child the subject of extensive lupus of the face and extremities (" Spina ventosa"). These nodes may retrograde to the normal size (West) or they may break down and perforate into a bronchus or the trachea. If they perforate into the pericardium, pleura, or mediastinum, inflam- mation results at these points. The mesenteric lymph-nodes may enlarge and cause pain or tuber- culous infection of the peritoneum (tabes meseraica). In some cases they may be palpated through the abdominal wall. ■ Bones and Joints. — The extremities of the long bones are most frequently the seat of disease ; the diaphysis rarely so. The phalanges of the fingers, the toes, the radius, the ulna, and fibula, are affected in the order of naming. The joint-cavities may at first contain exudate without perforation of the cartilage; later, pus is found in the cavity. 416 THE SPECIFIC INFECTIOUS DISEASES. All of the structures of the joint are involved, and the joint may eventually be destroyed. Suppuration of a chronic nature may. as stated elsewhere, tend to amyloid degeneration of the liver and spleen. There is, in addition, a progressive ansemia. The temperature is sometimes raised a half or three-quarters of a degree above the normal, at others it is normal. Exhausting sweats occur; the dis- turbances of nutrition become in some cases extreme. There may be intestinal diarrhoea. Course and Prognosis. — This condition is not necessarily fatal. Many eases make a good recovery under proper management. The disease may retrogTade if localized to certain lymph-nodes or bone foci. Diagnosis. — The diagnosis is made from the clinical history; either from the presence of the tubercle bacillus in the pus or lesions of the disease, or in those forms in which it is not always possible to decide whether the process is tuberculous or pyogenic by the pres- ence of the tuberculin reaction. Most striking is the cutaneous tuber- culin reaction in cases in which there is a so-called tuberculo-toxic effect on the tissues. Here we have latent tuberculous foci out of reach of observation. The tuberculous toxins permeate the tissues and as a result the " allergic " reaction of Von Pirquet is very marked ; more so than in cases in which there are open foci and tubercle bacilli can be demonstrated. The reaction is large, fully 10 cm. in diam- eter and may develop to necrotic ulcers. The clinical history and blood examination will be of service in differentiating scrofulosis from leukaemia, pseudoleukfemia, and lymphomata of a malignant nature and late forms of hereditary syphilis. Treatment. — The treatment of scrofulosis is directed toward lim- iting if possible the spread of the infection, preventing reinfection of the patient, and instituting local treatment of the lesion. In order that the disease may be treated successfully, the patient should be placed in good hygienic surroundings. If the patient is in the city, removal to the country is advisable. The food should be plain and nutritious ; milk, eggs, meat, vegetables, and cereals should form the diet. The hygiene of the skin is important. Alkaline or sea baths give tone to the skin. Moderate exercise in the open air is also of great service in correcting the anaemia and tendency to inaction shown by these patients. In a word, the patient should be removed from the conditions and surroundings which originally induced the infection. The medical treatment is limited to the exhibition of such tonics as iron, Fowler's solution, and strychnine. The intestines should receive attention during the administration of iron. Fowler's solu- tion gives better results in pyogenic lymphadenitis than in the tuber- culous form. The syrup of ferric iodide in full doses has a tonic effect on the mucous membranes. Baginsky advises the exhibition TUBERCULOSIS. 417 of preparations of thyroid gland. I have not seen any markedly good results obtained by this method of treatment. Cod-liver oil is of great value in this disease. In the form of emulsions it should be given in full doses; with young children its use must sometimes be suspended on account of the laxative effect on the intestines. The tuberculin treatment by very small hypodermic injections of Koch's old tuberculin (%oooo of a milligram at a dose) causes a remarkable improvement in these cases. The complete restoration is indicated by an absence of the cutaneous tuberculin reaction. The local skin lesions should receive appropriate treatment, as should also the bones, joints, and suppurating lymph-nodes. It is not within the province of this work to enter upon the surgical details of such treatment. TUBERCULOSIS. Definition. — Tuberculosis is a specific infectious disease caused by the invasion of the body by the tubercle bacillus. Clinical Varieties.^ — The tuberculous infection in children may be general or local. If general, tuberculosis may manifest itself as a primary infec- tion without demonstrable port of entry or it may be secondary to a well-marked primary focus of infection. If local the tuberculosis may remain localized at the primary focus of infection or may extend from an evident port of entry by con- tinuity but remain localized. Clinically it is not always possible to fix on the primary source of infection, but postmortem we can judge which focus was primary and which secondary, especially in tuberculosis, on account of the anatomical changes in the retrogressive lesions such as cicatrization, calcification and encapsulation. Thus during life what appears as a pulmonary tuberculous lesion may postmortem reveal itself as sec- ondary to some partially cicatrized ulcer of the intestine or a calcified mesenteric lymph-node. Moreover, all forms of tuberculosis can not be definitely classed as above. There are especially in children mixed forms. All tuberculosis is not fatal and a great many of those affected with tuberculosis may never have shown any clinical symp- toms. In these cases of healed tuberculosis the lesion is revealed by some intercurrent affection or accidental death. Frequency of Tuberculosis in Childhood.- — Kossel in 286 autopsies found that the frequency in the first year of life was 6 per cent., from the first to the fifth year 8 per cent., and from the first to the tenth year 36 per cent. The frequency of tuberculosis in children 27 418 THE SPECIFIC INFECTIOUS DISEASES. varies in different localities. Thus in 600 autopsies in children, Dennig found 7 per cent, tuberculous; Bollinger, 13.6 per cent, in 500 autopsies; Seidl, 27.9 per cent, in 64G autopsies, and Raczynoki, 18.3 per cent, in 3341 autopsies. From a study of all tables of various authors we may say that in one hundred autopsies on children 29 or 30 either died of tuberculosis or that it was found as a concomitant with the fatal lesion. Tuber- culosis under the age of three months is rare and only occasional up to the twelfth month of life. The frequency then rapidly increases up to the sixth year of childhood, after which it decreases. During the first four weeks of infancy Trepinski found no deaths from tuber- culosis, from the fifth to the ninth week one case which may have been intra-uterine, and from the third month of infancy to the third year of childhood a gradually increasing ratio until the fifth year, when a decrease was noted. In short, in the first five years of child- hood tuberculosis is found in fully 50 per cent, of autopsies. Localization of the Lesion in Tuberculous Children. Bronchial Mesenteric Primary In- Peri- Lymph Nodes. Nodes. testinal T. toneum. Nodes. 10.6 Bovaird 80% 66% Carr 16.6 Dennig 14.7 21.3 Grosser 0.052 J Holt 34.0 Northrup 7C % 2.5 Still 72% 23.4 Trepinski 90.4 70.8 17.4 20.8 17.9 75.8 Kossel 40 Including mesen- teric glands. 9 4.5 51 Pathogenesis. Portals of Entry and Modes of Spread. — The tuber- culous infection may be aerogenous (inhalation), enterogenous or alimentary (inclusive of amygdalogenous), lymphogenous or hsema- togenous, dermogenous (through the skin), and finally hereditary or congenital. Aerogenous Form. — This form of infection, that by inhalation, by far the most frequent form in the adult, is also the commonest type in children. Dennig found that 58 per cent, of his cases of tuberculosis occurred in families in whom tuberculosis was prevalent. That inhalation tuberculous infection is by far the most natural form of infection in children is proven by Lubarsch, who in 1820 autopsies found tuberculosis of the lungs, and bronchial lymph-nodes in 80 to TUBEBCULOSIS. 419 96 per cent, of the cases. Tubercle bacilli which are inhaled may give rise to intestinal or enterogenous or alimentary infection by gaining access to the alimentary tract, leaving the lungs intact. Enterogenous or Alimentary Form.- — This variety in children takes an especial rank of interest on account of the possibility of infection through the milk of infected cov^s. This question has been discussed at interminable lenglh and an attempt has been made to reconcile the varying statistics in different countries. In England it is considered a rather frequent form of infection. Still attributes 25 per cent, of his cases to it. Alimentary infection may result not only from the ingestion of food containing tubercle bacilli but also by the accidental entrance of bacilli into the mouth and thence into the alimentary tract. From a study of all aspects of this question it would appear that this form of infection undoubtedly occurs but is exceedingly rare. Tuberculosis of the tonsils which is included under the general section of alimentary form of infection is also exceedingly rare. I have published a case of primary infection of the tonsils leading to general tuberculous infection. Hwmatogenous or Lymphogenous Form. — ^This type is never pri- mary but occurs through the breaking down of some tuberculous focus, the opening up of a bloodvessel or lymph-channel and the spreading thus of tuberculous material through the circulation. Dermogenous .Form. — This form is seen in those cases of tuber- culous cutaneous disease in persons whose occupation brings them into close contact with tuberculous tissues or animals. Such are the autopsy tubercles and the cutaneous tuberculosis seen among butchers who have handled tuberculous meat. It is therefore scarcely to be considered a form of infection in children. Predisposing Causes. — The infectious diseases play an important role as predisposing factors in tuberculosis. Measles, scarlet fever, pertussis, and influenza, by lessening the resistance of the economy and impairing the integrity of the air-passages, favor the infection. Tuberculous bronchopneumonia occurs under these conditions, either because the tubercle bacillus was present in the body before the infec- tion was contracted or gained access subsequently (Frankel). In the majority of cases the former condition is the rule. Cold, un- hygienic surroundings, and poor food, all predispose to infection as with adults. Congenital or Foetal Tuberculosis. — Foetal infection may take place either through an infected sperma or ovum (germinative), through the placenta (intra-uterine), or it may be pseudo-congenital, that is, occur very shortly after birth. The last form has caused much discussion, especially in cases of tuberculosis in which the infant dies 420 THE SPECIFIC INFECTIOUS DISEASES. of tuberculosis some weeks after birth. It is then an open question as to whether the infection was intra-uterine or post-partum. There are six cases of undoubted foetal tuberculosis in the literature ( Jacobi, Birsch Hirschfeld, Lehman, Schmorl, Kockel and Wollstein), Of the cases occurring in very early infancy and the newborn, very few exist in the literature which may be traced to intra-uterine infection, and are therefore to be considered as congenital. In these cases the children died so soon after birth, and the lesions were so far advanced, as to justify this assumption. Tubercle bacilli are exceed- ingly rare in the testis or sperma, and it is questionable whether in such cases a tuberculous foetus can result. In the human subject there is not one authentic example of infection through the sperma of a tuberculous individual. Among animals we find that there are many cases of observed intra-uterine infection ; but no cases in the human subject of infection brought about by insemination of the male. The spermatozoon and testis may contain tubercle bacilli in the absence of gross tuberculous lesions of the organ (l^akarai and Kockel). Tuberculosis may in this way be conveyed into the uterus at the time of conception. Jahni and Weigert found tubercle bacilli also in the Fallopian tubes of women dying of phthisis, although there were no gross changes in the tubes. The ovum may thus convey tubercle bacilli. True congenital tuberculosis, therefore, in the sense just intimated, is rare. Foetal tuberculosis occurs, as shown above, but is not such an important mode of infection for so widespread a disease as tuberculosis. There is another form of foetal tuberculosis, and that is the so- called bacillosis or bacillary form. In this form the foetus is found to be free from the lesions of tuberculosis, but bacilli are found in the umbilical vein or in the liver or in the foetal organs. Such are the cases, including that of Bugge, of foetal tuberculosis without lesions. The rarity of the tuberculosis of the foetus is due to the fact that bacillosis of the mother is rare. Bacilli occurring free in the circu- lation in advanced phthisis is rare in itself; and they soon become localized in the tissues. The placenta, as also the liver of the foetus, acts as a barrier and filter of the tubercle bacilli, or they die in the blood-stream. The characteristics of foetal tubercle are: (1) That it is rarely pulmonary. The liver is frequently afiected, also the spleen, kidneys, and suprarenal capsules ; whereas in the lungs only isolated tubercles are found. (2) Foetal tissues are a favorable soil for tubercle. (3) Giant cells are wanting. (4) Bacilli may be present in large num- bers without the development of gross lesions (bacillosis without lesions). ' Under placental infection are to be included those cases in which TUBERCULOSIS. 421 the tubercle bacillus has been found in the blood of the foetus without accompanying changes in the organs (Schmorl), and those in which tubercle nodules and enlarged lymph-nodes have been found at birth (Landouzy and Lehman). In both these forms of tuberculous infec- tion the mother had suffered from acute miliary tuberculosis. Pulmonary Tuberculosis. — Seventy per cent, of the infants and children who die from tuberculosis show lung-changes (Dennig). Infection first occurs through the respiratory tract. A cheesy lymph- node may burst into the bronchi, and bacilli may thus gain access to the lung alveoli and cause changes, as they do in the adult lung. Haematogenous infection occurs through the bursting of a small tuber- culous nodule into a bloodvessel, thus flooding the lung with infec- tious matter, or by the carrying of minute emboli of this material to distant parts of the lung. Tuberculous bronchial lymph-nodes, bone, and pleura may also give rise to infection of the lung through the lymph-channels. The part played by the infectious diseases in its dissemination has been already mentioned. Morbid Anatomy. — The three principal forms of tuberculosis of the lungs which occur in infants and children are : Miliary Form. — The miliary form, which is characterized by the eruption of miliary tubercles throughout the lung. The lung is on section found to be dark red, hypersemic, and to contain less air than the normal lung. The bronchial mucous membrane is hypersemic and covered with blood and mucus. Cheesy or Cheesy Ulcerative Form. — The cheesy or cheesy ulcera- tive form, also called florid phthisis, takes the form of cheesy lobar or lobular pneumonia. In recent cases the lung is grayish red, and there are areas which rapidly become cheesy, and are not encapsu- lated. These may coalesce, involving the greater part of a lobe in the process. Small cavities are frequent, large ones rare. The cheesy ulcerative form occurs as a result of the aspiration of large numbers of tubercle bacilli. Chronic Form. — The chronic form, which is a cheesy fibroua bronchopneumonia, is essentially a tuberculous bronchopneumonia. Round cheesy nodules are found surrounded by a fibrocellular zone resulting from the destruction of extensive areas of lung-tissue. The pulmonary pleura is thickened. The bloodvessels participate in the process. There is endarteritis with miliary tubercle in the walls of the bloodvessels, and there may be thrombosis. The tubercles may burst into the interior of the bloodvessels. The bronchi, trachea, and larynx may be affected. There are ulcerations of the mucous mem- brane and destruction of cartilage. The bronchial lymph-nodes or glands are enlarged and infected in most cases of tuberculosis of the 422 THE SPECIFIC INFECTIOUS DISEASES. lungs in children. Henoch has, however, shown that the bronchial nodes may be tuberculous and greatly enlarged without involvement of the lung-tissues. jSTorthrup found the bronchial lymph-nodes affected in 125 consecutive autopsies. The whole node is converted into a cheesy mass, which may soften and break down. If there is a perforation into a bronchus, masses of bacilli may be discharged into the lung. Perforation into the bloodvessels may also occur. The nodes may form small masses or large mediastinal tumors at the root of the lung. Localization. — The apices of the lungs of infants and children are not as in adults the region most frequently affected by tuberculosis. The first change may appear in the lower lobe or the lower portion of the upper lobe, and spread thence. This is accounted for by the miliary character of the affection in the lungs of infants and children (Rindfleisch), and also by the fact that in many cases the process spreads from the bronchial nodes or glands to adjacent parts (Weigert) . Symptoms. — The symptoms of tuberculosis of the lungs in infants and young children are not so characteristic as in the adult, nor is there a gTadual development of the symptoms pointing to involvement of the lungs. After the fifth year of life the symptoms closely resem- ble those seen in the adult. As regards infants, we shall describe only clinical types of the disease. Even these exhibit many varieties, Henoch has described forms of tuberculosis in infants which closely resemble cases of marasmus due to gastro-enteric disease. In many of them there are steady emaciation and progressive muscular weakness ; the infant lies helpless ; the abdomen is retracted ; the eyes may present a conjunctivitis; the cervical, axillary, and inguinal glands may be slightly enlarged; there is constipation alternating with diarrhoea ; the skin is easily inflamed and abscesses may form. In the terminal period vomiting sets in. The lungs throughout the course of the disease may present few signs, or there may be evidences of a general bronchitis. In these slowly emaciating infants there is no cough of sufficient severity to indicate involvement of the lung. The terminal stage may present cerebral symptoms of a mild type, such as rigidity of the neck, with periods of stupidity alternating with irritability. The infants die with a progressive loss of flesh and streng-th. The temperature is for days normal or a little above normal. In other ty])es the disease is masked by an acute or sub- acute bronehoi)]icninonia. In these cases the infant, after suffering from exposure or some infectious disease, suddenly exhibits all the signs of a bronchopneumonia. There are severe cough, high tem- perature, dyspnoea, and cyanosis, as in the ordinary bronchopneu- monia. Death may ensue in a few days or in a week. In other forms fatal results take place after several weeks, with symptoms TUBEBCULOSIS. 423 closely resembling those of a persistent broncliopneiinionia of the ordinary non-tuberculous variety. In other cases the symptoms of an acute bronchopneumonia are present, sometimes complicated with empyema. Evacuation of the pus is followed by apparent improvement, and the empyema may even heal, but the infant or child gradually emaciates, and the cough, which may have abated, becomes aggravated. Examination of the chest reveals new areas of lung involvement. In these cases the pus does not always contain the tubercle bacilli. The empyema may be the result of mixed infection, and the pus may contain only simple streptococci, the physician being frequently misled as to the true con- dition. Many forms of tuberculosis of the lungs in infants and children may cause death with the terminal symptoms of tuberculous meningitis. Especially characteristic in older children, as compared with the adult, are- those cases of tuberculosis of the lung which follow some slight injury, blow, or exposure, and in which there are for weeks no signs in the lung or elsewhere to account for the gradual emacia- tion and intermittent or remittent temperature. After a variable length of time signs of involvement are detected at one apex, or posteriorly over the base or mid-area of the lung. Even then the cough may be absent and no sputum be expectorated. The child then has intervals of stupidity; there is delirium at night accompanied by the typical hydrocephalic cry. Irritability of temper is marked, the emaciation is very rapid, and coma and death with terminal paral- yses show that the infection has involved the cerebral meninges. Temperature. — The temperature is irregular in course. It may be normal for a few days, after which it rises one or two degrees daily in the afternoon and falls to the normal toward morning. Hcemoptysis. — Haemoptysis is very rare in infants. Henoch has seen 3 cases in young infants and 1 in a child of two years. Acker has reported a case in a child of three years. I have seen several cases in children of more than six years of age. Sputum. — Infants do not expectorate. At most a frothy mucus collects around the orifice of the mouth after a coughing spell. Even older children expectorate very little, and must be taught to do so. Holt has recently devised a method by which tubercle bacilli may be obtained in sputum adherent to the epiglottis by carrying a small cotton swab into the fauces and catching the mucus from the epiglottis in the act of coughing. Course,^ — Up to the second year of life, the course of tuberculosis of the lungs is generally acute (Henoch). The disease may pursue a subacute course, but it is rarely as prolonged as in the adult. In 424 TRE SPECIFIC INFECTIOUS DISEASES. children beyond tlie fifth year its course closely resembles that taken in the adult. Diagnosis. — The diagnosis of tuberculosis of the lung in infancy and early childhood must, for the most part, be made from the his- tory of the case. In many of the cases the physical signs in no way differ from those seen in non-tuberculous diseases. Cases in which marked consolidation of the lung persists, with progressive emacia- tion, and cases in which auscultation reveals the presence of cavities, are certainly suspicious. There is no reliable method of determining the nature of an acutely developing bronchopneumonia ; the detection of the tubercle bacillus in the vomit, in the faces, or in the exudate of a complicating pleurisy or empyema, is of diagnostic aid. Fig. 77. HOUR "r--''^ =:|= = -■=.':='=> 'a;, -= ■^'-- V': = ^yj'-- ■= =>;:i =:'= - V^ '^ ■= ^- X'^ -^ ^-^ ^ ^'^JX''-=-^^^':^Pl^^^^^f^:=^ 2 104° 103° V ; 1 ! ^ , /.\ / ! ' 1 1 ■ 1 1 \ : ; : J . X_ 1 1 |ii'/\/ \ / \ \ / \ \ \ ' \ ' J \ / \ / V \ / -V _J — ~4 — ^A^ — H — '<- ' 1 y^ V-/ \ / H — 4-^ \ f^ -t:.^;— -^ \-^ •' \ \ \y — ^ V-/ — i: — - — : \ . i tn — — — — — -- — Y 1 i i 1 1 ; ; ~ — E _ i-- ' ; : ■ ■ . ; : ■ i> - ^ - ~ E ~ _ z i: zt E 1 1 ! i 1 ! ' 1 d = E == -T-T- H-^- -S-s^£ ' ! i i i i ' 1 ' ^^ E F F E E PULSE Hill 1 i^sgiS 2: S £ 1 ' ! £| = 2= =' S = S|2 Si jscS O ^ 2 ■H' ill 2 RESP. -i-i i ls«?^s?i; :?i S; ,?t ?i - : ?;?;£?iS: X-. zzzzz i\\ '^f:f. S :-. r, I •?;, ,* e Subcutaneous injection, tubercuUn negative at first and positive on the second injec- tion. Case of peritoneal tuberculosis. The existence of enlarged lymph-nodes in the mediastinum or the root of the lung is, according to some authors, revealed by symptoms of pressure. Pressure on the bronchi may give rise to dyspnoea ; on the large veins, to nervous congestion and cyanosis, or oedema of the lungs ; on the recurrent laryngeal nerves, to asthma or laryngospasm ; on the oesophagus to dysphagia. Although in exceptional cases such symptoms may be thus correctly interpreted, I believe with Henoch that diagnosis of these enlarged nodes during life is highly uncertain. TuBEECULiN Test. — The tuberculin test for tuberculosis will aid in corroborating the diagnosis in any particular case. There are three well recognized tuberculin tests: The subcutaneous test, the conjunctival test of Calmette and Wolf-Eissner, and the cutaneous scarification test of von Pirquet. There is also a fourth test, the so-called Moro inunction test, but this is not in general use. PLATE XXIV Cutaneous Reaction with Tuberculin. Case of glandular tuberculosis in a child six years of age. TUBERCULOSIS. 425 Fig. 78. Subcutaneous Test. — The subcutaneous test consists of injecting underneath the skin 0.1 to 0.5 of a milligram of old tuberculin Koch. Within 24 hours there occurs a so-called reaction or rise of tempera- ture to a variable extent ; after a short time the temperature again falls to the normal without further symptoms (Fig. 77). Conjunctival Test. — The conjunctival test is not generallv applied in children on account of the untoward effects which may follow its application in certain cases. When a drop of tuberculin solution is instilled into the eye of an individual in whom there is tuberculous virus, there occurs in from four to twenty-four hours an injection of the pal- pebral conjunctiva, semilunar fold, caruncle and orbital conjunctiva, which varies in intensity in different individuals. It is attended by lachry- mation and a fibrinous or fibrino-purulent exu- date. This may go on to profuse suppuration attended by very marked swelling of the tissues of the orbit. This reaction reaches its maximum in 24 to 48 hours and then gradually subsides. Cutaneous Scarification Test. — The cutaneous scarification test consists in scarifying the skin by means of a so-called borer. The skin of the left forearm on the anterior and radial aspect is cleansed with ether and three punctate scarifica- tions are made by means of the V. Pirquet (Fig. 78). This instrument is shaped very much like a watchmaker's screw-driver. It is held perpen- dicularly to the arm and with a twisting, rotary motion in the manner in which the watch-maker screws the screw into its socket the scarifications, three in number, are rapidly made. Two of the scarifications are inoculated with a minute drop of old tuberculin; the third scarification is left untouched for control. After three or four seconds the tuberculin is wiped off the scarifica- tions. In from five to twenty-four hours there develops a piuk areola around the scarifications inoculated with tuberculin. This areola ranges from five to ten millimetres in diameter and is somewhat infil- trated and papular. The extent of the areola and infiltration varies in different individuals. It fades after a variable length of time, persisting longest in scrofulous individuals or in those having abun- dant antibody, as it is called, in the blood (Plate XXIV.). This reaction of Yon Pirquet is certainly clinically the most useful of all the so-called tuberculin tests. It is never followed by any untoward results. It is absent in many cases before death, and Borer for making the cutaneous tuber- culin test. 426 THE SPECIFIC INFECTIOUS DISEASES. in cases of measles in the first week of the period of Koplik spots and the skin exanthema. The principle of all the reactions has been explained by Von Pirquet on the theory of so-called "allergic" (allergistic reaction), that is to say, when an individual contracts tuberculosis, there develops a hyper-sensitiveness of the tissue-cells to the poison of the tubercle bacillus ; in other words, there is an acquired immunity to the tubercle poison against which the system attempts to protect itself. This acquired immunity is developed by the creation in the blood of a so-called antibody or " antigone." It is sometimes necessary in the presence of a negative result to repeat the test. A test negative on the first trial may result positive on the second inoculation. These cases include many so-called latent cases of tuberculosis. Treatment. — From a study of the symptomatology it will be seen that the treatment of tuberculosis of the lung in young infants and children must be simply symptomatic and will not differ materially from that of the adult. A case of suspected tuberculosis should be isolated from other children. The fever needs little attention if it remains low ; if high, it is treated as in a case of simple bronchopneu- monia. The cough and restlessness are also treated symptomatically. The feeding and general nutrition are of extreme importance as well as change of climate and hygienic surroundings. Tuberculosis of the Peritoneum {Tuberculous Peritonitis). — Occurrence. — According to the statistics of Dennij, Miiller, Biedert, and Simmonds, tuberculous peritonitis occurs in from 8 to 21 per cent, of all the cases of tuberculous disease. Sixty-five per cent, of the cases operated on by Herzfeld were under the age of fifteen years. The frequency varies in different localities. Acute tuberculosis of the peritoneum is seen in acute phthisis as a complication, when there may be also an exudate with miliary tuber- culosis of the peritoneum. This form of peritoneal tuberculosis is of no clinical interest. Chronic Form. — This is the form under consideration. It is rare in the newborn ; in a statistic of 100 cases Still found the disease most frequent from the second to the fifth year of life. 'Next in frequency was the period of five to ten years. Etiology,- — Tuberculous peritonitis is rarely if ever primary, although such cases have been described by Henoch and Miiller. The peritoneum may become infected through the blood-channels (ha'matogenous) ; under these conditions tuberculosis of the perito- neum is simply a feature of the manifestation of acute miliary tuber- culosis. The peritoneum may become infected through the lymphatics or lymph channels (lymphogenous). Under these conditions it is the result of infection from adjacent organs, such as the intestines. TUBEECULOSIS. 427 the genito-nriiiary tract, the mesenteric, peritoneal, retroperitoneal, or l>ronchial, lymph-nodes, and the vertebrse and pleura. Morbid Anatomy.- — There are, according to Herzfeld, three main forms of tubercnlons peritonitis: the miliary, submiliary or exudative form ; the nodular or sclerosing form ; and the adhesive form. The Miliary, Suhmiliary, and Exudative Form. — In this form there is an eruption on the jjeritoneal surface, of gray, transparent tubercles of varying sizes. The intestinal coils are covered with fibrin, and are slightly adherent to one another. There is a clear serous, serofibrinous, serojDurulent, or even ichorous exudate (mixed infection). The Nodular or Sclerosing Form. — In this form the quantity of the exudate in the abdominal cavity is small. The omentum is con- verted into a solid cylindrical mass, containing tumors of a tuber- culous nature as large as an apple. The mesentery is thickened and covered with tubercles. The intestinal wall is thickened and covered with gray or grayish-yellow tubercles, which may attain the size of tumors. The coils of gut are adherent, and the whole peritoneal cavity may be obliterated. The Adhesive Form. — In this form the intestines form an adher- ent mass, witb masses of exudate between the coils of gut, forming pseudocysts. This exudate may be of a puriform nature. AggTe- gations of tubercles between the coils of gut break down and perforate into the gut, or become adherent to the abdominal wall and perforate externally, forming intestinal or abdominal fistulse. Perforation may thus occur in the absence of any real ulceration on the mucous membrane of the gut. In addition to the above principal forms of tuberculous perito- nitis, mixed forms occur. The exudate in the peritoneal cavity may be purely serous (ascites), or the serum may, as in a case which I observed, have a chylous appearance, due to the admixture of fat. In other forms the exudate may be seropurulent, hemorrhagic, or, in mixed infections, putrid.' In the purely ascitic variety the fluid is free ; in the puru- lent form, it is frequently sacculated between the adhesions on the coils of gut. Symptoms.— The disease is, as a rule, insidious and slow in devel- opment. The stage of abdominal distention has usually been reached when the patient is first brought to the physician. The history shows that the child has been for some time gradually losing weight, that the appetite is capricious, and that there have been attacks of abdom- inal pain. This pain vasij be localized or radiate from one point, may be constant, or may resemble visceral neuralgia. Sometimes there is no history of pain, but it may be detected by pressure on 428 THE SPECIFIC IXFECTIOUS DISEASES. parts of the abdomen. There may be a slight rise of temperature toward evening (Fig. 79) ; diarrhoea may alternate with constipation. The abdominal distention is the leading feature. It may take the form of a uniform ascitic accumulation (Fig. 80) ; the surface of the abdomen may be uneven and irregular (Fig. 81), and tumors with cystic formation may be felt through the abdominal walls. The movements, which are rich in fat, sometimes resemble icteric evacuations. This condition was formerly considered pathognomonic of tuberculous peritonitis (Biedert, Conitzer). Vomiting of f »cal or biliary matter resembling that seen in appen- dicitis may occur. In marked contrast with these is a form which in its acute onset may simulate acute perforative peritonitis. In this variety the tubercle mass may cause perforation either of the appendix or the Fig. 79. D*Y 1 •2 ' i 5 6 ' s 9 xo -| HOjS -^ = ;-,= =^ ^ = = z »-- = <' -.---2 ,.=; :,,'=2 .. -=': ^=2 ..=2 , = =s ._ . ^=, „==; ...= -. = D -,..=:i ,.,2 „.»': — < 101- q; 100'- H 99'- -^ r ^ ^ = =f ^ ^ N \^^ ^ n ^ ^ /^ ^ -^ ^ r X^ i^ -^^ ^ W .■■... .1, \f- Tuberculous peritonitis. Female child, five years of age. Ten days of her temperature immediately preceding operation (laparotomy). intestine. Symptoms of acute perforative peritonitis which in every way resemble those of appendicitis set in. It is only by resort to laparotomy that the nature of the affection can be discovered. Physical Signs. — The physical signs in the miliary and the nodular forms are due to the presence of free fluid in the abdominal cavity. If ascites is present, there will be the percussion-wave, the flatness in the flanks, and change of tympanitic area will occur with change in the position of the patient. If adhesions are present and there are encapsulations of fluid, the signs will not vary on changing the posi- tion of the patient. On the other hand, in the adhesive form there will be evidences of tumor masses in the abdominal cavity, cystic for- mations caused by the encapsulated exudate, and little or no fluid. In cases of adhesions in tuberculous peritonitis of the miliary form, the fact that when the patient is in the recumbent position the coils of gut may here and there be seen outlined over the abdominal parietes, is of diagnostic value (Fig. 81). I was able by this means to confirm the diagnosis of adhesions in one such case, and have detected them clinically in other cases in which this form of perito- nitis had been diagnosed. TUBERCULOSIS. 429 Tiie liver may be enlarged as a result of amyloid degeneration or tuberculous interstitial hepatitis. The spleen may be enlarged as a result of amyloid degeneration. Rectal examination may reveal miliary nodules or peritoneal masses palpable through the walls of the rectum. Diagnosis. — The diagnosis is based on the slovv^ and insidious onset, the colicky abdominal pains, abdominal tenderness on palpa- tion, the presence of ascites or tumor masses, constipation alternating with diarrhoea, progressive loss of strength, intermittent fever or slight rise of tem- perature in the evenings, and the pres- ence of tuberculosis in other organs. At the outset tuberculous infection in other parts of the body may be difficult of detection. A rectal examination should always be made. This form of peritonitis should be differentiated from the non-tuberculous form. Inas- much as some authors, notably linger and l^othnagel, doubt the occurrence of idiopathic non-tuberculous perito- nitis, caution should be exercised in making a diagnosis of simple chronic peritonitis. Absence of emaciation and retrogression of symptoms by no means prove that the disease may not have been tuberculous, since some forms of tuberculosis of the peritoneum present such peculiarities. This form of peritonitis must also be differentiated from cirrhosis of the liver, new growths, cardiac and renal affections. In some forms of tuberculous peritonitis, especially of the miliary type, the child will fail to show a temperature above the normal for weeks, and, being in tolerably good condition, the question will arise as to the nature of the abdominal process. In these cases a diagnosis is facilitated by the use of tuberculin. A reaction may be thus attained varying from a degree or more above the normal. The patient is placed in bed, the temperature previously observed every three hours for a few days, and is then given subcutaneously 0.25 milligramme of tuberculin. If no reaction takes place, 0.50 milli- gramme is given after a few days. The dose may be increased to a Uniform abdominal distention due to ascites of tuberculous peritonitis ; enlarged spleen. 430 THE SPECIFIC INFECTIOUS DISEASES. milligramme with older children. A reaction takes place, if the process is tuberculous, within twent j-four hours ; though I have seen it delayed for forty-eight hours (Fig. 77). The cutaneous tuber- culin test is also applicable in these cases. Fig. 8L Tuberculous peritonitis, miliary form, female child, five years of age. Irregular contour of abdominal parietes in the recumbent posture, showing intestinal agglutination. Course. — The course of the disease is chronic. Frequently the symptoms retrograde and there is an apparent recovery. The ascites may at times diminish, and again increase. The chronic forms unless operated upon lead to the formation of abdominal fistulse, to perforative peritonitis, to tuberculosis of the organs, and to amyloid degeneration of the liver and spleen, with emaciation, exhaustion, and death. Treatment. — Laparotomy, when there is no advanced tuberculosis in other organs, is, according to Herzfeld, curative in 54 per cent, of cases. In a series of 29 cases of all ages operated upon by him, 19 were under the age of fifteen years. With operative treat- TUBERCULOSIS. 431 ment must also be combined the medicinal and hygienic treatment suitable to cases of pulmonary or local tuberculosis. On the other hand, in the forms which resemble cases of tabes mesenterica, in which emaciation and cachexia are present before much exudate is formed, it is difficult to decide as to the proj)riety of operative meas- ures, especially if diarrhoea be present. In these proper feeding should be begun and the condition of the patient improved before laparotomy is attempted. Tuberculosis of the Mesenteric Glands (Tabes Mesenteric a).- — Definition. — This term is applied to a set of cases in which we can clinically detect enlargement of the mesenteric lymph-nodes. There is wasting and fever without tuberculosis of the peritoneum. As a Fig. 82. r \ im t 3t . 101 ^ - - I S o _-■ --- -* H r, _ 6LS 1 J * iL / -^'' %_ U 2: \ \ 7 , £ n \ 1 \ \1 •^ ao ' / 1 -Kl. \ \ \ 1 1 ' PULSE |;:iS5rf:^-:?5^§^§5"^!?'s|lt2iS5S!o| |g - SS| §§3 gSg REsp. ?;?;?;?;?;?;?; Si ?;?;,iiJ^?;sS ?;?;?;;;!?; 3 3,?;,?;i?;,s,?;i jss ggg sss g§?5 Tuberculin reaction. Miliary form of tuberculous peritonitis. Diagnosis confirmed by operation. Boy four years of age. clinical entity this condition is not common inasmuch as in 60 per cent, of all cases of tuberculosis there is associated tuberculosis of the mesenteric lymph-nodes. Pathogenesis. — In a recent inquiry into the frequency and types of primary tuberculosis of the mesenteric lymph-nodes, Hess found that in 60 per cent, of the cases the disease was caused by the bovine type of tubercle bacilli. This type was most frequent in children. In both children and adults these lymph-nodes may heal or retro- grade. In two cases reported by Hess the bacilli were of the human type. Symptoms. — In most of the cases there have been progressive wast- ing and colicy pains referred to the abdomen. These symptoms may extend over weeks or months. The pain is not severe, the children are ill-tempered, the appetite is capricious, there is diarrhoea alter- nating with constipation, and a. low, irregular type of temperature. Diagnosis. — The only positive evidence of the disease is the pres- ence of lymph-nodes on either side of the spine. They may be pal- pated at the level of the umbilicus. 432 TRE SPECIFIC INFECTIOUS DISEASES. Prognosis. — The prognosis is good. I have seen cases recover completely. Treatment. — The treatment consists in a study of correct diet, hygienic surroundings and open-air life. There is no indication in the absence of complications for surgical interference. Other Forms of Tuberculosis. — Tuberculosis of the Larynx. — Tu- berculosis of the larynx is rare in children. It occurs in from 3 to 4 per cent, of the total number of cases of tuberculosis (Reiner, Steffen, Barthez, Rilliet). Demme has reported a case in a child of four and one-half years. Tuberculosis of the Pleura and Pericardium. — Primary tuberculosis of the pleura is rare. Dennig reports that it occurred as a feature of general tuberculosis in 14 per cent, of his cases. Pericarditis of the tuberculous variety occurs in only 3 per cent, of the cases of gen- eral tuberculosis. Tuberculosis of the Heart. — Tuberculosis of the heart muscle is very uncommon. Sanger reports a case in a child of nine months, and Demme one in a patient of five years. The endocardium may be involved in general tuberculosis (Perroud). Tuberculous Meningitis (Acute Internal Hydrocephalus j Basilar Meningitis.) — Occurrence. — Tuberculous meningitis has been observed in infants as early as the third month (Steifen). Barthez andRilliet have seen cases in infants five months old. The frequency of tuber- culous meningitis varies vs^ith the locality. Dennig places the fre- quency of tuberculous meningitis among children vp'ho suffer from tuberculous disease at 60 per cent., while Medin found this form of meningitis in 15 per cent, of tuberculous children. It is most fre- quent in the nursing period; Y5 per cent, of all cases occur under the fifth year. The second year of infancy shows the greatest num- ber of cases (Steffen). It is more frequent among male than female children. Of 26 of my cases of tuberculous meningitis, substantiated either by autopsy or by the presence of tubercle bacilli in the fluid obtained by lumbar puncture, 46 per cent. (12) were under four years of age, .53 per cent, were four years of age or over; the average age was four years and four months. The oldest case was ten years, and the youngest seven months. Etiology and Morbid Anatomy. — Exposure to cold and traumatism predispose to the affection. In many cases there is, in addition to the meningeal disease, disseminated tuberculosis of the lungs, pleura, spleen, liver, and peritoneum. In other cases the meninges are the chief seat of the disease, only a few isolated foci of tuberculosis being present elsewhere, as in the mesenteric or bronchial lymph-nodes. It is rare to find the lesions confined to the meninges, and some authors TUBEBCULOSIS. 433 deny the possibility of such a condition. It is not always possible to determine the primary focus of infection. The tubercle bacilli, which are the causative factors, may be carried by the blood (hsematogen) to the meninges, and there give rise to a more or less extensive miliary deposit. The original focus is involved in inflammatory exudate. The tissue of the cord and the nerve-elements may be the seat of degenerative processes. Symptoms. — The symptoms of tuberculous meningitis cannot be clearly classified according to stages. There is an indefinite period of premonitory symptoms followed rather abruptly by manifestations of cerebral irritation, and ending with a period in which pressure- symptoms are pronounced. As a rule, the disease is slow of develop- ment, although cases occur in which the rapid malignant course simu- lates that seen in rapidly fatal cerebrospinal meningitis of the epi- demic type. The disease gives a varying clinical picture in the different periods of childhood. The infant of from seven to twelve months refuses to nurse, has a low fever, and may have diarrhoea alternating with obstinate consti- pation. The illness of an infant is often attributed to a fall occur- ring while it is learning to walk. A weakness of the extremities is thus indicated. The infant becomes indifferent to its surroundings and passes into a somnolent condition. Emaciation is progressive. Vomiting occurs once or twice daily, the food being ejected from the mouth after nursing without apparent effort. The vomiting may be followed by a convulsion, after which the infant becomes unconscious. There may be strabismus, or rigidity of the extremities, or the ex- tremities may be in constant motion of an automatic character. The convulsions may follow one another without cessation. These symp- toms may set in after a period of one, two, or five weeks of ailing. In other cases the infant may have suffered from a chronic otorrhcea, although otherwise in apparent health. Suddenly, vomiting followed by a convulsion sets in. This convulsion is the forerunner of symp- toms, such as coma, which denote that the disease has become estab- lished without having attracted the notice of the parents. In children of five years of age the symptoms are more marked. The child may have an attack of vomiting and diarrhoea and appar- ently recover ; after a few weeks, during which there are irritability, loss of appetite, and progressive emaciation, the child no longer desires to be up and about, but lies quiet in its crib, with its head in a char- acteristic rigid position. It develops strabismus, becomes soporose, and cries out at night. This cry is sometimes piercing in character, and is the cause of much concern to the mother. When the symptoms of cerebral pressure are fully developed, the picture is in the majority of cases much the same. The infant after the first convulsion lies in 28 434 TEE SPECIFIC INFECTIOUS DISEASES. a soporose or comatose condition. The eyes are open and there is a vacant stare ; the sclera may be apparent above the cornea ; the fonta- nelle if still open is tense and bulging, and there may be horizontal nystagmus. The infant cries if disturbed, or may be indifferent to its surroundings. The pupils may be unequal in size and react to light. In one case which I observed the pressure-symptoms were extreme. The infant lay on its back with rigid neck and arched back (opis- thotonos), and emitted a piercing cry at intervals. At each cry the pupils became successively dilated and contracted (hippus). I have seen this phenomenon in two cases of tuberculous meningitis. Opis- thotonos may be present, and the retraction of the head may relax at Fig. 83. Babinski's reflex. Tuberculous meningitis ; stage of facial palsies. Boy seven years of age. intervals, the muscles of the back being lax. In some cases there is apparently no rigidity of the neck. As a rule there are no convul- sions. As the infant or child lies quietly in its crib the inspirations during the stage of cerebral pressure may be very irregular or may be of the Cheyne-Stokes type. The outline of the abdomen is at first normal or there may be a slight retraction at the upper part. The abdominal wall may be quite lax, so that the coils of gut can be made out. If the case is protracted, retraction of the abdomen occurs in the final stages of the disease. This condition has been described as the boat-like abdomen. It is not diagnostic of this form of meningitis. TUBERCULOSIS. 435 In rare cases spastic symptoms occur after the initial convulsion, rigidly flexed arms; the Chvo- stek and Trousseau symptoms are present. In all of these cases, if the skin is stroked with the finger ever so lightly, a red mark appears over the stroked area (tache cerebrale). In the spastic cases the knee-reflexes may he increased, but in the non-spastic cases they are di- minished. It is difficult to elicit Kernig's symptom in spastic cases, because the infants lie with the knees flexed. By straightening the legs and thighs it is possible in the majority of children to obtain the symptom. The most important symp- toms of the final stage of tuber- culous meningitis, both in in- fants and older children, are the localized facial palsies. For several days or weeks preceding the fatal issue, one side of the face is seen to be flatter than the other. There may be ptosis or lagophthalmus of the eyelids. One eye may be rotated inter- nally, owing to paralysis of the abducens. The extremities are also paretic. The arm and leg of one side may be rigid or flexed, while those of the oppo- site side are lax. Irritation of the soles of the feet may give a Babinski reac- tion (Fig. 83). In some cases this reaction is present inde- pendently of any irritation of the plantar surface. Toward the end, convulsive twitchings appear in the muscles of one closely resembling those of tetany The infant lies comatose, with 436 THE SPECIFIC INFECTIOUS DISEASES. or the other side of the face or of the extremities. Death supervenes in coma with convulsions. The heart may continue to beat for some time after the cessation of respiration. Children from six to nine years of age present a more decided clinical picture in the premonitory stage. For some weeks before the onset of symptoms of irritation they complain of headaches, fron- tal, sincipital, or parietal. The jDatient is listless, walks with an unsteady gait, and has no desire to study or play. In one case the child had for some time complained of pain in the left side of the chest and had lost weight steadily. There were mild pleurisy and signs of slight consolidation at the apex of the left lung. There was daily elevation of a few degrees of temperature in the evening, and a nornaal temperature in the morning. In this case, although there were distinct signs of pulmonary involvement of a Fig. 85. DAY OF rLLNESS 1 2 3 1 5 :7 8 9 10 11 12 13 14 1 104 103° '5'l02° I < ■i lof ti 100 99° M E M E M E M E M E M E M E M E M E M E M E M E M E M E — — ' — — — — — — — — — — — — — — — — — — 1 — — — — — — — — — — — — — — — — — — — — 1 — — — —^ TTrT — — — — — — — 1 — — — — — - — m- — — — — — 1 — — — — ' ^z. — — — rzzj — -<- — — 4\ — —j — — 1 — ^ — &: =^ ^^ 3 ^^ -f" ::^ t= E i^ 3 E 'ZZ- ;= a -= f^ EI ^ v^ f—^^ ^ -<-' :iz = E — — — — — — 98° ? ___ ^ -" ^^A pJ _ ^ cr zz. zz. z;: PULSE S S 3 2 o - i o s ' 1 ' s ^ o t o 3 ' o :: o CD ' o S 1 o- o- STOOL 1 2 1 1 2 1 1 2 1 1 1 1 Tuberculous meningitis, observed from the outset of the symptoms. Female infant, fourteen months old. mild type, the emaciation was progressive and the leucocyte counts low (8000 W.B.C.). At night the typical cry of tuberculous menin- gitis was present. In the early stages of the disease the patient was conscious during the day, but later became listless, irritable, and slept or was drowsy during the day. When questioned, a slow, stupid answer was given. The child vomited and at times became nau- seated. The Kcruig symptom ap])earcd. Right lagophthalmos was present. The pupils were uiioqua] in size, the left being dilated. The pulse at this time varied from 00 to 100 and was compressible. Finally, coma set in with left facial palsy and convulsive twitchings of the left side of the face. This case was for three months under constant observation. In other cases the vomiting is rapidly fol- TUBERCULOSIS. 437 lowed by paralytic symptoms such as ptosis and facial paralysis on the same side. There are no convulsions and no cry, but there is rigidity of the neck and extremities ; one patellar reflex may be absent. The Kernig symptom and Babinski reflex are present in the majority of cases in children. The very rapid and fatal cases of tuberculous meningitis have been described by Osier and Dennig. In these the patient is over- whelmed by the toxaemia of the disease, no marked tuberculous lesion being present in any organ but the brain. A patient in apparently good health is suddenly seized with convulsions followed by a period Fig. 86. Tuberculous meningitis ; general miliary tuberculosis ; terminal stage ; coma and paralysis. Boy, seven years of age. of unconsciousness. There are muscular relaxation and a vacant stare. The convulsions may be repeated at intervals of a few minutes or half an hour. There then follow opisthotonos and spasms, and the abdomen is tympanitic. There is neither vomiting, tache, nor elevation of temperature. There are spastic contractures of the extremities alternating with relaxations. Death occurs in a convul- sive seizure within ten hours. Schlessinger reports a case of tuberculous meningitis in a child two and a half years old, setting in with convulsions, followed by hemiplegia and aphasia within thirty-six hours. After these pre- monitory phenomena the ordinary symptoms of the disease appeared. Such cases are exceedingly rare. The temperature-curve in tuberculous meningitis is not charac- 438 TEE SPECIFIC INFECTIOUS DISEASES. teristic. In some cases the temperature will not rise more than a degree or two above the normal, intermitting to the normal or nearly so. In other cases it may be normal for days, then rise a degree or more, rarely above 103° "^F. (39.4° C), and then fall again to the normal. In cases in which there is a general miliary process the temperature mounts to 105°-106° F. (40.5°-41.1° C.) or higher toward the close. The fatal issue in other cases occurs with a sub- normal temperature (96° F., 35.5° C.) lasting for a day or more before death. If the case is a protracted one, the normal diurnal variations may be reversed — that is to say, the highest temperature may be reached in the morning hours and the lowest toward evening. In the majority of cases, however, the temperature is rarely higher than 103° F. (30.4° C). The pulse is increased at the onset, but during the course of the disease becomes slow and may range from 60 to 100 or more during the twenty-four hours. The respirations are irregular, and may vary from 18 to 60 within the twenty-four hours, even if no pulmonary lesion is present. Individual Symptoms. — Onset. — Of 26 cases which I have utilized for the purposes of this article, the onset was slow and insidious in 77 per cent. The mother of the child related that the patient was not quite well, or complained of slight headache, and vomited from time to time before the appearance of marked symptoms. In those cases which have come under my observation early in the disease, as early as the second day after marked symptoms were observed by the parents, there was no history of vomiting; as a rule, the child had a slight elevation of temperature, was irritable from time to time, refused to nurse, and on the whole the mother observed a change in the general attitude of the child toward herself and others. It was only in those cases which had lasted at least a week that there was a history of vomiting. It was only in exceptional cases that the mother asserted the disease began suddenly with vomiting and convulsions. Vomiting.- — Vomiting sets in, on the average, eighteen days before the fatal issue, and may occur once or twice daily. It may be absent in some cases. "With the vomiting there may be localized con- vulsions, which appear with the vomiting, as has been stated in exceptional cases in which the onset is sudden, or may appear two weeks after the initial vomiting attack. Rigidity. — There are some cases of tuberculous meningitis in which rigidity of the neck is absent throughout the disease. In only one of my cases was there opisthotonos ; and the rigidity, if present, as a rule, was but slightly marked ; that is, the head was movable almost to a normal degree. The rigidity is tested simply as the child > w X X < TUBEECULOSIS, 439 lies in bed; the head is raised, or an attempt made to draw the chin toward the sternum and note the resistance. In only 25 per cent, of the cases was there palpable rigidity or stiffness of the neck, and this appeared late in the course of the disease. HypercBsthesia. — Hyperaesthesia, either of the surface or of the senses, is absent, as a rule, in tuberculous meningitis; that is, the child reacts feebly or not at all to irritation, and, when roused, momentarily protests and then falls into sopor again. In 90 per cent. of the cases there was an absence of hypersesthesia either of the sur- face or of the senses; and in this respect tuberculous meningitis is quite the opposite of cerebrospinal forms of purulent meningitis of the epidemic type, in which hypersesthesia is the rule and forms part of the general symptomatology of the disease, Kernig Symptom. — This symptom is present in only 50 per cent, of the cases. Its presence or absence does not materially aid in the diagnosis. Babinski Reflex.- — In children over two years of age the Babinski reflex is a valuable guide clinically as to the nature of a menin- gitis, if meningeal symptoms are present ; more so than the Kernig symptom. Of 26 cases of tuberculous meningitis, the Babinski reflex was present in 15. It is found exceptionally in the cerebrospinal menin- gitis of the epidemic type, or the suppurative forms of meningitis. The general reflexes are present in tuberculous meningitis early in the disease ; whereas late in the disease, when paralysis supervenes, they are absent. Pulse. — The irregularity of the ]3ulse is of no special diagnostic value in tuberculous meningitis, and if present is only incidental. The irregularity of the pulse is quite a feature in other forms of meningitis, especially of the cerebrospinal type. In these cases the pulse at one moment may be 85, and immediately after may suddenly mount to 120 beats a minute. In tuberculous meningitis, however, the pulse, as a rule, is slower than that of meningitis of the cerebro- spinal type. Respiration. — The respiration is irregular in most forms of men- ingeal trouble in children. In the tuberculous form of meningitis, after the disease is well inaugurated, the respirations are irregular and shallow, and in a few cases, where cerebral pressure is very marked late in the disease, the respirations may assume the so-called Cheyne-Stokes rhythm. The irregularity of respiration or pulse is scarcely an aid as to differential diagnosis of the form of meningitis present. Temperaiure. — Of greater utility in the diagnosis is an exact observation of the course of the temperature. Although there are 440 TKE SPECIFIC INFECTIOUS DISEASES. cases of tiiberculoiis meningitis in Avhich the temperature ranges as high as 104° to 105° F., this high temperature is present only in the presence of complications of the lung, or at a late period of the disease, toward the fatal issue. In most eases of tuberculous menin- gitis which I have seen, a low range of temperature has been the rule. Blood. — In all my cases of tuberculous meningitis I have had the blood examined at intervals of three days ; in two-thirds of the cases there was a leucocyte count ranging below 20,000 to the cubic milli- metre. In the remainder of the cases, however, I obtained a leucocyte count ranging from 20,000 to 25,000 to the cubic millimetre. In some cases there was at some period of the disease a so-called leuco- penia. In no case except one, in which the leucocytes just before the fatal issue mounted to 32,000 to the cubic millimetre, did the leuco- cyte count exceed 25,000 to the cubic millimetre; therefore a leuco- penia, however presumptive evidence in the face of other symptoms of the tuberculous form of meningitis, is certainly not a positive evi- dence of the presence of the disease. The lowest count in my cases was 5000 leucocytes to the cubic millimetre. Eyes. — The condition of the fundus of the eyes is of special interest in this form of meningitis, as compared with the condition of the disk and retina in other types, such as the cerebrospinal form of meningitis. In 20 consecutive cases of tuberculous meningitis exam- ined by the expert ophthalmologist in my hospital service, the fundus was normal at an early or late period of the disease in 25 per cent, of the cases. In 75 per cent, of the cases, however, there was some change in the disk (optic neuritis), or there were present also tuber- cles in the choroid. In some cases the disk was simply swollen, and indistinct at the margin ; in other cases the veins were congested. Tubercle was found in the choroid in 6 of the 20 cases examined. Choroid tubercle was seen as early as the first and as late as the sixth week of the disease. The cerebral cry present at night is not distinctive of this form of meningitis; the emaciation, the retraction of the abdomen, the bulging of the fontanelle may be present in other forms of menin- gitis, especially in that form described by English authors as the posterior-basic form. Of great service in making a clinical diagnosis in this disease is the presence of palsies of the cranial nerves, facial paralysis; ptosis, strabismus, paralysis of the internal rectus of one side, or ptosis of one side with or without lagophthalmos of the oppo- site side, are indicative of a lesion at the base of the brain. These palsies are seen more frequently in the tuberculous forms of menin- gitis than in the epidemic cerebrospinal type of meningitis. I have, however, seen these palsies in cases of cerebrospinal meningitis either TUBEBCULOSIS. 441 in infants or children, and in these cases the palsies appeared early in the disease rather than late, as in the tuberculous form. Maceivens Sign. — This sign is elicited by percussion along the parietal or frontal bone over the situation of the anterior horn of the ventricles, and in infants and children below two years of age is of very little value as to the diagnosis of tuberculous meningitis with consequent accumulation of fluid in the ventricle as a result of this disease, inasmuch as in certain children suffering from pronounced rachitis with slight accumulation of fluid in the ventricles, so-called hydrocephalus, this tympanitic note of Macewen may be obtained. The Macewen tympanitic note is therefore of value only in children above two years of age, and must always be sought by sitting the patient upright in bed, inclining the head toward one or the other shoulder, and percussing the inferior side of the skull over the parietal or frontal bone. When carried out in this manner, a marked tympa- nitic note over the anterior horn of the ventricle is presumptive evi- dence of fluid in the same as a result of inflammatory processes at the base of the brain and obstruction of the veins of Galen. Lwmhar Puncture. — Lumbar puncture is to-day the most valuable aid we possess in making a positive diagnosis of the various forms of meningitis. In tuberculous meningitis there has been discussion as to the value of an examination of the puncture fluid in the diag- nosis. First, as to the cyto diagnosis, it may be said that in 15 of my cases of tuberculous meningitis studied with a view of noting the character of the cell elements in the puncture fluid, 14 showed a pre- dominance of mononuclear cells. In 1 case there was an equal num- ber of mononuclear and polynuclear cells. It would seem, therefore, that in tuberculous meningitis there is a prevalence of mononuclear cells, and that this is so constant that it would appear to be charac- teristic. There are forms of cerebrospinal meningitis, however, espe- cially the chronic cases, and those of the posterior-basic type of long duration, in which, instead of a polynuclear picture in the sediment of the fluid obtained by lumbar puncture, the mononuclear picture is apt to present itself, thus closely resembling what is seen in tuber- culous meningitis. The bacteriology of the fluid obtained from cases of tuberculous meningitis by means of lumbar puncture has been a matter of close study and difference of opinion; whereas Lichtheim, Lenhartz, and Bernheim found that tubercle bacilli were constant in the sediment of the fluid obtained from these cases; Cassell and Marfan have asserted that their presence is only occasional. Of late we have examined the puncture fluid of 14 consecutive cases of tuberculous meningitis, which were clinically diagnosed as tuberculous in char- acter before the puncture. In 13 of these cases tubercle bacilli 442 THE SPECIFIC INFECTIOUS DISEASES. were found bv Bernstein of the hospital laboratory. The fluids were carefully centrifuged, and the search was exceedingly pains- taking. In some cases, especially of children coming under obser- vation late in the disease, tubercle bacilli were not found during life in the puncture fluid, but were found postmortem. This is explained by the fact that in these cases the tubercle bacilli were present in but few numbers which during life were kept evenly dis- tributed throughout the subarachnoid space, and were found in the puncture fluid only after prolonged search. I am inclined to believe that the search for tubercle bacilli in the puncture fluid obtained from cases of tuberculous meningitis is the most positive and valuable aid to the diagnosis, and the bacilli can be found in the majority of cases, if carefully looked for. Tuberculin Test. — Finally the cutaneous tuberculin test is of great value in the early stages of the disease in arriving at a diagnosis. Differential Diagnosis. — Tuberculous meningitis must be differen- tiated from epidemic cerebrospinal meningitis or sporadic cerebro- spinal meningitis, suppurative forms of meningitis, posterior-basic meningitis, polioencephalitis, apex pneumonia, typhoid fever, sepsis, disturbances of the stomach and gut, ursemia, helminthiasis, and finally the various forms of otitis. From cerebrospinal meningitis it can be differentiated by the slow onset, by the absence of opistho- tonos, and in the majority of cases a slight rigidity of the neck, by the absence of hypersesthesia, the presence of changes in the fundus of the eye, other optic neuritis or the presence of choroid tubercle, which will be absent in cases of cerebrospinal meningitis and posterior- basic meningitis, by the low range of the temperature, by the absence of a leucocytosis above 25,000 to the cubic millimetre, and finally by the results of an examination of the fluid obtained by lumbar puncture. Pneumonia with cerebral symptoms may simulate tuberculous meningitis. Here again the history and the character of the delirium in older patients will aid us. The signs in the lung and the presence of leucocytosis, which is marked in pneumonia and generally absent in tuberculous disease, are significant. In the majority of cases of typhoid fever the history will be of service in connection with the roseola, the Widal reaction, the enlarged spleen, and the absence of leucocytosis. Diarrhoea may be present in typhoid. Disturbances of the gut, ursemia, and helminthiasis may present symptoms resembling those of tuberculous meningitis, but the symp- toms in time retrograde or are cleared up by a study of the case. I have seen otitis media in nurslings with very limited areas of bronchopneumonia, simulate tuberculous meningitis. In these cases the infants may have been ill for two weeks or more. They start from sleep, are irritable on awakening, and lose appetite. TUBEBCULOSIS. 443 In one case the ocular symptoms closely simulated those of tuber- culous meningitis. As a rule there are intervals during which the child is not only free from pain, but also has a normal temperature. At other times the temperature has a septic intermittent character, and mounts higher (104° F., 40° C.) than in tuberculous meningitis. Aural examination only will remove doubt. Duration. — The duration of the disease varies within wide limits ; I have seen cases which extended over three months. The majority of cases last from two to three weeks, but cases lasting five weeks are not unusual. The very rapid cases in which death ensued within twenty-four hours have been mentioned. Prognosis. — The prognosis is usually fatal. Isolated cases of recovery have been reported. Martin has recently collected some twenty cases of undoubted tuberculous meningitis which recovered or had periods of complete remission of symptoms extending over years. In some of these cases the lesion in the meninges subse- quently became a focus of fresh infection which terminated fatally. Treatment. — The treatment is directed to alleviating the suffer- ings of the patient. Lumbar puncture is not curative, and should not be repeated after the first diagnostic puncture has been per- formed. Tuberculosis of the Brain (Solitary Tubercle of the Brain). — In this there may be a single localized tuberculous nodule or mass in the brain, or several such formations may be present. Demme found a growth of this kind in an infant twenty-three days old. Henoch has published a case in an infant eleven days old. The majority of cases occur between the second and the fifth year. Morbid Anatomy. — Tubercle bacilli of diminished virulence and limited number are carried from the focus of tuberculosis to the brain through the blood-channels, and there lodged in a terminal blood- vessel, forming solitary tuberculous masses varying from the size of a pea to that of a hazelnut. These are surrounded by a zone of granulation-tissue. The neuroglia in the immediate vicinity is the seat of proliferation, and may form a capsule around the growth. Circumscribed meningitis over the situation of the growth, with adhe- sions of the pia mater to the dura, may be present. Fully half of these solitary growths occur in the cerebellum (Gerhardt). The growth may be single or there may be one large growth and several of smaller size. Starr and Seidl found a solitary growth in Y7 per cent, of the cases. The larger number of brain tumors in infancy and children are tuberculous. Starr found this variety in 152 out of 300 cases of all kinds of tumors. The symptoms are those common to all tumors, and will be de- scribed in the section devoted to Brain Tumors. 444 TRE SPECIFIC INFECTIOUS DISEASES. SYPHILIS. Acquired Syphilis of Infancy and Childhood. — Definition. — Syph- ilis is an infectious disease caused by the Spirochseta pallida of Schaudinn and Hoffman, The spirochsetse are found in the blood and luetic lesions. Mode of Infection. — Of 42 cases of acquired syphilis collected by Fournier, 19 were infected by the father or mother after birth, and 8 by the nurse. ISTo case was infected in passing through the mater- nal parts, and no infant was infected by the mother if she had contracted the disease prior to her accouchement. A child of a syphi- litic mother, if born free from signs of syphilis, cannot contract a primary lesion at birth from the maternal parts, even if these parts are the seat of condylomata, nor can such an infant be infected sub- sequent to birth. It has an acquired immunity against the disease. A chancre or primary lesion is, in the infant as in the adult, the only evidence of acquired syphilis. It is the result of infection, and must be present in order that the diagnosis may be certain. Chancres are rarely genital. They are found, as a rule, in the mouth, on the face, and on the abdomen and perineum. An infant may be infected by the nipple of the nurse's breast. The act of kissing, contaminated nipples of the nursing-bottle, instruments, sponges, ritual circum- cision, and humanized vaccine virus, are all means of infecting the infant. Since humanized vaccine virus is no longer used, this mode of infection has been eliminated. Symptoms.- — The symptoms consist of a chancre or initial lesion, rarely genital, which appears three or four weeks after inoculation. The other accidents, such as bubo or adenopathies, the eruption, and all the secondary symptoms of acquired syphilis, appear in due course as in the adult. The genital chancre is seen in infections caused by ritual circumcision. Prognosis. — The prognosis as to life is good in comparison with that in the hereditary form of the disease. While in the hereditary form the mortality is from 70 to 80 per cent., that in the acquired form is very low. Fournier lost only 1 in 42 cases of acquired syphilis. The course in infants and children is benign. The chancre is not well developed ; the induration is present only a short time, or may even escape notice. The infants enjoy good health in spite of the presence of the secondary symptoms. I have confirmed these state- ments by observing 7 cases of genital chancre. The tertiary mani- festations, such as gummata, bone lesions, joint-affections, eye and laryngeal symptoms, and cerebrospinal lesions, appear from five to twenty-five years after the initial lesion. Differential Diagnosis. — Acquired syphilis must be differentiated SYPHILIS. 445 from the hereditary form of the disease. Hereditary or congenital syphilis appears early without an initial lesion, showing general sec- ondary symptoms from four to six weeks after birth. The chancre is the first manifestation in acquired syphilis. In Fournier's 42 cases the chancre appeared during the first year of life in 19, and during the second year in 10 cases. The snuffles, pemphigus, and pseudoparalysis are not present in acquired syphilis. Secondary accidents, such as mucous patches or papules about the genitals, appearing during later childhood are probably traceable to a post- natal infection. Interstitial keratitis, bone syphilis, and cutaneous stigmata are common to the hereditary and acquired forms of the disease. It is sometimes very difficult to decide which form of the disease is present. Thus far no one has shown conclusively that Hutchinson's teeth are present in acquired forms of syphilis in in- fancy and childhood. Their presence is therefore strong presumptive evidence of hereditary syphilis. Late Hereditary Syphilis (Syphilis Hereditaria Tarda). — • Definition. — Fournier defines late hereditary syphilis as a symptom- complex of accidents of syphilis originating in a hereditary infection, which manifests itself at a more or less advanced period of life, that is to say, in the majority of cases between the third and the twenty- eighth year. Classification. — There are two classes of cases. In the first, the patient has remained in perfect health without any of the eruptive or other symptoms of hereditary syphilis until at an advanced period of childhood one or more of the symptoms of late hereditary syphilis are developed. In the second, the late symptoms have been preceded by the early symptoms of hereditary syphilis. The late symptoms may develop after an interval of from ten to fifteen years. The cases of the former class have been the subject of much discussion. The occurrence of the second class of cases is now well established ; it is often very difficult to determine the hereditary or acquired nature of the original infection. Symptoms. — Fournier, in classifying the symptoms of 212 cases of late hereditary syphilis, found the eye to be the organ most fre- quently affected, ^ext in order of frequency are the lesions of the bones and skin. The rarer affections are those of the kidney, larynx, spinal cord, testes, and lungs. The subjects of late hereditary syphilis have certain well-defined general characteristics. They are constitutionally delicate and have an emaciated habitus. The skin presents a grayish ansemia. There is an arrest in the development of bone and musculature. The men are undersized and present the picture which has been characterized as infantilism. The sigTis of virility, such as the beard, hair under 446 TEE SPECIFIC INFECTIOUS DISEASES. the arm and on the pubes, are scantily developed. The testes are rudimentary. The adult has the appearance of a boy of fourteen or fifteen years. The women are correspondingly backward in devel- opment. The Eye. — The eye symptoms appear most frequently at the age of ten or fifteen years, but may become evident as early as the third year. The principal symptom is a keratitis of the diffuse intersti- tial variety, the so-called keratitis of Hutchinson. The cornea has a slightly cloudy or filmy appearance, or the whole structure is diffusely Fig. 87. l I 1 s / 1 • i mm / ■ ^. K --^ 1^ J Late hereditary syphilis ; bone deformity and sinus. Child, three years of age. opaque. The other ocular accidents are plastic iritis, which fixes the iris, thus limiting its action and causing a difference in the size of the pupils. The rarest manifestations are miliary gummata of the iris. Bone-lesions.- — -The bone-lesions are most frequent between the fifth and the twelfth year. The head presents a cuboidal shape ; the forehead is prominent ; the frontal bones have large bosses, as have also the parietal bones. The longitudinal suture is depressed, giving a natiform shape to the head. The cranium may have the form seen in mild degrees of hydrocephalus. The nose, on account of the destruction of the bony septum, has a depressed bridge. The bony and cartilaginous septa form an acute angle, and a peculiar retrousse appearance is given to the organ. SYPHILIS. 447 Both bony and cartilaginous septa may be destroyed. The whole organ is flattened, the tip of the nose being wrinkled into three or more folds. The long bones are especially affected by the accidents of late hereditary syphilis, the tibia being most frequently affected. The lesion may consist in an osteoperiostitis, a gummatous osteoperiostitis, or a gummatous osteomyelitis. If osteoperiostitis is present, there are diffuse swelling and thick- ening of the bone — the so-called sabre-like deformity (Fig. 87). This process may affect the long bones of the upper extremities. The gummatous lesions of osteoperiostitis form numerous irregular pain- ful swellings on the bone. Gummata are present on the flat bones of the cranium. When these break down, the destructive processes may expose the dura mater. Arthropathies with synovitis may be mis- taken for tuberculosis of the joint. This form of synovitis is gener- FiG. 88. Radius affected with osteoperiostitis due to late syphilis. ally bilateral. One of my cases, a child five years of age, gave no history of syphilis. The radius on both sides was affected by osteo- periostitis (Fig. 88). The joints may be deformed by osteophytic growths involving the epiphysis or head of the bone. Ear. — The ear is affected by an otitis with destruction of the ossicles, and even by mastoid disease. In other cases deafness super- venes without premonitory symptoms. SMn and Mucous Membranes. — The skin and mucous membranes show certain stigmata in the form of cicatrices of recent or old ulcera- tions. These may exist on any part of the body, but are especially characteristic on the vermilion border of the lips and at the corners of the mouth, where they are seen as radiating, linear pale-white fissures. Lymph-nodes. — The lymph-nodes may be enlarged, especially 448 TRE SPECIFIC INFECTIOUS DISEASES. those on each side of the neck, below the jaw, and in the axilla and inguinal regions. Spleen. — The spleen is enlarged, but not so frequently as is stated by some authors. Fournier found it enlarged in 15 out of 212 eases. Liver. — The liver was enlarged in 25 cases. In one of my cases of late hereditary syphilis in a child eight years of age, postmortem examination revealed cirrhosis of the liver of the hypertrophic type. There were enlargement of the spleen, icterus, and ascites ; Hutchin- son's teeth were well marked, and there were also adenopathies and changes in the bloodvessels. Mental and Other Symptoms. — Fournier among others has de- scribed forms of idiocy and epilepsy of syphilitic origin, but there is great difference of opinion on this question. The theory of Parrot, that rachitis is the result of syphilis, is now generally abandoned. The deformities of the teeth which occur in late hereditary syphilis will be found fully described in the section devoted to Dentition. Congenital or Hereditary Syphilis. — Etiology.— Congenital or hereditary syphilis results from the infection of the ovule or foetus in utero. This may occur in a number of ways, but in the great majority of instances it results from infection of the foetus through the father. The more recent the syphilis of the father, the more likely is the infection to occur. It is most certain to occur if both the father and mother suffer from recent syphilis at the time of con- ception. The father may at the time of insemination suffer from recent syphilis and the mother be healthy. Under such conditions the child is born syphilitic. The mother may not show any signs of active syphilis either during pregnancy or at any subsequent period. The mother may suckle her offspring, which shows all the marks of active hereditary syphilis, without becoming infected, but the child will infect any strange nurse. The mother has during pregnancy acquired an immunity against the infection. This phenomenon, which is a matter of daily observation, was first brought to the notice of the profession by the distinguished surgeon Colles, and has since become known as Colles's law. The longer the mother is subjected to the influence of the syphilitic virus, the more permanent does her immunity become. Thus a mother who has at first miscarried may eventually give birth to a living infant which bears the marks of syphilis. As the virus becomes weakened, the mother may bear an infant to all appearances healthy. In the interval, although repeat- edly pregnant, the mother has shown no signs of active syphilis. If the father is healthy at the time of insemination and the mother the subject of recent syphilis, the infant will be born syphilitic. On the other hand, if the mother contracts syphilis after conception, the father at the time of conception having been healthy, the infant SYPHILIS. 449 may or maj not be born syphilitic. The nearer the time of the infec- tion of the mother to the end of her period of pregnancy, the more likely is the infant to escape (Monti, Zeissel, Hutchinson). Such an infant if born healthy may become infected in the ordinary way from the mother after birth. A father who has passed through the secondary manifestations of syphilis may in the late secondary period or tertiary stage fail to convey the poison in the sperma. The result will be an infant free from syphilis (Fournier, ITeuman). Yet so far-reaching is the influ- ence of the syphilitic dyscrasia that such an infant, although born healthy and at no time showing signs of syphilis, may present certain signs, such as peculiarities of bone formation (teeth) traceable to the syphilitic virus (parasyphilitic). Exceptions to Colles's law occur, as is to be expected. Fournier has recorded cases in which mothers apparently immune have devel- oped signs of secondary syphilis after the birth of the infant. Finger has met cases in which tertiary syphilis developed in the mother sub- sequent to pregTiancy without the occurrence in her of any of the signs of secondary syphilis. Of 218 mothers who had borne syphilitic infants, Hochsinger found 72 who were free from manifestations of secondary or tertiary syphilis although observed for years. Morbi^ Anatomy. — In considering the pathology of hereditary syphilis, Hochsinger divides the cases into four classes : The first class of cases die in utero before the eighth month. Autopsies upon such foetuses show general parenchymatous involve- ment of the glandular apparatus with epiphyseal osteochondritis. The second class includes infants born living or dead before the end of pregnancy. They present at birth a papulobullous syphilide. In these cases diffuse parenchymatous changes are found in the vis- cera, and frequently marked epiphysitis. The third class comprises infants born living and without any exanthema, but which later develop an exanthema independently of visceral or bony changes. The fourth class comprises infants born without an exanthema, but having at birth marked visceral and bone-changes. The lesions as found in the various parts of the body, in detail, are as follows : SJcin. — We find that the skin shows an increase in the thickness of the rete Malpighii, caused by swelling of the cells of the rete, serous infiltration of this layer, and an increase of the spaces between the cells of the rete. The horny layer of the skin is much thinned in comparison, although there is a constant throwing-off of the cells of this layer in lamellae. The epithelium of the sweat-glands is swollen 29 450 THE SPECIFIC INFECTIOUS DISEASES. ' and there is a small round-cell infiltration between the glands. There is a vasculitis of the small bloodvessels affecting the external coat chiefly. Pemphigus and bullse result from infiltration of the rete and the lifting up and separation of the horny from the papillary layer by serum. The Lungs. — The changes in the lungs may be considered under two heads : First, the lungs of infants born dead or who have died soon after birth, are collapsed, devoid of air, hyperasmic, and dark red in color. In rare cases the lungs may be diffusely whitish yellow in color, giving the appearance of the so-called pneumonia alba. The second class comprises infants that have breathed, and that show a gray or grayish-white discoloration of the lungs in places. There is residual air in the lungs, and they are denser and larger than is normal. Ziegler has shown that the changes in the lungs consist chiefly in an increase in the interalveolar connective tissue, the formation of new vessels, and vasculitis of the bloodvessels. In the majority of newly born infants the alveolar epithelium is but little affected. In pneumonia alba there is a proliferation of the alveolar epithelium, giving a peculiar appearance and color, hence the name. The Liver.- — Changes in the liver are quite constant in hereditary syphilis. These may or may not be associated with enlargement of the organ. Out of 148 cases of congenital syphilis, Hochsinger found the liver enlarged in 46 ; in all but 2 the spleen also was enlarged ; in the severer cases the liver was markedly enlarged. The pathological changes in the liver have been described by Hudelo, Hochsinger, and Heller. There may be simply diffuse, small round-cell infiltration of the interstitial connective tissue, with inflammatory changes in the smaller arteries. The liver in these cases is not enlarged. In the cases presenting an enlarged liver there is interacinous proliferation of connective tissue, beginning at the periportal region and following the course of the bloodvessels. Ther^ is vasculitis, shown in a thickening of the adventitia of the blood- vessels. The parenchyma is degenerated. In other cases interacinous collections of small round cells are on gross sections of the liver seen as yellow pinhead-sized spots. These are called by Hochsinger miliary gummata. Fully developed gummata of large size are very rare in the liver of infants affected with hereditary syphilis. Spleen. — The spleen is in some cases enlarged to ten times its normal size. Gummata, single or multiple, occur, but are rare. In hereditary syphilis not only is the parenchyma increased, but also the connective tissue of the spleen. Kidneys. — In rare cases there are indni'ation and contraction of PLATE XXV r Congenital Syphilis. Showing nasal deformity. Newborn infant. SYPHILIS. 451 the kidnej. The parenchyma is retarded in development by intra- uterine syphilis and the connective tissue increased. Panc7-eas.- — The pancreas may be enlarged and infiltrated, the parenchyma hard, and the interstitial connective tissue increased. There may be condylomatous ulcerations on the tongue, pharynx, and tonsil. Glandular Apparatus. — According to Hochsinger, the glandular apparatus of the gut may show a diffuse small-cell infiltration, Peyer's patches may be infiltrated, and the vessels may be the seat of a vasculitis. The lymph-nodes are, as a rule, little changed except in cases with late manifestations. The thymus gland in cases of hereditary syphilis has been found to be the seat of cystic degenera- tion (Eberle, Ribbert), caused by the dilated epithelial spaces of the foetal thymus. Bone-changes. — The bone-changes in hereditary syphilis occur principally at that part of the bone between the epiphysis and diaphysis in the lower end of the femur, tibia, and radius. In the milder forms of bone-change there is, according to Ziegler, little real inflammation. There are irregularity in the deposit of lime salts and the formation of marrow-spaces. In severe forms there is a true inflammatory process. In the vicinity of the joint-cartilage, grayish- red, yellowish-white, or yellowish-green foci of osteomyelitis are found. The irregular deposit of lime salts and the formation of marrow-spaces are evidenced by reddish-yellow projections of marrow- spaces into the adjacent proliferated cartilage. These give the epi- physeal junction a more irregular and widened appearance than is normal. Sometimes separation of the epiphysis at the junction of the diaphysis occurs. The above changes are frequent, although not constant. In the later stages of syphilis in children there are, as in the adult, caries, necrosis, and gumma formations in the long and flat cranial bones. Symptoms. — The symptomatology of hereditary syphilis varies largely with the class of cases. In some cases the foetus is expelled dead, bearing the marks of fully developed syphilis in the shape of skin, bone, and visceral lesions. In others the infant is born living, but presents a few very characteristic signs of syphilis, such as the presence of buUse or pemphigus either on the palms or on the soles of the feet. The vesicles may be filled with a purulent fluid. As a rule these infants are emaciated. In some cases the bridge of the nose is sharply depressed and forms a distinct angle with the cartilaginous septum (Plate XXVI. ). This intra-uterine deformity in the new- born infant has been studied by Epstein. Such infants sufl^er from a troublesome coryza and cannot breathe freely through the nose. They present enlargement of the liver and spleen, and there may 452 TEE SPECIFIC INFECTIOUS DISEASES. be a few copper-colored discolorations on the skin of tlie forehead and nose. The lips have a shiny, glossy appearance, and after a time may present distinct rhagades. Some days after birth there is a diffuse syphilitic eruption of papules or vesicopapules, with the so-called diffuse induration of the skin of the palms of the hand and soles of the feet, described by Hochsinger. Here and there discol- ored spots which were formerly mistaken for papules may be seen. The skin of the face may have a diffuse coppery color. Patches of discolored skin appear and become confluent, the coryza and rhagades Fig. 89. Hereditary sj-philis ; rhagades and mueous patches of the lips. along the lips and at the angle of the mouth become more marked, and the rhagades bleed easily. In another class of cases the infant is born well nourished and has a good color. Within from two to four weeks a general eruption of ])a])ules and vesico-papuh s appears. Some of the vesico-papules are ]nirulent, and after bursting dry up, leaving the surface covered with crusts on a copper-colored base. In these cases the manifestations on the mucous membranes, including coryza, mucous patches, and rhagades are also gTadually developed (Fig. 81) ). If the above symp- toms are marked, we may find enlargement of the liver and spleen. I have seen the most marked signs of h( rcditary syjjhilis of the skin without the slightest enlargement of the liver or spleen. As a rule, SYPHILIS. 453 the arms will present papules, which may ulcerate at the points of contact with adjacent surfaces of skin. The typical condyloma lata is not frequent in early hereditary syphilis. The nates have a cop- pery shining color, are cracked in places and diffusely indurated (Hochsinger's induration). The trunk may present few symptoms. The bicipital glands are enlarged if the syphilitic exanthema is fully developed. The thighs show brownish, copper-colored patches. These patches give the skin a marbled appearance, which differs from that of the so-called healthy marbled skin in that the discolored areas are surrounded by normally colored skin, while in ordinary marbled skin the opposite condition obtains. On exposed areas, such as the knees, Fig. 90. Congenital syphilis ; circinate syphilide of the nose. nates, soles of the feet, and palms of the hands, the skin is diffusely indurated. In a detailed consideration of the lesions, those of the skin are the first to engage attention. The most common forms of eruption are the papular or the papulopustular form of syphilide. This may be combined with the macular form ; in fact, it is common to find in the same case all forms in various stages of development. The papules occur on the forehead, palmar surface of the hands and plantar surface of the feet, and on the nates (Fig. 90). They show a distinct induration of the skin, are raised above the surface, and have a glossy, copper-colored appearance. On the nates or in the gi'oin the papules may ulcerate ; very rarely these form condylomata 454 THE SPECIFIC INFECTIOUS DISEASES. lata in the early periods of congenital syphilis. The condyloma is a feature of the later period of this disease (Plate XXVII.). Ma- cules develop within the first three months of life, and from the sixth to the tenth week are associated with seborrhoea. Infants thus affected are born with a peculiar anaemia, in which the skin has a cadaveric hue. The macules appear on the forehead and face as copper-hued spots, which increase in number until the skin has a general marbled appearance (roseola syphilitica). They then fade, leaving the sur- face covered with brownish-red areas. These persist around the alse nasi and the forehead for a long time, giving the face a peculiar dirty- yellow spotted appearance. The diffuse syphilitic infiltration of the skin has been studied by Hochsinger, It is not the forerunner or the sequence of any papular eruption. It may be present as in one of my cases in the first week after birth, but appears in the third week in 50 per cent, of the cases, and reaches its height between the eighth and the tenth week. It first presents discolored areas on the palms and on the soles of the feet, on the nates, the calves of the legs, also on the cheeks and chin, where it forms rose-colored or copper-colored areas which coalesce. The soles and palms may appear diffusely red or bluish and glossy. The skin is dift'usely thickened on the palms and soles and desqua- mates in lamellae. At the junction of the mucous membranes and skin fissures result on account of the thickening of the skin. The lips appear anaemic as a result of the infiltration of the mucous membrane, and are fissured. There are rhagades at the alae nasi. The rhagades at the angles of the mouth are covered with a bluish-white pellicle, and the surrounding skin is copper-colored. There are swelling of the nasal mucous membrane with a thin, purulent discharge mixed with blood. The hair falls out on account of the infiltration of the scalp; the scrotum is thickened and fissured from the same cause. The blood shows all stages of anaemia, from the mildest to the grave pseudoleukaemic anaemia of von Jaksch, which some authors trace to syphilitic influences. The bones are affected with an osteochondritis, already described. This may appear in the first few weeks or at a much later period. It manifests itself l)y ])(iiii in moving the joints. The infant cries when handled. The mother notices that one or the other arm lies motionless at the side, and that every attempt to move it causes pain. Parrot described this condition as a pseudoparalysis. At the junction of the epij)hysis and diaphysis at the lower end of the humerus or radius the bone may be swollen and painful. As a rule, the process affects the upper extremity on one side (m]y, bnt in severe cases both the upper and lower extremities may be involved. In some cases this symptom may be present without a skin eruption. The other conditions which > X X w < (D cn < <:•-. en i: -^ (^ S >> -»-) c (D ^ h -a .^ r m u ^ 01 _r; 0- C >< "^ m 01 _, 03 03 s C 0) m >j o 73 U U SYPHILIS. 455 simulate it are septic osteomyelitis involving the joints, scurvy, and severe rachitis. I have known instances in which prolonged obser- vation was necessary to clear up the case. A very characteristic but not common affection of the bones is the so-called dactylitis syphilitica (Fig. 91). This may appear as early as the fourth week, and may be associated with swelling of the epiphyses of the long bones. It consists of a fusiform swelling of the phalanges of one or more fingers. According to Taylor, this is primarily a gummatous infiltration of the skin, the periosteum, bone, and epiphyseal cartilage. In another form the periosteum and the Fig. 91. Congenital syphilis ; onychia of all the nails ; dactylitis of the phalanx of the index finger. Infant, four months of age. bone itself are the seat of the gummatous inflammation, the epiphysis and the joint becoming involved later in the process. In neglected cases, fistulee and destruction of the joint may result from necrosis of the epiphysis. The diagnosis of these forms of dactylitis from tuberculous spina ventosa is sometimes difficult, and often impossible without mercurial treatment. Cases of rachitis which involve the phalanges of all the fingers simulate very closely the above affection (see Rachitis). Syphilitic affection of the liver gives no symptoms. Henoch records cases in which icterus was associated with enlaro;ement of 456 THE SPECIFIC INFECTIOUS DISEASES. the organ. Hochsinger denies the occurrence during the nursing period of any authentic case of syphilis of the liver with icterus or ascites. Sonima, Fischl, and Kohts have described symptoms of cerebral syphilis in infants that were subjects of hereditary syphilis. Con- vulsions, hydrocephalus, epilepsy, and paralyses have been traced to the presence of gummous meningitis or sclerosis. That such changes occur as a direct result of syphilis at so early a period is doubted by Henoch. I have not seen manifestations of cerebral syphilis in in- fants. Henoch is also inclined to include Mracek's cases of hemor- rhagic syphilis among the septic diseases of the newborn occurring in syphilitic infants. Antonelli in 1897 described changes in the fundus oculi of new- born syphilitic infants. These consisted of optic neuritis, retinitis Fig. 92. Hereditary syphilis ; gummata of the cranial bones. Child, eighteen months of age. vascularis, and retinochoroiditis. He believes these changes to be causative in the production of myopia and strabismus in such infants. Diagnosis. — The diagnosis of hereditary syphilis is not difficult in the vast majority of cases. If the fcetus is expelled dead it bears the marks of syphilitic infection, such as bullae and affections of the internal organs. Maceration alone is not indicative of syphilis. If the infant is born living, the evidences of syphilis are sometimes very few and equivocal. After a few months the diagnosis will sometimes be difficult ; the eruption will have disappeared, leaving only an anaemia of uncertain origin, with a few discolored areas about the nasolabial folds and around the temporal region. There is a suspicious dirty-looking SYPHILIS. 457 seborrhoea of the supra-orbital region. A rebellious anal eczema or copper-colored intertrigo which resists treatment should arouse sus- picion. Pustular papules are not pathognomonic even if combined with joint-affections. A case came under my notice in which an infant had a varicella-like eruption with a painful swelling of the right elbow-joint. A diagnosis of epiphysitis syphilitica had been made and the eruption had been mistaken for a syphilide. The color of the eruption was not that of a syphilide. Expectant treatment and immobility of the joint proved, after a few days, that the case was one of varicella with the joint-complication sometimes seen in that disease. In the diagnosis of late hereditary syphilis the symptomatology is of service. In cases with bone-lesions it is often very difficult to differentiate it from tuberculous affections (Fig. 93). An active course of treatment then becomes necessary, with a view to diagnosis; This is especially the case in arthropathies, and also in late forms of dactylitis. Fig. 93. Tuberculous affection of the bones of the hand simulating syphilitic disease. Child, sixteen months of age. Both in the hereditary and acquired forms of syphilis the Spiro- chgetse are found in the blood at a very early period of the disease. In the acquired form it is found three weeks before the appearance of the roseola. In the congenital form it is found in the blood and internal organs and in the lymph which bathes the skin lesions, such as moist papules. Inasmuch as the recognition of Spirochsetse re- quires special apparatus and skill in staining, an expert must decide their presence. This is also the case with the Wassermann blood reaction. Prognosis. — The prognosis as to life depends upon several factors. A breast-fed infant is more likely to survive than a bottle-fed infant. The possibility of complete restoration to the normal is slight. The 458 TKE SPECIFIC INFECTIOUS DISEASES. majority of infants bear the marks of the disease into adult life, even under very favorable conditions of treatment and environment, and develop late in life the so-called late symptoms of hereditary syphilis. Some infants while progressing favorably under treatment, die suddenly without apparent cause ; others remain stunted and deli- cate throughout childhood. Eachitis and its sequelae seem to be very prevalent among infants who are the subjects of hereditary syphilis. Treatment. — The treatment of congenital syphilis may be either internal, by inunctions or subcutaneous injections. I have found internal treatment to be the most satisfactory. The effects of mer- cury are not so injurious as is the case with the inunction methods. The drug employed was calomel in combination with the saccharated ferric carbonate (this was a favorite remedy with Widerhofer) : Calomel gr. ^ (0.01). Ferri carb. sacc gr- iij (0.18). Ft. pulver. A powder of this size may be given every three hours or four times a day. Some authors (Baginsky) prefer the protoiodide of mercury, grain i to 2 (0.01 to 0.03). If there is intolerance to calomel, satis- factory results may be obtained by the use of Lustgarten's preparation of hydrarg. oxydulatum tannicum, in doses of grains ij to v (0.1 to 0.3), repeated every three hours or four times daily. If the rhagades, especially those about the anus, bleed or heal slowly, they should be stimulated with a weak solution of silver nitrate. Calomel should be dusted upon condylomata lata three times daily. Baths of sublimate are recommended in severe cases of pemphigus, but it is not often necessary to resort to them. Infants in the nursing period do not bear inunctions well. I have seen several cases treated by this method which lost weight rapidly or died suddenly, and this has been the experience of others (Monti). The old method was to place grains viij to xv (0.5 to 1.0) of unguentum hydrarg. under the flannel abdominal binder daily, and allow it to be absorbed, or the same quantity of ointment was rubbed in daily on various parts of the body. Severe rhinitis is best treated by washing out the nasal passages once a day with a solution of corrosive sublimate (1:2000). The small glass syringe with a blunt soft-rubber nozzle is best for this purpose. After the syringing, unguentum iodoform is applied to the interior of the nose by means of a camel's hair pencil. How long should treatment be continued ? No matter what method of treatment is adoi)ted, mercury should be administered until all discoloration of the skin has disappeared. To attain this result ACUTE ABTICULAB EHEUMATISM. 459 will take a varying length of time in different cases. After the skin is clear and the anaemia has disappeared, it is well to cease the admin- istration of drugs and observe the patient for further symptoms. Sometimes a patient will be brought to the physician for the treat- ment of a rebellious intertrigo long after all signs of general syphilis have disappeared. Such an intertrigo may have a copper color, and may ulcerate, the ulcers having a peculiar lardaceous appearance. In these cases, even if all other signs of congenital syphilis are absent, the internal administration of mercury gives brilliant results. The treatment of late hereditary syphilis will depend much upon the nature of the therapeutic measures adopted earlier in life. In the majority of cases, the subjects being in later childhood or adoles- cence, it is well to begin treatment by a full inunction course, conducted on the same plan as with adult subjects with acquired syphilis. In addition, if gummatous affections of the bones are present, and if as in one of my cases visceral lesions, such as enlargement of the liver, have appeared, the patient is put upon gradually increasing doses of iodide of potassium. In one of my cases large doses of iodide of potassium failed to relieve the intense headache. This patient mar- ried, and after having a miscarriage gave birth under specific treat- ment to a healthy infant. The treatment of acquired syphilis does not differ from that of congenital or late hereditary syphilis. ACUTE ARTICULAR RHEUMATISM. (Polyarthritis Eheumatica; BJieumatic Fever.) Etiology. — Although acute articular rheumatism is still regarded by some authors as a constitutional disease caused by disturbances of nutrition which result in local manifestations, the general tendency is to regard it as an acute, infectious disease. The infectious agent, whether bacterial or toxic, attack the serous cavities, such as those of the joints, the pericardium and endocardium, and the pleura. The resemblance of rheumatism, especially in children, to the infec- tions is sufficiently great to warrant a serious consideration of this theory. Thus in septic endocarditis in children, as in the adult, there are symptoms of pain in the joints. Chronic cases of endocarditis of a rheumatic nature in course of relapse occasionally take a septic course. There are found circulating in the blood streptococci of dif- ferent grades of virulency. Certain diseases, such as erythema nodo- sum and peliosisrheumatica, in which the joint-symptoms are marked, are regarded as being caused by infection of a bacterial nature. I have seen such a case of peliosis. In other diseases, such as scarlet fever, measles, and varicella, there are joint-affections which are recognized to be of an infectious nature. Lastly, both American 460 TEE SPECIFIC INFECTIOUS DISEASES. (Packard) and Englisli writers liave called attention to the well- observed clinical fact that there are forms of rheumatism and endo- carditis which follow attacks of tonsillitis of the lacunar type or accompany them. It is true that the infectious agent, whether bac- terial or toxic (Chvostek), is still to be discovered. Time may show that not one, but a variety of micro-org-anisms are capable of causing rheumatism of the acute articular type in a susceptible organism. Streptococci, the so-called Streptococcus or DijDlococcus rheumatica, have been found in the exudate of the joints (Hlava) and in the blood. Staphylococcus aureus, citreus, and albus have been found in the blood (Gutmann, Tizzoni, Bouchard). The pneumococci of Frankel and the Diplococcus tenuis have been found in the joints (Leyden). Singer has found similar micro-organisms in the urine. Heredity is among the predisposing causes. Children whose parents are markedly rheumatic, may suffer severely from the affec- tion. Cold and exposure certainly predispose to the disease or pre- cipitate attacks. The disease is common in countries such as England and America, in which climatic influences are favorable to its devel- opment, and is especially prevalent in the moist and cold seasons of the year. Age. — Rheumatism has been described as occurring in early in- fancy (Jacobi). I have published a case in an infant of nine months. Rauchfus, Chapin, and others have also described cases in infants. These cases were collected by Miller, who, with his own case (nine months), found 19 authentic cases in the literature in nursing infants. Although rare in infancy, rheumatism is not uncommon in children from the fifth to the tenth year. The majority of the cases of rheu- matism occur between the tenth and the twentieth year. Sex. — Among adults, males are more subject to the disease. In children, however, although certain observers contend that it is more prevalent among girls, other statistics show that it has the same fre- quency of occurrence in the sexes. Symptoms. — Certain peculiarities, pointed out by Jacobi, seem to differentiate acute articular rheumatism of infants and children from the same affection in adults. But few joints are attacked. The pain and swelling are generally not very marked. The redness of the joints is slight or altogether absent. The temperature is rarely high. The smaller joints, such as the maxilla, sternoclavicular articulation, and those of the vertebra3, are rarely attacked. The larger ones, such as the ankle-, knee-, and wrist-joints, are most commonly affected. Cardiac complication is the rule. As Jacobi has pointed out, endocarditis is sometimes the first manifestation of the disease. In many cases obscure pains in the joints of months' duration precede the development of a murmur. ACUTE ABTICULAB BHEUMATISM. 461 Clinical Types. — In infants and young children the first signs are swelling and pain in the affected joints. The infant in the nursing period cries, has fever, and is restless. On investigation it is found that the patient favors one, extremity, and shrieks v^ith pain when it is touched. Children of two and one-half years or more refuse to walk, and will complain of the affected joint, ankle, or knee. There will be fever and constitutional symptoms. The ankle, and in some cases the smaller joints of the foot are swollen. One of the knees, the wrist, and elbow may also be swollen, red, and painful. The fever rarely rises above 103° or 103.5° F. (39.4° C). In other cases there are fever and restlessness, and sometimes pains of an indefinite character in the joints. A history of pain may be elicited by careful questioning and examination. Monarticular pain is very characteristic of the form of rheuma- tism seen in children. Still and Barlow call attention to the fact that a pain in the hip may be mistaken for tuberculous hip-disease, when in truth it is rheumatic. I have seen these cases, but have been impressed with the fact that in infants scurvy also begins in this way. The physician may find an angina, slight or marked; the heart may show signs of endocarditis of an acute type. There are pains in the joints but no true rheumatic swellings. The pains more closely resemble those in uncomplicated angina tonsillaris. In older chil- dren, a history of joint-pains with endocarditis may be obtained. In other cases, the pains in various joints are the only symptoms. There is no swelling or redness, and no endocarditis. Some cases have no fever. The classical cases, however, closely resemble those of the affection as seen in the adult. There may be premGnitory symptoms, but as a rule the patient is brought to the physician with the enlarge- ment of the joints fully developed. After the joints have become enlarged they may return to the normal in a few days, but may again be the seat of pain and swelling. The swelling in the joints of chil- dren does not persist as long as in the adult subject, and as a rule children are less disabled. In many cases there are gastric pains. The children do not show any greater tendency to perspire than adults. Endocarditis. — Endocarditis is usually a complication of rheu- matism in children. Its absence is rare. Only 2 of 15 of my hos- pital cases were free from cardiac complication. The most common cardiac lesion is found at the mitral valve and is manifested by a single systolic murmur at the apex. Three of the cases showed the presence of a double mitral murmur. Endocarditis sometimes does not reveal its presence by any symptoms, and is only discovered on a careful examination. In many of the cases there is also a peri- cardial friction first heard at the apex or base of the heart. The pericardial friction is more common in children than is generally 462 TEE SPECIFIC INFECTIOUS DISEASES. supposed. The pericarditis frequently remains in the dry friction stage, and does not advance to effusion. Pleuritis and bronchopneu- monia are among the less common manifestations. The endocarditis sometimes occasions pain and distress. The presence of endocarditis as an acute affection in first attacks of rheumatism has been dilated upon in the section on Endocarditis. Chorea. — The relationship of chorea and rheumatism has been discussed. I have seen a child of two and one-half years born of a rheumatic mother, develop first rheumatism and endocarditis, and, within a few days, marked chorea. On the other hand, in many cases of chorea, there is neither endocarditis nor a history of rheumatism in children or parents. The statistics of chorea in hospital service show a greater frequency (39 per cent.) of cardiac disease with or without a history of rheumatism than the ambulatory cases. This is explained by the fact that only the severer cases of chorea come to the hospital. Prognosis.- — The prognosis of acute articular rheumatism in in- fancy is good as to life. On the other hand, it is a disease which is likely to recur and to be complicated by endocarditis. The latter fact should cause the physician to reserve any definite prognosis until the course of the disease has been carefully studied. The prognosis of rheumatic endocarditis can never be definitely made. All depends on the amount of damage done to the valves and the frequency of the recurring attacks. Treatment. — The treatment of acute articular rheumatism in chil- dren is not essentially different from that followed in the adult. Sali- cylic acid, bicarbonate of sodium, salicylate of sodium, aspirin, and oil of wintergreen are the remedies usually given. The bowels should be kept open with an alkaline cathartic. The Carlsbad salt or Rochelle salt given daily is best adapted for this purpose. The patient is put on a milk diet ; fruit juices are allowed. The patient is kept in bed. The affected joints, if painful, are either immobilized or wrapped in cotton. Some prefer to paint the joints with a solution of oil of wintergreen, and then wrap them in cotton. Salicylate of sodium is given internally in doses of grains ij to v (0.12 to 0.3) according to the age. A grain of salicylate of soda is given for every year of the age combined with twice the quantity of bicarbonate of soda. Young children are given a dose every three hours. Older children are given doses of grains vij to x (0.5 to 0.6). The effect is watched. Salol or salophen may be given. The sali- cylates sometimes not only act as irritants to the stomach, but also have no appreciable effect on the course of the disease. Aspirin has in my hands been useful in cases in which the salicylates were inef- fective. In some cases I give bicarbonate of sodium in increasing ACUTE AETICULAE SHEUMATISM. 463 doses until the urine becomes alkaline. Endocarditis is treated on the principles laid down in the section on that disease. While under treatment the patient is given alkaline waters. During convales- cence the various preparations of iron are of great value. The prepa- rations of lithium are useful in cases in which there are indefinite pains in the joints. The carbonate is given in doses of grain j (0.06) three times daily. It is given in capsule to older children after meals. The method of treating rheumatic subjects by the occasional administration of salol or salicylates for months has been suggested. The salicylates upset the stomach, so that the alkalies alone are avail- able. The patient is given grains v (0.3) of sodium bicarbonate twice daily. Vichy water is used regularly. In some cases the tablets of vichy taken once or twice daily are of great value. Rheumatoid Arthritis {Arthritis Deformans; Still's Disease'). — This affection should be sharply differentiated from all forms of chronic or subacute articular inflammation. Charcot and Weil have described this form of arthritis in children. The cases are not com- mon. After the publication of my case, two others were described in the American literature, one of the descriptions being given by Manges. Cases of arthritis deformans or rheumatoid arthritis in children are referred to by Osier (4 cases) and Henoch (5 cases). Symptoms. — The onset of the disease is -either sudden after an exposure to cold and wet, or slow. In one form, after an onset of chills and fever, soreness and pain in several joints appear. The child is at first able to be about, but, as the joints become more and more affected, complete disability results. The pain in the joints becomes so marked as to interfere with sleep. After a few months the patients may be unable to walk. In some cases the enlargements and pain begin in the lower extremities and gradually involve other joints. In others the onset is slow. The joints of the upper and lower extremities gradually become painful, and after repeated attacks remain swollen and limited as to motion. The ends of the bones are enlarged and there is effusion in some joints. With the progressive involvement of the joints there is atrophy of the muscles, as in the adult form of the disease. When the disease is fully developed the condition is pitiable. In my case almost every joint in the body, including those of the cervical vertebrae, was involved; the temporo- maxillary articulation, the shoulder, the elbow, the small finger-joints, the hips, knees, ankles, and toes, were all affected. The patient slept in a semi-upright posture, and had to be carried from place to place. There was very limited and painful motion in all the affected joints (Fig. 94). Brabazon found that of 100 cases of this affection, only 3 per 464 THE SPECIFIC INFECTIOUS DISEASES. cent, occurred between the ages of five and fifteen years. Two theories have been advanced to exjDlain this j oint-aif ection ; one, that of Charcot and Weil, is the neurotic theory, which is plausible because of the bilateral nature of the aft'ection, the atrophy of the muscles around the joints, the changes in the skin which becomes in time tense and shining, and the enlargement of the ends of the bones which enter into the formation of the joints. The infectious theory is sup- ported by the fact that there is in many cases a diurnal fluctuation of temperature of a degTee or a fraction of a degTee above the normal. Fig. 94. Rheumatoid arthritis in a child seven years old. Deformity of all the joints with fixation. Child forced to assume this attitude awake and in sleep. The lymph-nodes are enlarged ; the liver and spleen are also enlarged in some cases (see Still's Disease). The heart is not usually involved. Prognosis. — The prognosis as to life is good. Treatment. — Treatment Ijy massage, warm baths, and patient manipulation of the joints under anesthesia, may effect slight im- provement. In my case improvement was noted after a year of con- stant treatment. Iodide of potassium is the only drug which relieves ACUTE ABTICULAB RHEUMATISM. 465 the pain. In some cases it exerts a favorable influence upon the course of the disease. Still's Disease. — This form of rheumatoid arthritis probably be- longs in the same class as that just discussed. It is described by Still and is thought by him to be essentially peculiar in its symptom- atology to children. Etiology. — It is apparently an acute infection of obscure etiology, rheumatoid in its nature, afl'ecting for the most part the larger joints, especially the elbows, wrists, knees, ankles, and in some cases the smaller joints, especially of the fingers. Fig. 95. still's Disease in boy of eight years. Large and small joints affected, also cervical vertebrae ; enlarged lymph nodes, liver and spleen. Symptoms. — It is accompanied by periods of pyrexia and hyper- pyrexia and what is mainly characteristic, enlargement of the lymph- nodes, liver, and in most cases of the spleen. The joints of the cer- vical vertebrae were involved in the cases described by Still. There was no clinical involvement of the heart, though postmortem there was adherent pericardium in some cases and mitral involvement in another (Fig. 95). The condition in half the cases began before the second dentition, girls being more often affected than boys. The enlargement of the 30 466 THE SPECIFIC INFECTIOUS DISEASES. joints is fusiform without redness but with varying amount of ten- derness. There may be limitation of pain and in three of my cases there was limitation of motion. The lymph-nodes affected are the axillary, epitrochlear, and posterior cervical. In some cases the spleen was not enlarged. Still wishes to place these cases in a dis- tinct class on account of the enlarged lymph-nodes, spleen, and liver. I have had four cases of this form of rheumatoid arthritis, one of which made a very excellent recovery. Treatment. — The treatment is 1he same as in rheumatoid arthritis. Other Forms of So-called Rheumatism. — (Rheumatoid Affec- tions). — There are three forms of joint-affection which it is not yet advisable to class with true articular rheumatism, but which are con- stantly and incorrectly called rheumatic. Gonorrhceal Form. — The gonorrhoeal form of rheumatoid affection is seen in infants and children who suffer from gonorrhoeal vulvo- vaginitis or urethritis (Hartley, Koplik, Moncorvo). It may be monarticular or many joints may be affected. It is not, as a rule, combined with endocarditis. I know of no such case in the literature. Peliosis. — Cases of so-called peliosis rheumatica closely resemble acute articular rheumatism. I have seen several in older children. In one there were for weeks repeated painful swellings of the joints, with purpuric eruption about them. The gastric pains and critical sweats so often seen in rheumatism were present. These cases rarely present a temperature above 100.5° F. (38° C). They show no cardiac lesion. Tonsillitis with Joint-pains and Endocarditis, — Under the proper heading I have referred to cases of tonsillitis with indefinite pains in the joints and complicated with endocarditis. Erythema Nodosum. — I have seen many cases of erythema nodosum in children. In all, the typical painful swellings on the anterior aspect of the tibia were present. There were also joint-pains, but in only 5 cases could I establish the presence of an endocardial murmur. I am therefore not willing to accept without reserve the contention of French authors that endocarditis is frequent in these cases. Subcutaneous Rheumatic Nodules. — The so-called subcutaneous rheumatic nodules are seen in children less frequently in this country than in England. They occur in endocarditis, and were present in 20 per cent, of Coult's cases (Donkin). They may be present in the absence of fever or in the febrile stage of rheumatism. They may be minute or of the size of an almond. They appear in crops, and may alternately appear and disappear for weeks. The nodules occur about the joints, elbows, knees, patella, over the vertebrae and scapula, and are freely movable under the skin which is not discolored. I have seen them in a case of rheumatoid arthritis, and also in one of peliosis rheumatica. ACUTE AETICULAB EHEUMATISM. 467 Muscular Rheumatism. — Muscular rheumatism is rare in infancy and childhood. Henoch describes cases of contracture of the muscles of the neck and of the nape of the neck. Among such contractures are forms of torticollis which are said to have a rheumatic origin. I have met many cases of torticollis in v^hich v^ith the contracture there was swelling of the cervical lymph-nodes. In such cases I have found eczematous affections of the scalp. It is possible that there was an acute infectious neuritis or myositis. There may, however, be cases resting on a purely rheumatic basis. All forms of torticollis due to hsematoma of the sternomastoid muscles or to cervical bone disease, glandular disease, or neuritis should be excluded before a definite con- clusion is reached. Henoch also refers to contractures of the abduc- tors of the thigh which are of rheumatic origin. I have never seen cases of the kind. SECTION VI. DISEASES OF THE MOUTH, TONGUE AND (ESOPHAGUS. DISEASES OF THE MOUTH. Physiological Facts. — The mouth of the infant up to about the eighth month is devoid of teeth, and thus nature indicates that the infant is not prepared to masticate solid food. The salivary glands show very little activity in the first three months of infancy, the secre- tion of saliva at this time being small in quantity. In the newborn, before it has partaken of food, the reaction of the secretions of the mouth is neutral or slightly alkaline. Though an amylolytic ferment is present in the secretion of the parotid gland in the first days after birth (Zweifel), the function of this ferment is as yet a matter of speculation, inasmuch as the food of the newborn breast-fed infant contains nothing in which the action of such a fer- ment might be manifest. Of interest is the act of nursing, which in the infant takes the place of the process of mastication. Physiology of the Act of Nursing. — If an attempt is made to feed the newborn infant with fluids, either from the spoon or pipette, there follows an abortive attempt at swallowing, accompanied by choking; it thus requires some skill and practice to induce the newborn infant to swallow fluids administered in this way. Not so with the breast. The newborn child instinctly takes the nipple of the breast, and nurses without previous education or preparation. The act of nursing, there- fore, is purely reflex. Thompson has described the so-called lip reflex. If the infant at rest or sleeping is gently tapped or touched on the upper or lower lip in the neighborhood of the commissure, there follows a reflex movement of the lips. If they have been separated, they close and form themselves into a pouting position; in other words, they purse themselves as if in readiness to take something into the mouth. The breast-nipple, therefore, performs a function for the infant similar to that of the finger in producing this so-called reflex of the lip. The nipple once having touched the lips of the infant is re- ceived by the pursed lips into a funnel-shaped opening, and the lips grasp the nipple and some of the adjacent skin. It is received be- tween the hard palate above and the superior surface of the tong-ue 468 DISEASES OF THE MOUTH. 469 below. The lower jaw aids in making tlie contact between the lips and the nipple complete. The act of nursing itself is the estab- lishment, first, of a negative pressure, caused by the act of suction, equal to 0.5 to 0.9 centimetres of mercury. This alone would not determine the flow of milk into the mouth of the nursling were it not for the muscular pressure from below of the lower jaw. The combined force of the negative pressure produced by the act of suction and the muscular pressure from below on the nipple as it joins the breast is equal to 4 centimetres of mercury. This has been shown experimentally to be quite sufficient to determine a steady flow of milk from the breast into the mouth of the nursling. It takes from three to four acts of suction and muscular pressure to fill the mouth sufficiently to cause one act of swallowing on the part of the infant. Landmarks of the Normal Mouth. — There are certain localities of the mucous membrane of the mouth which are especially liable to aphthae or ulceration. Among these we must mention the mucous membrane over the hamular process of the palate bone, where it is normally paler than the surrounding tissue. This pale area on either side of the median line may be the seat of the so-called Bednar's aphthae. Midway in the raphe of the hard palate in most newborn infants are seen one or two, at most three, yellowish- white, sago-like objects; these are called Epstein's pearls, because they were first described by this clinician. They are collections of epithelial cells, the remains of embryonal formations. These epithelial pearls are quite susceptible to traumatism, and if injured in any way become the seat of ulceration. Laterally on the hard palate over the alveolar process, above and below the mucous membrane is thin and has a white reflex. Any slight traumatism in this locality may cause ulcer- ation. The tonsils of the newborn infant are scarcely visible. The posterior pharyngeal wall is glossy, of a bluish-pink color. On closer examination of the fauces of infants, bodies resembling drops of dew or vesicles are seen just in front of the tonsil. These are collections of lymphoid tissue, and are normal to the infant's mouth. They may become inflamed and form aphthous ulcerations, and when so inflamed are called herpes of the tonsil. There are also visible on the soft palate of children minute miliary, transparent bodies resembling vesicles, which are likely to enlarge in any disease affecting the mucous membrane of the mouth, as in the exanthemata. These also are aggregations of lymphoid tissue. Bacteria of the Mouth. — The bacterial flora of the mouth of the infant have been the subject of investigation by Lewkowicz. Only the leading flora can be mentioned here : the pneumococcus, which is constantly present but not pathogenic ; the streptococcus, in long chains similar to the pyogenic variety but not pathogenic ; the Strep- tococcus salivse of Veillon, the Streptococcus aggregatus of Seitz, the 470 DISEASES OF THE MOUTH. Staphylococcus pyogenes albus, the Streptococcus intestinalis or en- teritidis of Escherich, the Micrococcus candidans (Fliigge), the Ba- cillus acidiphilus of Moro, the most constant and frequent of the bacillary group ; and the pseudodiiDhtheria bacillus. There are also, strange to say, anaerobic bacteria to be found in the mouth of infants, the most important being the Bacillus bifidus communis of Tissier. In all there are 23 varieties of bacteria normal to the buccal cavity of nursing infants. Normal Dentition. — The teeth, both temporary and permanent, are contained in the so-called tooth-sacs, which are situated in the alveolar process of the upper and the body of the lov^er jaw. The formation of these sacs begins in the sixth month of foetal life, by a coalescence of the folds and papillae formed in the jaw. There are twenty temporary teeth, and the sacs of the permanent teeth are situated against the posterior wall of the sacs of the temporary teeth, and probably communicate with them. As a result of the growth of the roots of the teeth, the temporary teeth are pushed through the cartilaginous border of the jaw and the mucous membrane, and thus appear externally. Temporary or Milk Teeth. — The eruption of the temporary or milk teeth begins about the sixth or seventh month with the lower incisors, and ends about the third year with the posterior molars. The erup- tion of the teeth, even in normal infants, varies within wide limits, some infants being precocious and others late in this process, without necessarily showing any signs of bone disease, such as rachitis. We might gToup the eruption of the milk teeth into five groups as follows : The first would include the two lower incisors, which erupt at from the seventh to the ninth month. There is then an interval of from three to nine weeks, when the second group, consisting of the four upper incisors, appears from the eighth to the tenth month. After this there is an interval of from six to twelve weeks, when the third group appears. This consists of the first molars and two lower lateral incisors, which erupt from the twelfth to the fifteenth month. An interval of three months then occurs, and the canines appear in the fourth group from the eighteenth to the twenty-fourth month. There is an interval of two months, and the four second molars ap]iear. At the fifth or sixth year the third molar appears, and then the second dentition begins. As exceptions to the al)ove order, we may have the two upper lateral incisors delayed until the sixteenth month; the two upper incisors and the four posterior molars may be delayed as late as the thirty-sixth month. At the twelfth month an infant should have the four upper and two lower central incisors, with two lower lateral incisors coming. The lower incisors may not appear until the eighth or ninth month, and then be followed rapidly by others. I have seen DISEASES OF THE MOUTH. 471 several infants with one or two incisors at birth ; they, as a rule, were imperfectly formed and resembled canines. These prematurely erupted teeth should be extracted if they interfere with nursing and lacerate the nipple of the breast. In some cases the upper incisors may appear first, and rarely canines may appear before molars. Permanent Teeth. — The second dentition begins at the end of the sixth or seventh year with the eruption of the first molar behind the second temporary molar. The milk teeth at this time loosen because their arteries become obliterated, the nerves disappear, the alveolar sacs enlarge, and they fall out or may become carious. The perma- nent teeth appear in the second dentition, as has been said, very much in the order that the milk teeth appear — the central incisors about the eighth year, the lateral incisors at the ninth year, and the last molars from the eighteenth to the twentieth year, or even later. Abnormal Dentition. — Rachitis. — Rachitis is a common cause of delayed dentition. Artificially-fed infants are backward in cutting their first incisors. It is common to see bottle-fed infants cutting the lower anterior incisors at the ninth month. The infants may be in other respects normal. Rachitis affects the teeth of the first denti- tion mostly, but may influence the form and structure of the teeth of the second dentition. The teeth of the first dentition in rachitis are easily broken and are unnaturally white. In many cases the anterior incisors show an incurvation on the lower cutting edge, which is often mistaken for Hutchinson's deformity. The first teeth in rachitis are easily eroded. It is not uncommon to see a rachitic infant with its whole dental system in process of decay. The permanent teeth pre- sent abnormalities in inordinate size and longitudinal furrows. Sjrphilis. — The permanent teeth are affected by syphilis in a char- acteristic fashion. Fig. 96. Hutchinson's teeth in a boy, twelve years of age. Hutchinson s Teeth. — Hutchinson's teeth are so called because they were first described by Jonathan Hutchinson. They are the only teeth of the permanent set which are pathognomonic of congen- ital or very early acquired syphilis (infancy) (Fig. 96). In a large 472 DISEASES OF THE MOUTH. experience with syphilis in infancy and childhood I have seen but few perfect examples of these teeth. The teeth presenting the de- formity are the central upper incisors of the permanent set, and these only. " These teeth show a central single, rather broad notch." In this notch the dentine, lightly covered by enamel, is exposed. It is Fig. 97. Permanent teeth deformed through stomatitis in early childhood, resembling Hutchin- son's teeth. Female child, nine years of age. Fig. 98. seen as a ridge in the incurvation. The teeth are shorter and broader than is natural, and almost always have their angles sloped oif . They are thus narrower at their cutting edge than higher up. They are seldom or never of good color, and frequently are not placed quite straight, but slope either toward or away from each other. Teeth which are the seat of erosion may resemble Hutchinson's teeth (Fig. 97). Fournier has described teeth in the temporary set which closely resembled Hutch- inson's teeth. I have met an exquisite ex- ample of such teeth in an infant sixteen months old, the subject of syphilis (Fig. 98). In syphilitic subjects we find the follow- ing def onnities in the permanent teeth. These peculiarities are not characteristic of syphilis alone, but are found in those who are not syphilitic, but have suffered from stomatitis or dyscrasia of some kind. The changes are bilateral and symmetrical. Dental Erosions. — The most important erosions, such as those of Hutchinson just described, affect the central incisors. Other erosions give the teeth an incurvated appearance on their cutting edge. In this incurvation is seen a supernumerary crown ribbed in a longitu- Central upper Incisors of the first dentition resem- bling Hutchinson's teeth. Syphilis of the flat and long bones. Child, sixteen months of age. DISEASES OF THE MOUTH. Al?, dinal direction (Figs. 99 and 100). The whole may be mistaken for Hutchinson's deformity. They result from malnutrition or stoma- titis with faulty formation of dentine and enamel deposit in the eruptive period of the permanent teeth. The first molars show very characteristic deformities, which Fournier places next in importance to those of the Hutchinson teeth, but does not regard as pathog- nomonic of syphilis, although they are met in syphilitic subjects. This deformity of the first molars is shown in Fig. 101, taken from a Fig. 99. I'IG. 100. Upper central incisors, with erosions not syphilitic. Lower incisors, with erosions not syphilitic. Child, eight years of age. child who showed other erosions, but gave no history of syphilis. I have seen these erosions very well marked in children who had posi- tive syphilitic manifestations. The top of the crown is constricted, and there appears to be a double crown. Erosions are also seen in the canine teeth. Microdontism. — The teeth are quite small, but if cared for remain perfect in shape,, pearly and transparent. They are seen in children Fig. 101. Fig. 102. Erosion of molars, not nec- essarily syphilitic. Molar tooth, showing erosion at crown. Boy, twelve years of age ; same patient as with Hutchinson's teeth. whose parents may have suffered from syphilis. The children may also have obstinate eczema of the anus (parasyphilitic). Micro- dontism may occur also as a result of any non-syphilitic dyscrasia. Dental Infantilism. — Dental infantilism, described by Fournier, occurs in children who are syphilitic. Small teeth presenting ero- sions are interspersed among teeth which are normal in size and shape. Amorphism. — Amorphism, or the tendency of a tooth, such as the 474 DISEASES OF THE MOUTH. incisor, to take the shape of a canine, has been noted by Fournier. I have also met with cases of this deformity in congenitally syphilitic children. It is seen in children who have had syphilis, but may be met with in those who have no snch history. Children, subjects of syphilis, do not always present deformities of the teeth. In a girl of fourteen years, who gave a history of infan- tile syphilis, and who had late manifestations, such as gummata in almost all the bones, joint-affections, and gummata of the liver, the teeth, both ujDper and lower, were normal and of great beauty. Pathology of Dentition. — The period of infantile dentition is one of gTeat physiological activity and growth. The organism is forming at this time. The nervous system is in a condition of insta- bility. The gut is exposed to and is very susceptible to all varieties of infections. During this period the infant or child suffers from a number of diseases and exhibits a variety of symptoms which in former times were difficult of interpretation. With advancing knowl- edge and the possibility of making more accurate diagnoses than were formerly feasible, the diseases incidental to dentition have become more a matter of speculation. There are clinicians of note who still believe that irritation of the trigeminal branches by an erupting tooth may cause reflex eclampsia. It is difficult, and not necessary, to pass here on the status of that section of infantile pathology which treats of the disorders incident to dentition. In the presence of mys- tifying symptoms the physician should make a very careful examina- tion, in order to make a diagnosis. Clinical observation of a case for a few days, and accurate registration of the pulse, respiration, and temperature every three hours, may show that the diagnosis of dentition must give way to something more tangible. Should the Gums be Incised? — I have often found the tooth- sacs to be swollen and the seat of painful distention just before the eruption of the teeth. In one case the tooth-sac was distended by a hemorrhage into its cavity. Many cases of tense tooth-sacs or hemor- rhage into such tooth-sacs are evidences of scurvy or disturbed nutri- tion. Under these conditions I have not yielded to the entreaties of the mother to lance the gums. I have seen no ill effects result from this laissez faire method. Very painful ulcerations result from friction, and uncontrollable hemorrhage may follow incision. In cases in which the sacs are distended, the functions of the stomach and gut should be kept normal, in order that complications may not be added to existing conditions. In rare cases I have seen suppuration in the tooth-sac, and have incised. In cases of scurvy in which the tooth-sacs are distended and bluish in appearance, treatment of the scurvy improves this condition. Ulcerations or Erosions of the Angles of the Mouth (Fr., Per- DISEASES OF THE MOUTH. 475 Uchej Grer, (Faule Echen) Epstein). — Definition. — This is a form of non-specific ulceration or rhagade occurring at the corners of the mouth, affecting the vermilion border of the mucous membrane. Occurrence. — This affection is seen in children who present other signs of malnutrition, such as scrofulosis or lymphatism. They are anaemic, suffer from nasopharyngeal catarrh or skin eruptions, aiid live in unhygienic surroundings. The disease is seen in children under two years of age, and mostly beyond that period. The disease is confined to the corners of the mouth, and may be strictly limited to them, though the author has often seen it combined with erosions of the alEe nasi. Symptoms. — These erosions, fissures, or rhagades consist of lineal ulcers of the corners of the mouth, which may have a red base and elevated borders, or the base and borders may have a bluish tinge, resembling mucous patches. In these children the question of diag- nosis of these rhagades from those due to syphilis is constantly arising. The induration of the base of the ulcer which is present in syphilis is absent in the non-specific rhagade. The surface of the ulcer has a more lardaceous appearance in syphilis as a rule, the lips are in- volved, and there are mucous patches elsewhere. The affection which we are describing is found isolated and lim- ited to the corners of the mouth. The borders of the rhagade may be surrounded by minute pustules. The rhagade is symmetrical, involving both sides of the mouth. It is not painful unless the mouth is put on the stretch or acid substances applied to the base of the ulcer. In other cases the borders of the rhagades are raised and indurated. I have seen a large number of these rhagades ; some, at least, so closely resembling a syphilitic lesion as always to warrant a careful exclusion in each case of this affection. Diagnosis. — The diagnosis offers no difficulty, though it is an affection which rarely comes to the physician to be treated as an isolated disease, and is generally met in combination with other dis- eases. I have seen it in children suffering from typhoid fever. The disease may be mistaken for diphtheritic infection, inasmuch as in some cases the base of the rhagade is covered by a pseudomembranous, whitish deposit. The culture tube will decide the true nature of the lesion in such cases. Course.^ — The duration of the disease extends over a period of two or three weeks ; if untreated, it usually becomes chronic. I have suc- ceeded in curing these rhagades by touching them once daily with a 10 per cent, solution of nitrate of silver, and then applying the oint- ment of red oxide of mercury. Another remedy is the application of a solution of corrosive sublimate (1 : 2000). Bednar's Aphthse. — Bednar's aphthae, named after the distin- 476 DISEASES OF THE MOUTH. guished Viennese pediatrist wlio first described them, are two sym- metrical ulcerations over the hamular process of the palate bone, seen in the newly born or very young infant (Fig. 103). They are the result of traumatism. They are seen in infants in whom the mouth has been too scrupulously cleansed. In these cases the finger of the nurse in the act of cleaning impinges against the hamular process of the palate bone and abrades the epithelium. Any bacteria which may be present in the mouth or on the finger thus gain foothold and ulceration results. Epstein has shown that in the newly born infant such ulcers may be the starting-point of a general sepsis. Fig. 103. View of the hard and soft palate. Lateral ulcerations — so-called Bednar's aphthae. The infant may refuse to nurse, or if it does attempt to do so, the pain caused by the act of suckling causes it to desist. There may be intestinal disturbance, manifested by greenish stools, and there may be infection of the gut by the bacterial flora of the ulceration. Treatment. — The ulcer should neither be washed nor traumatized. The rest of the mouth and tongue should be washed gently twice daily with a saturated aqueous solution of boric acid. The ulcers should be touched once or twice a day with a ten per cent, solution of silver nitrate applied with a small piece of cotton on an applicator. Sprue {Thrush; Muguet (Fr.) ; Soor (Ger.)). — Sprue is a para- sitic growth on the mucous membrane of the buccal cavity of the infant. It may spread to the nose in cases of cleft palate ; in other cases it may spread to the pharynx, larynx, oesophagus (Parrot, and even to the stomach (Parrot, Henoch, JSTorthrup)). The latter sit- uation is not favorable to its growth. The parasite has been found in the intestinal movements of infants suft'ering from the disease. DISEASES OF THE MOUTH. 477 Nature. — Sprue is a mould fungus. Its classification by various authors varies with the species examined. Older authors classed sprue vt^ith the oi'dium as Oidium albicans. Rees, Grawitz, and Kehrer classified it as a Mycoderma albicans, consisting of conidia and mycelia. Plant classifies it as a common mould fungus (Monilia Candida). In the early stages it presents large or small irregular whitish masses. These may at first be very minute^ covering only the sum- mits of the papillae of the tongue. On the buccal mucous membrane they may be as large as a pin's head or coalesce into masses resembling curdled milk. They may be seen on the roof of the mouth, on the soft palate, tonsils, and posterior pharyngeal wall. If the affection is progressive, the tongue and inner surface of the cheelcs become coated with a white, closely adherent pellicle. In neglected cases the sprue may be of a yellowish color if sarcinse are present, or blackish or grayish in hue if other fungi have obtained lodgement. Consid- erable force is required to dislodge the growth from the mucous mem- brane, and the operation will cause bleeding and considerable pain and traumatism. Occurrence. — Sprue is introduced into the mouth from without. It is present in the vaginal secretions of the mother, and has been found on the breast nipple. An abrasion of the mucous membrane must exist in order that the fungus may obtain lodgement. It is therefore found in infants whose mouths have been harshly washed with unclean fingers or into whose mouths unclean breast or bottle nipples have been introduced. The fungus having gained access to the cement-substance between the epithelial cells, proliferates into the deeper layers of epithelium, and may even invade the underlying connective tissue. Sprue carries with it any other bacterial flora which may be present in the mouth. A perfectly normal mucous membrane is invulnerable to sprue. The sprue conidia and mycelia are found in the secretions of the mouth of the normal baby. Sprue is seen chiefly in infants whose health is below the average, who are inmates of institutions, or who have been in unhygienic surroundings. Henoch describes cases of sprue of the stomach. This is admit- tedly rare, and occurs in the form of slightly prominent plaques. Parrot describes sprue of the gastric mucous membrane as not infrequent. Symptoms. — The local symptoms are due to the presence of the growth. In mild cases the patches are few in number and very minute. In neglected cases not only is the whole mouth the seat of the disease, but also evidences of infections of a pyogenic nature occur in the form of erosions of the buccal mucous membrane, yellowish plaque-like ulcerations and fissures which bleed easily. There is also 478 DISEASES OF THE MOUTH. dryness of the mucous membrane which has not been attacked or which has been freed from the fungus. Sprue, in fact, causes dis- tinct reaction of the healthy mucous membrane in the vicinity of its invasion. Infants, even in the early stages, suffer from mild disturb- ances of the gastro-enteric tract, manifested by vomiting and greenish movements. In neglected cases marantic symptoms are also present. Older writers (Parrot) believed sprue to be a causal factor in athrep- sia, but it is simply a complication. That pain is felt is evinced by the lack of desire to nurse. A febrile movement occurs if the intestinal tract is involved. Treatment. — Prophylactic. — Everything that is introduced into the mouth of the infant should be scrupulously clean. If the infant is breast-fed, the breast nipple should be cleansed before and after nursing with a pledget of cotton moistened with boric acid solution. The infant's mouth should not be cleansed after nursing. In cases in which the roof of the mouth has been carelessly cleansed there are not only the aphthae of Bednar, but also sprue and other aphthae in the median line as a result of traumatism to Epstein's pearls. If infants are fed artificially, the nipple of the nursing-bottle should be boiled in soda solution once daily. If these precautions are carefully observed, and the fingers never introduced into the infant's mouth, sprue will rarely if ever occur. The normal epithelium and normal secretions are safeguards against the fungus. Curative. — The growth should be reimoved by cleansing the mouth gently three times a day with a saturated solution of boric acid. The utmost gentleness should be used. Even in mild cases the removal of the sprue may extend over a number of days, because the parasite quickly reproduces itself. I use one piece of absorbent cotton attached to an applicator of wood or a tooth pick for the roof of the mouth, another for the tongue, and another for the cheeks and lips. If it can be avoided, the mucous membrane should not be caused to bleed. If aphthae exist, they should be touched lightly with a 2 per cent, solution of silver nitrate. The bowels should be opened by an initia- tive mild cathartic. Everything should be scupulously clean. The severe cases, in which there is a septic condition due to extension of the sprue to the gastro-enteric tract, occur chiefly in foundling asy- lums. The infants die of septic infections. In private practice the prognosis is good if the case is seen early and correctly treated. Baginsky recommends potassium permanganate (1 : 150) ; others rec- ommend corrosive sublimate (1 : 2000), or formalin (1-100) (Holt), but boric acid will be found to be equally satisfactory. Aphthous Stomatitis {Stomatitis Aphthosa). — In this condition there are formed on the soft and the hard palate, the mucous mem- brane of the gums and tongue, and on the inner surface of the lips DISEASES OF THE MOUTH. 479 and cheeks, small, round, yellowish superficial ulcerations. These ulcerations, which vary in form and number, may coalesce and form irregular plaques. It is a question whether the ulcerations are the rerbains of vesicles which have burst, thus exposing an ulcerated base, or whether they are primarily ulcers. I am inclined to the former view, for in the so-called herpetic aphthae of the tonsils the natural development of the aphthous ulcerations can be observed to advance from the vesicular to the ulcerative stage. This condition is very common in infancy and childhood, and according to Monti is most frequent between the first and the third year. Etiology.- — The etiology is still obscure. Some authors consider aphthous stomatitis an acute infection derived from the gut, possibly caused by toxins generated in contaminated milk (Forcheimer, Eitter, Kmeriem, Schamtyr). Others, basing their opinion on bacteriolog- ical studies, regard it as a purely local affection. The clinical course of the disease tends to support the former view. It has been com- pared by Forcheimer and others to the so-called foot-and-mouth dis- ease of cattle. The condition may occur idiopathically or may complicate intes- tinal infection, the exanthemata, bronchitis, tonsillitis, and pneumonia. Some authors believe that the affection may be communicated to others by the secretions of the mouth. Bacteriology. — The forms of bacteria most commonly found in the ulcerations are the various streptococci and staphylococci (Judas- sohn). Bernabei has found the pneumobacillus of Friedlander. As these bacteria are present in the normal secretions of the mouth, it is doubtful whether they bear a causal relation to the condition. Symptoms. — These aphthae vary from the size of a pin's head to that of a split pea. They are invariably surrounded by an areola of inflamed mucous membrane. The outline of the ulceration may be round or irregular; as a rule the ulcerations are superficial. At the line of junction of the teeth and gums they may show a tendency to bleed if touched. There is considerable pain, with salivation, and in young infants also a distinct febrile condition and green diarrhoeal movements. In other cases there may be an accompanying angina with swelling not only of the lymph-nodes at the angle of the jaw, but also of those underneath the jaw. In addition there are loss of appe- tite, and restlessness at night. Course.' — In well-nourished infants and children the tendency is to limitation of the aphthae and spontaneous recovery within three or four days. In marantic or badly nourished children in unhygienic surroundings, the aphthae are likely to spread, the ulcerations pre- senting the appearance of a mixed infection. Such cases are difficult 480 DISEASES OF THE MOUTH. to control. As a rule, however, the disease runs its course without leaving any lasting ill results. Treatment. — The treatment of the cases in which the ulcerations or aphthae remain discrete and in which mixed infection does not occur is begun with a saline cathartic, such as magnesia, or a dose of castor oil. The mouth should not be washed. ' Careless attempts to cleanse the mouth are likely to cause the aphthae to coalesce and spread, and also to cause intense pain. I administer a small dose of ferric chloride, made up with glycerin, every three hours. In most cases this will suffice. The use of potassium chlorate should be avoided with infants. If the edges of the gums adjacent to the teeth are affected, the teeth should be gently washed three times daily with a weak solution of tincture of myrrh or a saturated solution of boric acid. If the aphthae coalesce, they should be touched once daily with a 2 per cent, solution of silver nitrate. With intractable young chil- dren, care should be taken in washing the mouth not to traumatize the unaffected mucous membrane. Toxic Stomatitis. — I have seen a number of cases of stomatitis caused by irritant poisons, such as potash and ammonia. The chil- dren so affected had attempted to drink a solution of potash or ammonia from a bottle left within their reach. Symptoms. — The symptoms were purely local. The mucous mem- branes of the lips had a characteristic oedematous, swollen, and trans- parent appearance, the buccal mucous membrane and the tongue were l^ale and oedematous, and the papillae were erect and transparent. Treatment. — The treatment is expectant. A mixture containing bismuth subcarbonate seemed to give most relief. On subsidence of the oedema the mucous membrane presented a dry appearance. Some- times small aphthous ulcerations appeared, which healed under appli- cations of a 2 per cent, solution of silver nitrate. In one case, five years of age, symptoms of oesophageal stricture were present three months after the ingestion of the irritant. Strict- ures of the oesophagus are more common after the ingestion of potash or lye solutions than after corrosion by ammonia. Ulcerative Stomatitis {Stomatitis ulcerosa; Stomacacw ; Ger., Mundfdule) . — Ulcerative stomatitis is a disease of the mucous mem- brane of the mouth, g-ums, and tongue, characterized by ulceration with a fetid odor. Etiology. — The etiology is still obscure. Friihwald and Bernheim found bacilli and spirocha^tae (spirilla) in the ulcers. The fetid odor of the breath was reproduced in the cultures of Bernheim. The bacillus is lanceolate in form and resembles the diphtheria bacillus. These bacilli and spirilla are probably identical with those described in 1896 by Vincent as occurring in hospital gangrene. DISEASES OF THE MOUTH. 481 Occurrence.^ — The affection is most common between the fourth and the eighth year. The period of infancy seems to be exempt, in my opinion, because of the absence of teeth. It occurs in children who have been neglected or who have lived in unhygienic surround- ings, and is therefore very common in patients of clinics and dis- pensaries. Symptoms. — In the milder forms there is a line of yellowish ulcer- ation along the margin of the gums at the point of contact with the teeth, and the adjacent mucous membrane is red and inflamed. When the gums are touched either in washing or in examination, bleeding readily occurs. There is a fetid odor to the breath, the tongue is coated; some children have pain and loss of appetite, and a slight fever. In the severer cases there are deep ulcerations along the margins of the gums, which bleed on the slightest provocation. Ulcers with a greenish-yellowish base are seen along the border of the tongue and beneath it. In these cases the lymph-nodes beneath the body of the jaw are enlarged and painful as a result of the infection. The salivation, pain, and local disturbance are considerable, and the fetor oris is marked. The buccal mucous membrane at the points of contact with the teeth may be deeply ulcerated, indurations of the tissues of the adjacent mucous membrane being also present. Small particles of necrotic tissue are seen to flow away in the saliva. So great is the pain that some children refuse to open the mouth or par- take of food. I have seen the teeth become loose and necrosis of the alveolar process result. Under the latter condition there is much swelling of the tissues above and beneath the jaw with enlarged lymph-nodes. The tonsils may also be the seat of ulceration of the same character as that occurring at the lateral margin of the tongue. Treatment. — Cleanliness is the first step toward lessening the intensity of the inflammation. The mouth is washed every three hours with a solution of potassium chlorate, made by adding a tea- spoonful of the saturated solution to a small glassful of water, or with a 0.5 per cent, solution of formalin. Internally, liberal doses of ferric chloride, made up with glycerin and water, have given the best results. If there are extensive ulcerative processes along the gums, the line of ulceration is gently touched, once a day with a 10 per cent, solution of silver nitrate. In addition, the patient must have an abundance of fresh air, and is given a nutritious fluid diet, with fresh fruits and a small allowance of wine. Gonorrhoeal Infection of the Mouth, — Gonorrhoeal or blennor- rhceal stomatitis is an infection of the mucous membrane of the mouth by the gonococcus of IS'eisser. Infection occurs only in places where the mucous membrane has been injured. There may be an associated gonorrhoeal infection of the eyes or the vulva and vagina. The infec- 31 482 DISEASES OF THE MOVTH. tion may be introduced into the month by the fingers of the nurse or mother. If the mother is suffering from gonorrhoea, infection may occur at the time of birth or subsequent to parturition. The cases thus far reported (Rosinski, Kast) have developed from two to thir- teen days after birth. Ssmiptoms. — The constitutional disturbance is slight in some cases ; there is no fever, no pain, and no interference with suckling. In other cases I have observed depression and sepsis with a mixed phlegmonous infection of the fauces, inability to nurse, and asthenia with death. The lesions occur on those parts of the hard palate most likely to suffer from traumatism and subsequent infection — the parts favored by Bednar's aphthae, the median raphe in the alveolar proc- esses of the hard palate, and the anterior two-thirds of the tongue. Inspection reveals yellowish-white patches, due to infiltration of the superficial epithelial layers of the mucous membrane with inflamma- tory products. There is no pseudomembranous formation, but a pul- taceous thickening. There is little tendency to spread, and no inflam- matory reaction of the adjacent mucous membrane. The discharge is so slight that the saliva remains clear. Examination of the secretion from the patches on the hard palate (which are generally symmetrical) and on the tongue reveals the presence of abundant gonococci not only on the surface, but also in- vading the mucous membrane along the cement-substance between the epithelial cells. The infection differs from that seen in adults (Cutler), in whom great constitutional disturbance and severe inflam- mation of the whole mucous membrane of the mouth are combined with a profuse ichorous buccal discharge and with pain. Some cases recover; others, as mentioned above, develop sepsis and asthenia and die. Treatment. — The treatment is limited to the enforcement of strict cleanliness, and to local applications of weak solutions of silver nitrate (2 per cent.). The mouth may be washed twice daily with a 10 per cent, solution of protargol or argyrol. Pseudodiphtheritic Stomatitis. — This form of stomatitis was first accurately described by Epstein. It is seen in newborn infants who have sustained a traumatism of the mucous membrane of the mouth. An infection of the injured membrane with streptococci results in the formation of a membrane resembling that seen in true diphtheria. These cases occur in foundling-hospitals and amid unhygienic sur- roundings. Symptoms. — The pseudomembrane is of a greenish-yellow hue, and may spread over the hard and soft palate, the tongue, and the pharynx. It may involve secondarily the entrance to the larynx, as happened in the cases of Epstein, and the epiglottis and oesophagus as well. DISEASES OF TEE MOUTH. 483 Gastro-intestinal symptoms and secondary septic pneumonia are developed. The temperature may, as in other cases of sepsis, be normal, or even subnormal. As a rule, the lymph-nodes are not enlarged. The condition must be differentiated from sprue and aphthous stomatitis. Aphthous stomatitis does not show any pseudo- membrane; microscopical examination will aid in differentiating this disease from sprue and gonorrhceal stomatitis. Treatment. — Inasmuch as these cases are of sej)tic origin, their course is progressive. On the other hand, small patches of mem- brane may be limited by applications of a 10 per cent, solution of silver nitrate. The membrane should not be peeled off, nor should the mouth be cleansed with the finger. Antistreptococcic serum is of no use in these cases. Noma {Cancrum Oris). — ISToma is a specific bacterial infection which attacks the tissues of one or both sides of the face, resulting in gangrene and destruction of the soft and hard parts. Babes and Zambolovici differentiate it from all other forms of gangrenous sto- matitis and gangrene, such as those described by Henoch as occurring on the vulva. Etiology. — The etiology is still obscure. Investigations thus far tend to show that several conditions clinically similar have been found to have a diverse etiology. Babes and Zambolovici isolated a very minute bacillus, and by inoculation experiments in animals produced typical noma. They found that this bacillus extends through the mucous membrane of the mouth, especially that of the gums. Accom- panying it are a large number of streptococci, spirochgetse, and other bacilli. The latter play an active secondary role in the production of the gangrene. Gangrene is caused by an overwhelming bacterial invasion of the tissues. The toxins produced cause death of cell-life and necrosis in mass. In another set of cases, Walsh found the bacillus of diphtheria. These cases would appear to correspond to those published by Freimuth and Petruschky, who found a bacillus identical with the diphtheria bacillus in cases of noma of the vulva. The greater number of cases of noma occur after measles. It may follow any of the exanthemata, typhus, typhoid fever, or any disease through which the power of resistance to infection is lessened. Symptoms. — Henoch and Baginsky hold that in many cases an ulcerative stomatitis has preceded the main affection. The disease begins on the mucous membrane and invades the cheeks from within. Henoch alone has seen it begin from without in the form of a phleg- mon of the cheek. It is first seen as a small ulcer with a blackish- gray base on the buccal mucous membrane opposite the teeth, or it may begin as a vesicle with serosanguinolent contents. After a period of time varying from a few hours to three or seven days the 484 DISEASES OF THE MOUTH. tissues of the cheeks become brawny and cedematous, the oedema involving the eyelids and lips. A dark, livid area finally appears on the corresponding exterior surface of the cheek. This area becomes black and gangrenous. Perforation and spreading of the gangrene rapidly result. The jaw may necrose and the teeth fall out. The process may spread downward along the neck, involving the shoulder in an oedematous, emphysematous, gangrenous mass. The indura- tion of the tissues of the cheek occurring in many forms of stomatitis ulcerosa should not be confounded with this affection ; in these forms of induration gangrene is absent. In all cases of noma a marked gangrenous odor pervades the atmosphere about the patient. The general condition of many cases is astonishingly good at first. The children seem unconcerned, and sit up in bed and play. The patient finally succumbs to the toxsemia accompanying such great destruction of tissue. There may be a febrile movement (103° to 104° F., 39.4° to 40° C). The swallowing of gangrenous products in some cases causes a prostrating and uncontrollable diarrhoea of a septic character. There is little or no pain. Death results within two or three weeks, either from general toxsemia and heart failure or complicating pneumonia. Occurrence and Prognosis. — From a study of the literature, noma is found to occur most frequently between the second and the seventh year. The mortality is very high — fully Y5 per cent. (Woronichin). Treatment. — The most diverse methods have been employed in an endeavor to arrest the progress of this affection. To support the strength of the patient is the first consideration; careful ventilation, antiseptic and deodorizing solutions to destroy the gangrenous odor, good food, and wine, are all of service. The local treatment varies. Some authors advise dusting iodo- form on the gangrenous area ; others advocate the use of caustic zinc pastes in order to determine the line of demarcation between the gan- grenous and healthy tissues. The Paquelin cautery with knife-blade attachment has been employed to remove the gangrenous tissue. So- lutions of boric acid, thymol, and salicylic acid, should be freely emjjloyed to keep the mouth and parts clean. In those cases, probably a distinct group, in which the bacillus of diphtheria is found, diphtheria antitoxin should be injected in proper doses. DISEASES OF THE TONGUE. Congenital Anomalies of Size (Macroglossia). — The tongue of some infants who are otherwise normal is unusually large and pro- trudes slightly from the mouth, but is of normal shape. It is pointed, but somewhat thicker in the middle (Fig. 104). As the infant grows DISEASES OF THE TONGUE. 485 older this anomaly becomes less apparent. In extreme cases the tongue protrudes from the mouth as a tumor mass. It is discolored • — generally of a livid hue — and becomes ulcerated, especially at the line of the teeth. Infants thus affected cannot nurse, and the tongue must be reduced in size by surgical means. This congenital enlarge- ment of the tongue may be due to an increase either of the connective or muscular tissues, or of both. In other cases the lymph-spaces of part or the vv^hole of the organ are dilated — there is a lymphangioma of the tongue. There are thus tv\^o forms of macroglossia-^the one is called macroglossia lymphatica congenita, the other macroglossia congenita hypertrophica. The lymphatic form shows for the most part a gross Fig. 104. ^^ ^ ^ %. cr y l^'' Simple macroglossia. hypertrophy of the organ and more rapid grov^th, combined v\7ith sec- ondary changes in the lov^er jaw and teeth. The surface of the tongue is changed in appearance through defects of the epithelium and the results of inflammatory processes. The papillae are enlarged, the organ is bluish red, nodular, not changed by muscular action and can be compressed. Speech is for the most part changed. The tongue in the hypertrophic form is smooth, the surface enlarged, the growth slow, the tongue less movable than normally and changed by muscular action. It cannot be compressed, as in the lymphatic form, and is less apt to become inflamed. The surgical procedures have consisted in compression, excision, and an ignipuncture, the latter being the most advisable (Eras). In cretins and the Mongolian forms of idiocy the tongue is also enlarged. It is broad, thick and 486 DISEASES OF TEE TONGUE. flat, and protrudes from between the lips. In these patients the con- dition calls for no special treatment. Ringworm of the Tongue (Wandering Bash of the Tongue; Lingua Geographica). — Eingworm of the tongue is a common affec- tion of infants and children. It was probably first described by Santulus in 1854. Parrot regarded it as a symptom of hereditary syphilis — a view which has no clinical support. In 103 cases reported by Bohm, the condition occurred sometimes in early infancy, sometimes as late as the twelfth year of life, and was most frequent between the first and the second year. Etiology. — The etiology is obscure. Bohm believes it to be con- nected with a lymphatic diathesis (scrofulosis). It is found chiefly among children of the lower classes. It may, however, be seen in children in good hygienic surroundings and who are otherwise healthy. Fig. 105. Fig. 106. Ringworm or wandering rash of the tongue, lingua geographica. Epithelial desquamation of the tongue. If scrapings from the borders of the patches of an affected tongue be examined microscopically when fresh, large numbers of zooglsea of coccus form, in some cases mingled with sarcina?, will be seen. The presence of the latter micro-organism explains the yellow color of the border of the patches in some cases. The disease sometimes affects several children of a family. Symptoms. — The symptoms are limited to the appearance of the patches on the tongue. At the tip, but most frequently at the sides of the tong-ue, are seen areas sharply circumscribed by narrow, sin- uous, perfectly oval or round borders (Fig, 105). The border is not only distinctly raised above the epithelium of the tongue, but also is of limited breadth and has a more pronounced whitish or yellow- white color than the rest of the tongue. Inside this border, if the DISEASES OF THE TONGUE. 487 patch is oval, the tongue seems to be denuded of its epithelium and is reddish in color. This condition should be differentiated from desquamation of the epithelium on the dorsum of the tongue, which presents a similar appearance, but in which the patches have not the band-like border (Fig. 106). Children do not appear to suffer incon- venience from this condition of the tongue. Treatment.- — Treatment of the most diverse kinds, including local application of tincture of iodine and the use of ferric chloride, has in my experience failed to produce results. Desquamation of the Epithelium of the Tongue.— In this con- dition, which has been confounded with that just described, there are seen areas of irregular size and apparently denuded of epithelium. The boundary of these areas is sharply outlined, but the epithelium bounding the areas is apparently normal (Fig. 106). The tongue looks as if the epithelium had been scraped off. The condition demands no treatment, since it is only a symptom of mild derange- ment of the digestive processes. Tongue-swallowing. — Tongue-swallowing is a term applied to a peculiar phenomenon seen in some infants who are the subjects of nasal obstruction. Infants normally breathe through the nose when at rest, the tongue being in contact with the roof of the mouth. If nasal breathing is obstructed either by swelling of the mucous mem- brane or by deformity of bone, or adenoids, the infant experiences great difficulty in breathing through the nose. As a result, not being accustomed to keeping the mouth open and the tongue on the floor of the mouth, the ineffectual efforts at nasal and mouth-breathing cause the infant to draw the tongue inward. The tip of the organ folds on itself,, and may be drawn backward into the mouth in the efforts at mouth-breathing, causing a peculiar snapping noise to be heard on inspiration. Treatment. — The remedy in these cases is nasal douching, and dilatation of the nasal passages with pledgets of cotton. The cotton is rolled around a probe or applicator, moistened with castor oil, introduced once a day into the nares, and allowed to remain about five minutes. If the infant has adenoids they should be removed. Tongue-tie.— Tongue-tie is a condition for the relief of which the physician is frequently consulted. Some mothers will ascribe ineffi- cient nursing to this condition. With a breast secreting sufficient milk tongue-tie would not prevent nursing. The existence of the condition is readily detected if the organ is bifid at its tip when pro- truded. The frenulum will in such cases be seen to extend to the extreme tip of the tongue in a fan-shaped manner. Treatment. — The frenulum being membranous is easily divided. It should be caught in the bifid groove of the pocket-case director 488 DISEASES OF THE (ESOPHAGUS. and made tense, and the membranous portion divided with a pair of round-ended scissors. The ends of the scissors should be directed to the floor of the mouth. There is little bleeding. The infant should be placed at the breast directly after the operation, so that the act of suckling maj stop the hemorrhage. MALFORMATIONS OF THE UVULA. The uvula is often bifid in infants. This condition is only of anatomical interest. There are cases in which the uvula is relaxed and elongated. In one case, in a boy five years of age, the uvula was so long that it gave rise to an incessant night-cough. On excision of the uvula the cough ceased. DISEASES OF THE (ESOPHAGUS. Congenital Anomalies. — Branchial Fistulse.^ — Among the congen- ital anomalies connected with the oesophagus is the so-called fistula colli congenita. This is due to a faulty closure of the branchial clefts in foetal life. This fistula is generally unilateral, and is found at the inner side of the sternomastoid muscle. It may be bilateral. It generally leads to the pharynx or oesophagus, and may end in a blind canal. The canal may discharge mucus containing ciliated epithe- lium and leucocytes. Hennes described a cartilaginous grovrth in the neck, of which I have seen an instance. It occurs in the same situa- tion as the above fistula, and is traceable to the same faulty closure of the branchial clefts. Branchial Cysts. — Branchial cysts are cystic tumors of the neck and some parts of the head, originating from congenital defects of development. The primary origin of these tumors corresponds to the location of one of the branchial clefts, most frequently the second and third, in the vicinity of the larynx and pharynx. They are in intimate relation with the sheaths of the large vessels of the neck, the jugular vein, and carotid artery. The cysts are classified, according to their contents, into mucous, atheromatous, serous, and hematocysts. Branchial cysts are of rare occurrence. The serous variety is ob- served in early life, either congenital or develops during infancy or childhood, whereas the atheromatous cysts are seen in early adult life. These cysts are seen most frequently on the left side of the neck. Their further consideration and treatment is of a surgical nature. Diverticula of the (Esophagus. — These occur in childhood, are con- genital in origin, and are accompanied by symptoms of diSicult deglu- tition of solid foods, though fluids may be swallowed. In some cases the food collects in the diverticulum, causing swelling of the neck, DISEASES OF TEE CESOPHAGUS. 489 with spells of coughing and consequent emptying of the diverticulum. With the difficulty of deglutition there is regurgitation of the food after eating. In a case recorded by Kurz there were undulatory movements at the side of the neck and gurgling noises heard on swal- lowing. A sound could be passed into the stomach, but at the junc- tion of the upper third with the lower two-thirds of the oesophagus the sound passed into a pocket. In this case food could be caused to pass into the stomach while the patient was placed in a certain position. In an interesting case described by Adams the diverticulum commu- nicated with the trachea. Fig. 107. Congenital branchial cyst. Infant seven months of age (Dr. Henry Heiman's case). The above diverticulum may be primary, of the congenital variety ; or secondary, due either to a stricture of the oesophagus and dilatation above the stricture, or to traction from without on the oesophagus by a caseous lymph-node. Congenital Stricture of the CEsophagus. — Sneider has collected 15 cases of congenital stricture of the oesophagus, most of which gave no symptoms during infancy and childhood. The stricture in these cases was either in the form of a ring of tissue or folds with thickening of the mucosa. They were present either in the upper or lower part of the oesophagus. Only 2 of the 15 cases died during childhood, the symptoms appearing for the most part in early youth. The case recorded by Turner was that of a child eighteen months old. It had always suffered from difficulty in swallowing, and weighed only 14|^ pounds. The mother said that since the period of 490 DISEASES OF TEE (ESOPEAGUS. weaning the child had become emaciated, and the difficulty in swal- lowing had increased so that finally all food was rejected. A sound having the diameter of the small finger could not be introduced into the stomach. Postmortem, the stenosis was found at the cardiac end of the stomach and was of the size of a l^o. 2 catheter. Congenital Atresia or A'bsence of the (Esophagus. — The oesophagus may be entirely wanting, and in such cases other organs show anoma- lies ; or there may be atresia of the middle third of the oesophagus ; or the oesophagus may communicate in part with the larger bronchi. The stomach may be absent in some of these cases. In such cases the infants swallow, choke, have cyanotic attacks, and in three or four days cease to live. In one case published by Simon the oesophagus ran circularly around the trachea; the patient survived and died in adult life. CEsophagitis. — Any inflammation of the mouth or the pharynx may extend into the oesophagus, such as croup, diphtheria, burns, cor- rosions, sprue. These affections cause no characteristic symptoms apart from the primary disease. Caustic (Esophagitis (Traumatic Stncture of the (Esophagus). — This is caused by the action of caustic alkalies or mineral acids on the tissues of the oesophagus, and the intensity of the corrosion varies with the amount and strength of the caustic taken internally. The caustic alkalies, such as potash and ammonia, are especially likely to be swallowed by children. The effects of the corroding agent are shown first externally. If a concentrated mineral acid has been taken, there is a brown or a black eschar. In less concentration we have white or grayish eschars, and later mild inflammatory reaction. Alkalies cause gelatinous swelling of the mucous membranes covering the lips, tongue, and buccal cavity. If the alkali be very strong, the tissues are converted into a yellow or brownish mass, and the fatal issue sets in before any reaction takes place. If the agent be dilute, superficial ulcers form after the primary corrosion. Reaction sets in, and, following the inflammatory stage of the reaction, cicatricial effects result, such as stricture. Symptoms. — The symptoms accompanying the swallowing of cor- rosive poisons are pain, which is constant, incessant crying, restless- ness, due to a burning sensation in the mouth, attended with great pain and difficulty in swallowing. In some cases blood and purulent matter are vomited. There is great thirst. In other cases, where the concentration of the alkali has not been great, the lips are swollen, the mucous membrane of the mouth presents a whitish, gelatinous, swollen appearance. There is constant salivation ; the children refuse to take solids or liquids, inasmuch as the least attempt at swallowing causes great pain. DISEASES OF THE (ESOPHAGUS.^ 491 Treatment. — The treatment of these cases is at first medical. De- mulcents and milk are given in large quantities, and the physician should refrain from examinations with instruments lest perforation of the oesophagus or stomach result. After a few weeks, the primary effects of the corrosion having passed off and cicatrization of the ulcers having taken place, a stricture of the cesophagus results. The treatment of this stricture is surgical. Peri-oesophageal Abscess (Retro-oesophageal Abscess). — Griffith has reported 12 cases of this affection. It is not infrequent in infancy and childhood. The oesophagus begins above at the seventh cervical vertebra, lying in front of the spine. It passes behind the right bronchus between the two pleural sacs, behind the pericardium, and finally passes through the diaphragm. Any affection of the spine, pleura, pericardium, or lymph-nodes at the root of the lung may either cause pressure on the oesophagus, involve it in inflammation, or, if suppuration exists, the pus may break into the lumen of the oesoph- agus. Cases are recorded in which the pressure of an intubation tube or diphtheria of the pharynx has involved the perioesophageal tissue and caused abscess; or a foreign body in the oesophagus may cause perforation and ulcer, involving the adjacent connective tissue. If a foreign body is lodged in the cesophagus and is contaminated, as in the case of Soltmann, with actinomycosis, abscess of the oesophagus and lung may result, with actinomycosis of the latter organ. The most frequent cause, however, of peri- or retro-oesophageal abscess is disease of the vertebrae of a tuberculous nature. Symptoms. — These will vary with the cause. An abscess of the pleura or a lymph-node pressing on the oesophagus will give symptoms of oesophageal stenosis. In some cases the pressure may interfere not only with deglutition but with respiration, and give rise to symp- toms resembling laryngeal stenosis, necessitating intubation. As soon as the tube, however, is withdrawn from the larynx, the dyspnoea returns. The larynx may also be pushed to one side. There may be temperature, due to the primary disease. In one of my own cases there were spasmodic attacks of coughing, accompanied by cyanosis, and in one of the attacks a discharge of pus. The source of the pus in this case was probably an empyema which had opened into the oesophagus. These attacks were repeated at intervals, though with less expectoration of pus. The child finally made a good recovery. In spondylitis there will be symptoms of disease of the vertebrse. If perforation occur from a bronchus or caseous gland, there are attacks of coughing, vomiting of food and pus, and finally symptoms resembling putrid bronchitis, and in same cases lung gangrene. Diagnosis.- — In some cases the diagnosis is not only difficult, l)ut impossible. If the cause is evident and the abscess can be reached 492 DISEASES OF THE (ESOPHAGUS. with the finger, the diagnosis can be made ; but if the abscess is deep- seated, beyond the reach of exploring instruments, the disease is diag- nosed only at the autopsy table. If the swallowing of a foreign body has preceded symptoms which resemble retro-cesophageal abscess, an rc-ray should be taken to locate the body. Prognosis, — The prognosis in deep-seated retro-oesophageal abscess is bad ; that in spondylitis likewise. The spontaneous rupture of the abscess, with discharge of pus externally and recovery, is exceptional. The spontaneous rupture of a retro-oesophageal abscess may result in pus finding its way into the larynx, thereby causing suft"ocation. Treatment. — The treatment of retro-oesophageal abscess, if diag- nosed promptly, is surgical. It may be stated, however, that these abscesses are best opened from without, and we should hesitate to make an internal incision in a deep-seated retro-oesophageal abscess. SECTION VII. DISEASES OF THE STOMACH AND INTESTINES. Classification.- — The classification of the diseases of the gastro- enteric tract occurring in infancy and childhood must necessarily be schematic for the present, for much is yet to be learned, from chem- ical, physiological, and pathological standpoints, concerning some of these affections. Any classification, therefore, must be founded on a mixed etiological basis, and must, of necessity, be subject to future revision. For the present we may divide these diseases into: i^*>s^.— Those due to some congenital defect in the constitution or anatomical construction of the body. Second. — Those v^^hich are due to some fault in the functional assimilation of the food. The food in these cases is free from bac- terial contamination and is not assimilated and the infant does not thrive. There is no pathological lesion in these cases. In this class belong the acute dyspepsias, both of the stomach and intestines, various forms of vomiting, colic and tympanites, all leading to the main result, an atrophy or marasmus. Third. — Those disturbances due to infection. Bacteria and their toxins are the agents by which these diseases are brought about. In this class belongs the acute gastro-enteric infections, including cholera infantum. In these diseases the anatomical lesion, if any exists, is in the majority of cases only temporary, for the patients recover. In the fatal cases the anatomical lesions are very slight and disproportionate to the severity of the disease, being due, it is at pres- ent supposed, to the direct action of the bacteria and their toxins on the superficial structures of the stomach and gut. Fourth. — Those diseases which are due to the direct action of the bacteria themselves, which, in addition to causing constitutional symp- toms, due to the passage of the toxins into the circulation, also cause serious anatomical changes in the tissues of the gut, some of these changes causing eventually the death of the patient. In this class we would place dysentery of infancy and childhood, and the various forms of ileocolitis, which have, as yet, no firm etiological basis estab- lished by investigation and experiment. Fifth. — A series of diseases caused by some anatomical condition or neurosis. In this class must be placed the forms of congenital stenosis of the pylorus, dilatation of the stomach, which, though pri- marily caused by dyspeptic disturbances, eventually supervenes as the 493 494 DISEASES OF THE STOMACH AND INTESTINES. result of anatomical weakness of the muscular structures of the stomach. In this class we would place the various forms of consti- pation dejDending upon congenital dilatation of the colon. The Stomach, — ^Anatomy. — The oesophagus enters the diaphragm at about the level of the ninth dorsal vertebra ; the cardia is on a level with the tenth dorsal vertebra ; the pylorus is in the majority of cases situated in the median line, but in some cases is slightly to the right of it. It is midway between the tip of the xiphoid cartilage and the umbilicus, and, being behind the liver, is not normally palpable. The stomach lies in an oblique position, passing from behind forward and downward. The pylorus is from two to two and one-half bodies of a vertebra lower than the cardia. In the newborn infant the infe- rior portion of the stomach has a fundus form (Pfaundler), which later becomes more marked. Occasionally there is no fundus, and the stomach is then of cylindrical shape. Between the time of birth and the seventh month the fundus of the stomach increases to fully twice its original length (Pfaundler), Capacity. — The capacity of the stomach is still a matter of specu- lation. The absolute capacity, as given by Fleischman, Drewitz, Pfaundler, Holt, and Eotch, varies vdth the method employed to determine it. The work thus far done has been carried out on the cadaver, and, moreover, the methods employed presuppose an amount of pressure (14 c.c. to 30 c.c.) of water which does not exist in the normal state during life. The stomach contracts after death (sys- tole) ; the distention with air or fluids is thus partly artificial. Lastly, the stomach capacity is of little aid in determining the point at issue - — the quantity of food which should be taken by a healthy infant at each feeding. Figures giving absolute stomach capacity are useful only as indicating the actual size of the organ when full of fluid, a condition rarely present during life. In the following table (p. 495) Plaundler's results are compared with those of others. They were obtained by postmortem distention with fluid at a pressure of 30 c.c. of water. Fleischman distended the stomach at 14 c.c. of water pressure. Function and Motility. ^ — The stomach of breast-fed infants empties itself in two hours after the ingestion of a full nursing. If the quantity of milk taken is small, a shorter time suffices. Bottle-fed infants taking cows' milk need fully three hours to accomplish the same result. These facts teach that intervals of rest between the nursings, and a rest of four or five hours once in twenty-four honrs, are necessary. Marking out the Stomach by Percussion. — This procedure is diffi- cult with infants and children. The normal stomach is rarely found outside of the left hypochondrinm. The liver fully covers the stomach DISEASES OF TEE STOMACH AND INTESTINES. 495 in the collapsed state. In the recumbent posture the stomach may be mapped out on the anterior abdominal parietes. It comes forward in the triangle formed on one side by the border of the left lobe of the liver and on the other by the border of the ribs. Above, the apex of the triangle is formed by a junction of the ribs and the left lobe of the liver. Below, the base of the triangle is of variable length. In the axillary line the fundus in a moderately distended state is in contact with the thoracic walls, between the liver above and the spleen below. Above, it is separated. from the lung resonance by a strip of dulness (the left lobe of the liver) which changes position with the movements of the diaphragm. The tympanitic resonance reaches downward in a vertical direction from the sixth to the eighth rib. Behind this, tympany is limited by the posterior axillary line; in Fleisch- Drewitz. MAN c.c. c.c. At birth 30 One week 45 One month 77 99 Two months 79 215 Tliree months 140 130 Four months 165 Five months 290 253 Six months 260 297 Seven months . . 217 Eight months 289 Nine months . . 510 Ten months 375 350 Eleven months 535 Twelve months , . 500 One to two years 220 588 front, by the triangle above referred to. I have frequently been able to confirm these statements of Fleischman. Anteriorly, I have with the aid of a gastrodiaphane shown that the transverse colon passes in front of the stomach just beneath the liver. It should be remem- bered that tympanitic resonance in the epigastrium is not always due to the stomach. Acids of the Stomach. — When digestion is not in progress the stomach contains a tenacious, colorless mucus, neutra,l in reaction. When food is in the stomach, the reaction is acid. Hydrochloric acid is normally present in the stomach of the infant (Leo, Van Puteren, Wohlman) ; lactic acid only occasionally. Heub- ner found 0.16 to 0.2 pro mille of lactic acid present. A considerable amount of hydrochloric acid unites with the salts and albumin of the milk, and is found as combined hydrochloric acid. When combina- tion is no longer possible, , the residue appears as free hydrochloric acid. The amount of free hydrochloric acid depends on the quantity of milk ingested, and varies from 0.8 to 2.1 pro mille. I have fre- Pfaund- ROTCH. Holt. LER. cc. C.C. c.c. 30 30 36 150 75 60 175 96 99 200 100 135 230 107 150 260 108 170 295 , . 264 330 365 406 445 485 243 515 640 496 DISEASES OF THE STOMACH AND INTESTINES. quentlv failed to find free HCl in the stomach contents of infants wlio are fed irregularly at frequent intervals. In healthy breast-fed in- fants free hydrochloric acid is found in from one and a quarter to two hours, and in bottle-fed infants in from two to two and a half hours after nursing. The effect of the lab-enzyme on the milk is marked in breast-fed as compared with that in bottle-fed infants. In the former the action of the acid delays that of the lab-ferment, while in the latter coagulation of the casein occurs in a short time and in large flocculi. The difference in retarding the action of the lab- ferment is due to the increased alkalescence of mother's milk, which requires more acid to neutralize the alkali, and thus to render coagu- lation possible : hence the greater digestibility of mother's milk. Gastric contents containing free hydrochloric acid are bacteri- cidal, while combined hydrochloric acid has no such properties. Stomach Digestion. — Stomach digestion in the infant divides itself into three periods : The first, in which the milk is split by the lab- ferment into casein coagulum and soluble albumin; the second, in which the stomach contents become acid, having been previously neutral or alkaline, and in which chlorine combinations are entered into by the casein and lactic acid is formed; and third, in which the above phase of stomach digestion is completed, the contents pass into the gut and free hydrochloric acid appears. Lobb-feniwnt. — Digestion is thus accomplished by a soluble fer- ment, so-called lab-ferment or pexin, which coagulates the casein of the milk; a soluble ferment, pepsin, which partly dissolves and pep- tonizes this coagulum; and chlorine combinations (HCl), which unite the partially peptonized casein, and toward the end of digestion pro- duce free hydrochloric acid. Thus the principal changes in the milk, so far as the stomach is concerned, occur in connection with the casein.. As soon as the milk enters the stomach, it is coagulated by the lab- ferment, whether its reaction is neutral, alkaline, or acid. This casein coagulation depends upon the lab and not upon the acid reac- tion of the stomach juice. Lab-ferment is present in the infant's stomach as such, and can be demonstrated in the stomach of prema- ture and sick infants. Lab-coagulation of the casein is accomplished, according to Duclaux, in about fifteen minutes. Part of the casein coagulum is acted on by the pepsin and chlorine combinations and is converted into absorbable peptones (casease or caseon), the remainder passes into the intestine, where digestion is completed by the pan- creatic ferments. The casein coagulum of cows' and of human-breast milk are essen- tially different, the former being a firm mass, containing in its meshes the fat of the milk ; the latter being in fine flocculi with little of the fat of the milk, and easily acted on by the stomach j uices. In DISEASES OF THE STOMACH AND INTESTINES. 497 the bottle-fed infant the stomach, half an hour after feeding, still contains large coagula, whereas at this time the breast-fed infant's stomach contents consist of an easily absorbable homogeneous mass. Liquefaction is the work of the pepsin, which is present in the stomach juices of the newborn infant, though throughout infancy its action is weak and only sufficient to act on the proteids of the milk. Thus, half an hour after feeding, albumoses and peptones are found in the stomach both of breast-fed and bottle-fed infants. Milk Sugar. — Milk sugar is split partly into lactic acid about fifteen minutes after feeding, and by the action of lactase (Marfan) into giycose and galactose. This view, however, is not accepted by all observers, lactic acid not being admitted as normal to the stomach. The salts of the milk which have not been precipitated are directly absorbed. The fats enter, with the casein coagula, into the gut almost entirely unchanged, or a fractional part is saponified by lipase (Mar- fan) and absorbed in the stomach. In general, it may be stated that in breast-fed infants digestion is completed in one and one-half to two hours ; in artificially fed infants taking boiled milk in two and one-half to three hours, and in four hours in those taking raw milk. Bacterial Flora. — The bacterial flora of the infant stomach are as yet not fully investigated. So far as known the stomach may con- tain the Bacterium coli commune, the Bacterium lactis aerogenes, the Bacillus subtilis and the related species, Tyrothrix granulatus and Bacillus butyricus of Hueppe, the Bacillus pyocyaneus, the Bac- terium lactis aerogenes, the Bacillus megatherium, the Spirillum rugula, a leptothrix. Staphylococcus pyogenes, Sarcina ventriculi, oidium, hay bacillus, and mould fungi. Intestinal Digestion. — The stomach content of the infant as it is passed into the intestine consists of unabsorbed water; proteids which are made up of casein coagula and in part of syntonin; albu- moses and peptones in combination with chlorides and ammonia ; the fatty acids, leucin, tyrosin ; and finally gases, especially carbon diox- ide. There are present also the unabsorbed portion of milk sugar and a small quantity of lactic acid. The fats pass into the intestine for the most part suspended in the watery elements of the milk or entrapped in the meshes of the casein coagula. The whole stomach content has, as it passes into the intestine, an acid reaction, more marked in the artificially fed than in the breast-fed infant. The intestinal secretions concerned in the digestion of the above stomach content are those of the pancreas, liver, and intestinal wall (follicles of Lieberklihn and Brunner's glands). Pancreas. — This organ is developed at birth, has a weight of 32 grammes or 1 ounce, and is, therefore, compared with the body- 32 498 DISEASES OF THE STOMACH AND INTESTINES. weight, much larger than iu the adult. Whereas in the infant the pancreas weighs %oo, in the adult it is %oo of the body-weight. Ferments. — In the adult pancreatic juice there are three fer- ments — trypsin, ptyalin, and a fat-emulsifying ferment, steapsin. The infant's pancreatic secretion reveals trypsin and steapsin at birth, and even in the foetal state. These ferments are present in small, but for the infant's uses sufficient, amounts. There is still a differ- ence of opinion as to whether ptyalin is present at all in the pancreatic juice of the newborn. According to Karowin, a saccharifying power can be detected in the pancreatic juice not earlier than the sixth month of infancy, whereas Moro has found traces of such a ferment in the pancreas at birth. The fact of its absence or presence in but small quantity at birth has been brought forward as an argument against the use of amylacea in the food of the artificially fed infant at this age. Liver.- — The formation of bile begins at the third month of foetal life, and at birth both bile and glycogen are found to be formed by the liver. The bile, which in quantity is comparatively greater at birth than in the adult, contains cholesterin, fats, lecithin, mineral salts, excepting iron. It contains small quantities of taurocholic acid, and but little or no glycocholic acid. It is not strongly anti- fermentative at this time. It contains bilirubin and biliverdin, and in the young infant urea. Its function in digestion seems to be limited to aiding emulsification of the fats. Secretions of the Intestinal Walls. — The intestinal juices secreted by the follicles of Lieberkiihn and the glands of Brunner are alkaline in reaction, and in the foetus and newborn the ferments, present in these juices in the adult, seem to be absent (Miura). The role played by these juices in digestion is still a subject for study. Digestion, — The principal process taking place in intestinal diges- tion of the infant is the transformation of the casein of the milk by the trypsin of the pancreatic juice into peptone and hemipeptone. Part of the casein is rapidly changed into joeptone by the pancreatic juice, whereas the other portion is acted upon at gTeat length, and from hemipeptone changed into absorbable substances which, partly crystalline, are taken up by the mucous membrane of the gut and synthetically transformed into albumins. In the breast-fed infant the casein flocculi are digested and dis- solved in the duodenum, and the contents of this portion of the gut are slightly acid. In bottle-fed infants the digestion and solution of the casein is less complete in the duodenum than in the breast-fed infant, and the reaction of the contents of this portion of the intestine is distinctly acid. Milk Sugar. — The milk sugar is split in the gut into galactase DISEASES OF THE STOMACH AND INTESTINES. 499 and dextrose and thus absorbed. This is accomplished, according to Marfan, by the lactase of the intestinal juices. Fats. — The fats of the milk pass from the stomach into the duo: denum but little changed. They are suspended in the watery element of the milk or entrapped in the meshes of the casein flocculi or coagula. The fats are partly emulsified and in part split up by the pancreatic juice into fatty acids and glycerin, and in these forms absorbed by the intestinal villi. The digestion and absorption of the fats, how- ever, is incomplete in the intestine of the infant, and much of it is excreted in the fseces in the form of neutral fats and fatty acids. In the healthy breast-fed infant most of the above digestive trans- formation is completed in the duodenum and the products are absorbed in the upper part of the small intestine. This is especially true of the casein or proteids, of which only traces are found in the lower portion of the small intestine. Intestinal Residue. — After the absorption of the nutritive portion of the intestinal mess, the contents of the intestine consist of biliary remains, amido-acids, various products of bacterial fermentation, acids, and soaps, which are in part taken up and transformed by the liver and in part excreted. In addition, there are neutral fats and fatty acids. The minute quantity of proteids which has escaped digestion and solution and has not been absorbed is transformed by the bacterial flora of the gut into the products of decomposition, and as such are found as indol, skatol, phenols, and ammonia in the faeces. These also are in part taken up by the liver and in part excreted. The processes of decomposition, which are quite limited in the breast- fed and marked in the artificially fed infant, reach their highest development in the colon. Characteristics of the Stools of Normal Infants. — It may be stated that the movements of bottle-fed differ from those of breast-fed infants in that they are lighter in color and in the main more bulky. In the perfectly normal breast-fed infant the stools may at times vary in color and general consistence ; thus we can scarcely speak of a uniformly normal movement. Gregor has accounted for this by assuming that the stool of the infant at the breast may vary because of the composition of the breast-milk from day to day and at different hours of the day. Inasmuch as the percentage of fat in breast milk varies so widely, the appearance of the stool will vary likewise. In- fants fed on cows' milk and carbohydrates will have movements resem- bling those of breast-fed infants. If a number of normal infants are observed, it will be seen that from time to time even the breast-fed infant will present movements the consistence of which is more or less watery, and which contain coarse white curds and particles without any disturbance of the func- 500 DISEASES OF THE STOMACH AND INTESTINES. tions of the gut. Moreover, the amount of water contained in a normal movement is considerably more so tlian would appear from its ordinary putty-like consistence on the diaper (Czerny). Infants taking a malted food will present movements that are dry and broken up into crumbs, and which have a distinct odor of malt. The move- ment of breast-fed babies and those fed upon carbohydrates and fatty food are softer than those of babies fed upon cows' milk exclusively. The movements of infants fed on cows' milk exclusively are lighter in color than those of the breast-fed child. In general the faeces of infants may be said to contain digested absorbable substances, undigestible substances, digested products of digestion and decomposition, anatomical elements of the digestive organs of the stomach and gut, mucus elements, and bacteria. If the movements of the breast-fed infants are closely examined, they are found to contain small whitish curd particles, the milk granules of Uffelmann. These were at first thought to be composed of casein : it is now known that they are made up of fat-crystals, and zoogloea of bacteria. ' Talbot has lately demonstrated that, in addition to fat and soap crystals, these curds contain nitrogen. In addition, there are found in the fffices of infants epithelial elements, bilirubin crys- tals, and cholesterin plates. Fat appears in the faeces of infants rarely as fat crystals, but generally as fatty acids, neutral fats, and soaps. The movements of infants fed on a mixed diet contain free starch- granules, cellulose, and also cholesterin plates and bilirubin; the prod- ucts of decomposition — indol, skatol, and phenol — are also found, according to the time which has elapsed since the voidance of the movements (Blauberg). Sugar is not found in the fseces of infants, or only in small quantities (Uffelmann and Blauberg). Michael has found that the gross weight of faeces in the newborn breast-fed infant was about 1.5 per cent, of the gross amount of food ingested; while later in infanc}'- the movements were 2.7 per cent, of the amount of food ingested. Rubner and Heubner found that in bottle-fed infants fhe fsEces were about 4.7 per cent, of the amount of food ingested. Michael found that the faeces in the first days of infant life contained about 72 per cent, of water, while in the ninth month of infancy they contained 85 per cent. Reaction of the Stools. — The reaction of the stools of infants, both breast- and bottle-fed, has been the subject of much discussion, because of the difference of opinion among investigators as to what constitutes a normal movement in an infant. It may be stated, however, that the stool of the breast-fed infant is regularly acid in reaction and has an acid odor even after being passed for some time. The infant fed upon cows' milk has a stool which is alkaline in reaction, sometimes DISEASES OF THE STOMACH AND INTESTINES. 501 neutral, and, under certain conditions which no longer may be looked upon as absolutely normal, slightly acid. The stools of these infants have an odor more or less recalling that of stale cheese ; in other words, an odor of decomposition. The Daily Number of Movements. — The normal infant, whether on the breast or the bottle, will have one, two, or even three movements daily when in perfect health. In the breast-fed infants these move- ments may be small or large and even contain quite an amount of fluid and still be within the limits of health. In the bottle-fed in- fants, however, the stools are, as a rule, larger in bulk than those of the breast-fed infants, and contain less water. I have seen bottle-fed infants in perfect health who have had as many as four movements daily, all having normal characteristics. Infants may have six movements daily and still be in perfect health. If the consistence and color are within normal limits, the number simply indicates the amount of intestinal residue, and not disease. Bacterial Flora — -Within two or three days after birth the meco- nium changes its characteristics and assumes those of milk faeces. In the milk fseces of the infant nursed at the breast we find as predominant, first, a bacillus described by Tissier, which stains with Gram's stain, and which in the crude specimen seems to occupy most of the microscopic field. This is called the Bacillus bifidus communis. It is an anaerobe. In addition to this bacillus, we find next in numbers the so-called Bacillus acidophilus of Moro and Fink- elstein. The latter also stains with the Gram stain. In addition to these two bacilli, which are found in greatest numbers in the fseces of the breast-fed infant, we have a few coli bacilli, and also some numbers of the Bacillus lactis aerogenes. The faeces of the infant fed on cows' milk present a much more luxuriant flora of bacteria than those of the breast-fed infant. There are: (1) the Bacillus coli communis, (2) the Bacillus acidophilus in small numbers, (3) other Gram-staining bacilli, (4) the Micrococcus ovalis (Escherich and Tissier), (5) the enterococcus of Thiercelin, (6) a diplococcus staining with Gram, (7) streptococci and staphylo- cocci, (8) Sarcina minuta, (9) the Bacillus lactis aerogenes. The Bacillus lactis aerogenes splits milk sugar into lactic acid, carbonic acid, and water, and causes the intestinal contents to become acid. In the lower part of the gut we find the Bacillus coli communis, a micro-organism which may exist in the presence of any reaction, and which splits milk sugar into lactic acid, carbonic acid, and water, and partly splits fat into fatty acids. It is the prevalent micro-organism in the stools, though with it we have a number of the Bacillus lactis aerogenes, a yellow fluorescent or fluidifying coccus, three fluidifying cocci, a Micrococcus ovalis, a porcelain coccus, the tetrad coccus, the 502 DISEASES OF TEE STOMACH AXD IXTESTINES. white and red hay bacillii?. a capsule bacillus, the Mouilia Candida, all of which exist in varving numl^ers. Acute Gastric Dyspepsia (Indigestion). — Acute gastric dvsjoep- sia may clinically be divided into two forms, that affecting infants, either at the breast or bottle, and that affecting older children. The period of infancy is one of frequent disttirbances. Mental excite- ment on the part of the nurse may cause the milk to disagree with a breast-fed infant. The ingestion of an undue quantity of breast- milk, even if of good quality, may cause indigestion. Certain articles of food, if partaken of by the mother, may cause gastric irritation. ISTursing a breast in which the milk has caked will also cause indi- gestion. Ssrmptoms. — Vomiting is the first evidence of disturbance of the digestive processes in the infant. It occurs after feeding, and is at first not accomj^anied by constitutional symptoms or diarrhoea. If the exciting cause continues, a slight febrile movement is noted, and also slight prostration. The infant is restless, but having vomited is relieved, and if permitted will again take the breast, or bottle, the vomiting taking place after each nursing. The bowel movements then become disturbed. They may not only be green, but also frequent and in some cases fluid. There are in all cases colic and tympanites. Acute gastric dyspepsia in older children may be caused by some article of diet which has disagreed with the patient. The symptoms are much the same as those seen later in life. It is important both with infants and children to determine whether the symptoms are due to improper food or whether proper food has for some reason dis- agreed. Bottle-fed infants are liable to indigestion if the milk con- tains any extraneous substances, not necessarily toxic ones. A baby may have thrived for weeks on a certain food-mixture, when suddenly, without apparent cause, symptoms of gastric dyspep- sia supervene. In such cases it will be found that the acidity of the milk was greater than usual, or that the fodder of the cows furnishing the milk has been changed. In some cases the infant, whether on the breast or bottle, will spit up curds of an exceedingly acid nature or vomit a watery acid substance after feeding. Course. — If the food is suspended and jDroper treatment instituted, the symptoms subside and the infant recovers, but if the exciting cause is not removed, more serious disturbance of the stomach and gut will develop. Treatment. — It is best both with breast-fed and bottle-fed infants to discontinue the giving of all food as soon as symptoms of indiges- tion appear. With the suspension of food the administration of a simple cathartic (castor oil) is all that is necessary. The infant is l>ut for twelve hours on a solution of white of egg, and the breast DISEASES OF THE STOMACH AND INTESTINES. 503 pumped regularly every three hours to prevent caking. The breast may then be cautiously exhibited. Stomach v^^ashing should not be resorted to, and the breast should not be denied for too long a period. If, on resuming breast-feeding, symptoms reappear, an analysis of the milk should be made. Its composition may have changed and too much fat may be present. We should not be hasty in taking an infant from the breast and placing it on the bottle on account of a few symptoms of gastric dyspepsia. Proper regulation of the diet and the taking of proper exercise by 'the nurse will frequently cause the desired adjustment of the constituents of the milk and the disap- pearance of symptoms. Habitual Vomiting of Infants. — Habitual vomiting of infants refers to the regurgitation of milk in the uncoagulated state shortly after nursing. It occurs in infants in apparently good health, and is not followed by loss of weight or disturbance in the functions of the 'gut. Some infants vomit curdled milk in the same manner. The cause of this form of vomiting has been variously explained. The simplest explanation is, that by slight pressure the food is forced into the oesophagus and thence reaches the mouth. It is a well-known fact that the stomach of the infant can be emptied by gentle abdominal l^ressure. Another explanation is that on deep inspiration the nega- tive pressure caused by descent of the diaphragm forces a certain amount of fluid from the stomach, which is almost vertical in the infant, into the oesophagus and thence into the mouth. This form of vomiting requires no treatment. The general impression is that it can be stopped by regulating the amount of breast-feeding, but this belief is erroneous, as the vomiting persists after such precautions have been adopted. Fleischman thinks that the habit is hereditary in certain families. Cyclic Vomiting (Periodic vomiting; Recurrent vomiting). — Definition.' — Cyclic vomiting is a condition in which there appear at intervals more or less remote from each other attacks of vomiting, accompanied by marked prostration without rise of temperature, in which there is an absolute intolerance of the stomach for even fluid food. This condition has been described under various headings both in France, 1841, by Dr. Gruere; by Lombare, in 1861; in England by Gee, and in America by Eotch, Holt, Rachford, Edsall, Koplik, and others. Etiology. — The etiology of this condition is obscure, and it is most probable that the theory of Rachford is correct — that the symptom- complex is one of gastro-intestinal lithsemia, due to an increased acidity of the fluids of the body as the result of disturbed metabolism. In one of these cases Herter has analyzed the amount of uric acid in the periods preceding, during, and following the attack. In such an 504 DISEASES OF THE STOMACH AND INTESTINES. analysis the gross amount of uric acid was greatest on the second day of the disease, and fell rapidly on the third day to near the normal. The normal relation of nric acid to urea in these patients was as 1 : 54. During the attack the relation of uric acid to urea, as a rule, was 1 : 85, and in the normal condition it fell to 1 : 42. Griffith considers the condition a species of toxaemia. It seems to me, from a study of a number of my own cases, that the condition described by Rachford must obtain; in addition, how- ever, these are crises in which the patients seem to suffer distinctly from attacks of intestinal intoxication, inasmuch as treatment directed toward placing the conditions in the gut on a normal basis seems to benefit them materially. In most of my own cases there has been a history of constipation extending over long periods of time, and an intolerance of milk as the main article of diet in other cases. Other observers (Holt) have not found constipation to be a promi- nent factor in their cases, but rather that the ingestion of certain forms of foods, such as amylacea, are apt to precipitate an attack. In only one of my cases have I found that amylacea were badly borne, and the ingestion in this case of a cereal gruel seemed to precipitate an attack ; constipation, however, existed in this case from infancy. Symptoms. — The symptoms in these cases are quite characteristic ; the subjects of this form of disturbance may be well developed, but, as a rule, they are pale. In some of them the anaemia is quite marked, and the children have a pasty complexion. The attack is preceded by a period during which the child complains of slight pain in the stomach ; in some cases this may be absent. The child awakens in the morning, feels tired, has no appetite for breakfast, and has pronounced pallor. Vomiting sets in; the food is first rejected and then vomiting persists ; in some cases even blood with mucus is vom- ited from the stomach. In other cases the contents of the duodenum may appear in the vomitus in the form of biliary matter. The child finds most comfort in lying quietly on its back, refusing to take any food ; even water is vomited. There is no temperature ; there may be a slight increase of the pulse-rate, and it may have a bounding character, and the heart-impulse may be increased in force. There may be a complaint of epigastric pain. The prostration in some cases is extreme ; the condition may last twenty-four hours to two or three days, until normal conditions are established. The vomiting may recur several times in twenty-four hours; it gradually diminishes in frequency and disappears. During this time there is no movement from the bowels, or there may be a constipated movement as the result of enemata, with the voidance of a large quantity of mucus. The stools have an exceedingly offensive odor. The following is a char- acteristic case: DISEASES OF THE STOMACH AND INTESTINES. 505 Dorothy E., five years of age, fed in infancy on modified milk; has never suft'ered from any disease of greater severity than a grippal attack. She has been constipated since infancy, and this constipa- tion has lately become more marked. After having been put on raw milk and cream, the constipation abated for a few weeks and then returned. The constipation was only relieved by the constant use of cathartics, and sometimes these were not effective. The child is a well-developed girl, thirty-five pounds in weight, with a body-length of 102 cm. (3 feet 4 inches) ; the abdomen is protuberant; there is no disease of the heart or lungs ; the liver and spleen are normal in size. The urine does not contain albumin or casts. The child is anaemic, has a tired expression, and her intestinal movements contain considerable mucus. Her vomiting attacks began when she was four years of age. These attacks last two or three days, during which the child rejects all food. The attacks begin very much in the manner just described. In one of these attacks the vomiting was so severe that there was an alarming hemorrhage from the stomach. The odor of the breath in the first day of the attack is "sweetish" (acetone). Some of my cases during the attacks presented albumin and a few hyaline casts in the urine. These disappeared after subsidence of the attack. Acetone bodies may be present in the urine in in- creased quantity, or they may be absent. Diagnosis. — The practitioner should be exceedingly cautious when presented with a case of vomiting in a child from four to five years of age not to hastily conclude that it is one of cyclic vomiting before making a thorough examination, not only of the urine, but of the other viscera. A case has recently come under my notice, observed for four years, in which a diagnosis was made of cyclic vomiting, but which is one distinctly of nephritis with recurrent attacks of ursemia. Other cases may be masked appendical attacks. Some authors, such as Rotch, have laid stress on the fact that these attacks may also simulate meningitis. Course and Prognosis. — The prognosis in this condition, so far as life is concerned, is good. There are some cases recorded which have terminated fatally. The course of the disease, if properly handled, ends, as a rule, in recovery in from twenty-four hours to three or four days. Treatment. — The treatment of cyclic vomiting is divided into the treatment of the attack and the intervals between the attacks. The Attach. — The patient is put to bed, kept perfectly quiet, and little or no fiuid is given by the stomach- — certainly no solid food. The stomach is quieted with small doses of codeia. This is the only remedy which in my hands seems to have had any influence in con- 506 DISEASES OF THE STOMACH AND INTESTINES. trolling prolonged vomiting. Enemata consisting of saline solution are given twice daily. They should be high enemata, and at least a quart of water should be thrown into the rectum at each sitting. In the intervals between the enemata the child should be nourished by the rectum. Somatose solution^ — 1 drachm of somatose to 8 ounces of cold water — is heated to a lukewarm temperature, and given by the rectum in quantities varying from 2 to 4 ounces every three hours. The patient is given small pieces of ice to swallow, in the case of older children. 'No other treatment is necessary until the attacks of vomiting subside of their own accord within twenty-four hours. It is surprising to see how comfortable these little patients will be if little or no fluid is taken by the mouth; in fact, some of them are intelligent enough to find this out for themselves and refuse all nourishment. On the second day of the disease, when the vomit- ing has subsided to a great extent, we may give the patient broths, fruit juices, diluted gruels; and on the third day we may gradually return, if the stomach is tolerant, to a semi-solid diet, and finally to a full diet. As soon as the stomach is tolerant of fluids, and even at the height of the attack, small quantities of Vichy given by the stomach seem to be grateful to the patient. During this period also the alkaline treatment, which will be spoken of, may be inaugurated ; and finally we may, toward the close of the attack, if this is possible, give a vigorous cathartic, such as cascara, or Rochelle salts. The Intervals. — In the intervals between the attacks these patients do best on the following treatment : The bowels should be kept in a normal condition; if the child is constipated a rectal enema should be given daily, and, if this is not effective, it should be supplemented by some cathartic, such as cascara, in order to facilitate a complete daily evacuation of the bowel. The diet in these children should be a mixed one. I have found that whereas some of these children will not tolerate cereals, others will. The rule, however, is that we should reduce the quantity of milk, especially in the older children, to a minimum, and, if possible, place the patient on a diet in which milk enters but little. They should be placed, so far as medicinal agents are concerned, on the so-called alkaline treatment, which has been found to be most successful in these cases. For a child from three to five years of age I prescribe a powder composed of 2 to 3 grains of bicarbonate of soda and -|- to -J grain of carbonate of lithium. This powder is given three times daily after meals in a glass of Vichy Celestins. The children are bathed daily in a bath in which a hand- ful of bicarbonate of soda and a handful of salt have been dissolved. and are rubbed down after the bath with a very dilute solution of alcohol in water and a rough towel. The muscles of the body are kneaded, if a masseuse is available. Sojourn in the open air as DISEASES OF THE STOMACH AND INTESTINES. 507 mucli as possible is advised, and sports which, involve muscular exer- tion encouraged. Regularity at meals is inculcated, and these little dues are taught, if possible, to evacuate the bowel regularly. In some of these cases the coarser the diet, the more successful seems to be the treatment, for in the most aggravated cases that I have seen there has been a too " finicky " selection of a few articles of diet for these patients, and the little ones have been kept in some cases on milk, gruels, and fruits, to the exclusion of everything else, for months. ' Other Forms of Vomiting. — There are other forms of vomiting which are of interest in this connection: a. Some children vomit when irritated or after outbursts of tem- per, or may vomit at will if their food or anything in connection with their discipline does not meet their approval. Some of the little patients know intuitively that vomiting alarms the mother, conse- tf'tiently it will appear whenever any concession is to be obtained in the nursery. h. Vomiting, especially after eating, may be caused by a severe attack of coughing. If vomiting occurs frequently under these con- ditions, whooping-cough should be suspected. c. The vomiting of pyloric stenosis of the congenital type is char- acteristic. It is more in the nature of a regurgitation. When lying oh the back the baby vomits at intervals, and in small quantities. After a nursing there is an interval, after which the infant vomits two or three times the amount of food taken at the recent nursing. This is explained by the fact that in this condition there is some little vomiting constantly going on, due to the increased peristalsis of the stomach. There is, however, a small quantity of food retained in the stomach. This residual quantity increases with each feeding, and is finally rejected in the manner just described. d. The vomiting of appendicitis is also characteristic. The pa- tient is seized suddenly with sharp abdominal pain and then begins to vomit. The vomiting may recur once or twice, and then cease. In neglected cases, in the final agonal stage, vomiting due to sepsis and toxaemia may be persistent. e. Vomiting is the first symptom in intestinal obstruction. It may be followed by a very small movement, and then for a short time there is, as a rule, no action on the part of the bowels. The vomiting may not recur in the first twenty-four or forty-eight hours, except at long intervals, but the bloody movements recur frequently, and pain is also present. The vomiting returns when the intussus- ception is more marked, and late in the affection becomes fsecal. /. Vomiting occurs at the outset of the infectious diseases. Per- 508 DISEASES OF THE STOMACH AND INTESTINES. sistent vomiting extending over a period of months is often of nephritic origin. g. The vomiting which accompanies meningitis occurs at the out- set in that disease, and is quickly followed by cerebral symptoms. In tuberculous meningitis it occurs at the onset and after the appear- ance of a vague series of cerebral symptoms. It is rarely persistent after the initial attack. The subsidence of the vomiting and the sequence of cerebral symptoms and a febrile movement will easily distinguish this form of vomiting from others. Tumors and abscess of the brain are accompanied by vomiting at intervals. There is in these and in all cerebral cases persistent, severe localized headache. Colic. — Colic is not a disease, but a symptom of disturbed con- ditions in the intestine. It is really a painful contraction of the muscle-fibre of portions of the intestine. In the simplest form the painful contractions are incited by actual distention of the lumen of the intestine. The pain caused in colic is in the majority of cases not of the character which arises in certain other affections of the intestine which are neurotic in nature, nor is it of the same nature as that seen in enteritis. Pain similar to that in colic may be caused by the administration of some such drug as lead, arsenic, etc. Cause. — In the great majority of cases the affection is caused by some disturbance of the processes of assimilation. It is uncommon in infants in good condition, and its appearance in any case indi- cates the necessity of a study into the condition of the digestive processes in the stomach and intestine. The form of pain or colic accompanied by distention (tympanites) seen in newborn infants, and also at the height of pneumonia in older children, has an etiology distinct from that of the ordinary variety. ISTot only is the pain of neurotic origin, but also the distention is a result of paralysis of the muscular fibre of the intestine. The intestinal processes may be disturbed as a result of the pneumonia. Colic may occur in breast- fed or in artificially fed infants. In the former it is not always pos- sible to discover the exact cause. The breast milk may be abundant, of good color, and of correct composition, and still there may be very violent colicky pains. In artificially fed infants the cause of the colic may lie in the very nature of the food (cows' milk) and the diffi- culty of complete assimilation. Thus an excess of fats in the milk cause colic. Symptoms. — An attack of colic is preceded by general uneasiness; the infant cries and cannot be quieted. The severe colicky pain is accompanied by sharp crie-, the arms and lower extremities are drawn up, and the abdomen is rigid. After the passing of gas the infant is quieted and falls asleep quite exhausted. These attacks of colic > X < ^ > OJ Q O (-1 Co •S Q G DISEASES OF TEE STOMACH AND INTESTINES. 509 dej^rive the infant of sleep ; they may or may not be accompanied by tympanites. The movements are rarely normal, or may be normal for some days and then take on a curdy character or become greenish. Sometimes the colicky attacks are accompanied by a mild form of diarrhoea ; the pain may be so severe as to cause convulsions. Treatment. — See below under Tympanites. Tympanites. — Tympanites is a condition of distention of the in- testine with gas, which may supervene in inflammatory states of the peritoneum. In such conditions (peritonitis, appendicitis) the paral- ysis of the muscular wall of the intestine is the real cause of the dis- tention. In other states, such as pneumonia, it may be the result of inefficient action of the diaphragm in not expelling the intestinal gases and of an enteric catarrh which sometimes accompanies that disease. In the newborn infant, tympanites is a result of an inherent muscular weakness of the intestinal wall. In colic due to imperfect assimilative processes, the tympanites is due to the formation of gases of which the intestine is unable to rid itself rapidly (Plate XXVIII. ). In pneumonia the tympanitic distention is sometimes extreme, causes great distress, and is frequently mistaken for peritonitis. In the forms of distention in the newborn infant the distress is not so great. In rachitis there is a state of tympanitic distention of the abdomen due not only to defective assimilative processes, but also to a lax condition of the muscle-fibre of the intestinal walls. Treatment of Colic and Tympanites. — If the food of a bottle-fed infant is at fault, the modification of milk must be altered so that the proportion of the fats may be lower. A reduction of fat will not always remedy the condition; the proportion of sugar is sometimes at fault, especially in infants fed on condensed milk. Xot more than 6 per cent, of sugar should be added to any milk modification. Some infants can take a large quantity of malt-sugar in their food and not suffer from colic. If a breast-fed infant suffers from colic, the hygiene of the nurse should be attended to. If after the taking of exercise and regulation of diet the colic persists and becomes a fea- ture in the case, the wet-nurse should be changed. The attack of colic is best combated by giving the infant an enema. In some cases a small amount of dilute hydrochloric acid and pepsin given three times daily will alleviate the symptoms. In other cases a small dose of pancreatic extract and bicarbonate of soda will, after feeding, succeed in alleviating symptoms. If in spite of all efforts an artificially fed baby suffers with colic and does not increase regularly in weight, it should be placed at the breast. Dilatation of the Stomach. — Etiology. — Dilatation of the stomach may be due to mechanical causes, such as stenosis of the pylorus, resulting in overfilling of the stomach, with consequent dilatation ; or 510 DISEASES OF THE STOMACH AND INTESTINES. it may be caused bj muscular atony, such as is present in general atrophy or rachitis. In mechanical stenosis of the pylorus the mus- cular structures are intact at first ; hypertrophy subsequently appears in the region of the pylorus, with secondary dilatation of the fundus of the stomach. An hour-glass distortion of the form of the stomach and, subsequent to this, a sausage-shaped dilatation of the organ result, the long diameter of the dilatation being in the long axis of the stomach. This last-named deformity is permanent. The location of a dilated stomach in the child differs somewhat from that in the adult. The pylorus in the child lies deepest and near the umbilicus in the mid-line; the fundus lies transversely across the abdomen at the situation of the umbilicus ; whereas in the vicinity of the border of the ribs it passes abruptly upward. The muscular coat of the stomach in these cases is thin and atrophic. If there is overloading of the stomach, or the ingestion of indigestible sub- stances, the organ is not thoroughly emptied, and as a result there are fermentation and accumulation of food in the stomach. Muscular relaxation results, and then atrophy of an otherwise weak muscula- ture. In arthrepsia and rachitis the musculature of the stomach is primarily weak, and repeated attacks of dyspepsia with overloading result in dilatation. Symptoms. — The symptoms of dilatation of the stomach as a result of pyloric stenosis are described elsewhere. As a result of chronic dyspepsia and overloading of the stomach in younger children there are at first the ordinary symptoms of evanescent dyspepsia. There is vomiting after meals, and after a time this vomiting takes place after the food has accumulated in the stomach. With the attacks of vom- iting there is loss of appetite, and finally an intolerance of all food, even in very small quantities. Constipation follows as a result of lack of appetite and the avoidance of food. Meteorism is present in some of these cases ; whereas in others intestinal catarrh may alternate with the constipation. In older children dilatation of the stomach results from repeated attacks of dyspepsia which extend over months. The development of the disease is slow. There are loss of appetite, a feeling of ten-, sion and overloading after meals ; the odor of the breath is bad ; the tongue is coated ; children complain of headaches ; the bowels are very irregular, sometimes constipated ; and finally vomiting after meals sets in. The vomited matter contains not only particles of food, but sarcinse and other species of bacteria. The reaction of the stomach- contents may be neutral or acid, the hydrochloric acid and propeptone may be increased or may vary on different days ; lactic, butyric, and acetic acids may be present in the vomited matter as a result of fermentation. DISEASES OF THE STOMACH AND INTESTINES. 511 Physical Signs. — The physical signs consist of persistoit meteor- ism and tympanites. The abdomen is very much enlarged, and in some cases the stomach can be distinctly outlined, especially the greater curvature. If the child is examined lying on its back, with its knees raised and the pelvis supported with one hand while the other taps the abdomen sharply over the situation of the stomach, the distended organ will yield a so-called succussion sound, due to accu- mulated contents in the organ. In many cases a dilated colon may be mistaken for a dilated stomach. By means of gastrodiaphany the author has been able to mark out quite distinctly the greater curva- ture of the stomach. Prognosis. — The prognosis will vary according to the exciting cause. If the dilatation of the stomach is caused by congenital stenosis of the pylorus the prognosis is doubtful ; if caused by repeated attacks of gastric dyspepsia the prognosis is more favorable. It is not as favorable in severely rachitic children, in whom there may be at the same time a progressive atrophy of the muscular tissue of the stomach. Treatment. — The treatment of dilatation of the stomach in infants and children does not differ materially from the treatment of the same condition in the adult. In infants the quantity of solid food •and fluids given at each meal is reduced to a minimum. The sys- tematic washing of the stomach at intervals is indicated in these cases, as in older children and adults. With older children the amount of fluids is also limited. Soups are excluded and milk is peptonized. Bread, meat, and digestible substances are preferred to fluids. In these cases also the stomach is washed systematically. The medical treatment of these cases consists in the administra- tion of hydrochloric acid, pepsin, general hygiene, massage, faradiza- tion of the stomach in severe cases, as in the adult. Ulcer of the Stomach. — Ulcer of the stomach may occur as a complication in sepsis of the newborn, in acute gastritis, and in tuber- culosis. As a primary disease, this affection is very rare in infancy and childhood, although cases are reported in the literature as a com- plication of infectious diseases, such as scarlet fever, typhoid fever, measles, tuberculosis. Reimer records a case in a child three and a half years of age. Hibbard met a case in an infant four months of age. Botch reports a case in an infant seven weeks old. It is rare, however, between the ages of one and ten years. In 226 autopsies Brinton saw it twice. I have seen it at an autopsy in a case of em- pyema. It occurs in chlorotic girls toward the age of puberty, and is not essentially a disease of infancy and childhood. Congenital Pyloric Spasm and Congenital Hypertrophic Stenosis of the Pylorus {Congenital Stenosis of the Pylorus; Congenital 512 DISEASES OF THE STOMACH AND INTESTINES. Hypertrophy of the Pylorus and Stomach-waU; Congenital Gastric Spasm).- — Hypertrophic pyloric stenosis is a congenital condition which appears from a few days to several weeks (three months) after birth, and manifests itself in persistent vomiting. In a few instances several infants in the same family have been thus affected. The first case of pyloric stenosis was described by Dr. Beardsley in the Transactions of the New Haven Medical Society (Osier). Landerer (1879), Maier (1885), and Hirschsprung (1887) re- opened the study of this affection. Etiology. — The etiology of the affection is obscure. Since in the majority of the cases which have been carefully studied the infants were overfed or improperly fed, it is supposed that some irritant to the stomach is the exciting cause. Thomson, who has made careful studies of these cases, believes that the condition originates in intra- uterine life, and is due to the ingestion of liquor amnii. This fluid, by irritating the mucous membrane of the stomach, excites both that organ and the pylorus to overaction. Pf aundler denies that there is a true hypertrophy of the pylorus, and asserts that the condition during life is that of functional spasm. The postmortem condition is due to toxic agonal contracture of the pylorus. Another theory is that congenitally there may be some narrowing of the orifice of the pylorus, but not sufficient to prevent the passage of food. Such infants are immediately after birth in apparent health and only later the spasm amounting to a real stenosis of the pylorus makes its appearance, due to an increased acidity of the con- tents of the stomach reacting on a sensitive mucous membrane and causing a spasm of the already impaired sphincter. This acidity is supposed to be due to improper feeding or excess of some element of the food such as fat. Morbid Anatomy. — The stomach and CEsophagus have been found to be dilated in fully one-third of the reported cases. The mucous membrane shows the usual change, such as the congestion which is seen in a stomach in which there have been functional disturbances. The mucous membrane of the pylorus is thrown into voluminous folds. The lumen has in some cases been found patent to a small probe, but fluids cannot be forced from the stomach through the pylorus (Thom- son). The muscular fibres show characteristic change. The circular fibres are thickened and hypertrophied (Thomson). In Finkelstein's case the longitudinal fibres were also thus affected. Some deny this hypertrophy and contend that it is an agonal contraction. Classes of Cases. — To my mind there are two distinct sets of cases which give rise to symptoms to be detailed. In one set there is a dis- tinct spasm of the pylorus and stomach without any marked hyper- trophy and with a limited amount perhaps of stenosis of the pylorus. DISEASES OF TEE STOMACH AND INTESTINES. 513 After a time such cases improve and eventually recover, leaving no trace of the illness in the patient. In the other set there is a congenital condition of marked stenosis of the lumen of the pylorus and to this there is superadded a spasm vsrhich causes this lumen to become completely obstructed. To this is added a marked hypertrophy of the muscular fibres v^hich enter into the structure of the pylorus. The mucous membrane and mus- cular coats are thickened and thrown into obstructing folds of tissue. In a great many instances this condition admits of improvement. The spasm relaxes, the lumen of the pylorus opens up and, though it may remain narrovt^ed, under correct diet the patient improves and increases in weight. I have published such cases as well as cases illustrating the purely spastic condition of the pyloric orifice. Symptoms. — Infants in whom this condition is present are of normal weight and appearance when born. The great majority of them have been breast-fed ; I should say from the literature that fully two-thirds of the children were breast-fed from the start. After a while, varying from one to four days, in other cases seven days, and in a great many cases the third week after birth, in exceptional cases the eighth week after birth, the vomiting begins. In a few cases, as in some of my own, there is a history that an attempt was made to feed the baby, in addition to the breast, on the bottle, and in these cases the vomiting began from the attempts at mixed feeding. In other cases there is no such history, the mother's milk being the only food ; the milk seemed to be abundant, and there was no change in the milk or in the mother to account for the disturbance in the child. The vomiting occurs at first at intervals throughout the twenty- four hours, and soon becomes persistent, the child rejecting sometimes a portion or all of every nursing. Sometimes the history will show that the infant has rejected more than it had taken. This is quite characteristic, and points toward a retention in the stomach of some of the previous feedings. With the vomiting there is a steady ema- ciation or a stationary weight. If the weight is stationary, the patient is fortunate. If the emaciation is progressive, in a few weeks an infant which had been perfectly well at birth, weighing the normal or above the normal, is reduced to a distinctly marantic con- dition. With the vomiting there are other signs of constitutional disturbance. It seems that every time the breast is given to the child, or within a few minutes after nursing, there are evidences in some cases of pain ; the children will cry and this will be told to the physician by the mother. In addition there is constipation in most cases, or the movements are small, minimal in quantity, sometimes fluid in con- 33 514 DISEASES OF THE STOMACH AXD IXTESIIXES. sistency, or tliey may be greenish. As a rule, the movements indi- cate that very little has passed through the gut. Physical examination in these cases reveals in the vast majority of instances a characteristic condition of the surface of the abdomen. On the introduction of food there is a peristalsis visible to a greater or less extent on the surface of the abdonien. This peristalsis begins underneath the left costal border^ passes forward to Traube's triangle, and there seems to stop, being interrupted by a sort of groove, and is taken u]3 again by a second wave of peristalsis which passes onward beyond the ensiform cartilage^ then downward, and disappears (Fig. 108). Fig. 108. Peristalsis as seen in congenital pyloric stenosis. Case of Ibrahim. Some authors have described a reverse peristalsis just previous to vomiting, but I could never convince myself of the fact, possibly because I have not seen these particular cases. If there is a reverse wave of peristalsis, it must be instantaneoiis. and I have not yet observed it. Ibrahim also expresses his lack of information on this reverse wave. In some cases I have seen the peristalsis so extreme that just previous to vomiting the stomach would in a manner erect itself on the abdomen and divide itself distinctly from what ajDpears to be the pyloric end of the stomach ; it would contract, and then the vomiting would take place. The vomiting is projectile in its nature, as if there was a sudden violent contraction of the stomach and a forcing upward of the con- tents. In some cases careful examination during this period of con- traction and peristalsis reveals a small hard nodule, cartilage-like in consistency, situated sometimes beneath the liver or its border and running directly downward toward the umbilicus. This structure, situated deeply against the vertebral column, is undoubtedly the pyloric end or valve of the stomach as it meets the duodenum. DISEASES OF THE STOMACH AND INTESTINES. 515 Some authors like Ibrahim have described singultus in these cases, and also eructations of gas, but inasmuch as these are quite common in healthy breast-fed infants, it seems to obscure the picture by laying any stress upon them. The peristalsis which I have described is present in a majority of cases, but it is not necessarily an accompaniment of all of them. It is sometimes entirely absent during the height of the affection, and is only seen at times. The pylorus also may not be palpable, and may not be felt at times. As to the peristalsis, we must be very careful also how we conclude as to its presence or absence. A normal mild form of peristalsis seen in emaciated infants must not be confounded with the violent peristalsis present in some forms of this affection. Some of the most violent cases of vomiting with spasm or congenital stenosis of the pylorus have passed through my hands without the detection of the situation of the pylorus. Diagnosis. — Clinically there should be a distinction between cases which seem to be those of pure spasm of the pylorus with only relative or temporary stenosis and those in which there is a true hypertrophy with stenosis of the pylorus of congenital origin. In simple spasm there is persistent vomiting, retention of stomach contents, steady emaciation, and constipation. There may be no peristalsis and the pylorus is not distinctly felt. If indeed it is palpable, it is only so as a very small, indistinct nodule. There are one or two daily stools which contain a very small amount of milk fseces. In hypertrophic stenosis all the above symptoms are present to an aggravated degree. There is marked visible peristalsis, the constipation is complete, the stools show no milk fseces, only bile-stained mucus. The pylorus is distinctly palpable. Congenital conditions, such as real growths of the pylorus or atresia of the pylorus, are exceedingly rare, and can scarcely be brought into consideration in connection with conditions which are considered in this paper. The symptoms in congenital atresia and growths which completely obstruct the pylorus must come on imme- diately after birth, and are rapidly fatal, unlike the conditions in which the symptoms appear some time after birth. Congenital stenosis of the jejunum or duodenum may be confounded with that of stenosis of the pylorus, if the congenital atresia of the gut is situated high and near the pylorus. There may then be a series of symptoms on the part of the stomach indistinguishable from those of pyloric obstruction. Pure pyloric spasm, I feel, may well occur and does occur with very slight hypertrophy of the pylorus, giving rise to only a limited form of stenosis. Ibrahim doubts the existence of pure pyloric spasm, but I have tried to show that it does occur, and this also in quite a 51(3 DISEASES OF THE STOMACH AND INTESTINES. percentage of cases; more especially is this so in those cases of per- sistent vomiting in which there is sudden or gradual cessation of symptoms upon the inauguration of correct diet and feeding. I think, in considering the question as to whether a spasm or severe form of stenosis is present, one of the most useful clinical guides is the amount and quantity of the stools. If in a given case the stools consist mostly of bile-stained mucus and very little fsecal matter, in spite of the ingestion of an ideal food, such as breast milk, we are driven to the conclusion of the presence not only of spasm of the pylorus, but also of narrowing and stenosis of high degree. If, in spite of vomiting at every feeding, peristalsis and even a palpably contracted gut in the region of the pylorus, there is one or two stools daily containing some milk faeces, we must feel, as in certain of my cases which at times appeared hopeless, that the stenosis at the pylorus is not of high degree, and that the spasm relaxes at times and allows a certain amount of food to pass and nourish the patient. It is in most of these cases that we can feel that the ultimate outcome will be favorable, no matter how exasperating present symptoms appear to be. Prognosis. — The ultimate fate of these eases is extremely inter- esting in view of the recent contention from some quarters that as soon as the diagnosis of hypertrophic congenital stenosis is made the surgeon must interfere in behalf of the infant. I have tried to show that a large number of cases are really spasm cases, and will eventually recover on internal therapy. Persistent trial of feeding, the most diverse, will eventually result in overcoming the condition. As to the ultimate prognosis of true hypertrophic stenosis of the pylorus my own feeling is that there can be no absolute statement to fit all cases. The majority, I am certain, will recover under per- sistent attempts at feeding, and from my own experience ultimate recovery by internal management is not impossible in cases which it would seem must be operated upon. It is the exceptional case which will come under the notice of the surgeon. According to some writers fully 85 per cent, of the cases of spasm or stenosis will recover with- out resort to the knife. My own experience, which is quite large, seems to support this contention. Treatment. — T shall consider for conciseness: (a) Feeding; (h) mechanical means of therapy; (c) drugs; and (d) operative means. Feeding. — In a given case of hypertrophic stenosis or of congen- ital spasm the feeding is undoubtedly by far the most important element in the treatment. Breast feeding is the ideal method of feeding these cases, but not every breast will be found adapted to the infant. The breast is given at long intervals and short nursings. Many infants who have not improved on a given breast, or to whom DISEASES OF THE STOMACH AND INTESTINES. 517 a breast is not available, will be tided over their illness by some of tbe many and diverse forms of substitutes for the breast at command of the physician. I do not think any artificial food is ideal, and no one is a panacea in this condition. Some insist that the food contain a minimal fat, and I have seen many cases recover on a food which all pediatrists agree is the most unsuitable in the long run under ordinary con- ditions. In other words, though this condition seems in a certain proportion of cases to have been inaugurated by some error in diet, there is no royal road to the feeding. In artificial as in breast feed- ing the method must presuppose small amounts at each feeding, at long or short intervals, as the case may be. Mechanical. — Mechanical means of therapy include the applica- tion of warm cataplasms of flax seed and hops, or dry warmth, stomach washing, and enteroclysis. Stomach washing is in some cases, when the infant is in a weakened condition, an exhausting procedure, though some observers, such as Pfaundler and Feer, laud its use highly. It may be tried at first and if no immediate relief result it should be suspended. Gavage. — I have used gavage with some degree of success in cer- tain cases and recently Saunders has had markedly favorable results with this procedure. By it fixed amounts of food are introduced into the stomach at intervals. Enemata are useful in the form of enteroclysis of small amounts of normal saline solution to maintain nutrition. They are given several times daily. Drugs. — Heubner advises opiates, others derivatives of opium, in very small amounts to quiet the spasm of the pylorus and adjacent stomach wall. Heubner uses the tincture. In most of my cases no opiate was resorted to, and in only one was it given, and then only after improvement was well inaugurated and only in exceedingly small doses and at desultory intervals. I have found but temporary benefit from the administration of citrate of soda, or soda and pancreatin. Operative Therapy. — An operation such as is proposed for the relief of congenital hypertrophic stenosis of the pylorus presupposes great technical skill on the part of the surgeon. The published mor- tality under the knife varies from 50 per cent, to 75 per cent, and this does not give us any idea of the cases which have in the hands of some surgeons given a higher mortality. The operation of selection is posterior gastro-enterostomy. Acute Gastro-enteric Infection (including Cholera Infantum) {Summer Diarrhoea; Acute Gastro-enteric Infection). — Acute gastro- enteric infection is a form of intestinal disturbance usually accom- 518 DISEASES OF THE STOMACH AND INTESTINES. panied bj gastric symptoms. It is prevalent in the summer, but may also occur during tbe winter months. Bottle-fed infants are more subject to the affection, although it occasionally attacks infants at the breast. In institutions epidemics of the disease occur in breast-fed infants. In large cities more than one-half the deaths among infants under the age of twelve months are caused by summer diarrhoea. In Paris, Chaterinkoff found that of 20,000 children dying of gastro-intestinal disorders, fully three-fifths were bottle-fed. This high rate of the mortality of bottle-fed infants, as compared with that of breast-fed infants, is not alone due to the difference in the nature of the food; no matter how carefully it is handled before it reaches the infant, milk passes through many channels, and in each of these it is exposed to infection. The intense heat of summer also favors the increase of infectious agents. Etiology and Classification. — The various forms of acute gastro- intestinal infection may be divided into those whose source of infec- tion lies outside the body (ectogenous) and those in which the elements of infection are pre-existent in the body (endogenous). This classi- fication (Escherich) is both practical and in accordance with the results of recent study. In the first class are included the diarrhceas of toxic origin and cholera infantum; in the second are included the diarrhoeas which are caused by varieties of bacteria pre-existent in the intestine, but which, in the opinion of Booker, Escherich, and Marfan, may under favorable conditions increase to enormous numbers and become viru- lent. According to Booker, no one sjDecific micro-organism is the essential cause of acute summer diarrhoea, Escherich has shown that the coli group may under certain conditions become virulent. Of the bacteria which are found in certain forms of gastro-intestinal infection, the Streptococcus enteritidis seems to have attracted the greatest atttention, Booker first insisted on the importance and pecu- liar role of this micro-organism. He found these streptococci in great numbers not only in the stools of infants suffering from acute summer diarrhoea, but also in the walls of the gut and in the various organs of the body. Escherich and his pupils, Libman and Hirsch, have confirmed the results of Booker. Escherich regards the Strep- tococcus enteriditis as an ectogenous infection. The udder of the cow may be the source of this micro-organism. Marfan and Booker are also inclined to believe that streptococci are able under certain conditions to increase in number and virulence and that they are one of the endogenous forms of infection by a micro-organism normally present in the gut. Among the other bacteria found in enormous numbers in the movements of infants and children suffering from acute gastro-entcric infection are the Bacillus pyocyaneus (Kosseland DISEASES OF THE STOMACH AND INTESTINES. 519 Baginsky), Proteus vulgarus (found bj Booker in clioleriform diar- rhoea), and the proteolytic bacteria. The second class comprises peptonizing bacteria, such as the Ba- cillus subtilus, Bacillus mesentericus vulgatus, and Tyrotrix tenuis. These peptonizing bacteria are not found in the gut or stools of the breast-fed infant either when in good health or sick. We may thus classify all diarrhceas of acute gastro-enteric infection as follows : 1. Those due to improper food, or the so-called mechanical irri- tative diarrhoeas (Booker). 2. The infectious forms (endogenous and ectogenous). This class would include the toxic diarrhoeas of some authors. ISTot only the food and the bacteria, but also certain changes in the intestine play an important role in acute gastro-enteric infection. Morbid Anatomy. — Stomach and Intestines. — Booker has described a superficial loss of the epithelium of the stomach and gut, as a con- stant lesion in all fatal cases of gastro-enteric infection. It may be intact in some places and destroyed or eroded in others. The mucous membrane of the jejunum and duodenum may show less denudation than other parts of the gut. The epithelial layer of the mucosa is infil- trated with leucocytes in diffuse areas or nests. The infiltration may push the epithelial layer upward. The mucosa itself is infiltrated with polynuclear and mononuclear leucocytes to a varying extent. The mucosa shows superficial or deep ulcerations involving the crypts or villi. Heubner has described a form of necrosis which chiefly affects the epithelial structure without involving the deep mucosa. This occurs in cholera infantum. Booker also describes a bronchitis and a form of bronchopneumonia which are quite constantly found in fatal cases. Hemorrhages into the lung tissue are common. Kidneys. — In the kidneys there is necrosis of epithelium in the convoluted and irregular tubules (Booker). Liver. — The liver shows fatty degeneration and necrosis of the liver-cells. Lymph-nodes. — The lymph-nodes show focal necrosis. The Role of the Bacteria. — Booker has demonstrated that no bac- teria are found in the mucosa of the intestine if the superficial epi- thelium is intact. If there is a lesion of continuity of the superficial layer, the bacteria invade the mucosa in large numbers. There is reason to believe that the toxins generated by the bacteria in the gut cause the superficial erosions and prepare the way for invasion of the lymph-channels and bloodvessels. Bacteria are not always found in the lesions, but as a rule the ulcerations of the mucosa show vast numbers. Booker found bacteria in cultures taken from the solid organs and blood, thus confirming what Czerny and Mozer found to 520 DISEASES OF THE STOMACH AND INTESTINES. be the case during life. The lungs especially showed large numbers of bacilli and cocci. Symptoms, — In the mild form of gastro-enteric infection the infant is restless and cries at intervals because of colicky pains. It may previously have been in good health, but with the advance of these symptoms there will also be noticed a slight febrile movement and a disinclination to take the bottle or breast. Vomiting occurs after feeding, the rejected contents of the stomach being curdled and having a marked acid odor. In mild cases the vomiting is usually not severe. It may be repeated three or four times in the twenty-four hours. The movements are at first normal; they afterward become frequent and contain whitish curds or greenish and white curds, are more fluid than is normal, and may have a very offensive odor. In mild cases there may be only two or three such movements in the twenty-four hours or they may number six or more. Later, the fever also becomes more marked, the temperature sometimes mounting as high as 103° F. (39.4° C). If the feeding is continued, the vomiting persists. The infant shows little or no prostration. In severe cases the vomiting is marked from the outset. The infant not only vomits its regular food, but will also often vomit all fluid that is taken into the stomach. The diarrhoea is also more severe than in the mild forms. The movements are at first yellow or greenish and contain white curds, but as the disease advances they become more fluid, until in very severe cases only a greenish malo- dorous liquid containing small particles of mucus and faecal matter is voided. The infant has a febrile movement which varies from 101° to 103° F. (38.8° to 39.4° C), and there is marked prostra- tion. In the acute forms of gastro-enteric infection there is consid- erable loss of weight; the infant becomes pale and languid, and the pulse is rapid and weak ; the number of daily evacuations may reach twenty. In some cases the straining causes a descent of the lower part of the rectum, and the movements contain a slight amount of bloody mucus. The odor of the evacuation may not be offensive. If the patient improves, the symptoms retrograde — the vomiting becomes less frequent, the stools more fsecal in character and less numerous, and the fever subsides. If, on the other hand, the symp- toms progress, the movements not only continue frequent and fluid, but also blood and particles of mucus are mingled with the fsecal mat- ter. The vomiting may cease entirely. The infant loses in weight steadily; the movements are small and passed with tenesmus; the patient passes into the subacute stage. In some cases there is colic ; the infants are restless or pass into an apathetic condition. Little urine is passed, and in the majority of cases of mild or severe gastro- enteric infection albumin is present. It rarely amounts to more than DISEASES OF TEE STOMACH AND INTESTINES. 521 a trace. In severe cases there are leucocytes and epithelial, hyaline, and blood-casts in the urine ; sometimes in addition a few blood-cells are found. In the subacute forms of gastro-enteric infection which last for more than a week, bronchopneumonia may be a complication. This form of bronchopneumonia is described in the section on Pneumonia. In some cases it is of short duration, in others persistent. Broncho- pneumonia with slowly resolving areas of consolidation in the lung is the type met with. Course and Prognosis. — The prognosis of the mild forms is good, if proper measures are adopted. The severe forms are exceedingly fatal in summer. The mortality varies with the environment. In the crowded tenements of large cities and in unhygienic surroundings the mortality is great, as is also the case in institutions and hospitals. In private practice the isolation of the patient and special nursing reduce the mortality to a minimum by preventing reinfection. Rein- fection is caused by lack of care in handling the diapers and in pre- paring the food, by giving improper food, and by placing a number of cases in the same room. There can be no question that in hospitals patients are affected unfavorably by proximity to other patients suf- fering with the same disease. ISTo matter how careful the nursing under such circumstances, reinfection cannot be prevented. Also, perfect cleanliness is not attainable in hospitals as in private practice. Treatment. — See under Cholera Infantum. Cholera Infantum. — Cholera infantum is the severest form of summer diarrhoea prevalent among infants. It is believed that it has a specific origin, but this has not as yet been demonstrated. Cholera infantum does not occur so frequently as has been hitherto supposed. Of hundreds of cases of gastro-enteric infection of the acute variety which come under my care yearly, only a few can be called typical of this form of infectious diarrhoea. These cases occur for the most part in weakly bottle-fed infants. Breast-fed infants may occasionally be affected, especially in hospitals. Symptoms. — The infants as a rule have been suffering from a mild diarrhoea. Following a slight febrile movement, vomiting and diarrhoea of a severe and exhausting character set in. The bowel movements are frequent, but contain very little fsecal matter after the first few have been passed. They are at first greenish, afterward becoming watery, resembling barley-water; they contain but a few flocculi of mucus, and may not have much odor. The vomiting is incessant. First the stomach contents are vomited, and finally a greenish fluid. Within a few hours the infant is reduced to a condi- tion of great prostration. The loss of weight is marked, even in the first twenty-four hours. The skin on the thighs is wrinkled. 522 DISEASES OF IKE STOMACH AND INTESTINES. The face and trunk are pale and tlie face is drawn. There is fever to a marked degree (101°-103° F., 38.3°-39.4° C), and the pulse is rapid and thready. Toward the close the movements are passed involuntarily. The whole picture is that of a choleriform disease. As the fatal issue approaches the eyes become sunken and glassy, the fontanelle is depressed, and the mouth is open. The con- dition described elsewhere as hydrocephaloid sets in. Convulsions and a rise of temperature (105="'to 107° F., 40.5° to 41.6° C.) pre- cede the fatal issue. Occurrence. — These severe choleriform diarrhoeas resemble Asiatic cholera very closely, and should be sharply differentiated from severe forms of gastro-enteric infection. They occur in bottle-fed infants under the age of two years, and chiefly in the months of July and August. Heat and infected food are the main etiological factors. A diarrhoea of a mild type is the forerunner in the majority of cases. These cases are not so frequent to-day as they were in the days when infants were fed with decomposed milk containing bacterial toxins. This form of diarrhoea must therefore be looked upon as a purely ectogenous infection. Duration and Prognosis. ^ — The prognosis in the majority of cases of cholera infantum is grave. The disease is an exceedingly fatal one, occurring as it does for the most part in infants fed on the bottle whose general condition is poor. It lasts for from twenty-four hours to two or three days. The rapidity of the development of the symptoms and of the fatal results precludes the possibility of any complications other than those due to the great drain on the system. The condition of hydrocephaloid is hardly a complication ; it is a ter- minal set of cerebral symptoms. Sclerema, mentioned by some authors, I have not met in true cholera infantum; it is seen in the terminal stage of acute forms of gastro-enteric infection. This form of sclerema affects the thighs at the upper and inner part. It is described in the section devoted to that subject. Kjelberg, Felsenthal, Bernard, Morse, and the writer, found albumin and casts in the urine of children suffering from all- forms of gastro-enteric infection, acute and subacute, including cholera in- fantum. Morse as well as the author found that the urine was concentrated and contained hyaline, granular, and epithelial casts, with leucocytes and blood and blood-casts. The albumin is rarely present to a marked degree. It is a trace or a distinct reaction. The urine is suppressed in severe cases, and lessened in quantity in others. In some cases of the severe types there is slight oedema of the subcutaneous tissues, especially on the inner part of the thighs, the legs, and dorsum of the foot. We are not in a position to trace any close relationshij? between DISEASES OF THE STOMACH AND INTESTINES. 523 the general symptoms and the disturbances of the kidney. The toxa?mia in this disease, causing as it does vomiting and nervous symp- toms, masks the nephritic symptoms if they are present. Diagnosis. — The diagnosis of acute gastro-enteric infection is not difficult. There are, hov^ever, many infectious diseases, the onset of which it closely resembles. Scarlet fever, for example, begins with vomiting, and in some cases with diarrhoea. There is a form of grippe which in its onset, with vomiting and diarrhoea, closely resem- bles an attack of gastro-enteric disease. In fact, these symptoms may persist in the course of the former affection. The physician should not be satisfied with a history of gastro- enteric symptoms, but should carefully examine the skin, throat, and chest at every visit. In the severe forms of diarrhoea a small particle of the movement may be spread on a cover-glass and examined for an excessive number of streptococci. In mild, protracted forms of diarrhoea we should not fail to make a Widal test of the blood and a count of the leucocytes, to eliminate the possibility of typhoid fever. This will especially be indicated in cases in which there is enlarge- ment of the spleen. Treatment of Acute Gastro-enteric Infection and Cholera Infantum. — Prophylaxis. — The nursing bottles when emptied by the infant should be filled with a saturated solution of sodium bicarbonate, allowed to stand for a few hours, and then carefully washed inside and out with a bristle brush. The nipples should be sterilized daily. The nurse or mother, after attending to the diapers of the infant, should carefully cleanse the hands before feeding the baby. The milk should be diluted as directed in the section on Infant Feeding, pasteurized or sterilized, and then kept on ice until needed. The milk should be fresh and delivered for modification within a few hours of the milking-time. The nursing should be conducted at stated intervals. If there is a residue in the nursing bottle, it should not be utilized for a subse- quent nursing. The infant is given a full bath daily. By attend- ing to all these details, infection of the food and of the infant may be avoided. With breast-fed infants prophylaxis is of great impor- tance. A baby at the breast should be fed at regular intervals. The breast-nipples should be washed with a saturated solution of boric acid before and after nursing. The baby should not be allowed to nurse a breast with a fissured nipple. The milk of such a breast is pumped off, and an attempt is made to heal the nipple in the manner elsewhere described. If there is caking of the breast, the condition should be remedied before the infant is allowed to nurse. Abun- dance of fresh air and bathing are indicated in these infants as in bottle-fed infants. SicJc Infants. — As soon as a baby shows signs of even mild dys- 524 DISEASES OF THE STOMACH AND INTESTINES. pepsia or gastro-enteric infection the milk should be discontinued, a simple cathartic given, and the infant kept for twenty-four hours on a solution of egg-albumin. Vomiting which has occurred only once or twice does not call for active treatment, as it will disappear as soon as the milk is discontinued. After the bowels have moved, if the infant shows no exacerbation of symptoms feeding should be resumed cautiously. In this way a severe illness can be averted. If the food is not suitable, causing signs of dyspepsia such as colic, it should be changed if possible, else severer symptoms may result. If in spite of all precautions an attack develops, the patient should be treated on the following lines : 1. The food is stopped and another of a safe character substituted. 2. The toxins are eliminated and the strength of the patient sup- ported by the so-called mechanical methods. 3. Drugs are used to abate the symptoms and support the strength of the patient. The milk, whether of the breast or bottle, is discontinued. The infant is given a solution of albumin-water, acorn-cocoa, or beef -juice expressed and diluted with barley-water. A baby can be kept for days upon these mixtures without any danger of reducing the strength. According to Czerny, 100 c.c. of breast milk are equivalent to 61 calories; 100 c.c. of the white of egg are equal to 75.1 calories. The white of one egg weighs about 30 grammes ; therefore the white of an egg is equal to about 25 calories. It is digestible, and is well borne by infants. Albumin-water may be used alternately with the solution of acorn-cocoa or beef -juice and barley-water. To older children we may sometimes have difficulty in administering albumin- water or acorn-cocoa. Under such conditions, when the acute stage is passed, I frequently resort to a dextrinized gruel or the so-called Liebig's soup mixture which Keller devised. The cathartic given at the onset should be castor oil or calomel, ^ grain (0.03) doses twice or three times a day. Infants who are vom- iting are given calomel in preference to castor oil. Vomiting. — If the vomiting is not severe and the case is under treatment from the onset, it is best not to wash out the stomach at once. It often happens that the vomiting ceases as soon as the regular food is stopped. If, however, the vomiting persists for twenty-four hours, we proceed to wash out the stomach. If the vomiting con- tinues after this, it is either toxic or may in rare cases be due to some other causes. As a rule, it ceases after one irrigation of the stomach. Diarrhoea. — The diarrhoea is controlled by irrigation of the gut. The rectum and gut are washed out in those cases in which the diar- rhoea is not only persistent, but progressive. The object in washing DISEASES OF THE STOMACH AND INTESTINES. 525 out the lower bowel is two-fold: (a) to remove any residue of fseces that may have collected in the lower bowel and rectum, and to stimu- late peristalsis and thereby favor evacuation from above; (&) to stimulate the heart and add to the body an amount of normal solu- tion to compensate for the drain caused by the diarrhoea. The Can- tani normal salt solution is utilized in the manner described. The rectal enemata are given under a pressure obtained by an elevation of at most two feet from the bed. A temperature of 107° to 110° F. (40.5° to 43.3° C.) is the best and most stimulating in these cases. Fully a quart of water is thrown into the rectum in half-pint portions. As the half-pint flows in, the funnel on the rectal tube is disconnected and the contents of the bowel are allowed to escape. Another portion is then allowed to flow into the bowel. The water will sometimes escape alongside of the tube. This is rather a favorable sign, being significant of the contractile powers of the gut and abdominal walls. Only two enemata daily are necessary, even in severe cases. As the diarrhoea and symptoms subside we reduce the number of enemata to one, finally discontinuing them entirely as the infant improves. It sometimes happens that after a few days the enemata are fol- lowed by movements containing blood and mucus, the tenesmus being aggravated. In these exceptional cases an enema must be given only every other day, and the effect on the rectal discharges watched. By stopping the enemata altogether it can be determined whether the dis- charges of mucus and blood are caused by the therapy or the disease. Hypodermoclysis. — The injection of normal salt solution under the skin is indicated only in the severe cases in which, as in cholera infantum, the course of the disease is rapid and the prostration ex- treme. Personal experience rather discourages the employment of large injections by this method. I have seen two cases of infection by the Bacillus capsulatus aerogenes (Welch) following hypoder- moclysis. These occurred through the use of saline solution evidently insufficiently sterilized, and which had probably been allowed to stand before being used. In a third case hemorrhages over large areas occurred at the point of the injection of the salt solution. These injections are also very painful. Because of these dangers and disadvantages the subcutaneous injections of salt solutions should be utilized as a last resource in desperate cases. Small rather than large amounts of fluid should be injected subcutaneously. The salt solution for the hypodermoclysis is that of Cantani. It should be sterilized at a temperature of 212° F. (100° C.) for at least an hour, to kill sporulated bacteria if possible. Baths. — In all cases, whether with or without elevation of tem- 526 DISEASES OF THE STOMACH AND INTESTINES. perature, the benefit obtained from warm baths cannot be overesti- mated. In cases of great i^rostration a bath at 108° F, (42.2° C.) for fire minutes is stimulating to the nervous centres and is followed in many cases by diminution of the apathy and an apparent reduction of the effects of toxaemia. If the temperature rises above 103° F. (39.4° C), sponging with water at 80°-85° F. (26.6°-29.4° C-.) is all that is needed. This should not be done oftener than once in every three hours. Alcohol. — Of late years, alcohol is given less and less in cases of acute gastro-enteric infection. In these cases there is a special intol- erance of the stomach and also of the economy to alcohol. Infants after taking it for twenty-four hours will become stupid, apathetic, and exhibit a constant retching if they do not vomit. This appears to be due more to the effect of the alcohol locally on the stomach and also systemically than to toxaemia of the disease. I therefore deprecate the use of alcohol except in extreme cases, when whiskey is given in small doses at short intervals. Strychnine.- — Strychnine is useful; grain 3^oo (0.0002) is given to an infant of six months, and grain %oo (0.0003) to older infants every three hours. Atropine. — Atropine, lately advised as a cardiac stimulant in these cases, especially in cholera infantum, is of questionable utility, and should not be employed. I have seen grain %5o (0.0004) give rise to constant tremulous and convulsive twitching. Resorcin. — If the vomiting is constant, grain -J (0.008) of resor- cin given every three hours is a safe and very u&eful remedy. Bismuth. — Bismuth in the form of the subcarbonate is the only drug useful in allaying the vomiting and the tenesmus of the bowel. Grains ij or iij (0.12 or 0.18) are given in powder form every two or three hours. Opium. — Opium in any form has fallen into disuse. In the severe cases it is dangerous, and may increase the prostration ; in the milder cases its use is justifiable only if the colicky pains are exces- sive. The milder preparations such as the wine and the camphorated tincture are of value, because they can be given in graduated doses, and the effects determined more exactly than can be done with the stronger preparations. Salol.—Salol in grain ^ (0.03) doses every three hours may be combined with the bismuth to alla}^ the colicky pains. Tannigen. — Tannigen is a useful drug in the chronic forms of intestinal disease, but an irritant in the acute forms. Colic. — Colic has been mentioned so often that a few words as to the treatment may not be out of place. Passing of the rectal tube rarely relieves it. A small rectal enema has been found to be a very effective remedy. DISEASES OF THE STOMACH AND INTESTINES. 527 As the symptoms improve care should be taken not to return to a milk diet too quickly. The milk is given in dilutions and is steri- lized carefully. Infants in an enfeebled condition as a rule bear this form of milk best, since it is not apt "to be irritating to the gut. When the danger is past any form of milk may be given — ravsr, pasteurized, or sterilized — care being taken that all the precautions as to freshness, cleanliness, and proper preparation are observed. I have mentioned the fact that before returning to dilutions of milk the exhibition of dextrinized gruels has been successful with very weak infants. The malt, the cereal, and the milk acted upon by the ferment contained in these mixtures are all easily digestible and assimilable, and promote increase of weight. As a matter of course, the effect of the gruel mixture on the stomach and gut should be carefully studied. Whatever methods are employed in the treatment, it is necessary to avoid the error of overtreatment. It should be remembered that hours of rest do more than hours of treatment. Three-hour intervals should elapse between the application of remedial measures. Fresh air in the room or a sojourn of a few hours in the open with absolute quiet, is of the greatest value in these cases. Acute and Subacute Enterocolitis (Enteritis Follicularis; En- teric Catarrh). — Enterocolitis is peculiarly a diarrhoeal disease of infancy and early childhood. It was formerly classified as a form of dysentery, because in these cases the movements are tinged with blood and contain mucus. The cases are, however, of a milder type, and present many symptoms foreign to true dysentery. Etiology. — In many of its features this affection resembles acute and subacute gastro-enteric infection. It is prevalent during the summer months. It occurs in infants after the first year of life, and may be primary or follow an ordinary dyspeptic diarrhoea, one of the exanthemata, pertussis, or bronchopneumonia. Booker his described the great number of streptococci found in certain of these cases. Fink- elstein and Escherich and his pupils have confirmed these results, and have in addition presented the view that these diarrhoeas are infec- tious and may be caused by bacteria of the coli group. The bacteria may be introduced from without, or the coli organism in the gut under certain conditions may become virulent. With reference to their origin, these cases may be considered as bearing a relationship to cases of true dysentery, from which with our present imperfect knowl- edge it is not always possible to distinguish them. Morbid Anatomy. — The mucous membrane is hypersemic and swollen ; in cases of long duration the mucosa is infiltrated with small round cells. The follicles of the gut are enlarged and elevated above the surface of the mucous membrane. The Peyer's patches are en- larged and surrounded by a zone of hypersemia. The villi show 528 DISEASES OF THE STOMACH AND INTESTINES. desquamated epithelium and infiltration of the walls with small round cells. The follicles are swollen, and at the surface may burst and present follicular ulcers. The epithelium of the gut may be lacking in places. Symptoms. — In the beginning there are fever and slight vomiting. The movements are fluid, greenish, and have a disagreeable odor, contain mucus, and are streaked with blood. They may number ten or twelve in twenty-four hours. Straining at times accompanies the movement. As a rule the infant is pale and prostrated. The char- acter of the movements is unchanged for days or weeks, when improve- ment begins and recovery ensues. On the other hand, in protracted cases the infant may develop a bronchopneumonia in one or both lungs, but may even then recover under good management. The pic- ture thus resembles that of a mild dysentery, but the subjects are younger, and there is in a number of cases a history of antecedent intestinal disturbance of extensive duration. Treatment. — The treatment should be carried out on the fame lines as in acute gastro-enteric infection. Caution should be exercised in returning to a diet composed exclusively of milk. While in true dysen- tery in older children I advise the administration of milk sterilized in some form, in younger infants such a procedure would be unwise. I keep these infants on a diet devoid of milk, such as beef -juice and barley-water, albumin-water or solution of acorn-cocoa, as long as possible. As the character of the movements improves the infants are put on a dilution of albumin-water and milk or cocoa and milk, or, what is far preferable, dextrinized gruel and milk. The amount of milk in the dextrinized mixture is gradually increased until the quantities appropriate to the age of the infant are given. Dysentery and Paradysentery (Ileocolitis ; Colitis Contagiosa; Coli Colitis; Enteritis Follicularis; Enterocolitis). — Dysentery is an acute infectious diarrhoeal affection of the intestine. In the United States it occurs both sporadically and in localized epidemics. It is endemic in the tropics, where the etiology is somewhat different from that in our climate. The amoebic infection seems, according to Kar- tullis, to be characteristic of the tropical form. Although amoebic dysentery is occasionally seen here sporadically and in cases of per- sons recently returned from the tropics, it is not the form which com- monly occurs in infants and children. The form to which these patients are liable is seen during July, August, and September, and late in the autumn. It may affect nurslings who are fed artificially, but most often occurs in children who are on a mixed diet. Escherich has described epidemics of limited character in private families and hospitals. I have met this form of dysentery in sporadic cases or small local outbreaks, and have also seen outbreaks at seaside resorts DISEASES OF THE STOMACH AND INTESTINES. 529 among children of from two to four years of age who had partaken- of drinking-water which had been rendered unfit for use by con- tamination. Forms. — There are three forms of the disease: (1) the true epi- demic dysentery which occurs occasionally in America and on the Continent but is epidemic and endemic in the tropics; (2) the amoebic form, which is also endemic in the tropics; and (3) the form which occurs in infants and children in the summer months as a rule sporadically, rarely epidemically, except in institutions. Etiology. — The essential cause of dysentery or ileocolitis is now recognized to be bacterial. Shiga, in 1897 and 1898, isolated a bacillus from the fseces of a number of cases of dysentery occurring in Japan. H'e discovered also that the blood-serum of the persons afflicted caused a clumping of the bacillus isolated when mixed with cultures of the latter in the proper dilutions. These cases of dysentery cited by Shiga did not include the amoebic variety. The characteristics of the bacillus iso- lated from these cases closely resembled those of the bacillus of typhoid fever, except that it was not motile. In 1902 Flexner and his pupils, Duval and Bassett, studied 53 cases of diarrhoea of the dysenteric type, and obtained cultures of the bacillus of Shiga in 42 of the cases investigated. Since then a num- ber of investigators have studied the dysenteries of children in local epidemics, and have substantiated the work of Duval and Bassett. In 1903, Flexner and Holt in a collective study of the occurrence of the true Shiga-Kruse bacillus and the Flexner bacillus in dysen- tery or ileocolitis of children found that the cases divided themselves into those in which the bacillus of Shiga-Kruse was found and those in which the Flexner bacillus was present. The cases of the latter class were the most frequent. It may be said that the form of ileo- colitis met with in the summer in infants and children is of the group caused by the Bacillus dysenteric of Flexner and allied bacilli, whereas the cases caused by the true dysentery bacillus of Shiga and Kruse are very uncommon. The Flexner bacillus differs from that of Shiga-Kruse in that it forms acid in media and does not ferment milk or sugar. Like the Shiga-Kruse bacillus it is immobile and unlike it has little tendency to form toxins. These facts have been confirmed by Jehle, Leiner and Knoepfel- macher. It has therefore been proposed to reserve the term dysen- tery for the true epidemic tropical form of the disease and that of paradysentery for the endemic form of dysentery which occurs in infants and children and which is due to the bacillus dysenteries of Flexner and allied micro-organisms. The bacillus dysenterige Flex- ner has been found in the stools of normal children who have been in 34 530 DISEASES OF THE STOMACH AXD IXTESTIXES. the Ticinitj of children suffering from dysentery or who in the past may have had an attack of the disease. WoUstein, however, failed to find it in a number of normal children. The coli bacilli (Escherich ) and streptococci found in the intestine in dysentery or paradysentery play an important role in the mixed infections of these diseases. Morbid Anatomy. — Dysentery may affect different sections of the intestine at the same time, the rectal or sigmoid flexure alone, the ascending colon, the transverse or the descending colon only. In rare cases the disease may pass beyond the ileocsecal valve and involve the lower part of the ileum. There are two forms which may be present separately or simultaneously, the catarrhal and the necrotic form. In the milder catarrhal form of dysentery the mucous membrane is hypersemic and swollen, and the summits of the intestinal folds are studded with hemorrhages in small foci or streaks. The submucosa is infiltrated with small round cells and the vessels filled with blood. The epithelium of the follicles is swollen and proliferated, and there is infiltration of the surrounding connective tissue with round cells. In severe forms the surface of the mucous membrane is covered with mucus containing leucocytes and blood-cells. The follicles are ele- vated above the surface. In other cases the intestine is studded with ulcerations which mark the necrotic follicles. The ulcerations reach to the muscularis mucosa. If the process extends to the small intes- tine the Peyer's patches are swollen and surrounded by a hypersemic zone. If the disease has advanced to the necrotic stage, the mucosa is thickened and infiltrated with round cells. There are areas of loss of tissue which extend deep to the muscular coat (gangrene). The mucous membrane is covered with a grayish exudate of a pseudo- membranous character. In severe cases large areas of the mucous membrane may necrose and be cast off. The necrotic areas show an abundant invasion of bacteria of the streptococcus and coli type, in scattered masses or zoogloea. The lymph-nodes of the mesentery are swollen; the spleen may be enlarged; the kidneys may show degen- erative changes, and the lungs may be the seat of bronchopneumonia. Symptoms. — The symptoms of dysentery in infants and children closely resemble those seen in the adult subject. The onset may follow some indiscretion of diet or be entirely independent of any such error. There may be a preceding headache, and there is, as a rule, some fever. Abdominal pain is the first symptom until diarrhoea sets in. The diarrhoea at first resembles an ordinary dyspeptic diar- rhoea, but in a few hours or after one or two movements, it assumes the characteristics which mark it as specific. The patient passes stools which are fluid and contain mucus mixed with blood and shreds of tissue, and which may have an offensive odor. They are passed DISEASES OF THE STOMACH AND INTESTINES. 531 with miicli abdominal pain and rectal tenesmus. If the abdominal pain is severe there are vomiting and great prostration. As many as twenty to thirty small bloody mucoid movements may be passed daily. Fig 109 IUNeTs 1 2 3 4 5 G J 1 HOUR 3 6 9I12 aaV,. 3J6|9'i: 3 6 9 '1? sis 9 '12 3\s'9'k aU 9i: 3 6 9 12 316 9 12 3U|9'12 3 i 6 ! 9 il2 3!d!9jl2 3 6I9;i2 3:6|»'12 102° 5 101° i 100° 99° i \ ^ L_ N ■ H z I H-V ^-y\ it : i / 'Y~ -^y\ k=q j -^ ~ - - - 3j_^:\ > 4=^ ~i^ -^ -^ 1 ;»:^ 1 ' ^ - - u ~ ^/•^V '^ 1 1 1 ' 1 -i- |-^ ^^^ —4— r-^\ — f^ - -\ ^ 1 1 , ■ ^— V^r ^— ^t- 1 \ i / -^-^ ^ H p 1 : / —r\-n \ , •^ \ 1 , 1 \ PULSE 1 '1 = 1 II SB 1=32 |i ,|| ^-il 1 ?• S 5 5 SSI; S -. 2^3 2=1 RESP. i s,ss SS,5,S s S SS 5), ,;i,s; s 5: - - - ~i ~,~r.~ s s ~ s- ?;- ?: 3 s,- ?: ,?:> s S S 3 URINE 'xjxix ; 1 IX X X xl i ix ' x.x X X x X 'x X X X X XX i STOOL ln| 1 1 1 1 ■ 1 '1 ■ ; ■ 1 :iPl II llllilll II 1 1 1 1 1 'I 1 1 1 1 i WEIGHT 1 ( 1 i 1 1 1 ! 1 . , ,52 1{BS.. _LL _ _ 1 Dysentery of ordinary severity. First week of illness. Duration three weeks ; recovery. Boy, seven years of age. The fever varies in intensity. In mild cases the temperature may range from 101° to 102° F. (38° to 38.5° C.) (Fig. 109) ; in severe ones it may reach 104° (40° C.) (Fig. 110). If the disease per- I ""l G 110 illnVss 4 5 G 7 8 9 10 HOUR 3 6 9 12 3 s 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 5 9 12 316 9 12 3« 9 12 3 6 9 12 3 619112 106° 105° 104 1 los" g 102° 101° 100° 99° 1 1 / ? - i 1 1 [ 1 1 i 1 i\ 1 1 1 \ f ^ i ' \ \ \ ' i 1 / 1 ) 1 \ / / 1 1 ^ - _ _ ^ '-tll- -^V- ~V— /1 -^ _ -In _ _ 1 ~ — — — — -\ f- ci^\^ — ^ — \/ — ' — '■ 1 V^ ^in'" — ~i- — - . i i ,1/ «- 1 PULSE s!2 -i- = 52 s ~r'~~ jilglg £SS3 ISi2 5 Si i^il'S s i RESP. 2|3-|:s = 'S'3 ..u. -=' 3 ° = n' '«'s2 'H^'^ s'ssls -s'33 J 2^5 2 URLNE X X X XX X X X XX x:x 3 X ? X XX ^ x'x'x' x'x x' X xl X X STOOL 1 ' 1 1 1 ' ' 1 1 1 1 1 II „ II 1 II 1 II 11 1 1 1 1 1 1 1 1 1 M 1 ■ WEIGHT 23 B i. 8 :. ! 1 Necrotic colitis ; fatal, in a girl sis years of age. sists beyond a few days, there is rapid emaciation and the abdomen becomes sunken and board-like. In some cases palpation in the region 532 DISEASES OF THE STOMACH AND INTESTINES. of the cEeciim and ascending colon may detect the contracted, thick- ened gut. In severe forms of the necrotic type it is possible to mark out the cEecum and ascending colon as a contracted, thickened tube. In protracted cases the spleen becomes enlarged and the tongue dry and coated, in this respect resembling the condition seen in typhoid fever. Multiple hemorrhages may appear under the skin. The urine contains albumin, and in some cases hyaline and epithelial casts. Course. — The fulminating cases run their course in a few days with high fever, terminating in death. Other cases may be compara- tively mild and last only a few days or a week. In such cases there may be recurrences. In other cases the disease runs a course of from three to six weeks. After this period, from time to time, blood, evi- dently derived from bleeding ulcers in process of repair, may appear in the movements. The movements gradually become formed and fsecal in character, and the patient recovers. In cases which have come under my care in hospital service, the disease ran a moderately severe course until the seventh or eighth day. The fever, however, remained high and delirium set in on the ninth day. The appear- ance of the patient became septic, sopor supervened, and the urine and faeces were passed involuntarily. Death took place on the thir- teenth day. In other cases of a severe necrotic type death took place at the end of a week. Complications. — The most dangerous complication is perforation and general peritonitis. Periproctitic abscess may occur, Avith sub- sequent fistula. In septic cases, abscess of the liver and spleen have been observed. Hemorrhages may occur under the skin late in the disease. In all of my cases these were quite extensive, but recovery nevertheless took place. In one fatal case I noted metastatic paro- titis. Some authors have recorded arthritis as a complication; as a rule it retrogrades and recovery takes place. Prognosis. — The prognosis varies with the severity of the case. The mortality ranges from 30 to 40 per cent. The croupous or necrotic cases are very fatal. With good management the mild cases give a favorable prognosis. The severity of the infection and the prevalence of an epidemic will influence the course of the affection. Treatment. — Prophylaxis.- — The movements are not only infec- tious, but may also communicate the disease to others if a particle is introduced into the gut. The hands of the patient and his body should be kept scrupulously clean to avoid reinfection. The move- ments should be disinfected in the same manner as those of a patient suffering with typhoid fever. The hands of the nurse should be scrupulously cleansed and washed in an antiseptic solution. General. — The patient is given a cathartic, preferably castor oil, as the initial step of treatment. In this way all irritating food par- DISEASES OF THE STOMACH AND INTESTINES. 533 tides and residual faeces are cleared from the gut. All food, even milk, is withheld at first. The patient for the first twenty-four hours is given a solution of egg-albumin, acorn-cocoa, beef-juice broths, or expressed beef -juice and barley-water in equal parts. The following are the lines along which the later management of these cases should proceed : a. An absolutely non-irritating and easily assimilable food is given. h. The pain and tenderness are relieved with drugs, the diarrhoea being also partially controlled in this manner. c. The rectum is irrigated. After a day or two, during which the patient has been fed upon albumin-water, expressed beef-juice, and barley-water or acorn-cocoa solutions, sterilized or pasteurized milk is substituted. In these cases, as in typhoid fever, the patients are given during twenty-four hours, two or more quarts of milk sterilized at 212° F. (100° C.) or pasteurized at 164° F. (73° C). I wait until the severely acute symptoms have subsided before placing these patients on a milk diet. At best, milk leaves a large residue in the gut, and in the acute stage of the disease the coagulum may in a mechanical way irritate the acutely inflamed walls. Pasteurized and sterilized milk is well borne in the later stages of the affection. Milk in a raw state, no matter how good, will sometimes tend to aggravate the acute symptoms. Pain and tenesmus are relieved by the exhibition of Dover's powder, grains -J to ij (0.03 to 0.12), every two hours according to the age of the infant or child. Codeine sulphate, grain i to i (0.01 to 0.015), according to the age of the patient, is preferable to morphine or tinc- ture of opium. The administration of powdered ipecacuanha will be found very useful in certain cases. In others the vomiting rather interferes with its administration; grains j to ij or iij (0.06 to 0.12 or 0.2) every two or three hours are indicated. It may be combined with bismuth subcarbonate, grain v (0.3) every three hours. In older children this mode of treatment has lately given good results. I have had no experience with the administration of lead salts. In the acute cases the internal administration of preparations, such as tannigen, is irritating. Enemata.- — Rectal enemata should be employed with care in the treatment of colitis or dysentery. Unless caution is exercised, their use is in many cases followed by an exacerbation or perpetuation of symptoms. The most useful form of enema is the warm (108°— 110° F., 42.2°-43.3° C.) saline (Cantani) solution. Fully a quart of fluid is allowed to flow into the gut. The greater part of it returns, but I believe that if a portion of this solution is retained it acts in the manner of enteroclysis and supports the patient. These enemata are given three times in the twenty-four hours, for a day or two ; they 534 DISEASES OF THE STOMACH AND INTESTINES. are subsequently given twice a day, and finally, as the symptoms sub- side, only once a day. I have never been able to convince myself that silver nitrate (1:1000) or tannic acid added to the enemata is of value. On the contrary, I believe that in cases in the acute stage these medicated enemata are distinctly irritating. In the later stages of the disease, small quantities of fluid blood are passed with the fsecal movements, tenesmus being present ; small enemata of silver nitrate (1:1000) given low down twice daily cause cessation of the bleeding which is due to the presence of ulcers low down in the rectum. In the subacute stage, the enemata will often be followed by an exacerbation of bloody mucous passages. Under these conditions it is well to discontinue the enemata and to watch the results of the suspension of local treatment. Serum. — The serum devised by Flexner, though protective in animals against infection, is not effective in the human subject. Amoebic Dysentery (Amoebic Colitis). — Amoebic dysentery is not, strictly speaking, a disease of infancy and childhood. It is caused by the Amoebse coli of Losch. Of 35 cases reported by Harris, 4 were under ten years of age. Amberg has recently published 5 addi- tional cases. I have seen two cases in my hospital service, one in a boy 8 years of age, another in a girl 11 years old. The etiological factor is the Amoebse coli, which are found in large numbers in the movements. With the amoeba, Charcot-Leyden crystals are found in most cases. The cases published by Amberg were of a mild type, and seemed in no way to differ in symptomatology from the form of the disease seen in the adult subject. There were diarrhoea of a bloody character, tenesmus, and in some cases fever and prostration. As many as from four to six movements containing blood and mucus, and microscopically eosinophile cells, were passed in twenty-four hours. After the acute symptoms subside there may be recurrences in the form of attacks of diarrhoea with blood and mucus in the evacuations and the appearance from time to time of the amoebse in the stools. Diagnosis. — The diagnosis is made from the presence of the amoebse in the movements. Bloody passages containing Charcot- Leyden crystals should cause the physician to entertain a suspicion of the presence of this affection. Other amoebse, such as the Monocercomonas hominis (Grassi), have been found in the movementsof infants suffering from diarrhoea. Epstein describes an epidemic of diarrhoea in which the monocer- comonas abounded in the movements. He thinks that in this epi- demic the diarrhoea was caused by well-water which contained the amoebse. I have found the Monocercomonas hominis in the move- ments of infants who were suffering from diarrha^a, but also of those DISEASES OF THE STOMACH AND INTESTINES. 535 whose bowels were not in an abnormal condition. Tbe role of the monocercomonas as an etiological factor in the causation of these diarrhoeas is not understood. It is doubtful whether they have any causal connection with the diarrhoea. Treatment. — The treatment consists in dieting on a fluid diet, the administration of quinine internally, and injections in the rectum of solutions of quinine 1 in 500. Constipation in Infants and Children. — Constipation may be classified as congenital and acquired. Congenital Constipation. — Congenital constipation is noticed imme- diately after birth, or in the days subsequent to it. The causes of congenital constipation are generally an absence of the anus or its occlusion by a thin membrane, or by a thick, hard membrane resem- bling the skin ; or there may be an anus and a shallow or deep cul-de- sac leading from the anus for some distance into the rectum, or this may be occluded at a varying distance from the external orifice. The rectum may be occluded by one or several membranes. Its walls may be thickened, so that meconium or fseces cannot pass ; or its walls may be agglutinated. The rectum, as has been stated, may end at some distance from the anus in a blind cul-de-sdc, and from this point upward the rectum may either exist in its normal calibre, or may be simply indicated by a fibrous cord; in other words, there may be a congenital absence of the rectum. The rectum may end in a preter- natural opening into the bladder, the urethra or vagina, or may, by a common opening, a sort of cloaca, terminate in the perineum through the urethra or vagina. In such cases there is scarcely constipation, but rather a difiiculty in voiding the fseces. There may be, as has been intimated, partial or complete absence of the rectum or colon; or a large part of the larger bowel may be absent, or it may be stenosed in part of its extent and dilated in another part. It may be abnor- mally contracted. The colon or any part of it may be rudimentary. There may be obstruction, as in the rectum, in any part of the course of the colon. There may be a congenital occlusion of the ileocsecal valve. Jacobi has described a case of congenital constipation due to mis- placement of the large gut and inordinate dilatation of this viscus. In some cases of congenital malformation the small intestine may be entirely obliterated; or the small intestine in part of its extent may be normal, especially the duodenum ; whereas the ileum may be rudi- mentary and the large gut enormously dilated. There are cases on record in which there was no connection between the large and the small intestine, and there may be congenital stricture in any part of the small intestine, either the duodenum or the ileum; or there may 536 DISEASES OF THE STOMACH AND INTESTINES. be an obstruction due to a small diaphragm extending into the lumen of the intestine in any part of its course. It may be seen from a simple enumeration of the causes of con- genital constipation that the conditions found are extremely varied, and in most cases cannot be remedied by surgical means unless the obstruction diagnosed is low down in the rectum or sigmoid flexure, and exists without any accompanying deformity of the rest of the intestine. A congenital absence or rudimentary condition of the small or large intestine must eventually prove fatal. The symptoms of all the cases recorded of congenital constipation are those of obstruc- tion, in the end resulting in rejection of all fluids, vomiting, and ending fatally if unrelieved. A further discussion of this form of constipation is scarcely within the scope of this treatise. Acquired Constipation. — Acide. — Acute constipation is really a surgical disease, and is caused in infants and children by some acute obstruction of the gut, such as intussusception, volvulus, strangula- tion, through a slit in the omentum, strangulation by peritonitic bands, or by the persistence of Meckel's diverticulum; hernia of all kinds, strangulation or paralysis of the intestine as a result of trau- matism. Peritonitis may cause acute constipation, and with this we must consider diseases such as appendicitis. Foreign bodies may obstruct the lumen of the bowel. Watkins relates the case of a boy, ten years of age, who had swallowed an immense quantity of figs, which obstructed the lower part of the intes- tine near the anus, and had to be removed by surgical means before movements were established. J. Lewis Smith relates the case of a girl, four years old, in whom acute constipation developed suddenly as the result of the impaction of a mass of intertwined worms in the intestine. This acute obstruction was attended by distention of the abdomen and great suffering. A large gall-stone is mentioned as obstructing the ileocsecal valve, and in this way suspending for a time the passage of faeces through this structure. The diagnosis of acute constipation presupposes a diagnosis of the primary causal condition, and this can only be made by a careful study of the case. Cases of intussusception, volvulus, strangulation, either by bands or hernia or forms of peritonitis, will give symptoms of these diseases. It is scarcely the place here to enter upon these fully. In those cases in which worms cause obstruction, the diagnosis can only be made after relief has been established by passage of the corpus deliciu, unless enough faeces are voided to examine the same for eggs of the worms. Chronic. — Chronic constipation may be dependent upon obstruc- tion of the large or small intestine in any part of its extent, either by morbid growths, sarcomata, carcinomata, or tuberculous perito- DISEASES OF THE STOMACH AND INTESTINES. 537 nitis. The latter form of obstruction by tuberculous masses is of especial interest, inasmuch as these cases form a part of the sympto- matology of tuberculous peritonitis. I saw a case of tuberculous peritonitis in which large masses were palpable in the abdomen, and in which one of these masses involved the descending colon to such an extent as to almost completely occlude its lumen. Anal fissure is a common cause of chronic constipation in infants and children. In these cases there is always a history of great pain when the movement is passed, and for some time afterward. Blood may accompany movements when there is a fissure of the anus. Children suffering in this manner do not void a movement for days, and when the movement is passed the suffering sometimes is intense. In some children there is a spasm of the anus due to a nervous condi- tion, and sometimes brought about by an excoriated state of the anus. Examination does not reveal any fissure, but there is a distinct spasm of the sphincter which prevents the successful evacuation of the rectum. In all of these cases chronic constipation is really a surgical disease, and can only be relieved by surgical measures. In some cases caused by cancerous, sarcomatous, or tuberculous growths the surgeon is unable to relieve the patient. Constipation caused by anal fissure, spasms of the sphincter, or excoriations around the anus yields more successfully to surgical treatment, which is the same as a treatment for similar conditions in the adult, viz., forcible dilatation of the sphincter. Chronic Habitual Constipation. — The next form of chronic con- stipation is that which most interests the general practitioner, and is known as chronic habitual constipation. Of all the conditions within the domain of pediatrics habitual constipation is the most difficult of management. It is not always possible in these infants and chil- dren to fix on the absolute causes of a constipated habit. Etiology. — Infants at the breast may be constipated from birth, though normal in every other respect, and continue this habit through- out childhood. In many of these cases the mother is of a constipated habit. Some signs of rachitis may be present in certain cases. In these cases, however, it is reasonable to conclude that the mother's milk is lacking in some element, such as fat, which tends to perpet- uate the constipation. In other cases the milk may be absolutely normal, and still a condition of atony of the gut of an hereditary type may exist. Constitutional Dyscrasia. — Rachitis, when marked, is associated with constipation in a large proportion of cases. In a manner similar to the bones, so the muscular apparatus lacks tone, and it is not sur- prising that with the muscular atony the glandular elements of the gut should be deficient in furnishing elements necessary to a normal 538 DISEASES OF THE STOMACH AND INTESTINES. maintenance of the functions and evacuation of the intestinal contents. Heredity. — Heredity has been named as a cause of constipation in breast-fed infants, and it is not infrequent to meet the same condi- tion, possibly due to the same cause, in bottle-fed infants. Incorrect Feeding. — Incorrect feeding is certainly one of the most frequent causes of constipation in artificially fed infants and children. Some infants who have been started on very dilute modifications of milk are constipated from the beginning, or their constipation has been fostered by heating the milk to a greater or less degree, and in these cases the constipation, if allowed to persist for any length of time, is perpetuated into the period of childhood. In other cases raw milk will cause constipation. In older chil- dren a simple diet of two or three articles of food, which have been religiously adhered to from the time of weaning to a varying period of childhood, is the direct cause of constipation. There has been a failure in these cases to give an appropriately mixed diet. I have seen constipated children, at varying periods of childhood, who have been kept systematically on a diet of milk and fruits, for fear that any other article of diet would cause intestinal disturbance. The result has been an inordinate constipation of chronic duration with accompanying symptoms. Symptoms. — One can scarcely speak of the symptoms of constipa- tion which in itself is a symptom of disturbed intestinal conditions and metabolism. There are certain features, however, of the move- ments of constipated infants and children which are of importance. Stools. — The intestinal movements of infants suffering from con- stipation may be hard and formed, or may be unformed and dry. Ordinarily a healthy infant has two, three, or four movements daily, the rule being two. A healthy infant may have six movements a day and still be within the limits of health. We judge by the char- acter rather than by the number of the movements. The normal characteristics of intestinal evacuations have been dilated upon else- where, and the reader is referred to the section treating of this subject. In constipated infants the movements consist almost entirely of marble-like masses, resembling those seen in the lower animals. They rarely have a movement unaided. They have great pain in passing the faeces, and in time develop fissuration of the anus to a greater or less extent, with accompanying bleeding due to the stretching of the fissure. In other cases this bleeding is accompanied by slight pro- lapsus of the gut during the movement, which often creates the im- pression that the infant is suffering from hemorrhoids. • Many of these constipated movements are coated with mucus, or mucus is voided after the movement is passed. These masses are not mem- branous, and if examined will be seen to be composed mostly of mucus. DISEASES OF TEE STOMACH AND INTESTINES. 539 Other Symptoms.- — Constipated infants after a time develop a pallor and anaemia which is characteristic, and seem to suffer from intestinal absorption and toxaemia which results from time to time in periodical attacks of vomiting, discussed elsewhere. These children also complain from time to time of a vertigo and nausea, especially in the morning. Many children who are thus constipated will reject their food in the morning. They lose their appetite and have all the symptoms of intestinal intoxication. Treatment. — The treatment of constipation is dietetic and medic- inal. If the infants who are constipated are fed at the mother's or nurse's breast, the bowels of the mother or nurse need regulating, and they should take regular exercise. In many cases a nutritious diet to the mother or nurse will cause the milk to change in its composi- tion, containing more fat, and thus improve the condition in the infant. On the other hand, an increase of the fats will decidedly aggravate the constipation in some children. Therefore we diminish the fat of the milk in such cases. If artificially fed children are constipated, the heating of the milk should be stopped. If for some reason milk must be pasteurized or sterilized, the time of heating should be reduced to a minimum. Constipated infants may be fed on raw milk if the milk is fresh and carefully kept. The formula should contain sufficient fat to make the diet nutritious, but the fat should not form more than 4 per cent, of the mixture. As a rule, artificially fed infants do well on a smaller quantity of fat than the average breast-fed infant. Thus 2.5 to 3 per cent, of fat meet the requirements of most infants. Some infants fed on raw milk and an increase of fats become more constipated. The stools are hard and dry and there is an unmistakable anaemia. Children from the sixteenth month to the second year who suffer from constipation should be gradually weaned to a mixed diet. In many cases this procedure will regulate the bowels. The children should be given green vegetables, such as peas and spinach, in the form of a puree. The diet should include cereals of the various varieties, especially wheatena, oatmeal, granum, and rusk (Zwieback). The milk should be given raw with a moderate mixture of cream. Fruit, such as oranges, raw apples, and pears, is also given in moder- ation. If the constipation cannot be remedied by these measures, recourse is had to medicinal treatment. Cathartics. — At best, cathartics are a makeshift. Some older children will do well with a small dose, grain Yioo (0.0004), of strychnine once a day, and a simple cathartic, such as the aromatic fluid extract of cascara, twice or three times a week. A child two years of age may be given TIX xx to xxx (1.0 to 2.0) once a day. The preparations of rhubarb are useful, but do not give uniformly satis- 540 . DISEASES OF TEE STOMACH AND INTESTINES. factory results. The mercurial cathartics are available only once a week in the majority of cases. We are thus reduced to the necessity of giving suppositories or enemata. With very young infants a small cylindrical piece of soap inserted with oil into the rectum once a day will be effective. With older children the glycerin suppository given every other day is very useful. Enemaia. — In many cases it is necessary to give enemata : to younger infants they are given once a day; to older children an enema is given twice a week. When the child becomes pale and listless a brisk cathartic aided by a large high enema is given. In this way an attack of vomiting may be avoided. Massage. — Massage of the abdomen gives very unsatisfactory results. Gymnastics or calisthenic exercises in the morning after a bath are useful in some cases. Hahits. — The inculcating of a habit of evacuating the bowel at regular intervals daily will do much toward overcoming constipation. The children are placed on the toilet and are taught to keep their minds on the object to be attained. The results in some cases are gratifying. Useful f ormulse are the following : 1. Pulv. glycyrrMzae comp. . . . 3ss to 5j (2.0 to 4.0) as necessary. 2. Infus. sennse comp 3j-3ij (4.0-8.0) as necessary. , 3. PodophyUin gr. ij (0.12). Syr. rhei arom Jij (60.0). Sig. 3j (4.0) pro dosi. Congenital Dilatation of the Colon, With or Without Hyper- trophy of Its Walls (Hirschsprung's Disease). — This deformity is one of the rarer causes of habitual constipation in infants and chil- dren. We distingaiish three forms of this condition. a. In this form there is an increase in the length of the colon descendens and the sigmoid flexure. As a result of the increased length of the colon this portion of the intestine bends two or three times on itself. There is a stagnation of the fseces and consequent constipation. Toxaemia results and emaciation follows. With the above there are symptoms of fermentation in the gut, and constipation alternates with diarrhoea. The diarrhoeal movements are foul, con- taining mucus and blood. There is some meteorism. Prognosis. — The prognosis of this form is not bad, provided a complicating colitis does not ensue. As the child grows older the above symptoms improve and normal conditions ultimately supervene. h. In this class of cases the colon is not only lengthened and dilated, but its walls are thickened. Such are the cases of Mya, Formad, Griffith, and Hirschsprung. According to Concetti, the mucosa is not only thickened, but the connective tissue and muscular DISEASES OF THE STOMACH AND INTESTINES. 541 coats of the intestine show the same changes, and the arteries are the seat of arteritis. The cases belonging to this class in the literature range from eight to fifty years of age. It is in this set of cases that stagnation of the faeces is accompanied at times with ulceration of the gut. c. In this class of cases there is a combination of the dilatation of the colon with thin walls; or the colon may be normal in its lower portion and slightly ectatic, with hypertrophied walls above. Symptoms. — The symptoms of the last two sets of cases are more severe in the younger and milder in the older children. They are severe if the condition has lasted for two or three years, and milder if the patient has survived until the tenth or twelfth year. From the second to the fourth day after birth great meteorism appears. ISTo meconium is passed for some time, and there is no stenosis of the Fig. 111. Infant nine weeks old. Congenital dilatation of the colon, strictures in the sig- moid flexure. Enormous, abdominal distention ; inordinate constipation ; coils of large intestine visible on the abdomen. Eventual death. gut; laxatives succeed in bringing away only a small amount of meconium or fseces. The constipation is very obstinate, the faeces are foul-smelling, and from time to time colitis may supervene, or every eight to thirty days hard, malodorous masses are evacuated with slime and blood. There is a condition of an auto-intoxication and a resultant cachexia. The abdomen becomes enormously distended, and the coils of the intestine can be made out on the surf ace (Fig. 111). The children die during the first and second years of life, either through cachexia or perforation of the gut. Of the 21 cases collected by Concetti only 2 lived. One was a case of his own, and another that of Osier; in both an artificial anus was made for the relief of the condition. Colitis, with or without perforation of the intestine, 542 DISEASES OF TEE STOMACH AND INTESTINES. is the most frequent cause of death. The remaining cases die of cachexia. Treatment. — The first class of cases are treated in much the same manner as is constipation. In the second and third forms surgical interference is indicated as soon as the diagnosis is made. The colon is resected. Thus far surgical interference has not been attended with great success. Acute Intestinal Obstruction (Intussusception). — Intussuscep- tion, according to Treves, is the prolapse of one part of the intestine into the lumen of an immediately adjoining part. It causes more than one-third of all the varieties of obstruction of the gut. Varieties. — Invagination of the gut may take place in any part, from the duodenum to the rectum. There are the following forms : Enteric. — The enteric form, which may involve any part of the small intestine, but which most commonly involves the lower part of the jejunum or the ileum. Colic. — The colic form, which may involve any portion of the colon. Ileoccecal.- — The ileocgecal, which is the most common form. In the ileocsecal variety the ileum and csecum pass into the colon, the valve preceding and forming the apex of the intussusception. In the ileocolic form, the valve remains stationary and the ileum passes into the colon. In the latter form there is an invagination of the csecum and colon, of a secondary character. Etiology.- — Xothnagel demonstrated that intussusception is caused by irregular muscular action in the wall of the intestine; in acute intussusception this is of a spasmodic character. In 50 per cent, of the cases little is known of the exciting cause. Diarrhoea, the various forms of enteritis, polypi, and diverticula, improper food, traumatism, and exposure to cold, have all been regarded as exciting causes. Typhoid fever and pertussis have been complicated or followed by intussusception. I have recently seen a case following typhoid fever in a boy three years old. Meckel's diverticulum and the appendix have been the cause and seat of intussusception. In the latter case the inverted appendix caused ileocsecal intussusception. Frequency. — Intussusception is more common in males than in females. The disproportion diminishes after the first year of life. Fifty per cent, of all the cases occur before the tenth year, and chiefly in individuals who are not in good physical condition (Treves). In the cases that I have seen, the infants were not noticeable for being in previous delicate health or may have been robust infants at the breast in whom there has been a previous history of intestinal indigestion. DISEASES OF THE STOMACH AND INTESTINES. 543 The youngest case I have met was five and a half months of age. This infant was breast fed, had suffered with colic, and had had green movements from birth; there was an ileocsecal invagination eight inches in length. Symptoms." — The onset is sudden in 75 per cent, of the cases ; in the colic and rectal varieties it may be gradual. In many cases the disease makes its appearance while the infant is nursing or during sleep. The patient, being attacked with pain, suddenly awakes from sleep with a cry and begins to vomit ; on the same day or the follow- ing day a bloody movement appears, the amount of f seces being small. In a few cases there are no fsecal evacuations. If the case is progres- sive, the pain returns in paroxysms, the hemorrhagic movements are repeated, and the vomiting keeps pace with the increase of the obstruc- tion. The general condition of the patient grows worse ; apathy and collapse ensue. I have seen cases begin with a mild diarrhoea ; the pain suddenly appears, and also the hemorrhages from the bowel, the infant at once going into collapse. There is apathy due to intestinal intoxication from which it is difficult to rouse the patient. If the case continues to progress with- out relief the movements become frequent, exhaustion increases, and finally death from asthenia results. The pain is great at the onset, usually reaches its maximum intensity within a short time, and then gradually subsides. It is of a paroxysmal character and is colicky during the advance of the invagination; as adhesion takes place or gangrene occurs it diminishes. The intervals between the paroxysms of pain are at first of considerable length ; later they become shorter. The pain is most severe in the ileocsecal form, and is in all forms caused by irregular intestinal peristalsis. Vomiting. — Vomiting is not so prominent a symptom as in other forms of intestinal obstruction (Treves). In 75 per cent, of the cases it comes on early with or directly after the pain. It may not recur for hours. In a child taken with sudden pain of a colicky char- acter, vomiting, and bloody stools, the vomiting recurred only twice within twenty-four hours. It is apt to be less violent as long as there is not complete obstruction of the gut; in other words, it is more marked in those cases in which no faeces pass. As long as the pain recurs in paroxysms (progression of the intussusceptum) the vomit- ing is not apt to be marked. The vomited matter is composed of the stomach contents and is biliary; stercoraceous vomiting was found late in only 25 per cent, of Leichtenstern's cases; Gibson also found it to be rare and late. If stercoraceous vomiting was present, it appeared from the fourth to the seventh or to the fourteenth day. In the case referred to, in the infant of five and one-half months, it appeared during the first' twelve hours of the disease. 544 DISEASES OF THE STOMACH AND INTESTINES. The condition of the bowel is important. It is generally stated that constipation occurs from the outset ; this is not universally true. Cases in which constipation exists throughout, that is to say, in which no fseces whatever are passed, are not common, and form only 30 per cent, of the total number. Diarrhoea is the common condition at the outset; as the obstruction increases, the amount of faeces in the stools diminishes, and finally only mucus and blood are passed. The most important symptom in connection with the bowels is hemorrhage. Hemorrhage from the bowel, in connection with pain and other abdominal symptoms, is considered by Gibson as pathog- nomonic. It was present in 80 per cent, of the cases tabulated by Leichtenstern. As a rule it is considerable. It is said by Treves to have been in some cases so great as to cause death. The blood and faeces have a cadaveric odor, which, however, is not always, as some writers affirm, a sign of gangrene. I have perceived this odor in an intussusception which operation showed not to be the seat of gan- grene. It is caused by decomposition of the blood in the gut. The temperature is normal, slightly subnormal, or slightly ele- vated. There may be a slight elevation of temperature without peri- tonitis. The quantity of urine may as in other forms of intestinal obstruction be diminished. Tenesmus. — Tenesmus is present in 55 per cent, of the cases; it depends more or less on the presence of the intussusception in the rectum. It is usually an early symptom in the rectal form, and is more common in the ileocascal variety than in the enteric. The abdomen is not at first distended; it may, on the contrary, be retracted; if tympanites occurs at all, it does so late and in the presence of a general peritonitis. Palpation of the abdomen is at fij-st well borne, but after a time there is sensitiveness. Tumor.- — A tumor felt through the abdominal wall or in the rectum is of the greatest value in the diagnosis. It cannot be felt if the intussusception is in the hepatic or splenic flexure of the colon. It is variable in distinctness, and is most frequently felt in the region of the descending colon or of the sigmoid flexure. Infants below one year of age who were brought under my obser- vation early presented a distinct tumor in the region of the ascending and transverse colon if the intussusception was ileocsecal. Gentle superficial palpation is more effective in infants than rnde examina- tion; the latter is apt to cause crying and abdominal rigidity. It is hard and resistant, and rarely more than six inches long. It is often said to be sausage-shaped, but the statement is misleading. The tumor is rarely felt in the ileocsecal region, for the reason that the intussusception in this locality is small, and is that of a small gut inside of a large one. In one-third of the cases the rectum, if exam- DISEASES OF THE STOMACH AND INTESTINES. 545 ined, shows the presence of the intussusceptum. The rectal tumor is commonly found in children, because in them the colon is mobile. In very early cases I have not found a rectal tumor. The intestine may reach the anus as early as the second day, the average time being the seventh day. It may protrude from the anus from three to eight inches, and may be in a gangrenous state; under these conditions it has been mistaken for a polypus or hemorrhoid. Prognosis. — As regards duration, there are three varieties of intus- susception — the ultra acute, the acute, and the subacute. The ultra acute cases are exceedingly rare. Leichtenstern found only 5 of this form in a total or 7269 cases ; 4 of the 5 occurred in infants less than a year old. All were fatal. The rate of mortality in intussusception, excluding the ultra acute forms, varies as given in the statements of different authors. Gib- son's statistics place the mortality at 53 per cent. It varies with the age of the patient, the duration of the disease before operating, and the success in reducing the intussusception. Intussusception is ex- tremely fatal in infants under the first year. If the diagnosis is made early I have found the prognosis in infants below one year of age not as bad as some writers would lead us to suppose. According to Treves, the mortality under one year of age is 80 per cent. On the other hand, if we study the cases as Gibson has done, we find that the cases operated on during the first day of the disease had a mortality of 41 per cent. ; those on the fourth day, 72 per cent. The reducible cases showed a mortality of 38 per cent. ; the irreducible, of 88 per cent. Diagnosis. — From the studies made by Gibson, it may be seen that, in children, a bloody discharge with abdominal pain of a paroxysmal nature is almost pathognomonic of intussusception. The presence of a tumor fixes the diagnosis absolutely. Fsecal vomiting is of very little value as a diagnostic sign. It is very infrequent, and is in any case present only late in the disease, when occlusion of the gut has occurred. ' If enteritis exists in a young infant, it is often difficult in the absence of any abdominal or rectal tumor to make a diagnosis. The course of the case will guide the physician. In dysentery the hemor- rhage from the bowel is not great ; it is composed of blood-tinged mucus with fseces. Cases of scurvy may simulate intussusception if bloody discharges appear with the intestinal movements. In these cases the amount of blood voided per rectum is fully as great as in cases of intussusception. In scurvy, however, there is faecal matter in the movements, in the cases coming under observation of the author, as also signs of scurvy, such as tenderness of the bones and spongy, bleeding gums. Appendicitis has been mistaken for intussusception. 35 546 DISEASES OF TEE STOMACH AXD INTESTINES. It frequently occurs with it, aud thns obscures the picture. Peri- tonitis can hardly be mistaken for intussusception. In peritonitis the pain is continuous and there is tympanites, but no bloody dis- charge. Peritonitis is. however, a late symptom. Tuberculous peri- tonitis is sometimes mistaken for intussusception. In tuberculous peritonitis the symptoms are not progTessive, and also there is not likely to be a bloody discharge. The case following typhoid fever, to which I referred, simulated a hemorrhage from a typhoidal ulcer. A careful examination under an ansesthetic cleared up the case. In complete relaxation under ansesthesia, a tumor could be felt in the csecal region of the ascend- ing colon. The result of examination was verified by operation. In all doubtful cases in which the restlessness of the child interferes with a careful examination an ansesthetic should be given. There is a characteristic condition which in some cases can be detected by examination. As the finger is inserted into the anus the rectum is felt to be inflated. This is due to traction on the gut by the invagi- nation. I have found this inflated state of the rectum in two infants suffering from intussusception. Spontaneous Cure. — There is little doubt of the possibility of spon- taneous recovery in invagination; such cases have been seen by com- petent observers. Henoch has seen typical intussusception retrograde and the patient recover. There is another mode of recovery which occurs in cases of irreducible intussusception : the intussusceptum sloughs off and is passed per anum. This occurred in 43 per cent, of the unrelieved cases (Leichtenstern), but in 40 per cent, of these the patient succumbed to general sepsis with or without peritonitis or to subsequent obstruction of the gut from swelling after the gan- grenous portion had sloughed away, Henoch reported a case of this kind. Treatment, — The diagnosis of intussusception once made, the case is one for surgical interference. The sooner surgical treatment is begun, the better the chances of recovery. Injections of air, gas under pressure, and enemata of water and oil have been tried, with some measure of success. Their use, however, delays the radical treatment and reduces the chances of ultimate recovery, and apparent improve- ment frequently gives way to an exacerbation of symptoms. Surgical aid then comes too late. The objections to the treatment by injection are as follows: the intestine is viable in these cases, and is liable to be ruptured by injec- tion of gas or air under pressure ; an enema of water under only four feet of pressure has been known to produce this result. Snow published a case in which an injection of oil was made ; postmortem the oil was found above the point of obstruction. The enema may thus pass DISEASES OF THE STOMACH AND INTESTINES. 547 through the lumen of the gut without relieving the intussusception. Enemata should be given, if at all, during the first 24 hours, and should he allowed to flow into the rectum under very low pressure. The amount of fluid varies ; certainly not more than a quart should be given. The fluid, a saline solution at 100° F. (37.7° C), is allowed to remain in the rectum for ten minutes, the patient being under an anaesthetic. A Davidson syringe should not be used. The ordinary fountain bag irrigator is best for this purpose. If one enema fails and the diagnosis is moderately certain there should be no delay in seeking surgical assistance. Appendicitis (Perityphlitis; Paratyphlitis) — Anatomical Pecul- iarities. — Vallee examined the appendix in 100 infants and children postmortem. He found that in fully 75 per cent, the csecum is situ- ated above the anterior superior spine, on the right side, a position higher than that occupied in the adult. It is above the plane of the anterior superior spine of the ileum, is almost 5 centimetres long, and has a general longitudinal ascending or descending direction. In one case the appendix was situated entirely to the left of the median line, there being no transposition of the other viscera. Knowledge of these facts is of importance in the examination for the appendix in conditions of disease. I have frequently succeeded in palpating the normal appendix at one side of the csecum. It is felt as a cylindrical body having the diameter of a quill. Acute Appendicitis. — Frequency. — Although the statistics show- ing the frequency of appendicitis in infancy and childhood vary with the number of cases collected by each author, the combined statistics of Matterstock, Fitz, Sonnenburg, and ISTothnagel, show that the dis- ease is not very frequent before the tenth year. Only 8 per cent, of the cases occur at this age. It may occur in early infancy. Savage records a case in an infant two months old; Demme also records a case in a very young infant. The literature shows occasional cases at all periods of infancy. Among the cases collected and tabulated from the service of my col- leagues, Grerster and Lillienthal, at the Mount Sinai Hospital, there is one of an infant one year of age. Of 50 cases of appendicitis in children taken from the service of these surgeons, 1 occurred in an infant one year of age, 17 from the third to the sixth year, and 32 from the sixth to the tenth year of life. Thus in a statistical collec- tion of cases occurring in children, only one-third occurred before the sixth year of life. Varieties. — The forms of the disease are the same as in the adult subject. The perforative form seems to be the most common among children. Thus of 50 cases coming to the hospital for operation, 31 were perforative with or without abscess, 9 were of the gangrenous 548 DISEASES OF TEE STOMACH AND INTESTINES. variety, and 6 of the catarrlial form. It will thus be seen that in children the tendency in this disease as in others, such as pleurisy, is toward suppuration and the formation of abscess. Ssonptoms. — The symptoms will vary with the variety, whethei" catarrhal, perforative, or gangrenous. Catarrhal Form.- — In the catarrhal form the patient is, after some indiscretion in diet, seized with colicky abdominal pain, vomit- ing, and some fever. In other cases the children simply complain of pain which is not sufficiently severe to prevent their being up and about. The pain is not always located by the patient in the appendix. When the patients are in the recumbent posture, the right knee may be flexed and the thigh flexed on the abdomen ; when they walk, they do so in a bent position, favoring the affected side. Physical exami- nation reveals a localized resistance or tenderness in the right iliac fossa. In some cases there is distention of the caecum with faeces, in others I have felt the appendix and the caecum matted together in a mass of the size of the index finger. The pain is not always referred to the iliac fossa, but may be distinctly located around the umbilicus or over the lower part of the abdomen. It may not always be possible to palpate the appendix, which may be behind the caecum. Under such conditions no intumescence will be found. Z\IcBurney's point will be considered in the diagnosis. The history of many of the catarrhal cases is one of recovery under careful treatment. The fever subsides or may never have been above 101° F. (38.3° C.) ; the pain also subsides, and in from a few days to a week the patient is apparently well. Attacks of this kind may recur. Perforative or Suppurative Fo7'm. — In the perforative or suppu- rative form the symptoms are more violent. In this form also the onset of the disease seems to date from some indiscretion in diet. The patient is seized with sudden sharp pains in the abdomen, accom- panied by vomiting, fever, and rapidity of pulse. The pain is located either in the upper or the lower part of the abdomen, or in a few cases in the right iliac fossa. After one or two attacks of vomiting this symptom may subside and not recur until the second or third day, when perforation occurs. Tympanites occurs early and may set in after the second day of the disease. The pain and tympanites cause an increase in the respiratory movements, which are shallow. The patients lie in the recumbent posture. The escape of gas and intestinal contents, if perforation occurs, causes a disappearance of the liver dulness, with peritonitis and a formation of fluid in the peritoneal cavity with a movable dulness in the flanks on percussion. The pulse is at first rapid and thready, and quickly mounts above DISEASES OF THE STOMACH AND INTESTINES. 549 120 after perforation has occurred. The prostration is great, and in some cases of a septic type jaundice is present. Gangrenous Form. — In the gangrenous form the symptoms are very similar to those of the perforative form, but are very much inten- sified. It is not possible to tell from the symptoms whether the process is gangrenous, simply perforative, or catarrhal follov^^ed by abscess. Course. — In both the perforative and the gangrenous cases in chil- dren as in the adult, localized adhesions may form with a small or large collection of pus or several foci of pus. In other cases a gen- eral peritonitis follows the perforation. In children, as in adults, the moment of perforation is followed by a temporary fall in the temperature and a cessation in the pain and vomiting, the pulse, how- FiG. 112. 6'D,./,-.n,: Method of examination of the region of the appendix vermiformis. ever, continuing rapid. The lull, however, is of short duration, and is quickly followed by an increase in the severity of the symptoms. Diagnosis. — The above outline gives very little idea of the great and sometimes insurmountable difficulties of diagnosis of appendicitis in young children. To guard against error, a very careful routine should be followed. The patient is completely undressed and lies in the recumbent posture, the shoulders being slightly raised. The phy- sician should stand or sit at the patient's right. The contour of the abdomen is noted. If it is normal and not distended, there is prob- ably no peritonitis. The abdomen is very gently palpated in different places to ascertain if there is distributed or localized tenderness. The left palm is then placed underneath the right loin, and with the palmar surface of the fingers of the right hand the region of the appendix is gently palpated (Fig. 112). Superficial palpation is practised at first. The hand is then depressed deeper into the iliac fossa in search of resistance or tumor. 550 DISEASES OF THE STOMACH AND INTESTINES. The intensity of the pain caused bv manipulation is carefully gauged by "\vatching the face of the patient. The right iliac region haying been carefully palpated, rectal exploration should be made in all doubtful cases. This is necessary in the cases in which a general tympanites or general abdominal tenderness makes the diagnosis difficult. With the well-oiled index finger of the right hand the rectum is explored as high up as possible. In young children this can be done without causing pain if gentleness and caution are exer- cised. If children are very intractable,, this method of examination cannot be carried out. Rectal examination is exceedingly dangerous in those cases in which there is a localized abscess. Any careless manipulation may break up the delicate adhesions between the coils of gut and evacuate the abscess into the general peritoneal cavity. The following points are important in the diagnosis : Tympanites. — If the abdomen is distended and there is general pain with increase of the number of respirations, there is probably peritonitis localized or diffuse. In the latter case there is disappear- ance of the liver dulness if the tympanites is extreme. Percussion.- — Percussion will sometimes, even in general peri- tonitis, give a localized dulness in the right iliac fossa. Localized pain and intumescence or a localized mass in the right iliac fossa are of great import. McBurney's Point. — McBurney's point is of less value in children than in the adult. In children, as will be seen from Vallee's work, the appendix is situated higher than in the adult, and McBurney's point is therefore too low for palpation. Some children complain of epigastric, others of umbilical pain, which is not so distinctly localized as in the adult. Fever. — The fever is of little value, there being nothing charac- teristic in the curve. The temperature may be normal or in severely septic cases slightly raised. After perforation, the temperature be- comes subnormal, as it does in the adult. Tuberculous Peritonitis. — Appendicitis in children may simulate tuberculous peritonitis. In the latter disease there is sometimes severe pain of the colicky variety. Tuberculous peritonitis and ap- pendicitis may be coincident. Pain.— Pain in appendicitis resembles very closely that in gastro- enteritis and dysentery. Griffith has published 2 cases of appendi- citis in children who had entero-colitis at the same time. Perinephritic Abscess. — I have had one case in which a peri- nephritic abscess simulated an appendicitis. The contrary may also occur. Appendicular abscess may simulate a coxalgia with abscess. I have seen a few cases of typhoidal affection of the appendix which DISEASES OF THE STOMACH AND INTESTINES. 551 for a few days simulated an appendicitis very closely, so as to mis- lead the surgeon into operating upon them. Appendicitis with in- vagination of the appendix into the csecum is a rare condition, as is also intussusception with appendicitis. In the typhoidal cases, a Widal reaction may be obtained, and mil be of assistance in diag-nosis. Care should be taken that a perforating typhoidal ulcer does not escape diagnosis. Intussusception will give the characteristic symp- toms of that condition. Lobar Pneumonia. — I have seen cases of lobar pneumonia of the lower lobe of the right lung, in which the pleuritic pain radiated down the right side into the iliac fossa. There were also epigastric pain and vomiting at the onset of the disease. The excessive rapidity of the respirations, the marked dyspnoea, and absence of tympanites and pain on deep pressure in the region of the appendix, led me to examine the lung. Prognosis. — Of the 50 hospital cases which I have tabulated above, only 3 recovered without operation ; they were of the catarrhal variety. These figures give no accurate idea of the proportion of recoveries made under careful and conservative treatment in private practice. The mortality in the cases operated upon was 35 per cent. The rate is not high considering that many cases came under the knife later than would have been the case in private practice. On the other hand, it should be remembered that the rate of mortality is also influenced by the nature of the infection and the power of resistance of the patient. Thus cases with a gangrenous appendix died although operated upon on the second day; others of the same kind recovered although the disease had lasted from four to seven days before opera- tion. Some perforative cases died on the second or third day of the disease, while others recovered although operated upon from six to twelve days after the onset of symptoms. Gangrenous cases in this statistical table in children show a lower rate of mortality than those cases in which the appendix perforates, forms an abscess, and causes general peritonitis. Chronic Appendicitis. — This form of appendicitis occurs in older children. The symptoms are frequently mistaken for those of dys- pepsia. The history is much the same as in the adult. A child otherwise in good health has attacks during which there is abdominal pain not of great severity, accompanied, at times, by vomiting, but which may last for a few hours and disappear, leaving the patient well. The pain is very rarely referred to the appendix ; it is abdom- inal, the umbilical region being generally indicated as the seat of dis- comfort. The temperature may reach 100° F. (37. Y° C.) ; the pulse in a child of eight years was 96 and regular. There is no vomiting 652 DISEASES OF THE STOMACH AND INTESTINES. and no prostration. The pain is sufficiently severe to make the patient wish to lie down ; it is not excessive when the appendix is palpated. The bowels are regular. The cases may in the intervals between the attacks show a slight intumescence in the region of the appendix, but nothing is felt in the rectum. The signs in the interval may be very indefinite or quite distinct. The caecum and appendix are felt to be matted together. Three cases in which there had been repeated attacks extending over a period of from one to two years, were operated upon for me by leading surgeons. The patients were girls between the ages of six and eight years. In each case there was evidence of a chronic catarrhal process. In one case the appendix contained a faecal cal- culus, in another there were constricting adhesions. Treatment.^ — The treatment of both acute and chronic appendicitis in infants and children does not differ from that followed in the adult subject. Rectum. — In infants a large portion of the rectum is situated in the abdominal cavity rather than in the pelvis. In infants and chil- dren it has three curves — one lateral and two anteroposterior. The gut is nearly straight and occupies a more or less vertical position, hence the frequency of prolapse. The attachment of the rectum to the surrounding parts is not extended as high in children as in adults, hence the rectum is more liable to be pushed out. The rectum of the newborn infant may be divided into three parts. The first lies in front of the sacrum and ends at the lower end of the bone ; the second is short, and in this respect differs from the adult gut, being also more vertical ; the third portion is long, and extends downward, and some- what backward. The second portion being short, when the rectum is distended, the gut is straightened out and the whole rectum extends downward and backward (Symington). All these data are of impor- tance in applying methods of therapy (enteroclysis, etc.) to this organ. Prolapsus Ani. — Prolapsus ani is a condition frequently met with in infants and children. It may amount only to an eversion of the mucous membrane. There is in some cases a complete descent of part of the rectum, which protrudes from the anus to the length of one or two inches. Etiology. — The etiology of this condition is obscure. It evidently occurs only in cases in which the pelvic attachments of the lower bowel are lax. It is favored by anatomical conditions elsewhere mentioned. It is seen in children who are constipated, in those who suffer from diarrhoea, and also in those whose movements are not normal. Any abnormal condition in the neighboring organs, such as the bladder and urethra (stone), may cause excessive straining and consequent prolapse of the gut. A rectal polypus may cause prolapse. DISEASES OF THE STOMACH AND INTESTINES. 553 Symptoms. — In some cases the only symptom is the appearance of a small quantity of mucus and blood on the diaper with each move- ment; in these cases the prolapse returns spontaneously. In other cases the bowel descends to the extent of one or two inches with the movement, and remains prolapsed. If a polypus of the lower part of the rectum is the cause of the prolapse, it is seen protruding from the prolapsed portion. Treatment. — The iirst step is to replace the protruding gut. The gut is anointed with olive oil or vaseline and gently replaced with a towel. The movements are so regulated by diet and cathartics that the stools are passed without straining. Three times daily a supposi- tory containing grains ij to iij (0.12 to 0.2) of tannic acid is placed in the lower bowel. While the movements are being passed the pa- tient is kept in the recumbent posture on a bedpan. This treatment is frequently successful. In other cases, the buttocks are drawn together by adhesive straps and the child is allowed to pass movements thus strapped. Cocaine and strychnine are used both in suppositories and hypodermically. The protruding portion is painted with cocaine. These measures have their failures and successes. The only satis- factory method is that first advised — of a strict diet, the recumbent posture at stool, and the astringent suppository. The Paquelin cautery is sometimes employed to cauterize the mucous membrane. The danger in this method is the substitution of a traumatic stricture of the anus for the comparatively harmless prolapse. Application of the pure stick of silver nitrate to the anus twice a week, has given good results. If a polypus of the rectum is the cause of the prolapse, the growth should be removed by surgical means. Fissure of the Anus.- — Fissure of the anus is seen in syphilitic infants, in those suffering from marked constipation, and in infants that have eczema of the anus. It may be the result of the repeated introduction of the hard nozzle of an enema syringe. The fissure may be so slight as to be only a line-like tearing of the mucous mem- brane, or may consist of a broad ulcer with a hard granulating base. Symptoms. — ^As a rule, the infants are constipated. When a movement is passed, the infant cries and there is great pain. A few drops of blood are passed on the diaper. Diagnosis. — The presence of a fissure of the anus sometimes escapes the notice of the physician. If there is a history of the above symptoms, the physician should place the infant on a table, grasp the buttocks with the palm of the hands and separate them forcibly with the thumb. The anus is thus everted, and if a fissure is present it will at once become apparent. Treatment. — A small fissure is sometimes very successfully treated by regulating the bowels. It is touched with a 10 per cent, solution 554 DISEASES OF THE STOMACH AND INTESTINES. of silver nitrate once a day. In the severe cases silver applications will not avail; forcible dilatation of the rectum by means of the thumbs must be resorted to. This procedure not only cures the fissure, but is also an effectual remedy for the accompanying constipation. Spasm of the Anus.- — -Cases of nervous spasm of the sphincter ani occur in infants. The infant is constipated and cries at each movement. There is no bleeding, nor does examination reveal any fissure, but only marked contracture of the anal opening. In these cases it is almost impossible in an examination to bring down the upper part of the anal gut. The remedy is to regulate the bowels. If by this means success in overcoming the spasm is not attained, forcible dilatation is the only resource. Proctitis. — Apart from the membranous and catarrhal forms of proctitis, which occur with similar conditions of the intestine, the only form which is of interest is the gonorrhoeal. This occurs as a complication of vulvovaginal gonorrhoeal inflammation. In these cases the introduction of the gonococcus from the vagina into the gut has occurred through careless thermometry or the giving of enemata without previous cleansing of the parts. The disease is very painful and at the same time trying to the infant or child. With the dis- charge of pus from the anus there are tenesmus and a bloody discharge with the movements. The purulent discharge shows gonococci. Treatment. — The treatment consists in the injection of protargol solutions, 2 per cent., at a temperature of 105° to 108° F. (40.5° to 42.5° C), into the rectum twice daily. The bowels are regulated. Suppositories of tannin or tannigen are also of value and give great relief; one containing grains iij (0.18) is given per rectum twice daily. In the later stages it may be necessary to paint the lower bowel with a very weak solution (0.5 per cent.) of silver nitrate. Polypus of the Rectum. — Polypus of the rectum is not rare in childhood, but is not often seen in infancy. It occurs most frequently from the third to the seventh year of life. The polypi are adenomata. I have examined several, and have found them to have the structure described by Baginsky. They may be single or multiple, usually have a pedicle, but may be attached to the wall of the gut by a broad base. As a rule they are situated on the posterior wall of the rectum seven or eight centimetres above the anal ring, but may be on the anterior wall. In most cases the polypi exist here only, but I have seen them higher up in the gut, and in one case in a child of five years from whom several rectal polypi had previously been removed, I diagnosed a number in the descending colon. In this case lapa- rotomy and incision of the gut proved the diagnosis to have been correct. The polypi may, if they become numerous, assume a malig- INTESTINAL PABASITES. 555 iiant character; this is especially true of the growths with a large, hroad intestinal base. Symptoms. — The characteristic symptom is intermittent hemor- rhages from the gut, which may be profuse. At times the outer surface of the movements is streaked with blood, the bowels being constipated or normal, with an occasional mucous diarrhoea. If the polypus is low down, there is straining at stool with prolapsus of the gut. Many of the children thus affected are pale, have a pasty hue of the skin, and show evidences of lymphatism. Diagnosis. — Bleeding from the bowel, in the absence of other symp- toms, should at once suggest the necessity of digital exploration of the lower bowel. If a polypus is not found, a careful palpation of the abdomen made when the patient is fasting should be the next procedure. If the child is tractable and the abdomen soft, it may be possible in rare cases to feel a tumor the size of a hazelnut at one side of the umbilicus. Prognosis. — The prognosis is good ; removal of the polypi is rarely followed by recurrence of symptoms, even in cases in which they are situated in the descending colon. If they are removable and not very numerous, the patient recovers. Treatment. — If the polypus is low down and pedunculated, it may easily be snared with or without the aid of a rectal speculum., and crushed or ligated off. If it is high in the sigmoid flexure, the anus should be dilated and the growth reached by means of a speculum. In cases in which the growth is in the colon, laparotomy, enterotomy, and ligation are indicated. INTESTINAL PARASITES. The most common parasites found in infants and children are the ISTematoda, or round worms, and the Cestoda, or tapeworms. The round worm is smooth and light brown or reddish in color, the female being larger than the male. The eggs are found in the stools ; they are from 0.05 to 0.06 mm. in diameter and are surrounded by an albu- minous envelope. The worm is several inches long. Oxyuris vermi- cularis is about 1 cm. long, the male having a length of 4: mm. The eggs measure 0.05 mm. in their long diameter. The tapeworms in mature state consist of rectangular segments. The head and neck are called the scolex; the segments, proglottides. The worms are hermaphrodites. The solium is sometimes several metres long. The head is of the size of a pin's head, with a pro- jecting proboscis armed with booklets. The eggs of the solium are ovoidal, 0.3 mm. in diameter. The Taenia mediocanellata has a more cuboidal head without booklets (Fig. 113). 556 INTESTINAL FABASITES. Diagnosis. — There are no symptoms which can be traced to the presence of these worms in the gut. If they increase in enormous numbers, they may cause symptoms of mechanical obstruction. Without the presence of the eggs or links of the worm, a diagnosis is not possible. Their presence is made known by the passage per anus of the links of such worms as the tapeworm. Round worms may also pass out of the anus, or may be vomited if they gain access to the stomach. Thread worms may cause excessive pruritus, and may not be discovered external to the anus. In that case the faeces should be carefully examined for the eggs of the worms. Fig. 113. 1 2 3 4 1. Oxyuris vermicularis, pin worm, natural size. 2. Egg of Ascaris lumbricoides. 3. Egg of Oxyuris vermicularis, pin worm. 4. Egg of TiBnia solium. 5. Proglottides or links of Taenia solium. 6. Proglottides of Bothriocephalus latus. Round Worms (Ascarides Lumbricoides). — This parasite is found in the small gut ; it may invade the stomach or may pass down- ward into the rectum. Cases are recorded (Borger) in which it has passed into the bile-duct and caused abscess of the liver. There may be only one or many of these worms in the gut. Leuckart states that they may form large masses in the gut, and thus cause intestinal obstruction. They have been known to perforate the gut and cause peritonitis. The eggs are introduced into the gut through the medium of drinking-water, fruit, and vegetables. Epstein cultivated the eggs outside of the body and then introduced them into the gut, where they developed. The male worm is 250 mm. long, the female being longer. Symptoms. — The symptoms caused when these parasites have once gained access to the body are not characteristic, I have seen the worms passed or vomited by children apparently in normal condition. Treatment. — The treatment consists in placing the patient on a milk diet. After a few days the following powder is administered two or three times daily : INTESTINAL PAEASITES. 557 Calomel, Santonin aa gr. ^ (0.016). Santonin is sometimes administered in the form of pastiles, but is not more satisfactory than the above preparation. Oxyuris Vermicularis (Pin Worm; Thread Worm). — Brass showed that the habitat of these worms is the small intestine, whence they pass into the csecum. The female worm lays its ova in the folds of the gut. They may pass into the stomach and thence into the mouth, but more frequently pass out of the anus into the vagina or into the prepuce and urethra. They exist in enormous numbers in the gut, are exceedingly small, and have the appearance of fibres of cotton fabric. They can be seen by spreading the nates apart. They are then found in the anus, or in female children in the four- chette. The principal symptom is intolerable pruritus, so intense as to deprive the children of sleep. This worm is found only in the human subject. It is conveyed from person to person through un- cleanliness. The larvae adhere to the fingers, and thence are intro- duced into food-stuffs. Treatment. — It is a very difficult task to dislodge these worms; injections by the rectum cannot reach those higher in the intestine. The plan which I have followed, and which gives relief, is to give daily enemata of quassia wood before bedtime: Quassia wood (ground) 5J (31.0). AquJB dest Oj (500.0). Make an infusion and strain. I have in addition utilized the prescription of santonin and calomel given above for the round worms. Schmitz recommends the administration of naphthalin, grains j to iij (0.06 to 0.18), t. i. d., for a week, after which it is discontinued for a few days, and then given again. Tapeworm {Tcenia). — Taenia are quite common in children, and have been found in the newborn infant (Miiller and Armor). ISTu- merous cases have been recorded of the presence of these worms in infants from the third to the twelfth month. They are most fre- quently found between the first and the third year. The varieties most commonly found in children are : Taenia solium. Taenia medio- canellata, Taenia elliptica, Bothriocephalus latus. Sources and Varieties. — Tcenia Elliptica. — The lice of the house- dog and cat are introduced by the fingers of the children into their mouths, and thus gain access to the gut. There the larvae of the tapeworm which they contain develop. Taenia Solium. — The larvae of this worm are found in badly cooked pork or beef. Tcenia Medio canellata. — The larvae of this worm are found in 558 INTESTINAL PABASITES. beef. Bothriocepiialiis latus is introduced by the ingestion of infected fish-food. The larva3 of tapeworm may exist in the flesh of the hare, pigeon, pheasant, chicken, goose, or duck. Ice, if made from infected water, may be a means of introducing the larvae in the body. It is thus not necessarily the meat-eating children who run the danger of swal- lowing the larvse of tapeworm ; milk if diluted with infected water may contain them. Symptoms. — Tapeworms may exist for months or years in the body of a child without causing untoward symptoms. As many as three varieties of the worm have been found in the same child. The symptoms are not characteristic. The passage in the movements of the links of the tsenia is the only positive evidence of their presence. Treatment. — The only successful treatment for the expulsion of the tapeworm is that which consists in the administration of filix mas in some form. It should be freshly prepared and given in liberal doses: Ext. seth. filix mas, TlXxxx (2.0) to 5j or 5ij (4.0 or 8.0), is made into an emulsion with gum tragacanth, and mixed with equal parts of castor oil. The administration of this mixture is pre- ceded by a day or more of milk diet. The child is then given from half a drachm to a drachm (2.0 to 4.0) of the filix mas with castor oil in divided doses. The recumbent posture is maintained in case nausea should be experienced. The movements containing the worm are carefully washed through a sieve, and the smallest part of the worm sought for in order to see if the head has come away. The patient should be given a drawing of the comparative size of the head and links of the worm, in order that the head may not be lost, or the physician may seek it himself. Uncinariasis or Hook-worm Disease. — This disease is widely prevalent in the South, where some two million men, women and chil- dren are said to be affected. The children are the principal victims. Etiology. — This disease was brought to America by the negro, whose habits lead to infection of the soil and spread of the disease to the white man. The hook-worm was known to the Egyptians. In, Europe it was discovered in the badger by Goeze in 1782 and was named by Froelich hook-worm. It was long recognized in the South, but Stiles isolated a distinct American species of Anchylostoma duo- denale, the European worm, in 1902. . Since then the literature is rich in clinical descriptions of the affection now called hook-worm disease. Adams described some cases in children. The hook-worm, or Uncinaria americana, is so called because in the American variety the head turns backward, forming a hook, while in the European variety the Anchylostoma duodenale, the mouth contains four hood-like processes by means of which the INTESTINAL PABASITES. 559 parasite fastens itself to tlie intestine (Fig. 114). The worm is half an inch long, its habitat is the intestine, it sucks blood and at the same time injects into the circulation a toxin. The parasite produces eggs which may be hatched outside of the intestine in about 24 hours, pro- ducing larvae. The infection is carried by the hands and drinking water. It is found in the soil of the sandy southern districts. It may enter the body, as established by Loos, through the skin. Enter- ing the hair-follicles, it gains admission into the circulation, then into the lungs and cesophagus and into the stomach. Symptoms. — The symptoms consist in a progressive ansemia; the hemoglobin in Adams's case was reduced to 20 per cent. The skin is dark, waxy and hydrsemic, the face is bloated, the abdomen pro- FiG. 114. American hook-worm larvae, eggs. Small figure shows actual size. tuberant and emaciation results, with a tendency to skin ulceration. The tongue is brown and spotted and the mucous membranes pale. The temperature may be subnormal or there is occasional fever. The muscular weakness is extreme and mental apathy and stupidity are characteristic. There is headache, dizziness, epigastric pain and a craving for peculiar articles of diet. I^early all of the victims of the affection are dirt-eaters. There may be constipation or diarrhoea. The blood shows diminution of white blood-cells and eosinophilia. Diagnosis. — The diagnosis is made from an examination of the fseces in which the eggs of the parasite are found. Stiles describes the eggs, which are 60 to 70 /^ in length and 41 to 46 /x in width. The larvse may be developed from them artificially. The disease may last for years if not eradicated by treatment. ISTeglected cases cannot be cured. Treatment. — Treatment is the administration of thymol suggested by Bozzolo. There must be an abstinence during treatment from alcohol or fatty substances which dissolve the thymol. Adams gave his patient, a boy of twelve, 30 grains, in doses of 10 grains every 560 DISEASES OF TEE LIVEB. hour and a half, followed bv Epsom salts. After a time the faeces are examined. If the ova are still present, the treatment is repeated. Good food and tonics aid restitution. DISEASES OF THE LIVER. Anatomical. — The weight of the liver in infants and children is from one-twentieth to one-thirtieth of the body weight; in the adult it is one-fortieth. Weight. — Birch-Hirschfeld gives the following weights of the liver : Birth 127 5 years 480 6 montlis 197 10 Tears 830 1 year 312 Adult 1627 2 years 346 Examination. — The liver is examined with the patient in the recumbent or semirecumbent posture. The physician may palpate for the liver or mark out the organ more accurately by percussion. In marking out the organ, the upper limit, the lower edge, and the area of superficial dulness are determined. Perfect accuracy by deep percussion is not feasible, because in order to obtain absolute dulness some force must be used, and vibratory echoes of other neighboring organs — ^the lungs and intestines — are thus caused. In all cases it it well to determine the upper limit of dulness at a point where the liver comes in contact with the chest-wall. The lower border of the liver is determined by palpation and per- cussion. The lower border projects normally in infants and children below the border of the ribs. In the right mamillary line this pro- jection may vary from 1 to 2.5 cm. At the xiphoid appendix the liver may project to the extent of 2 to 6 cm. and still be within the normal limits. These conditions may exist up to the tenth year. The exact age at which the liver assumes the adult dimensions has not been determined. In some adults, however, the projection below the border of the ribs is the same as in children. Since the size of the liver varies, caution should be exercised in pronouncing the organ enlarged. The gut, ascites, and tympanitic distention may obscure the lower limit of the liver both to palpation and percussion. Palpation. — By palpation, the location of the lower border of 1he liver may be determined, and whether it is rounded or sharp, also, if the liver be enlarged, the character of the projecting portion, whether smooth or even. In infants and children the region of the gall-bladder is palpated, but it is difficult to determine in these subjects whether this organ is enlarged or absent. Henoch and Murchison have re- corded fatal cases of increasing and persistent icterus in which there was congenital absence of the gall-bladder. DISEASES OF THE LIVER. 561 Percussion. — Percussion should be performed in the mid-line from the base of the xiphoid cartilage downward, in the right mammillarj line from above downward, and sometimes in the mid-axillary line. In order to determine accurately the superficial dulness, the whole extent of the dulness should be measured. This is rarely necessary except in investigations for scientific purposes. In cases of effusion into the pleural cavity, the upper limit of dulness is continuous with the dulness or flatness of the fluid. The displacement below the border of the ribs only can then be determined. In rare cases of sub- FiG. 115. Method of palpating the projection of the liver below the ribs. phrenic abscess there is an extension of the upper limit of dulness into the limits of the chest cavity, and displacement of the lower border of the liver downward. StefFen gives the following measurements of the superficial liver dulness in the median and mammillary lines : Midline. Mammillary line. At birth 3.5 cm. 2 cm. At one month 5 " 5 " At six month.s 4.5 " 4.5 " At one year 4.5 " 4 " At two years 5.2 " 5 " At five years . . 5 " 6.5 " At ten years 5 " 6 " These measurements also vary greatly, especially in infants under one year of age. Tumors and Conditions Simulating Enlargement or Disease of the Liver. — The following tumors and conditions simulate enlarge- ment or disease of the liver: normal rotation of the liver; phantom tumor; circumscribed empyema, or pleuritic effusion; subphrenic abscess ; circumscribed peritoneal effusion between the liver and dia- phragm ; tumors or cysts of the right kidney. Normal Rotation of the Liver.- — In infants below two years of age the liver may have a lax suspensory ligament. In such cases the 36 5G2 DISEASES OF TEE LIVER. liver will rotate and be found for a varying distance below the free border of the ribs, depending mncb on the amount of distention of the intestine. When the latter is not distended the liver will rise up beneath the free border of the ribs. Phantom Tumor. — Phantom tumor is described by Murchison. It is a soft or hard epigastric tumor, which may project downward as far as the umbilicus. Whether it is dull with a tympanitic note, or tympanitic, depends on the amount of muscular contraction. There is no fluctuation or flatness. The tumor is present when the patient is standing or in the recumbent position. It disappears under anaes- thesia. A tumor of this kind should not be punctured until it has been observed under anaesthesia, since there is danger of puncturing the intestine and causing peritonitis. Empyema. — In simple or encapsulated empyema on the right side, the liver is displaced downward. The upper dulness extends into the pleural cavity; the lower part of the thorax may enlarge to such an extent as to press the ribs apart and cause fluctuation between them. There will be dulness or flatness in front or behind over the lower part of the pleural space, and perhaps disappearance of the respiratory murmur. It should not be forgotten that there is always a possibility of the presence of subphrenic abscess, or of abscess in the upper part or on the surface of the liver, bulging into the pleural cavity. In that case there will not only be bulging of the lower ribs^ but also a continuation of dulness for a variable distance upward. The liver may be enlarged downward or not at all. If the tumor is beneath the diaphragm and displaces the liver downward, the respira- tory murmur may be heard to the normal, or almost normal, limit, and yet dulness due to the upward projection of the tumor may be present. Kidney Tumor. — Kidney tumor may extend from behind, beneath the liver, and simulate liver tumor. In such cases, the lumbar flat- ness extending below the border of the ribs will be a guide. Enlargements of the Liver. — Enlargements of the liver in infancy and childhood present much the same physical signs as in 'the adult, but there are some states which are peculiar to early life. Anaemia Infantum Pseudoleukaemica of von Jaksch. — Anaemia in- fantum pseudoleukEcmiea of von Jaksch causes great enlargement of the liver and spleen. The lower edge of the liver is rounded; the lymph-nodes are enlarged, and the blood presents certain features characteristic of this anaemia. Simple Rachitis. — Simple rachitis causes slight or marked enlarge- ment of the liver, as well as real enlargement of the spleen. • In some cases, the liver is not really enlarged, bnt ma}" be disjDlaced downward DISEASES OF THE LIVEB. 563 bj the deformity of the thorax. Simple icterus usually causes en- largement of the liver, which retrogrades after a few weeks. Still's Rheumatoid Arthritis. — In Still's rheumatoid arthritis there is considerable enlargement of the liver. Congenital Syphilis. — Congenital syphilis may cause slight en- largement of the liver which, up to the end of the second year, is present without icterus. The liver is enlarged in cirrhosis abscess, and fatty degeneration of the organ. It is greatly enlarged in acute and chronic leukaemia. Jaundice {Catarrhal Icterus; Catarrhal Jaundice; Infectious Icterus). — Simple jaundice is a common disease of infancy and child- hood. In its simplest form, it was formerly believed to be due to an obstruction of the common bile-duct with mucus. In recent years, the French clinicians have described a form of jaundice which they regarded as infectious. The first cases of the kind were published in 1881 by Weiss, Chauffard, and Landouzy, in France, and by Weil, in Germany. There is at present a tendency to regard all cases of jaundice in infants and children, not due to mechanical obstruction of the duct or disease of the liver, as infectious (Botkin, Hennig^ Barthez, Henoch, and others). Thus simple icterus would be re- garded as a mild form of infectious icterus. This view has recently been elaborated by Kissel. The theory that errors of diet cause a catarrh of the gut, extending into the duct and thus obstructing it, finds little support. On the other hand, the theory of the infectious nature of even the mildest cases of jaundice is supported by the fact that these cases occur in groups and epidemics. Morbid Anatomy. — In cases of fatal icterus, there are found atrophy and fatty degeneration of the liver cells. The interstitial tissue around the portal vein is infiltrated with small round cells. There is parenchymatous degeneration of the kidney. The whole picture resembles that of acute yellow atrophy. The mild cases of icterus have not yet been studied. Bacteriology. — The bacteriology of the various forms of icterus remains to be studied. In one case Jager found a bacillus of the proteus group in the urine. Occurrence.^ — The disease may appear at any period of infancy and childhood. It is most common between the second and fifth years. At present, all primary forms of jaundice may be clinically clas- sified as follows : The very mild forms (catarrhal icterus) ; the severer forms ; the fatal forms. It is highly probable that all are infectious in origin. The secondary forms of jaundice are not considered in this section. Symptoms. — In the mildest forms there are no symptoms at the onset. In some mild cases there are vomiting, constipation or symp- 564 DISEASES OF THE LIFEB. toms of intestinal indigestion and fetor of the breath, and the tongue is coated. The skin assumes a saffron hue and the conjunctivse are distinctly yellow. The appetite is capricious ; the urine is brownish and contains bile-pigment. The movements are like clay, and may have a bad odor. There is pruritus of the surface. The child may be somewhat depressed. In the very mild forms there is no febrile movement. In the majority of cases, there is rapidity of pulse and, in some cases, irregularity. In the severer forms the symptoms are more marked. The vomiting recurs at intervals, the intensity of the jaundice is much the same as in the mild forms, and the temperature may in the course of the disease be raised a degree or more. The attack may be ushered in by a chill. There is some prostration and, in a few cases, diarrhoea. The fatal cases, which were first described by Weiss and the French school, are severer forms of infection. The symptoms of cholsemia are much more marked. There are delirium, unconsciousness, and cerebral symptoms. The pulse is greatly in- creased and the respirations are irregular. The patients die in an asthenic state. The liver is enlarged in even the mildest forms. In a recent series of 20 cases of mild icterus, I found the liver enlarged from four to seven centimetres below the border of the ribs, in the mam- millary line. The spleen was enlarged in most cases. The fact that in the mildest forms there is enlargement of the spleen lends support to the infectious theory of the disease. In the majority of my cases, the liver remained enlarged long after the icterus had disappeared. Kissel also found this to be the case. In some cases, three months elapsed before the liver returned to the normal limits. Duration. — The disease, even in the mild form, lasts from two to three weeks. The fatal forms may run their course much more rapidly. Treatment. — The treatment of icterus is very simple. An initial dose of calomel is given and the bowels are well evacuated. The patient is put on a milk diet, and is given a daily enema of water at a temperature of 85° F. (29.4° C). On every second day a small dose of calomel, grain i (0.03), is given to aid the enemata. Fresh air and daily alkaline baths are beneficial. Alkaline baths are made by adding a few tablespoonfuls of sodium carbonate and an equal quantity of salt to the water. Congenital Obstruction of the Bile-ducts. — Etiology. — The etiol- ogy of this affection is obscure. Some TO cases of this condition were recently collected by ]\rorse from the literature. The infants may be apparently normal at 1)irth. Symptoms. — liilcnsc jaundice is the first symptom noticed at birth, or oji lh(; second 1o 1lic foui-lli day after birth. Meconium is first DISEASES OF THE LIVEB. 565 passed by the infant, and then the stools are clay colored. The urine contains biliary coloring-matter. The liver is enlarged, as is also the spleen. Hemorrhages from the stomach and intestine and into the skin occur in tirde. Death occurs early, or in from three to eight months. In one of my cases three months of age, laparotomy showed the gall-bladder to be empty and shrunken. The liver was enlarged. There was an absence of the ducts leading to the gall-bladder. The stools were formed, white like curd of milk, stained only slightly as the tissues with bile. There were extensive subcutaneous hemorrhages. Morbid Anatomy. — Some portion of the bile-ducts may be oblit- erated and replaced by connective tissue. In other cases the walls of the ducts are simply swollen. The liver is enlarged and the seat of cirrhotic changes. Cirrhosis of the Liver. — This disease is rare in infancy and childhood. Of 62 cases collected from the literature by v. Kahlden, 5 occurred in the newborn, 12 in the first two years of life, and 28 from the ninth to the thirteenth year. It is more prevalent in the male sex. Of those cases in which the size of the liver was recorded 19 were atrophic, 15 hypertrophic, and 6 normal in size. Etiology. — Demme has published 2 cases in children addicted to the use of alcohol. The influence of heart disease and the infectious diseases, such as scarlet fever and measles, in causing cirrhosis of the liver is not as yet understood. Cirrhosis of the liver occurs in forms of peritoneal tuberculosis and in syphilis. Morbid Anatomy. — The morbid anatomy of the affection is the same as in the adult. Symptoms. — The symptoms, which are the same as in the adult, include enlargement of the liver and spleen, icterus, and ascites. The icterus is, as in the adult, constant. The liver is not always enlarged, and in the cases in which it is of normal size the difficulties of diagTiosis are increased. The spleen is most constantly enlarged. The recorded cases of cirrhosis following or complicating the exanthemata and diphtheria gave no previous symptoms. Fatty Degeneration of the Liver. — Fatty degeneration of the liver, with or without enlargement of the organ, occurs in forms of subacute and chronic constitutional dyscrasia. I have seen this dis- ease in infants Avho died with tuberculosis, chronic or subacute intes- tinal diarrhoea, rachitis, Henoch's purpura, or acute leukaemia. I have also seen it in cases of phosphorus-poisoning. The symptoms and signs do not differ from those seen in the adult. The diagnosis can hardly be made during life. Syphilis of the Liver. — Enlargement of the liver is common in syphilis of infants and children. The spleen may also be enlarged. 566 DISEASES OF TEE LIVEE. There may be icterus. There may be other symptoms of syphilis, but none which can be traced to enlargement of the liver. There are four histological forms of this variety of hepatic en- largement : a. The form in which gummata are found in the liver. This is rare. I saw a case in an infant sixteen months of age in which there were also gummata of the cranial and the long bones. h. The diffusely cirrhotic liver. In this form the connective tissue is quite evenly distributed throughout the liver. c. The lobulated liver, in which the connective tissue divides the organ into sections. I have seen a case in a girl eight years of age. d. The so-called miliary syphilis of the liver, in which the organ is strewn with miliar}^ collections of round cells closely resembling miliary tubercle. The nodules are situated in the interstitial con- nective tissue. They rapidly undergo fatty degeneration. Clinically the cases which I have met were mostly those in which the liver, hard and nodular, could be felt below the border of the ribs. In one case there was a history of syphilitic accidents, in another old cicatrices existed on the lips and face. In a third case the patient had' Hutchinson teeth; the liver and spleen were both enlarged and nodular. Abscess of the Liver (Suppurative Hepatitis). — Etiology. — This disease occurs in the newborn as a form of sepsis. Otherwise its etiology in infancy and childhood is identical with that in the adult. It may follow a traumatism or complicate appendicitis (septic), it may occur in peritonitis with pyelophlebitis. or it may follow the infectious diseases, or dysentery. In the literature rare cases are described, in which Ascarides lumbricoides have caused abscess of the liver in children, by migrating into the gall-bladder through the common duct. The occurrence of this disease, though not rare in tropical coun- tries, is less frequent in districts in which dysentery is not endemic. It may occur as early as the fifth month of infancy (Oliveira). The left lobe of the liver is most frequently involved. The Amoeba coli is not always the cause, being an etiological factor in 20 per cent, of the cases. Symptoms. — The symptoms in these cases are first those of dysen- tery; then, after improvement sets in, the symptoms of abscess, with fever, swelling of the abdomen, and enlargement of the liver upon palpation appear. The liver may enlarge as much as 10 cm. below the tip of the ensiform cartilage. Course. — The abscess may perforate into the intestine, pleura, or peritoneum. If it perforate into the intestine recovery results. Any other termination is disastrous. DISEASES OF THE PEBITONEUM. 567 Treatment. — The treatment of abscess of the liver in children is much the same as in the adult. If operated early the prognosis is good. Acute Yellow Atrophy of the Liver. — The disease is extremely rare in infancy and childhood. Lanz published a case in a boy four years of age. In that there was no splenic tumor or hemorrhages, it differed from the picture in adult cases. The cases in the literature are as follows : Pollitzer, infant, one month of age ; Senator, infant, eight months; Mann, infant, ten months; Greves, infant, twenty months ; Widerhofer, child, one and three-fourths years ; Eehn, child, two and one-half years; Loschner, child, three and one-half years; Mettenhemier, child, four years; West, child, six years; Merkel, child, six and one-half years ; Rosenheim, child, ten years ; Steiner, child, ten years ; Folwarczny, child, fourteen years. I have seen only one case of atrophic liver. The patient, a boy of eleven years of age, with very small kidneys, had nephritis which had appeared six years after an attack of scarlet fever. The liver dulness became gradually smaller from the time of admission to the hospital until death. At autopsy, the liver was found to have one- half the normal weight and to be the seat of marked parenchymatous degeneration. Tumors of the Liver.- — Tumors of the liver in infancy and child- hood may be benign or malignant. The benign are cavernous tumors or cystic degenerations of the liver. The malignant tumors are the carcinomata or adeno-carcinomata and more rarely sarcomata. Steffen collected 39 cases of primary malignant growths of the liver occurring mostly in the newborn. Stoos observed an adeno-carcinoma in a child five years of age. Parasites of the Liver. — These are exceedingly rare and are classified by Stoos as Distoma hepaticum, Ascarides, Echinococcus, Cystocerci, and Pantastomum denticulatum. Biliary Calculi. — Still has collected 8 cases ranging from 2 to 14 years of age. I have had two cases in older children. Lillienthal has operated in several cases, one a boy of five years of age. The symptoms are similar to those in the adult. Still's cases were mostly in the newborn, the main symptom being intense per- sistent icterus. On autojDsy multiple calculi were found in the biliary ducts. DISEASES OF THE PERITONEUM. Ascites. — Ascites is a serous effusion into the peritoneal sac, and, as in the adult subject, it is generally secondary either to some disease 568 DISEASES OF THE PEBITONEUM. of the peritonenm, siicli as tuberculosis, or chronic disease of the heart, liver, or kidneys. It may also be due to some obstruction of the portal circulation, caused by enlarged glands or tumors of the peritoneum. Ordinary ascites has the same characteristics in the infant and child as in the adult, and is recognized by the same phys- ical signs. It is therefore superfluous to go into details in this place as to the physical characteristics of the fluid accumulation in the peri- toneal cavity of infants or children. Some rare forms of ascites may be congenital. In diagnosing ascites in infants and children, v^e must be careful not to confound it with local accumulations of fluid due to cysts or tumors in the peri- toneal cavity. Cysts, or cystic tumors, have local circumscribed physical characteristics, and with care they cannot be mistaken for ascites. There is a form of ascites which occurs rarely in children, and of which I have seen one example in a boy six years of age. It is called chylous ascites, and is marked by its chronicity and the milky or fatty nature of the exudate. It is more frequent in adults ; but when present in infants or children, it is found between the ages of seven and ten years. In one case recorded by Wicklen, the accu- mulation followed an attack of pertussis in an infant six months of age. In a case recently reported by Kerr the ascites disappeared after abdominal tap. There was a history of syphilis. The etiology of chylous ascites is obscure, although in some cases tuberculosis of the peritoneum has been found postmortem. It has followed traumatism, eruptive fevers, or an infection with filaria. The symptoms are those of ascites, and it is not until the withdrawal of the fluid that the true nature of the affection is discovered. The fluid withdrawn has a milky, opalescent appearance, and is of two forms, in one of which there is a fine emulsion of fat-globules with red and white blood-cells ; the other form contains no such element, but is chylous in color. At autopsy various lesions have been found, as stated, including tuberculosis, syphilis of the liver, cirrhosis of the liver, an enlarged spleen, with lesions of the thoracic duct. In some cases there has been tuberculosis of the thoracic duct, or this combined with tuberculous disease of the lymph-nodes, with apparent obstruc- tion of the lymph-vessels. Treatment. — The treatment of ascites in children is carried out along the same lines as in the adult patient. Acute Peritonitis. — Acute peritonitis may be general or local, and is due to an infection of the peritoneum. Etiology. — According to Tavel, Lanz, and Treves, the disease is caused by various bacteria, such as streptococci, staphylococci, pneu- mococci, or coli bacteria, but the most active role, even in the traumatic and perforative forms, is played by the Bacterium coli communis. DISEASES OF THE PEEITONEUM. 569 Krogius examined 40 cases of perforative peritonitis following appen- dicitis, in 20 of which he found two or three species of bacteria ; in only 7 cases did he find Bacterium coli alone. The species found were generally coli bacteria in combination with diplococci, pneumo- cocci, Diplococcus intestinalis, streptococci, coli gracilis. The re- maining cases contained the Streptococcus pyogenes, pyocyaneus, and Proteus vulgaris. The coli, however, was the most frequent micro- organism found. It is to be remarked that in 21 cases the Diplo- coccus pneumoniae was found combined with the Bacterium coli. This form must not be confounded with the cases in which the pneu- mococcus is found as the causative agent of peritonitis, especially in children (JSTetter, Sevestre, and others). "We may have: (1) Acute tuberculous peritonitis, (2) Perfora- tive peritonitis, due to traumatism or some pathological perforation of the viscera or the serous coat of the intestine as a result of tuber- culosis, typhoid fever, dysentery, perforating ulcer of the stomach or duodenum, abscess of the liver, cyst of the liver, kidney, or spleen, rupture of the gall-bladder, strangulated hernia, intestinal intussus- ception, appendicitis, perforating lumbricoides — all these can be accompanied by the escape of gas, faecal matter, bile, or blood into the peritoneal cavity. (3) Peritonitis may take place by extension, as is observed in cases where inflammation extends from a viscus without perforations. (4) Peritonitis may occur as the result of traumatism, as a blow or fall or an operation. (5) Pneumococci may cause an acute primary peritonitis, or may give rise to the affec- tion by extension from the pleura or lung. (6) There is a gonor- rhoeal form of peritonitis. (7) Peritonitis may occur in the foetus or in the newborn. The latter has been described by Billard as fol- lowing intra-uterine infection, as a result of maternal disease; or in the newborn peritonitis may be caused by streptococcal infection of the umbilicus, and extension from this point to the peritoneum. Symptoms. — The symptoms of acute peritonitis at the onset may be insidious. Such forms occur in cachectic, marantic infants, or children; or the onset may be acute and sudden, as in the primary form. Pain may be localized either in the iliac fossa or around the umbil- icus, spreading thence over the whole abdomen. The child lies quietly on the back, with superficial respiratory movement. There is, as in the adult subject, meteorism or tympanites. There is vomiting, first of the contents of the stomach, then the vomitus becomes green or biliary. It may subside after two or three days. There may be a diarrhoea, but in most cases there is constipation as obstinate as in intestinal obstruction. The tongue is moist, then dry; the buccal mucous membrane may be covered with sprue ; the urine may be sup- 570 DISEASES OF THE PEEITONEUM. pressed, and, as in the adult, there may be facies. The pulse ranges from 120 to 150, small and thready. The fever varies in extent, depending very much on the acuity of the infection. In perforative peritonitis there will be a sharp rise of temperature. Physical Signs. — The physical signs are much the same as are found in the adult. There is tympanites, the abdomen is distended, there is a disappearance of the liver dulness. In localized peritonitis there is local pain ; in general peritonitis the pain is general. If the peritonitis becomes general, there is, as a rule, an accumulation of fluid in the peritoneal cavity, and this may be made out by dulness in the flanks. As a rule, an examination of the blood will reveal an increased number of leucocytes or so-called leucocytosis, especially in the perforative forms. This latter sign is not of much value unless a previous leucocyte-count has been made or the case has been under constant observation, such as in forms of perforation occurring in typhoid fever, for even in these cases the increase in the number of the leucocytes is only comparative. Thus the leucocyte-count in the course of typhoid fever may be 6000 to 8000 ; whereas after perfora- tion the leucocytes may not increase beyond 10,000 to 12,000. In other words, they may simply reach the normal limit. Course and Termination.- — Acute peritonitis, as in the adult, may remain localized or may spread and become general. In the latter case the prognosis is very grave. If local the exudate may become encysted, or, if general and left to itself, may result fatally, or the exudate in the peritoneal cavity may rupture in the vicinity of the umbilicus or through the vagina or rectum. Foudroyant cases last two or three days and result in death. This is especially so of the newborn. Complications. — Among the complications of acute peritonitis, either general or localized, are pleurisy, pericarditis, meningitis, pyaemia. Prognosis. — As stated, the general perforative forms present the gravest prognosis. Peritonitis of the newborn is fatal. Differential Diagnosis. — Peritonitis, acute, localized, or diffuse, must be differentiated from typhoid fever. In the latter disease there is sometimes a severe inflammation in the vicinity of the vermiform appendix, and in such cases we should be very careful that a perfora- tion has not escaped our notice. Colprostasis, or intestinal invagination, and gastro-enteric infec- tion may be mistaken for appendicitis, especially in young children, if the meteorism is great. Gonococcal Peritonitis.- — Gonococcal peritonitis results from an infection of the peritoneal cavity by the Gonococcus of Neisser. Comby records 7 cases of gonococcal peritonitis. Hunner and Harris DISEASES OF THE PEBITONEUM. 571 record 7 cases. I have seen 2 cases. The infection takes place by way of the nterus and Fallopian tubes in the majority of cases. Etiology. — The gonococcus is the etiological factor in these cases, and the majority of recorded cases in children have occurred in young infants and children suffering from vulvovaginitis of a gonorrhoeal nature. In my tvsi'o cases this was the etiological factor. The symp- toms are sudden pain, vomiting, fever ; or in other cases there results in the course of the vaginitis severe pelvic pain. In some cases the pain and fever are of short duration, and it must be surmised in these cases that the inflammation remains well localized to the pelvis. I have seen quite a numiber of these cases complicating vaginitis in young girls. ~ The French have given the name of peritonism to these cases, thereby wishing to indicate their benign nature. The symptoms are so slight that one can scarcely believe that inflammatory reaction is present. Baginsky has published a case of general peritonitis resulting from gonorrhoea of the tubes, with an abscess-formation in Douglas's pouch. The gonococcus of this form of peritonitis may be associated with other bacteria, such as the staphylococcus. There are several forms of gonorrhoeal peritonitis : the general acute form, ending in death; the benign pelvic form, with subumbilical pain, and a third form occurring as a pelvioperitonitis with adhesions and salpingitis. Diagnosis must be made from appendicitis, for which it may be mis- taken. Given a case of gonorrhoeal infection of the genitals in chil- dren, with sudden abdominal pain, fever, and general abdominal distention, the diagnosis presents no difficulties. Prognosis.- — The French writers insist that the prognosis of gon- orrhoeal peritonitis is benign. On the other hand, such a prognosis will depend very much on the severity of the infection. Inasmuch as I have personally seen three fatal cases found at autopsy to have been due to gonorrhoeal peritonitis complicating vulvovaginitis, I can- not regard the general form of gonorrhoeal peritonitis as anything but a grave infection particularly fatal to children. Treatment. — The treatment of gonorrhoeal peritonitis varies ac- cording to the extent of the infection. If the peritonitis is localized to the pelvis it is quite evident that the treatment should be mostly on the lines laid down for the adult subject. If the peritonitis becomes general there will be a difference of opinion as to whether surgical interference is necessary. It is not within the scope of this work to discuss this aspect of the subject; but in a resume of the subject by Hunner and Harris the surgical interference in gonorrhoeal perito- nitis is rather discouraged. In general peritonitis of gonorrhoeal nature rest in bed, hot turpentine-stupes alternating every hour with 572 DISEASES OF THE PEBITONEUM. warm stupes, mild catharsis, liquid diet, hydrotherapy, and general medical treatment are rather to be advocated. Pneumococcal Peritonitis. — Pneumococcal peritonitis, as has been stated, may be primary, and as such occurs most frequently from the second to the twelfth year of life. It may be secondary to pul- monary disease, such as pneumonia or pleurisy ; or may be primary, resulting from an infection of the peritoneum either through the blood or the genitals. The frequency of encapsulation of the pus around the umbilicus makes the genital way of infection very probable. Symptoms. — The course of the symptoms in this disease recalls that of a pneumonia, by its sudden onset in subjects previously in good health. There is a chill, followed by fever, pain, vomiting, and some diarrhoea. After a period of eight days there is a deferves- cence of the fever and abatement of the symptoms. The abdomen, which has been previously distended and generally painful, with all the physical signs found in other forms of peritonitis, remains large and distended, pus accumulates, the umbilicus becomes prominent, and in this way we have a picture resembling ascites or tuberculosis of the peritoneum. I have seen a case in which the latter diagnosis was made. Pus may break spontaneously at the umbilicus or per- forate through the vagina. The disease is more frequent in girls than in boys, and, as has been stated, the pus has a tendency to be- come encysted and discharge at the umbilicus. The pus is of a creamy, yellow color, without odor. Michant has collected 33 cases of pneumococcal peritonitis occur- ring in children: 27 of these were girls; 22 were encysted, 11 were generalized. In 27 cases the disease was primary. Diagnosis. — This form of peritonitis is naturally mistaken for peritonitis following appendicitis. It may be distinguished from the latter, however, by its benign course. The pus, if it becomes encysted, may distend the abdomen to an enormous extent. I have seen a case in which the distention of the abdomen was enormous, resulting in the obstruction of the portal circulation, with dilatation of the super- ficial abdominal veins. There was perforation at the umbilicus, and a discharge of several pints of pus, followed by recovery of the patient. Appendicitis is more acute in its nature and does not extend over such a long period of time, with the benign result, as seen in this form of peritonitis. Tuberculosis of the peritoneum can hardly be mistaken for this form of peritonitis. Given a distention of the abdomen by a fluid pointing at the umbilicus, which fluid is found to be pus, we may surmise that there is a pneumococcal peritonitis. A positive diag- nosis can only be made by bacterial examination of the pus. Prognosis. — The prognosis, as a rule, is good, for in most of the DISEASES OF TEE PEBITONEUM. 573 cases, the pus being encysted, the general peritoneal cavity remains free of infection. In the general form, however, the prognosis is more grave. Of 11 cases of this form 9 died of sepsis. Simple Chronic Peritonitis. — Although Henoch and Miiller have reported cases of chronic idiopathic non-tuberculous peritonitis, its occurrence is still a matter of dispute. ISTothnagel, linger, and Heubner, while not denying in toto its possible occurrence, insist on its extreme rarity. The absence in these cases of progressive emacia- tion is no proof of the non-tuberculous nature of the affection. The absence of the tubercle bacillus in the abdominal exudate is of slight diagnostic value. In 29 cases of undoubted tuberculosis of the peri- toneum Herzfeld found the bacillus only once in the ascitic fluid. In some forms of tuberculous peritonitis the nutrition may not only be good, but there may be no history of tuberculosis or scrofulosis. It is manifest that under these conditions it is impossible to describe a disease the existence of which is still in doubt. SECTION VIII. DISEASES OF THE RESPIRATORY SYSTEM. DISEASES OF THE NOSE AND NASOPHARYNX. Examination of the nose in infants and children should first include a general inspection of the organ. In this way anv con- genital deformity, particularly of the septum nasi, is noted. Some forms of congenital syphilis carry with them a malformation of the bony septum, by which the bridge of the nose is markedly depressed in very much the same manner as that of the adult. Deviations of the bony septum are sometimes indicated by an angular deflection of the organ to one or the other side. The interior of the nares may be inspected, as in the adult, by elevating the tip of the nose upward and backward, or by means of small-sized specula. One of the most useful methods with the author of discovering any obstruction in the nares, especially in the newborn and young infant, in whom instruments, such as specula, cannot be applied, is the passage of a small probe into the nares in a backward direction. This procedure is painless, and in the majority of cases will sufiice to discover any swelling of the mucous membrane or bony obstruc- tion, if such be present. The introduction of the index finger of one or the other hand into the nasopharyngeal space for the purpose of palpating the walls of this structure has been dilated upon elsewhere in discussing adenoids. In older children the inspection of the pos- terior nasal space by mirror, if this is possible, is much to be preferred to the digital examination. Acute Nasal Catarrh. — This is a common affection of infancy and early childhood. In the newborn it follows as a direct result of exposure combined with infection, either by the lochia of the mother or uncleanliness of the bath water. In older infants and children acute coryza occurs sporadically or in epidemic form. It is apt to be seen at certain seasons of the year — early spring or autumn — when children are subjected to sudden changes of temperature of the outer air and that of the living apartments. Infection by bacteria plays a leading role in this disease, as in other affections of the nasopharynx. Infants and children are apt to be infected by adults around them, especially careless nurses. One child may infect the other, or acute nasal catarrh may usher in the acute infectious diseases, such as measles, bronchitis, influenza, pneumonia, pertussis, and in some r,74 DISEASES OF TEE NOSE AND NASOPHABYNX. 575 cases cerebrospinal meningitis. One attack of nasal catarrh may lead to another, and thus, in the end, to chronic nasopharyngeal catarrh. Some infants and children have a tendency to contract coryza upon the least exposure to a cold or dust-laden atmosphere. Such infants and children are pale or rachitic or show some constitu- tional dyscrasia, such as lymphatism. Symptoms. — The symptoms of acute nasal catarrh, or coryza, con- sist in a slight discharge of a serous or seropurulent secretion from the nostrils. This discharge may be thin or mucoid in consistence, and may be small in quantity, occur in the early morning, but slight in amount during the day. There is, as a rule, but little or no febrile disturbance in mild cases. In the severer types there may be in- volvement of the lachrymal ducts, with slight or marked redness of the conjunctiva, orbital and palpebral. In the latter form there is lachrymation and photophobia, with or without slight febrile move- ment. In other cases the infants or young children are uneasy, do not take their usual day naps or their food, and have a slight cough. An inspection of the fauces may reveal but little inflammatory reac- tion, and the tonsils may be enlarged to a slight degree. As a rule, all these organs are drawn into the picture. In some cases conjuncti- vitis may be the first symptom, and the nasopharyngeal catarrh may follow. Restlessness in some cases and temporarily high temperature are explained by an inspection of the drumhead of the ears, which may be slightly or even markedly red without bulging of that struc- ture. In other words, a myringitis may give rise to a temperature of short duration. Course. — As a rule, the affection is self-limited, lasts two or three days, and then retrogrades ; in other cases the physician is annoyed at the persistence with which certain symptoms continue and refuse to recede with therapeutical measures. When the symptoms are apparently subsiding the temperature may suddenly rise to 104° T., and this in the face of the most trivial physical signs. In such cases an inspection of the ear-drum may reveal a slight or marked otitis. In the nursing infant the obstruction and swelling in the nose may cause difficulties in nursing, and the bowels may show slight evidences of infection, caused by the infant swallowing the discharges from the nasopharynx. Diagnosis. — This is not difficult, but in the face of any coryza of an acute type the patients should be examined as to the presence or absence of measles, bronchitis, pneumonia, or otitis, especially if a temperature of a high intermittent type is present after the second day of the disease. Prognosis. — The prognosis is good, but it is not invariably so, as to a rapid termination in an uncomplicated recovery. During the 576 DISEASES OF TEE BESPIBATOBY SYSTEM. early spring an acute coryza is not infrequently followed by an otitis, which may be catarrhal, purulent, or even eventually involve the mastoid. We should therefore not regard lightly any coryza in an infant if the symptoms persist beyond the third day, and other organs, such as the ears or bronchi, become involved. Treatment. — The mild forms of acute nasal catarrh in infancy and childhood are self-limited as to duration, and simple cleanliness with nursing will in most cases suffice in the treatment of the disease. In infants the nose should be carefully cleansed with a spud of cotton after the morning bath, and then a drop of castor oil allowed to flow back into the nares. If this one application does not suffice to keep the nares clear of secretion, and nursing is difficult on account of the accumulation of secretion in the nares, this procedure must be re- peated during the day. Mild cases need no medicinal treatment. If the throat is drawn into the picture, a small dose of 2 or 3 minims of the tincture of the chloride if iron combined with glycerin may be given every three hours. If there is much conjunctivitis a satu- rated solution of boric acid flushed in the eye two or three times daily is, as a rule, efficient; and in the subacute stages of the conjunctivitis a drop of a solution of sulphate of zinc, 2 grains to the ounce, may be instilled into the eye once or twice daily. The application of a copper pencil to the conjunctivae once in the subacute state is advised by some, though the author thinks that such procedure should be carried out by the oculist. The reaction which follows the application of copper subsides soon, to leave the con- junctivae in a less angry condition. If an inspection of the ear-drum shows a redness without bulging of the drumhead, we may temporize, and if there is reason to believe that pain is present, a drop of warm hyoscyamus oil instilled into the ear once or twice daily will give relief. Marked otitis requires more elaborate treatment, which should be carried out by the otitic specialist. Sprays and douches are not applicable to infants and young chil- dren, on account of the resistance made by these patients to any therapy of this kind. Only older children can be taught to gargle or spray. Where this is possible a mild solution of listerine or Dobell's solution is all that is called for. I have never found it necessary to use stronger drugs in children. If temperature is not present, the open air is certainly not contraindicated ; on the con- trary, it may cut short a rebellious catarrh. Chronic Nasal Catarrh.. — This is a condition found in infants and children, as a result of repeated attacks of acute nasal catarrh, in a constitution undermined by a pre-existent dyscrasia, such as lymphatism. In most infants and children this tendency to chronic catarrh is hereditary. There are evidences in these little ones of DISEASES OF THE NOSE AND NASOPHABYNX. 577 similar conditions elsewhere. Such infants and children may suffer from forms of conjunctivitis. Keratitis, dermal eczema, or erup- tions of various kinds, anaemia, adenoids, nasal polypi, deviated nasal septum — may be combined v^ith hypertrophy of the nasal mucous membrane. A chronic nasal discharge is present, and with it erosion of the nostrils and a distinct odor to the breath (ozsena). The tonsils in this stage are enlarged. Foreign bodies may set up a chronic inflammatory condition of the nares in children suffering from chronic catarrh; this fact must never be lost sight of. Sjnnptoms. — Symptoms of chronic nasal catarrh are combined with certain chronic hypertrophic conditions of the throat and naso- pharynx. Thus, very young infants, unless they are subjects of syphilis or adenoids, are not chronic sufferers from nasal catarrh. There is then a constant discharge from the nose and the nasopharynx. In older children, from five to eight years of age, the hypertrophy of the nasal mucous membrane and the nasopharynx results in a profuse mucopurulent secretion in the pharynx and nose. These children have a constant cough, and are subject to repeated attacks of so-called cold, the tonsils being enlarged, the lymph-nodes at the angle of the jaw are also enlarged, as also the nodes of the neck behind the sternomastoid muscle, and elsewhere in the body. The alse nasi are thickened and reveal erosions. The lips are also thickened as the result of obstructed circulation. Breathing is mostly oral. An inspection of the fauces shows the posterior pharyngeal walls coated with mucopus and studded with hypertrophied struc- tures made up of lymjjhoid tissue called follicles. In older children these symptoms may be combined with symptoms of atrophic rhinitis, in which the mucous membrane of the nose loses its hypertrophic appearance and becomes thin, atrophic, and coated with dry greenish crusts. Instead of obstruction there is found a wide nasal passage, and there is distinct odor to the breath and nasal discharges. There are forms of chronic nasal catarrh in which the above symptoms are present to a very mild degree. Thus, with the nasal catarrh there are enlarged tonsils and a few adenoids, and only an occasional odor to the breath. This condition is found in children who have been treated with indifferent success. The very marked cases of nasal catarrh in lymphatic subjects may be combined with a conjunctivitis of a chronic type or granular lids and eruptions, such as ecthyma and pustular eczema of the chronic type, all of which indicate the presence of a dyscrasia. Treatment. — The treatment of the above conditions are first local ; the tonsils and growths in the nasopharynx must either be removed or treated locally. The minutiae of such treatment belongs to the realm of nasal specialism. The local treatment must, however, be 37 578 DISEASES OF THE EESPIEATOBT SYSTEM. combined witli general constitutional livgiene and treatment. The remedies best suited to the conditions above are discussed under the heading of Scrofulosis and Ljmphatisni. Diphtheritic Rhinitis. — An apparent simple rhinitis of a catarrhal character may in a short time take on the characteristics of a diph- theritic process, due to an infection with the Klebs-Loffler bacillus. There is a profuse seropurulent or serosang-uinolent discharge from the nose, with shreds of pseudomembrane, erosions of the nares, and extension of the membrane backward to the nasopharynx and down- ward to the larynx. This true diphtheria is accompanied by the glandular swellings and constitutional symptoms characteristic of the disease elsewhere. On the other hand, there is a form of rhinitis called pseudomembranous rhinitis, in which the disease remains fairly limited to the nose. There are two forms of pseudomembranous rhinitis, the truly diphtheritic form, in which the Klebs-Loffler bacillus is an etiological factor, and the streptococcal form, both of which have a similar symptomatology. The form of disease to which we refer is mild in its course, and begins like a catarrhal rhinitis, but on the third day a white coating is formed over most of the inflamed area ; that is, on the turbinated bodies and the septum of the nose. This coating, which is pseudomembrane, cannot be either washed off or Aviped away with absorbent cotton, but may be peeled off with the forceps. As soon as the membrane is removed, however, it reforms ; it is dead white and opaque, and firmly attached to the parts beneath, and, when detached, considerable violence must be used, and a bleeding surface is left. Treatment. — In some cases easts of pseudomembrane may be re- moved from the nostrils. Chapin, Bresgan, Schuler, Hartmann, and Muldenhauer have all described these cases. This membranous condition lasts in some cases from twelve to fourteen days, and though, as has been intimated, some of them must be looked upon as true diphtheria, the prognosis is generally good. In the streptococcal cases the prognosis also is good. We must never forget, however, that though there is in a certain ])roportion of cases of membranous rhinitis very few constitutional symptoms, and very little tendency of the disease to spread dowmward from the nasopharynx to the larynx, these cases should always be examined for the presence of the Klebs-Loffler bacillus, and if found sh<;)uld bo treated as a diph- theritic process. Foreign Bodies in the Nose. — Children are prone to put beans, buttons, pins, and foreign bodies of all kinds into their noses. These foreign bodies at first cause little disturbance ; after awhile, however, they become a source of pain and irritation, and, if not discovered, DISEASES OF THE NOSE AND NASOPHABYNX. 579 chronic nasal catarrh, ulceration, and even abscess may result. The removal of foreign bodies from the nose in many cases requires noth- ing more than ordinary skill. Some children can be taught to blov9" the foreign body out of the nostril by occluding the unobstructed nostril with the fingers. In other cases the foreign body can be re- moved with the forceps. In the third set of cases, a scoop introduced into the nostril so as to hook the body posteriorly is an efficient means to remove it ; in other words, a bent probe or buttonhook. Epistaxis.- — Epistaxis is rare in the newborn, except as a mani- festation of syphilis or sepsis. In infants and children it may be caused by traumatism of any kind, and is seen mostly in school chil- dren who have been confined in warm rooms and have developed nasal catarrh with or without adenoid vegetations. There may be in these cases small ulcers or erosions of the septum nasi. Epistaxis occurs in the course of acute or chronic rhinitis, typhoid fever, pneu- monia, infectious diseases, diseases of the heart, chlorosis, haemophilia, scurvy, morbus maculosus, and finally, it occurs in young girls enter- ing on the period of menstrual activity. It may occur in these sub- jects also as a vicarious form of menstruation. Epistaxis, as a rule, is unaccompanied by any symptoms other than those of the bleeding, in drops, from the nose. In very few cases does this hemorrhage become alarming unless there is a history of hsemophilia. The quantity of blood lost is often exaggerated by the patients, and rarely exceeds an ounce. K^asal hemorrhage may occur daily, or it may recur every few days or weeks, in which case there is always a suspicion either of traumatism, such as picking the nose, or a chronic nasal catarrh. Some children complain of dizzi- ness or vertigo preceding the attack. Others become greatly alarmed by the sight of blood. Children below the age of three or four years rarely have epis- taxis except as a result of traumatism or nasal ulceration. In some cases hemorrhage is really alarming, amounting to a rhinorrhagia. In these cases there is a suspicion of dyscrasia ; in many cases blood may during sleep flow down the posterior nares into the oesophagus and stomach, and after a time the clotted blood may be vomited or passed in the movements, thus simulating hemorrhage from the stomach or bowels, and in young infants melsena. Adenoid Growths {Adenoid Vegetations). — Adenoid growths are masses of hypertrophied lymphoid tissue found in the vault of the nasopharynx. In 1868 Meyer of Copenhagen first drew attention to adenoid growths as a clinical entity. Since then the increased importance of a recognition and study of these growths has become quite evident. Occurrence. — They occur in persons of all climes and countries but 580 DISEASES OF THE BESPIRAIOEY SYSTEM. Fig. 116. are less prevalent in warm climates and in high and dry mountainous districts than in cold and damp countries. The adenoid growths occur at all ages from the newborn infant to old age. The greatest frequency according to all statistics is from the sixth to the tenth year of life. Of 4000 cases Wingrave found 1144 to occur at this period of childhood. Situation. — Adenoid growths are found on the posterior, superior and lateral walls of the nasopharynx. They are met most frequently in the so-called fornix of this space. They may he grouped around the openings of the Eustachian tubes. They have a crostate, cylin- drical or flat form. They thus are nothing more or less than the hypertrophied pharyngeal or Luschka's tonsil (Fig. 116). Etiology. — The true cause of adenoid growths is still a matter of speculation. They are found both in breast-fed and artificially fed children, but undoubtedly ac- company a so-called lymphatism prevalent in some families as well as children. There is also a heredi- tary element in the etiology of many cases. An infection of some kind is the starting point. This results in a chronic catarrh of the nasopharynx w^hich favors hyper- trophy' of adenoid tissue. If the nasal and pharyngeal passages are congenitally narrow and conditions are not favorable to the clear- ing out of contained secretions, then the elements arise which favor hypertrophy in keeping alive inflammatory conditions in those parts. An investigation into their nature by Macfayden and Macconkey has revealed the occasional presence of tubercle bacilli, but not to any greater extent than would be called accidental, in the face of tubercle bacilli in neighboring organs, such as the lungs or larynx. The acute infectious diseases, such as measles, scarlet fever, diph- theria, or any disease in which there is accompanying catarrh and inflammation of the tonsils and structure of the nasopharynx, are followed by a subacute catarrhal condition of these parts which ulti- mately results in the formation of adenoid growths and enlarged tonsils. Symptoms. ^ — The symptoms may be grouped under four heads: rhinitis or nasal discharge, snoring, mouth-breathing, and vocal defects. Rhinitis. — A nasal discharge is a constant symptom of adenoids. Adenoid growth with centimetre scale. Shows lobulated structure. DISEASES OF THE NOSE AND NASOPHARYNX. 581 Even to a mild degree it may be looked upon as presumptive evidence of their presence. With the nasal catarrh and discharge there are also attacks of epistaxis and earache which will be taken up later. Mouth-hreathing. — Mouth-breathing, both by day and night, is almost a pathognomonic symptom. The peculiar condition of the mouth leads to a sort of adenoid facies, which is quite characteristic and easily recognized. With the facies, the open mouth, the thick lips, the sunken alse nasi, and in some cases eroded nostrils, the pic- ture of the adenoid sufferer is complete (Fig. 117). Fig. 117. Children with adenoid growths, marked and moderate in degree. Snoring. — Snoring, which occurs at night and in young infants, is a rattling noise in the throat which is due to ineffectual attempts at breathing. Speech. — The speech is affected and thick, the niceties of pronun- ciation in forming the letters m, s, ng, etc., are lost in an altered substitute which is more easily formed by the obstructed nasal and pharyngeal spaces. With the obstruction of the nasal passages comes an uneasy sleep and restlessness at night, with accompanying night- terrors. Lymphcitism. — Many or most of these cases are anaemic, the anaemia being in part an expression of the general constitutional con- dition of lymphatism. Deafness. — Deafness is a final result of the ill effects of adenoids allowed to continue without treatment. Of deaf mutes fully 17 to 70 per cent, have adenoids. Children suffering from adenoids hear very imperfectly at times and at others quite well. This is traceable to the condition of 582 DISEASES OF THE BESPIBATOB¥ SYSTEM. catarrh in the nasopharynx as affecting the Eustachian tubes. Otitis is a frequent accompaniment of adenoids and recurrent otitis with persistent nasal discharge is not uncommon. Bronchitis. — In some cases the chronic catarrhal conditions in the nasopharynx cause a constant hacking cough and in many cases the catarrh passes down the respiratory passages, giving rise to bron- chitis or bronchitis of a chronic type, with emphysema and asthmatic attacks. Classes of Cases. — Clinically there are three distinct classes of cases that suffer from adenoids : The first class comprises those in which the adenoids cause few or no symptoms. The children when in good health breathe through the nose and keep the mouth closed during sleep. They are pecu- liarly susceptible to slight colds or catarrh, and when thus affected Fig. 118. Enlarged tonsils enucleated entire in case with concomitant adenoid growths. the tonsils enlarge, the nose becomes obstructed by secretion, there is difficulty in breathing, and the patient sleeps with open mouth. On the subsidence of the inflammatory condition the normal status is re-established. The children are subject to recurrent attacks of ton- sillitis, and with each recurrence the symptoms of adenoids become more marked. The patients contract obstinate coughs which resist all treatment, and epistaxis occurs from causes apparently trivial. The second class of cases comprises those in which, in addition to enlarged tonsils, there are enlarged lymph-nodes in various regions of the body. The patients are pale and present all the symptoms of lymphatism. Their voices have a nasal intonation, the lips are always parted, and they sleep with the mouth open (mouth-breathers). The third class comprises the extreme cases of adenoids. The nasal passages are the seat of a chronic hypertrophic rhinitis, the tonsils are enlarged, there is obstructed breathing, and the mouth is always open. The infants and children make a peculiar snarling sound in breathing and have a stupid look. They are not neces- sarily lymphatic. Many children suffering from adenoids are slightly deaf, and all are subject to repeated catarrhal attacks (Fig. 118). DISEASES OF THE NOSE AND NASOPHARYNX. 583 Between the extremes are seen all gradations of the affection. Many children who suffer from adenoids are well developed and in other respects perfectly normal. The deformities of the chest which have been ascribed to adenoids can hardly be so regarded. They are coincidental. Many of them are due to rachitis in early life and to unhygienic living. To trace enuresis, chorea, and masturbation to the presence of adenoids, seems also somewhat extreme. Adenoids Fig. 119. Examination for adenoid growtlis. Position of patient and examiner. are an obstruction to the breathing, a menace to the hearing, and also a focus for repeated infections of the nasopharynx or the ears. These are sufficient reasons for their removal. Diagnosis. — The diagnosis is not difficult from the above set of symp- toms. jSTasal polypi in older children, if they exist, may be seen in the nasal passages. A fibroid tumor of the nasopharynx is hard and a malignant growth is scarcely probable as it is rare in infancy and childhood and gives a series of quite distinctive symptoms. There are enlarged tonsils ; they are probably accompanied by adenoids. If 584 DISEASES OF TEE BESPIBATOBY SYSTEM. on inspection of the posterior nasopharyngeal wall there is an en- largement of the follicular adenoid structure of the mucous mem- brane it may well be surmised that adenoids exist higher up. Method of Examination. — An inspection of the nasopharynx may be made by the rhinoscopic mirror or the nasopharyngoscope, recently devised by Hays, or by digital exploration. Rhinoscopy is only feasible in older tractable children, as is also the nasopharyngoscopy. Accordingly, in infants and children the digital exploration alone is feasible. The finger-nail of the index finger of the right hand is scrupulously cleaned and trimmed so as not to traumatize the parts and infect them. The physician " stands behind the patient, who is seated in a chair. The child is told to open the mouth and the thumb of the left hand presses the left cheek between the teeth. The index-finger of the right hand is carried round the soft palate into the nasopharynx where the finger will come in contact (if adenoids be present) with a variable soft mass which bleeds readily. With practice this examination can be conducted so expeditiously that the child has not got time to struggle or get frightened" (G. A. G. Simpson) (Fig. 119). Indications for Operation. — ISTursing infants who cannot nurse or in whom sleep is palpably disturbed should be operated upon without delay, as in these patients the operation is simple and is followed by immediate relief. The indications for removal of the growths, even if only small amounts of adenoid tissue are present, are in older chil- dren a persistent rhinitis or repeated attacks of acute rhinitis, inter- mittent attacks of deafness with pale retracted ear-drums, or exuda- tive catarrh of the middle ear, chronic aural discharge which will not improve, mouth-breathing, snoring at night, and backwardness in phonation ; in young children a persistent dry cough or bronchitis or an irritable cough. Of great importance is the recognition of the fact that some obstinate ear-discharges will not yield to treatment until existing adenoids be removed. Prognosis. — The operation for the removal of adenoids is exceed- ingly simple and unaccompanied by danger to life. It should be borne in mind that any operation of this nature may be followed by infections, especially of the ears. In this respect no operator is exempt from the chagrin of finding occasionally a complicating otitis follow the operation. Adenoids are apt to "return" or grow after being removed ; a secondary operation then becomes necessary. Treatment. — When the diagnosis of adenoids has once been made, it is well not to temporize with douches and sprays, as this mode of treatment acts only in a cleansing manner and merely delays the ultimate necessity of removing the growths. This removal is so much in the domain of specialistic procedures that it is well for the DISEASES OF TEE NOSE AND NASOPHABYNX. 585 practitioner not to rely entirely on descriptive methods but to see, if he can, the operation performed once or twice by an expert before resorting to a personal attempt. Contraindications to iterations. — The tonsils and adenoids being portals of infection, there are certain states in which operations in this region may be followed by reinfection. Thus cases of chorea with endocarditis, if still active, should not be subjected to operation. The chorea is likely to recur with gTeater severity, and the danger of a renewed heart lesion is great. Children who are in the active stages of endocarditis or recently recovered should not be operated upon. In all these cases palliative measures, such as sprays and douches, should be employed until the conditions above mentioned are thoroughly quiescent. In one case of chorea I saw an operation for adenoids followed in three days by a chill and high fever, endo- pericarditis, chorea insaniens, and death within ten days. While such cases are exceptional, they teach the necessity of caution in deciding to operate upon the adenoids in chorea and heart cases. Acute Retropharyngeal Abscess {Idiopathic Retropharyngeal Abscess; Retropharyngeal Lymphadenitis). — The retropharyngeal space, according to Gillette, is the seat of lymph-nodes, which are intimately connected with the lymph-vessels and lymph-spaces of the tonsils, and also with the system of lymph-vessels of the soft palate, these being also connected with the deep lymph-nodes of the face and neck. Processes such as catarrhal angina, diphtheria, scar- let fever, measles, or any lesion of the mouth, are likely to involve the retropharyngeal nodes (Karewski). Sometimes only the lymph- nodes in the median line of the retropharynx opposite the base of the tongue are affected. In this form the tumor in the midline is seen when the mouth is opened. In other cases several lymph-nodes are involved, and the process is then seen both as a swelling in the mouth and as an external swelling at the side of the neck. The swelling appears at or beneath the angle of the jaw, in front of or behind the sternomastoid muscles. Retropharyngeal abscess may occur in the foUovdng forms : 1. Acute retropharyngeal abscess : a. That which points wholly in the mouth. h. That which points both externally and internally. c. That which forms a tumor chiefly external. 2. Chronic tuberculous retropharyngeal abscess. 3. Septic retropharyngeal abscess. This third class of retropharyngeal abscesses are those which complicate or follow the exanthemata, and which have a tendency to burrow downward, bursting into the mediastinum or to involve important structures, such as the large arteries in the neck, thus causing fatal hemorrhage. A few such cases occur in the literature. 586 DISEASES OF THE EESPIEATOEY SYSTEM. Frequency and Etiology. — Retropharyngeal abscess is peculiarly a disease of infancy and early childhood. The frequency diminishes in later childhood, the disease being rare after the fifth year. Of 77 of my cases. 4 occurred between the first to the third month; 10 between the third and the sixth month ; 41 between the sixth and the tweKth month: 19 between the first and the fifth year, and the remainder after the fifth year. One infant was only one month of age, and in two cases the patient was two months of age. The figures correspond to those of Bokai. The frequency in early infancy is probably exj^lained by the structure of the retropharyngeal lymph- spaces and the susceptibility of the lymph-nodes to suppurative infec- tions at that period of life. Simon has described the lymphatics in the retropharyngeal region of infants and children as forming a small network of lymph-vessels and nodes on either side of the median line. This lymphatic net- work is situated between the superior constrictor and the aponeurosis of the prevertebral muscles. After the third year of life these lymphatics and nodes are said to disappear. This fact, as Blackader points out, would indicate a close connection between the time of activity of these nodes and the period when retropharyngeal abscess is most prevalent. It would help also to explain the absence of this form of abscess in older children and in adults who are frequently affected by tonsillar (quinsy) abscess. I have examined the pus from many of these abscesses, and found that it contains quite uniformly a streptococcus of the short or the long variety, not as a rule very virulent. It may be assumed that in all probability these bacteria are the essential cause of the abscesse-s. They gain access to the retropharynx either through the tonsils or the mucous membrane of the pharyngeal space. The abscess may thus be secondary to any form of inflammation of these structures. It occurs as a complication of simple tonsillitis, pharyngitis, influenza, or any of the exanthemata. Symptoms. — The symptoms of retropharyngeal abscess are not at first distinctive. The development of the abscess is insidious. At the outset there are the symptoms of ordinary tonsillitis or pharyn- gitis. The fever is high at the beginning. After the acute symptoms subside it is noticed that the lymph-nodes at the angle of the jaw con- tinue to be enlarged, and that the fever continues to show a remittent type. There is some prostration, the infant does not nurse prop- erly, cries, and is frequently restless. Inspection of the throat on the fourth or fifth day of a tonsillitis may reveal nothing except some swelling or oedema of the posterior pharyngeal wall or of the pillars of the fauces, no tumor being visible. After an interval of a few days, generally on the seventh or eighth after the initial symptoms. DISEASES OF TEE NOSE AND NASOPHABYNX. 587 it is noticed that the voice of the infant has a nasal quality, that the head is thrown back, and that the breathing is noisy and nasal. Examination shows that the lymph-nodes at the angle of the jaw in front or behind the sterno-mastoid are swollen ; inspection of the interior of the fauces shows a distinct swelling at the side of the pharynx pushing the tonsil and pillar of the fauces of that side forward. On introducing the finger a tense, fluctuating swelling, which may reach downward toward the larynx, can be felt. In other cases there is very little external swelling, and the internal tumor is situated nearer the median line, pushing the posterior pharyngeal wall forward. This swelling is covered by mucous membrane, is tense and fluctuating. If the tumor is allowed to increase in size, there is pronounced interference with the breathing. I have seen cases in rachitic infants in which the inspiratory sound was distinctly of a crowing character, showing incoordinate action of the vocal cords. These cases show great prostration and feebleness of pulse. Course. — If not treated, the abscess may press on the larynx and cause asphyxia, or may burst spontaneously into the larynx, suffo- cating the patient if it occurs during sleep, or may burst into the ear through the Eustachian tube and discharge externally. All of these results are rare if the abscess is detected in time for incision. Diagnosis. — The diagnosis of retropharyngeal abscess is difiicult to the beginner, but is simple after the observation of one or two cases. The quality of the voice and the cry are so characteristic that after being once heard they are unmistakable. The breathing also is typical. The external swelling is present in most cases, and the head slightly retracted. Finally, digital examination should always be resorted to in all cases in which a slight or marked internal swelling is present. The index finger of the right hand is passed into the mouth and the posterior pharyngeal wall palpated. If an abscess be present, it will be apparent as a hard or tense, globular, deep or super- ficially fluctuating tumor. Care should be taken not to mistake the prominence of the body of the seventh cervical vertebra for an abscess. The bony tumor is deeper, as a rule, than the retropharyn- geal abscess, and is not fluctuating. All manipulation should be carried out gently, else the abscess may burst and suffocate the patient or rude exploration may cause a peculiar form of collapse which some- times follows digital examination in this region. Prognosis.- — The prognosis of simple acute retropharyngeal abscess is good. Bokai lost only 4 per cent, of his cases. With early diag- nosis and proper treatment recovery is the rule. Treatment. — The treatment of acute retropharyngeal abscess is incision. This varies with the nature and location of the abscess. In the majority of cases the abscess is near the median line, and its 588 DISEASES OF THE EESPIEATOET SYSTEM. wall is just beneath tlie surface of the mucous membrane. An in- ternal incision will then afford immediate and permanent relief. In other cases the abscess is at one side and internal, and may also be safely incised from within. In making an internal incision the fol- lowing method should be pursued : the child is wrapped in a blanket and held upright in the lap of the nurse, facing a good light. An assistant steadies the head from behind. The tongue is depressed with a tongue-depressor, and a bistoury, with the edge guarded by rubber plaster, leaving only a half inch of the tip exposed, is plunged into the most prominent part of the tumor. When the pus escapes, the incision is enlarged from above downward. The instrument should not be directed toward the side of the neck, for fear of wound- ing a vessel. As soon as the pus escapes freely the head of the infant is thrown forward and the pus allowed to drain into a basin, pressure being made from without, on the side of the neck. The internal incision should be made as rapidly and as gently as possible. I have seen death result within a few hours from aspiration of pus in a case in which an abscess burst as a consequence of rough digital exploration. If necessary, the incision may be enlarged with a dressing-forceps. In some cases the wound should be prevented from closing by intro- ducing the forceps daily. There is another class of cases in which the deep cervical glands at the side of the neck are involved and the abscess points partly internally and partly externally. In these cases it is unsafe to incise from within, nor is complete relief afforded by so doing. The abscess should be approached from without through a careful dissec- tion by a surgeon. The tuberculous abscess is due to spinal caries. and is best opened and drained from without, as are also septic abscesses. DISEASES OF THE TONSILS. The tonsils are really lymph-nodes, as has been shown by Stohr and Hodenpyle. In severe forms of inflammation they are enlarged. and the so-called crypts become plugged with bacteria and the products of inflammation (leucocytes, fibrin, serum). The crypts appear at the surface of the tonsil as yellowish specks. A catarrhally inflamed tonsil may not show them at the surface, because the products of inflammation do not coagulate, and are thus thrown off more readily. There is nothing specific about a lacunar or follicular amygdalitis. It is only a clinical picture of the large class of catarrhal inflamma- tions, in all of which the crypts and the tissue of the tonsil are infil- trated with inflammatory products. DISEASES OF THE TONSILS. 589 Acute Follicular Amygdalitis (Acute Catarrhal Tonsillitis; Acute Lacunar Amygdalitis; Catar-rhal Angina). — Acute follicular amyg- dalitis is an infectious disease, communicable either through the secretions or by direct contact, as in the act of kissing. It occurs both as a primary and as a secondary affection. As a primary affec- tion, it occurs at all periods of infancy and childhood. It was formerly taught that follicular amygdalitis was rare in infants. This is scarcely true. Of 1284- cases of lacunar amygdalitis, 333 occurred in infants under the age of twelve months, and 76 from the first to the fifth month; of the latter, only 5 occurred in the first month. It is frequent in children from the second to the fourth year, but is more common after than before the fourth year. The tonsils are secondarily involved in the exanthemata — scarlet fever, measles, and varicella — and in parotitis, influenza, pneumonia, and pertussis. In all these affections they are red, swollen, and in some cases present the appearance seen in the typical lacunar type of the disease. Etiology. — The predisposing causes of catarrhal tonsillitis or lacunar amygdalitis are exposure to cold, traumatism, and the swal- lowing of corrosive or irritant substances. The exciting causes of follicular or lacunar amygdalitis and catarrhal amygdalitis are the Streptococcus pyogenes, the Staphylococcus pyogenes, and the pneu- mococcus. The diplococcus described by E,oux is also found in the tonsillar crypts. Symptoms.— The affection rarely begins with a chill. The infant is restless, peevish, and wakeful at night ; it breathes rapidly, and there are high fever and marked prostration. ISFursing is interfered with, not only on account of the pain in swallowing, but because in the majority of cases there is more or less rhinitis. The bowels are disturbed as a result of swallowing infectious secretions from the mouth with the food. The action of the bacteria is manifested in green stools, which are frequent and watery. Inspection of the throat should be conducted with patience and in a good light. The tonsils, normally very small, are seen to be enlarged and studded with whitish or yellowish-white points. The lymph-nodes at the angle of the jaw may be enlarged. In older infants and children the tonsils are enlarged, and the crypts plugged with inflammatory products. The surface of the tonsils is covered with mucopurulent exudate, or there may be a small necrotic, ulcerated area in one of the tonsils. The neighboring struc- tures, such as the uvula, the pharyngeal mucous membrane, the pillars of the fauces, and even the larynx, may share in the catarrhal inflammation. The lymph-nodes at the angle of the jaw may be enlarged. The fever, as a rule, is high at first, ranging from 104° 590 DISEASES OF THE BESPIBATOBY SYSTEM. to 105° F. (40° to 40.5° C.) or above. The pulse is correspondingly rapid, and the respirations may be increased in frequency. The duration of a typical case of primary tonsillitis varies. As a rule, the temperature remains high for tv\^o or three days,' with daily remissions. It then subsides and the patient convalesces. In some cases the temperature continues high for five or ten days, and then drops. In all of these cases there is some latent or apparent complication, such as retropharyngeal abscess, otitis, or, as has been recently pointed out by Packard and others, an insidious endocarditis. When otitis supervenes the tonsillar affection subsides. The fever, however, continues, with daily remissions. Infants and young children do not indicate the existence of pain in the ear. The patient is restless at night, and wakes with a start or in a peevish mood. In many cases the otitis can be diagnosed only by exclusion. In other cases the temperature continues high for a week or longer, reaching 103.5° F. (39.7° C.) during the day. The infant seems weaker, the tonsils are not enlarged or severely inflamed, the pulse is accelerated, and the respirations may number 40. In such cases the lungs show no sign of involvement, but careful examination of the heart will often reveal the presence of a systolic murmur at the apex and a slight increase of the area of cardiac dulness beyond the nipple. These are the so-called rheumatic cases. Frequently the urine shows a trace of albumin. In rare cases it contains in addition to the albu- min elements pointing to parenchymatous irritation of the kidney. I saw a case in a child six years of age, in whom, after a mild attack of tonsillitis, there were a few casts, blood-cells, and a small amount of albumin in the urine. Months elapsed before the urine ceased to show evidences of the nephritis. In these cases the albu- minuria may assume the so-called cyclic character. Prognosis. — The prognosis of simple catarrhal tonsillitis is good, recovery taking place in a few days. On the other hand, tonsillitis is not the simple entity formerly supposed. In infants and children this is especially true. The physician should be watchful for possi- ble complications and sequelse, such as otitis, retropharyngeal abscess, endocarditis, and nephritis. Diagnosis. — The diagnosis of tonsillitis is usually a simple matter. If an infant refuses the breast and the temperature is elevated, the throat should be carefully inspected. It is good practice to make a bacteriological culture with the secretionsfrom the throat, even though th(! appearances arc not diphtheritic at the first visit (for technique, see section on Diphtheria). Treatment. — The treatment of acute tonsillitis is symptomatic. Sponging with cold water or water at 85° F. (29.4° C.) containing DISEASES OF TEE TONSILS. 591 a dash of alcohol, will lower the temperature. A dose of quinine should be given twice daily, and if the lymph-nodes at the angle of the jaw are enlarged, cold applications should be made externally. Sprays are not required unless Ihere is a harassing cough. Dobell's solution sprayed three times daily will relieve that symptom. In nursing infants the number of feedings by the breast or bottle is reduced. If there is disturbance of the bowel, a teaspoonful of castor oil or grain -J (0.03) of calomel, given twice daily, will empty the bowel. The infant is then dieted on albumin-water or barley-water, or a solu- tion of acorn cocoa or beef-juice and barley-water, until the intestinal irritation has disappeared. A return to a milk diet may be made as soon as the movements become normal. Small doses of ferric chloride have a beneficial effect on older children. In mixture form it is an excellent local application to the tonsils. The custom of giving potassium chlorate in this mixture is now generally abandoned, the drug being highly irritant to the kidneys. In nursing infants ferric chloride causes diarrhcea. For this reason it should not be admin- istered to them for long periods. Herpes of the Tonsils. — Herpes of the tonsils are small vesicular formations seen on the anterior pillars of the fauces, just in front of the tonsils. They occur in a number of slight febrile conditions, may accompany an angina of a simple type, and are part of the clin- ical picture of aphthous stomatitis. The vesicles burst, leaving yel- lowish ulcerations of the size of a pin's head and surrounded by a pink areola. They heal without treatment after a few days. Ulceromembranous Tonsillitis or Angina (Associated ivith the so-called Fusiform Bacillus of Vincent). — This is a peculiar affec- tion occurring in children. At first one tonsil is affected, generally the right. After a few days the affection may spread to the other tonsil. Most of the cases I have seen were unilateral. In addition to the tonsillar ulcerations, a stomatitis of an ulcerative type is often present, and there may be ulcers on the tongue, cheeks and gums. The size of the tonsillar ulcer varies from that of a lentil to an involvement of a greater part of the tonsil, the shape of the ulcer- ation being irregular, and its character rather of a chancroidal type. It has a worm-eaten base with sharp, overhanging edges, which may be slightly raised above the surface of the tonsil. The rest of the tonsil is but very slightly inflamed. The color of the ulceration is a yellowish-green gray, or dirty brown, and from the first it appears as though the base of the ulcer were covered by membrane. The depth of the ulcer is quite, considerable, varying from -| to |- inch. The submaxillary glands may be enlarged, or the lymph-nodes com- 592 DISEASES OF THE BESPIBATOBY SYSTEM. municating with tlie tonsil at the angle of the jaw may also be enlarged. Etiology, — The etiology of ulceromembranous tonsillitis or angina has been carefully worked out by Friihwald, Vincent, Lemoine, Abel, and in our own country by Sobel, Herrman, and others. This form of tonsillitis is caused by a bacillus, described more particularly by Vincent, and a spirillum. The bacillus is fusiform, about twice as long as the dij)htheria bacillus, is pointed at both ends. Some of the bacilli are bent into crescent shapes. They vary in size, some being larger and thicker than others. The spirilla are long, corkscrew- like, with wide curves. They also vary in size, the larger and thicker ones staining more deeply. The bacilli and spirilla are motile. Symptoms. — This affection can scarcely be classed as one of the more serious affections of the tonsil, although at times of a subacute chronicity. The children are brought to the physician with a history of an ordinary sore throat, and when examined this ulcer of a deep- spread, pseudomembranous type is found on one or the other tonsil. The appearance is as if an irregular hole were punched out of the tissue of the tonsil. There is no spreading of membrane, nothing resembling diphtheria. There is slight fever, rarely higher than 103° or 105° F. The symptoms at the outset are so mild that when the patient is brought to the physician the ulceration has taken place. In those cases in which there is accompanying stomatitis on the tongue, gums, or buccal mucous membrane, there is also foetor of the breath. In some cases there may be pallor of a distinctly septic type. Diagnosis. — The clinical diagnosis must be made from that of diphtheritic ulcers, resembling very much what has just been de- scribed. Henoch and the author have described ulcers of a truly diphtheritic character very much resembling ulceromembranous an- gina. The only test is that of the culture-tube or the smear. An ordinary microscopical smear stained from the base of the tonsillar ulcer will reveal its true character if of the Vincent type. If the bacillus and spirilla are not evident at once, we should make a culture for the diphtheria bacillus. Prognosis. — The prognosis is invariably good; although in some cases the course of the disease is apt to become subacute, on account of the difficulty of reaching the base of the ulcer with remedies. Some cases may last as long as three weeks ; others recover within a few days. Lemoine relates one case which lasted seventy days. Treatment. — The treatment is much the same as that of an ordi- nary tonsillitis. The tincture of the chloride of iron is given in doses of from 3 to 5 minims, combined with glycerin and water, every three hours. The base of the ulcer may be touched daily either with Lugol's solution or a 10 per cent, solution of nitrate of silver. DISEASES OF TEE LABYNX. 593 DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis (Catarrhal Croup ; Spasmodic Croup; Spasmodic Laryngitis; Pseudocroup). — Etioloi^y.- — Exposure to cold or wet are predisposing causes. Like the majority of catarrhal in- flammations of the respiratory passages, acute catarrhal laryngitis is due to the invasion of bacteria. It occurs as a primary affection, and in a modified form is met with secondarily in measles and in- fluenza. The classical form of " croup " is a primary affection, and is most common from the second to the fifth year. It is also seen in very young infants. One attack predisposes to others. Symptoms. — Catarrhal croup or catarrhal laryngitis is an affection that causes much concern to mothers when a first attack develops without warning. During the day the infant may have had a mild coryza with a slight elevation of temperature. Toward evening a croupy cough, accompanied by croupy breathing or voice, suddenly develops. In some cases the symptoms remain mild, and only the cough disturbs the patients. They breathe freely, and dyspnoea is not marked. In other cases the infant or child goes to sleep free from alarming symptoms. Coryza may have been present unnoticed during the day. During the night the patient awakes with a croupy cough, which rapidly becomes worse. The breathing is noisy ( croupy ) and may be heard in an adjoining room. The cough is especially terrifying. The patients are restless, and cry during the paroxysms of cough- ing. In some cases they sit upright and gasp for breath. The face is pale and wet with cold perspiration. Fever may be slight or marked and may reach 104° F. In the majority of cases the dyspnoea is real; there is drawing inward of the suprasternal region and the peri-pneumonic groove at the epigastrium. Toward morn- ing the dyspnoea, cough, and croupy breathing subside, and the patients fall asleep, worn out with the night's suffering. The next day the patients are apparently well, with the exception of a slight or marked croupy cough, coryza, swollen tonsils, with redness of the pharynx. For two or three successive nights or days there may be a repetition of the attack. This condition should be differentiated from laryngismus stridulus. In the latter there is no fever, the breathing is stridulous during only a short spasmodic attack, and there is no croupy cough. On the other hand, pseudocroup may occur in children who are rachitic and the subjects of laryngismus. There are forms of diphtheritic laryngitis without the formation of membrane, which in their symptomatology are identical with the form of laryngitis above described. This is true in very young infants and in children above five years of age. A culture-test is the 38 594 DISEASES OF THE JRESFIBATOEY SYSTEM. only certain mode of differentiating the affections. The pathological condition giving rise to jDseudocronp is believed to be a swelling of the mucous membrane beneath the vocal cords. Diagnosis. — The diagnosis is not difficnlt except in cases in Avhich the croiipy cough, breathing, and stridor increase as the day or night wanes and no relief comes to the sufferer. In other cases the obstruc- tion to the breathing in the larynx increases as in truly membranous cases. Only a repeated culture will reveal the nature of such an affection, because one culture may be liegative even in a truly diph- theritic case. In the severe forms of " croup," in the face of increas- ing laryngeal obstruction, the interests of the patient are best sub- served by assuming the ]3resence of a diphtheritic process until the bacteriological culture proves the contrary to be the case. Prognosis. — The prognosis is good. I have never met a fatal case of non-diphtheritic catarrhal croup. On the other hand, many of these cases are due to a grippal infection. Such an infection may carry in its train complications, such as bronchopneumonia or ear affections, which may endanger the life of the patient. Treatment. — The patient is isolated, and placed under a tent im- provised over the crib. The tent is kept filled with steam generated by any of the devices for croup in the market (croup-kettle) ; the steam is saturated with turpentine, thymol, or benzoin. At intervals of an hour 10 grains of calomel are sublimed underneath the tent until the croupy cough and breathing abate. To relieve the laryngeal spasm, especially if there is a temperature, antipyrin. in doses of a grain to every year of the age, is efficient and induces rest and sleep. Antimony (/4oo grain) combined with ipecacuanha (/loo grain) may be given every two hours, or 20 drops of the syrup of ipecac every two hours until emesis occurs. Turpeth mineral is given by some to induce vomiting. I do not use the drug. If symptoms of progressive stenosis set in, intubation is justified, and in localities where bacteriological examinations are not feasible, diphtheria antitoxin should be administered, lest a membranous diph- theritic process be overlooked. I have seen cases, however, which developed cyanosis recover without intubation. It is questionable whether it is justifiable to allow the patient to suffer when such a simple means, as the introduction of a tube in the larynx, is feasible. The application of counterirritants to the larynx is of questionable utility. The same may be said of the application of heat or cold externally. (Edema Glottidis (Submucous Laryngitis j Phlegmonous Laryn- gitis). — Definition. — This is a serous or seropurulent infiltration of the submucous cellular tissue of the region rif the upper larynx, or glottis, and the aryepiglottic folds. DISEASES OF THE LABYNX. 595 Etiology. — There are two forms — first, the simple serous infil- tration of the glottis; and, second, the inflammatory infiltration, the so-called phlegmonous laryngitis, in which the submucous connective tissue is involved. The serous form is secondary to and accompanies acute and chronic nephritis, infectious diseases, scarlet fever, variola, syphilis, typhoid fever, inflammation or ulceration of the structures adjacent to the larynx, especially of an erysipelatous nature. The second form, the phlegmonous laryngitis, is due to trauma- tism, such as the direct inhalation of steam, customary among chil- dren of the tenements when playing in the kitchen ; chemicals, foreign bodies, and injuries. Morbid Anatomy. — In the serous form of oedema glottidis the sub- mucous tissue is tense, infiltrated, pale or yellowish red; there is swelling of the upper laryngeal area. In the phlegmonous form the mucous membrane is dark red, swollen, covered with pus, and there may be ulceration of the mucous membrane of the larynx and vocal cords. Symptoms. — In the forms accompanying nephritis and the infec- tious diseases, the first symptoms to appear are those of stenosis of the larynx. In the traumatic form of phlegmonous laryngitis with consequent oedema of the glottis, especially in cases in which steam has been inhaled by children, there is pain in the mouth and pharynx,, dysphagia, and dyspnoeic attacks. Inspection shows the mucous membrane of the mouth and pharynx to be inflamed and the tissues of the epiglottis swollen; and an inspection of the larynx reveals swelling of the false vocal cords and narrowing of the rima glottidis. Course.- — The course of the disease depends on the nature of the primary affection. The milder cases, especially those accompanying acute or chronic nephritis, may retrograde. Other cases, especially the traumatic, if unrelieved, may result in fatal suffocation. Prognosis. — The prognosis must depend on the prognosis in the first form of the primary affection, and in the traumatic and phleg- monous forms of laryngitis the prognosis of the oedema glottidis depends on the severity of the disease. Treatment. — The treatment must consist, if a nephritis be present^ in the treatment of the nephritis, and we must not forget that intuba- tion or scarification in children is in most cases ineffectual. Intuba- tion is apt to be ineffectual on account of the additional traumatism caused by the attempts at introduction of a tube, with consequent formation of false pockets. If the symptoms are such that suffo- cation is imminent, tracheotomy offers the simplest and safest means of relief. In many cases of oedema of the glottis, especially of the milder type, a small dose of the opiates will quiet the patient and have a 696 DISEASES OF THE EESPIRATOBY SYSTEM. tendency to relieve the apparent dyspnoea until such time as the symptoms of the primary disease retrograde. Especially difficult of treatment will be the secondary cases, with phlegmonous disease in- volving structures adjacent the larynx, such as angina Ludovici. In these cases the swelling of the structures may be so great as to make tracheotomy a very difficult operation. Intubation in these cases is scarcely to be thought of. Syphilis of the Larynx.^ — This affection is rare in infancy and childhood, inasmuch as it accompanies the later forms of syphilis. The seat of election of this disease is the epiglottis, where ulcers and condylomata are formed. The structures are thickened, inflamed, covered with white, diffuse patches, and the same changes are seen in the interior of the larynx as on the aryepiglottic folds. Cicatrices may form and cause marked symptoms of stenosis. Ulcers are seen on the back of the tongue and on the vocal cords. Gummatous infil- trations may form, ulcerate, and lead to inflammation of the cartilages and necrosis of these structures, causing stenotic symptoms. Diagnosis. — The diagnosis depends on a discovery of syphilitic lesions elsewhere. Prognosis. — The prognosis depends on how soon anti-syphilitic treatment can be inaugurated before ulceration and cicatrization results. Treatment. — The treatment of this affection consists in applying the anti-syphilitic remedies ; and when stenosis of the larynx occurs as a result of cicatrization and contraction of the structures of the larynx, intubation offers the most effective means of relief. Tuberculosis of the Larynx. — This is very rare in infancy and childhood, and is more common toward the age of puberty. It can affect any part of the larynx, causing hoarseness. It is rarely pri- mary, being, as a rule, secondary to tuberculosis of the lungs or other organs. Treatment. — The treatment belongs in the realm of special laryn- geal work. Growths in the Larynx.- — The most common tumors found in the larynx are papillomata, granulomata, and fibromata. Malignant tumors are rare. Fully 25 per cent, of the papillomata are congen- ital, and manifest themselves from birth by symptoms of hoarseness and troubled cough. A frequent case of granulomata and papillo- mata of the larynx is recurrent laryngitis and oj^erations upon the larynx, such as intubation or tracheotomy. Symptoms. ^ — Tumors of all kinds cause hoarseness, accompanied by paroxysms of coughing with difficulty of respiration due to a cer- tain amount of stenosis, varying according to the size of the tumor. Some of these tumors may give rise to symptoms of suffocation. The DISEASES OF TEE B BON CHI. 597 granulomata which follow tracheotomy cause symptoms of asphyxia after the removal of the tube. In addition to the above symptoms, there are evidences, in all cases of tumor of the larynx, of catarrhal inflammation of the neigh- boring structures. Treatment. — The treatment of growths in the larynx belongs to the realm of throat surgery. Foreign Bodies in the Larynx. — During play children often aspi- rate bodies of all kinds into the larynx, and the symptoms caused depend very much upon the size and shape of the body aspirated. In rare cases the body lodges in the larynx, and may cause instant death by suffocation. Smaller bodies lodging in the ventricle of the larynx may cause attacks of dyspnoea, which subside when the patient takes the recumbent position ; but even these small bodies may cause instant death if they once lodge in the rima glottidis and close the opening of the larynx. Some of these bodies may after a time lodge in the bronchi and cause pneumonia. Prognosis. — The j^rognosis depends upon the nature of the body and the possibility of dislodging it. Treatment. — If the body is small, it may sometimes be dislodged by standing the patient, as it were, on the head. It then emerges into the larynx and is coughed out. If such is not possible, it is best to locate the body by means of a radiograph, and then attempt its removal by the branchoscope and surgical means. DISEASES OF THE BRONCHI. Acute Simple Bronchitis. — Bronchitis, acute and simple, is an affection of the larger and medium-sized bronchi. In very young infants the disease is apt to be very severe and to attack the smallest bronchioles; it is then called capillary bronchitis. A capillary bron- chitis is really a bronchitis in which there is a certain amount of peribronchitic pneumonia. Acute bronchitis may occur at any period of infancy or childhood. It is, however, less common before the sixth month of infancy than during the period up to the third year, when its frequency diminishes. Etiology. — Bronchitis may be caused by an exposure to cold or wet or by traumatism to the mucous membrane of the air-passages through the inhalation of dust or irritating vapors. It occurs in the acute infectious diseases, such as malaria, scarlet fever, measles, rotheln, varicella, typhus and typhoid fevers, and frequently compli- cates pneumonia of the lobular or lobar type. Rachitis and syphilis predispose to attacks of bronchitis. The bronchitis of heart disease or nephritis should be regarded as of a different class. 598 DISEASES OF THE BESPIBATOBY SYSTEM. Pathology. — The bronchi may be filled with a mucous, serous, pur- ulent, or mucopurulent exudate, which is secreted by the epithelium of the mucous membrane and the mucous glands in the wall of the bronchi. In recent acute bronchitis the mucus is quite abundant. In the exudate on the mucous membrane of the bronchi and in the lumen, epithelial cells, leucocytes, and sometimes red blood-cells are found. The structure of the mucous membrane is infiltrated with small round cells to a greater or less degree. In some places the epithelial lining of the bronchi may be raised by extidate ; in others there may be loss of the superficial epithelium. If the bronchitis lasts any length of time, there may be atrophy of the structures of the mucous membrane. In the severer forms of bronchitis which afi^ect the smaller bronchi the peribronchitic connective tissue is infiltrated with small round cells. In these cases there is an inflammatory exudate in the surrounding alveoli of the lung. There is then peri- bronchitis or bronchopneumonia. Symptoms. — In some cases the infant or child suffering from acute bronchitis will have a simple angina as an initial symptom. There is mild redness of the fauces with a slight rise of temperature which may last a day or more. The cough which was present at first per- sists, and there may be slight disturbance of the bowels, the move- ments are green and contain large curds of undigested matter. The cough may in aggravated cases give rise to occasional attacks of vomiting, especially immediately after nursing; at other times the coughing spells may cause the patient to <^ry. There is evidently pain, especially in the cases of bronchitis affecting the larger bronchi. The infant sometimes suffers from gTeat difficulty in expelling the accumulated secretion. The attacks of coughing closely resemble those seen in old people who suffer from bronchitis. In many cases the infant or child is quite comfortable in the intervals between the coughing spells. In others the respirations are increased, and there may for some days be a slight evening rise of temperature, the patient showing signs of being seriously ill. In very young infants who are rachitic there may be a distinct drawing in of the sides of the chest and of the peripneumonic groove at each respiration. In cases of severe involvement of the smaller bronchi, there may be slight cyanosis of the lips and pallor of the surface. In the severer forms of bronchitis, especially of the grippal variety, there is a febrile temperature for several days. It may rise to 102^-103= F. (38.8°-39.4° C), or even higher, with a correspond- ing increase in the number of respirations and the pulse-rate. In weak and very young infants there may be little or no cough. The infant lies in a soporose state, does not nurse well or refuses the breast. Older children may run about and play while suffering from DISEASES OF THE BBONCEI. 599 bronchial trouble; severe bronchial disturbance may appear to have little effect on the general health. Expectoration is exceptional; a frothy mucus collects about the lips of young infants after an attack of coughing. In older children it may be very difficult to collect sputum, even if they are old enough to understand the necessity of expectorating. The conclusion has been that children swallow the sputum ; it is more rational to suppose that the efforts at coughing are not equal to rais- ing any considerable quantity of secretion or that the amount of secretion in bronchitis is not so great as has been generally supposed. In many cases the cough is severer at night than during the day, but children cough and fall asleep immediately afterward, and therefore do not lose much rest. I have never met with a simple acute bron- chitis ushered in by a chill or convulsion. I have, however, seen severe forms of bronchitis cause petechial extravasations on the skin, similar to those seen in pertussis. The petechise are apt to occur about the forehead and eyes of very weak infants. Physical Signs. — In mild cases the number of respirations may be slightly above the normal ; in severer cases there are signs of dyspnoea and the respirations are increased in number. In very severe forms the peripneumonic groove may be drawn inward with each respira- tory act. In capillary bronchitis the lips may show some cyanosis, the surface may be pale, and the finger-tips slightly cyanosed. Palpation. — If the palms of the hands are placed on the anterior and posterior chest wall, the so-called rhonchal fremitus may be de- tected. The vibrations caused by accumulated secretion in the large and small bronchi give a sensation resembling that felt in stroking a purring cat. Percussion. — In simple acute bronchitis, percussion may elicit nothing abnormal. If infants have suffered from repeated attacks of bronchitis, the note may, owing to a slight emphysema, be hyper- resonant or vesiculotympanitic. In severe forms of capillary bron- chitis there may be areas of peribronchitic pneumonia or broncho- pneumonia, over which careful percussion will detect slight dulness with a resonant note. Auscultation. — In a number of cases, bronchitis at the outset, gives on auscultation nothing but a rude respiratory murmur which is more markedly puerile than normal. As the secretion accumu- lates there will be sonorous, sibilant, and crepitant rales, and also sonorous breathing. In the form called capillary bronchitis, with the subcrepitant rales there will be rales of much finer quality, resem- bling crepitant rales. The latter, which are unmistakable, are heard on inspiration, and appear to indicate areas of peribronchitic pneu- monia. In newly born and weakly infants there are, in this form 600 DISEASES OF IRE EESPIBATOEY SYSTEM. of bronchitis, areas in whicli the air is not heard to enter the lungs (atelectasis). Treatment. — The treatment of simple acute bronchitis should be supporting and expectant. If the cough is harassing, a mild opiate mixture in combination with a small quantity of ipecac may be given. The following prescription has been found useful : J^ Tinet. opii camph 5j (4.0). Syr. ipecacuanhee n\, xxxij (2.0). Syr. tolutani ^ij (60.0). Sig. Teaspoonful every three hours. The patients are allowed to be in the open air in fine weather, and the room should be well ventilated at night. In cases in which there is great relaxation of the mucous membranes, a dose of strychninse sulph., grain %oo (0.0003), may be given three or four times daily. The child is kept warmly clad, and wool is worn next the skin. Douching with cold water is to be avoided in acute cases. The oil- silk jacket may be worn, but it has no superiority to warm clothing. Applications of oil to the chest are of no value. The drugs of the coal-tar series (antipyrin or phenacetin) should not be used, except that one dose may be given at the very outset to relieve restlessness or headache. The bowels are relieved by means of calomel or a saline cathartic. In the subacute stage, syrup of ferric iodide may be given as a tonic for the mucous membrane. In rachitic infants and children, cod-liver oil is indicated. The treatment of so-called capillary bronchitis approaches very closely that of bronchopneumonia. The heart should be supported. Digitalis in the form of tincture is the most useful remedy. Strych- nine, caffeine, camphor, and musk in form of powder, all have here their legitimate sphere. The temperature, as a rule, needs no treatment. With older chil- dren, if the secretion is very profuse, carbonate of guaiacol is exceed- ingly useful and gives much relief. Fibrinous or Plastic Bronchitis. — This is a form of bronchitis in which membranous masses or fibrinous exudate are coughed up at intervals. These masses may have the form of the bronchi, or may consist of shreds or bands of membrane. Etiology. — Bronchitis of this form complicates diphtheria and pneumonia, and also occurs in the acute infectious diseases — measles, scarlet fever, tuberculosis, erysipelas, typhus and typhoid fevers. It is found in diseases of the heart and lungs, and may result from traumatism through the inhalation of jDoisonons gases. The above are the secondary forms; the primary form of fibrinous bronchitis is obscure in its etiology, and is rare in infancy and childhood. DISEASES OF THE BBONCEI. 601 Morbid Anatomy. — The casts which are coiiglied up are cylindrical in shape and branched in the form of the larger and smaller bronchi. The larger ones may be hollow and cylindrical, while the smaller ramifications may be solid or thready. In other cases the whole cast is solid ; small air-bubbles may be confined in the fibrinous cylinders. The casts may be 10-12 cm. in length, the extremities being nodular, thready, or flat. Under the microscope they are seen to be formed in layers ; in the centre of the oldest layers are found epithelium of the bronchi, leucocytes, and bacteria. Spirals formed of fibrin are occa- sionally found in the expectorated masses, especially in the diph- theritic, pneumonic, and the so-called idiopathic cases. Symptoms. — Attachs of Dyspnoea. — This form of bronchitis is characterized by attacks of dyspnoea and coughing. During the attacks clots of purulent fibrinous masses are expectorated, some- times with a slight amount of blood. In spite of the expectoration of blood there are no signs of tuberculosis. The presence of blood is probably caused by the detachment of the membranous casts from the walls of the bronchi. The expectorated masses may contain asthma crystals. In the intervals between the attacks, there may be symptoms of an ordinary bronchitis with mucopurulent expectora- tion, or there may be absolute freedom from symptoms. Cough. — The cough, which is present during the attacks, may be accompanied by a snarling or fluttering sound. Cyanosis. — Cyanosis may be present during the attack to a marked degree or may be absent. Fever. — Fever is present in the acute form, but has no special characteristics. Splenic Tumor. — Splenic tumor may be present. Physical Signs. — The physical signs of bronchitis may be present with rales of all kinds. If the membranous masses hang detached in the bronchi, a snarling or flapping sound may be heard on auscultation. The general condition of patients in the intervals and during the attacks varies greatly. In some cases it is fairly good. Complications. — A tuberculous bronchitis or pneumonia may be a complicating condition. Diagnosis. — The diagnosis is made from the presence of the fibrin- ous casts. Treatment. — The treatment has thus far been very unsatisfactory ; mercury, and also inhalations and sprays of all kinds have been tried in the acute cases. Iodide of potassium is of value in the intervals. If diphtheria is present, the antitoxin is given. Emphysema and Chronic Bronchitis of the Lungs. — Frequency. — Emphysema is a condition frequently seen postmortem in the lungs of infants and children (Steffen). 'No disease of the lungs runs its 602 DISEASES OF THE BESPIBATOBY SYSTEM. course without causing some emphysema. The condition is much more common in children than in adults, because it is favored by the peculiar structure of the lung in early life. Most of the forms of emphysema of the lungs of infants and children retrograde, allowing the lung to return to its normal state. Otherwise emphysema would be more common in adult life than it is. Clinically, emphysema combined with various forms of pulmonary disease, especially bron- chitis, is very common in infants and children. My experience in this respect confirms that of Steffen and Osier. It seems to be common to certain classes of children, especially those of rachitic tendencies. Morbid Anatomy. — Steffen has made a very careful study of the pathological condition in emphysema of the lungs of infants and children. The thorax has not the typical barrel shape seen in the adult, and occasionally found in older children. In younger chil- dren, especially those with rachitis, the sides of the lower portion of the thorax are incurved; the upper part of the thorax in front underneath the clavicles may be full and prominent. On opening the chest, the lungs are found to be inflated, to retain their form, and to show along the situation of the ribs a series of indentations due to pressure. The depressed portions may be denser than those raised, and show areas of circumscribed persistent pneumonia. In vesicular emphysema, air-vesicles may rupture into one another, giving rise to large sac-like formations which communicate with a bronchus. Some of the air-vesicles may rupture into the subpleural tissue. Vesicular emphysema rarely involves a whole lung or both lungs, but is localized to certain areas, such as the apices, anterior borders, or the lingula. The emphysematous areas are whitish, yellowish white, or red- dish yellow, the color varying with the amount of blood contained. They are raised above the surface, are elastic and velvety to the touch, and crepitate with the air contained. In children, in contrast to the condition in the adult, the heart is rarely dilated, and the liver and kidneys rarely affected. This is due to the temporary nature of the process. Bronchitis, trachitis, and laryngitis may exist as primary or secondary conditions. It is not possible to consider emphysema in infants and children as an isolated condition. Since it is most frequently seen in pronounced bronchial affections, it will be con- venient to consider it in connection with bronchitis. Symptoms. — Some infants and children suffer from a chronic catarrhal bronchitis which is more or less present at all times, and which may be interrupted by attacks of acute bronchitis. Infants and children thus affected are more or less rachitic; some have lymphatism in the form of chronic hypertrophic rhinitis and also adenoids or enlarged tonsils. In the intervals between the attacks of acute bronchitis; the patients do not seem to suffer much constitu- DISEASES OF TEE BBONCHI. 603 tional disturbance. There is no fever, and no change in the respira- tion except that it assumes a noisy character. There is a cough which comes on at intervals, especially at night. The infants are pale, with rather flabby muscles, and may be fat, but impress the physician as being below the normal in point of strength. Physical Signs. — If the bronchitis has persisted a long time, the upper part of the chest is, even in infants under the age of twelve months, abnormally full. The upper costosternal region is high and Fig. 120. Emphj'sema of the lung in a boy eight years of age ; diminished cardiac area of relative dulness. the intercostal spaces are filled out. In milder cases there are no signs to be detected on inspection. Palpation. — There is distinct rhonchal fremitus felt anteriorly and posteriorly. Percussio7i. — If there have been a number of acute attacks, there will be emphysema of a vesicular type, giving a hyper-resonant note. In pronounced rachitis the hyper-resonance is apt to be marked. The area of relative cardiac dulness in older children is much diminished (Fig. 120). Auscultation. — Voice-sounds are normal. The breathing is rude or sonorous. The respiratory murmur may be prolonged. There are sonorous, mucous, and subcrepitant rales. 604 DISEASES OF THE SESPISATOEY SYSTEM. A second set of eases of chronic bronchitis comprises those in which a condition of prononnced emphysema of a vesicular character is present, and in which there are distinct attacks of dyspnoea or asthma. These cases must be differentiated from the purely neurotic cases of spasmodic asthma. The latter condition is rare in children, and is not accompanied by chronic catarrhal bronchitis. The history of these cases is one of repeated attacks of acute bronchitis. The lung may in the interval be wholly free from signs of bronchitis. A condition of this kind is apt to be left in the lung after a severe attack of pertussis. The infants or children may bear the marks of rachitis, and are usually anaemic. In the intervals between the acute attacks of asthma, the general condition is good. There is no fever ; there may be dyspnoea on exertion. An attack of asthma is precipitated by exposure to cold or wet. During the attacks infants and children do not suifer much, although they show signs of marked dyspnoea. There are none of the typical signs of an attack of spasmodic asthma in the adult. An infant showing very marked dyspnoea will play in the arms of the mother. The lips may be cyanosed and the surface pale and cool. There is no temperature. There is in these subjects a tendency to develop a cough of a laryngeal type on the least expo- sure. Examination of the chest shows nothing except a prolonged rude respiratory murmur, while percnssionwill give a hyper-resonant note over the whole chest. Suddenly an attack of so-called asthma will develop, with all the physical signs given below. The onset of the attack is sometimes signalized by a slight rise of temperature, 100° to 101° F. (37.7° to 38.3° C), and an increase in the number of respirations, 32 to 36 per minute. On examination, the chest shows all the signs of an acute attack of bronchitic asthma. An attack lasts for from a few hours to a few days. The children usually play about and seem little disturbed by their condition. During- an Attack of Spasmodic Dyspnoea. — Inspection. — - Inspection shows a drawing inward of the supersternal structures on inspiration, and a depression of the peripneumonic groove. The upper part of the chest is high and filled out, and moves little on inspiration and expiration. The lower part of the thorax has also little movement. In rachitic children, there is not only drawing inward of the lower part of the thorax, but also a distinct incurvation of the lower ribs, caused by the repeated attacks of dyspnoea. The chest is moved as a whole. In children of seven or eight years the dyspnoea may be severe in the absence of cyanosis. These patients apparently suffer more than infants. In older children, the chest has the typical barrel shape seen in the adult sufferer from asthma (Fig, 120). In some cases there is a drawing inward of the intercostal spaces on inspiration. Some cases have a constant cough and frothy expectoration. DISEASES OF THE BliONCHI. 605 Palpation. — Palpation gives rhonchal fremitus and faint cardiac impulse. Peixussion. — Percussion gives a ve^iculotympanitic or hyper- resonant note over the whole chest, and cardiac dulness obscured and diminished by the emphysematous lung. Auscultation. — Auscultation gives a prolonged expiratory mur- mur and sibilant and sonorous rales. Heart-sounds are feeble. Betweeist Attacks of Dyspncea. — Between the attacks of dysp- noea the chest retains the above forms. There may be a slight con- FiG. 121. Emphysema of lung : boy eight years of age ; barrel-shaped thorax. as Fig. 120. Same patient stant dyspnoea or none at all. The patient feels quite well, and does not complain of the dyspnoea. The heart apex-impulse is diffused. Palpation gives little or no rhonchal fremitus. Percussion. — Percussion shows a note hyper-resonant, but not as markedly so as during the paroxysm of dyspnoea. Cardiac relative dulness is obscured by the presence of emphysema. Auscultation. — In older children the expiratory murmur may be prolonged or inaudible. There are signs of residual bronchitis, sibi- lant, sonorous, and subcrepitant rales, and in young infants, large mucous rales. The signs may be hardly noticeable or heard only in certain portions of the chest. 606 DISEASES OF THE BESPIEATOBT SYSTEM. Prognosis. — In both forms of chronic bronchitis the prognosis as to life is very good. The chances of nltimate restoration of the lung to the normal condition depend much on the mode of living and the power of the individual to outgrow the conditions of rachitis and lymphatism which exist in many of these cases. Many of these forms of chronic bronchitis disappear ultimately ; the emphysematous form may persist into adult life. Treatment.- — The treatment of chronic bronchitis is directed to- ward improving the general tone of the economy and also the muscu- lature of the heart. It must be assumed that in these cases the heart as well as the other organs suffers from a lack of power, to which may be attributed the relaxed condition of the circulation in the mucous membrane of the bronchi. Life in the open air, hydriatic treatment, and drugs, such as strychnine, will have beneficial effects. The mucous membranes are benefited by preparations of iron which con- tain iodine (syrup of the iodide of iron), freshly j^repared and given in large doses. Cod-liver oil is an excellent tonic in winter. The skin should be protected from extremes of heat and cold by suitable underwear. Moderate participation in sports in the open air im- proves the action of the heart. Running and gymnastics are to be preferred to bicycle-riding. A dry climate will do much toward improving the condition of the lung. During the attack of dyspnoea, iodide of potassium will be of service in alleviating the symptoms. This is the most useful remedy. It is also of great benefit when given in the intervals between the attacks. The other drugs used with adults are not indi- cated. An exception is Fowler's solution, which is an exceedingly useful remedy in moderate dosage in the intervals of the attacks, to be given, over a prolonged period. I have seen good results follow the use of digitalis in the form of the tincture, in combination with the iodide of potassium. The heart is thus greatly aided in improv- ing the circulatory conditions in the emphysematous lung. Rest from exertion is indicated during the attack, but patients may be kept out of doors if they will remain quiet. Codeine is most useful in allaying the cough. The administration of a large dose once or twice daily is preferable to giving small doses at shorter intervals. Bronchiectasis, Including Putrid Bronchitis. — Bronchiectasis, or dilatation of the bronchi, is not a very uncommon condition in infants and children. In most pulmonary disorders in infants and children, very slight dilatation of the bronchi may result. These have no clin- ical significance, and retrograde to the normal state in time. The marked dilatations are the congenital bronchiectasis and the acquired or inflammatory form. Varieties. — Congenital. — This is a condition in the newly born DISEASES OF THE BBONCEI. 607 infant which has been known to persist into adult life (Grawitz, Welch, Kessler, Frankel). It generally affects one lung or a part of one lung. The lung structure is replaced by cystic formations which contain a serous fluid, in which are found nuclei and ciliated epithe- lium. The main bronchi may be cystic, with a system of minor cavi- ties separated from the main cavity by a series of septa. In this way numerous recesses are formed. The walls of the cysts may be cov- ered with several layers of cuboidal epithelium. jSTo distinctive symptomatology has been reported in these cases. Etiology. — Whatever the exact cause of a bronchiectasis, there is certainly a diminished resistance of the walls of the bronchus to the inroads of inflammatory processes. In order to explain the imme- diate formation of these cavities, Hoffman has assumed that a stenosis of the lumen of the bronchus (as shown by Frankel and Lichtheim), must be produced by inflammatory processes and that under these conditions the repeated attacks of coughing produce dilatation. Such stenosis may have its origin in a peribronchitis or a pneumonia caus- ing thickening of the wall of the bronchus. Pleurisy, chronic pneu- monia, croupous or catarrhal, syphilis, and foreign bodies lodged in the lumen of the bronchi may be the direct cause of a bronchiectasis. Finally, there are the forms of bronchiectasis called primary, because their etiology has not as yet been explained. Infiamrnatory.- — The inflammatory form of bronchiectasis may be sacculated, spindle-shaped, or cylindrical (vicarious). The cylin- drical bronchiectasis shows the bronchus dilated into a cylindrical form. This dilatation may merge gradually or abruptly into the main bronchus. The spindle-shaped bronchiectasis is only a form of the cylindrical variety. Pathology. — The sacculated bronchiectasis is the most common variety, and clinically the most important. It usually affects the smaller bronchi. A sac communicates with the trachea, and has no other outlet. The entry into the sac may be by way of a normal, a dilated, or a stenosed bronchus. If the infundibula are dilated, small cavities are formed (pulmonary vacuoles). In other cases the afferent bronchus may be obliterated, and the cystic formations are then of varying size. The wall of the bronchus leading to a cavity of this nature is in a state of catarrh, and may be thickened or infil- trated. The epithelium may be present only in spots. The infiltra- tion may affect the walls of the alveolar septa. The mucous mem- brane may after a time become atrophic. The cartilages of the bronchi may also become atrophic and be replaced by connective tissue which may extend for varying distances into the lung sub- stance, forming trabeculse. The epithelium of the bronchi may be replaced by pavement epithelium. The mucous membrane becomes 608 DISEASES OF THE BESPIBATOEY SYSTEM. thickened or is replaced by polypoid masses. The bloodvessels finally become dilated. There may thus be formed throughout the lung small aneurismal dilatations of the bloodvessels. The remaining lung tissue may be emphysematous or sclerosed as above. The pleura may be thickened. Symptomatology. — The symptoms include expectoration, a cough, dyspnoea, deformity of the chest, and fever. Expectoration.- — There is expectoration of a mucopurulent char- acter, which cannot be differentiated from the expectoration of some forms of bronchitis. In other cases, large quantities of a fetid, puru- lent material are expectorated. This expectoration may at times be mingled with streaks of blood, or there may be a distinct hemorrhage, Fig. 122. HOUR 309 12 309 12 389 12 369 12 369 12 369 12 369 12 SeU 12 369 12 369 12 358 12 36S 12 36 9 12 3S9 12 103 I- 1- 1 J 1 1 ,0, _^_^ ^^^^ ^^^^^^^^^^^^^^^^^^^ ^ \ XlOl— ^— ;— ;-- ^ — t »= = = = = = t = - ^^^^^^-^^-^^^^^^^^^ i""EEEEEE^EE;;ES=EEEE|EE3=E5EE=?=EEEEEE=EEEEEEEE=EEEEEEEEEEE .'EEEEEEEEE ;EEfeEbE^d'-E E^EE-=EE?==if^^E=^E^!SE=?^iiE MWw 98 i-h- 1 * PULSE S|2SS2slslli3§S"g|Sg2ggSSgSgSSS|SgSS|gSg3S3S3SSSSggggSg RESP. sssgi§ssjsssss?jss3s;?;s;?i?;?isssgggg?isagg§s§s?i?;?;s?;35;5;3;3ssas;5i5i URINE X X S X 7 X 6 X 4X68 XXX 6 A- 14 XXX X6X8 X2X 6XX XX STOOL 1 1 1 i 1 1 1 1 1 1 1 WEIGHT 34 LBp. 32 LBS. Bronchiectasis ; febrile and afebrile periods. Boy, seven years of age. resulting in some cases in a fatal haemoptysis. Sometimes the sputum is profuse, exceedingly fetid, fluid, and purulent, and will on standing separate into a serous and a purulent portion. Cough. — The cough may be occasional or, if the bronchiectasis exists in the apex of the lung, incessant. It is apt to be more marked in the morning, and may at that time be accompanied by the expecto- ration of the sputum accumulated during the night. At other times, change of position will cause paroxysms of coughing and the evacua- tion of large quantities of sputum. Dyspnoea. — Dyspnoea is present not only during the paroxysms of coughing, but also in the intervals, especially if there are extensive secondary changes in the lungs or pleura. Fever. — Fever of a hectic character is very likely to be present at times when the secretion in the lung accumulates. The temperature DISEASES OF THE BRONCHI. 609 will then rise a degree or more, but subside when the lung is again cleared of bronchiectatic accumulations (Fig. 122). These rises of temperature may simulate those in the course of empyema or tuber- culosis. If abscess of the liver or kidney, endocarditis, or pneumonia occurs as a complication, the rise of temperature will be more marked. Deformity. — Deformity of the chest is apt to occur in severe cases in which there is emphysema of the lung or j)leuritis. In 3 of my cases there have been deformities of the finger and toes. These, the so-called clubbed fingers, are not characteristic of bronchiectasis, since they are found in congenital cardiac disease and tuberculosis of the lung. There is pain as a result of existent pleurisy. Albuminuria may be present as a result of amyloid changes. Hsemoptyosis is generally a late symptom, but is not very common. Diarrhoea of a septic nature may occur in the course of the disease. Complications. — Complications include decomposition of the bron- chiectatic accumulations, pneumonia, gangrene of the lung, emphy- sema, pleurisy, empyema, perforation of the lung, laryngeal disease, kidney and heart disease, liver abscess, abscess of the brain, and finally amyloid degeneration of the liver, spleen, and kidneys. Diagnosis. — A positive diagnosis of bronchiectasis cannot always be made, especially in those cases in which there are all the signs of a localized empyema. Such cases show localized dulness or flatness, bronchophony, and absence of fremitus in a certain portion of the chest, generally at the lower portion behind. A needle, on being introduced, withdraws pus, which in the cases I have seen was min- gled with air bubbles. On operation, the pleura is found to be normal. In three instances I found this to be true. The evidence of a bron- chiectatic cavity lay in the persistence of signs and symptoms after the healing of the chest wounds. In all 3 cases the expectoration persisted in profuse quantities after operation (Fig. 123). Physical Signs. — The physical signs in all of my cases included a localized area of dulness or flatness, over which there was broncho- phony and bronchial breathing, in some cases with gurgles. Above this area, over the base behind, there was on percussion a tympanitic note, indicating the enlarged bronchus containing air. Tuberculosis is excluded by the absence of tubercle bacilli in the sputum, though bronchiectasis and tuberculosis may coexist. In most of my cases there was a history of an antecedent attack of pneumonia. Exclusion of abscess of the lung is very difficult in severe cases in which the quantity of sputum is excessive. The bronchiectatic cavity in these cases is very large. With the bronchiectasis, there may be diffuse bronchitis and emphysema of the lung. Course, — Soiue of the cases in which the bronchiectasis is not marked or progressive result in spontaneous recovery. In others 39 610 DISEASES OF THE EESPIEATOEY SYSTEM. there may be tuberculosis, gangrene of the lung, or empyema, as complications. A fatal hemoptysis may close the scene of this very offensive affection. Treatment. — Treatment does not give very satisfactory results. It includes the inhalation of balsams of all kinds, out-of-door life in high altitudes, and surgical interference including exposure of the lung and incision of the bronchiectatic cavity. The latter is a des- perate remedy ; in some cases it has resulted in fatal hemorrhage and in others has not afforded relief. A cure has resulted in a few rare Fig. 123, Showing bronchiectatic cavitj' in case of a girl eight years of age, with signs as noted in text. cases in which there was a simple cavity in the lung near the pleural surface. The injection of these cavities with drugs has also been very unsatisfactory. DISEASES OF THE LUNGS. General Considerations. — The lungs at birth are small as com- pared to the other organs in the chest. They grow comparatively more in the first few months of infancy; but in children they remain small as compared to the body-weight and length. Compared to the heart in volume during the first month of infancy, the lungs are as 3.5 or 4 to 1. In the later months of infancy the lungs develop more DISEASES OF TEE LUNGS. 611 rapidly, and then the ratio of volume of the lungs to the heart is as 5.5 or 6.2 to 1. Movements of the Chest. — The movements of the chest may nor- mally be irregular in rhythm ; the sides move in unison. In disease, especially in conditions of pressure on one side of the neck, one side of the chest may remain immobile, the other being retracted with each respiration to an exaggerated degree. I have observed this condition after operations for retropharyngeal abscess in the neck, incases in which the nerves in this region were pressed upon or injured, thus interfering with the normal action of the diaphragm. In effusion into one side of the chest, there is diminished motion on the diseased side. Emphysema may restrict the normal movements. In forms of pleurisy with effusion the intercostal spaces are retracted more than is normal at each descent of the diaphragm. This may be due to adhesions. The precordial region may be drawn inward with the recoil of the heart, as is sometimes seen in adherent pericardium. Scoliosis of the spine may deform the chest, giving undue promi- nence to one side. Retraction occurs after the absorption of pleuritic effusions. Fremitus. — The method of obtaining fremitus in children has been described. It may be mentioned here that fremitus is well marked normally in the posterior axillary line and in the inter- scapular region. The Normal Limits of the Lungs. — In the mammillary line on the right side to the sixth rib ; in the mid-axillary line to the ninth rib. Posteriorly on the right side to the tenth rib ; on the left side to the eleventh rib. Thus the limits are practically the same as in the adult subject (Symington). The amount of lung-tissue above the clavicle cannot be mapped out in infants and children. Resiliency of the Chest-wall. — The chest-wall in infants and chil- dren has a normal resiliency to percussion. The wall yields beneath the percussing finger. This is a definite feature. In any disease of the chest which interposes fluid between the chest-wall and the lung this resiliency of the wall is diminished or absent. In infants and children, as in adults, there are normally : Pulmonary resonance ; Dulness varying to flatness ; Tympanitic resonance. Pulmonary Resonance. — Pulmonary resonance is lower in pitch than in the adult. Anteriorly over the right infraclavicular region it is less marked than on the left side; the note is also slightly higher and of shorter duration. 612 DISEASES OF THE EESPIEATOEY SYSTEM. Dulness. — Dulness is found normally over the heart, liver, and spleen ; ako, anteriorly on the right side from the fourth to the sixth rib. From the sixth rib to the borders of the ribs the note is flat. In the mid-axillary line on the right side there is dulness from the fifth to the seventh rib; from this point to the free border, the note is quite flat. On the left side at the level of the sixth rib, just above the spleen, there is a narrow strip of relative dulness, due to the pres- ence beneath the diaphragm of the left lobe of the liver (Fleischman) (Fig. 124). Fig. 124. SI rip of relative dulness described by Fleischiiiaii. :in 12 :> 6'iJ V2 a:o :>V2 3 I-.' 3 1) V- 3 G]y V2 3,0 >J;12 3 9 11-2 3 s 9 12 3 6 !> 12 106° 105° 104° ^103° <102° 3 101° |ioo° 99° 98° 97° UJ LJ ujtui 1 t ' / 1 s PULSE -f'O'o ^1 gg'g '^ 2 H 1 2|'g2 "llr o 3 ■" SEJ S s H g g O s s S RESP. ? ^'^!^ ?i3?! o s:^;. 33 a g s'ggig g ?; §s g s 3 g s s s ^ s - URINE 6 l20i X ^ 8' 8 ,0 i i X X X STOOL 1 1 1 i i CVT.Es" ii w 1 11 too io op Lobar pneumonia ; pseudocrisis and crisis. Leucocyte count before and after crisis indi- cated. Boy, four years of age. Individual Symptoms. — Temperature. — The temperature-curve in lobar or fibrinous pneumonia may be of several distinct types. In the majority of cases the temperature remains persistently high for the whole period of the illness. There are morning remissions of a degree or more, but the afternoon or evening rise may reach 104°, 105°, 106° F. (40°, 40.5°, 41.1° C). In a typical case the morn- ing remissions are not so great as those in pneumonia of the broncho- pneumonic type. The crisis is not as a rule preceded by a rise. The drop of the temperature at the crisis in a fairly typical case may begin at 9 a. m., and the temperature may be subnormal at 9 p. m. of the same day (Fig. 126). In another form, crisis may be rapidly followed by a temporary rise in the temperature, not due to any rein- 620 DISEASES OF THE FiESPIBATOB¥ SYSTEM. fection of the lung, but to a slight post-pneimionic toxsemia. The temperature will in such cases reach the subnormal within thirty- six hours. Fio. 126. HOUR 3J6|9 ^ I 6|9|l2 3|6|9|l2 3|6]9|l2 3|6{9|l2 o 1 6 1 9 Il2 3 1 1 9 |l2 3 & 9 12 3 6 9 12 3 6 9 12 3 6J9|l2 3|6|9|l2 3|8|9b2 3I8M12 104° 103' ^102° X < - 101° q! <- 100° 99° ^ '^ m ^ , 1 - E E = = - , 1 ^"-W -^. — \ i , I — 1- -^^ 1 ' ' 1 , ._ _ _ 1 _ _ _ _ _ _ _ 1 ■ 1 - - - — n - - — — - — - -^ ^ — -^ - — - — — -^ - : ' 7 / v k,v 'VI v^^.i ^ ' 1 1 I "■'i 1 ; St ■ ■ 1 1 1 1 1 1 1 1 1 ' LEUOO- OYTES 1 1 1 Lobar pneumonia, right lung, lower lobe. Crisis on the eighth day. Leucocyte count indicated. Female child, two years and Ave months of age. Fig. 127. HOUR 3 is 9 12 3 6 9 12 3 III II 8912369 12 369 12 3J6 9 il2 3 3 9 12 3 ( 6 1 9 12 3 6 9 12 3 6 9 12 3 6 1 9 !l2 3 6 9 12 3 , a j s 11. 3 6 9,. 106° — ] rf^- ^^^^^^g--| 9-^ C4S.^S..i--S- ^H— \m " r lOi — i ^=^^-rd K=^iA — - gfr^—^ — -- ^-^ 5103 nF-- - — u— \/^ ^-^^^--^ ^g^^^^^M^ — U-L ■— T=|= L^ ^ ^ . ^^ ^ . ^ \ - ' — : — ■■ \ — : — ■ [ \ ■■ 1 i — ^— -T-^- Y 1 ' -^ _^-^ _^ r_ __^ ^ \ ' -+- ^— -\ ^ — 1 . 1 1 1 ' ' . 1.1 ' ' / N- ; \ — 1 — 1 — ' — ' — \ 1 — ' — \ — ■ \ — ' — '■ ' — j — [ \ — ' — \ — ■ --^ — \r / \\ 99 r^ -■- i 1 - ^~' -f^ — ^: -^ =t ~— - PULSE 3S|§i§i SSiSSSS,^^;; 5 H 1 1 iW S'S'SSit 1 1 ; , III . ' '4- V. s ?. ?. RESP. ; Si.s .?';; ; 3 3|sSgg5S-;:' i i - '1 ^;^(S g:?iSS5,|. g:5 3^KSSHSSi;S5S ;! s? g'g UR.NE XXX XX X[X X XX X X X ,X X X|X, X xjX XjXj .X XX X i x! STOOL 111 1 II 1 1 I . i| 1111 1 I j ' i 1 'i WEIGHT 34 LBS- 9 '■ 1 1 1 i 1 LEUCO- Si CTTES J T, s 'i ^ 5 V 'S Lobar pneumonia, right lung, lower lolie: lemperature falls by lysis. Leucocytosis indi- cated in the chart. Female child, four years of age. Another very di.stinct form of temperature-curve is the remittent. This temperature-curve is at first glance exactly similar to that of bronchopneumonia. The remissions in the morning may reach the normal within a fraction of a degree. Such cases may also show at DISEASES OF THE LUNGS. 621 the terminal end of the curve a critical drop to the normal. In other cases the fall of temperature at the beginning of convalescence takes place by v^hat is known as lysis (Fig. 127). In other words, the temperature reaches the normal or subnormal by remission of temperature in a gradually descending scale extending over two or more days. Some cases show a remission of the temperature which begins at the ninth day of the disease, and is not completed until the fifteenth day. This is occasionally seen in cases in which there are apparently no complications. The more common type is that in which the lysis begins on the seventh or eighth day, and is completed in two or three days. Of 57 cases of lobar pneumonia in which a reliable history could be obtained, the temperature fell by crisis in 36 and by lysis in 21 cases. The crisis, as a rule, occurs from the fifth Fig 1 2 8 IUNe" i: - 8 •J J 10 11 V2 i:! u 1.1 IC 17 ',* 1 HOUR 12 11 12 S \2 ■i ]2 612 6 12 6 12 8 12 ^.'■2 pi2| 6 12 6,2 .,2 6 12 S 12 0,12 6 12 •3 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 e,2 12 lOl" --^l03° ^ z q P p ^,12 p - — p+- u_p -|-- nr -p -r- -p -p — — -r- ^ E :- —~' i^ '^ ~ = = ~ ~ ^ ~ - ^ IE ~~ = ~ ~|~ 1 m ~~ 1 E = — < 102° ^ 100° = — i t 1 E Et f ■ t ^4 f 5 \" - A - = i 1 i E = ^ E 1 1 9Q PULSE E £ in )J- I-I i =^ :ri III L i = YT' y_ ± ± — fe di ^ I— ^ RESP. s s :s. ?! S ss hi s § S s - ?,-. 7, -- -'- -- r.r, r.?-, DS ?:r, T, r. r..- r.- 7. S -~ J'. 7 7.?. ?. - -: URINE 9 8 6 8 8 1 X 10 6 "1 10! 11 3 11 STOOL 1 1 \ 1 1 ' WEIGHT sIl 02 1 LEUCO- CYTES 14,000 10,600 15,000 10,600 10,000 18,200 11.400 Lobar pneumonia, right lung, middle lobe ; effusion into the pleura. Temperature after crisis due to pleurisy. Boy. eight years of age. to the ninth day of the disease (60 per cent, of my cases). After the lysis or crisis there may be a slight daily rise in temperature of a degree or even less, probably indicative of a very mild form of post- pneumonic pleurisy. The temperature in such cases falls gradually, and in four or five days reaches the normal (Fig. 128). The subnormal temperature after the crisis or lysis is quite a common phenomenon. I have learned not to fear this symptom, but to regard it as favorable (Fig. 129). A subnormal temperature may persist for days, or even a week or longer, and not uncommonly, espe- cially in fibrinous pneumonia which has run a sharp or moderately severe course, is accompanied by irregularity or abnormal slowness of pulse. A slow pulse (bradycardia) which is at the same time regular is apt to alarm the physician^ but I have never seen any ill effects in these cases if they were treated in a rational manner. Such conditions of pulse and temperature should be regarded as a result of the toxsemia which has affected the heart muscle. 622 DISEASES OF THE EESPIEATOEY SYSTEM. Chills. — Chills, or chilly sensations followed by a rise of tempera- ture during the course of the disease, are in most cases accompanied by physical signs of an invasion of a new area of lung. This should at least be kept in mind, especially if the rise of temperature is abrupt. At the crisis in lobar pneumonia I have, in exceptional cases, seen the temperature drop within an hour from 103° to 94° F. (34.4° to 39.9° C.) and the pulse to 48; within an hour the temperature rose to 96° F. (35.5° C.) and the pulse to TO. The temperature grad- ually rose, so that within seven hours it was again 99° F. (37,2° C.) in the rectum, the pulse 96. The symptoms of mild collapse may accompany the pronounced fall. Cough. — Some infants and children cough very little; in others the cough is a very harassing symptom. There is no sputum even in the older children, or only after the crisis; pain accompanies the Fig. 129. Lobar pneumonia, light lung, upper lobe : remittent temperature-curve ; prolonged subnormal temperature intermittent in character ; recovery. Female child, two vears and six months of age. cough, and may be suspected if the infant or child cries when it coughs. The pain is referred to the side of the chest, to the epigas- trium, or to the region of the umbilicus or appendix. The pain referred to the appendix in cases of lobar pneumonia is probably radiated from a diaphragmatic pleurisy. Dyspnoea. — Infants and young children show marked dyspnoea. The alse nasi are dilated and the peripneumonic groove is depressed with each inspiration. In very severe dyspnoea in young infants, there may be a drawing inward at the suprasternal notch. This occurs even in the absence of any laryngeal disturbance, and fre- quently simulates laryngeal stenosis. Nervous Symptoms. — The cerebral symptoms may at the outset simulate those of menina-ifis fmeningisnO- There are delirium. DISEASES OF THE LUNGS. 623 rigidity of the muscles of the neck, and even opisthotonos. There may be no true meningitis. Older children may have a low, mutter- ing delirium during the whole course of the disease. Xear the crisis and just before the fall of temperature, I have in a few cases seen maniacal delirium, in which the patients were very noisy and at- tempted to get ou-t of bed. I have seen cases of melancholia with crying spells during convalescence in female children, and also in boys. These symptoms all subsided in time and the patients were eventually fully restored. Blood. — It has been noted by Tumas and von Jaksch that in pneu- monia of the fibrinous variety there are a marked leucocytosis and an increase in the multinuclear leucocytes, which is especially marked at or near the crisis. The proportion of leucocytes to the red blood-cells in the cubic millimetre may reach 1 : 40 to 1 : 70. Ehrlich believes this leucocytosis to be a very constant occurrence in typical pneumonia. Billings has investigated the relationship of the leucocytosis to the prognosis more fully. His work will be referred to in the considera- tion of the prognosis. My own experience covers a large number of cases of fibrinous and bronchopneumonia, examined with reference to leucocytosis. Leucocytosis is present in both forms of pneumonia in infancy and childhood, but is more marked in the fibrinous forms, the number of leucocytes to the cubic millimetre being about twice as great as in the catarrhal forms. There is marked, leucocytosis in the fatal cases of both forms of pneumonia. The increase of the leucocytes in the fibrinous forms was espe- cially marked at the time of the crisis. In the bronchopneumonic forms the leucocytes were also high at or about the time of the drop in temperature. The diminution of the number of leucocytes was in both forms marked either just previous to or after the fall in the temperature. From the observations of Billings and Ewing, it must be concluded that leucocytosis is a favorable sign in fibrinous pneu- monia. It does not, however, as Ewing believed, bear any exact ratio to the extent of lung involved. I have found a much higher per- centage of leucocytes to the cubic millimetre in children than Ewing found in the adult. This is probably due to the fact that any leuco- cytosis is more marked in infants and children than in the adult sub- ject. The absence of leucocytosis is certainly a grave prognostic sign, but the presence of marked leucocytosis in children does not in my experience preclude a fatal issue. Physical Signs. — The signs obtained by physical examination of the chest in fibrinous pneumonia of infants and children resemble those of the same condition in the adult. In forms of bronchopneu- monia or catarrhal pneumonia in which areas of considerable extent are consolidated the signs will closely resemble those obtained in the 626 DISEASES OF THE BESPIBATOBY SYSTEM. cases of Levy and Jlirgensen were fatal within twenty-four to thirty- six hours. I have never observed such cases of fibrinous pneumonia in children, but have seen lobar pneumonia with a history of short duration (Fig. 130). In cases running a very short course there is doubt as to whether the signs obtained over the chest may not have been connected with a preceding attack. Henoch has, however, met a few cases which ran a rapidly fatal course, with the whole symp- tomatology of lobar pneumonia, including physical signs, in forty- eight hours. Fig. 130. 104^ 103^ -102° < iiof < S H 100 99° 98° 97° 1 's >^ j \ / \ 1 / / / / 1 "s / j S, '■"^ 1 1 ^ V, ^ - A , \ / ' / O o \ . s^ i< — ■-i. ^^ \ ■^ ' \ OJ J- \ s ,^ s _ ^ r' ■ m . < .. , PULSE § o o S o T-l l-H s S i I ^ S ro g to § § § g s RESP. S5 ?i S SI ^. m S s ^ ? % g S S « S s S |S s S ;; URINE X X X X X X X > ( X X X X X X X X X X STOOL 1 1 1 1 1 DAY OF ILLNESS Third Fourth Fifth Sixth 1 Lobar pneumonia, midregion of the right lung ; crisis on the fourth day of disease, seven years of age. (Author's case.) Boy, Complications. — Among the complications of fibrinous pneumonia in infants and children are otitis, pleurisy, pericarditis, endocarditis, empyema, and meningitis, arthritis and osteomyelitis and peritonitis. Gastro-enteritis is quite a common complication. Otitis. — Otitis is common, its frequency varies in diiferent epi- demics. It affects younger children and infants more frequently than older subjects. The temperature in these cases becomes more markedly remittent and remains higher for a greater length of time than in the uncomplicated cases. I have frequently suspected otitis from a study of the temjx'vattire-cin'vc, which is not, however, an DISEASES OF THE LUNGS. 627 altogether reliable guide. Suppuration in the pleura will give a similar curve. Therefore, in a concrete case of persistent high tem- perature-curve with morning remissions, otitis should be suspected, but not positively diagnosed without careful exclusion of other com- plications and otoscopic examination. Otitis as such does not seem to give any strildng symptoms of pain. The patient may without warning present perforation of the drum of one or both ears and a purulent discharge. The temperature will then fall to the normal. Diplococcus pneumonige has been found by a number of observers in this discharge. The otitis is of a benign nature. Meningitis. — Meningitis occurs in a number of cases, and may usher in the disease. I have seen it persist for weeks. The prog- Fig 131. illSJess + 5 G 8- 1 9 10 " 12 IS u l.-> 10 17 1 HOUR 12 6112 6 12 6,12 s 12 6 112 ►1 12 6 12 6 12 a 12 •! 12 i 12 6 12 6,12 6 12 6 12 6 12 6 12 5 12 5 12 6 12 5 12 3 I.' 5 12 •i 12 B 12 5 12 101° p i i E^ EE i 11 M ' — ^ = — =E EE z;^ — — =:= ^ — P 103" ^ 102° = 1 1 1 i =i^ i i p 1 1 i =fE ^ P P "v v" 1 EE EE EE EE ■^ 101° S 100° = EE 1 ^ = = E 1 = ^ E 1- gE i p = E P EE 1 ^ I 1 1 i = - 99° 98' P = = == ^ =. p = p p = EE E E EE EE EZ. ^^ EE ee;! zE -rr — 1 1 rzz r=: = = = == = -r= :-=z IIZI ^- _^^ =:;; ^ IIZ^ H^ ^ ^ =^-_ eeI -- :- ~t ^ PULSE = WW ii i¥ fi ¥w T¥ O" Fl fl FW- ^ IT f¥ iE if if J~ =f f^ ~T E= ^ f^ ^ p RESP. 2 V. ~ -. ■^ s ? 3 s 5 52 =. '4 2"^ r. 2 52 = i 3 s i s 3 ? 3 H '4 2 = 3 5 - 3 s 3 3 URINE 5 X X X 5 X X, X X r, X 1 X 5 X 4 X X :i X X STOOL 1 1 1 i 1 1 1 WEIGHT 1 35 L B9. 54 .85. 13 O'.Z., 1 1 1 1 LEUCO- CyTES 18,000 L'0,000 10,000 16,400 10,400 12,400 Lobar pneumonia, lower lobe, left lung ; complicating pleurisy ; temperature falling gradually to the normal. Leucocyte count indicated. Boy, five years of age. nosis in this form of meningitis, if it assumes the cerebrospinal type, is graver than when it occurs as a primary disease, with the intra- cellular diplococcus of Weichselbaum as a causative factor. ISTetter seems to have met a larger number of cases of the pneumococcus form of meningitis than any other author. The cases of meningitis complicating pneumonia may be due to either the pneumococcus, streptococcus or meningococcus. The cerebrospinal symptoms, or meningism, as it is called, seen at the outset or at the crisis in some cases of pneumonia do not last for any great length of time, and do not present the true symptoms of meningitis. In other cases it is sometimes impossible to diiferentiate between simple cerebral symp- toms or the so-called meningism and the existence of a complicating meningitis. Even after close study a lumbar puncture may be nec- essary to clear up the diag*nosis. Pleurisy and Emijyema. — Many cases of fibrinous pneumonia 626 DISEASES OF THE SESPIBATOBT SYSTEM. cases of Levy and Jiirgenseu were fatal within twenty-four to thirty- six hours. I have never observed such cases of fibrinous pneumonia in children, but have seen lobar pneumonia with a history of short duration (Fig. 130). In cases running a very short course there is doubt as to whether the signs obtained over the chest may not have- been connected with a preceding attack. Henoch has, however, met a few cases which ran a rapidly fatal course, with the whole symp- tomatology of lobar pneumonia, including physical signs, in forty- eight hours. Fig. 130. 103" -^102" I < i lof < HlOO" 99' 98" 97° 1 1 /V ^*<.^ / ^ i' — ^ / \ 1 ^ 1 1 . \i 1 \ 1 I 1 . 1 1 1 I 1 - ' / \ / o o \ ^ o "- "1 l\ ---1 tM CM ^ \ ^ ^ ^• - •1 ni ' \ < "i , PULSE o S S 2 S S^S S 3 <=> CS Ci § g o eO I g S s RESP. ^ SI § U i5|Sli?? g s § e=> N «3 eo 1 to CI !?» s a 1^! IS o ^ URINE X X X X X X X X X X X X X ! X| IX X X X STOOL 1 1 1 1 1 Mil 1 DAY OF ILLNESS Third Fourth Fifth Sixth 1 Lobar pneumonia, midregion of the right lung ; crisis on the fourth day of disease. Boy, seven years of age. (Author's case.) Complications. — Among the complications of fibrinous pneumonia in infants and children are otitis, pleurisy, pericarditis, endocarditis, empyema, and meningitis, arthritis and osteomj'elitis and peritonitis. Gastro-enteritis is quite a common complication. Otitis. — Otitis is common, its frequency varies in different epi- demics. It affects younger children and infants more frequently than older subjects. The temperature in these cases becomes more markedly remittent and remains higher for a greater length of time than in the uncomplicated cases. I have frequently suspected otitis from a study of the temperature-curve, which is not, however, an DISEASES OF THE LUNGS. 627 altogether reliable guide. Suppuration in the pleura will give a similar curve. Therefore, in a concrete case of persistent high tem- perature-curve with morning remissions, otitis should be suspected, but not positively diagnosed without careful exclusion of other com- plications and otoscopic examination. Otitis as such does not seem to give any striking symptoms of pain. The patient may without warning present perforation of the drum of one or both ears and a purulent discharge. The temperature will then fall to the normal, Diplococcus pneumoniae has been found by a number of observers in this discharge. The otitis is of a benign nature. Meningitis. — Meningitis occurs in a number of cases, and may usher in the disease. I have seen it persist for weeks. The prog- Fig 131 D«r OF + .-. G 7 8* 10 11 la i:! .1 15 l(> " 1 HOUR - 12 ^ ~T~ T 8 12 8(12 ^ 9 1 8 12 8 12 8 12 — , f f 6 12 ^_J2^ 8|l2 6,12 8,12 8; 12 t 6!l2 6'12 i 0il2 8 12 sll2 _8 12 103° ^ 102° < --- 101° = I |- ^ T \- — - ~pr f \~ ^ -i- — _ -_ -— -^ ^ = : E — ~ V 7 M \ r f ",: V V / l/\ : J \ i Tt - = = -i- -^ v/ ^ S; V V / b^ '\ ■--1 ! , , ._ _ „ ji V / 1 .. E= - - = ^ -— Jr- 1^ t t \ - - i: m 100° 99° 'M E- ^ ^ — — — I— — y^ -^ E- A- — V W t; = = r- -- ^ j^ 3 r r- -1 - i - r - r - - - - — — — -r - - - ■- - - - - - - - - - t f- PULSE - I f I S 1" § o^ r -i ^ ■T- t7 IT ^ -^ T- 3 1 i 5 w 2 S w g s f r 3 I - - ^ - - 3 i" - Q - •s f- RESP. g S a s s « >; = s 5 3 ^ = s S i8 s sis - ; = s 3 3 = 5 s '■? =s i? ■£ s s - ^ s 3 s URINE X X X 5 •J X X X 6 X J X 8 X 1 X X 4 X X 2 STOOL 1 1 1 1 1 1 1 WEIGHT 3 L BS. 4 .B s. 12 ?. LEUCO- CYTES IS.OOO 113,600 15,400 10,400 12,400 Lobar pneumonia, lower lobe, left lung ; complicating pleurisy ; temperature falling gradually to the, normal. Leucocyte count indicated. Boy, five years of age. nosis in this form of meningitis, if it assumes the cerebrospinal type, is graver than when it occurs as a primary disease, with the intra- cellular diplococcus of Weichselbaum as a causative factor. ISTetter seems to have met a larger number of cases of the pneumococcus form of meningitis than any other author. The cases of meningitis complicating pneumonia may be due to either the pneumococcus, streptococcus or meningococcus. The cerebrospinal symptoms, or meningism, as it is called, seen at the outset or at the crisis in some cases of pneumonia do not last for any great length of time, and do not present the true symptoms of meningitis. In other cases it is sometimes impossible to differentiate between simple cerebral symp- toms or the so-called meningism and the existence of a complicating meningitis. Even after close study a lumbar puncture may be nec- essary to clear up the diagnosis. Pleurisy and Empyema. — Many cases of fibrinous pneumonia 628 DISEASES OF THE BESPIEATOBT SYSTEM. show a dry pleurisy sometimes persisting for a long time after con- valescence. Of greater moment are the cases of pleurisy with effu- sion, which follow a lobar pneumonia. In these, there is always the danger that the exudate may eventuate in an empyema. The dura- tion, of the exudate is no guide in determining whether it is of a serous or a purulent nature. It is frequently found that after a pneumonia has run its course the temperature remains raised a degTee or more toward evening. Such a rise in temperature may, in the absence of signs of fluid, indicate a dry plastic pleurisy (Fig. 131). On the other hand, if there are signs of fluid and the temperature- curve shows irregularities of rise, emj^yema may be present. I have seen empyema without any rise of temperature in infants who showed the physical signs of fluid in the chest. These points will be more fully discussed in considering Empyema. Pericarditis. — I have seen pericarditis in infants who died of a fibrinous pneumonia, but the diagnosis was not made during life. Von Jaksch notes such cases. In older children, pericarditis is a complication found in cases of fibrinouspneumonia which have simul- taneously developed empyema. Such cases are very uncommon. In the form of pericarditis which I have seen in infants, the quantity of effusion has not been sufficiently great to enable a diagnosis to be made with certainty, and the rales in the lung obscured the friction- sounds in the pericardium if they were present. Purulent pericar- ditis in these subjects is very fatal under such conditions. In older children I have seen pneumonia combined with a fibrinous pericar- ditis pure and simple, without fatal issue. Prognosis. — The prognosis of lobar pneumonia varies within cer- tain limits. Text-books give statistics taken from hospital cases, notably the most unfavorable material. Henoch gives the mortality of his cases at 5 per cent. ; Baginsky, at S per cent. ; Holt, at 12 per cent. ; my own hospital cases during the past year showed a mortality of 8 per cent. On the other hand, in private practice death from an acute fibrinous pneumonia rarely occurs in a child previously healthy and living in good surroundings. The mortality is influenced by the season of the year, being greater from December to February, and by the presence of an epidemic. If pneumonia is prevalent during an epidemic of influenza, the mor- tality will increase. Pericarditis or complicating empyema influence the death-rate. The previous condition of the patient, the mode of feeding (whether by the breast or the bottle), and a rachitic or ma- rantic condition, affect the prognosis. The age of the patient is also an important factor. Infants under one 3'ear of age are in greater danger than older ones. The prognosis is best from the third to the tenth year. The younger the bottle-fed baby, the more serious the DISEASES OF THE LUNGS. 629 complication of empyema. In making a prognosis in any concrete casie, the physician should be guided by the extent of lung involve- ment and the general condition of the circulation. If one lobe alone is involved and there is an absence of bronchitis in the unaffected lung, the outlook is good. If the heart action is good and there is an absence of cyanosis, recovery can be predicted even if the temperature be high. If, on the other hand, the lysis or crisis is delayed and the dulness or flatness involves a whole side of the chest, in the presence of signs of a weak heart the prognosis should be made with caution. Meningitis is grave. I have seen cases of meningococcus menin- gitis which complicated pneumonia recover, but pneumococcus and streptococcus meningitis are fatal. Pericarditis in young infants and children is a complication invariably fatal. Where facilities exist, a leucocyte-count should be taken every second day, accom- panied by a differential count of leucocytes. A very low leucocyte- count, with marked signs of pneumonia and a high temperature, is a grave- prognostic sign, though such cases may recover. On the other hand, a continued high leucocyte-count, as has been pointed out, may be present with extensive inflammation of both lungs, and death may ensue. Diagnosis.- — The diagnosis of lobar pneumonia in infancy and childhood ordinarily presents few difficulties, but is not easily made if in addition to the pneumonia there is an effusion in the chest. The diagnosis should never be made early in the disease without positive signs. The crepitant rale sometimes escapes observation. The physician should then wait for the appearance of dulness or bronchial voice and breathing before arriving at a conclusion as to the ]iresence or absence of consolidation. Cases of influenza with a harassing cough are fre- quently diagnosed as central pneumonia. A pneumonia which is central will give physical signs when the consolidated area approaches the pleura. If after the time set for the crisis or lysis, the tempera- ture persists and becomes remittent, careful examination should be made for evidences of fluid in the chest. The nature of the fluid should be determined by exploration with the aspirating needle, if the fever does not subside and if the dyspnoea increases. A chest effu- sion in infants and children is apt to be purulent. The cerebral cases present difficulties of diagnosis. Convulsions, delirium and rigidity of the neck, accompanied by high fever and a cough, with increase of the pulse-rate and the number of respirations, indicate the necessity of making a very careful examination of the chest. In cases which begin with a lobar pneumonia, typhoid fever may be suspected if, after the first days of illness, a roseola or an enlarge- 630 DISEASES OF THE BESPIRATOBY SYSTEM. ment of the spleen develops with a continuance or gradual rise of temperature. In such cases the presence of an epidemic of typhoid fever and the Widal blood reaction will be of service in clearing up the diagnosis. Treatment. — The treatment of lobar pneumonia is pre-eminently expectant. The disease is self limited, and complications cannot be prevented. The temperature should be treated within certain limits, and the heart and the strength of the patient supported. The tem- perature should be treated not with a view to its actual reduction, but in order to mitigate its ill effects. Infants and children will be less affected by a temperature of 103° F. (39.4° C.) during a pneu- monia than by the same temperature in typhoid fever. The toxaemia of pneumonia is of a more benign character. Hydrotherapy. — Sponging is efficient in cases in which the tem- perature does not generally range above 104° or 104.5° F. (40° C). The younger the infant the less energetic need it be, for a tempera- ture of 104.5^ F. (40° C.) is not high for an infant under two years of age. I content myself with sponging the body with water at 80° F. (26.6° C), to which some alcohol has been added. If the tem- perature remits a degree or more during the twenty-four hours, there will be less need of sponging. The temperature should never be taken more often than every three hours. If it is above 103.5° F. (39.7° C), the patient is sponged for fifteen minutes and then given absolute rest for three hours. Frequent sponging is pernicious. Some infants when sponged with water at 80° F. (26.6° C.) become cyanosed, with rapid and thready pulse. With these patients a warm bath at a temperature of 105° to 107° F. (40.5° to 41.6° C.) is stimulating. It supports the strength and certainly lessens the ill effects of the temperature, although it may not reduce it palpably. I do not use the full cold bath in the treatment of lobar pneumonia in infants and children. If the temperature reaches 105°-106° F. (40.5°-41.1° C), a full bath of the temperature of 85°-90° F. (29.4°~32.2° C.) or higher may be given, certainly never lower. One of the most useful methods of hydrotherapy in the treatment of pneumonia in young infants is the so-called chest compress. These compresses renewed every hour will cause the restlessness to diminish, the heart action to improve, and the patient to fall into a quiet slum- ber. The actual reduction of temperature is not so marked as the favorable effect on the general condition of the patient. The appli- cation of compresses is discontinued if the temperature falls below 103° F. (39.4° C). Medicinal Treatment. — The licart action if good needs no atten- tion. At most, a limited amount of alcohol in form of wine or whiskey is adiiiinislfi-ofl. Infants may rof^oi\'c half a drafhin (2.0) DISEASES OF THE LUNGS. ^ 631 every few hours; older children, a drachm (4.0). Alcohol should hot be given as a routine remedy. If the temperature is high, neces- sitating hydrotherapy, and the pulse is above 120, alcohol should be given. If the pulse is high, 150-160, a few minims of the tincture of digitalis may be given to older children. Younger children rarely need more than half a minim every two or three hours. If the pulse- rate is reduced after the administration of digitalis, the drug should be discontinued before the pulse drops below 100. There is no doubt that its effect is more cumulative in some subjects than in others. Strychnine is of value in the treatment of pneumonia, not so much in the cases with rapid as in those with slow and irregular pulse. Infants will bear grain Hoo to M.50 (0.0003 to 0.0004) every three hours, for days. Caffeine is of great value in the treatment of irregularities of the heart which indicate a myocarditic toxsemia. The pain is the result of a pleuritic process. The local application of iodine or mustard paper is an efficient counter-irritant. If the cough is troublesome, codeine in moderate dosage is the most useful remedy. I do not use morphine with infants and children. In young infants the milder preparations of opium, such as camphorated tinc- ture or the wine, are more useful. Four minims (0.25) of the cam- phorated tincture of opium every two or three hours will be found efficient in children under two years of age. To older children a small dose of codeia may be given several times daily if needed. The aim is to alleviate, not abolish, the pain and cough. The bowels should be evacuated daily ; for this purpose hydrarg. cum creta is one of the best remedies. Grain v (0.3) may be given. Infants should receive an enema daily. If gastro-enteric disturb- ances are present, milk should be discontinued, broths substituted and the same procedure followed as in primary gastro-enteritis. Tympanites is sometimes troublesome, especially in young chil- dren. The best remedy is a high enema twice daily of salt solution, to which one or two teaspoonfuls of peppermint-water have been added. The passage of a soft catheter is not effective, nor are the turpentine stupes of any value. Milk should be eliminated tempo- rarily from the diet. The delirium, sometimes amounting to an acute mania, which appears just before the crisis in some cases, is best controlled by rectal administration of bromide of potassium and chloral hydrate. I have sometimes been forced to keep the patient under the influence of these drugs for a few days. The post-pneumonic melancholia seen in children is best treated by the administration of strychnine and the enforcement of perfect quiet. 632 DISEASES OF THE EESPIBATOEY SYSTEM. Should signs of extreme cardiac Tvc-akness set in with threatening oedema of the lung and paralysis of the right ventricle, nitroglycerin is of great value. Infants will bear grain /4oo (0.0003) every three hours. If in these cases cyanosis is present, oxygen is administered, preferably that containing 20 per cent, of nitrous oxide. It is given to infants, every half hour for five or ten minutes at a time by means of a cone. Hygiene. — The patient should be isolated if possible. The room should be ventilated and its temperature kept at 68°— 72° F. (20'- 22.2° C). The sputum should be received in pieces of gauze, which are burned. The mouth and teeth should be cleansed twice daily with a piece of soft linen and a solution of boric acid. In the intervals between feedings the tongue is kept moist by frequent draughts of water. Bronchopneumonia ( C atarrlial Ptieumonia, Lobular Pneumonia^ . — Bronchopneumonia is the prevalent type of pneumonia occurring before the fifth year, but many cases of lobar fibrinous pneumonia are seen during infancy and early childhood. Occurrence. — Bronchoj)neumonia occurs both as a primary and a secondary disease. As a primary disease it is most frequent during the first two years of life. Of 605 of my cases of bronchopneumonia, the incidence in regard to age was as follows : Cases. One to three months 32 Three to six months 68 Six to twelve months 207 One to two years 298 These figures correspond within certain limits to those of other observers, although Holt places the greatest frequency between the sixth and the twelfth months. Sex. — Of the 605 cases, 322 were males — a statement correspond- ing to that of Jiirgensen in regard to lobar pneumonia. Season. — The greatest frequency is during the winter months, when there are epidemics of influenza dtiring which many primary and secondary cases of bronchopneumonia occur. Surroundings. — The herding together of the poor certainly has a tendency to increase the prevalence of bronchopneumonia among them. If we believe in the epidemiological aspects of pneumonia, it is easy to account for the greater frequency of the disease among the poor : the gi'eater number of their children are rachitic, syphilitic, marantic, and ill-fed, and thus have increased susceptibility to in- fection. Secondary bronchopneumonia occurs as a complication in the DISEASES OF THE LUNGS. 633 exanthemata (measles, scarlet fever, typhoid fever), diphtheria, per- tussis, and influenza. By far the greater number of cases occur as a sequence of ordinary bronchitis. Etiology and Bacteriology. — Weichselbaum first d'^monstrated that the pneumococcus of Frankel could cause primary bronchopneumonia. His results have been confirmed by Cornil, Babes, and Neumann, the latter of v^^hom found the pneumococcus in cases of primary broncho- pneumonia. Quesiner and Neumann found the pneumococcus in the sputum of children suffering from bronchopneumonia. The secondary form of bronchopneumonia may be caused by streptococci (Northrup and Prudden), v^hich invade the lung-tissue from the trachea, as in diphtheria. Guarnieri also found strepto- cocci in the lungs of children dying with bronchopneumonia after measles. On the other hand, these secondary types of bronchopneu- monia may also be caused by the pneumococcus of Frankel, which is an etiological factor in the primary type of the disease. This has been shown in the work of Netter on the subject, and confirmed by Banti, Strelitz, and Baginsky. In diphtheria the Klebs-Loffler ba- cillus may be found in the lung areas of secondary bronchopneumonia (Babes, Frosch, Baginsky). The Eberth bacillus has been found in areas of bronchopneumonia complicating typhoid fever (Polyniere). Morbid Anatomy. — The essential lesion in bronchopneumonia is an inflammation of the walls of the bronchi and of the air-spaces sur- rounding the inflamed bronchi (Delafleld). The walls of the bronchi are thickened and infiltrated with small round cells ; those of the alveoli of the lung are thickened and their cavities filled with fibrin, pus, epithelial cells, and new connective tissue. The smaller bronchi are dilated and contain pus, their walls being infiltrated. The in- flammation may also be conveyed from the bronchi to the paren- chyma of the lung by aspiration of secretion (Ziegler). In the latter case the smaller bronchi are occluded, collapse of the lung follows (atelectasis), and a pneumonia thus results. On section there are seen grayish-red, gray, or yellowish-gray areas of varying consistency, which correspond to a cut bronchus and its surrounding peribron- chitic pneumonia. If the areas are croupous, they have a more granular appearance. Small areas of this form of pneumonia may coalesce, and thus whole lobules of the lung may be consolidated. These larger areas may be separated by lung-tissue which contains air, or a whole lobe may be- come consolidated, as in lobar pneumonia. The exudate found in the affected alveoli is at flrst composed of desquamated swollen epithelial cells, and later of leucocytes. If the exudate has a more fluid char- acter, it is called catarrhal. It then contains more serum than fibrin. Jf the fibrin is in excess, the exudate has greater consistency, resem- 634 DISEASES OF THE EESPIEATOEY SYSTEM. bling that of lobar pneumonia, and is then called croupous. The catarrhal and croupous forms of exudate may both exist in a lung affected with bronchopneumonia. Blood-cells mav predominate in the exudate, so that the lung may on section have a hemorrhagic appearance. This is apt to be the case in streptococcus inflammation and also if foul fluids have been aspirated. The mucous membrane of the bronchi is the seat of catarrhal inflammation. There is inflammation of the pleura to a varying degree. The bronchial and mediastinal lymph-nodes may be enlarged. There is oedema of the lung tissue which is not inflamed. Broncho- pneumonia may result in resolution and restoration to the normal. Suppuration and formation of abscess with destruction of lung tissue, or gangrene of the lung, may result in rare cases. Persistent bronchopneumonia in children leads to induration of the lung. There is an increase of the connective tissue of the alveolar septa, of the walls of the smaller and larger bronchi, and also of the walls of the peribronchial vascular tissue. The lung on section is seen to be studded with fibrous nodules, or a whole lobule or lobe may be converted into connective tissue. Symptoms. — Bronchopneumonia is divided clinically into several distinct types. In newly born and very young infants the disease may set in insidiously. The infant is born in normal condition: after some little exposure it develops slight snuffles and a slight cough. Dyspnoea then appears. All this may occur within the first eight days after birth. The cough becomes more harassing and the dyspnoea more marked. Slight cyanosis supervenes after a time. The infant is restless and does not sleep, the cyanosis becoming more marked and constant. The infant may have frequent convulsions. The dyspnoea finally becojmes so marked as to cause distinct drawing inward of the lower part of the chest-wall with each inspiration. In these cases there is little or no temperature ; in that respect they resemble cases of bronchopneumonia in extremely old people. The temperature may be slightly subnrjrmal even when the infant is mortally ill with a disseminated bronchopneumonia. The cough may nrjt be marked. These cases should be differentiated from those occurring in infants born with an atelectatic crjndition of the lungs. In the class of cases under consideration, atcdectasis develops as a sequence of the bronchitis and bronchopneumonia. The movements are greenish, cotntaining undigested curds. The infants may finally develop enteritis. The course of the disease is in these cases very acute. The infant either rapidly grows worse or begins to improve immediately. The former conrse is, however, the rule in this very dangerous and insidious form of bronchopneumonia. If the infant DISEASES OF THE LUNGS. 635 does not improve, the cyanosis becomes more marked, as does also the dyspnoea; the respirations increase to more than 80 a minute, the pulse becomes very rapid, and the heart feeble ; the infant lies in a soporose state; the end may supervene with tympanites, convulsions, and oedema of the lung. This form of bronchopneumonia is very fre- quently overlooked at the outset and mistaken for a simple bronchitis. Another form of bronchopneumonia in infancy begins as a simple bronchitis, and may be treated as such for days. Finally, posteriorly in both lungs there are found the fine crepitations which give warning of the presence of bronchopneumonic processes. Bronchopneumonia of this variety runs its course without temperature. It occurs in rachitic or weakly infants and children, or follows a mild attack of influenza. The attacks of coughing are especially troublesome, and are frequently followed by vomiting of the contents of the stomach. The movements are loose, and show greenish particles and undigested white flaky masses. The dyspnoea is constant and characteristic, and if the patient is out of bed, grows more marked toward the late after- noon. The alse nasi are dilated. The temperature rarely rises above 101° F. (38.3° C), and is generally 100° F. (37.2° C.) or even lower. The cough may persist for weeks after the subsidence of the acute symptoms, being especially marked at night. A more common form of bronchopneumonia in infancy begins as a simple bronchitis, which may last for a few days, when, without warning, the infant has a chill followed by a rise of temperature, the case having suddenly developed into a full bronchopneumonia. In a six weeks' old infant with disseminated patches of pneumonia, the chill was so severe as to cause extravasations of blood underneath the surface, with markings resembling those seen in marbling of the sur- face. In another case the chill was so severe that an immediate fatal issue was feared. In that bronchopneumonia sometimes begins with a chill, it resembles a lobar process. The most common type of bronchopneumonia may begin with a rise of temperature preceded by vomiting. The harassing cough is present from the outset, causing the patients to cry with pain at each attack. There is no sputum, but in very young infants a frothy mucus may in the later stages of the disease collect about the lips. The dyspnoea is marked. The alte nasi are dilated at each inspira- tory effort. The peripneumonic groove is retracted and in very severe dyspnoea the suprasternal region may also be depressed at each inspiration. Very frequently the dyspnoea will resemble that due to laryngeal stenosis. There are, however, none of the signs of laryn- geal obstruction, such as laryngeal breathing. Fever. — Fever is always present in infants and children, except in the classes of cases above noted. It may reach 106° F. (41.1° 636 DISEASES OF THE EESPIBATOBT SYSTEM. C), and is as a rule remittent. It may fall gradually to the normal, and in the favorable cases may reach the subnormal and remain there for a few days. The course of the fever is. however, not an indica- tion of the severity of the disease. Fatal bronchopneumonia some- times shows a steady decline in the temperature toward the approach of the fatal issue. In other cases the temperature may drop to the normal, remain there a few hours or a day. and then rise sharply to 104° F. (40° C.) or higher, thus indicating that a new area of the lung has been invaded by the disease (Fig. 132). Such rises of temperature after a fall to the normal are of grave import if they occur in an infant acutely ill with a process which has been severe for days. They show a tendency of the process to spread, and in young weakly infants such an extension of the process is apt to be Fig. 132. ?":?" Jan. 4 j 6 7 s « 10 I ,li."e°ss 3 4 5 6 7 8 9 1 HOUR 7^; 12 3|6[9 12 Ijl 9 12 3 1 6 1 9 |l2 3H9|12 sUlslia 3l.U|l2 3 i 6 ! 9 'l2 3 ! 6 1 9 112 3 ' 6 ! 9 'l2 s'eigM 3!6i9(l2 3j6|9M s'.U'i^ lOi i 103° % 102° •101° / / \ \ / / / / T \ / / 7 -M~/- 1 / \ . / v^ . K 4- — — — -~- \ j rr^J — -^^ \ / \ i~^~ _ _^ V _ j V 4 — 1 — r— 1 — — i — — -•- ~^v — — L-T- • . W ! ■ 1 _^ L — -^ - — -^ — - — -^ — r- —^ — y — r 1 : ^— ^F PULSE g 3 i S 3! 1 = ll 'E ' = S. ' §■ 'i £ IS i 12 1? |5 RESP. ? s g s = S ss:; = 5SHS ss 's S; =^' 5 5 ? S S r-: gfss S 'SS s s = S 2 ' 1 Fatal bronchopneumonia ; reinvasion of the lung on the fifth day. Infant, six months old. fatal. A drojD by lysis to a normal temperature which continues for a few days, and is followed by a slight gradual rise with subsequent remissions to the normal, is also common, and may indicate a return of the bronchopneumonia process, or a pleuritic effusion of a puru- lent character. The physician should be on the alert for an eifusion in the cases which have run an irregular or remittent temperature for a period of more than two weeks. I have, however, operated upon cases of empyema following bronchopneumonia in infants, in which the temperature-curve was normal for days, and then showed occa- sional rises to 101° or 102° F. (38.3° or 38.8° C). Pulse. — The pulse is as a rule rapid. It is difficult in infants to estimate its exact character. It is, however, always possible to dis- tinguish the abnormally weak and thready pulse even in the youngest infant. The rapidity of the pulse varies widely even in the favorable cases. Its ratio to the respiration (the pulse-respiration ratio) is, as a rule, maintained in favorable cases. Even if it be so much dis- torted as to present the ratio of 1 to 2, the patient may make a good DISEASES OF THE LUNGS. 637 rccoverj. The character of the pulse and respiration should there- fore be judged in connection with other signs of decreasing heart jxiwer, such as abnormal pallor, coldness of the surface, and cyanosis, huwever slight. In artificially fed infants who are above the average weight, the beginning of cardiac weakness is indicated by an abnormal pallor of the face and slight cyanosis of the lips. Sputum. — In 3'oung infants there is no sputum, nor is it probable that in uncomplicated cases of bronchopneumonia the younger infants cough up and swallow sputum, as is generally supposed. At most, there is after severe attacks of coughing a collection about the lips of frothy mucus, probably coming from the trachea. Fig. 133. Ordinary type of bronchopneumonia. Recovery. Female child, one year and six months of age. Gastro-enieric Tract. — The symptoms referable to the stomach and intestine are of great importance in severe bronchopneumonia of the primary type. Even up to the second year of life tympanites sets in very early. It may mislead the physician into thinking that peritonitis might be present. It is especially apt to set in with rachitic and weakly, artificially fed infants. It is appears late in a very sick infant, it is a symptom of grave import, and may some- times cause the fatal issue. In some cases the pre-agonal distention is very great, and so far as can be judged painful. Some infants begin to vomit from the outset of the pneumonia. The vomiting may occur once or twice in the twenty-four hours, or may be incessant. With the vomiting there may be the passage of greenish stools or a fully developed enteritis of severe type. So severe is the enteritis in some cases as to cause the death of a patient suffering from pneu- monia of only moderate severity. This form of the disease does not occur exclusively in the summer months, but is more prevalent at that time. 638 DISEASES OF THE BESPIEATOEY SYSTEM. Cerebral Symptoms. — The infant is in some cases stupid from the outset of the disease. Older children mav have slight convulsive twitchings of the muscles of the face and extremities. In some cases in children in the third year there may he complete unconsciousness and symptoms simulating those of meningitis, such as rigidity of the muscles of the neck. I have seen the cerebral symptoms persist for weeks in young infants v^^ho made complete recoveries. In other cases, the bronchopneumonia may partly resolve, and still there may be a continuance of the cerebral symptoms or even an exacerbation of them. In these eases the possibility of the presence of otitis or mastoid inflammation should be seriously considered. The secondary form of bronchopneumonia may complicate the exanthemata — measles, scarlet fever, varicella, typhoid fever, per- tussis, influenza, and dij)htheria, and also gastro-enteritis or any form of infection, such as that of septic wounds or osteomyelitis. Pertussis. — The symptoms of bronchopneumonia which compli- cates pertussis are of an unequivocal character. A febrile movement may be present with a simple bronchitis. If bronchopneumonia is imminent or present, the fever is marked and constant, and may reach 106° F. (41.1° C). The dyspnoea is very marked, but the cough may not be increased. In certain forms of pertussis without complications there is a slight constant dyspnoea, which is due to the disease. If bronchopneumonia is a complication the dyspnoea is more decided, the number of respirations three or four times the normal, and the pulse-rate increased. There is marked cyanosis. There may be all the symptoms of a severe bronchopneumonia, such as tympa- nites, vomiting, and green diarrhceal stools. The bronchopneumonia is, as a rule, of the disseminated type, with areas of consolidation of greater or lesser extent in both lungs. The infants are much more ill than they would be with a primary process of the same extent. A bronchopneumonia of this kind can be diagnosed if upon exami- nation there are, in addition to the physical signs of bronchitis, fine crepitations over the different parts of the chest, especially over the lower lobes of both lungs posteriorly. There may also be dulness with bronchophony and bronchial breathing over small areas, either in the upper or lower lobes of the lung on one or both sides. The bronchopneumonia of pertussis may supervene at any period of the disease, and is not the result of exposure. On the contrary, it may occur in infants and children who have been most carefully pro- tected from exposure. It is the result of the type of disease — a mixed infection. The pertussis probably makes the lung more liable to disease in some subjects than in others. The bronchopneumonia is a grave complication, and is very fatal. It may cause complica- tions, such as pleurisy of a serous or purulent nature, and often opens DISEASES OF TEE LUNGS. 639 the way for invasion of the lung bj tuberculosis. It may run a chronic course (persistent pneumonia) and reduce the patient to a very weak state. The patient will then develop consolidation of a whole lobe of the lung which will take weeks to clear up. Measles. — Bronchopneumonia complicating measles supervenes, as a rule, in the stage of eruption, and is a very serious complication. Its presence may be suspected if, on examination of the chest, there are found, in addition to the rales of bronchitis, very fine crepitant rales over areas disseminated through both lungs. This complication also causes a febrile movement after the fading of the eruption and repeated severe chills with every new area of the lung involved. There are severe cough and dyspnoea. The pulse may reach 180 to 190, and the respirations 90, but the patient may recover even if the signs of cardiac weakness, such as cyanosis, are marked. The patient is stupid, does not take food or notice his surroundings. Sometimes there may be other signs, such as hemorrhages into the eruption (so- called hemorrhagic measles), indicating that the process is one in which there is a mixed infection. There may be a complication of serous or seropurulent pleurisy. Typhoid Fever. — Bronchopneumonia complicating typhoid fever does not, as a rule, give very striking features apart from those be- longing to the latter disease. It seems to be of a mild and insidious character. The bronchopneumonia of typhoid fever is apt to mask the typhoid if it appears at the outset of the disease. There is then a typhoid beginning as a pneumonia. The area of bronchopneumonia is well localized. It may be a small area in the upper or mid-region of the lung. The febrile curve in these cases may range quite high at the outset and thus mislead the physician. The process persists for weeks, sometimes as long as five weeks. The lung is slow in clearing up. The signs of dulness, bronchial voice and breathing may persist into convalescence. In other cases the pneumonia may super- vene in the course of the disease. It can then be detected only if the cough is harassing and the dyspna-a marked. In delirious pa- tients the pneumonia can only be discovered by repeated and constant examination of the chest. These cases are not so apt to develop pleurisy of a serous or purulent nature as the pneumonia complicat- ing measles or scarlet fever. Varicella. — Varicella is only rarely complicated by bronchopneu- monia. In this disease also the pneumonia runs a protracted course, but is less serious in its outcome than in the other exanthemata. It occurs in the severer forms of varicella in which the eruption is com- plicated with abscesses or necrosis of the skin (mixed infection). Scarlet Fever. — Scarlet fever is not so frequently complicated by bronchopneumonia as measles, but when it does occur the broncho- 640 DISEASES OF THE EESPIEATOEY SYSTEM. pneumonia is of a very severe type. It occurs in the septic forms of scarlet fever, and may appear early in the disease, on the fading of the eruption. Scarlet fever complicated by bronchopneumonia is frequently followed by pleurisy of a purulent nature. Diphtheria. — ^The bronchopneumonia which complicates diph- theria has been carefully studied by Northrup and Prudden. It is the result of a streptococcic invasion of the lung or an invasion by the EHebs-Loffler bacillus. As a rule, however, it is a mixed infec- tion, as was pointed out by ISTorthrup and Prudden. The laryngeal form of diphtheria frequently proves fatal through this complication. Diarrhceal Condiiions. — Of special interest is the bronchopneu- monia which complicates chronic or subacute diarrhoeal conditions. This form, which is of a distinctly septic type, is caused by infection of the lung by streptococci, which invade the general circulation through erosions in the mucous membrane of the gut (Booker, Czerny, Fischl) . It is not always due. as was formerly supposed, to keeping the infant in the recumbent posture, nor does it occur in hospital practice alone, but is frequently seen in private practice in infants in unhygienic surroundings. It is of the persistent type, and runs its course with a daily high or low febrile curve, and results in areas of consolidation, which sometimes involve a whole lobe of a lung. This form of pneumonia is one of the fatal complications of the subacute intestinal catarrhs. Some infants, after one attack of bronchopneumonia, have re- peated or recurrent attacks on the least exposure (Fig. 134), in some cases developing catarrhal croup. In other cases, there develops an emphysematous condition of the lung, in which the least exposure or change in the atmosphere will cause an asthmatic attack. Course, Termination, and Complications.- — Bronchopneumonia may terminate in complete recovery and restoration of the lung to the normal, or may prove fatal. The mortality varies at different times and with the environment. The prognosis in marantic infants, and also in bottle-fed infants, is very bad. Rachitic infants have bron- chopneumonia with a very protracted course (Fig. 135). The forms which complicate measles, pertussis, scarlet fever, and infltienza are very fatal. Abscess or gangrene of the lung may be a complication. In some forms of otitis the symptoms may very closely simulate those of tuberculous meningitis. Otitis prolongs the disease and frequently misleads the physician. Especially trying are the forms of broncho- pneumonia of very limited extent in one or both lungs, in which there is a protracted, remittent or intermittent fever-curve. Serous pleu- risy and empyema are very common complications. Their presence may be suspected if the disease runs a course protracted beyond two weeks, and if signs, such as dulness, flatness, and bronchophony, per- sist and become more marked over the whole side of the chest. DISEASES OF THE LUNGS. 641 "H , 0£I ZT I*- 2EI Of < 0£I Of r^ OST OT 081 Of ^- on ff r 0^1 ze Ofl Of < »£X 88 k "" 981 08 OIT Of p- ■ 9n Of ^ sn Of fC i_ r"i- Z9I Tf - f^ fTI Kf - 4- OTt Of r TTI Of r? 09T 95 < 201 09 ■^ ~~! OZI 8S < i < > V ^, L 1 i' <, TjH t-l 6 kl i <■ 4 ;■ •i 021 8S J' OZI 02 8TI 8Z > 981 98 8Zl- D-£ ■f A J. r' on 88 ^ 091 8f J TOT fS 1^ 091 8S ■vl^ooe" :•: ■! 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OSl OR s. o 1-RI f-R X - 3 I • i REl If: I OR X ~- J •cr^ OR X 3 j T ■• — - T-Hi ir:i i::l IS 58 ^ z ^ 1 - 2- - 3 j rr -■■,:l OC -5 Jj_ J / N 1 ISU )!■ » is 3 I % 'co °Qj 'in 'cs °o °oo "^c- OOoOOCaosCi 1 i § - X s it -J o 41 642 DISEASES OF THE SESPII^AIOEY SYSTEM. Meningitis. — ^Meningitis may complicate the disease. Care should be taken not to confound cerebral symptoms with true meningitis. Pericarditis. — Pericarditis comi^licating bronchopneumonia is apt to be purulent, and is rarely diagnosed during life. I have seen cases in which during life repeated examinations failed to reveal positive signs of eifusion into the pericardium, but in which purulent pericarditis was found at autopsy. This is frequently true of cases in which the effusion is limited (30-50 grammes). If bronchopneu- monia occurs in the left lung with consolidation anteriorly and some pleural effusion, it is almost impossible to diagnose moderate peri- cardial effusion. The complication is very fatal. Osteomyelitis. — Pfisterer has recently published a number of cases of pneumococcus osteomyelitis and metastases occurring by way of the blood or lymph-stream. In some cases the arthritis may precede the pneumonia ; in others, may follow it. The portals of infection include the tonsil, among others the mouth or nose, the ear or peri- toneum. Traumatism may be a predisposing factor. J^etter found 3 of arthritis in 1218 cases of pneumonia. It is therefore rare as compared to other complications of pneumonia, such as otitis or men- ingitis. I have seen one case in a newborn infant, the subject of congenital syphilis, with bronchopneumonia of a syphilitic character. In this case the hip-joint was the seat of pneumococcus suppuration. I have since seen a number of cases of pneumococcus arthritis in in- fants. As a rule, the larger joints, the shoulder or knee, are affected. It is generally monarticular, but may be polyarticular. The symptoms in some cases escape observation ; in others, the symptoms are similar to those of osteomyelitis with arthritis. If the arthritis is very acute and other organs are involved, death may result ; but, on the other hand, if the joint is evacuated in time, recovery may take place. The pneumococcus arthritis involves the tissues surrounding the joints. The cartilages of the joint are rarely involved. Pneumo- coccus osteitis affects the cortical layers of the bone in the vicinity of the epiphyseal line. Large sequestra are rare. Of 41 cases, 15 occurred in childhood in the first two years of life. Of 44 cases of pneumococcus arthritis and osteitis collected by Pfisterer, 23 died. Death was due to pneumonia, empyema, menin- gitis, endo- or pericarditis. Physical Signs. — Clinically the physical signs of broncho]uieu- monia are divided in those of the following stages: the first stage — • invasion ; the second stage — consolidation ; the third stage — resolu- tion. There is no sharp line of demarcation between the signs of the stages. First Stage. — Inspection shows the face to be flushed on one or both sides, and the nostrils to be dilated ; with each inspiration there DISEASES OF THE LUNGS. 643 is drawing inward of the peripneiimonic groove and sometimes of the suprasternal tissues over the upper joart of the trachea. If bronchitis is present, there may be rhonchal fremitus, but it is frequently absent. In the early stage there is, just before consolidation, slight dulness over small areas, which in young infants with thin-walled chests may have a slightly tympanitic note (tympanitic dulness). Other parts of the chest may have a vesiculotympanitic note. If bronchitis is present, the rales of bronchitis may be heard. The respiratory murmur is rude. By careful examination of all parts of the chest one or more areas in which are heard fine crepitant rales may be found. They may easily be overlooked, and may dis- appear when the infant cries or coughs, and during the examination. Vocal resonance is sliahtlv increased over areas in which there is slight dulness or beginning consolidation. The whole posterior aspect of the thorax from above downward, and also the axillary region should be examined. The apex of the lung in front, and the lower part of the thorax in front and behind on both sides, should be carefully examined, as well as the areas of the borders of the lungs where they come in contact with the chest-wall. Increased vocal resonance and slight dulness alone, especially over the apex of the right lung in front and behind, should be accepted with great caution as indicative of the beginning of bronchopneumonia. Dyspnoea should not be looked uj)on as a sign of pneumonia. The crepitant rale in a circumscribed area or in several areas is the sign pathognomonic of this stage. Second Stage. — Inspection shows no condition differing from those of the first stage. If the area of consolidation is limited, there is no change, because the area and the chest are small. If there is effusion in the lower portion of the pleural cavity, the fremitus may be diminished over the lower part of the chest, although the pneumonia is in the upper part. Fremitus is therefore misleading, and is only confirmatory in the presence of other signs. Percussion reveals dulness in complete consolidation or dulness with a tympanitic note in the beginning of consolidation, and also flatness if fluid is present over the consolidated area in the lower part of the chest. The dulness may involve a very small area or an entire lobe of the lung. There may be slight resistance to the per- cussing flnger over the consolidated area. The unaffected lung is hyperresonant. Auscultation gives bronchophony and bronchial or bronchovesic- ular breathing over the consolidated areas. These are not necessarily present over consolidated lung. In infants and children there may 644 DISEASES OF THE EESPIBATOEY SYSTEM. onlj be abnormally rude respiratory murmur and increased vocal resonance. Fine crepitant pleuritic rales may be beard over tbe con- solidated area. Diagnostic stress is to be laid on complete dulness witb bron- cbopbony and broncbial breatbing. Third Stage. — Palpation will give increased fremitus if tbe con- solidated area is large and tbere is no fluid over tbis area. As in tbe first stage, tbere is dulness to a varying extent, witb a tympanitic note sbowing tbe return of air into tbe lung. Auscultation gives a crepitant rale, as in lobar pneumonia. Tbe voice and breatbing are less broncbopbonic. Dulness may persist for days or weeks. In some cases tbere is fluid, wbicb increases tbe dul- ness or flatness. Dulness, crepitant rales, broncbopbony and bron- cbial breatbing are constant features, and are diagnostic. In infants and cbildren, broncbopbony is more constantly present tban broncbial breatbing. In tbe broncbopneumonia of tbe newly born infant it is sometimes possible to discover witb tbe small bell of a stetboscope areas in wbicb air does not enter (atelectatic). Equivocal Signs Likely to te Mistaken for the Beginning of Broncho- pneumonia. — In infants and cbildren, tbe pbysician is apt to be easily misled into a diagnosis of incipient broncbopneumonia. Equivocal signs — i. e.j signs wbicb are not absolutely diagnostic — are apt to be met in certain parts of tbe cbest and in tbe presence of rational symp- toms, sucb as fever or apparent dyspnoea, undue importance may be atacbed to tbem. Tbese signs are as follows : a. A sligbtly bigb note on percussion and an increase of vocal resonance or fremitus, witb a rude respiratory murmur on tbe right side over tbe apex in front or bebind. It sbould not be forgotten tbat tbis region, especially in infants, normally sbows varying degrees of tbese signs as compared witb tbe left side. h. A sligbt dnlness over tbe lower part of tbe cbest on tbe rigbt side bebind, due to tbe presence of tbe liver, is normal. To be abnormal, tbe dulness must be very marked and tbe vocal resonance mucb increased. Tbe resistance to percussion must be pronounced in tbe absence of more positive signs, to justify a suspicion of tbe beginning of consolidation. c. Broncbial or broncbovesicnlar breatbing too near tbe vertebral column bebind on eitber side, between tbe scapula?, sbould be cau- tiously interpreted. In some infants, the breatbing in tbis region is normally broncbovesicnlar. It is in tbis region tbat the diagnosis of central pneumonia is so often made — a diagnosis rarely verified by the subsequent course of a case. d. In some infants and cbildren, especially from six to ten years of age, it is found tbat ibc fi'cmitns and vocal resonance diminish DISEASES OF THE LUNGS. 645 behind from a short distance below the angle of the scapula to the base of the lung; the breathing also is heard less distinctly. A diag- nosis of pneumonia or consolidation with fluid requires positive and unmistakable evidence very low down behind. The thick muscles of the back and organs behind the thorax, such as the kidney and liver, obscure slight signs below the ninth or tenth rib. Diagnosis. — Bronchopneumonia should be differentiated from the lobar fibrinous form of the disease. In children above five years of age this is not difiicult ; in those under the second year, in whom fibrinous or lobar pneumonia is not uncommon, a positive diagnosis of lobar pneumonia cannot be made until the stage of consolidation, and even at that time only as to distribution. In the main, it is made from the course of the temperature. In lobar pneumonia the temperature will fall by crisis after the usual j)eriod. A marked leucocytosis, which increases toward the day of crisis and then rapidly diminishes, is also a characteristic feature. There should be also the physical signs of lobar consolidation. If these symptoms and signs are all present, it may be assumed clinically that a lobar pneumonia is present. Such a diagnosis is always open to doubt, for a bronchopneumonia may have the lobar consolidation and the leucocytosis, but will rarely have the critical drop of temperature which occurs in lobar pneumonia. As to the onset, bronchopneumonia may set in with a chill, and lobar without one. The complications in both forms are identical ; empyema is as likely to occur in one as in the other. Lobar pneumonia is rarely prolonged in duration if complications are absent, while the broncho- pneumonic type of disease is, as a rule, of longer duration and may be prolonged into a chronic course. Disseminated patches of consolidation in a lung in which there is. general bronchitis point to bronchopneumonia; diffuse bronchitis, with fine crepitations in the lower lobes of both lungs, to broncho- pneumonia. The presence of a primary disease — measles, scarlet fever, typhoid fever, and influenza — will also influence the process in the lung. The secondary pneumonia is a bronchopneumonic process. Prognosis. — The mortality of bronchopneumonia, even under the favorable conditions of private practice, is as high as 25 per cent. In hospital practice it is much higher, and may reach 50 per cent, or more. It is greater in bottle-fed, rachitic, prematurely born, and syphilitic infants, and is greatest in the first year of life. The dis- ease is especially fatal in newly-born infants, and in cases of gastro- intestinal disorder. The mortality rate increases in iSTew York City in the months of December, January, and February, during which the weather is alternately moist, warm, and cold. Certain years show an increased mortality because of the severe nature of the epidemic. 646 DISEASES OF THE JSESPIEATOEY SYSTEM. At the bedside, a prognosis is based on the condition of the lung, temperature, heart, and the presence or absence of nervous symptoms. A persistently high temperature, if there are areas of consolidation in both lungs, is of serious import. An abnormal pallor or slight cyanosis in a bottle-fed baby, even if well-nourished, is a danger signal. Forced and irregular action of the diaphragm is serious ; marked drawing inward of the sides of the chest, sometimes as high as the eighth rob, is a very unfavorable sign in infants. These cases show a depression of the suprasternal notch as marked as that which occurs in laryngeal obstruction. Repeated convulsions and jaundice, with enlargement of the spleen, in rachitic infants indicate intense toxaemia. These cases are fatal. Marked tympanites at the end of the first week, in connection with diarrhoea and weakness of the heart, is an unfavorable symptom. Dyspnoea with respirations irregular in rhythm and dej)th denotes diffuse involvement of both lungs, and is present in the unfavorable cases. Cerebral symptoms supervening late in the disease are unfavorable. The favorable signs are a good muscular quality of the first sound of the heart, red lips and warm surface ; good reaction after hydro- therapy, and periods of quiet sleep with full noiseless breathing, movements of the bowels normal or slightly green, and an absence of marked tympanites. Caution should be exercised in making any prognosis in a bronchopneumonia which shows a marked tendency to involve new areas of lung with repeated chills and cyanosis. Treatment. — In the treatment of bronchopneumonia of infants and children, it should be borne in mind that the disease is a self-limited, acute, infectious one, and that there is no remedy which can abort it or prevent complications. As in lobar pncimionia, the ill effects of the disease must be counteracted as much as possible and the strength of the patient supported. Since the patients are of very tender age, remedies which are powerful in their ultimate effects are to be care- fully avoided. The indications in the treatment are to counteract the effects of the temperature and to support the heart. Hydrotherapy. — The temperature in the most fatal forms of this disease in newborn infants is below the normal at times, and rarely reaches a very high point. In other cases of bronchopneumonia in older infants and children, it remains persistently above 103° F. (39.7° C). In these cases, as in lobar pneumonia, the various forms of hydrotherapy are utilized. Of all the methods, the cold compress applied to the chest, as before described, seems to be the most effica- cious. Compresses lower than Y0° F. (21.1° C.) are not applied. The applications may be renewed every hour, if the patient bears them well. A couijjit'ss wrniig out in water at T0° F. (21.1° C.) will depress sftiiic ]);iticnts, causing cyanosis without reaction. In DISEASES OF THE LUNGS. 647 such cases, as in the lobar eases, I have found the warm bath, 105°— 107° (40.3°-41.6° C), of the greatest utility in relieving the nervous symptoms, such as restlessness and convulsive tv^itchings. Infants, as a rule, will not bear baths below 80° F. (26.6° C). I therefore do not utilize the cold full bath in infants. I do not think it advis- able to use the bath at 90° F. (32.2° C.) or higher, with cold douch- ing of the head and shoulders, to obtain reaction in infants. The 23rocedure rouses the patients only momentarily, and the subsequent depression is greater. Cold packs over the whole body are also heroic remedies, but are advocated by some authors. Medicinal. — The heart is supported b}^ means of digitalis, strych- nine, camphor, musk, caffeine, and ammonium carbonate. Of these agents, the most useful are digitalis, strychnine, and musk. Digitalis is administered in the form of the tincture. A drop is given for every six months of the age of the patient. It should not be used unless the pulse rate is high, and should then be given every three hours. It is discontinued after being administered for two or three days. The effects of stronger preparations, such as the fluid extract, cannot be gauged so carefully as those of the tincture, and they are therefore less useful. The cases in which digitalis is of the greatest value are those in which there is cyanosis to a mild degree, or exces- sive pallor denoting great cardiac weakness. Strophanthus may be administered alone or in combination with digitalis. The tincture is the form generally used. Strychnine is one of the most useful drugs in the treatment. An infant six months old will bear grain V250 or %oo (0.0003 or 0.00025) very well. Older infants and children bear grain M^o (0.0004) quite well. Strychnine should not be used in cases where there is increased excitability of the nervous system. Atropine, which is so useful in adults, is not well borne by infants and children. Ammonium carbonate is one of the most useful drugs when for any reason digitalis cannot be used. Convulsions or restlessness are treated with the bromides of potassium and sodium, which may be combined. Chloral hydrate is combined with both, especially where one dose of bromide of potassium and chloral hydrate is given per rectum. I do not use poultices. Some authors use them as a routine measure. Inhalations of benzoin and turpentine are of doubtful efficacy. They do not affect the local lesion in the lung, nor do they act on the mucous membrane as they do in catarrhal processes of the nose and throat. In some cases I have seen harm result from overloading the atmosphere with the odor of balsam. 648 DISEASES OF THE SESPIEATOSY SYSTEM. The patient should be isoh^ted from the healthy children of the family and the room kept at a temperature of from 68" to 70° F. (20° to 21,1° C.) and well ventilated. An open wood fire is the most satisfactory method of heating and ventilating the sick-room. In threatened oedema of the lungs I have found, as in lobar pneu- monia, that the right ventricle is best relieved by nitroglycerin, grain ^00 to /loo (0.0003 to 0.006) at a dose, and by the constant adminis- tration of oxygen containing 20 per cent, of nitrous oxide. Alcohol is so universally used that the mode of administering it should receive special mention. Alcohol should not be used as a routine remedy. In some 'of the milder cases its use is superfluous. There are other cases in which its use must be suspended because of the constant vomiting. In the severer types of bronchopneumonia, in which the temperature is persistently high, the effects of the tox- semia may be counteracted by administering whiskey. Infants receive from minims xx to xxx (1.2 to 2.0) ; older children a drachm (4.0^) every three hours. The whiskey should be well diluted, and should be given after the nursings. The feeding of infants who take a substitute for the breast should be carefully watched, especially in bronchopneumonia, a disease in which diarrhoea is apt to supervene. If diarrhoea is present, the milk should be discontinued and a cathartic given. The infant is given a high rectal injection of warm normal saline solution twice daily, and is kept on solutions of egg-albumin and acorn cocoa and cereal gruels until the intestinal symptoms subside. Milk is then again given. In these cases of intestinal disorder it is of the utmost im- portance to see that the milk is fresh and uncontaminated. The cases not complicated by diarrhoea are given a warm high rectal enema of the normal saline solution once daily. In infants, this procedure will ward off tympanitic distention of the abdomen and stimulate the heart. The cough is sometimes very harassing, and then only should be relieved. The camphorated tincture of opium or the wine may be given in moderate doses. Codeine is useful in older children. In the many hundreds of cases which I have treated I have not found it necessary to use morphine. Strapping the chest to relieve pain is harmful in infants and children. The chest in these subjects is resil- ient, and any limitation of its motion reacts unfavorably in prevent- ing a full expansion of the unaffected lung. Persistent Bronchopneumonia (Chronic Bronchopneumonia). — Persistent broncho] )ncumonia is a distinct type of bronchopneumonia the course of which extends over weeks or months, the patient mean- while becoming much reduced in flesh and strength. These cases occur in weakly infants, usually in those who are bottle-fed. A dis- DISEASES OF THE LUNGS. 649 tinct type of the disease complicates chronic enteric catarrh. Cases of this class belong in the category of Gastro- intestinal Sepsis of Fischl, Escherich, and Czerny. Cases of another set com- plicate and follow pertussis, measles, and influenza. Lastly, there is a true tuberculous form which is not strictly included in the above classification. The condition is thus rarely primary. Symptoms. — The infant or child has at first the symptoms of an ordinary bronchopneumonia. The fever, however, is of longer duration than in cases which recover. Cases of gastro-enteric affec- tion or pertussis will continue to have a remittently high temperature which may reach 105° (40.5° C), but fall to 101° or 100° (38.3° or 37.Y° C.) on the same day. It will remain normal for days, and then rise again, as indi- « cated in the chart (Fig. 136). There ^ are cough, dyspnoea, emaciation, and ^ gastro-intestinal disturbances. In cases of enteric catarrh the intestinal disease takes clinically a secondary place. Some of these cases eventually recover in spite of the progressive emaciation and high fever. This is especially the case in per- sistent bronchopneumonia which com- plicates pertussis. Blood. — In the case from which the chart was taken there was a distinct increase of the number of leucocytes with each new rise of temperature and fresh invasion of the lung. The num- ber of leucocytes mounted as high as 80,000 to the cubic millimetre. A dif- ferential count showed that the poly- nuclear neutrophiles ranged at different times from 73 to 82 per cent, of the leucocytes and the small lymj)hocytes (mononuclear) from 13 to 21 per cent. As the disease progressed, there were also signs of extreme ansemia, microcytes, megalocytes, and poikilocytes being present. o 1 1 i < ■ 003oti-o;a-M :=>• 1 3 1 1 1 ; 1 ; t- —7 i ^ J » 1 1 ' >; 00-^91. •0 rarMl i ' t 1 ; 1 ^ 005U •oj-a M l- r 1 s > 1 otoos -b -a •M.ef "o 1 iR i9is-o-s-M";r=»- "^ "= — — L •.i< - —; CS" 1* J cjoz^e ■0 a M ' l^ g > 1 ooepe a- fA — P- 5 1 C— — [^ 00*Sl 0- r Ia / M 5 R ~ ^ 5 J -^ 00881 op- IW 1 z=> 5 > ■^•^ 00902 o^a- w •<- r- **■ 1 1 > \ 0009* -0 -9 -M s ■ 5 ! i ''=sr^ 100 E/ a- V o — ■ — L « ]> > r- ^ ■" p> g f ^ g ^ . «;- ' S ? - r u !^ oz pi a- A * n 1^ i^ = •< i~- ^ "T" == - = s ^ S5 R- 1 T- " "( i ^1 1 1 tjoijd -J -a -M 1 i i "T^J i j - f 1 1 ^ f. i1 "t"^^ i^Si ! 5; J~"^^ OdSES'O'E ■N u €.a 650 DISEASES OF THE BESPIEATOET SYSTEM. Physical Signs. — ()ii examination, there are found areas of con- solifiation of varying extent, generally made out posteriorly over tlie ajjex or toward the base of the lung. There are signs of general bron- chitis, increase of fremitus, and dulness marked, slight, or combined with a tympanitic note. There may be fine crepitations here and there over the chest. If the areas are extensive, there may be bron- chophony or bronchial breathing. The complete consolidation of primary bronchopneumonia is not always present. The lung is only partially consolidated, so that the vocal resonance may simply be markedly increased or the breathing may be bronchovesicular. Diagnosis. — Persistent bronchopneumonia may be suspected if there is an area of dulness at the apex or in the midregion lower lobe posteriorly of one or both lungs which does not resolve after a lapse of weeks. The persistence of fremitus on the affected side, espe- cially in the midregion of the chest behind, will aid in excluding the presence of fluid if the area of consolidation is located in the mid- region, base or lateral aspect of the lung. The rest of the lung is in these cases resonant or hyperresonant. In doubtful cases the explor- ing-needle should be introduced into the chest to ascertain whether fluid is jDresent. Treatment. — The treatment is practically an extension of the treat- ment of the primary condition. If there is an affection of the gastro- enteric tract, it is treated. If there is pertussis, treatment proceeds on the lines usually followed in that affection. In some cases the administration of iodide of potassium in small doses has seemed to have a beneficial effect on the course of the process in the lung. DISEASES OF THE PLEURA. Pleurisy (Pleuritis). — Pleurisy in infancy usually occurs as a secondary disease ; it is rarely primary. Dry Pleurisy. — Dry pleurisy is the form in which the pleura is inflamed without any appreciable formation of exudate in the ]i]eural cavity. Pleurisy with Effusion. ^ — Pleurisy with effusion, or subacute pleu- ri.?y. as it is incorrectly called, is the form in which a serous or sero- fibrinous effusion is found in the pleural cavity. The form in which the effusion is of a seropurulent or markedly purulent character is also called empyema. Empyema. — Empyema is therefore a purulent or su])])urative pleurisy. There are other forms of pleurisy which occur with neo- ])]asms of the lung or pleurae. These are not discussed in this section. Dry Pleurisy. — Frequency. — Dry pleurisy, pure and simple, is, in my experience, clinically not common among infants and young chil- DISEASES OF THE PLEURA. 651 dreii. As an independent affection, it is found more frequently after the fifth year of life. Clinically, the cause of this infrequency in infancy cannot be easily explained. Young infants and children rarely indicate the pain which is the leading symptom. The disease is masked by other symptoms occurring at the same time. Older children locate the pain and direct attention to it. Etiology. — This form may be primary or secondary. As a pri- mary affection it is found in rheumatic subjects, especially those who are or have been subjects of disorders such as endocarditis or fibrinous adhesive pericarditis. In these cases the etiology is the same as that of rheumatism. The condition is secondary to pneumonia. It may be found complicating any of the infectious diseases — influenza, scar- let fever, measles, typhoid fever, or tuberculosis. In such cases the bacterial factor in the etiology is much the same as in the forms which will be considered under Pleurisy and Effusion. Pleurisy may com- plicate nephritis of the subacute or chronic type. Traumatism will cause this form of pleurisy ; exposure to cold or wet will predis- pose to it. Symptoms. — The cases of simple dry pleurisy not proceeding to the formation of effusion in the pleura, which have come under my notice, gave few symptoms. Pain. — The children in the majority of cases complained of dis- tinct localized pain on exertion or on deep inspiration. There is also some local pain on external pressure. I have seen marked pleu- risy of the dry form in which pain was absent. This is most likely to occur in pleurisies secondary to nephritis. In the primary type, the patients continue to walk about, but are pale and have an anxious expression of the face. There is sometimes a rise of a degree or more in temperature and the respirations are increased and superficial. Those forms described by Henoch as setting in with convulsions, high fever, and vomiting, have not in my experience remained dry fibrinous pleurisy, but have proceeded to the formation of effusion in the chest. The duration of dry pleurisy is variable, and in the rheumatic forms may extend over a long period of time. Diagnosis. — The diagnosis is not difficult, and is made from the physical signs and the history. On examination, a localized area over which there are a large number of dry crepitant rales is found. The rales are heard so close under the ear that they are distinguishable from the crepitant rales of pneumonia. In some cases there is a dry rubbing sound — a pleuritic friction — over the area affected. In the cases without complications there are no other signs. There is little or no dulness and no change in the voice or breathing-sounds. Prognosis. — The prognosis is very good. Tuberculous disease of the lung is not a causative agent in these cases in children so fre- 652 DISEASES OF THE BESFIBAIOHY SYSTEM. quently as in the adult. The primary dry pleurisies, Tvith proper care, subside and gradually disappear. Treatment. — The treatment of dry pleurisy is very simple. If the subjects are rheumatic, they are put on small doses of salicylate of sodium. The bowels are kept open with a saline cathartic, preferably Carlsbad salts. The patients are kept in bed. It is not advisable to strap the chest to relieve pain. The desired relief can be secured by some local application of iodine or a sinapism. Codeine is admin- istered in moderate doses to relieve the cough and pain. Pleurisy with Effusion (Subacute Pleurisy) and Empyema {Pur- uleni or Suppurative Pleurisy). — Frequency. — This form of pleurisy is common in infancy and childhood. The largest number of cases occur before the fifth year (Simmonds). The succeeding five years show the next greatest freqtiency, Israel found 29 per cent, of 206 cases to be purulent. ]\Iackey estimates the ptirulent cases at 40 per cent, of the whole number in children, as against 5 per cent, in adults. Combining the statistics of Simmonds and Hofmokl of Vienna, this form is found to have greater frequency in the male sex. According to these authors, the left side is more often the seat of the disease. Simmonds found the disease to be bilateral in only 7 out of 175 cases. Of 170 of my own cases of empyema, 3 were bilateral. Of these the majority occurred before the fifth year, and 25 per cent, before the age of two years. The youngest patient was two months of age. Etiology. — Primary pleurisy, whether suppurative or serous, is rare. The literature contains cases of acute effusion in the pleural cavity, in which there was apparently no exciting cause or primary lung affection. The etiology must in such cases remain in doubt. Infection may take place through so many avenues that it is difficult to point out the mode of entrance. Pleuritis, serous or purulent, is generally secondary in infancy and childhood. All forms of lobar or bronchopneumonia may give rise to pleurisy, most of the cases being traceable to this source. The infectious diseases — measles, scarlet fever, pertussis, typhus and typhoid fever, diphtheria, forms of tonsillitis, retropharyngeal and mediastinal abscess, may precede or directly cause an attack of pleu- risy. Chronic intestinal sepsis may cause empyema. In the latter case a pneumonia generally precedes the pleurisy or is present at the same time. In sepsis of the newly-born infant, there may be a com- plicating empyema. Osteomyelitis of the septic streptococcus variety may be complicated by purulent pleurisy. Tuberculous disease of the lung, actinomycosis of the lung, abscess of the liver, abscess in the mediastinum and abscess in the abdominal cavity involving the viscera, may cause pleurisy. Appendicitis may after the formation of abscess cause pleuritis by extension of the DISEASES OF THE PLEUBA. 053 jirocess along the coils of large intestine to the diaphragm. Finally, rheumatism may cause pleurisy of a serofibrinous nature. Exposure to cold and wet is undoubtedly a predisposing cause. In children, it is common to have a history of a fall or a blow occurring just prior to the attack of pleurisy. Morbid Anatomy. — Pleurisies which accompany acute pneumonia are the most frequent. In these, there may be a slight injection of the pulmonary pleura and a loss of the normal lustre. Here and there a few fibrinous threads or adhesions may be found coursing over the surface of the pleura or running from the costal to the pul- monary pleura (dry or fibrinous pleurisy (pleuritis sicca)). In other cases, there is a thickened condition of both pleural reflections, caused by the deposit of fibrin on the surface. Sometimes the amount of fluid is small, while the pleura is very much thickened. The pleura itself may be little altered ; underneath the flbrin the lymph- spaces and bloodvessels may be dilated. In some cases there is also a serous or seropurulent exudate containing leucocytes, endothelial cells, and bacteria. The fluid may be clear or bloody, turbid or opaque, yellow or greenish, and thinor creamy inconsistency. Large clots of fibrin may be found floating in the exudate. Adhesions may form pseudo-encapsulations of exudate, binding down the lung and preventing its expansion. In children, however, the tuberculous pleurisies are most likely to cause extensive thickening of the pleura. In addition to the deposit of fibrin on the costal and pulmonary pleura, there is a real inflammatory thickening of the tissue of the pleura itself, with a deposit of tubercle tissue. Serous or purulent exudate is encapsulated by adhesions, while the lung is bound down by layers of inflammatory tissue. In the tuberculous form the changes are progressive. In the acute inflam- matory forms, the exudates are absorbed and the fibrinous deposit is organized into new connective tissue. In time the pleura may be restored to the normal. Adhesions, however, form an important factor in acute pleurisy of children. The pleura may in some cases be permanently thickened by a new layer of connective tissue persist- ing throughout life. There are forms of pleurisy not tuberculous in which this thickened condition not only remains, but extends from the pulmonary pleura into the lung along the interlobular tissue of the lung itself. There are induration and destruction of lung tissue. This induration is seen in connection with persistent bronchopneu- monia. The amount of effusion (purulent) is sometimes quite large in children, and may reach 1000 to 5000 cubic centimetres (Sim- monds, Hofmokle). In scurvy and morbus Werlhofii, blood may be eft'used into the pleural exudate. Bacteriology. — Pleurisy or empyema is divided into several groups 654 DISEASES OF THE BESPIBATOBY SYSTEM. according to the class of bacteria found in the exudate. It is well established that the bacteria are the essential cause of the disease. The first and largest gToup is that in which the pneumococcus of Frankel, the lanceolate diplococcus, is found. These cases are called metapneumonic. Thev may occur during the progress of a pneu- monia or after it has run its course. In some cases the process in the lung plays clinically a secondary role. The pneumococcus seems to occasion very little disturbance in the lung and to spend its force on the pleura. Thus within three days after the initial chill the pleura is filled with serous or seropurulent fluid. Netter found that of 28 pleurisies in infants and children 53 per cent, were due to the pneu- mococcus. In 212 cases of empyema I found the pneumococcus by culture in 75 per cent. The second group comprises those cases in which the streptococcus alone, the staphylococcus, or the streptococcus with the pneumococcus or staphylococcus, is found. Xetter found that 17 per cent, of his cases were of the strejitococcus class ; 10 per cent, of my cases were due to this micro-organism. In cases of the septic type, such as com- plicate sepsis of the newborn or osteomyelitis, or follow scarlet fever, the StreiDtococcus longus is found in the exudate. These cases are severe. Six per cent, of my cases were caused by the staphylococcus. In 9 per cent, of my cases of empyema the streptococcus and pneumo- coccus were both found in the exudate. Although the pleurisies in which the streptococcus and staphylococcus are found may follow a pneumonia, they may also be secondary to a follicular amygdalitis, the exanthemata, typhoid fever, influenza, diphtheria, sepsis, and osteomyelitis. The third group of cases comprises those in which either the tubercle bacillus is found in the exudate, or the exudate is free from micro-organisms. The latter condition is frequently presumptive evidence of a tuberculous infection (Ehrlich). The tubercle bacillus was found in 1 per cent, of my cases, while in 3 cases the findings both by cover-glass spread and culture were negative. This would at most give a frequency^of 2 per cent, for the tuberculous variety of pleurisy or empyema. The last group is that in which microorganisms other than those mentioned are found in the pleuritic exudate. Such cases have been observed in connection with typhoid fever in which the Eberth bacillus has been found. Escherich has found the coli bacillus in a case of empyema. I have seen one case of this kind. The bacilli of the saprophytic variety and those which cause a putrid empyema are found in cases of this fourth class. The folloAving table shows the relative frequency of the various forms of pleurisy and empyema with the varieties of bacteria in the exudate: DISEASES OF THE PLEUEA. 655 Children, Netter Kopi.ik 28 cases. 212 cases. Pneumococcus 53.6 per cent. 75 per cent. Pneumococcus and Streptococcus 3.6 " 9 " Streptococcus 17.6 " 10 " Staphylococcus 6 " Putrid 10.7 " Tubercule bacillus ...... 14.3 " 2-3 " Fig. 137. Fig. 138, Adults. 17 per cent. 2.5 " 53 " 1.2 " 25 " \ Fig. 139. Fig. 140. Fig. 13 (.—Streptococci from the pus of empyema ; pure culture. Photomicrograph, x 1000. iiGS. 138 and 139. — Pneumococci (Diplococcus lanceolatus) from the pus of empyema Cover-glass preparations showing capsule. Photomicrograph, x 1000. Fig. 140. — Pneumococci (Diplococcus lanceolatus) ; pure culture from the pus of em- pyema. Photomicrograph, x 550. The most important fact to be dediieed from the statistics is that while tuberculous pleurisy in children has a frequency of 2 to 3 per 656 DISEASES OF THE FiESPIEATOBY SYSTEM. cent., adults show a mucli greater frequency, many of the strepto- coccus cases being tuberculous in the latter subjects. This figure added to the number of cases in which tubercle bacilli are found in the exudate would bring the frequency in the adult to at least the 45 per cent, given by Bowditch as the relative figure. Physical Characteristics. — The physical characteristics of an effu- sion in the chest are of clinical importance. An effusion if purulent has usually the gross physical characteristics of ordinary pus. In some cases the effusion is at first clear and serous, but is subsequently seen to be purulent without the occurrence of any extraneous infec- tion. In other cases the effusion may be a cloudy serum, which on exploratory puncture is after a few days found to be purulent. In rare cases the effusion or exudate in the pleura is hemorrhagic. An effusion of that character has not the same significance in children as in adults. In the latter such effusions may be tuberculous or due to some morbid growth of the pleura ; this is not necessarily the case in children. I have had a number of cases of hemorrhagic effusion into the pleural cavity. In none of them was there a tuberculous element. In all, streptococci were found in the effusion, and in some the admixture of blood could be traced to a scorbutic tendency. In one case, in an adolescent with localized effusion of a hemorrhagic nature, there was an actinomycosis of the pleura and lung. The history of this case was not that of an effusion of an acute, but of a subacute chronic nature. Symptoms. — There are no symptoms characteristic or pathogno- monic of effusion in the pleura or empyema. The condition is in most cases masked by the symptoms of the causal, affection. Cases following a pneumonia set in with a chill or a rapid rise of temperature, with which there may be a convulsion followed by stupor or cerebral symp- toms. After this onset the fever continues, ranging from 103° to 10.5° F. (39.4° to 40.5° C), the pulse being 140 to 180. There will be cough, great dyspnoea, and pain in the chest, which is especially manifest when the infant or child coughs. The breathing is shallow. xVfter a few days the acute symptoms subside, the fever becoming remittent. The temperature may be nearly normal. The dyspnoea continues, although the temperature and pulse may be normal during ]")art of the day. In some of the cases the effusion becomes apparent on the eighth day; in others a purulent effusion is found in the chest on the twelfth or fourteenth day of the disease. The effusion, which finally becomes apparent in the chest, has been coincident in its onset with a pneu- monia — there has been a pleuropneumonia. The process in the lung, however, takes a secondary place in the clinical picture when the effusion in the pleural cavity has accumulated. DISEASES OF TEE PLEUEA. 657 There is another set of cases in which the course of the disease is insidious. The patient may at the onset have had for two or three days a febrile movement which has subsided, leaving the child not quite well and with a slight febrile movement toward evening, a slight hacking cough, and some little pain in the chest on exertion. Langour and loss of strength are progressive. There may be exhausting sweats at night. Examination of the chest will reveal an effusion. The metapneumonic pleurisies in infants and children have a characteristic course. The patient has a typical pneumonia. The temperature on the ninth, tenth, or thirteenth day may drop to the normal or subnormal, the respirations continuing high. A gradual rise of temperature follows, with physical signs of fluid in the chest Fig 141. DAY OF DISEASE •'' G ' S 9 lU »> 12 13 11 15 IG 17 18 19 20 21 104" 2 103° < 102' ^ 101° 1 100° 98° -' -T -j- -:_-r ^^ -_r v-\- -^ -?- ^r rt: h^ R^ fe^ =T-- zr ^ -■r -^ br ^: -^ ^ ; ^ ;! i\ iV / \-i : --S ; - i^ n\ : "'i \^ y I'V s / V ; /' \ ■? r-£ i a] t \i . "= \ i^ ^v /: 1 ,^1 -2 " :^ / /; \^ :;i '■'A :=: V V 4 V fi ^^* ;* 7 /I V" /; ? '{^ !s :t| A ;» ■S I '-S \ /:\ i -/ N = J V \/ ;\ 1 <= ":^ z- 5 5 _ .* 5 ^ ;A /\ /^ / "-^ ^ ■s s ;- ; = i i"" ^ ; - PULSE S 2 3 2 2 S 2 5 s fj - ? a i II 1 ? :-• = 5 ? s 2 1 2 g if RESP. S § 3 s 3 8 s ? s 5 s s S S % s 8 s § £ 3 5; s s ^s Lobar pneumonia ; fall of temperature, by lysis ; gradual rise after the thirteenth day, due to empyema leucocytosis. Operation on the nineteenth day. Recovery. Boy, four years of age. (see Fig. 127). The pulse and respirations rise with the tempera- ture. Toward evening there may at times be chilly sensations. Ex- ploration may discover fully developed effusion in the chest, serous or purulent according to the severity of the pleuritic infection. As a rule the younger the subject, the more likely is the effusion to be of a purulent nature. The duration of the effusion in the chest will also be a guide in determining its nature. An effusion occurring after pneumonia in a young infant and persisting for a week after the pneumonia has run its course, is likely to be purulent. Diagnosis. — There are some symptoms, such as continued dyspnoea, a slight or troublesome cough, exhausting sweats, and a distinctly intermittent range of temperature, which in cases of pulmonary dis- ease should direct attention to the pleura. JSTone of these symptoms is, however, pathognomonic of pleurisy, serous or purulent, since they may be found in other pulmonary conditions. The diagnosis of pleu- risy with effusion or empyema should take into consideration not only the rational symptoms, but also the physical signs. Physical Signs. — The physical signs of pleurisy with effusion and of empyema are identical. 42 658 DISEASES OF TEE BESPIBATOET SYSTEM. Fig. 142. Fluid ix the Chest. — 1. The chest partly filled with fluid. 2. The chest full of fluid. 1. The Chest Partly Filled with Fuid. — It is assumed that the greater part of the fluid is in the lower portion of the chest (Fig. 142). In children and infants it does not cause displacement of the viscera. Inspection. — Inspection may show fulness of the lower part of the affected side; the lower part of the chest moves less than the opposite side. Palpation. — Vocal fremitus will be felt over the upper portion of the chest in front or behind, and will be lost over' the lower portion. Percussion. — Percussion of the chest in front will often give an exaggerated hyperresonant tone over the upper lobe of the lung. Behind, there is almost always dulness to a greater or less degree above over the scapula, due either to thick- ening of the pleura or to an exceedingly thin layer of fluid. This dulness can be distinguished from dulness due to other causes by firm percussion which will elicit the pulmonary note of the underlying lung. Below, over the fluid, the dulness changes to complete flatness. Auscultation. — The voice and breathing may be heard over the whole side with as much intensity as on the healthy side, or with diminished intensity below the level of the fluid. Rales, generally pleuritic crepitations, may be heard above the level of the fluid. Bronchial breathing and voice may be heard over the fluid or at the level of the fluid, but this sign is not absolute. Diagnosis to justify needle exploration must be based on absence of vocal fremitus over the fluid and its presence above the fluid, dulness behind above the fluid, which on firm percussion gives a faint puhnonary tone and flatness over the fluid with slightly increased resistance to the percussing finger. Note. — The method of examining infants for fluid is invariably that indicated in the earlier part of the book. It is a mistake to examine the infant as it lies in the lap of the mother, for in this position the fluid will gravitate. When the infant lies on the face, the fluid will again gravitate to the anterior part of the chest and thus not be made out. In the earlier stages of pleurisy the fluid only partly fills the thorax. On account of the small size of the Pleural cavity partly filled with fluid. DISEASES OF THE PLEUBA. 659 thorax in infants, it is impossible to determine the change of level of the fluid bj changing the position of the patient. The resonant note or Skodaic resonance over the lung apex in front should, in the presence of dulness behind and flatness below, always arouse suspicion of fluid, for in these cases the lung is com- pressed upward, forward, and inward, thus causing the vesiculo- tympanitic or amphoric note in front and above. The chest is partly filled with fluid, as is shown in Figs, 143 and 144. I have quite frequently found this condition in infants and children who have for a long time lain on the back, and in whom adhesions have kept a layer of fluid in the position shown in the flgure. It will be assumed for illustration that the right side is afl^ected : Fig. 143. Fig. 144. Fluid in a thin layer posteriorly in the pleura. Inspection. — On inspection, fulness of the intercostal spaces on that side may be detected ; the movement of the thorax is labored, and the intercostal spaces may be drawn inward on inspiration. Palpation. — Vocal fremitus due to the lung's being in contact with the chest-wall may be present over the anterior aspect of the chest. Posteriorly, the fremitus will be entirely absent. Percussion. — Anteriorly, the note may be vesiculotympanitic; posteriorly, there is complete dulness over the whole chest, which is more marked below. There is rarely the flatness obtained as when the chest is full or half full of fluid. There is also resistance to the percussing finger. By percussing firmly the note of the lung beneath will invariably 660 DISEASES OF THE FiESPIBATOEY SYSTEM. be elicited; Lreatbing-souiids and voice-sounds will be beard as normal or distant. Pleuritic Crepitations. — Pleuritic crepitations may be beard over tbe wbole affected side ; tbere is no displacement of tbe liver or beart on tbe left side. Diagnosis of fluid before exploratory puncture must rest on tbe complete or partial absence of fremitus bebind, and complete dulness or flatness. Tbe quantity of fluid is small; tbere is less resistance to percussion tban wben it is large. 2. The Chest Full of Fluid (Right Side). — Inspection. — On inspection tbe objective signs of intense or moderate dyspnoea are found: Tbe cbest on tbe affected side is immobile; tbe intercostal spaces are retracted witb eacb inspiration ; tbe affected side bulges visibly. Fig. 145. Fig. 146. I'leural cavity full of fluid. Flatness anteriorly and posteriorly. Pleural cavity filled with fluid. liung displaced upward and forward. Reso- nance anteriorly over the apex, either vesiculo-tympanitic or of the cracked- pot quality. Palpation. — \'ocal fremitus is lost over tbe v^'bole side in front and behind. In rare cases some fremitus is felt. Percussion. — Ordinary and fii-iii ])crciission give a flat note over tbe wbole chest in front and behind; tbe resistance to tbe percussing finger is wooden. In front, flatness ma,y be present over the apex of the lung (Tig, 14.">). In some cases tbe note over the apex of the lung may be am])boric or cracked-pot as over a cavity. This is due to Inng compression. In other cases tbe resonance in front, over the DISEASES OF THE PLEUEA. 661 lung of the affected side is vesiculotympanitic, owing to the pushing upward and forward of the lung and to its distention. Displacement of the Pleural Fold underneath the Sternum. — A very important aid in the diagnosis of fluid in either side of the chest is the displacement of the line of the reflection of the pleura in front. JSTormally the pleurae of both sides meet underneath the sternum in the median line. Above, at about the level of the second rib, they depart gradually from each other. If there is a large amount of fluid in the right chest, the pleural fold of that side becomes distended Fig. 147. DisplacemeDt of the left pleural fold in effusion (empyema) into the left pleural cavity; flatness to the right of the midsternum as indicated. and displaced to the left, and may be marked out above the heart by dulness to the left of the midsternum. If the left chest is full of fluid, the left pleural fold is displaced to the right and there is distinct dulness or flatness above, to the right of the midsternum (Fig. 14Y). _ Auscultation. — Auscultatory signs in infants and children are most puzzling when the chest is full of fluid, and little diagnostic value can be attached to them in some cases. The chest may be full of fluid while the breathing and the voice may be heard as on the 662 DISEASES OF THE BESPIRATOET SYSTEM. luiaffected side, and pleuritic crepitant rales or crepitations may be heard over the whole chest behind. In other cases, the breathing may be indistinct and distant, and in the lower part of the chest lost en- tirely. The voice may be bronchophonic in certain localities ; it may be of this quality over the whole diseased side of the chest behind, or the tubnlar sonnd may be conducted to the healthy side. The voice may be normal above and heard faintly below, toward the base of the lung. Diagnosis before exploratory puncture rests mainly on (a) com- plete absence of fremitus; (h) absolute flatness on percussion with resistance to percussion; (c) bronchial voice and breathing over the whole chest behind; (d) hyperresonance over the apex, and displace- ment of viscera, and of the pleural fold in front. Displacement of Visceea.- — Liver. — In infants and young chil- dren the presence of fluid may be indicated by displacement of the liver downward on the right side. I have been able to verify the dis- placement in cases in which large amounts of fluid were present. In infants, the liver is so large and the projection below the border of the ribs so undetermined, that it is difficult to estimate the exact amount of displacement. The chest is so easily dilated that an ordi- nary amount of fluid accommodates itself without markedly displac- ing so heavy an organ as the liver. In children I have been able to make out a displacement of the liver downward before the evacuation of large quantities of fluid. Displacement is of confirmatory value in diagnosis. Heart. — The heart-apex may be displaced toward the median line by fluid in the left pleural cavity. In children, when the amount of fluid is large, the apex is displaced and lies beneath the lower part of the sternum. A small amount of fluid will not always cause dis- placement, but will find its way around the heart. Remarks upon the Diagnosis of Fluid in the Chest, with Exceptional Signs. — It is not always easy, even for the expert, to decide without puncture as to the presence or absence of fluid in the chest of infants and young children. The following signs will be of service at the bedside. Duration of Illness. — If an infant or child has been ill for two weeks or more with signs of pneumonia during the early part of the disease, the physician should be watchful in the presence of the fol- lowing conditions : If the temperature does not fall, but though remit- ting still continues ; if the signs of consolidation of a small or large area give place to dulness or flatness over a whole side behind, with hronchopJiony over the whole side — for if the condition of the infant is tolerably good, it is evident that such bronchophony may not be due to the total consolidation of the whole lung, especially if there is DISEASES OF THE PLEUBA. 663 displacement of viscera, chiefly of the liver or the heart; if there is drawing inward of the intercostal spaces during inspiration, with real immobility and bulging of a side and dnlness or flatness and loss of fremitus. Fluid is very rarely encapsulated in a small area behind, about the midregion of the chest. Such areas are usually areas of per- sistent bronchopneumonia. In most cases, there is localized dulness, above and below which there is vesiculotympanic resonance, normal pulmonary resonance or exaggerated resonance. There is distinct respiratory movement of the affected side. On the other hand, a collection of fluid between the lobes of the lungs (interlobar) may give a localized flatness and all the auscultatory signs, such as bron- chial voice and breathing, of a local collection of fluid. This is gen- erally found in the midaxillary line or slightly toward the posterior axillary line on either side. There are certain localities in which the diagnosis of fluid must be made with reserve : a. In a case on which I operated, fluid was found posteriorly over the situation of the upper lobe of the right lung. The fluid was com- pletely shut off from the rest of the pleural cavity by a membrane stretching from the thoracic wall to the interlobar fissure of the lung. Postmortem showed the case to be tuberculous, the lung on the affected side being the seat of persistent tuberculous bronchopneumonia. I have seen similar cases which were metapneumonic. b. Fluid over the upper lobe in front only is rare. I have seen four cases in which the empyema was localized over the apex of the lung on either side. The signs in these cases were diagnostic. There was flatness on percussion, resistance to the percussing finger and complete absence of respiratory murmur. c. Fluid over the lower lobe of the lung, in front on the right or left side without corresponding signs behind, is uncommon. d. Circumscribed collections of fluid behind over the middle re- gion of the lung or toward or in the axillary line are exceedingly uncommon. e. In the chapter on the physical signs of pericarditis, it will be show;n how a pleurisy or empyema on the left side may be mistaken for pericarditic effusion. Physical signs having led the physician to suspect fluid, the chest should be explored for two distinct reasons : to determine absolutely the presence of fluid, and to ascertain whether it is serous or purulent. Diagnostic Exploratory Puncture of the Chest. — Instruments. — The instruments necessary are an exploring needle, a millimetre in calibre, and an aspirating syringe. The needle should not be too short, else it may snap off in the chest. The needle and syringe are boiled for 664 DISEASES OF THE BESFIBAIOET SYSTEM. a few moments before being used. The patient is held in the arms of the nurse or mother, so that the posterior aspect of the chest may be exposed. Older children may sit on a table. The chest is scrubbed with soap and water, washed off with ether, then with alcohol, and finally with a solution of sublimate (1:2000). The arms of the infant or child are firmly held and the chest steadied in such a manner that should the patient start suddenly the needle will not break in the chest (Plate XXIX). Introduction of the Needle. — The chest is again percussed and the needle introduced into the intercostal space in which pei'cussion elicits the most marked dulness or flatness. This rule should be invariably followed ; the needle should not be introduced into any particular intercostal space. On the right side the physician should avoid putting in the needle too low down (liver) ; on the left side he should avoid introducing it too deeply for fear of wounding a large vessel at the root of the lung. The needle should not be entered too near the vertebral column. The needle having been introduced one or two centimetres, the piston is drawn and held thus a few seconds. Sometimes the fluid is thick and does not flow freely into the syringe. The syringe should not be introducedandthen withdrawn and pointed up and down in various directions in quest of fluid, for fear that the struggles of the patient, even if he is firmly held, will cause puncture of the lung and bloodvessels. The needle should be withdrawn as rapidly as it was introduced and the whole operation completed in less than a minute. The external wound is covered with a small strip of sterile gauze held in place with rubber plaster. The needle while in the chest should be held loosely. If it is held firmly, any sudden movement of the patient will cause it to break off' in the chest. The needle should not be introduced too deeply lest it may enter a dilated bronchus and withdraw purulent secretion Avhich may be mistaken for empyema, or that it may wound the lung and cause hemorrhage or pneumothorax. Perforating Empyema. — An empyema may perforate externally. In that case there will be an extensive infiltration of the tissues ex- ternal to the ribs on the affected side, resembling a large phlegmon, and the signs of fluid will persist. If the perforation occurs on the left side, the movements of the heart are likely to be conducted to the external swelling, and there is then what has been called pulsating empyema. The empyema may perforate through the lung, and the signs will then vary with the length of time during which the perfora- tion has existed. It is customary for writers to repeat one another in recounting the physical signs of pneumothorax in a chest in which fluid (pleurisy or empyema) is present. In infants or very young children the following classical signs of pyopnenmothorax observed in PLATE XXIX Showing the correct position of the child and operator in making an exploratory puncture for fluid in the pleural cavity. The plate is not intended to illustrate the point of puncture, which is always at the discretion of the operator. DISEASES OF THE PLEVEA. 605 adults are not commonly found ; amphoric breathing, amphoric voice, metallic tinkle and succussion-sounds, Mj cases were in children under two years of age. The perforation in the lung must have been too small or too valvular to permit of the entrance of much air into the pleural cavity. These cases at first showed all the signs of the condition which was proved, on introducing the needle, to be em- pyema. Operation being refused, after a few weeks (three months after the beginning of the disease), the signs changed as follows : Periodic expectoration of large quantities of pus following cough- ing spells. Fremitus diminished over the whole right side and almost lost below. Dulness over the whole side in front and behind, with tympanitic note on deep percussion only. Voice normal; breathing normal — at least not varying from that on the healthy side. In the intervals of expectoration, there were in some cases bronchial voice and breathing. Fig. 148. cisL^/e 12 3 4 5 6 7 8 9 £ 101° .. , ; ]t_.k.._.»-p-,L_\- 24._L^», ^ --1-^ V - ---Nr\i PULSE o SS^^^ ^ 2 RESP. 3 nSSSS S f? Empyema, left pleura, followed thirteen days after operation by bronchopneumonia at the apex of the right lung. Male child, twenty months of age. Recovery. ]Sro succussion-sounds, no tinkling, no amphoric signs. The class- ical signs seen in adults are met in children above five years of age. Course and Termination. — Pleurisy with effusion and empyema have been considered together, because, in infants and children under two years of age, the effusion in the chest may at first be serous, but subsequently change into purulent exudate. A serous effusion may be followed by a purulent one ; it may remain serous and be absorbed as such. Thus it is best, especially in infants, to introduce an exploring-needle into the chest to determine the nature of the fluid as soon as its presence is suspected. In older children also this may be done at the outset. If a clear fluid is at first obtained and the symptoms do not retrograde within a short time, the needle should 666 DISEASES OF THE BE8PIBAT0B7 SYSTEM. be again introduced to determine whetlier the fluid has remained serous. It is frequently found to be purulent althougb no infection has occurred as a result of the first puncture. With ordinary clean- liness, the possibility of infecting a serous effusion in the chest and thereby causing it to become purulent is very slight. Purulent effu- sion appearing after the first exploratory puncture has shown the effusion to be serous, may be due to two causes : either to continuance of the pleuritic inflammation, or to the fact that if the infant or child has lain quietly in bed the purulent elements of the effusion have gravitated to the lower portion of the chest, leaving a clear serum above at the level of the puncture. Prognosis. — The prognosis of pleurisy with effusion and of em- pyema in infants and children is good. If treated in the proper manner, it is not more serious than the original causal affection. In private practice, the patient being under constant supervision of the physician, the outlook is very good. An effusion can be discovered early and the patient relieved. In hospital practice the results are still good if the cases are simple and come under treatment before systemic infection has taken place. In my service of 120 cases of all kinds, there were 20 deaths, 4 of which occurred from one to flve days after operation. Sepsis had been present before operation and caused the fatal issue. The septic cases therefore give an unfavorable prog- nosis, as do also those of a tuberculous nature. In the latter, as in other forms of tuberculosis in children, the outlook is better than in the adult and recoveries are not infrequent. Of the 20 cases of death after operation for empyema, broncho- pneumonia, either persistent or recurrent, caused the fatal issue in 11, general sepsis in 2, marasmus and ulcer of the duodenum in 1, and cerebral embolism in 2. A complicating pericarditis of a suppura- tive nature may cause death. It is not always possible to diagnose this condition during life. The complication most to be feared in empyema is a bronchopneumonia involving either lung. In many cases the bronchopneumonia is present at the time of operation, or it may come on a week or two afterward during apparent convalescence. The prognosis of tuberculous empyema is not so unfavorable in children as in the adult. In the former, empyema of a tuberculous nature, like other forrhs of tuberculosis, may with skilful management make an apparent recovery, though with marked deformities of the chest-wall. In this form of empyema the pleura is thickened, bind- ing down the lung and thus preventing expansion. Extensive rib resections thus become necessary in order to close up the suppurating cavity left by the unexpanded lung. Treatment.— If tm exploratory puncture a serous exudate which only partly fills the pleural cavity is found, the expectant plan is fol- DISEASES OF THE PLEUEA. 667 lowed. The bowels are kept open with an enema or a saline cathartic is administered daily. For this purpose a saline enema, or in older children a teaspoonful of Carlsbad salts in warm water mixed with milk is efficient. Local vesication is not needed nor is it advisable. The effusion is absorbed if the patients are kept quiet and the diet is easily assimilable. Citrate of potassium in grain v (0.3) doses every three hours may be given to older children. If the fluid increases in quantity, fills up the chest, causes dyspnoea or pressure symptoms, and is serous in character, the chest should be aspirated. The best form of aspirator for the practitioner is the Potain. The patient is aspirated in the sitting posture. The chest-wall having been cleansed, the needle is introduced in the posterior axillary line toward the lower third of the chest cavity. It is not withdrav^m until the flow has ceased or the lung can be felt against the needle in the pleural cavity. As soon as this occurs the needle is withdrawn and the puncture opening covered with a piece of iodoformized gauze. It sometimes happens that there are signs that the chest is filled with fluid and yet very little flows into the instrument. In such cases the needle should be withdrawn and introduced into the chest-wall at another point. The coughing attack which occurs during aspiration will subside on the patient's taking the recumbent posture. If the chest is quite full of fluid, it is well not to empty it entirely. Some- times alarming syncope with other signs of cardiac weakness, such as cyanosis, has supervened. If a limited quantity of fluid is removed, the absorption of the rest will follow rapidly. A daily saline cathartic is given ; the patient is kept quiet and allowed a nutritious and easily assimilable diet. The administration of salicylate of sodium may hasten absorption, especially in cases in which there is a rheumatic history. If there is pain or a harassing cough, small doses of codeine should be given. Empyema. — ^When the presence of pus in the chest is once estab- lished, it is imperative that it be evacuated with the least possible delay. In infants and children it is not advisable to temporize by first performing aspiration. Retention of even a limited quantity of purulent exudate in the pleural cavity not only leads to emaciation and physical weakness as a result of continued fever, but general sepsis may also result. Aspiration is not efficient,^ and is to-day prac- tically abandoned as a mode of treatment. The physician may either incise the intercostal space or resect a rib to obtain drainage. Simple incision in the intercostal space is efficient in many cases of empyema occurring in the first eighteen months of life. In these frail patients, excision of the rib has been sometimes accompanied by discouraging results. The greatest number of deaths after any operative procedure for 668 DISEASES OF THE BESPIEATOEY SYSTEM. the relief of empyema occur in eliildren under the age of eighteen months. The strength of the patient should be supported as much as possible. A general ansesthetic is not necessary for patients under this age. Bronchitis and pneumonia very frequently result from the general use of anaesthetics in young patients. Local anaesthesia Fig. 149. Kmi)y( incision in line willi the angle of the seiijiula. is all that is needed. Ethyl chloride in tubes is efficient. The su]-- face of the chest is carefully cleansed with soap and water, alcohol, ether, and sublimate. An incision two inches long or thereabouts is made obliqnely in the tissues over the intercostal space. The space in which a ih < die has been jn-eviously introduced and pus DISEASES OF THE PLEUEA. 669 found is chosen. The exploring-needle is always introduced just Ijef ore operation. Frequently, ahhough pus has been withdrawn from the chest, at a second aspiration none can be found. The theory is that either there was a small localized collection of pus at the first point of aspiration, or that the needle entered a bronchus and with- drew secretion collected there. On the right side the incision should not be too low, else a tube cannot be retained in the chest on account of the high position of the diaphragm. The seventh or the eighth space in the posterior axillary Fio. 150. Exsection of rib for empyema on the right side. Shows the resulting deformity. Five weeks after operation. Child, four years of age. ]ine is the best location if pus is present at this point (Fig. 149). On the left side, incisions should not be made too far forward, else the drainage-tube may impinge against the pericardium. The superficial tissues having been incised, the intercostal muscle is incised, the operator keeping as nearly as possible in the median line of the intercostal space and avoiding the lower border of the upper rib, yet not cutting too close to the lower rib. When the vicinity of the costal pleura is reached, a closed dressing-forceps is introduced into the pleural cavity and opened to widen the puncture. A small drainage-tube or two small tubes are placed in the jilpural 670 DISEASES OF THE EESPIBATOBY SYSTEM. cavity and prevented from falling into the pleural space by safety- pins passed through them at the distal ends. The pus is not evac- uated at the time of operation. The sudden evacuation of fluid which has been retained in the chest for a long time is apt to cause untoward syncopal symptoms. Gibson has made the excellent suggestion that as soon as the pleura is opened the drainage-tube should be quickly introduced into the chest, the gauze dressings applied, and the pus allowed to escape gradually into the dressings. The dressings consist of a pad of gauze around the tubes, covered by a dry sterilized gauze dressing which is renewed every day. The chest should not be irri- gated. ISTo instrument should be introduced into the chest cavity to loosen adhesions. The whole operation is extremely simple, and should not occupy more than a few minutes. Children under five years, and even older children may be treated by this method. In the older subjects, how- ever, the chest-wall is not so resilient; there are adhesions, and if they are numerous and clots are abundant in the exudate a subsequent excision of the rib may be necessary. On the other hand, the main object of the practitioner in these cases is to evacuate the pus, and incision will accomplish this quite as well as the other operation. If subsequently more drainage is needed, the patient will be stronger and better able to stand the more serious procedure. Incision is therefore the practitioner's operation even in older children, vdth whom anaesthesia must, however, be used. Chloro- form is easily taken ; very little need be used. As soon as the sMn incision has been made, anaesthesia should be suspended. Excision of the rib is best performed in children above the age of eighteen months, unless there is a contraindication. Severe pneu- monia, high fever, cardiac weakness, acute pericarditis or endocar- ditis, as complications, are contraindications. In such cases incision alone is performed. The rib is excised in the usual way, taking two- or three centimetres of rib subperiosteally and incising in the mid- line of the posterior layer of periosteum to enter the pleural cavity. The finger is not inserted into the pleura to loosen adhesions. After the pleura is opened, double drainage-tubes are introduced by Gibson's method, as in the operation of simple incision. Sinus. — After incision or resection of the rib, a suppurating sinus may remain for months. If a probe introduced into a sinus of this kind impinges against callus or denuded bone, a so-called secondary operation is necessary to take out the denuded rib or callus. This involves a difficult surgical procedure, which it is not necessary to describe here. A sinus of this form will not close until the bone is removed. Temporizing only subjects the patient to the dangers -oi prolonged suppuration (amyloid degeneration). DISEASES OF THE PLEURA. 671 Adhesions Binding Down the Lung. — There is another class of cases in which a large amount of fibrin has been thrown out on the visceral pulmonary pleura. The lung is thus cramped by an envelope of thickened pleura and cannot expand. A large suppurating cavity or a suppurating sinus is left between the pulmonary and costal pleura. This cavity must be made to close. In such cases the pa- tients are allowed to be up and about. They are taught to blow colored fluids from one bottle to another in the way described by James, of ISTew York (Fig. 151). Two bottles of equal size, each half filled with the fluid, are used. In simple cases this method is very efiicient; in others it is of no avail. The operation of taking out two or more ribs with the intervening pleura must then be per- formed. In other cases a more extensive operation — the so-called Fig. 151. James' apparatus for expanding the lungs in empyema. Estlander, in which large pieces of several ribs are excised with the intervening costal pleura — is necessary. If the lung is firmly bound down by a coating of fibrin, the chest-wall must be opened by reflect- ing a flap of several ribs and the soft parts. The pleura is peeled off the lung according to the method of Delorme. The lung expands, the costal flap is sewn back in its place, and the chest sinus is in time closed as a natural consequence. The question of irrigating the pleural isavity in the treatment of empyema after operation has been much discussed. As a rule, if the temperature drops after operation and remains low, and the dis- charge is not fetid, no irrigation is indicated. If, however, there are rises of temperature after operation, with a profuse or fetid discharge, the chest should be irrigated once daily with normal salt solution. Bilateral Empyema. — The treatment of bilateral empyema will tax the judgment of the physician. One side, preferably the left in 672 DISEASES OF TEE EESPIBATOBY SYSTEM. order to relieve the lieart, is first operated on by incision or rib exsec- tion; the other side is aspirated, and again aspirated if the flnid or inis accunmlates. After a week adhesions will have formed on the operated side, and the strength of the patient will warrant interfer- ence on the opposite side. When this is accomplished, the opening on the operated side must be closed by some device, such as a pad of gauze on which is placed rubber tissue covering, and the second side may be operated on by rib exsection or incision. I have followed this method in two cases without serious accident. The interval of a few days between the operations is sufficient to allow adhesions to form on the operated side to such an extent that, when the second side is opened, the lung of the side first operated on does not collapse. If the sides are operated on simultaneously, the con- sequent partial collapse of both lungs causes marked symptoms of asphyxia. Hemorrhagic Pleurisy. — Simple hemorrhagic pleurisy is not un- common. It is seen in pleurisy following simple pneumonia, influenza, the exanthemata, and in infants or children in whom there is a ten- dency to scorbutus. Cases which appear to be rheumatic have been published (Starck). The hemorrhagic form of pleurisy with effu- sion may occur in very young infants (Lewin, eleven months) or in young children. 'I have met a number of eases in children who sub- sequently made a complete recovery, and in whom I could find no tuberculous tendencies. The prognosis in this form of pleurisy is therefore much better in children than in adults. In the latter a hemorrhagic pleurisy is frequently indicative of a tuberculous factor in the etiology. Hemorrhagic Empyema. — Hemorrhagic empyema is also not un- common in infants and children. During the past year I have met four cases in which there was a hemorrhagic exudate. In one case the child was pale, though not emaciated. There may have been a scorbutic element. In another case, in a bo}", no such etiology was indicated. In a third case, in a girl, the child was much reduced in health. In three cases the hemorrhagic discharge persisted for days after the chest was opened and streptococci were found in the exu- date. In one case the discharging pus was for weeks tinged with blood. In none of the cases were tubercle bacilli found in the pleu- ritic exudate. Three of the cases made a very good recovery. In these cases also I am iiK-lincd to believe that tuberculosis is not always ail etiological factor. Subphrenic Abscess or Pyopneumothorax Subphrenicus. — The positive diagnosis of siil)i)hrenic abscess should be made with reserve, because no pathognomonic symptom or physical sign of the disease is known. It is a very valuable fact that in 50 per cent, of the cases DISEASES OF THE PLEUBA. 673 thus far recorded, the abscesses have contained gas or air. The con- dition is rare (Majdl) in adults and more so in infants and children. The abscess is situated beneath the diaphragm, and between that organ and the liver. It pushes the diaphragm upv\^ard, and may thus encroach on the pleural space and simulate a real pyopneumothorax. An area in the lower part of the thorax, which may give tympanitic resonance or tympanitic dulness from the second, third, or fourth rib downward, is thus caused. This resonance may even include the liver, which is displaced downward. Over the region of tympanitic resonance, especially posteriorly, the normal vesicular breathing is absent on expiration and present over the area on deep inspiration. It is a peculiarity of the condition that there may be amphoric breathing and metallic tinkle over the area, while anteriorly, just above it, from the second to the fourth rib, there is a sharp transition and normal breathing is heard. Behind, however, on deep inspira- tion, even over the region of tympanitic resonance, normal breathing may be heard over the lower part of the chest. Over the situation of the abscess the metallic tinkle and succussion-sounds may also be heard. As has been stated, the liver may be displaced downward, crepitations are heard anteriorly over the liver (perihepatitis), or it may be impossible on account of intestinal conditions to make out the lower border of the liver. I have seen a subphrenic abscess on the left side displace the left lobe of the liver and the spleen downward. The heart is not displaced inward if the abscess is on the left side, but if displaced at all, is so in an upward direction. The lower thorax region may show no abnormalities to inspection, while the upper abdominal region may be normal, painful to pressure, or slightly oedematous. Diagnosis and Treatment. — Exploratory puncture is resorted to in all of these cases. Diagnosis will be aided if the fluid obtained con- tains, in addition to pus, elements which denote the origin of the abscess, such as food particles, fseces, histological debris or pigment from the liver. In many cases the liver suffers from the vicinity of the abscess. The treatment is surgical. 43 SECTION IX. DISEASES OF THE CIRCULATORY SYSTEM. DISEASES OF THE PERICARDIUM. Pericarditis. — Pericarditis is an inflammation of the pericardium due to infection, which may take place through the blood- or Ivmph- channels or may occur through contiguity to infected areas in neigh- boring structures. The existence of primary pericarditis or so-called idiopathic pericarditis apart from rheumatism or infection is a matter of doubt. It is therefore to be regarded as secondary to other condi- tions or the result of direct systemic infection. Occurrence.- — Pericarditis occurs in foetal life (Billard, Tardieu, Heiter) ; Bednar describes cases in newly born infants ; it is common in infancy and childhood. Steffen and Baginsky describe a number of cases occurring in infancy. Of 66 cases of pericarditis in chil- dren, Baginsky found 20 to occur during the first year of life. The next greatest frequency was between the first and the fifth year. Etiology. — The majority of cases occur as complications of acute articular rheumatism (Steffen, Friedreich, Bauer, Baginsky), with or without chorea. Tuberculosis and pleuropneumonia rank next as etiological factors. Pericarditis occurs in the exanthemata, scarlet fever, measles, and typhoid fever. It may complicate pertussis, diarrha?al disorders, otitis, meningitis, peritonitis, mediastinitis, or any septic process, such as osteomyelitis. It is also in the newly born infant concomitant with septic conditions. Finally, trauma- tism may cause pericarditis. The tuberculous form is uncommon before the fifth year of life (See). Bacteriology. — The pyogenic bacteria most frequently found in pericardial effusions, and which play an etiological role, are the pyogenic streptococci and staphylococci, the pneumococcus of Frankel and Weichselbaum, the tubercle bacillus, the Friedlander bacillus, the Bacterium coli, and the Bacillus pyocyaneus (Ernst). Forms.- — There are the same forms of pericarditis in children as in the adult subject. The forms with effusions have, however, a tendency to become purulent, especially in infants and younger chil- dren (Baginsky). In these patients, the fibrinous forms result in localized or general adhesions of the two layers of the pericardium and in partial or complete obliteration of the pericardial sac (adher- ent pericardium). 674 DISEASES OF THE PEBICABDIUM. 675 Morbid Anatomy. — In the mildest forms, there is only a loss of lustre to the serosa in circumscribed or diffuse areas. The fluid in the pericardial sac may be increased in quantity and may contain cellular elements. In other forms, the surface of the pericardium is coated with a layer of fibrin of greater or less thickness. The fibrin may be in the form of bands or of small villous formations. There may be minute hemorrhages on the surface (Delafield). In more pronounced processes the fibrin is in the form of hemorrhagic tena- cious masses forming a thick network of strips or bands (cor villo- sum) . The quantity of fluid in the sac varies. The fluid may contain blood. In the first stage of inflammation, the connective tissue of the pericardium is infiltrated with lymphoid cells and the vessels are filled with blood. After the third day, new vessels appear in the fibrinous exudate on the surface. Fibroblasts, spindle-shaped, spher- ical, and branching, form a network in this new tissue (Ziegler). Granulation tissue and finally new connective tissue replace the fibrin- ous exudate, after a period of weeks (productive pericarditis). The so-called opaque areas of thickened pericardium, the maculae tendinese seen in adults, are rare in children (Steffen). Adhesions, either localized or general, may form between the two layers of the pericar- dial sac, causing its partial or complete obliteration. Tuberculous forms of pericarditis may occur as miliary infiltra- tion of the parietal and visceral layers of the pericardium. There may be serous, serofibrinous, purulent, or hemorrhagic exudate in the sac, or gray cheesy nodules of tubercle tissue may be present in the epicardial and subpericardial tissue (Ziegler, Baginsky). Myocarditis, circumscribed or general, may occur in all forms of pericarditis. The adhesive forms are complicated with myocarditis. Symptoms. — Pericarditis in children manifests itself by rational symptoms and physical signs. Rational Symptoms. — At the bedside, the symptoms of the differ- ent forms of pericarditis cannot be divided into classes. Some of the fibrinous or dry forms run an insidious course without giving any marked symptoms of the disease. On the other hand, large effusions may make their appearance without any previous rational symptoms which are characteristic. This is the case in the forms of pericarditis in infants and children, which occur in septic conditions, in pneu- monia, empyema, and in the exanthemata. If attention has been . drawn to the heart, it will be found that certain symptoms may be traced to the inflammatory process in the pericardium. If the pa- tients have been suffering from endocarditis of rheumatic origin, empyema, or one of the exanthemata, they show the symptoms of grave cardiac disease. They have an anxious facial expression, with 676 DISEASES OF THE CIBCULATOEY SYSTEM. marked pallor and cyanosis of the lips. They do not, as a rule, com- plain of pain. The respirations are markedly increased, as is also the pulse. Older children may complain of pain or uneasiness in the epigastrium. They also show marked dyspnoea and orthopnoea. In infants there are signs of pain on breathing. In some of the fibrinous forms there is fever, but dry forms of pericarditis may run their entire course without it. The purulent forms give a remittent temperature-curve. The pulse is rapid, varying from 120 to 150. In the forms with effusion, the pulse is irregular. If myocarditis is present, the pulse is irregular and persistently high, and there is an accompanying increase in the number of respirations. There is no case on record in which the diagnosis of mediastinopericarditis has beeii made in a child during life and confirmed at autopsy, nor does the so-called pulsus paradoxus give any assistance, since it is present in other conditions in childhood (Steffen), Physical Signs. — In pericarditis there are the physical signs of the dry plastic forms and the forms with effusion into the sac. The signs of the dry pericarditis and those of the first stage of that with effusion are practically identical and may be considered together. Inspection. — In dry plastic pericarditis and the first stage of peri- carditis with effusion there may be no signs to be detected by inspec- tion. There may be an increased impulse, apparent to the eye, over the whole cardiac area to the left. When effusion takes place, little or no pulsation can be made out over the cardiac area when the patient is in the recumbent position. There may. be distinct bulging of the cardiac area, varying with the amount of fluid present. No localized apex impulse is visible when the amounts of fluid are large. There may instead be a diffuse pulsation over the area of the apex and toward the sternum. Palpation. — In dry pericarditis, and in the first stage of pericar- ditis with effusion, there is a friction fremitus felt over the areas in which the friction murmur is heard. This may be at the apex, at the base, or along the right ventricle close to the left border of the sternum. The Apex-heat or Impulse and Its Relations to the Chest-wall in Pericarditis with Effusion. — As effusion takes place, it is indicated by certain physical signs relative to the heart apex, and by the line of dulness to the left. Investigations have shown that, when the patient is in the recumbent posture, pericardial efl'usion first collects at the base of the heart around the great vessels. It next collects over the anterior surface and in the aiitcrior-infci-ior cul-de-sac of the peri- cardium (Voinitch). When the patient is recumhont the effusion does not necessarily ]in~h up tlif npex-bcat. On the contrary, it separates the heart from DISEASES OF THE PEEICAEDIUM. 677 the anterior chest-wall. In moderate effusion the apex-beat may still be felt in the normal position. As the effusion increases, the apex- beat recedes and becomes less discernible and more diffuse, and in large effusion may disappear. This is especially the case if there is dilatation of the heart or adhesions at the apex. When the effusion is again absorbed, the apex-beat becomes evident in the former situation. When the patient is sitting^ the pericardial effusion collects be- neath and behind the heart, and, if the heart is not enlarged or held down by adhesions, the apex-beat may at first be displaced upiuard, and will be felt above and to the outside of its normal position. These facts will explain the failure in certain cases of pericarditis to obtain the displacement of the apex-beat upward. In one of my cases, a boy of six years, suffering from chorea, endocarditis, dilated heart, and pericarditis, the apex-beat was observed in the beginning of the stage of effusion to be located in the sixth space, slightly outside the nipple line. Effusion having occurred, the apex-beat could still be observed in its former locality, but the area of absolute dulness indi- cating effusion extended beyond the apex, four cubic centimetres to the left of the mammillary line. The effusion disappeared and the apex then corresponded with the line of dulness of the left ventricle. Percussion. — In dry fibrinous pericarditis, and in the dry stage of pericarditis with effusion, there is no increase in the area of cardiac dulness directly traceable to the disease. If there is a slight dilata- tion or relaxation of the ventricle due to myocarditic complication, the normal prsecordial dulness may be more distinct. The effusion must have a bulk of 40-60 grammes (1^ to 2 fiuid- ounces) before definite signs of its presence can be obtained. In young children, the area of dulness due to pericardial effusion does not have the triangular shape seen in adults. The position of the heart is more horizontal and its shape is retained by the distended sac. Thus, to the left, the dulness may extend in a curved line outside the situation of the nipple. Superiorly, it may extend as high as the first rib. It then extends in an almost horizontal line two or more centi- metres to the right of the sternum (Fig. 152), The line of dulness to the right of the sternum then extends downward in an almost vertical line to the liver at the sixth space or Eotch's space (Steffen, Baginsky, Ausset). These facts are very important in differentiating dulness resulting from pericardial effusion from dulness due to other causes. Even in moderate effusion there is resistance to the percussing finger. If the patient's position is changed from the recumbent to the sitting posture, the heart falls forward, the pericardial sac is distended, and the dulness to the left may come more toward the mammillary line and, to the right, toward the sternum (Baginsky). Percussion is painful in pericardial disease and the examiner should bear this in mind. 678 VISEASES OF THE CIECULATORY SYSTEM. Auscultation. — The friction sound is diagnostic in dry plastic pericarditis and in the first stage of pericarditis with effusion. It may, at the outset, be heard at the apex (Steffen), but is also heard to the left of the sternum over the base, or below, to the left of the sternum, over the fourth or fifth space. Steffen finds it in children, at first, most frequently at the apex. The friction may be heard on systole or diastole, or on systole only. It may or may not accom- p)any the valvular sounds. It is of very limited distribution, is not Fig. 152. Pericardial area of dulness due to effusion in boy, six years of age. Chorea, endo- carditis, and pericarditis ; x, apex-beat before effusion \ o o o o, friction murmur ; outer curved line shows general shape of distended pericardial sac. conducted, and is of a fine crepitant quality or has a shifting, rubbing, rasping or clicking sound. In the case of a boy suffering from recurrent chorea and pericar- ditis, there was a loud scraping friction at the apex with murmurs of mitral and aortic regurgitation, I was able in this case to confirm the statement of Walsh, that a loud pericardial friction may rarely be heard behind, between the scapulae, to the left of the spine. The friction may for the first day or two be of a crepitant quality and then acquire a rubbing quality. I observed this change in a child four years of age. The patient suffered from dilatation of the left ventricle with mitral insufficiency and stenosis with pericarditis. The friction for two days was crepitant in quality and just audible DISEASES OF THE PEBICABDIUM. 679 over the fourth and fifth spaces, to the left of the left border of the sternum and then acquired a loud rubbing quality. The murmur is sometimes very evanescent or may disappear or reappear at short intervals. The sounds may be intensified by causing the patient to lean forward. When effusion appears, the friction sounds may en- tirely disappear, or may be heard only in areas around the great vessels or indistinctly over the prsecordium. A knov^ledge of these facts is important in making a diagnosis of fluid in the pericardial sac. The friction sounds may reappear on absorption of fluid. Pleuropericardial friction sounds are rough or fine sounds ob- tained in children as in adults with the respiratory movements of the lung. They are intensified on expiration and disappear when respi- ration is momentarily suspended. They may be heard over any part of the prsecordium. They are caused by the rubbing of the inflamed pleura and pericardium against each other. This friction is limited to one edge of the cardiac area, generally the left, and is sometimes heard in the back, on the left side. Diagnosis. — The diagnosis of pericarditis can only be made from the physical signs. In dry plastic pericarditis and the first stages of pericarditis with effusion, the friction sound is the diagnostic sign. If a pericardial friction is once obtained, careful watch should be kept for the appearance of fluid. It is not possible at the outset to differentiate a dry pericarditis which will remain as such, from the first stage of a pericarditis with effusion. In the stage of effusion, small amounts of fluid will sometimes escape diagnosis. This is likely to occur if a process such as empyema is in progress on the left side. The first stage of a pericarditis may escape diagnosis if the friction sound is evanescent. If the effusion appears in considerable quantity over the great vessels, percussion is made in this region, especially to the right side of the sternum at the level of the second or third space, for an increase in dulness due to a distended pericardium. Absence of dulness in this region across the sternum and for a few centimetres to the right of the right border is presumptive evidence against the presence of any considerable effu- sion. If dulness exists to the right of the sternum, low down only on a level of the fourth interspace, there is probably no pericardial effusion, but, instead, dilatation of the right ventricle. Differential Localization hy Percussion of Pleural and Pericar- dial Effusions. — In cases in which pericardial effusion is very large or in which there is pleural effusion into the left side of the chest, a question may arise as to whether there is a simple pleural effusion, general or localized, pericardial effusion, or both. Percussion along the sternum will in simple left pleural effusion easily mark out the displaced left pleural fold. If there are large amounts of fluid, the 680 DISEASES OF TEE CIECULATOEY SYSTEM. fold of the left pleura will be found to be distinctly displaced toward the right border of the sternum. The pleural line will not pass beyond the border of the sternum to the right. If large pericardial effusion is present, the dull note of the effusion extends beyond the right border of the sternum, especially at Rotch's space. In left pleuritic effusion the apex of the heart is found by auscultation to be distinctly displaced to a situation beneath the sternum, while in pericarditis it will at first be found to be in the normal position and subsequently to disaj^pear or to be displaced upward and outward. Prognosis. — The prognosis of rheumatic pericarditis is good. The purulent forms of pericarditis are in the great majority of cases fatal, especially in very young infants. In older children, I have seen cases of purulent pericarditis, due to infection from a concurrent pneu- monia or empyema, recover with timely pericardotomy. The septic forms of purulent pericarditis, complicating sepsis of the newly born and forms of osteomyelitis, are fatal. Treatment. — The treatment of the dry fibrinous forms of pericar- ditis is limited to the relief of the pain and the treatment of the primary condition, rheumatism. The pain is best relieved by the administration of mild opiates. Codeine in small doses is efficient in many cases. I am not in favor of blistering the prsecordial region in children, or of applying a seton, as is done in adults. If the heart is tumultuous, small doses of digitalis in the tincture form and the con- stant application of an ice-bag over the prascordial region are the most effective remedies. Some authors believe that the ice-bag is also a very powerful means of limiting the inflammation. In rheumatic or choreic cases the salicylate of sodium is given, or if this disagrees with the patient, the ordinary bicarbonate of sodium in doses of grains x (6.5) three or four times daily. Perfect rest in bed, long after the process has run its course, is indicated, on account of the ill effects of strain on the heart affected by myocarditic changes which are undoubtedly present in many of the cases. When effusion has taken place, the question of the advisability of puncturing and exploring the pericardium always arises. It is very difficult to choose the proper time for entering the pericardium. I have had a number of cases of pericarditis with effusion recover without being subjected to what is at best a hazardous procedure. I temporize until the orthopnoea and cyanosis are extreme and evidences of pressure are marked. Too nmch ini])ortance should not be attached to ordinary symptoms. On the other hand, if the temperature is high and daily remits to near the normal, there may be a purulent effusion. If after a reasonable length of time tbe patient steadily loses ground and the signs of eff'usion are marked, the pericardium should be entered to determine the character of the exudate. If it is serous, DISEASES OF THE PEBICABDIUM. 681 ordinary aspiration will suffice, but if purulent, the operation of peri- cardotomy should be performed. Pericardial puncture or incision is performed in the same manner as in adults. It may be remarked that Henoch has never punctured the peri- cardium. In one of his cases, postmortem examination showed small sacculated purulent collections of fluid which could hardly have been evacuated by a single puncture. I found a similar condition post- mortem in a case in which puncture of the pericardium was under- taken, and resulted in puncture of the heart. Morse, on the other hand, advocates early puncture of the pericardium. Adherent Pericardium, — Adherent pericardium is an agglutina- tion, localized or complete, of the visceral and parietal walls of the pericardial sac which becomes partly or completely obliterated. Etiology.- — The condition follows either a dry plastic pericarditis or a pericarditis with effusion, in the stage of absorption. In the latter case, if the absorption of fluid has been observed and the redux friction-sound obtained, adhesion of the pericardium may be sus- pected from certain signs; otherwise, diagnosis even within probable limits would in many cases be an impossibility. Infants and chil- dren who have withstood an attack of pericarditis, especially of the rheumatic form, are very prone to contract this form of pericarditis. In most cases it causes myocarditis of a progressive type ; hence the importance of understanding the condition. Hypertrophy of the heart, atrophy of the heart, or dilatation of that organ may accom- pany adherence of the pericardium. Sjmiptoms. — The symptoms, especially in 'the rheumatic cases, develop late in the disease when myocarditis supervenes. The con- dition may prove fatal by progressive affection of the cardiac muscle. One of my cases, of rheumatic origin, showed postmortem no valvular lesion. There were complete obliteration of the sac and extreme dila- tation. The symptoms are at first negative. There may be a fric- tion sound or a roughening of the cardiac sounds at the base. There is in some cases a drawing inward of the apex area of the chest at the xiphoid cartilage. A wave-like undulation of the cardiac area with an increase of cardiac dulness is sometimes found. There may be persistent asystole not controlled by digitalis (See). In my cases there were angina, a persistently high pulse with an increase in the number of respirations, and in the last stages, all the symptoms of non-compensatory dilatation of the ventricle which are seen in val- vular disease. There may be a mitral systolic murmur simulating that seen in valvular disease. In spite of all these symptoms, it is rarely possible to make a positive diagnosis during life. 682 DISEASES OF THE CIECULATOEY SYSTEM. DISEASES OF THE HEART. The height of the heart and of the great vessels in children does not differ after the third year from that of the adult. The ratio of the transverse to the sagittal diameter of the chest in nev^born infants is 2 to 1, while in adults it is 3 to 1. This fact should not be forgotten in estimating the size of the heart in infants and children. What in an adult might appear to be a large heart, v^ould be normal to the infant or young child. Position. — In the first year of life the long axis of the heart is more horizontal than in later childhood or in adult life (Rauchfuss). At the third year, the position of the heart is practically that found in the adult (D wight). As the child becomes older the heart assumes more nearly the vertical position, and in older children the apex-beat may be found 0.75 to 1 centimetre within the mammillary line. The situation of the mammillary line is variable in young children ; the nipple is over the fourth rib, but further removed from the midsternal line than in older children on account of the great transverse as compared to the longitudinal diameter of the thorax. In older children the heart areas closely resemble those in the adult. In infants and young chil- dren there are certain variations from the adult condition which should be borne in mind. Size. — The heart is relatively larger in the infant than in the adult, having 0.89 per cent, of the body weight in the newborn infant, while in the adult it has only 0.52 per cent. (Vierordt). Apex-beat. — The apex-beat in the newborn infant may be felt higher than in the adult. On account of the greater breadth of heart as compared with that of the chest the apex is external to the mammil- lary line. Steffen says that normally the apex-beat may be found 1 centimetre external to the mammillary line, or in the mammillary line, or internal to the mammillary line. The apex-beat in infants and children is in the fifth space. Inspection. — Inspection shows in some cases an undulatory move- ment over the whole cardiac region. This is normal as long as it is confined to the left of the sternum, but an undula.tory movement to the right of the sternum is probably indicative of dilatation of the right ventricle with or without hypertrophy. In rachitis the cardiac region is sometimes unduly prominent. This condition must be dis- tinguished from the more pronounced fulness in the prsecordium occurring in cases of hypertrophy or of pericardial effusion. Children who in early childhood have suffered from cardiac dis- ease with dilatation and hypertrophy of the left ventricle may show a marked prominence of the prsecordium. DISEASES OF THE HEART. 683 The apex-beat should not be mistaken for an apparent apex-beat which is sometimes seen in yonng children in whom the intercostal space to the left of the large cardiac dulness is raised with each pulsa- tion of the apex. Percussion in these cases will show the apex to be situated elsewhere to the left and downward. In some cases the apex, instead of pushing the intercostal space forward, draws it distinctly inward. This is in part due to adhesions between the heart, peri- cardium, and parts external to the pericardium. When children are struggling, the systolic impulse of the heart is seen to be communi- cated to both the carotid artery and the jugular vein, the vein getting its impulse from its proximity to the artery. The vein may be found to be collapsed and the artery to show an impulse on systole. Palpation. — The following points may be determined by palpation with the tips of the fingers or full palm : 1. Location of the apex-beat. 2. Sometimes the location of the left boundary of the heart. 3. The force of the systole, hypertrophy or dilatation of the heart, especially if pulsation is evident to the right of the sternum, 4. Transposition of the heart to the right. 5. The closure of the valves of the pulmonary artery in the second or third space near the sternum. 6. Murmurs which cause friction (pericardial) or thrills (endo- cardial). 7. Rhythm of the heart action. Auscultation. — In infancy the muscular quality of the first sound is not apparent. The heart-sounds have more the character of the tick-tack of a watch. The muscular character of the first sound fully develops toward the second year of life. All through infancy and childhood there is a natural accentuation of the second pulmonic sound. Too much importance should not be attached to the accentua- tion even if it is marked. Percussion. — The percussion of the heart has been the subject of much refinement of methods, which only tends to confuse a simple matter. The following method will be found suitable for most clin- ical purposes : The line of demarcation is the midsternal line. All reckonings as to the limits of cardiac dulness may be safely made from the mid- sternal line, the situation of the mammillary line being variable in children. The right border of the sternum is not a good line to reckon from, since the width of the sternum varies. The recumbent posture is preferable in infants ; both the recumbent and upright posi- tions are suitable in older children. Method of Locating the Line of Dulness of the Left Ventricle. — To locate the external boundary of the ventricle, we begin to percuss in 684 DISEASES OF THE CIECULATOBT SYSTEM. the lines parallel with the second, third, fourth, and fifth ribs toward the heart, from the axillary line or the anterior axillary line. To percuss from the midsternal line outward does not in children give as good results. To locate the external border of the right ventricle^, we percuss along the fourth rib or fourth space toward the sternum from the right mammillary line. In young infants a portion of the right auricle and ventricle will be found as high as the junction of the second rib and the sternum (Symington), but it is an ultra-refinement of per- FiG. 153. Form of the normal relative cardiac dulness in a child two and one-half years of age. cussion to try to make out the projection of this part of the right auricle to the right of the sternum. It is found, anatomically, that the curve of the auricle to the right of the sternum begins at the third space, and is most marked behind the fourth costal cartilage. It is sufficient for clinical purposes to make out this most projecting part of the heart to the right of and behind the sternum. The apex of the heart is generally made out by percussing along the fifth rib or fifth space from the antero-lateral axillary line toward the midsternal line. The external boundary of the left ventricle is DISEASES OF THE HEART. 685 in children slightly outside the apex-beat. The area of cardiac diil- ness which is absolute and which is uncovered by lung can best be made out by percussing from above downward over the cardiac area. In children or infants this area cannot be marked out as definitely as in the adult. The younger the child or infant, the greater the diffi- culty. In infants and children interest centres rather in the apparent size of the heart (relative dulness) than in the area uncovered by lung. The dulness extends to the right and left of the midsternal line, at a level with the fourth rib, as is indicated by the following figures compiled from Steffen's tables : Infants under one year right v. 4 to 6.5 cm. to right. left V. 3.5 to 6.25 cm. to left. Children one to two years right v. 4 to 6.5 cm. to right. left V. 4 to 7.25 cm. to left._ Children two to three years right v. 4.5 to 7.5 cm. to right. left V. 4.5 to 6.5 cm. to left. Children five to six years right v. 5.5 to 7.25 cm. to right. left V. 5 to 8.25 cm. to left. Children nine to ten yeai-s right v. 5.5 to 8.5 cm. to right. left V. 5.5 to 8.5 cm. to left. Enough has been selected to show that the actual size of the heart as obtained by percussion in infants and children is extremely vari- able, and the examiner must be guided by the relative size. Congenital Heart Disease. — Congenital heart disease may be sus- pected from certain physical signs which occur in that condition and are in a sense characteristic of it. These are cyanosis, changes in the area of cardiac dulness, and the presence of characteristic murmurs. Cyanosis. — The cyanosis which is characteristic of congenital heart disease does not occur in any of the acquired cardiac lesions. It is most common in the congenital forms of pulmonary stenosis of the artery, conus, or ostium. On the other hand, it may be absent in marked congenital disease, as in deficient ventricular septum and open ductus arteriosus. In the latter disease it may appear late in the condition, only at intervals, or not at all. It may be absent at birth and appear in infancy or childhood. Cardiac Dilatation and Hypertrophy. — The presence of a murmur of congenital origin does not necessarily presuppose change from the normal in the area of cardiac dulness. In fact, a normal cardiac area is sometimes evidence of the congenital character of a murmur. Hypertrophy of the left ventricle should be present with hypertrophy of the right ventricle, and a murmur to indicate open ductus arteri- osus. Dilatation of the right ventricle is of value when present with a murmur indicating stenosis at the pulmonary valve. On the other hand, marked congenital defects may exist without any change in the size of the ventricle. Moreover, if the cardiac area is enlarged and the apex impulse weak, congenital disease may be suspected. The weak apex impulse indicates dilatation. 686 DISEASES OF THE CIECULATOBT SYSTEM. Murmurs. — The murmur most cbaracteristie of congenital heart disease is a systolic murmur at the situation of the space between the second and third costal cartilage to the left of the sternum, and not conducted into the arteries of the neck. It is only when there are complicated defects that murmurs are conducted into the carotids (open ductus arteriosus). Foetal endocarditis affecting the tricuspid or mitral valves is rare, and therefore murmurs of congenital origin are rare at these valves. Diastolic murmurs are, so far as congenital lesions are concerned, of theoretical interest only. Systolic murmurs, such as those heard in defects of the ventric- ular septum, and which cannot be attributed to valvular disease, occur at the pulmonic valves. In these cases the murmur has no point of greatest intensity, but is heard not only at the valve, but also over the whole prsecordium. The valvular sounds are distinct. The most marked congenital defect or disease of the heart may exist without any murmur or other physical signs during life. In simple pulmonary stenosis, the second pulmonic sound is weak ; in cases complicated with open ductus arteriosus and hypertrophy of the ventricles, it is accentuated; in cases of pulmonary stenosis and deficient ventricular septum, it is either weak or very low. Positive Diagnosis Often Impossible. — The diagnosis of the exact lesion in congenital heart disease is in many cases impossible. The reason for this is easily found in the fact that if the patient lives longer than the first year, the lesion is rarely simple, but occurs with other congenital defects in the heart. Another cause is the rarity of autopsies on uncomplicated cases which have been carefully studied during life. Lastly, in complex cases, even if the diagnosis has been confirmed at autopsy, it is impossible to say to what degree the lesion diagnosed and the other complicating conditions found at autopsy have been the cause of the signs and symptoms found during life. The physical signs of congenital heart disease vary as the lesion is a simple one or is combined with other congenital defects. The follow- ing classification of congenital heart disease of developmental or foetal endocarditic origin will be found useful in clinical work : 1. Septum Defects. — Auricular (foramen ovale) ; ventricular. 2. Pulmonary Artery. — Stenosis of the conus, trunk, or ostium : (a) simple cases (before the end of the first year of life) : (&) com- plicated cases with open foramen ovale or ductus arteriosus, defect of the ventricular septum, or transposition of the great vessels. 3. Aortic Valve Stenosis or General Contraction of the Aortic System. — The first may be due to developmental defect or to foetal endocarditis; the second, to developmental defect. All aortic condi- tions anomalous in character have, so far as is known, not been diag- nosed during childhood. DISEASES OF THE H.EAET. 687 4. Valvular Anomalies. — Valvular anomalies of the semilunar valves, due to foetal endocarditis or developmental irregularities are of purely scientific interest. 5. Open Ductus Arteriosus or Botalli. — (a) Simple; (&) com- bined with septum defects or pulmonary stenosis. 6. Transposition of the Heart and Congenital Anomalies of the Pericardium (of purely scientific interest). Fig. 154. Clubbed fingers of congenital heart disease. Child, six years of age. From the above account, which I have modified for practical use from the classification of Vierordt, it will be seen that only the con- genital anomalies of the auricular ventricular septum, the pulmonary artery, and the ductus arteriosus Botalli are of interest to the clinician. Stenosis of the Pulmonary Artery, Conus, or Ostium.^ — -This is the most common of all congenital heart lesions. If found after the thirteenth month of life, it is in most cases combined with a con- genital deficiency of the septum ventriculorum. Rauchfuss found a simple stenosis in only 10 per cent, of all the published cases. Most of the cases are due to foetal endocarditis. 688 DISEASES OF THE CIECULATOBY SYSTEM. Physical Signs. — Simple Stenosis. — Simple stenosis of the artery, conns, or ostinm, f onnd only before the thirteenth month (Rokitansky ) . Cyanosis. — Early and congenital cyanosis and signs of venous stasis, snch as clubbed extremities of the fingers, even in young in- fants. In cases which are met in later life the clubbing of the ex- tremities of the fingers and cyanosis of the finger-tips are marked. Blood. — The blood shows so-called polycythemia. The number of erythrocytes is increased above the normal, being 7 to 9,000,000 to the cubic millimetre, as shown by some of my cases. The hemo- globin index is also increased. The white blood-cells are normal in number. The increase in erythrocytes is regarded as an evidence of compensatory over-production caused by the increased need of oxygen on part of the tissues in the presence of cyanosis. Murmur. — A systolic murmur heard with greatest intensity at the situation of the pulmonary valve to the left of the sternum, be- tween the second and third costal cartilages, and not conducted into the carotids. A weakened second sound at the pulmonary valve; dilatation of the right ventricle. Simple stenosis is found in infants, but is rare. In most cases there are also present congenital defect of the ventricular septum, open ductus arteriosus, tricuspid changes, or the aorta arises from the right ventricle or both ventricles. The following facts should be kept in mind in the diagnosis of cases occurring after the thirteenth month of life: If the above signs are present with a weakened second pulmonic sound, there being absolutely no conduction of the murmur into the carotids, it may be assumed that there is a pulmonary stenosis with an open foramen ovale. Conduction of the murmur into the arteries of the neck, with a very distinct though not accentuated second pulmonic sound, points to the presence of a septum defect with a pulmonary stenosis. An accentuated second pulmonic sound with conduction of a murmur of a loud buzzing character into the subclavian and carotids, and a hypertrophy of the right and also of the left ventricle, will sup- port the theory of a pulmonary stenosis with a patency of the ductus arteriosus (Hochsinger). In these cases of open ductus arteriosus there is a thrill and a distinctly defined area of dulness in the second space to the left of the sternum above the base of the heart. This dulness is of great diagnostic import. It is due to the dilated great vessels at the base of the heart. As an exception to the above classification may be mentioned the case of Sansom, in which cyanosis and extreme ansemia were present. Ill rare cases, the second pulmonary sound may be very low. The murmur may be conducted into the axilla, the right heart not being dilated. DISEASES OF THE EEAET. 689 Open Ductus Arteriosus or Ductus Botalli {Ductus Disease). — This is a very rare congenital defect. There are in the literature only 20 cases of uncomplicated open ductus arteriosus in which autopsy confirmed the clinical diagnosis. Of these, only 5 occurred in infants under one year of age, and 5 others ranged from the first to the tenth year (Vierordt). The complicated cases occur with stenosis of the pulmonary artery, septum defects of small extent, and open foramen ovale. Physical Signs. — Cyanosis. — Cyanosis is not present in the major- ity of cases, or if present is so only at intervals and is not marked. Murmur. — The murmur is a loud buzzing systolic murmur heard with greatest intensity over the pulmonary artery, and not conducted downward, but conducted to the left of the sternum into the veins of the neck (Plochsinger). There is an accentuated second pulmonic sound which can be heard in the carotids. Right Ventricle. — The presence of hypertrophy of the right ven- tricle tends to confirm the diagnosis ; if the left ventricle is also hyper- trophied, greater certainty is added. This is of great moment, since hypertrophy of the left ventricle is not present in any of the other congenital defects, except those connected with the anomalies of the aorta and aortic system and which have only a scientific value, since the literature contains no cases which have been diagnosed during life. The dulness in the second space referred to under Pulmonic Stenosis is also of value. Congenital Defects of the Auricular Ventricular Septum ; Defects of Auricular Septum; Open Foramen Ovale. — Inasmuch as 44 per cent, of the autopsies upon individuals who during life showed abso- lutely no signs of cardiac disturbances reveal a patency of the foramen ovale, the diagnosis of the condition as an uncomplicated entity should be made with great reserve. This congenital defect is generally found to exist in connection with other defects of a congenital nature (stenosis of the pulmonary artery). Cyanosis has been found in all the cases in which autopsy has been made. In a case recorded by Foster, there was cyanosis with a varying systolic and presystolic murmur at the sternal end of the third or fourth costal cartilage. Walshe denies that a patency of the foramen ovale may of itself cause a murmur. - Congenital Deficiency of the Ventricular Septum; Maladie de Roger. — Autopsies have shown that this condition may exist during life without giving any signs of its presence. Moreover, it is so often combined with other congenital heart anomalies, such as stenosis of the pulmonary artery or ostium, or ductus Botalli that the signs of 44 690 DISEASES OF THE CIJRCULATOEY SYSTEM. the ventricular condition must of necessity be obscured by those of the complicating defect. Cyanosis. — Cyanosis has been present in some cases of uncompli- cated defect of the ventricular septum (Miiller) and absent in others. It is present in the cases complicated v^ith pulmonary stenosis. Murmur. — According to Roger, a loud systolic murmur is heard over the whole prsecordium, toward the median line, over the upper third of the cardiac area. According to others (Miiller), the murmur has no special point of greatest intensity. It is not conducted into the vessels of the neck. I have seen such a case in a child 13 months of age. Eauchfuss calls attention to the fact that with this murmur the distinct valvular character of the heart-sounds at the various valves should be heard. The case of Miiller was that of a cyanotic infant two months old. A loud murmur having no special point of greatest intensity was heard over the whole cardiac area. The valvular sounds were distinctly heard. Autopsy showed uncomplicated defect of the ventricular septum. Acute Endocarditis. — Acute endocarditis is an inflammation of the lining membrane of the heart. That covering the valves and their immediate vicinity is the area generally affected. There is also an inflammation, slight or marked, of the muscle tissue of the heart, and in some cases there is inflammation of the pericardium. Endo- carditis thus involves structures of the heart other than the endo- cardium. Acute endocarditis may be benign, septic or as formally called malignant. Between the two extremes, there are all gradations as to severity. All forms of endocarditis are caused by infection which in the malignant variety is of the severest septic type. Foetal endocarditis affects the right side of the heart; after birth, the left heart is chiefly affected. The condition is less frequent before than after the fifth year of life, and occurs with equal frequency among boys and girls (Steffen). Etiology. ^ — Acute endocarditis occurs most frequently with acute articular rheumatism, but may appear in any infectious disease. It is often found in scarlet fever; less often in measles. I have seen it in rare cases of erythema nodosum (2 cases). It may occur with typhoid fever, diphtheria, influenza, pneiimonia (ISTetter), cerebro- spinal meningitis, and tuberculosis. In fact, all forms of sepsis, such as osteomyelitis, either foetal or in the newborn infant or in children, may be accompanied by endocarditis. Endocarditis is present in 16 per cent, of the cases of chorea and is always present in fatal cases of that disease. Bacteriology. — The most important bacteria bearing an etiological relaliojiship to endocarditis are the streptococci of the various varie- DISEASES OF TEE HEART. 691 ties and the Staphylococcus pyogenes. Harbitz divides endocarditis into the infectious and the non-infectious varieties. He found bac- teria in the vegetations in most of the infectious cases, streptococci in 39,5 per cent, and staphylococci in 18.6 per cent, of the cases; other bacteria, such as the pneumococci, were also found. The cases in w^hich no bacteria were found were healed cases. He thinks that the staphylococci most often cause pysemic endocarditis with ulcerations and metastatic abscess. Welch and Lenhartz found streptococci in ulcerative endocarditis. The Diplococcus pneumoniae is next in im- portance as an etiological factor. Wright found the Bacillus diph- theria in one case. Other bacteria, such as the Gonococcus, the Bacillus endocarditidis griseus (Weichselbaum), the Micrococcus endocarditidis rugatus and capsulatus, the Diplococcus tenuis (Klem- perer), have been found in cases of adult endocarditis. Although they are all, as well as the Bacillus typhosus, doubtless capable of causing the same process in children, actual clinical cases are still to be published. All forms of endocarditis are thus septic processes due to the circulation in the blood of bacteria or their toxins. In some cases it is possible to discover the point of entrance of the bacteria into the circulation, in others it cannot be fixed upon. The various forms of endocarditis are not so uncommon in infants as is supposed. The tonsil is a great avenue for the entrance of bacteria or toxins into the circulation (Cheadle). It is believed that many cases of endo- carditis in children originate in this manner (Packard). I have frequently met with endocarditis in which the only other clinical manifestation was a slight redness or swelling of the tonsils. The integrity of the endothelium of the endocardium must be compro- mised if bacteria have invaded the tissue of the valvular endocardium (Prudden). It is supposed that the toxins produced by the bacteria circulating in the blood reduce the resistance of the endothelial lining of the endocardium, thus preparing the soil for bacterial invasion. Morbid Anatomy. — In some cases the only lesion is a swelling of the valves. They are thickened and succulent, their surface being smooth. The basement substance is swollen and there is an increase of connective-tissue cells (Delafield). In other cases the borders of the valves present transparent, gelatinous, whitish-yellow or reddish formations, varying from the size of a pin's head to that of a bean. These are irregular in shape, cover both surfaces of the valves, and may be single or multiple. They are also seen on the chordae tendinese. The free border of the valve is warty or papillomatous (endocarditis verrucosa or polyposa) (Ziegler). The papillae may appear on the free surface of the valves. There may be a loss of substance with the formation of adherent thrombi of a whitish or reddish color and of 692 DISEASES OF THE CIECULATOEY SYSTEM. tenacious consist eiicv (endocarditis ulcerosa). Small foci of pus may be present in the heart substance (endocarditis pustulosa). Bacterial invasion of the surface of the valves results in loss of substance, formation of thrombi, and changes in the nuclei of the con- nective tissue (necrobiosis). The mitral valve being more vascular is sooner affected than the aortic or pulmonary valves. Exudation on the valve is replaced by new connective tissue ; excrescences and new formations become permanent. If the bacteria penetrate deeply, thickening of the valve results. Large thrombi are organized, and the valves become shrunken and distorted. Ulceration and loss of substance may result in perforation of the valves. The thrombi just mentioned are sometimes made up of blood-plates ; in other cases leuco- cytes, blood-cells, and fibrin in varying amounts are present. There may be exudative pericarditis. The myocardium is the seat of degeneration, which leads to dilatation, abscess or aneurism of the heart muscle. Through the separation of portions of the thrombi or of the vegetations on the valves, these particles may be carried into the circulation. Containing, as they do, bacteria (my- cotic emboli), they cause secondary infections with necrosis or abscess in the kidney, spleen, and brain. Fig. 155. HOUR 3 9)2 3 C;9,12 3JC.91-2 3!Ci9 12 3G19V2 3 Gi912 3l0i9tl2 3|Gi9l2 3 6:912 3iS|9|l2 102° lioo' 99' 1 ■ 1 1 1 1 3 it t' rr, / \ \ . i-b \ A — f—l _- 1 _ L V V V~/i / \ / ■ I --V- — -\/^ VI n~\ ~ / — — \— ^ ~K^ L — \ / ^ / 1 ■ \ / , ^ • ' 1 PULSE i E'S:! r 5 2:SI 1 IS SISS i 5 z 2 5§ 3 2 siSS -- 1 RESP. ^2i'^ r '^ 5^,5 5.' ?, ,5S 3S§|=? s s nn X -^ X — S U:?iU a^Sg .^,! Endocarditis complicating influenza. Second week of the Illness. Mitral systolic murmur developed under observation. Female child, four years of age. Symptoms. — The symptoms of acute endocarditis are those of some general infection. They are not in infants and children so charac- teristic as to direct attention to the heart. Infants cannot and chil- dren do not complain of pain, palpitation, or uneasiness in the pre- cordial region as adults sometimes do, and therefore unless the heart is carefully examined as a routine procedure, the simple cases of endocarditis will escape observation. The most interesting cases are those which begin with all the symptoms of an attack of influenza or tonsillitis. There are fever, rapid pulse, and an increase of the respirations to 36 or 40. The fever, however, does not subside in DISEASES OF TEE HEART. 693 the time occuiDied by the course of one of the above affections; it continues high, 103''-104°-105° F. (39.4^-40.5° C), with morning or afternoon remissions. In such cases a most careful examination of the lungs and other organs fails to reveal anything abnormal. The heart, however, shows the presence of endocardial inflammation. In some obscure cases, there is an increasing pallor with a slight daily rise of half a degree or a degree in body temperature, which will continue for days or even weeks and give rise to a suspicion of paludal poisoning. There is also an increasing pallor. Examination of the heart reveals the lesion. In other cases there are a very slight but increasing pallor, weakness, and indefinite pains in the bones and joints. In children, more than in the adult subject, we are apt to have monarticular affec- tions of a rheumatic nature. Fig. 156 HOUR 8 2 8 8 2 8 8 2 8 8 2 8 8 8 8 2 8 8 2 8 8 ■2 8 8 ■2 8 8 2 8 8 2 8 8 2 8 8 2 8 8 2 8 8 2 8 8 2 8 _ 99° < t 98 K 97° A 4 , \ '^: , - _!_-:— _J y _ _ A 1 , . ~ ^ E ~ ~ ^ 2 =tt A ~h- *- = — P q — Eg r 3 fc -;^ r" — — ^ :-- V / d'k -. , ' — ' t f- /= fT L —J ^ L h- - -i - -1 n - — pH - r— fV- —A -i^X- -V — - M L — - - - - - - \-h- \i [^^- 5 t;^ —L- \ L_ r~ — Jz — _ L _ _ _l _ ^ — —V/ \/— _ ^ _ l',-^ W- 1 -^-^- — 1 — — — - — - ^ - H- ^]r^ -f- — h- — ^- \l — ^ - -+A' 1^ — ' 1 PULSE s 3 I s 3 3 - CO o 9-'fiU f. 7. t i s'?. r. ?. i V: 5 ? 2 v''? -i V. I S S 2 2 5 6 f 'S 5 -S'S RESP. Si SI s 3 S S s .. ?: 3?; T.T.T, 3 3?; ?, r, T, r,:r, r, r,T,r, ?i:T.i, f,.i,^ SS5! S' 3 S 3 S 3 3 3 .3 5?3§ Chronic cardiac disease, hypertrophy, and dilatation of the left and right ventricles. Enlarged liver and spleen, ascites, cyanosis, recurrent attacks of endocarditis. Tempera- ture by rectum shows a subnormal range. Boy, twelve years of age. I have seen several cases of monarticular joint-affection with an endocardial murmur in childhood. One case was that of a child two years and eight months of age, another was that of a child eight years of age. In the one case the ankle was swollen, painful, and slightly reddened. There was no temperature. There had been slight pain in one knee some days previous to the ankle-affection. In the other case the metatarsal phalangeal joint of the small toe was involved. In young children the joints may be painful, and still no history of joint-pain will be given, and the first indication of pain is a decided limp in walking. These obscure joint-pains are the first symptom of endocarditis. The rheumatic cases are as a rule easily diagnosed. The heart should be regularly examined in such cases. The endo- carditis which complicates chorea sometimes runs its entire course without any rise in the body temperature. I have, however, been able in such cases to confirm the statement of Jlirgensen, that the normal diurnal temperature variations are distorted — that is to say, the morning temperature may be higher than the evening tempera- 694 DISEASES OF TEE CIBCULATOBY SYSTEM. ture. In other cases of chorea there is a distinct rise of tempera- ture without any increase of the respirations and pulse-rate during the active stage of the endocarditis. x\fter the symptoms of chorea have begun to decline there is occasionally a rise of temperature last- ing a day or more, which may indicate a slight recurrence of the endocarditis. In other cases I have observed a subnormal tempera- ture of a degTee or more lasting for days. This occurred in a case of recurrent endocarditis. Thus the temperature is not at all charac- teristic. The heart in children is extremely irregular. It may vary from 60 to 120 per minute within a few days, and may vary at differ- ent times of the same day. Under such conditions it may be sur- mised that there is a myocarditis. The respirations are increased. The children do not complain of the heart. In pneumonia, scarlet fever, and measles, the endocarditis is masked by the symptoms of the primary disease. Physical Signs. — A murmur which develops while a child is under observation is indicative of acute endocarditis. Inspection. — Inspection may reveal nothing abnormal, or there may be extreme irregularity of the action of the heart. There may be increased action, as evinced by visible pulsation over the cardiac area. Palpation. — Palpation also may reveal nothing abnormal ; there may be a thrill over the apex. Percussion. — Percussion at first reveals nothing abnormal. In some cases there is a slight dilatation of the left ventricle (Steffen) as the disease progresses. I have seen this dilatation in cases in which the condition had existed for a week. During convalescence the dilatation may retrograde and the heart confines return to their normal limits. Auscultation. — In the majority of case?, a soft systolic murmur is heard over the apex and the mitral area. There is rarely a pre- systolic murmur. There may be murmurs at the other valves, having the characteristics of the same murmurs in the adult. In any acute disease, the physician should be careful to observe a murmur very carefully before pronouncing it organic. I have found murmurs, especially in typhoid and scarlet fever in young and older children, which appeared and disappeared. Such murmurs are haemic or myocarditic and functional ; they are very gentle, generally systolic, and are limited very closely to the apex or pulmonic area. They are not conducted and there are no positive signs of dilatation. Jacobi has described pulmonic murmurs in very young infants, which were at autopsy shown to be functional. On the other hand, if a murmur is distributed over a valvular area, takes the place of the valvular sound, is conducted into the arteries, and occurs in conncc- DISEASES OF THE EEAET. G95 tion witii signs of dilatation, the physician is justified, acute symptoms being in evidence, in assuming the presence of organic disease- Course and Prognosis. — Many cases of endocarditis, especially those not of rheumatic origin, run their course, do not recur, and in after-life give no symptoms referable to the heart. Others run an acute course without developing any physical signs until convales- cence. I have seen such forms follow chorea. The murmur develops in the intervals of freedom from symptoms of chorea. Rheumatic cases are likely to recur, and in this tendency lies the danger. The prognosis as to immediate recovery is very good in all of the ordi- narily severe cases of acute endocarditis. The severer septic or malignant cases give a grave prognosis. The future of cases of acute Fig. 15 7. HOUR ids' op -f- [12 0;12 G 112 12 I 12 'A 12 12 12 G 12 6 12 6 12 6 12 'A — 12 G 1 12 ± eli2 6 12 6 12 G 12 6 12 ^ 102" < „ t 101 99 r hr'' m ui^ ^ [= -f s- ^ ^ 4 ^ ! ^ 1 1 1 ^^ J '^F^. ^-r— # 1 1 =l\ _l_ V"- h -l - a N rJ^ . f T Sr f. 7^ -~ -H— ELJ i ■-' . :::_ __:-__ z;r-_ V-l :i^. V. _:- -1 7— \ £ /- ^-1 - i: •*-/ V > a s :: sT 1 « nn 9.7. f- s J-.l f.7. i,L K l-r.i K-. ^ ■- © - -U-*" 511 05 b' 1 T 1 . "4^ i-51 R5 t 1 'J_ j 1 ! 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CI z: z -: 001 M i - ^ . ^ — - -r—r f-- ■%" 51 / "' _> — - _^ i 001 ___ 71^ _=-^ - — - — — T~T sriT b' 051 1-5 t J ^ 1 __ V L- OS 051 "r- — — -^^ i^i' -—- — -j:. =^^ — p (W (C t ■ 5r. 15 c-l \ _,_^ _ 1 1 001 05 i- : itTiif TT^ frr' — -^- — - t^ = ^=^ -^ — '- Hil 05 X o o > < o I 2 S °i 2 1 2^ '^ 'S 'S (•dHVd) 3anxva3dw3i I 13 698 DISEASES OF THE CIECULATOBY SYSTEM. as a mixed infection due to septic organisms in the acute infectious fevers or which is secondary to the rheumatic affections of the valves. Symptoms.- — In one of my cases occurring in a boy with osteomye- litis of the tibia, staphylococci were found in the blood during life. In another case, which followed a pneumonia, streptococci were found in the blood during life. In the former case hemorrhagic symptoms and signs of severe cardiac disease, such as gallop-rhythm were observed. The latter case was seen in my hospital service. The child, a girl of eight years, had had a pneumonia three weeks previous to her admission. She had apparently recovered, had sat up in bed after ten days, and was about. A day before her admission the tempera- ture mounted to 104° F. (40° C), she vomited, and had diarrhoea. The child showed much prostration, and on examination an area of consolidation was found in the right lung behind. She had an active endocarditis giving a mitral systolic murmur. The liver and spleen were large; the temperature rose and fell twice daily, chills and dyspnceic attacks preceding each rise. The temperature subsided to the normal or subnormal after each rise. There were nausea, vomit- ing, and signs of cardiac failure. The heart did not at first show any enlarged area of dulness. After a few days the left ventricle showed an increased area of dulness to the extent of 2 to 3 centimetres outside the nipple-line (acute dilatation), with diffusion of the apex- beat. The right ventricle was dilated. With the extreme fluctua- tions of temperature, the child became delirious. The heart, as at the time of admission, showed a mitral systolic murmur. After ten days petechise appeared, first on the neck and upper thoracic region, and increased both in number and extent. The face and eyes became oedematous (cardiac failure). The patient became unconscious and died in coma with Cheyne-Stokes respiratory phenomena. The blood withdrawn during life showed in culture the presence of long streptococci. I have seen several cases of septic endocarditis in which the symp- toms were exceedingly mild in contrast with those described above. The patients showed few subjective symptoms, there was an increas- ing anaemia, and they even wished to be up and about. While there was some lassitude, the patients sat up in bed, played with their toys, and were in excellent humor. The rises in temperature were irreg- ular, rarely exceeding 103°. A few petechise were discoverable on the orbital conjunctiva?. There were the physical signs of endocar- ditis, such as murmurs and dilatation of the ventricle. These cases showed an attenuated form of Streptococcus in the blood by repeated culture. Such cases may recover or go on to more active symptoms and death (Fig. 159). DISEASES OF THE HEART. 699 Diagnosis. — The diagnosis of septic endocarditis rests on the his- tory and the presence of cardiac signs, the prostration, the fluctua- tions in temperature in severe cases resembling those in sinus throm- bosis in ear disease, the onset of chills and delirium, the presence of petechise, and lastly on the results of examination of the blood for bacteria. Of great interest in this connection, are the cases of chronic recur- rent endocarditis which toward the close of the disease have certain symptoms resembling those of the septic or so-called malignant cases. In a child of ten years suffering from chronic recurrent rheumatic endocarditis, there was toward the close of the illness a period during which phlebitis with thrombosis of the deep veins of the neck and arms on both sides and oedema of the corresponding extremities devel- oped successively. After a few weeks the symptoms of phlebitis and thrombosis gradually subsided and there was a period of a few weeks during which the patient was much improved. The fever and ana- sarca subsided and the heart action was good. Before the fatal issue the endocarditis recurred and there were fever and what appeared to be significant petechise on various portions of the body. The case was a rheumatic one and had been under observation for two years. Its outcome gives weight to the theory that a seemingly benign endo- carditis may at any time take on a malignant or septic nature. Prognosis. — All the severer forms of septic endocarditis give a grave prognosis. The milder forms may make an apparent tem- porary recovery. Thomson has recently reported such cases in adults. In children such an outcome is not impossible though the outlook even in the mildest forms of septic endocarditis is always linked with uncertainty. Treatment. — The treatment of septic endocarditis does not differ from that of acute endocarditis. There is, however, the question as to the annihilation of the bacteria in the blood as a preliminary to permanent cure. This is still one of the problems of internal medi- cine. We have no sera or vaccine which is effective. I have tried both with discouraging results. Chronic Valvular Disease of the Heart. — The lesions in chronic valvular disease in infancy and childhood are the same as in the adult subject. Etiology. — The etiology has been considered in the section on Endocarditis. Frequency. — Of YO of my cases of chronic valvular disease, 3Y were of the female and 33 of the male sex; 2 were below the age of two years ; 24 from the second to the fifth year, and 39 from the fifth to the tenth year of life. In 50 of the 70 cases the mitral valve was involved, causing either a systolic or a diastolic murmur, or both. 700 DISEASES OF IRE CIECULAIOEY SYSTEM. The foUo^ring table will give an idea of the relative frequency of the valvular lesions : 3Iitral insuffioiency 26 cases. Mitral stenosis 6 '" Mitral insufficiency and .stenosis 18 Aortic stenosis 6 " Aortic stenosis and insufficiency 1 case. Endocardial and pericardial disease o cases. Combined lesions of mitral and aortic valves 8 " Physical Signs. — The physical signs, the reservations noted in the section on cardiac murmnrs being made, are the same as in the adult subject. On the other hand, certain characteristics of the disease in childhood are not common to the adult subject. There are cases of chronic cardiac disease in infancy and childhood which escape recog- nition because the heart is not examined with sufficient care. Mur- murs of mild intensity pass unrecognized. There are cases of endocarditis which run an obscure course, give very few symptoms, and which are apt to recur at the onset of tonsil- litis or an attack of influenza. These cases of chronic endocardial y ^ disease give very few symptoms in the intervals between the at- tacks. There may be obscure pains in the limbs or joints which are not interpreted by the physician as purely rheumatic, but are believed to be of a grip- pal character. The patients may eventually develop symptoms of Simple mitral insufficiency; dilatation of cprimits nnrrlinr' i-ncn-ffipip-nr^v the left ventricle. Girl, six years of age. &eiiuut> LdiUidO iiib UiucieiltA . The cases of chronic valvular disease resulting from an attack of some infectious disease may leave the heart little compromised. It is true that upon examination there is a cardiac murmur, but the cases reveal no subjective symptoms. They have what is called a healed endocarditis. They may, how- ever, develop serious cardiac symptoms at the onset of an infection of the intestine or other organs. The heart in these cases may be called irritable. The patients do not develop inflammation of the endocardium or pericardium as do the rheumatic cases. On slight disturbance of the intestines, such a heart, even when there is no fever, acts very much like a hypertrophied organ. There is an in- crease not only of the frequency, but also of the force of the heart's impulse. The vessels are also affected, and there is a bounding full pulse at the radial. As a result of the infection and of the congestion brought about by the increased action of the heart, there will be albumin and casts in the urine. These symptoms subside and do not DISEASES OF THE HEART. 701 recur except at long intervals. In the intervals, with the exception of a valvular murmur, there are absolutely no signs of cardiac disease. In children, cases v^ith a slight or marked valvular lesion which is apparently at a standstill, give certain symptoms which are sig- nificant of defective cardiac action. On exertion, the children com- plain of pain in the side or the epigastrium. Examination will show Pig. 161. Chronic cardiac disease ; dilatation of the right and left ventricles. tion. Boy, six years of age. Epigastric pulsa- little change in the cardiac area. The valvular murmur is heard. Such hearts are also irritable. I have often found a distinct history of palpitation occurring at intervals and even in the absence of exer- tion. Many children with chronic cardiac disease of a very mild and absolutely quiescent type, exhibit a persistent pallor which does not yield to drugs. Children without other symptoms complain of headaches after slight excitement. Examination will, in these cases also, show a slight hitherto unrecognized chronic cardiac valvulitis. 702 DISEASES OF THE CIECULATOEY SYSTEM. Slight oedema of the eyes which is persistent should direct attention to the heart. Many cases without any other signs of chronic cardiac disease show a slight evanescent trace of albumin in the urine. There may be absolutely no signs of cardiac insufficiency or change in the physical character of the organ. Children with signs of quies- FiG. 162. Chronic cai-diac disease ; great cardiac dilatation ; recurrent attacks of endocar- ditis ; phlebitis and thrombosis of the deep veins of the neck and arm on both sides successively ; oedema of the corresponding arm and forearm ; great dilatation of the superficial cervical and thoracic veins. Female, ten years of age. cent cardiac disease often have obscure attacks of faintness and vom- iting, following every little excitement. The rheumatic recurrent cases of endocarditis in childhood ex- hibit very much the same symptoms of cardiac insufficiency as the corresponding cases in adults, viz., enlargement of the liver aud spleen. Children ajipear to recuperate more rapidly than adults, but, DISEASES OF TEE HEART. 703 on the other hand, the attacks are more likely to recur in them than in older subjects. A compromised heart in a child will bear more strain than in an adult. Cases are frequently seen in which children ■show on physical examination marked chronic disease, but are not- withstanding exceedingly active and show no symptoms referable to the heart. The signs of insufficiency of the cardiac muscle are the same in children as in the adult. There is dyspncea on exertion, slight oedema of the general surface, and enlargement of the liver and spleen. In the later stages, there are transudates in the pleura and abdomen. In some cases, especially where there is progressive inter- stitial myocarditis with adherent pericardium, the pleura may show unilateral transudate. In cases of cardiac insufficiency, the pulse is persistently high or very irregular. There is persistent dyspnoea. Children with car- diac disease suffer, as a rule, less than adult subjects. Cardiac angina is not an uncommon symptom in cases of aortic disease. It is present in cases in which there are signs of lack of compensation. The angina comes on in attacks occurring chiefly at night, and is very severe. I have seen a boy of eight years with an aortic murmur suffer from these attacks for days. In such cases there are a dilated ventricle and an enlargement of the liver and spleen. Prognosis. — The prognosis of chronic valvular disease in childhood depends very much on the type of disease. If the heart is only slightly affected and the patient not a rheumatic subject, the outlook is good. With careful management all ill after-effects can be avoided ; children thus affected may grow to adult life without suffering from any symptoms referable to the heart. If, on the other hand, they are attacked by any intercurrent disease, such as scarlet fever, the heart may again become the seat of inflammatory processes. The patients may, however, recover and continue free from symptoms for years. The rheumatic cases give the most unfavorable prognosis. These are prone to recurrent attacks of endocarditis, each attack leaving the heart in a more weakened condition than before. Most of my cases have been children who, having had one attack of rheumatic endo- carditis, suffered from the affection to a greater or lesser degree for years. Within a few years of the first attack they succumb to pro- gressive non-compensatory cardiac disease. Treatment. — Many cases of cardiac disease in infancy and child- hood give no symptoms and need very little treatment beyond careful and judicious management. Children thus affected should have a carefully regulated dietary, and should not indulge in sports which subject the heart to strain. They should not ride the bicycle, but may, however, indulge in many of the amusements of children, such as skating, roller skating, swimming to a moderate degree, and horse- 704 DISEASES OF THE CIBCULATOEY SYSTEM. back exercise. They should be under constant observation, and when attacked by any acute infection, however slight, should be put to bed, and kept quiet until long after convalescence. In these cases an anti- rheumatic course is pursued even although the illness be only a mild attack of influenza or tonsillitis. It is well to give the salicylates in small doses for several days and to keep the bowels open with some alkaline cathartic. With children who suffer from rheumatism, the nature of the primary disease should not be forgotten. They should have constant antirheumatic treatment even when the cardiac disease is at a standstill. Any rise of temperature should be regarded as a threatening sign and the patients put to bed for perfect rest until the crisis has passed. In cases in which there is marked dilatation or pericardial involve- ment, any exacerbation of symptoms is a signal for immediate rest in bed. Slight oedema of the surface and swelling of the liver and spleen will subside if treated with perfect rest, a light assimilable diet (milk), and mild alkaline catharsis. It is not always necessary to use digitalis. If given at all, it is best administered in the form of the infusion or a reliable tincture. I am accustomed to use this drug for a period of two or three days, after which I discontinue it. In some cases of uncontrollable vomiting the digitalis may effect- ually be given in form of infusion by the rectum. There is no doubt that its action continues after the administration is stopped. Con- vallaria in the form of the fluid extract is at times one of the most useful remedies in cases in which digitalis has failed to give relief. If there is great dyspnoea or orthopnoea, codeia in moderate doses should be used. Young children do not bear morphine well. It certainly should not be used hypoderm-atically. Nitroglycerin in doses of grain Moo (0.0006) relieves the angina. In aortic disease, I administer mor- phine only to older children, and then only when the nocturnal attacks of angina are very severe. In young children with irritable heart, codeia is an exceedingly useful remedy. I have not found strychnine very useful in the chronic forms of cardiac disease. Caf- feine in moderate dosage seems more useful in correcting the irreg- ularity of the pulse or bradycardia seen in some of these cases. In combination with digitalis it gives excellent results. If ascites appears, the patient should be promptly tapped to relieve the circula- tion and the abdomen supported by a binder. If there is a pleuritic effusion at the same time, it should not bo disturbed. With relief of the abdominal distention, the pleuritic effusion often disappears. Cardiac Murmurs. — Cardiac murmurs which are the result of disease or insufficiency of the valves of the heart have the same gen- eral character as those in adults, the following being the chief points of difference: DISEASES OF THE HEAET. 705 a. Cardiac disease of a very serious character may exist (as in congenital cyanosis) without any murmur. h. Cardiac murmurs are as a rule louder in children than in adults. The loudness is therefore no guide as to the seriousness of the affection. c. Cardiac murmurs in children are sometimes heard conducted over the whole chest; diagnosis of disease of a particular valve must be based on the greatest intensity of the murmur at that point. d. Hsemic and dynamic murmurs in children under four years of age are not so common as is supposed. There should be no hesita- tion in making the diagnosis of organic affections in systolic, basic, or apex murmurs if there are distinct conduction or signs of dilata- tion or hypertrophy. This is especially to be remembered in chorea, extreme anaemia, and in febrile affections where rapidity in time and rhythm (gallop-rhythms) causes adventitious sounds. e. The conduction of the aortic murmurs into the arteria femor- alis occurs in occasional cases in children. Pulsation of the liver or spleen, as found in aortic disease of adults, is rare in children (Steffen). The peculiarities of the aortic pulse and so-called pistol-shot sound in the femorals are observed in children as in adults. Accidental Cardiac Murmurs. — Accidental murmurs are divided into those heard over the heart, in the arteries, and in the veins. The study of the accidental murmur of the heart in infancy and childhood has been much neglected. West and Hochsinger give the most val- uable data. The principal points of difference between the murmurs in infants and children and those in the adult are as follows : Cardiac Murmurs. — Anwmia. — The severest forms of anaemia in my experience sometimes fail to give hsemic murmurs. !N^ot one of 200 cases under four years of age examined by Hochsinger gave anaemic murmurs. After the fourth year and up to the seventh year of life the frequency of the anaemic and haemic murmurs increases. I have in cases of pernicious anaemia found a mild blowing basic murmur. One such case occurred in a child under four years. Fevers. — The hsemic murmurs so common in the febrile affections of adult life are rarely heard even in severe febrile affections with anaemia, in patients under the age of three years. I have heard hsemic murmurs in children under three years of age, with severe typhoid fever. They are common in typhoid fever in older children. Characteristics of Anwmic Murmurs. — These never occur with signs of cardiac dilatation or hypertrophy. They are not conducted into the arteries. They never entirely take the place of the valvular cardiac sounds, but accompany them. They are soft blowing mur- murs, heard at times most loudly at the pulmonary valve, sometimes 45 706 DISEASES OF TEE CIBCULATOBY SYSTEM. heard over the base and whole prfecordium, and faintly heard at the apex. They are never heard at the aortic or tricuspid valves, or behind. They are inconstant, disappearing for a time and again appearing at the various points in the chest. Accidental Arterial Murmurs.- — The theory held by some observers, that pressure of the stethoscope on the arteries of the neck may cause a murmur, should be entertained with caution. Correct stethoscopy will hardly lead to such an error. A murmur in the large arteries of the neck is conducted from the heart and is invariably organic in origin. I have heard aortic murmurs conducted in the femoral artery. Venous Hum. — Although cardiac accidental murmurs due to anaemia are rarely heard in children, the venous hum due to the same cause is frequently heard. In young infants and children it is pres- ent in the veins of the neck, is quite loud, and is heard at either side of the upper part of the sternum. If there is ansemia due to valvular cardiac disease, the venous hum is heard in the arteries of the neck, with the organic murmur. Myocarditis. — Myocarditis is very frequent in infancy and child- hood. Most of the knowledge of this condition has been obtained from a study of the disease in young subjects. This is due to the fact that in early life the heart is especially exposed to the deleterious action of the toxins of the infectious diseases. Myocarditis is a degeneration or inflammation of the muscular substance of the heart, secondary to the action of poisons (phosphorus) to the toxins of bac- teria (as in the exanthemata, typhoid fever, diphtheria, pertussis, sepsis, osteomyelitis), or to the changes consequent upon disease of the pericardium, or endocardium, of rheumatic or infectious origin. Etiology. — The degenerative or inflammatory changes may be caused by the direct action of the bacteria (Almquist), but usually the influence of the bacteria themselves is only slight, since they do not find in the myocardium a favorable soil for growth. The toxins of these bacteria produced either elsewhere in the economy and circulating in the blood, or in the heart muscle itself, are chiefly instrumental in causing the degenerative changes (Welch, Flexner, Schamshin). - Fever, as such, has only a slight influence in causing my ocarditi s ( Werhof sky ) . Morbid Anatomy. ^ — If there is degeneration of the myocardium, the muscular fibre may be the seat of fatty changes. There is an increase of fat drops in the muscular tissue of the heart. In advanced conditions, the fatty changes are apparent to the naked eye as a yel- lowish discoloration beneath the endocardium. In other cases, there is a granular or hyaline degeneration of the muscle fibre or a vacuole formation. The cell protoplasm becomes cloudy, hyaline, loses its DISEASES OF THE HEABT. 707 striation, and disintegrates or is replaced by drops of fluid. This occurs in diphtheria, typhoid fever, pneumonia, chronic congestion, and in toxaemia of various kinds. Thrombi may form in hearts which are the seat of advanced degeneration. In toxaemia and the infectious diseases, there is inflammation of the myocardium. There is an invasion of the muscle tissue by bacteria from the endocardium (staphylococci, streptococci, and pneumococci). In such cases, there are also grayish or yellowish discoloration of the muscle tissue, vacuo- lization, and granular and hyaline degeneration. The muscle tissue is the seat of small cell infiltration or there may be abscesses of micro- scopic or macroscopic size. If recovery occurs these areas may cica- trize with formation of connective tissue. Tuberculous and syphilitic inflammations of the myocardium occur, but are rare. Symptoms. — The symptoms of myocarditis can best be understood by studying the heart in the various infectious diseases. In diph- theria, myocarditis may be suspected if there occur sudden syncope, faintness, chilly sensations, vertigo, and vomiting. The patients complain of prsecordial weakness ; there are all the symptoms of col- lapse and a flickering, irregular pulse. These phenomena may appear at intervals throughout the disease and persist far into convalescence. In this disease there is during convalescence an irregularity of the heart apparent in the rhythm and force. There will be two or three beats and then an interval, followed by two or three beats. The pulse at the wrist may be of varying compressibility. In these cases there may be no other manifestation of the effect of the poison of the disease on the heart-muscle and ganglia. There is no pain, no vom- iting, no prsecordial distress, yet for days the heart-action will remain irregular and cause great uneasiness to the physician. Such cases may make a good recovery. In some exceptional cases, however, these symptoms precede more serious disturbances of a severe and even fatal character. The forms of marked cardiac irregularity are especially disquieting if observed during or after diphtheria, even of a mild type. In these cases the physician is ill at ease on account of the well-known occurrence of sudden death in this disease. I have seen irregularity persist in these cases for weeks, to disappear finally ; and yet during all this time the physician can give no positive assurance that the case may not result fatally. Simple irregularity, as a rule, without signs of true mus- cular weakness of the heart, such as swelling of the liver or dilatation of the ventricle, retrogrades to the normal. The toxic myocarditis complicating diphtheria manifests itself in two forms: the slow irregularly acting heart and the rapidly acting organ. In those cases in which the heart-action is rapid, the eff"ect of the toxin is manifested in a rapid tumultuous action from the out- 708 DISEASES OF TEE CIECULATOBY SYSTEM. set. The pulse is thready, demonstrating the ineffective driving- power of the heart and great muscular weakness of that organ. The orthopnoea is great and there is swelling of the liver with epigastric pain and vomiting. In acute forms of pneumonia in which the toxaemia is very great, infants may, even at the outset, exhibit cardiac weakness. There are slight cyanosis of the lips and abnormal pallor of the face and gen- eral surface. The heart action is more rapid than in other cases of pneumonia in which the lung lesion is quite as extensive. At the crisis, the action of the poison on the heart is evinced l)y an irregu- larity or arrhythmia of the pulse. The pulse may be extremely slow (bradycardia). In septic conditions there will, late in the disease.be gallop-rhythm, distortion of the pulse-respiration ratio, cyanosis, and extreme prsecordial distress. Henoch, Osier, and the writer have shown that there may be degenerative changes in pertussis. These are clini- cally apparent in cases which have extended over a long period. A constant dyspnoea, an abnormally high pulse-rate, drowsiness, disin- clination to exertion, and slight oedema of the face and other parts of the body are present. In rare cases physical examination reveals a slight dilatation of the right ventricle. In other cases there is at the apex a faint systolic murmur of purely muscular origin. In adherent pericardium, the advance of the process into the myocardium is indicated by the symptoms above detailed. The myocarditis of chronic valvular disease is a progressive process. It manifests itself by the signs of lack of comj^ensation described in the section on Chronic Valvular Disease. The varying pulse, the dyspnoea, the enlargement of the liver and spleen, and transudates into the serous cavities, all indicate this form of progres- sive weakness of the cardiac muscle. Diagnosis. — Although the diagnosis cannot in all cases be made with a1>solute certainty, the presence of the condition may be sus- pected if the following sets of symptoms appear at regular intervals in the course of the disease — attacks of palpitation and faintness, pallor, cardiac irregularity, gallop-rhythm and weakness of the apex beat and of the first muscular sound of the heart, with intensification of thf second pulmonic sound. Treatment. — The treatment should sii])])ort the heart and lessen its work, and should also be directed toward the management of the primary condition. In all of these cases, ])rolonged rest for the heart, continued long after convalescence, is of primary importance. It should not be forgotten that even in a degenerated organ there is healthy tissue on which the drugs and treatment act. These healthy foci should be sustained, and not exhausted by the action of powerful drugs given in large doses. Degeneration cannot be cured by drugs; nature must heal the diseased areas. DISEASES OF TEE HEART. 709 Cardiac irregularity, pure and simple, with a pulse of moderate slowness, is best treated by means of strychnia and caffeine. To a child of three or four years of age, strychnia, %oo grain, is given with or without a grain of caffeine every three hours. Warmth is applied to the heart, and if the extremities are cold, warm bottles are applied also. Camphor is a very excellent remedy, but can only be used for a short length of time, for it is badly born© by the stomach, and in such cases must be used hypodermically. Oil of camphor, 30 minims, may be given to a child three years of age. Severe cases accompanied by a gallop-rhythm are treated with talis. This drug is an excellent remedy in these cases, but must be used cautiously, in small doses. To a child of three or four years of age, TlXij of the tincture of digitalis given every three hours is suffi- cient. If restlessness or vomiting appear, morphia is our only safe- guard, but should be used cautiously. Enough only is given to quiet the patient. One or two minims of Magendie's solution is given by the mouth to a child three to five years of age. Hypertrophy and Dilatation of the Heart. — Cardiac hypertrophy and dilatation, combined or singly, and without any valvular lesion, occur in isolated cases in childhood. The condition is rare before the fifth year. A number of cases occurring between the fifth and the tenth year have been reported. If hypertrophy alone is present, it may affect the left ventricle only, or both ventricles. Dilatation usually affects first the right and then the left ventricle. The condi- tion develops as a result of toxsemic influences, in the acute infectious diseases, such as scarlet fever, pneumonia, diphtheria, and typhoid fever. Hypertrophy, with or without dilatation, is one of the sequelae of acute or chronic nephritis. The nephritis complicating scarlet fever is frequently the cause of cardiac hypertrophy with or without dila- tation. Arterio-sclerosis with diminution of the calibre of the aorta may cause hypertrophy with or without dilatation. I have seen sev- eral of such cases in children. Acute dilatation as a result of heart strain is rare in children. Symptoms. — The symptoms are not characteristic. In the absence of all other heart lesions, the diagnosis of cardiac hypertrophy or dilatation is made from the physical signs. These do not differ from those found in the adult subject. The rational symptoms also resem- ble those of the adult. In dilatation of the heart, there are the irreg- ular heart action, the dyspnoea or orthopnoea, the pallor of the surface, cyanosis, and in the later stages swelling of the liver and spleen. Transudates in the pleural and abdominal cavities are apt to occur toward the close. Sudden death has occurred in some eases of dila- tation of the acute variety. In hypertrophy, the symptoms closely 710 DISEASES OF THE CIRCULATOBY SYSTEM. resemble those just detailed. At the bedside, the diagnosis of hyper- trophy, of dilatation, or of both, must of necessity rest on the physical signs. Treatment. — The treatment varies with the nature of the primary disease present. The nephritis should be treated and the heart will take care of itself. If there is an infectious disease, such as typhoid fever, diphtheria, or scarlet fever, both the heart and the primary affection should be treated. SECTION X. GENERAL CONSTITUTIONAL DISEASES. DIABETES MELLITUS. Diabetes mellitus is of very rare occurrence in infancy and child- hood. Simon says that he has met it in nurslings, but Monti doubts whether it can occur under the age of one year. In all his experience he has never seen such a case, Leroux, quoted by Monti, collected 147 cases of diabetes in children. The majority occurred between the fifth and tenth years. Of 159 cases collected by Saundby, 129 occurred between these years. Cotton has, in a recent article, shown that in children the ratio of deaths from diabetes to the whole death- rate is 0.04 per cent, in Chicago, and 1.2 per cent, in ]^ew York City. Etiology. — The etiology of diabetes in children is practically the same as in the adult subject. Frerichs, Blanchard, Pavy, and Roberts have shown that heredity plays an important role. In a case coming under my observation a sister of the patient had died of dia- betes and four members of the family on the mother's side. In an instance reported by Roberts, 8 children of the family had died of it. It appears that in certain families there is a tendency to con- tract diabetes. There is no ground for assuming that diabetes in children follows traumatism or the infectious diseases, such as scarlet fever, measles, diphtheria, etc., any more frequently than in the adult. In some statistics, the sexes are shown to be equally affected. In others the disease is given as more prevalent in one or the other. Lemonnis has seen diabetes complicate congenital syphilis, tubercu- losis of the lungs and of the mesenteric lymph-nodes. I have had a case complicated with tuberculosis of the mesenteric lymph-nodes. Symptoms. — The symptoms of diabetes in children, as given in the cases thus far published, do not extend over so great a period as in the adult. The cause of this must lie in the fact that there is a long period during which the symptoms are slight or escape notice. In a case which recently came under my care the child, nine years of age, showed symptoms only five months before she came under observa- tion. At that time the mother noticed that the appetite was voracious and that there were great thirst and frequent urination. In spite of the large quantity of food and liquid taken, the child lost in weight. The amount of urine passed may be quite large. In Cotton's case it reached 104 ounces, in mine 70 ounces daily. Monti has seen as 711 712 GENERAL CONSTITUTIONAL DISEASES. mucli as 16 litres passed in twenty-four hours. Heubner and Hirsch- sprung found that the daily excretion of sugar may be from 30 to 113 grammes to the litre. In most of the cases recorded there has been polydipsia. The skin is sometimes the seat of a lichen-like eruption which causes intolerable itching. Furuncles and boils are also of common occurrence. The urine may contain albumin, and hyaline and granular casts. In one of my cases albumin was present, but no casts. There is as a rule constipation. The temperature may be normal or subnormal. If there is complicating tuberculosis, there will be a slight daily rise of temperature toward evening. In all the cases thus far published there was progressive emaciation. Acetone in the odor of the breath and diabetic coma preceded by intervals of delirium close the clinical course of the disease. Diagnosis. — The methods of diagnosis do not vary from those pur- sued in the adult. The urine of a child suifering from polyuria, polydipsia, a voracious appetite, pruritus, and progressive emaciation, should be carefully examined for sugar. Infants who take foods such as malted milk, containing an enormous quantity of sugar, often show a temporary glycosuria, which should not be mistaken for true dia- betes, and which is not attended by any of the clinical symptoms of that disease (Epstein, Koplik). Treatment. — The treatment of diabetes in children does not differ from that of the adult, but I have been impressed with the necessity of keeping these patients in bed during the treatment, as it is impos- sible otherwise to observe the patient or follow out details of dietary. DIABETES INSIPIDUS. (Polyuria.) This is rare in infancy and childhood. If the daily amount of urine is three or more times the normal amount, there is polyuria. The specific gravity of the urine does not exceed 1006. Epstein col- lected 10 cases in which the symptoms developed as a result of a cerebral inflammation in the vicinity of the fourth ventricle. The aft'cction is sometimes hereditary. Cases have followed fright, the infectious diseases, meningitis, and traumatism. The cause is fre- quently obscure. The onset may be gradual or acute. Symptoms. — Sometimes intense thirst or nervous symptoms usher in the disease. The nnti'ition may bo maintained for years. The skin is dry, the body temperature below normal, and the symptoms do not differ from those manifested in the adult. The following case from my clinic was ])ul)lishe(l by my assistant, T)r. Lewi: Walter A., a?t. seven years, was first seen at the dispensary. The DIABETES INSIPIDUS. 713 family history was, for the most part, negative, except that three children had died of nervous diseases, one of them, aged three years, of spinal meningitis, and tv^^o others, v^hen babies, of convulsions. The patient when a baby was healthy; he was breast-fed one year and had never had a convulsion. When two years old he had vari- cella, followed by pertussis ; at the age of five he had measles, compli- cated with an obstinate conjunctivitis, but recovered. In October, 1892, while driving, he was thrown from a carriage in rapid motion, striking the right side of the head ; no ill effects were noticed at the time. In January, 1893, he began to complain of pain in the back and in the nape of the neck. At about the same time it was noticed that he arose several times at night to urinate, and would invariably drink water after micturition ; the mother noticed that he grew very nervous ; the frequent micturition and increased thirst gradually be- came noticeable during the day, becoming so persistent that he was obliged to leave school. He was placed in a hospital, where he re- mained seven months ; while there he lost flesh ; none of the symptoms improved. He was on a rigorous milk diet during the entire time. January 19, 1894, the child complained of pain on the right side of his head and felt chilly all the time and could not stand still a moment. His face is pale and has an old person's look, with features sharp and pinched. The eyes are large and prominent, and the veins Date. Sp. grav. Amount in 24 hours. TTrea. Jan. 25. 1.003 6.300 c.c. 6.3 grammes Feb. 4. 1.003^ 6.300 " 6.8 (( 6. 1.005 5.200 " 7.2 li 8. 1.002 7.000 " 6.5 (t " 10. 1.004 5.500 " 6.8 ti " 17. 1.002^ 7.500 " 7.8 11 " 24. 1.003 6.400 " 6.5 (< Mar. 18. 1.003 7.000 " 8. " " 30. 1.003 7.300 " 7. a Apr. 2. 1.003J 6.400 " 6.8 toms of the onset of morbus Basedowii. Cretinism. — Cretinism is a chronic affection which is character- ized by a defective gi'owth of the bones of the skeleton in their long axes, accompanied by a distinct set of mental symptoms and by changes in the soft parts. There are two forms, the endemic and the sporadic. Endemic Cretinism. — Endemic cretinism occurs in certain dis- tricts of Continental Europe. It does not exist in this country (Osier). The pictures presented by endemic and sporadic cretinism are similar. According to the recent studies of Dolega, His, and Bernard, their pathologic anatomy is also similar. Endemic cre- tinism is an advanced stage of a degeneration beginning with goitre manifestations. The resulting changes are due to "athyreosis," a suspension or disturbance of the functions of the thyroid gland. Sporadic cretinism, although also due to athyreosis, occurs without goitre. The peculiar formation of the skull in cretinism, endemic or sporadic, is now known not to be due to a premature synostosis of the OS basilare and the sphenoid, as was at first thought by Virchow. The DISEASES OF THE TH¥EOID GLAND. 719 brachycephalic skull as manifested in a broadening of the bridge of the nose, and the prognathous expression are due to a deficient growth of the bones at the base of the skull, in their long axes. The sutures and fontanelles remain open for a long time. Dentition is delayed. The skin is myxoedematous in sporadic cretinism only. Dwarfism and anaemia are common to both forms. Fig. 163. . / Enlarged thyroid in a cliild. Sporadic Cretinism. — Occurrence. — The disease may appear in utero or at any time after birth. Fully one-half of the cases develop before the eighteenth month (Fletcher Beach). Symptoms.- — I have published cases in which the symptoms were evident within a month or five weeks after birth. The history was as follows : In one case there was another cretin in the family ; in the others there was no such history. The birth as a rule was nor- mal (Fig. 149). The infant was jaundiced, but fairly well nour- ished. It lay in a torpid state and was only roused when severely teased. The infant was easily chilled. The cry was deep and coarse. ■20 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. The foretead was low and narrow. The eyelids were puffy. The- tongue was large, broad, and thick, at times protruding from the mouth. The abdomen was large, and the thighs and legs were out of proportion to the length of the trunk. The skin had a greenish hue. The thyroid gland could not be found. The surface was cool and the rectal temperature 97° or 97.8° F. (36.1°-36.5° C). The blood in these early cases has foetal characteristics. There isnoleuco- FiG. 164. Congenital sporadic cretinism. Infant, four weelis old. cytosis. In the cases which develop some months after birth the infant may at first be bright and normal. Six to nine months after birth it may have had some slight illness, such as an adenitis, and after this the change was noticed, or the change may have occurred without any preceding illness. The infant ceases to notice objects about it, and becomes stupid and weaker. It may previously have attempted to walk or stand, but ceases to make an effort to do so (Plate XXXI.). The child's expression is idiotic. It has a mean- ingless smile most of the time and does not play. The skin has a wi-inkled and myxoBdematous appearance, the color being not only pale, but also greenish. The nose is flattened, the lips are thickened, and the hair becomes dry and sparse. The forehead is narrow and PLATE XXXI .'^S^ ^--^S^rv j4 "N. ^^, ^.. ,.., sporadic Cretinism. Child fifteen monthis of age- DISEASES OF THE TH¥EOID GLAND. 721 the face has a prognathous expression — " monkey-like," as one mother expressed it. There are no teeth. The neck is short and thick. The genitals are large for the age. The skin of the scrotum is thick- FiG. 165. Sporadic cretinism ; myxoedema marked. Child, twenty months of age. ened. The anaemia in these cases is extreme. The haemoglobin may be as low as 18 per cent. The leucocytes may be as high as 18,000, and the red blood-cells 5,600,000. 46 722 LYMPE-NODES, DUCTLESS GLANDS AND BLOOD. In other cases, the symptoms are at first more of the myxoede- matous type. The skin, especially that of the face, has a greenish- yellow, waxy, puffy appearance. The npper and lower eye-lids are swollen, as in nephritis. With these appearances, there are the dry hair, the macrogiossia, the guttural voice, the dwarfish appearance, the protuberant abdomen, and the mental dulness. The expression of the face is less prognathous than in the first form. In one of my cases the infant was in good health until the sixteenth month. It then developed abscesses over the body, after which the symptoms of cretinism were noticed. The abscesses were peculiar, the granula- Fig. 166. ^^^^^^^^^^J ^P^ 9^1 ^^^^^^ -^ S . ^ hh ■ "^ J ? "''k9^^| ifl ^m -^yar^ M ^m 1 ■ J s '^^^^ Cast of the hand of a boy cretin, four years of age. Flat and spade-like in form ; shows also the thickened and hypertrophied hypothenar eminence. tions sluggish, and the pus was creamy. The skin was not (Edema- tous, but myxccdematous. In both forms the hands are large, flat, and spade-like. The hypothenar eminence is thick, square, and hypertrophied, as in the lower animals (Koplik and Lichtenstein) (Fig. 1G6). In some cases the thyroid gland cannot be felt, in others it is small, and in excep- tional cases there is goitre (7 cases of Osier's scries). In some cases, supraclavicular masses of fat or fatty tumors behind the sternomastoid muscles are apparent. I have seen these masses of fat in cases which had suffered a return of symptoms after suspension of treatment. Etiology. — The etiology of sporadic cretinism is as yet absolutely unknown. Experimental and operative pathology have demonstrated that interference with the function of the thyroid gland (athyreosis) will produce a condition (myxoedcma) closely resembling cretinism DISEASES OF THE THYROID GLAND. 723 (Horsely, Reverdin, Koclier). The essential cause of endemic cret- inism is thought to be some form of infection (Fagge). Sporadic cretinism is also ranked by some authors among the infections. Morbid Anatomy. — There are cases of sporadic cretinism in which the thyroid gland is absent. It has not developed in fcetal life and is not found at autopsy. In other cases there is found at autopsy a small atrophied gland which is sclerosed and much reduced in size. Such cases have been published as following the infectious diseases. Fig. 167. Cretin, myxcedematous type, 4 years of age. Lastly, there are cases with goitre. The changes in the thyroid, when it is found in sporadic cretinism, have been described by Barker. There is an increase of connective tissue. The parenchyma is re- placed by small and large irregularly shaped cells, which are granular and unlike the normal tissue. Some of the acini are almost solid ; others are cystic and filled with colloid material. The cells may con- tain vacuoles ; their nuclei may show " karyorrhexis." The nuclear 724 LYMPE-NODES, DUCTLESS GLANDS AND BLOOD. changes are characteristic of degenerative processes. Some of the acini are replaced by connective tissue. The Bones. — In the recent v^ork of His, Dolega, and Bernard, it has been clearly shown that ossification in the pre-existent cartilagi- nous structures of the skeleton is delayed in all its phases. This is evinced in the delayed appearance of ossification centres, the delayed bony transformation of the epiphyses, and in the persistence of the epiphyseal zones. In some cretins, ossification is completed at a very late period of life; in others, infantile conditions are perpetuated. The dwarfing of, the whole skeleton is thus explained, not by a pre- mature synostosis, but by faulty proliferation and ossification of the epiphyseal cartilages. The bones of the skull are affected in the same manner as the vertebrae and the long bones, in that they fail to grow in their long diameters and in that ossification centres appear late. Diagnosis. — The diagnosis is not difficult in advanced cases. The early cases require close study. In these, the stupidity increasing to absolute idiocy, the retarded growth, the change in the expression, the swollen eyelids, thick lips, dry hair, wrinkled myxoedematous skin, the flat, spade-like hands, the dwarfish appearance, and the reduced internal temperature, all point to the diagnosis. In later eases, the extreme anaemia, myxoedema, and pronounced prognathous expression of the face are apparent. Differential Diagnosis. — Mongolian Idiocy. — This is a form of genetous idiocy with which cretinism is frequently confounded. The idiots resemble cretins. The growth is stunted. The mouth is kept open. The facies seen in cases of adenoids is present but due in these cases to peculiar bone formations at the base of the skull. The tongue is large and fissured ; the papillas of the tongue are enlarged and erect. The tongue protrudes from the mouth (Plate XXXII.) ; the lips are thick; the voice is coarse and guttural. The temperature may be subnormal, but is generally normal. The skin is dry and the hair coarse. In young infants the skin may be delicate. The patients are easily chilled. The musculature is flabby. The infants cannot hold the head erect. The occiput is flattened, the neck short and thick. There is strabismus, and the axes of the eyelids have a Mongolian slant — that is to say, they converge. The inner eyelid comes down toward the nose with a rapid slope. The bridge of the nose is flat. The head is small and obtusely rounded; the antero-posterior diam- eter is nearly equal to the lateral one. The fontanelles remain open late. The skin, however, is not myxoedematous, nor is the expression prognathous as in the cretin. The ana?mia is as a rule marked; in some cases the skin has a greenish hue. There is a curving inward of the tip of the little finger. The second phalanx is short and the PLATE XXXII Mongolian Types of Idiocy. Infant and young children. DISEASES OF THE THYROID GLAND. 725 terminal phalanx displaced. West has shown that although this deformity is very common in these idiots, it is not pathognomonic of Mongolian idiocy. Many of the subjects of this form of idiocy grow to adult life and have varying degrees of intelligence. The Dwarf with Idiocy. — There may be several of these dwarfs in a family. The thyroid gland is enlarged at the beginning or during the course of the condition. The mental state is much stunted. The general growth of the body is retarded. Dwarfs are, however, well formed. The hands and extremities are perfect and the skin is not as a rule myxoedematous. Infmitilism. — Infantilism combined with lipomatosis may be con- founded with cretinism. In this form of disease there is no myx- edema and the skin is very delicate and soft. The genitals are atrophied. The expression of the face is that of child-like simplicity, the forehead is low and narrow. The hair is dry, and does not grow ; the finger-nails do not grow. There may be, as in the case I pub- lished, blindness. The mental state is one of mild idiocy. Treatment. — The treatment of cretinism constitutes one of the mar- vellous chapters of modern medicine developed by experimental path- ology. The administration of thyroid extract results in a partial restoration of the mental capacity and a return to growth and develop- ment approaching the normal. The writer published in 1897 some cases of cretinism diagnosed early in infancy, in which the treatment was begun at once. In those in which the treatment was begun at the age of one month, the children have become bright and apparently normal. In those in which it was inaugurated at the fifteenth month, the children have, after five years of treatment, remained somewhat backward in mental development. One patient, now a boy of six years, goes to school, and recites his alphabet, but is very simple in manner. In these late cases the treatment does not give the complete results at first expected. Treatment is begun by the administration of the dried extract of thyroids of sheep, grain |- (0.03) t. i. d., and increase the dose until the infant takes grain j (0.06) three times daily. After the symp- toms have retrograded, the dosage is kept stationary for a few months. It is then reduced or the remedy is given only every other day. If symptoms, such as stupidity, pallor, or reduced temperature reappear, the dose is increased. The first sign of improvement is a reduction of the anaemia, as evidenced in the increase of hsemoglobin. The body temperature rises to the normal. The skin becomes of normal delicacy and supple. The stature increases and the hair becomes glossy. Thomson, of Edinburgh, has published cases of adult cretins whose bones became softened after the prolonged administration of thyroids. These were cases in which treatment was begun late in 726 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. life. The symptoms of excessive administration of thyroids include rise of temperature and slight diarrhoea, due to toxins in the thyroids. I have found thyroid therapy of doubtful utility in cases of Mon- golian idiocy. In the dwarfs above mentioned, it causes increase of stature ; the intelligence, hovs^ever, remains backward. Fig. 168. Infantilism and lipomatosis universalis in a boy ten years of age. Dwarfism; Nanism. — A dwarf is a person of very small stature. The tallest dwarf according to Sainton should not exceed 1.5 metres or 59 inches in height. Differentiation from Infantilism. — Infantilism is frequently con- founded with dwarfism, but it is the direct opposite of the latter con- DISEASES OF TEE THYEOID GLAND. 727 dition. Meige defines infantilism as a physical and mental condition found in individuals whose sexual apparatus is congenitallj or acci- dentally in a state of arrested development. Infantilism is charac- terized by rounded face, dimpled features, gracile limbs, prominent lips, smooth skin, fine, clear complexion, delicate hair, slightly marked eyelashes and eyebrows, small nose, long torso, prominent abdomen, and a rounded obese conformity of the body (Fig. 168). There is an absence of hair on the pubes and axillae, the mental state is that of childhood and the stature is not that of a dwarf. They are not vicious, though at times moved to anger. An excellent example and portrait of this condition is given elsewhere. Dwarfism, on the other hand, is an arrest of development. The mental state varies ; at times dwarfs are quite clever. Varieties. — Sainton describes dwarfs as: 1. Myxcedematous dwarfs. 2. Achondroplasic dwarfs. 3. Rachitic dwarfs. 4. Spondylitic dwarfs. 5. Anangioplastic dwarfs. 6. Pygmies and dwarfs with lesions of the suprarenal capsules. 1. The myxcedematous dwarfs are quite numerous, the head is large, the face puffy, complexion yellow, skin thick, the genitals atrophic, the thyroid absent of scarcely perceptible, and the voice thin and high-pitched. The thyroid and glands supplying internal secretions are in a state of atrophy. Thus there is an etiological factor in this atrophy. The mental condition is not as bright as in other forms of dwarfism. 2. The achondroplastic dwarfs are elsewhere described. They are brighter than the above class. Their characteristics have been described by Pierre Marie. The arrest of development is most appar- ent in the lower extremities, the trunk and arms being almost normal. Micromelia is a term at times applied to this condition. 3 and 4. Spondylitic and rachitic dwarfs are not as frequent. The former condition depends on a curvature of the spine and a rigidity of the cervical vertebrse. 5. Anangioplastic dwarfs are most uncommon. They are per- fectly formed, small, graceful individuals. I have seen several ex- amples of this type and have described them. 6. Pygmies described by Poncet and Levair as having an absence of physical abnormalities, bodies are small but harmoniously devel- oped ; such are the dwarfs of the Eskimos, Laplanders, Fuegians, and Central Africa. Dwarfism is therefore a condition of mal-development dependent in many cases on mal-nutrition or a lack of the internal secretions. 728 LTMPH-NODES, DUCTLESS GLANDS AND BLOOD. DISEASES OF THE THYMUS GLAND. Landmarks, — The tlivmiis is a glandular organ enclosed in a cap- sule. It is situated in the anterior mediastinum, and contains in its structures a white tenacious fluid substance which is present in vary- ing quantities. Sappey shows that the thymus in the newhorn infant extends from the upper edge of the manubrium sterni, 5 cm. down- ward. Its upper border may reach the isthmus of the thyroid or may be removed 2-| cm. from it. It extends downward to the middle or upper third of the pericardium. In exceptional cases it may have a longitudinal diameter of 11-| cm., reaching the diaphrag-m (Triese- thau). The thymus is about 2 to 3 cm. wide. Luschka makes it unsymmetrical, consisting of two lobes united by an isthmus. It lies over the course of the pulmonary artery and is surrounded by a reflec- tion of the pericardium. It is separated from the sternum by loose connective tissue. Its length varies from 4 cm, in the nursling, to 11 cm. in the ninth year, the average ratio to the body length being 1 to 7 or 8. Weight. — Its weight varies. In the results which the writer obtained in collaboration with Jacobi, it did so within wide limits. In infancy the average weight is 20 grammes ; from the second to the fourteenth year it is 24 gTammes. After the twenty-fifth year the thymus atrophies and may weigh 2.2 gTammes (Friedeleben). In abnormal states the weight may be 32 grammes (Triesethau, Pott ). The causes of the enlargement of the gland and the conditions under which it occurs are not as yet known. The gland is large in infants dying of the most diverse diseases. Percussion." — Under the most favorable conditions it is difficult to ascertain the exact size. Tiie thymus has sometimes been marked out as large during life, and post mortem found to be small. As a rule, an area of dulness situated behind the upper part of the sternum, and discernible on gentle percussion, may be cautiously interpreted as due to the thymus (Sahli). An unsymmetrical area giving dul- ness on one side of the sternum is probably due to the thymus (Luschka), especially in subjects under the second year. The thymus may be seen by rc-ray as a shadow behind the upper sternal region. Abnormal Conditions. — Xone of the abnormal conditions of the thymus can be diagnosfd with certainty during life. Hypertrophy of the Thymus Gland, Including So-called ' ' Thymus Death." — Simple hypertrophy of the thymus gland, irrespective of its presence as a cause of sudden death, has been observed by Virchow, Grawitz, Jacobi, and others. It may exist without causing any symptoms, and only be discovered postmortem in children who have died of various diseases. In other cases an enlarged or hypertrophied thymus has been described as causing a series of symptoms similar DISEASES OF THE THYMUS GLAND. 729 to what is seen in tlie adult subject in forms of asthma. Virchow, Grawitz, West, and Goodhardt have described such cases under the head of " Thymic Asthma." These cases are attended with par- oxysms resembling those of laryngismus stridulus with difficult breathing. Some of the cases described by the above authorities have eventuated in convulsions and sudden death. Recently Hochsinger has attempted to revive the term " thymic asthma " as applying to cases of laryngeal stridor ; the symptom-complex in such cases being due, in his opinion, to an enlarged condition of the thymus. There has been much discussion as to the existence of such an entity as " thymic asthma." There is another form of sudden death, the so-called '' thymus death," which has been ascribed to hypertrophy of the thymus gland. These cases have been described by Virchow, Grawitz, Pott, and others, and there seems to be a tendency in some quarters to attribute certain cases of sudden death to the existence of an enlarged thymus. In one case, described by Pott, the thymus weighed 32 grammes, was 9 cm. long and 1^ cm. thick. Cases of thymus death have been described, for the most part, in children who are the victims of a condition known as status lymphaticus. This condition should be differentiated from that described under the heading of Scrofulosis, and for the sake of clearness will be described under the head of Status Lymphaticus combined with that of thymus death. In the work of Jacobi it was shown that hemorrhages of the thymus are not uncommon, and are present in a number of conditions, especially in pertussis. Inflammation of the thymus may be present in inflammatory conditions of the pleura and pericardium. Steu- dener has published a case of sarcoma of the thymus, and Vogel one of carcinoma of that organ, occurring in childhood. Demme pub- lished a case of isolated tuberculosis of the thymus. In the mono- graph of Jacobi, general tuberculous infection of the thymus was investigated, as was also the condition as found in diphtheria. In the latter disease necrobiosis of the thymus was found as described by Oertel in other organs. Congenital syphilis may manifest itself in arterial and connective-tissue changes. Abscess of the thymus is rare. Status Lymphaticus (Lymphatis'm; Lymphatic Constitution).- — - This condition is found chiefly in children who are subjects of rachitis and are moderately well nourished but angemic. They have enlarged lymph-nodes at the angle of the jaw, in the axilla, and in the groin, and may have attacks of laryngismus stridulus. They have enlarged tonsils, adenoid tissue in the posterior nares, and enlargement of the adenoid tissue at the base of the tongue. On the other hand, they present none of the skin-, bone-, and joint-affections seen in the scrof- 730 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. ulous or tuberciiloiis subject. Escherich has published cases in which there were 30 attacks of larrugospasm a day. The patients also have symptoms of increased excitability of the peripheral motor nerves, such as Trousseau's phenomena and Chvostek's symptom. I have had one case in which there was an attack of laryngismus at every crying-spell. The patients are in constant danger of sudden death. The reader is referred to the article on tetany for a further discussion of these cases. In rare case5 in which sudden death has occurred an enlarged thymus has been found, and other lesions which will now be described under the title of Thymus Death. Thymus Death. — There are two distinct sets of cases of sudden death in which the thymus has been found to be enlarged. The first are those in which, postmortem, absolutely no other change has been found than the presence of an enlarged thymus. In these cases the viscera were said to be absolutely normal, but, as has been stated else- where, there were evidences of lymphatism, such as enlarged tonsils, lymph-nodes, and solitary follicles in the intestine. The second set of cases is that in which the thymus was found not only to be enlarged, but apparently pressing on the trachea or arch of the aorta, causing complete obliteration of these organs. The latter set of cases were recorded by Beneke, Lange, and Weigert. But few of these cases published are to be considered in the category of thymus death, for these rather represent pathological growths of the thymus similar to any other tumor which might lead to pressure effects. Such a condition of the thymus is exceedingly rare. What interests the physician most, especially as the cause of sudden death, are the cases of enlarged thymus in which, as in the first set, no signs of pressure were found, either on the large vessels or the bronchi. That death in these cases is not caused by pressure is now generally conceded. The theory advanced by Paltauf and Escherich is not unreserv- edly accepted by all. Paltauf contends that the sudden death is due to an anomalous lymphato-chlorotic constitution, the enlarged thymus thus being only one of the manifestations of a general disturbance of nutrition, in which we also find enlarged lymph-nodes and tonsils, and hyperplasia of lymphatic tissue. Under the influence of this condi- tion there are changes in the nerve-centres of the heart, as a conse- quence of which the least excitement may result in fatal paralysis. Escherich, in addition, while accepting this theory, thinks that in the condition of lymphatism there is an auto-intoxication whereby the nervous system is in a state of morbid irritability and instability which results in heart-syncope. In this condition the functions of the thymus are probably disturbed, much like that of the thyroid in myxoedema or Basedow's disease. DISEASES OF THE THYMUS GLAND. 731 On the other hand, Richter has analyzed all the cases published of the so-called thymus death. In most of these cases there were present anatomically other conditions, such as bronchitis, intestinal catarrh, or some other disease, to account for the fatal issue. In most children overtaken by this form of death there is a condition of lymphatism, and this, in addition to the growing thymus, which at the age of two years is quite large, has been made accountable for the death of these infants and children, whereas close study will always reveal some other morbid condition fully equal to causing this issue. Thymus death is one of the rarer forms of sudden death in early infancy, as compared with other forms. I have seen it twice, and know of nothing more distressing than such an occurrence. The physician may be examining such a child for a slight movement, when suddenly the infant throws the head backward, there is a noiseless or snappy inspiration, the eyes turn upward and sideways, the pupils dilate, there is cyanosis both of the face and tongue as the latter be- comes swollen and caught in the jaw; there is a convulsive contrac- tion of the body backward. There are several inefficient, noiseless, shallow inspiratory movements, the body then relaxes, the face be- comes ashy pale, and the infant, within one or two minutes, is dead. The heart ceases to beat at the beginning of the attack. It is really a syncopal death. Escherich has recently grouped these cases under the category of tetany or latent tetany. There is another form of death in lymphatic infants and children which occurs in chloroform narcosis. In such cases the heart may suddenly cease to beat during the narcosis ; or, as in one of my cases, the child may have withstood the narcosis, though it was noticed to have taken the chloroform badly. Twelve hours after the operation — ^which in this case was one of appendicitis — the temperature rose slightly, there was a rapid increase in the heart action, the pulse mounting in a short time so that it could no longer be counted ; while the heart beat at the rate of over 200 a minute (cardiac paralysis),, the pulse could not be felt at the wrist. Death occurred with all the signs of paralysis of the cardiac ganglia. In the case last described the child was extremely lymphatic, had a thymus enlarged to percussion, and a year previous had been oper- ated on for adenoid vegetations and enlarged tonsils. The lymphatic nodes throughout the whole body were enlarged. The appendicitis from which the child suffered was one of the mild catarrhal type. There was no septic peritonitis. Treatment. — Inasmuch as death supervenes in these cases before anything can be done in an orderly way, it is almost superfluous to speak of treatment. Pott, however, and others have performed tracheotomy in these cases with a view not only of relieving the 732 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. spasm of the glottis, wliieli in some instances is present, but of per- forming artificial respiration. Others have intubated. In those cases in which the heart has ceased to beat, we can scarcely expect to revive its action. In one case of my own of a lymphatic child in which the heart failed at the outset of the chloroform narcosis, became irregular, and threatened to stop beating, artificial respiration, the Laborde method of resuscitation, and massage over the cardiac area according to the method described by Maas, brought the child to life again. We will not always succeed in this manner. The treatment of the general condition — the status lymphaticus — consists in the removal of the enlarged tonsils and adenoids. In these cases the condition of the lymphatic-node enlargements is vastly improved by the operation. Good food, cod-liver oil, and the prepa- rations of the iodide of iron are also indicated. Morse has recently suggested in cases of laryngismus with attacks of dyspnoea, the removal of the thymus if the organ was enlarged. Two cases thus treated were relieved temporarily, but the symptoms ultimately returned and the patients died. DISEASES OF THE SPLEEN. Anatomical. — At different periods of childhood the length of the spleen varies from 4 to 10 cm., the breadth from 2 to 5 cm., the aver- age thickness being about 0.5 cm. It forms an oval-shaped body, behind the ninth, tenth, and eleventh ribs, the long axis running in the direction of the ribs. Up to the second month of life, the anterior edge of the spleen is found in the midaxillary line ; after that, it may be found further forward than this line, or posteriorly to it. The upper edge corresponds to the upper edge of the ninth rib ; the lower border to the lower border of the eleventh rib. The spleen may be located by percussion and palpation. Percussion. — The patient is caused to lie on the back. It is not necessary to cause children to lie in an inclined lateral posture. The upper border is first located by percussing from above downward in the midaxillary line on the left side. At the seventh rib is a strip of slight dulness extending from the seventh to the ninth rib. I have been able to locate it in infants and in children imder the age of six years. There can be no question as to its existence, although there may be doubt as to its causation. Symmington, in his frozen section, shows that, in a girl six years of age, the left lobe of the liver is dis- tinctly on the left side behind the seventh and ninth ribs. Sahli ascribes the strip to what he calls the deep dulness of the spleen. From the ninth rib downward, there is absolute dulness, then flatness, due to the presence of the spleen proper behind the chest wall. The DISEASES OF THE SPLEEN. 733 anterior border of the spleen is located by percussing in a horizontal direction toward the axillary line along the tenth rib. Palpation. — The enlarged spleen can be distinctly made out by palpation. The abdomen should be relaxed. It is sometimes neces- sary to flex the thighs slightly, in order to relax the abdomen. In young infants this is not necessary. The physician stands at the right side of the patient and with the palmar surface of the fingers of the right hand palpates the ab- dominal parietes just beneath the border of the ribs (Fig. 169). As the patient inspires deeply, the hand is by steady pressure insinuated beneath the ribs in an upward and backward direction. In the vast majority of cases under the tenth year, the normal spleen may thus be felt. Fig. 1G9. Method of palpating the spleen. In practice, it may safely be said that a spleen which cannot be felt below the border of the ribs is not enlarged, unless some con- dition, such as the presence of fluid or tympanites, prevents thorough palpation, I have rarely failed to palpate the enlarged spleen satis- factorily. Enlargement of the spleen is found in rachitis, chronic gastro-enteritis, sepsis, typhoid fever, malarial fever, varicella, syph- ilis, ansemia infantum pseudoleuka?mica, leuksemia, Hodgkin's dis- ease, congenital syphilis, cirrhosis of the liver, amyloid degeneration, heart disease, and simple catarrhal jaundice. From these statements it will be seen that enlargement of the spleen in infancy and childhood is pathognomonic of no one disease, and should not lead to any one conclusion. It is only corroborative in the presence of other signs and symptoms. Without a very thor- ough and painstaking examination of the blood, the significance of the enlarged spleen in the febrile and afebrile afi^ections cannot be 734 LTMPE-NODES, DUCTLESS GLANDS AND BLOOD. determined. In enlargements of the spleen such as are met in rachitis, heart disease, syphilis, chronic gastro-enteritis, icterus, vari- cella, examination of the blood may not be necessary. Splenic and Kidney Tumors. — In rare cases in which sarcoma of the left kidney is suspected, it may be necessary to exclude tumor of the spleen. An enlarged spleen is smooth on the surface and has a sharp an- terior edge interrupted by an indentation — the hilus. The tumor is pointed and sharp below. It can be grasped deep in the lumbar re- gion behind. Kidney tumors are irregular on the surface and marked out into lobes, some of which may be cystic. The tumor projects upward behind into the lower part of the chest. The whole lumbar region is flat on percussion. The borders of the tumor are rounded. On the other hand, I have made an autopsy in a case of cirrhosis of the liver and spleen in which the latter organ during life showed uneven tumors on its surface (gummata). The physician must be partly guided by the history of a case. The urine should be examined in cases of sarcoma of the kidney, and the blood in cases of enlarged spleen. I have seen a subphrenic abscess displace the spleen downward. The left lobe of the liver was also displaced in the same direction. Under anaesthesia, a round mass could be felt above the spleen, which was enlarged. Behind, the lung came well down to the bottom of the chest, as was evinced by the presence of the respiratory murmur. Dulness was, however, present in the left axillary line and behind. On exploratory puncture in the posterior axillary line, the subphrenic abscess was found to be present. DISEASES OF THE BLOOD. Leading General Characteristics of the Blood in Infancy and Childhood. — For diagnostic purposes, it is important to bear in mind certain characteristics of the blood in infancy and childhood. Ehrlich has shown that conditions normal to the blood in early life are of grave import if found in the adult. The Red Blood-cells or Erythrocytes. — During the first three days of life, nucleated red blood-cells are found in the normal blood. In the newly born infant, the red blood-cells number from 4,500,000 to 6,500,000 to the cubic millimetre (Hayem). There is a polycy- thaemia. This condition is found during the first few days of life. On the fourteenth day there is an average of 5,500,000 red blood- cells to the cubic millimetre. From the second to the tenth year the average number is 5,000,000 (Otto, Schiff, Sorenson). The polycytha?mia in the newly born infant is greater if the tying of DISEASES OF THE BLOOD. 735 the umbilical cord is delayed until its pulsations cease. Weaklings show a diminished number of red blood-cells. In addition to imper- fect nutrition, anaemia of any kind, acute or chronic cachexia, and certain drugs, such as antipyrin, antifebrin, phenacetin, and lacto- phenin, reduce the number of red blood-cells by disintegrating a certain proportion of them (Monti). Infectious diseases, such as malaria, scarlet fever, typhoid fever, and sepsis, have a similar influence. In severe anaemia, such as that accompanying rachitis, nucleated red blood-cells appear in the blood. These are also found in the severe primary ana?mias, in acute leukaemia, and in pernicious anaemia of infants and children. The White Blood-cells or Leucocytes. — The number of leucocytes in the nev^ly born infant is high, being from 18,000 to 30,000 to the cubic millimetre (Hayem, Guppen). It gradually falls to 12,000 to the cubic millimetre, the average for infants. The percentage of lymphocytes is at first small in comparison with that of the poly- nuclear leucocytes. Gundobin, whose work has been confirmed by Carstanjen, found that the polynuclear leucocytes preponderate in the newborn infant. They increase and reach their highest figure in the first forty-eight hours of life. They then diminish in number, while the mononuclear lymphocytes increase proportionately until the seventh or tenth day, when the blood assumes the characteristics which distinguish it during the period of infancy. During infancy the mononuclear lymphocytes are more numerous than the polymor- phonuclear leucocytes. The following table is taken from Gundobin's figures : Polymorphonuclear Mononuclear Transitional leucocytes. lymphocytes. forms. Immediately after birth ... 63 per cent. 25 per cent. 12 per cent. Forty-eight hours after birth . 70 per cent. 21 per cent. 19 per cent. Infancy 34.6 per cent. 59 per cent. 6.4 per cent. In normal infants and young children, the number of leucocytes to the cubic millimetre may vary from 13,000 to 20,000 (Japha). The so-called digestive leucocytosis found in the adult is inconstant in infants and young children (Japha). There is an inflammatory leucocytosis in infants and children similar to that seen in the adult. It occurs in pneumonia, scarlet fever, rheumatism, sepsis, diphtheria, post-hemorrhagic anaemia, and cachexia (sarcoma). In the normal state, the leucocytes may reach a minimum of 6000 to the cubic milli- metre (Monti). This fact should be borne in mind in estimating the leucopoenia in typhoid fever, malaria, tuberculosis, and in other infec- tious or toxic states. The transitional forms of leucocytes are numerous in the newly born infant, reaching their maximum from the sixth to the ninth day. The eosinophiles are present in the same number as in later life (Japha). 736 LYMPE-NODES, DUCTLESS GLANDS AND BLOOD. The HEemoglobin. — The blood is richer in hsemoglobin at birth than later in life (Morse, Leichtenstern, Eotch). After birth the percentage of haemoglobin sinks, and at the third month reaches that of later Hfe. Carstanjen found the haemoglobin on the average 100 per cent, up to the twelfth day. The lowest percentages are found from the sixth month to the second year. There is, in exceptional cases in normal children, a very high percentage from the fifth to the tenth year, ranging from 95 to 110 (Widowitz, Leichtenstern, Hock, and Schlessinger). The percentage in healthy children may be as low as 60 (Fleischl) or 8.4 grammes to 100 c.c. of blood. At the third month of infancy it may range from 69 to 94; up to the second year it may range from 62 to 81 (Monti). There seems to be no fixed normal limit. Anaemia or toxsemia of any kind and infectious diseases diminish the hgemoglobin. The Specific Gravity. — The exact clinical significance of the spe- cific gTavity of the blood is little understood. The specific gravity is high in the newly born infant, ranging from 1.056 to 1.066. From the sixth month to the tenth year it varies from 1.050 to 1.056 (Monti). These figures correspond to those of Hock, Schlessinger, Lloyd, Jones, and others. The blood of strong children and breast-fed infants has a higher specific gravity. Diarrhoea may raise it, but rarely to a ratio of more than 0.004 part per 1000. The specific gravity is increased in the infectious diseases, pneumonia, pleuritis, endocarditis, typhoid fever, and tuberculous meningitis, and falls on the decline of these processes. It is also increased in congenital heart disease, chorea with endocarditis, icterus, and diphtheria. It dim- inishes with the loss in weight accompanying anaemia and nephritis, and in cachexia (Hock, Schlessinger, Monti, Hammersley, and Felsenthal). Anaemia. — Anaemia is a condition resulting from a deficiency in the blood of one or more of its constituent elements. It may be either congenital or acquired. In the latter case it may either be secondary to other conditions or occur as a primary disease. Congenital anaemia is seen at birth in infants born of badly nourished mothers, who dur- ing pregnancy have suffered from some disease of the placenta, or from syphilis, tuberculosis, or malaria. The foetus in utero becomes anaemic. Acquired anaemia appears after birth. It is either sec- ondary to some acute loss of blood (post-hemorrhagic), to chronic loss of blood, or is caused by defective nutrition, unhygienic surroundings, diseases of the various organs, toxaemia, infectious diseases, or parasites. Primary or essential anaemia is the form in which the changes in the blood play so important a role that it is assumed there is a dis- ease of the blood itself or of the blood-forming organs. Such are the forms of leukaemia, chlorosis, and pernicious anaemia. DISEASES OF THE BLOOD. 737 Simple Anaemia (Secondary Anoemia). — Etiology. — Secondary simple aiisemia may follow some acute or chronic loss of blood. In acute post-hemoTrhagic anaemia, the increase of fluid elements keeps pace with the loss of blood if the loss, though small, is repeated at short intervals. Children show the effects of loss of blood much more quickly than adults. Hydrsemia is the condition which results when the loss is marked. The fluid elements increase, and there is a diminution in the specific gravity of the blood and in the amount of hsemogiobin. Hydrasmia may result in children without hemorrhage ; that is to say, it may occur in extreme severe anaemia secondary to some disturbance of nutrition or to illness. In post-hemorrhagic anaemia the coagulability of the blood is increased immediately after the hemorrhage. Ehrlich supposes this to be due to an increase in the number of blood-plates. After the hemorrhage, the regeneration of blood in the infant, as in the adult, is indicated by the formation or appearance in the blood of microcytes, megalocytes, and nucleated red blood-cells (normoblasts). The severe forms of this variety of anaemia also show polychromatophilic properties of the red blood-cells. These are so poor in haemoglobin that with various stains the normal reaction is very much changed. There are various shades of the stained red blood-cells. In recent and severe cases of post-hemorrha- gic anaemia there may be leucocytosis. There is an increase of the polynuclear neutrophilic leucocytes (Monti, Ehrlich). iSTucleated red blood-cells (normoblasts) may appear in severe cases. Poikilocy- tosis is also one of the changes seen in the blood. Secondary anaemia of a mild or of a severe type is also seen in infants and children who suffer from defective nutrition. It com- plicates or accompanies rachitis, syphilis, scrofula, tuberculosis, gastro-intestinal catarrh, chronic endocarditis, purpura, morbus Werlhofii, and infectious diseases. Symptoms. — The symptoms of mild anaemia in infants and chil- dren do not differ materially from those of adults. The patient is pale and the mucous membranes have a characteristic pallor. The appetite is capricious. The patients also suffer from symptoms due to the primary affection — syphilis, rachitis, acute infectious disease, gastro-enteric disturbance (acute or chronic), or cardiac affection. The pallor of cardiac disease or nephritis is characteristic in infants and children, as in the adult. The anaemia if of a severe type takes the hydraemic form. In the severe forms of anaemia, especially in infants and very young children who suffer from syphilis or rachitis, the skin is waxy or yel- lowish white. The ears are absolutely devoid of any color of blood. In cretinism the skin has a greenish-yellow hue. Infants do not show the symptoms, such as dyspnoea or palpitation, seen in older 47 738 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. children on exertion. The muscles are flabby and there is a disposi- tion to lie quietly in the crib. The spleen may be large, and the liver also, especially if rachitis or syj)hilis is present. In cases in which the anaemia is extreme, the spleen may be normal. Infants and very young children do not always show the anaemic murmurs which are heard over the heart area in older children. In older children murmurs of that variety may be present with a venous hum in the neck, and the symptoms of mild and severe anaemia are essentially those of later life. These are indisposition to exertion, feelings of weakness, drowsiness, lack of appetite, irritability, and restlessness. Some of the severe forms of anemia show for weeks a very slight irregular febrile curve. In many cases the fever is due to intestinal toxaemia. The Blood. — The mild forms of simple anaemia may show only a diminution in the amount of haemoglobin, a very slight diminution in the number of red cells, a reduction of the specific gravity, and if there is a primary affection which, like pneumonia, causes an increase in the number of leucocytes, leucocytosis. My records of severe forms of anaemia in infants and young children show a diminution in the amount of haemoglobin (18 per cent.). The blood shows microcytes, megalocytes, megaloblasts, and normoblasts. Increase of mononuclear lymphocytes is proportionate to that of the poly- nuclear leucocytes. Poikilocytosis/in various forms is present, as are also polychromatophilic phenomena. In the severe forms of anaemia due to malarial poisoning I found, in addition to the plasmodium. microcytes, megalocytes, and megaloblasts. The eosinophiles are not increased. In severe anaemia, the physical characteristics of the blood are striking. It may be so thin as to seperate on puncture into a reddish and a colorless portion resembling beef-water. Chlorosis.- — Chlorosis is a form of primary anaemia. It is not a disease of infancy or childhood, and is mentioned here only in order to complete the classification of diseases of the blood. Its etiology is obscure. Virchow believed it to be due to congenital narrowness of the whole arterial system and smallness of the heart. This theory does not explain the cases in which recovery takes place. Meinert ascribed the condition to an irritation of the abdominal sympathetic. Hofman thought that developmental conditions of the genital ap- paratus were causal in chlorosis. Forcheimer contends that intestinal auto-infection is etiological in producing the chlorotic state, since there is in chlorosis an interference with the production of haemo- globin, the principal source of which is the gut. Occurrence. — Chlorosis is more common in females than in males, and occurs at the time of puberty. The condition of the blood has been described bv Monti. The DISEASES OF THE BLOOD. 739 hsemoglobin is diminished. The number of red blood-cells is in mild cases scarcely at all reduced. In severe cases it may fall to 1,000,000 to the cubic millimetre. The absolute amount of hsemoglobin may reach 4 to 8 in 100 cubic millimetres of blood. The specific weight may be reduced to 1035. There are niicrocytes in the blood. There Fig. 170. Pseudoleuksemic anajmia, enlarged spleen and liver. is no leucocytosis. There are poikilocytosis and polychromatophilic appearances in the stained blood. Pseudoleuksemic Anaemia of von Jaksch (Ancemia Infantum •Pseudolev.Jccemica.) — In 1889 von Jaksch described a symptom-com- plex met with among infants and young children, to which he gave 740 LTMPH-XODES, DUCTLESS GLANDS AND BLOOD. the name of anaemia infantum psendoleuksemica. He described the condition as a clinical entity which, in running its course, gives the picture of severe ljmj)hatic angemia. There are enormous enlarge- ment of the spleen, slight enlargement of the liver, some enlargement of the lymph-nodes, and changes in the blood. It is a secondary anaemia rather than a distinct disease. For this reason Fischl, Epstein, and others deny that it is a clinical entity. On the other hand, Monti and Luzet have described numbers of cases. I have records of 9 cases, which were published. The aneemia is extreme. Etiology. — It is difficult to determine the etiology. Von Jaksch and Monti trace an intimate connection between this condition and rachitis. Wentworth and the Italian school regard it as secondary to some form of intestinal infection. Occurrence. — The condition is rarely found before the age of six months. My cases ranged from the ages of eleven to twenty months. It may occur up to the third year, and is most common from the seventh to the twelfth month. Most of the cases thus far pub- lished have occurred in infants or children suffering from rachitis or congenital syphilis. In all of my cases there were signs of rachitis. Some of the children had previously suffered from chronic gastro- enteric derangement. Morbid Anatomy. — The post-mortem findings published by von Jaksch, Luzet, Baginsky, Holt, Glockner, Lehndorf, and the writer correspond very closely. The spleen was large and firm, the liver hard and enlarged, and the mesenteric lymph-nodes were enlarged. A histological exami- nation revealed the bone-marrow rich in cells ; there were normo- blasts, leukocytes with granules and those without granules ; there were myelocytes, eosinophiles, and giant cells, also cells containing pigment. The marrow was a richly cellular mixed marrow. The liver cells were normal; there were nucleated red blood cells in the capillaries, and myelocytes. The kidney showed parenchymatous degeneration, the heart was negative, the lungs showed peribronchitic infiltration, the spleen showed increased connective tissue, pulp rich in cells, capillaries dilated, eosinophiles present in moderate numbers, nothing abnormal found. Lehndorf was inclined, from the appear- ances, to regard the anatomical diagnosis of myelemia, especially supported by the appearances found in the liver, and kidney, although the spleen and lymph-nodes were less affected, and there was no siderosis. It will be shown later on how little justified this conclusion was. Symptoms. — The infants affected have as a rule suffered from chronic intestinal disturbances. Most of them are bottle-fed and atrophic. Although the skin is intensely anaemic and of a yellow, DISEASES OF THE BLOOD. 741 waxy tinge, there is sometimes a panniciiius of fat. The musculature is flabby and the abdomen large. As a rule there are signs of rachitis. The fontanelle is open and the eruption of the teeth delayed. The infants are irritable, peevish, do not willingly take food, and do not assimilate it. In one of my cases, there was complicating pneumonia. There is, as a rule, no fever, unless it is due to intestinal toxaemia. The picture is one of progressive emaciation and anemia. In some cases there is complicating icterus, and the spleen reaches to the crest of the ileum. The edge of the spleen is sharp and the hilus can be distinctly felt. The liver is slightly enlarged; its edge is round and smooth. In one of my cases, it extended two and one-half inches below the free border of the ribs (Fig. 170). The lymph-nodes in the groin and axillse are slightly enlarged, sometimes only to the size of a bean. The Blood. — The specific gravity of the blood is reduced. The haemoglobin may be reduced to one-quarter the normal percentage. It may be as low as 17 per cent. There is a marked diminution of the number of red blood-cells. The nucleated forms of erythrocytes are abundant. There are megaloblasts, which show karyokinesis. In addition there are red blood-cells of all sizes — microcytes and megalocytes. There is poikilocytosis to a marked degree, and also polychromatophilia. The leucocytes are only moderately increased. In the severe cases the proportion of white blood-cells to the red may be as 1:100, 1:80, or 1:15 (Monti). The picture given by the leucocytes is different from that of leukaemia. Most authors agree that the various forms are represented and increased in equal ratio. In my nine cases the blood-picture was as follows : The hemo- globin ranged from 28 to 65 per cent.; the count of red blood-cells or erythrocytes fell as low as 1,400,000 and in others was as high as 4,448,000 ; and the leucocytes ranged from 5,200 to 7,500 to 40,000 and 80,000 to the cubic millimeter. In all cases there were nucleated red blood-cells, normoblasts, and megaloblasts from 7 to 15 per cent. In some cases the white cells varied from 11,000 to 80,000 to the cubic millimeter in a given case, with erythrocyte count of 2,600,000 to 3,700,000. Some writers think there is a predominance of polynuclear leuco- cytes, but this is scarcely so, as in some cases they comprised 80 per cent, of the white blood cells, while in others they fell as low as 14 to 15 per cent. This may occur in the same case in which blood-counts have been taken a few days apart. A leucocytosis or a polynuclear leucocytosis, therefore, is of no diagnostic import. The myelocytes were present in all cases, varying in frequency from -J per cent, to 7 per cent. In some cases at different times the myelocytes varied from -J per cent, to 4^ per cent, in different counts. 742 LTMPE-NODES, DUCTLESS GLANDS AND BLOOD. It has been shown elsewhere that the myelocytes, also, are not of specific value as differentiating these cases from other cases of severe anaemia, and the variation in the same case, at different times of the percentage of these cells, would tend to confirm this view. The eosinophiles were present in normal percentages in all the cases. Mast cells were present in all cases in percentages varying from 1 per cent, to 4 per cent. A study of the blood pictures in my uncomplicated cases only tends to confirm the belief expressed by others that the blood picture in this disease is not a definite pathological picture of anything but a severe anaemia in children in whom any disturbances of the functions of the blood-forming organs causes a retrogi-ade to the fcetal structure. A comparison of the above blood pictures with those published by Lehndorf, Fowler, Monti and Berggriin, Zelenski and Cybulski show a remarkable correspondence, and prove my contention that though the blood picture is not specific, the clinical features of these cases are characteristic, inasmuch as so many observers agree as to the physical, clinical signs. Diagnosis and Course. — The clinical picture presented by cases of anaemia, described by Von Jaksch, and following him by writers mentioned, is certainly easy of recognition. The anaemic habitus, the tumored abdomen, the spleen of enor- mous size, the increased size of the liver, the intestinal disturbances, easily enable us to recognize such cases apart from the cases of slight anaemia, with moderate enlargement of the spleen. There is nothing, however, in these cases which suggests leukaemia, except it be the large liver and spleen. The course of some of these cases result- ing in complete and satisfactory recovery, certainly impresses me with the fact that the condition is rather one of a severe disturbance of the nutritive functions of certain organs, such as the intestine, and its large secretive glandular system, reacting upon certain organs, such as the spleen, causing changes in the same, with secondary changes in the blood, which may assume a role of primary impor- tance. Von Jaksch's anaemia is, therefore, a severe secondary anaemia, with or without marked leucocytosis. Those cases which have been reported as terminating in true leukaemia were really cases of leukae- mia from the outset. Cases of true Von Jaksch disease, if they terminate fatally, do so from some intercurrent disease, such as pneumonia or tuberculosis, to which they fall easy victims. Treatment. — Thus far the treatment has been empirical. Small doses of Fowler's solution are indicated. If rachitis is present, phosphorus is given by some in small doses. I have seen cases do DISEASES OF THE BLOOD. 743 badly under that treatment. Tonics and an easily assimilable diet are indicated. The bowels should be kept clear by enemata given daily in order to lessen the possibility of infection of the gut. Leukaemia (Leukocythaemia). — Leukaemia is a persistent condi- tion of the blood in which there is an increase of the white blood- cells, and a diminution of the red ones. It is a primary disease of the blood itself. Accompanying it are changes in the spleen, liver, bone-marrow, lymph-nodes, and lymphoid tissues. Virchow called the condition "white blood." French writers have called it leukocy- thaemia. The proportion between the white and the red blood-cells is not so distinguishing a feature as the appearance of large numbers of lymphocytes in the blood, in which they are normally present in only small numbers. In one form the appearance of mononuclear neutrophile-staining myelocytes which are normally absent is a dis- tinguishing feature. Ehrlich characterizes leukaemia as a mixed leucocytosis of chronic course, since white blood-cells of all kinds are present in the blood. This is not the case in the polynuclear and eosinophile leucocytosis. Occurrence. — The disease is rare in childhood, but some authors believe it to be more common in the first year of life than is generally supposed (Monti, Mosler). Fifteen to 20 per cent, of the cases occur in the first decade of life (Baginsky). Males are more frequently affected than females. The disease is believed to be hereditary. Etiology. — The etiology of the affection is still unknown. In a few cases, micro-organisms and sporozoa have been found in the blood (Eoux, Kelsch, Veillard, Lowit). The sporozoa of Lowit are de- scribed by him as being free in the blood as well as in the leucocytes and in the blood-making organs. In lymphatic leukaemia they are described as being intracellular only. Auer has described intracellu- lar bodies in the leucocytes resembling capsulated bacteria. Some writers think that rachitis and syphilis predispose to the development of leukaemia, especially if the bones are involved as well as the liver, spleen, and lymph-nodes. Certain forms of anaemia fol- lowing malaria, diphtheria, and scarlet fever, and accompanied by enlargement of the liver, spleen, and lymph-nodes, may, according to some writers, pave the way for leukaemia. Physical or mental strain, unhygienic living, defective nutrition, and traumatism of the spleen, have all been regarded as predisposing factors. Forms. — The simplest classification of leukaemia is that based upon the anatomical appearances of the blood. Such is the classifica- tion of Ehrlich, which is as follows : (a) Lymphatic leukaemia, in which there is a marked hyper- plasia of lymphoid tissue. (&) Myelogenous leukaemia, in which there is hyperplasia of 744 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. myelogenous tissue. Ljmphatic kuksemia may run an acute or a chronic course. In both forms the distinguishing feature is the appearance in the blood of large numbers of the mononuclear lym- phocytes and the displacement of the polynuclear leucocytes. The acute form is rare. It occurs in childhood. Eight cases have oc- curred in my hospital service in the past six years. Its course is rapid. There are slight or marked tumor of the spleen, slight or very marked enlargement of the liver, and a tendency to petechise and to general hemorrhages. Some authors regard these cases as infectious. The chronic forms show marked enlargement of the spleen. Changes in the Blood, ^ — As was previously stated, the lymphatic forms of leukaemia are distinguished by the appearance, in the blood, of large numbers of the small and large mononuclear lymphocytes. In the myelogenous forms, a cell which is normally not present in the blood, but is indigenous to the bone-marrow, appears in large num- bers. This cell is the large mononuclear neutrophilic staining cell, the myelocyte of Ehrlich. The mast-cells are also found in these cases, but are not peculiar to this form of anaemia. In addition there is in the myelogenous forms of leukaemia an increase in the number of all three types of granulated white cells, the neutrophiles, the eosinophiles, and the mast-cells. There are dwarf forms of the white blood-cells, mitoses, and lastly large numbers of nucleated red blood- cells, l^ormoblasts, megaloblasts, and myelocytes are not normally' present in the blood. They are occasionally found in penumonia, and in leucocytosis. The eosinophiles are increased to fifteen times their normal number. The slow coagulability of leuksemic blood is characteristic. The spleen is enlarged. It is at first soft, often firm, and is infiltrated with lymph-cells. The capsule is thickened; the connec- tive-tissue stroma is increased and infiltrated with lymph-cells. The lymph-nodes show similar changes, and may be enlarged, forming tumors of considerable size. The bone-marrow is so infiltrated with lymph-cells as to acquire the appearance of a purulent infiltration. The same lymphoid infil- tration is found in the liver. The follicles of the gut are swollen. There is an increase of lymphoid cells and tissues. The lymphoid tissues elsewhere, such as the tonsils, thymus, skin, and even the retina, show the same changes. There are hemorrhages and exudate in the ear, and the nerves and nervous tissue of the central nervous system are the seat of lymphoid cellular invasion. Symptoms. — The Acute Form. — Cases of acute leukaemia in infancy and childhood have lately been increasing in the literature. The most recent cases include those of McCrae, in a boy aged three years, and of Miller, in an infant of eight months. Cases have also DISEASES OF THE BLOOD. 745 been reported by Morse, Japha, Strauss, Monti, Berggriin. The most frequent is the lymphatic form. The symptoms in all the published cases were similar. In a boy eight years old, admitted to my hospital service, there were no premonitory symptoms. Two months before admission he was in good health. He became very pale, there were irritability and loss of appetite, and the abdomen increased markedly in size. He complained of pains in the legs, and at the onset had chills and fever every other day. After the appearance of the chills Fig. 171. Acute lymphatic leuksemia. Enlarged lymph-nodes, spleen, and liver, one-half years of age. Boy four and he suffered from a low irregular fever. A week before death, the skin had a waxy color, there were petechise on the extremities, the gums bled easily, and the lymph-nodes of the axillae and groin were enlarged. There was an ansemic murmur with the first sound of the heart ; the liver was enlarged below the free border of the ribs to the extent of two fingers' breadth ; the spleen was enlarged to the level of the umbilicus; the fundus of the eye showed retinal hemorrhages. Examination of the blood showed the haemoglobin to be reduced to 15 746 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. per cent. (Fleisclil). The red blood-cells numbered 1,012,000 to the cubic millimetre ; the white blood-cells, 37,000. There was an im- mense preponderance of lymphocytes (mononuclear). The patient died with signs of progressive weakness. Coma was preceded by vomiting and the appearance of a few petechise. The blood state continued much the same as at first. In another case the number of mononuclear lymphocytes was fully 75 per cent, of the white blood- cells. In both these cases the spleen and liver diminished in size before death. The proportion of white, to red blood-cells may not be far from normal. In another case the nucleated red blood-cells, large and small, were very numerous. In this case, in a boy of four and one-half years, the nodes around the parotid and angle of the jaw, in the axilla, and in the inguinal region, increased in a short time to a large size, and the spleen grew rapidly larger and reached to the crest of the ilium. The liver reached to the umbilicus. These mediastinal lymph-nodes were enlarged and caused great dyspnoea. The distress way very great just before the lethal issue (Fig. 171). In a case of V. JSToorden's the proportion of the white to the red blood-cells was 1 : 200. The predominance of the lymphocytes is diagnostic. Most of the cases published showed a slight temperature. The fatal issue usually results a few weeks or a month or two after the onset of symptoms. The Chronic Form.- — The symptoms of the chronic form extend over a greater length of time. For months there are ansemia, lassi- tude, and extreme physical weakness. The appetite is good, but in spite of abundant nourishment, emaciation is progressive. In some eases there are periodic diarrhceal attacks. Profuse hemorrhage may occur without warning either from the nose or intestines. Chills and fever resembling those of paludism are sometimes present. ITone of these symptoms is particularly characteristic. As the disease progresses there are headache and pain in the limbs and in the region of the spleen. The ansemia after a time assumes a severe type, and the skin becomes waxy and yellow. At this stage the spleen and liver enlarge and distend the abdomen. There are dyspnoea and palpitation; the ansemia takes the hydrsemic form, and there is oedema of the face, hands, and feet. Hemorrhages then occur from the nose, lungs, mouth, intestines, but rarely from the kidneys. There are petechise in the skin and hemorrhages in the retina. In the lymphatic form the lymph-nodes in various parts of the body enlarge and form masses which are painless and covered with unaffected skin. The skin may be affected by the process. The mesenteric nodes may sometimes be felt through the abdomen. The spleen attains an enormous size. The liver may extend as far as the PLATE XXXIII w*^ Hodgkin's Disease in a Child. DISEASES OF THE BLOOD. 747 umbilicus. Eespiratory difficulties, heart weakness, and nervous symptoms (such as vertigo, somnolence, and coma) end the clinical course of the disease. The urine is diminished, and contains hyaline casts, lymphoid cells, and a trace of albumin. There may be a slight continued fever in the course of the disease. Prognosis. — The prognosis is unfavorable. Of 39 cases collected by Birch-Hirschfeld, only 4 recovered. Only in the early stage is recovery possible. Death supervenes from exhaustion with hemor- rhages or from intercurrent pleuritis or pericarditis. Treatment. — The treatment of a disease whose exact nature is still unknown is difficult. Good food, and hygienic surroundings are the first requisite. In the treatment of anaemia, the iodide of iron, cod- liver oil, and arsenic are the chief drugs employed. In the lymphatic form, arsenic in the form of Fowler's solution gives the best results, Hodgkins' Disease (Ance7nia Lymphatica; Adeniej Pseudoleu- I'cpmia; Lymphadenoma) . — This disease is really not an affection of infancy and childhood inasmuch as 75 per cent, of the cases occur above the age of ten years. It is mentioned here to emphasize its characteristics as distinct from tuberculous adenitis or scrofulous enlargements of the lymph-nodes. It is an affection beginning with the enlargement of the lymph-nodes of the neck, usually of one side, and accompanied by an enlarged spleen and liver. In the spleen, liver, and other organs there are nodular growths. There is a pro- gressive cachexia accompanied by febrile periods. The disease is fatal either in a short time of a few months or after a period of two or three years, during which there may be intervals of improvement. There are no changes in the blood such as are seen in true leuksemia, and in this lies the main element of differential diagnosis. A most complete account of the nature of this rare affection will be found in a recent monograph by Dr. Reed, published in the Johns Hopkins Hospital Reports, Vol. X., and in a monograph by Clarke in which he collected 43 cases. The Hemorrhagic Diatheses. — In this class of diseases are em- braced only those affections which are due to some primary -change in the blood or in the circulatory apparatus. Thus conditions which are due to local disease of some organ, or the hemorrhages which follow the acute infectious diseases or drug poisoning are not included. Experimental pathology has as yet not given any clue to the etiology of the hemorrhagic diatheses. The contention of William Koch and Ajello, that they are infectious diseases or are due to some auto- intoxication, is not universally accepted. At present the clinical classification of these diatheses into the transitory forms in which are included purpura simplex, peliosis rheumatica hsemorrhagica, scorbu- tus, and the persistent form hereditary in character, such as ha?mo- 748 LYMFH-NODES, DUCTLESS GLANDS AND BLOOD. philia, may be accepted. In the latter, the hemorrhage may be exten- sive, difficult to control, and due to some very slight cause. Simple Purpura. — This is a transitory condition characterized by small hemorrhages or petechise, or large, irregularly shaped extrav- asations of blood. These are as a rule discrete, but may be confluent, and are situated in the epidermis or in the superficial layers of the cutis. Immediately after the extravasation the hemorrhages have a bluish-purple tinge. After a few days they become brown or green- ish-yellow. These extravasations are seen most frequently on the lower extremities, generally on the extensor surface. They also occur in other localities. As a rule there are few or no symptoms. There may be crops of petechise appearing at short intervals. In a few cases there are, after an exacerbation of the local phenomena, loss of appetite, vomiting, and general malaise. The so-called purpura cachecticorum appears on the body, abdomen, back, and upper extremities in children under two years, suffering from diarrhoea and other exhausting diseases. In the latter case there may be leucocytosis, due to the original affec- tion. The changes in the blood in simple purpura are still to be studied. Etiology. — The cause of this purpura is still unknown. It may be due to some obscure toxaemia. Prognosis. — The prognosis is very good in the primary form. In the secondary form it will depend on the nature of the original affec- tion. Treatment. — The treatment will depend on the nature of the origi- nal disease. I treat the purpura itself in the same manner as cases of purpura h£emorrhagica, which will later be fully described. Haemophilia. — Hsemophilia is a rare condition of the blood and blood tissues which may be congenital or hereditary. It becomes apparent at birth or in early infancy, and is rare in later life. Nature. — The nature of the affection is obscure. It is a type of hemorrhagic diathesis which is transmitted from generation to gene- ration in the female line. It is characterized by the occurrence of uncontrollable hemorrhage after very slight injuries, and operations, and also in the absence of known traumatism. Etiology. — Many theories of the cause of the affection have been advanced. They may be grouped as follows : (a) An abnormal delicacy and friability of the bloodvessels. (b) An increase of the volume of blood (Immerman). (c) A defect in the coagulable constituents of the blood. (d) Certain agencies acting as toxins on the elements of the blood, causing their dissolution (Koch). The condition is most common in the Slavic races. Children PLATE XXXIV Haemophilia. Boy six years of age. Haematoma of the face ; hemorrhage into the knee-joint. (Case of Dr. Martin Ware.) DISEASES OF THE BLOOD. 749 dying of the affection show evidences of intense antemia, but may be well nourished. Virchow has demonstrated that there is a narrow- ness in the arteries and also a thinness of their walls. Birch-Hirsch- feld found that the endothelium of the arteries was enlarged, and that the nuclei were swollen. The blood itself shows no changes except those proper to post-hemorrhagic anaemia. The hemorrhages may occur in any region and from any organ of the body. There may be hemorrhage into joints, profuse epistaxis, intestinal hemorrhage or uncontrollable hemorrhage from the mouth or lung. The drawing of a tooth, the incision of an abscess, or a minor operation such as circumcision, may cause uncontrollable and fatal hemorrhage. In the newly born infant, there may be fatal hemorrhage from the cord. In the case pictured in Plate XXXIV. there were hemorrhages into the joints and into the face, without distinct traumatism. This case came of a family of bleeders in which there had been fatalities following surgical operations. The condition lasts weeks, months, or years — in fact, it persists during the life of the individual. Some authors believe that the female members of families thus affected should not marry. Treatment. — The treatment is mainly prophylactic. The infant should nurse a wet-nurse, in order that the noxious influence of its own mother's milk may be lessened. Good food and fruits of all kinds should be given. All operations and traumatism should be carefully avoided. Purpura Hsemorrhagica {Morbus Maculosus Werlhofii). — In the prodromal period before the appearance of the hemorrhages, there may be several days of general malaise, disturbance of appetite and digestion, and febrile movement. There are ansemia, pain in the limbs, and oedema of the feet. The hemorrhages may appear without any symptoms. They are especially frequent in the lower extremities, and next most frequent in the upper extremities and on the chest, face, and trunk. They consist of extravasations of blood in the skin and subcutaneous tissue. The mucous membranes are frequently affected. Epistaxis, bleeding of the gums, bloody movements, and bloody urine result. There are ecchymoses in the conjunctiva and bleeding from the ear. The hemorrhages in the skin may be petechise, or irregular bluish or purple blotches which subsequently become yellow- ish or greenish yellow. They occur spontaneously or follow slight traumatism or pressure. There may be hemorrhages into the joints. There may be exacerbations and recurrences of hemorrhages extend- ing over weeks. The tendency of the mucous membrane to bleed has been mentioned. The gums are spongy and bleed easily. There are hemorrhages or petechiae on the soft and the hard palate. The hemor- 750 LYMPH-XODES, DUCTLESS GLANDS AND BLOOD. rhages from the kidney cause the appearance of albumin and blood in the urine. The urine is red and blood-coloring matter may be found by the turpentine-guaiac test. Hemorrhages in the brain and central nervous system may occur, causing paralyses and coma. In mild cases there is no disturbance of nutrition, but in severe ones the • anaemia is marked, as is also the emaciation. The blood shows few changes. The number of red blood-cells is diminished, as is also the specific gravity. In severe cases there is a slight leucocytosis ; the polynuclear leucocytes are increased, eosinophiles are few, microcytes are present, and there are a few normoblasts. The leucocytosis im- proves as recovery sets in. Etiology. — The etiology of this affection is still obscure. Because of its infectious nature, William Koch believes it to be allied to scorbutus and other hemorrhagic affections. His view is not sup- ported by other writers. Ajello and Schwab regard the condition as an auto-infection or a form of toxemia. Kolb, Tizzoni, and Babes have found bacteria in the blood of fatal cases. Others have isolated streptococci and staphylococci from the blood (Lebreton). In one of my cases there was a history of an insect-bite. The disease is rare in breast-fed infants and is more common after than before the age of two years. The infants and children attacked may have pre- viously been in good health. Diagnosis. — The diagnosis is made from the course of the affection and the size and nature of the hemorrhages. The constitutional dis- turbance is more marked than in simple purpura. The hemorrhages are blotchy, in that respect differing from the petechia of peliosis. The joints are not swollen, as in the latter affection. Prognosis. — The cases of ordinary severity recover. Severe cases may recover or may result fatally. Treatment. — The treatment consists in placing the patient in hygienic surroundings, and giving a nutritious diet with a liberal allowance of fruit and vegetable acids. In marked cases, Fowler's solution, given in moderate doses, gives good results. Purpura Rheumatica {Peliosis Rheumatica of Schonlein) .■ — Pur- pura rheumatica consists of an eruption of small discrete purpuric spots in the vicinity of the large joints, especially of the lower extrem- ities about the knee. The accompanying symptoms are pain and swelling of the joints of the lower or upper extremities. Etiology. — The etiology is obscure. The disease occurs in children previously healthy. It is seen in older children only, and has no apparrnt relation to acute articular rheumatism. Symptoms. — Slight fever is followed by tbe appearance of the purpuric spots and the swelling of the joints of the lower and rarely of the upper extremities. The joints are painful, as in rheumatism. DISEASES OF THE BLOOD. 751 At times the swelling of the joints is less apparent, but there is nevertheless tenderness on pressure. The purpuric spots are partic- ularly numerous in the vicinity of the joints. A general urticaria may precede the appearance of the purpura. There are no heart complications. The condition of the blood is not as yet understood. There may be several crops of purpuric spots appearing at intervals of days or weeks. In other cases there are oedema of the face and enlargement of the spleen. In one of my cases there were at first slight hemorrhages from the bowel. There may be epigastric pain and tenderness in the course of the disease. The average duration of the affection is from ten to fourteen days. There may be relapses extending over weeks. Prognosis. — The prognosis is good even when there are several relapses and when the affection takes a subacute course. Treatment. — Rest in bed is the first requisite of treatment. The patient is put on a nutritious diet in which there is an abundant allowance of fruit and vegetable acids. Lemonade and orange-juice are especially indicated. The bowels are regulated and the salicylate of sodium is given in moderate doses. A child four years of age is given grains v (0.3) three times daily. The pains in the joints are easily controlled by rest. In the subacute stage small doses of Fowler's solution are of great benefit. Henoch's Purpura. — Henoch in 1874 described a series of 4 cases of purpura which he classified as distinct from purpura hsemorrhagica or poliosis rheuniatica. The symptoms were as follows: Children in apparent good health were attacked by a form of purpura in which there were arthritic pain, vomiting, and intense abdominal pains with bloody diarrhoea. The rheumatoid pains were accompanied by swell- ing of the joints. The purpura was of the hemorrhagic type — that is to say, there were extravasations of blood in the form of ecchymoses or raised exanthematic areas, not disappearing on pressure. The areas were situated on the abdomen and lower extremities. The joints affected were those of the wrist, elbow, and ankle. The intesti- nal symptoms consisted of repeated vomiting, tympanites, excruciat- ing colicky pains, bloody "stools, and tenesmus. One case was fatal. Such cases have been from time to time described by other observers. I have seen a number of cases. These cases are at present regarded as due to a form of intestinal infection the exact nature of which is still obscure. They constitute a group probably belonging to the class of primary hemorrhagic affec- tions in which is included the so-called poliosis rheumatica. Diagnosis of Forms of Purpura. — It is not always possible, clinically, to assign each form of purpura to its proper class. This is especially true with young children, in whom there occur forms of purpura 752 LYMPE-NODES, DUCTLESS GLANDS AND BLOOD. showing a diversity of symptoms and not fitting into any sharply defined class. ISTor is it always possible at the bedside to decide whether the condition present is scorbutus or idiopathic purpura. Characteristic of both purpura and scorbutus are the hemorrhages into the skin, the internal organs, the serous cavities, and the mucous membranes. On the other hand, the frequency of hemorrhages and affections of the giims, the prodromal cachexia, the joint-affections, and the periosteal hemorrhages are peculiarly characteristic of that form of scurvy called Barlow's disease, which is seen in nurslings and young children. The purpuric affections of so-called idiopathic type, in which a purpuric exanthema is spread over the whole surface, may be called simple purpura. In the so-called rheumatic purpura or poliosis rheumatica there is a blotchy hemorrhagic exudate over the surface in the vicinity of the joints, with pain in the joints, and gastric pains. There is always a tendency to relapses. Hemorrhages from the mucous membranes and bowels are rare, but occasionally occur. In purpura hsemorrhagica or morbus Werlhofii there are minute or blotchy hemorrhages in the skin and internal hemorrhages from the mucous membranes, stomach, and intestines. Attempts to define sharply each of these sets of cases have been made. It is not always possible or desirable to do so. I have seen cases of poliosis with bowel hemorrhages and gastric crises, and cases of purpura hsemor- rhagica in infants, in which there were pains in the joints, evinced by the distress shown when the joints were moved. The forms of purpura regarded by Henoch as a distinct type are classed by others as purpura rheumatica. The different classes of idiopathic purpura therefore overlap, one case frequently showing symptoms of two types. The only possible conclusion is that there may be a common cause of all forms of purpura — probably an infection. Pernicious Anaemia. — This is a primary anaemia which causes progressive impoverishment of the blood and results in death. It is not common in infancy and childhood. The condition of the blood in pernicious anaemia in infancy and childhood has not as yet been closely studied. The changes in the blood which have been published as characteristic of this condition in infancy and childhood are found in other states, such as the severe anaemia of rachitis and syphilis. Ehrlich is not disposed to accept these cases without question. Blood pictures which in the adult may be diagnostic of pernicious anaemia cannot be thus interpreted when found in infants and young children. Observers of note, such as Monti, Berggrlin, and Baginsky, have pub- lished cases in infants and young children. I have met a case in an infant which had been bitten by a rat. After an interval, anaemia of a progressive and fatal type set in. The changes in the blood were DISEASES OF THE SUPBAEENAL BODIES. 753 similar to those characteristic of the same form of ansemia in the adult. Monti has collected 16 cases, 2 of which were in infants; 5 ranged from one to six years ; 9 were above the age of five years. On the other hand, Ehrlich found that of 240 authentic cases, only 1 occurred in the first decade of life. That case was in a girl of eight years. In the face of such great diversity of opinion, it is wise to await the results of further research. For the purpose of reference, the following account of the changes in the blood which, according to Ehrlich, are diagnostic of pernicious ansemia in the adult, is ap- pended : (a.) The volume of blood is markedly diminished. (&) The color is at first normal, but later resembles that of beef- water. (c) The haemoglobin may be as low as 10 per cent. (Fleischl). This is due to a diminution of the number of red blood-cells, for the individual cell may have a hjemoglobin content equal to the normal or above it. (d) There are microcytes, megalocytes, and sometimes giganto- cytes. The megalocytes may constitute 70 per cent, of the red blood- cells. They become fewer on convalescence. There are few megalo- blasts, but characterictic normoblasts are found. (e) Clumps of free granules are found in the blood. The red blood-cells may contain granules. (/) Staining solutions produce polychromatophilic effects. (g) The eosinophiles are normal in number. (h) The number of white blood-cells is diminished as well as that of the polynuclear neutrophiles. The latter condition indicates serious involvement of the bone-marrow. The lymphocytes are proportionately increased. (^) The leucocytes show no changes. Improvement is ushered in by leucocytosis. (j) The specific gravity of the blood is diminished, as is also its coagulability. In my case the nucleated red blood-cells were numerous. DISEASE OF THE SUPRARENAL BODIES. Addison's Disease (Morbus Addisonii) . — This is an exceedingly rare aifeetion before the tenth year of life. Of 48 cases collected by Dezirot, only 6 occurred before the tenth year. Most of the cases col- lected by this author (in children) occurred before the twelfth and fifteenth years. It may occur in the newborn. It is caused by tuber- culous degeneration of the suprarenal capsule, although in one case there was carinoma of this organ. Apart from asthenia and melano- 48 754 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. dermie, gastro-intestinal disturbances and convulsions dominate the development of the disease. Vomiting is very frequent. The con- junctiva and nails escape pigmentation. The duration is shorter and the disease more rapidly fatal in children than in adults. Sudden death is a frequent termination. Enlargement of the mesenteric lymph-nodes and Peyer's patches ^nd solitary follicles have been observed. The pigmentation of the buccal and other mucous membranes remain, as in the adult, pathognomonic of the disease. It must be differentiated from tuberculosis of the peritoneum with melanodermie and gastro-intestinal crises. Pigmen- tation, however, of the mucous membranes remains characteristic of Addison's disease. Treatment. — Inasmuch as the operative treatment in adults has in certain cases caused an amelioration of the symj)toms, it might also be tried, if the diagnosis is certain, in children. SECTION XII. DISEASES OF THE BONES. General Considerations.^ — In examining the joints, it should he borne in mind that the bones entering into the formation of the joints may be affected. The diaphysis may be diseased without accompany- ing involvement of the joint. Tuberculosis. — In all bone lesions tuberculosis should be excluded. In infants and children, the question as to whether the existing con- dition is tuberculosis of the bone or syphilis is constantly arising. Syphilis affects by predilection the long bones in the diaphysis, while tubercle affects the short bones, especially in the vicinity of the joints. In this region, also, tubercle attacks the epiphyses of the bone and may thus involve the joints secondarily. Pain in syphilitic bone lesions is very marked, acute, and with nocturnal exacerbations; while the pain of tubercular bone lesions is obseure and indefinite, although persistent. The swelling in syphilis is in the form of a periostitis or an ostitis involving only the bone ; in tuberculosis, the surrounding tissues are affected as well as the bone, and abscess and fungous granulation result. Syphilis rarely suppurates ; the contrary is true of tuberculosis. Syphilis of the bones does not as a rule lead to cachexia ; tuber- culosis of the bone eventually causes cachexia and emaciation. There are cases in which doubt will arise as to the true nature of the bone affection. This is especially the case when the small bones of the hand are affected. In such cases a tuberculin test is indicated. ' Sudden painful swelling of the long bones occurring in corre- sponding bones on both sides should awaken a suspicion of syphilis, even in the absence of other signs of syphilitic disease. A long bone which has been affected by syphilis will be irregularly thickened, owing to the repeated attacks of periostitis. This thickening is likely to be confounded with that caused by rachitis. In rachitis, the bone is less painful than in syphilis and the thickening is invariably uniform and smooth. In scurvy there may be a thickening of the long bones due to hemorrhage in the periosteum. In these cases the history and also the presence of other signs of scorbutus, such as hemorrhages in the skin or bleeding of the gums, will aid diagnosis. 755 756 DISEASES OF THE BOXES. Craniotabes. — In locating patches of so-called craniotabes, the surface of the occipital and other hones of the skull is examined for deficiency of hone formation. The occipital bone will in rachitis present membranous spots more frequently than is generally sup- posed. The most common tumors found on the scalp are those due to traumatism at birth, such as cephaloha?matoma, tumor of the scalp with depressed bone, and tumor due to syphilis. The cephaloheema- toma is found after birth and need not be described here. If an infant falls on one side of the head from a height, a depression of the skull may at once take place. This occurs if the bones are soft and not yet completely ossified. The depression is filled with an effusion of blood and serum. A soft tumor results which may not project above the surface at all or only slightly so. Around the border of the tumor the rim of bone bordering the depression can be felt. In this respect the condition differs from the cephalic hsematoma found after birth. In the latter, the whole tumor is raised from the surface, and on physical examination there are no evidences of depression. Sypiilis. — Syphilis (Fig. 92) may cause the formation of tumors on the surface of the frontal and parietal bones varying from the size of a hazelnut to that of a walnut. They may at first be hard and subsequently soften. They resemble abscesses, and should be differ- entiated from them. Tuberculosis of the bones may also cause such tumors. Tuberculosis of the skull bones in infancy is of rarer occur- rence than syphilis of the skull, the cases of mastoid disease being excepted. In a concrete case, syphilis should be assumed until it can be excluded. The difficulties of diagnosis may be cleared by a tuber- culin test. Abscess may be diagnosed if there are abscesses elsewhere in the body. This is the case in folliculitis abscedens of Escherich. Mistakes rarely occur in these cases, since all the sigTis of abscess are present. Acute Infectious Osteomyelitis.- — Osteomyelitis is an acute in- fectious inflammation of the structure of the bones. It is common in infancy and childhood. Of 50 cases below the thirteenth year col- lected by Blumenfeld, 50 per cent, were under five years of age. The sexes were equally affected. Etiology." — In the majority of cases the essential cause is the Staphylococcus pyogenes aureus. The disease may, however, be caused by any pyogenic micro-organism, such as the Streptococcus pyogenes, the pneumococcus, the Bacillus typhosus, the Recurrens spirillum, Bacterium coli, and the gonococcus. Of 90 cases collected and reported by Lannr longue, only 10 were due to the streptococcus. Launelongue and Achard were the first to show that osteomyelitis may be caused by streptococci in 1890. Van Arsdale and the writer, in 1891 , published 4 cases of osteomyelitis caused by streptococci. These DISEASES OF THE BONES. 757 occurred in newborn infants or followed scarlet fever and pneumonia. The streptococcus osteomyelitis is of especial interest to the physician, as it occurs in infants and children under two years of age. It fre- quently follows infection of the umbilicus in the newborn infant, the exanthemata (scarlet fever and measles), and pneumonia. It differs from the staphylococcus variety in that the inflammation of the bone is less likely to involve the medullary canal, but affects the epiphysis. There is also involvement of the joints, with suppuration. The bacteria gain access to the circulation (Garre), and to the bones through some wound, such as the umbilicus ; through the mucous membranes, as in ulcerations of the mouth ; through some lesions of the skin, such as an eczema or furuncle, or through the gut. Of the 47 cases cited above, 17 were due to trauma, and 5 followed infectious diseases. The causative bacteria are found in the joints and in cases of sepsis in the blood. Pfisterer has recently published 7 cases of arthritis caused by the pneumococcus. In most of these cases the disease was monarticular; though in one case several joints were involved. The arthritis of this variety for the most part involves the larger joints. The symp- toms are similar to the streptococcus form, and yield kindly to treat- ment. Some of the cases may complicate a pneumonia, or they may also occur independently of this disease. If complicating a pneu- monia, the affection may appear from the first to the ninth week of convalescence. Morbid Anatomy. — The seat of inflammation is the periosteum and the medullary substance of the bone chiefly. The inflammation of the marrow and spongy part of the bone involving the cortical bone layer is often spoken of as osteitis, that of the periosteum as periosti- tis. There is a primary form and one secondary to infections else- where in the body. It is a disease of young people and involves mostly the long bones. The periosteum is swollen, hyperasmic, the seat of hemorrhages and finally of purulent infiltration. The bone marrow and neighboring bone tissue is hypersemic, the seat of hem- orrhages, and after a time purulent infiltration. The whole marrow canal may be converted into a pus cavity, and pus may form under- neath the periosteum. The bone tissue becomes infiltrated with pus, breaks down and forms sequestra. Abscesses may form in the bone. In the subsequent history of the separation of the diseased from the healthy bone the processes are those seen in all bone inflammations. Symptoms. — In older children, the symptoms differ little from those of the adult subject. The femur and tibia are most commonly involved ; next the humerus, superior maxilla, inferior maxilla, ileum, and radius, in the order named. In some cases the onset is sudden and the fatal issue takes place in a few days. In others, the inva- 758 DISEASES OF TEE BONES. sion is gTadual. lu older children there are the regular symptoms of chill, fever, and vomiting, followed by local symptoms. In young infants the signs of osteomyelitis are obscure. In the puerperal cases in newborn infants, the umbilicus may be inflamed for some days, after which the infant begins to cry when handled in the bath. The umbilicus may be healed and the symptoms referable to the joints may not appear until weeks after birth. One extremity is not moved and a joint may be swollen (Plate VII.) . Swelling of the joint may escape notice until the child is examined by the physician. After scarlet fever, the swelling of the joints is quite apparent, and also after pneumonia. In the newborn infant several joints may be swollen. In one of my cases in an infant ten months old, the elbow- joint and wrist-joint were involved, the whole radius being the seat of osteomyelitis. Similar cases have been published in this country by Gibney. The frequency of joint-involvement is a feature of osteomyelitis in children. Of 50 cases of osteomyelitis published by Blumenfeld, the joints were involved in 30. I have seen the multiple joint-suppurations most frequently in newborn infants. In all cases, there are evident swelling of the tissues about the joints and fluctua- tion in the joint-cavity. The joint contains pus. Bacteria are found in the pus and in the blood. In the newborn a meningitis of the same bacterial nature as that of the joints may close the symptomatology. Diagnosis. — The diagnosis is not difiicult. If an infant cries when it is handled, every joint should be carefully examined. Osteomyeli- tis may be confounded with scorbutus. In the latter affection, the joints are painful and swollen, but do not contain fluid. In scorbutus there are ecchymoses, swelling and sponginess of the gums, and hemorrhagic lesions underneath the skin, all of which will aid in diagnosis. A history of umbilical inflammation or of scarlet fever is of great value. There are in congenital syphilis of young infants forms of inflammation about the joints which at flrst simulate osteomyelitis. In such cases the infant should be examined for other evidences of congenital syphilis, such as fissures and rhagades about the mouth and anus, mucous patches, and coppery discolorations of the skin. Tuberculous inflammation in the long bones or in the heads of the l)ones may present some difiiculties of diagnosis. A study of the case and the absence of a history of acute trouble will solve the difficulty. Prognosis. — The prognosis of acute osteomyelitis in newly born infants is grave. The majority of cases are fatal owing to the form- ation of multiple foci of suppuration. The prognosis is also grave in infants under one year of age. The mortality of all cases under the fifth year is 50 per cent. In oldtr diildrcn it is 20 per cent. Treatment.- Ilic li-eatnicut of acute infectious osteomyelitis is surgical. SECTION XIII. DISEASES OF THE EAR. Otitis in Infancy and Childhood. — Frequency. — Otitis media, ca- tarrhal or purulent, is a very conimou disease of iufancv and child- hood. It is, as a rule, a secondary aflection, but may in rare cases occur as a primary disease. Parrot first called attention to the fre- quency of otitis as a complication of bronchopneumonia, i^ettermade the first bacteriological examinations of the discharges from the ear. The subjects were 20 children whose ages ranged from nine days to two years. Kossel, Easch, and Ponfick have investigated the fre- quency and nature of this affection in children. The results of their work show striking uniformity. Fully 85 per cent, of infants and children, examined post mortem, were found to have diseased ears. Most of the infants, especially those examined by Ponfick, had died of gastro-enteritis, acute or chronic. Some had suffered from gastro- enteritis, pneumonia, or congenital syphilis. Etiology. — The etiology of acute catarrhal, acute suppurative otitis media and of acute suppurative mastoiditis is much the same. The naso-pharynx and the Eustachian tube are normally the habitat of various forms of bacteria. This is the case in infants and children who have enlarged tonsils and adenoid gTOwths. A reduction of the vitality of the individual or any acute disease favors invasion of the ear by bacteria entering the Eustachian tube. Thus the exanthemata, especially scarlet fever and measles, furnish a large quota of cases. Diphtheria, typhoid fever, typhus fever, varicella, influenza, gastro- enteritis, tonsillitis, and simple angina, also cause a large number of cases of otitis. Pertussis, cerebK)spinal meningitis, and pneumonia are complicated by the disease. Sea-bathing, exposure to cold, and nasal douching favor its onset. Bacteriology. — The bacteria found by different observers in the otitic discharges and in the cavities of the ear include the Staphy- lococcus pyogenes aureus, citreus, and albus, the Streptococcus pyo- genes, the pneumococcus of Frankel. the influenza bacillus and pseudo-influenza bacillus, the Bacillus foetidus, and the Bacillus pyo- cyaneus (N^etter, Kossel, Ponfick). The streptococci and influenza bacilli cause an especially severe inflammation, the pneumococcus a milder form. The diphtheria bacillus also causes otitis. Morbid Anatomy. — In both forms of otitis and also in mastoid disease the tympanic membrane is injected and the vessels at its 759 760 DISEASES OF THE EAE. border are increased in size. The vessels of the hammer are injected. The epidermis of the tympanic membrane may be intact. The tym- panic cavity may be filled with cellular elements. There may be a serous, mucous, purulent, or mucopurulent exudate. The mucous membrane of the tympanic cavity may be intact but injected, or may shovr gross defects. If the bony structures are involved, there v^^ill be necrosis of bone, especially of the tegmen tympani. There may be perforation of this structure or of the point of the mastoid process. The dura mater or sinuses of the dura may, in progressive mastoid, be inflamed. T/iere may be cerebral abscess. If the pus does not escape by way of the Eustachian tube, it may perforate the tym- panum. The exudate which fills the tjanpanic cavity contains epi- thelial cells, leucocytes, and blood-cells. Otitis Media Catarrhalis. — Acute catarrhal otitis is, in a vast num- ber of cases, simply a forerunner of otitis media purulenta or of an acute suppurative otitis. It will be couA-enient for the practitioner to consider these affections together. They are more common among infants and children than among adults, and may occur at the earliest period of infancy. They occur most frequently in the spring and summer. The causation has been considered under the etiology, and is the same in both affections. Symptomatology. — In young infants and in children under two years of age, the symptoms are frequently masked by those of the primary disease. In many cases, the otitis gives no special warning of its presence. Perforation of the drum and a purulent discharge are the first intimation of the condition. This is especially the case in otitis in young nurslings who have suffered from acute tonsilitis or pneumonia, but these are not the cases which the practitioner is called upon to diagnose. In another set of cases, especially in those in which otitis is coincident with gastro-intestinal disorders of a chronic type, tending to atrophy, Heermann and Ponfick have shown that during life the otitis gives no objective symptoms although on otoscopic examination the tympanic cavity is found to be filled with pus, so-called marantic cases. In cases which follow the milder types of influenza or angina, there may be a most puzzling set of symptoms which can only be referred to the ear. In these cases the physician finds, two or three days after the onset of tonsillitis or influenza, that the temperature does not drop to the normal; it may mount to 104° F. (40° C.) toward evening, and in the morning may drop to or within a degree of the normal. While the temperature is low the infant takes its food and plays. When it rises the infant becomes fretful, or stupid, or sleeps most of the time. There is no iiiflication of pain. OTITIS IN INFANCY AND CHILDHOOD. 761 In other cases the infants will start from sleep and cry with pain. In some cases the infants perspire freely at the falling of the temper- ature. These simulate in many respects cases of malaria or of meningitis of the tuberculous type, except that the temperature rises higher than in the latter disease (Fig. 172). Local facial pareses may complete the resemblance to meningitis. The intermittent or recurrent curve of temperature may continue for a week or ten days. Only the careful exclusion of disease of other organs, and especially of the lungs and of the heart, will lead the physician to suspect disease of the ear. In nursing infants the bowels will be abnormal and the movements greenish, containing white curds. The temperature is, however, much higher than in any diarrhoea, and is more persistent and regular in its daily fluctuations. Fig. 17 2. dTsea°se 1 2 3 i 3 e 7 « 9 10 107° -^ h^ i ' 1 ' 1 ' 1 M -+ _- 1 [ 1 I -j-pji 106° - -1 r ^- — - _J_ 1 « ■ - 1 1 : ,^ .... if -- 7^ S 5 105 ^ >r- - — /\ "r«' " ■ A 1 ' ^ n A I 1 1 1 1°F ^ 103°^3J L\ g I02°--f--r ::::S::(:::5^ #M s-fP /J/!/-^ ^':i^ ^ m 100° J 99° 98° ,_ 97° i-'-i-"-^- -:\ / — — _J . — . — _^ i W^ PULSE q:?3 S. 'i X 2 1 S 2 O T^ g? 1 1 RESP. S3S 5 o 5 3 o n ?i '-- S 53 Otitis media purulenta in a child eighteen months of age. Symptoms and curve simu- lating closely a meningitis of the basal type. In cases of broncho-pneumonia complicated with otitis, previous to the spontaneous perforation of the drum the temperature will have shown more decided fluctuations than would occur at a late stage of the primary disease. However, in pneumonia there are few or no objective signs of the affection. Older children may have certain definite symptoms such as dull headache and pain in the ear, which, if sharp and stinging, will cause them to start in sleep, or to awake and cry out or put the hand to the ear. This last sign, so often men- tioned in the text-books, I have seldom seen. There may be delirium and the fever may be quite high. Children who can talk complain of pain at night. There may be rushing, singing, or buzzing noises in the ear. Very characteristic is the starting of infants during sleep. Older children are out of sorts, and angry on awakening. Course. — Spontaneous perforation in a number of cases occurs in a few hours or a few days after the onset of the disease. As a rule, however, pain continues with fever until artificial paracentesis of the drum is practised. After spontaneous rupture of the tympa- num, or paracentesis, the discharge may continue, being in some cases serous or serosanguinolent, and later becoming purulent. The puru- lent discharge may be profuse and the disease may advance into the 762 DISEASES OF THE EAB. mastoid or labyrintli. This frequently occurs in cases of tlie ex- anthemata or in pneumonia or influenza. In severe cases, the discharge may continue and become chronic, resulting in destruction of the structures of the ear. Complications may intervene, such as facial erysipelas, meningitis, cerebral abscess, thrombosis of the cerebral sinuses, and finally in suppurative cases pyiemia may inter- vene. On the other hand, after spontaneous rupture or paracentesis of one or both drums, the serous or purulent discharge may gradually cease and the ears be restored without any defect of hearing. In many cases incision of the drum in the early stages of the disease is not followed by the discharge of pus; the symptoms cease, and the riG. 173. Examination of the ear with head minor and reflector. patient recovers. In other cases there is no rupture of the tym- panum, although the tympanic cavity is filled with exudate, which discharges through the Eustachian tube. The pus may be swallowed and cause diarrhoea or pneumonia. In the cases of marasmus with otitis descril)ed by Hecrmann, the pus is believed to have found its way from the middle ear through the tube to the naso]>harpix. Method of Examination of the Ear in Infants and Children. — The examination of these young ])atients must often be made at the bed- side, where the examiner does not have all the conveniences of the ofRce equipment, so that he should be prepared for the use of the head-mirror with the light from a candle or a kerosene lamp which is still better. If the examiner is mvoi)ic, this is in his favor, but if he has OTITIS IN INFANCY AND CHILDHOOD. 763 liypermetropia or is presbyopic, the necessary correcting glasses should be worn, for without good vision for the near-point, it will be difficult to make out any details. If there are no contra-indications such as weak cardiac action, the young patient should be placed in an upright position on the lap of an assistant and the entire body from the neck downwards should be wrapped in a blanket or sheet, with the arms down and fully extended alongside of the body (Fig. 173). Fig. 174. Examination of the ear witli the electric headlight. The assistant holding the child should be seated on a firm chair with a back. In the examination of the right ear, the assistant presses the back of the child's head against the chest, by holding the patient's forehead with the left hand, and for the left ear, vice versa, — care being taken that the other arm firmly encircles the child's body and arms. If the electric head-light is used, or the electro-otoscope or a nearby gas or electric light, no further assistance will be required, but if a candle or kerosene lamp is brought into requisition, a third party may be needed to hold the light a little above and behind the patient's head (Fig. 174). Furunculosis and impacted cerumen are very infrequent among children, but foreign bodies such as peas and pebbles and small insects must be considered as likely to obstruct vision. 764 DISEASES OF THE EAR. One of the greatest obstacles to a proper examination of the mem- hrana tympani in children is the presence of exfoliated epithelium which is often pnli^y in consistence and covers the external surface of the membrana tvmpani in a thin layer, thereby hiding the details of its appearance. The presence of this deposit indicates an inflammation of the tympanum often only of a sub-acute type, but which has been present for some days. The removal of this deposit by irrigation with a warm borax solution will reveal the surface of the tympanum. In selecting a speculum one should be chosen which does not crowd the canal, as this is also apt to give unnecessary pain, and when introduced, it should be inserted by a revolving motion. It must be remembered that the plane of the drum-head lies more horizontal in the young than the older subject, and in making traction upon the auricle, one should make traction somewhat downwards and back- wards, instead of upwards and backwards as in older subjects. In cases where there are large sub- or retro-maxillary glands, the floor of the canal may have been pushed upwards so that it is some- times almost impossible to see the fundus of the canal even with the smallest speculum. In such cases it is best to pack a little strip of gauze into the canal for a few hours, and upon its removal the canal will be sufficiently dilated to permit of the introduction of a speculum. In all cases, both ears should be examined, even though we have manifest evidence of disease in one ear only. Diagnosis. — The diagnosis is first made from the rational symp- toms. In my experience, the temperature-curve is a very useful guide in infants who give no evidence of pain. Otoscopic examina- tion is the only positive means of making a diagnosis. There is congestion of the tympanum above Shrapnell's membrane and the long handle of the malleus. In the catarrhal cases the tympanum is red and angry or has a gTayish lustre. The handle appears as a red or yellowish-white point. In some cases there are vesicles and interlamellar abscess. The exudate may cause bulging of Shrap- nell's membrane or of the posterior-superior quadrant. Congestion remains long after resolution. In the suppurative cases the epithe- lium of the tympanic membrane may peel off. The tympanum is dull and lustreless. The auditory canal may be swollen. Perfora- tion occurs, chiefly in the posterior-inferior quadrant. There may be pulsation of the membrane as well as bulging. The lymph- nodes beneath the ear may enlarge and that region may be very sensitive. Prognosis. — The prognosis in ordinary cases is good. In cases following the exanthemata it is grave, on account of the possibility of complications and of ultimate loss of hearing. MASTOID DISEASE. 765 Fig. 175. Mastoid Disease. — General Facts. — The mastoid region is impor- tant on account of the frequency of mastoid disease in infancy and childhood. In early life there is pneumatic tissue, but no mastoid cells are found. The mastoid j)rocess contains one large cell (Symington) (Fig. 175). The external wall is less thick and compact than in the adult. The petrosquamous suture is patent. The petrosquamous sinus is persistent in some cases, passes through a foramen on the inside of the skull, and appears externally behind the glenoid fossa and tympanic ring. Thus infectious material may easily be con- veyed internally. In infants and children pus finds its way exter- nally more readily through the open fissura mastoideo-squamosa. Etiology. — Inflammation of the mastoid is rarely primary. The mastoid may at the outset be inflamed when there has been no antecedent otitis. As a rule, however, inflammation of the mastoid is secondary to acute or chronic otitis. The causation is identical with that of acute or chronic otitis. Of 39 cases of mastoid disease under eight years of age, collected by Knapp, 7 occurred in the first year, and 9 in the second. The greatest frequency is there- fore after the second year. It may occur as early as the second month. I have had a case in an infant three months of age. The anatomical conditions favor the occur- rence of mastoid disease in infancy and childhood. The Eustachian tube is short and of large calibre ; infec- tious material from the nasopharynx can easily gain access to the ear. Symptoms. — Clinically, mastoid disease in infancy and childhood manifests itself by rational symptoms and physical signs. There may be extensive mastoid disease without any external physical signs. In one of my cases of otitis, which was observed by an expert from the outset, extensive mastoid disease in a child of three years of age did not give any external signs. The clinical symptoms are character- istic. The drum may have been perforated after otitis, or paracen- tesis may have been performed. After perforation, the temperature present during the preceding otitis drops to the normal. The patient is able to be up and about. The ear discharges freely. After two or three weeks there is a sudden or gradual rise of temperature, which may be slight or may reach 103° or 105° F. (39.4° to 40.5° C). There is restlessness at night. On inspection, the ear may not show anything abnormal. The temperature, how- -V. L'.S. Coronal section of the mastoid process in an infant 3 months of age. This is the infantile type of mastoid. (Symington.) 766 DISEASES OF THE EAB. ever, coiitiimes to be remittent for several clays. On otoscopic examination, there is found to be swelling of the roof of the auditory canal or of the floor of the attic. In other cases, after a very early and timely paracentesis of the drum, the patient does not do well. The child is restless at night, at intervals irritable and then playful, and starts from sleep (Fig. 176). The temperature fluctuates daily from 100.8° to 102° F. (38.8° C.) . On some days it may be normal or subnormal. The ear discharges for days, but a slight temperature continues. If the patient is an infant or a young child, it may be very diffi- cult to ascertain whether pain is present on pressure backward over the region of the antrum behind the ear. There is in early cases no swelling or redness behind and above the auricle. As was stated Fig. 176. DAY OF DISEASE 9 10 11 12 13 14 15 16 17 IS 19 •20 21 22 23 HOUR ^ti = 2 = a = 2 »'- »ii ■^2 ■--a ---'a ■- rj -■=:2 ^a = 2 -i^ ■-=2 J~^ 3a --'2 ^e J^ -'s »b --2 »- -a =|2 »p =|2 .l. 104' d 103' < 102' 1 100° '" 99' ^: ■ ^;- =; ¥= 1L-; ^ z:zz ^= :i^ ^-= -_- =; =r^ =i- J: r" _ ; -' . =r — 2 =fe| -:^ 5^ -'^ X £= :i= eE ^ Efc 1/ : ^- -?\ V --- =1 -_-- <;S /- I =£; 7S ^;^ =^ ^E - ■ ■^ . ^A \ A ^S j^ ^;l fl ~i =/" :-^ .:t:^ -^ — :_ -J \J '-' ^1 '\ A ^ J \ ^y ^ :\ 2;^ - -T w— ._ ^ Hj V A J h:sz \f^ p ^- ^T^ ^- ■^ ^-^ ^ ":^ L-^: i^ V pr ;■ -;— — \t z fcV -_v 11 T : _-^ PULSE 1 5 5 52 :£ 5 = 3 s a 3 I S ~=i 2 = 3 = 2 = ss HS 5§ 5' 11 i 1 RESP. 1 s '1 s!= is 1 .1. s! \s \s 1 1 -1 .1 ^1° s| S|S .l sjs 1 SjS °F SjS gS( .la is 1 otitis media in a female child, three years of age. Observed from the onset. Early paracentesis, fall of temperature, then rise again. Subsequent mastoid involvement necessitating operation. above, there may be extensive and advanced mastoid disease without external redness or swelling. In such cases the lymph-nodes behind the ear and at the angle of the jaw may be swollen and painful. Young children and infants do not complain of pain. It is only in older children that it can be noted. Mastoid disease which follows the exanthemata, especially scarlet fever or measles, or occurs late in typhoid, shows certain charac- teristic clinical features. During the fifth or sixth week of scarlet fever the ears may discharge profusely. There is a daily rise of temperature in the afternoon, which is slight in some cases. The patients play in the early portion of the day, but in the afternoon appear listless, and have a slight frontal headache. As days pass, the children become stupid during the afternoon rise. In many cases of scarlet fever otitis is a complication. The tem- perature does not fall to the normal, as it should, after the fading of the eruption. There is slight aural pain at night, which is sometimes sufficiently severe to deprive the patient of sleep. In other cases the temperature drops to the norma] and suddenly rises in the second MASTOID DISEASE. 767 week. In both these sets of cases there is an otitis which may develop into mastoid disease, or in which mastoid disease may have been present from the outset. Korner calls attention to the fact that in late typhoid fever, chills, with rises of temperature, may be, in the absence of other signs, indicative of serious mastoid disease. Physical Signs. — Pain. — Pain is a physical sign of mastoid dis- ease in children. In most cases it cannot be elicited by the most skillful manipulation. In others, on account of the fear and rest- lessness of the patient, it is impossible to come to a definite conclu- sion. In older children pain may be elicited by pressing the mastoid bone in a backward direction, care being taken not to press on the Fig. 177. Mastoid disease in a child eigliteen months of age. Swelling behind the ear over the mastoid. The ear is displaced away from the scalp. auricle. The pressure should be firm and continuous. Pain in the tip of the mastoid is not of value unless there has been a perforation and phlegmon at that point (Dench). Otoscopic Examination. — There is a shortening of the external canal in its posterior and upper aspect (Dench). The upper pos- terior wall sinks. There is bulging of the upper portion of the tympanum. Tumefaction. — Tumefaction posteriorly and above the external structures of the ear occurs in infants only in neglected cases. Ac- cording to Dench, in these cases the pus escapes from the antrum through the auditus ad antrum into the tympanic vault. It then finds its way through the Eivinian fissure along the upper wall of 768 DISEASES OF THE EAR. the canal to the external surface of the mastoid. In children cases in which this swelling appears are less serions than adult cases. The swelling also appears much earlier in infants and children. Diagnosis. — The life of the patient often depends upon the early recognition of mastoid disease. The diagnosis in infancy and child- hood should not only be made early, but should be made chiefly from the clinical symptoms of temperature, which will in its fluctuations show a septic curve, and from the physical signs and otoscopic exami- nation. The history of the case is of service. Presence of pain is of no value in infants and young children. The daily otoscopic examination of the discharging ear will give positive evidence of mastoid disease. The signs detailed in the paragraph on symptoms are of great importance. A profuse discharge does not preclude mastoid disease. Facial paralysis is of no value. I have seen it in cases in which mastoid disease was on operation found to be absent. Tumefaction is seen only in late cases. Redness is sometimes ap- parent before the appearance of swelling behind the ear. Course. — In neglected cases pus from the mastoid may force its way through the tympanic roof and cause cerebral abscess or menin- gitis. It may destroy the plate (lamina vitrea) of the sigmoid sinus and cause thrombosis, may find its way through the tip of the mas- toid along the border of the sternomastoid, and cause phlegmon, or may force itself through the sutura mastoideo-squamosa, causing swelling behind the auricle. Treatment. — Prophylaxis. — Children can be taught to tolerate the therapeutic measures which, if catarrhal inflammation of the fauces is present, as in the exanthemata, will cleanse the parts. Thus in scarlet fever, an intelligent child will readily allow the throat to be sprayed with normal salt solution. Swabbing the throat or apply- ing any drug locally is impracticable in children. If the pain is excessive a mild opiate, such as paregoric, is administered. In young infants the severity of pain cannot be esti- mated. In older children dry heat applied externally to the ear by means of a water cushion relieves the pain. Some authors advise the application of leeches behind the ear, or the instillation of water at 110° F. (43.3° C.) into the canal with a dropper. Inflation of the ear in the early stages of otitis media has been advocated and condemned. Suction by means of a catheter introduced into the Eustachian tube is also practised. If the pain and fever are not relieved by these measures, incision of the drum is resorted to. Whether the otitis is catarrhal or purulent, paracentesis is best performed early, since damage to the car may thus be avoided. The method of per- forming paracentesis of the drum is best learnt from special text- MASTOID DISEASE. 769 books on the subject. Duel advises enlargement of the opening in cases in which spontaneous rupture of the drum has taken place. Drainage bj the introduction of sterilized absorbent gauze into the canal is superior to syringing. If this is not possible, syringing with 1 : 5000 bichloride is useful. The indications for the performance of mastoid operation are protracted otitis with profuse otorrhcea, there being no tendency to resolution, acute otitis in which there is a tendency to resorption and in which paracentesis has not established drainage, also muco- purulent otitis maintained by mastoid involvement, otitis with symp- toms pointing to meningeal complications, and finally otitis with complicating stenosis of the external canal, preventing drainage. 49 SE( TION XIY. DISEASES OF THE KIDNEYS AND UROGENITAL TRACT. The weight of the kidneys is /ii;o of the body weight in the infant and /44o in the adult. It is not, as a rnle, possible to palpate the normal kidney in the infant or child. I have, however, seen in young infants exceptional cases in which the kidneys Avere situated very low down and could be easily palpated through the abdomen. I have found floating kidneys in infants and older children, but not so frequently as other observers. Comby in 1898 reported 18 cases, of ages ranging from one month to ten years of age. Steiuer. Stewart, and Abt have also reported a number of cases. I believe that the displaced and fixed kidney is congenital. As the child grows and the parts are stretched, the attachments of the kidneys, congenitally low, become more re- laxed. This would account for a number of cases. Jacobi believes that floating kidney in children is a congenital anomaly. Sixteen of Comby's cases occurred in girls. A displaced, fixed kidney in infants canses no symptoms. In cases of movable kidney or floating kidney the main symptom is pain, either epigastric or radiating from the iliac region. In a girl of eight years with float- ing kidney, there was no dilRculty in palpating the enlarged movable kidney below the liver. There were attacks of acute colicky epigas- tric pain, which occurred independently of the ingestion of food. The child was nervous and hysterical. DISEASES OF THE KIDNEY. Cyclic Albuminuria (Fostural Alhumimnia ; Orthostatic or Lor- dotic Albuminuna). — Cases of this form of albuminuria were first published by Vogel, Ultzmann, Gull, and Leube. The systematic description was first given by Pavy. by whom it has been carefully studied. Cyclic albuminuria occurs principally in children and adoles- cents; 40 per cent, of the cases occur in children from the first to the fifteenth year, and 80 per cent, of the cases occur before the twentieth year, Jehle places the greatest frequency from the sixth to the four- teenth year. It is, therefore, distinctly a disease or condition ob- served in a period of metabolic activity and growth. 770 DISEASES OF THE KIDNEY. 771 Tlie characteristic symptom is the appearance of albumin in the urine in the forenoon and afternoon, and its disappearance after a night's rest in the recumbent position. It is not present in the morn- ing directly after rising, but appears soon after the upright position has been assumed. Mode of Occurrence. — Heubner traces a connection between this form of albuminuria and the position of the body. He finds that patients excreted albumin when their position was changed from recumbent to the upright posture ; therefore, during rest in bed there is, in such individuals, no albuminuria. But it regularly appears when they get out of bed and exert themselves. He therefore pro- posed the term orthostatic albuminuria for these cases. Etiology. — Jehle points out the relationship of this form of albu- minuria to lordosis of the lumbar vertebrae. In children having a marked lordosis in the upper part of the lumbar spine albuminuria occurred in the upright military position or in normal children in whom an over-accentuation of the normal lordosis was produced arti- ficially or by some form of exertion. The lordosis causes the albu- minuria by a change in the circulatory conditions of the kidnej^ The greatest frequency of an abnormal lumbar lordosis and therefore of the albuminuria occurred in children from the sixth to the fourteenth year. There was a slight preponderance of the female sex. There is no doubt as to the existence of this form of albuminuria in children, but its significance is a matter of wide diversity of opin- ion. Heubner has published some cases and collected 22 cases in children from one to fifteen years of age. Some authors, among them Heubner, are inclined to regard them as physiological forms of albuminuria. Others, among them Henoch, Leube, and Senator, are inclined to regard them as due to insidious changes in the kidney following infectious disease. It should be remembered that after influenza, scarlet fever, or diphtheria, small quantities of albumin are, at intervals, present in the urine for months and years. There may also be occasional hyaline or epithelial casts and a few blood- cells. These disappear either with or without treatment of diet and rest, but later reappear. I have seen this occur in children in good health. Symptoms. — The Urine. — The albuminuria occurs in from one to three or five minutes after the erect posture is assumed. The amount of albumin varies from a trace to a heavy precipitate. The presence or absence of form elements from the kidney has been a matter of much discussion as to the correct interpretation of their presence. Some observers (Heubner, Langstein) look upon casts and blood and cylindroids as a sign of disease of the kidney, but Jehle goes so far as to insist that at the moment of the 2;reatest 772 DISEASES OF KIDNEYS AND UBOGENITAL TRACT. albuminuria, casts, gi-auular, hyaline and cylindroids, and even blood, may appear to disappear when the so-called insult is removed from the kidney in the absence of any nephritis. Such a view would appear to require some confirmative observations. It should be remembered that, in nephritis, the albumin in the urine frequently takes a cyclic course (Senator). Prognosis and Course. — The prognosis must remain conditional on the prolonged observation of the patient if there is albumin in the urine, for a few of the published cases have in later years developed nephritis. It is said, also, that this form of albuminuria has been met in several members of the same family, and in fami- lies in which albuminuria and nephritis have existed. The term cyclic albuminuria should, it seems to me, for the present be lim- ited to those cases in which there has never at any time previous to or during observation been any form-elements of the kidney in the urine. Many of the cases published, and those which I have observed, occurred in children with lymphatic constitutions; in others there was scrofulosis and tuberculosis (Pfaundler). They showed a marked ansemia at times. There was an oedema of the face but not of the extremities. The children complained at various times of headaches or a heavy feeling in the occiput, were easily tired, awoke feeling tired. They were subject to dreams and were of a nervous temperament. In one of my cases the child was free from the above symptoms, and was the picture of health. In this case there were periods early in the disease in which very scanty form-elements occurred in the urine with the albumin ; at others, none could be found. The case was at first diagnosed as cyclic albu- minuria; but my fears have been justified, inasmuch as lately the form-elements, such as casts and blood, have increased in the urine and have become permanent, thus showing the danger of diagnosing these cases on short periods of observation. Two cases which I have seen, after many repeated examinations (extending over a year) of the urine, failed to reveal anything ])ointing toward an affection of the kidney. The albuminuria is present some time after rising in tlio morning, and after exercise. It disappears on enforced rest. Treatment, — It has been proposed in cases of cyclic albuminuria to enforce at intervals periods of rest of one or two weeks at a time, and the limitation of exercise and sports, I have tried this method, at the same time dieting -the patient, but have not found it as suc- cessful in improving the general condition of the patient as moderate out-door exercise in the open high country — freedom from mental worry, such as the suspension of studies ; good, simple food ; perhaps a tonic of the iron series. City and school life are not conducive to aiding the physician in treating these cases. A persistent ana-mia DISEASES OF THE KIDNEY. 773 sets in under these conditions, and is the symptom that baffles the physician in the treatment. ISTothing will improve the patient so much as out-door exposure in the open country. CEdema or Hydrsemia without Kidney Lesion. — Weak infants who have suffered from chronic gastro-enteric catarrh have swelling or an oedematous condition of the dorsum of the feet and ankles. There may be slight anasarca elsewhere. There is no real kidney lesion; the condition is one of hydrsemia. The changed state of the tissues, including the vessels and blood, allows of a transudation of serum into the subcutaneous structures. On examination, the urine is found to be abundant and of low specific gravity, but without evi- dences of nephritic degeneration. In children of two years of age this condition of slight subcutaneous oedema occurs in simple anaemia of a severe type. In these cases the skin is yellowish, the ears have a waxy clearness, the eyes have an oedematous appearance, and the lips, hands, and feet are puffy. The condition is known as hydrsemia or hydrsemic anaemia. Dysuria. — Dysuria, or difficult and painful micturition, is a con- dition in which there is partial obstruction to the free flow of urine from the urethra. It is not uncommon in young infants and chil- dren, and may be due to a variety of causes. If lithiasis is the cause, there is not only pain in passing the urine, but there may, in the intervals, be acute attacks of pain, due to the passage of calculi along the ureter. Examination of the urethra in the male often results in finding a calculus of very small size in the anterior penile urethra. In lithiasis, there is sometimes very painful micturition without the formation of calculi of any size. The minute crystals of uric acid cause a smarting sensation as the urine passes over the urethra. In febrile states with concentrated urine, the acidity of the urine, and the excess of uric acid with free crystals, cause painful micturition. Simple or gonorrhoeal inflammation of the urethra may cause difficult and painful micturition. Dysuria is painful at the onset of vulvovaginitis. Cellular Atresia of Labia. — Another condition of congenital origin, which was described by Bokai as cellular atresia of the labia, is a very common cause of dysuria. It is seen in very young female infants. From birth, the urine is passed in drops and with great straining and pain. In some cases it is passed without pain, but the condition of atresia attracts attention. On gently separating the labia majora a thin pinkish- white membrane is seen to occlude the introitus vaginse completely. At the urethral end of this membrane a very minute opening is seen, through which the urine filters. These membranes can be divided by means of a dull director. It is then seen that the hymen and urethra are directly behind the mem- 774 DISEASES OF KIBNEYS AXD VEOGEXITAL lEACT. brane. The operation of dividing the membrane is exceedingly simple and causes little or no bleeding. Bokai has described a similar condition in boys, which is some- what less common. It is a cellular adhesion of the prepuce and glans penis which not only causes false phimosis, but also difl&cult and painful urination. He found that in the newly born infant the prepuce was sometimes adherent to the tip of the glans penis, and that across the opening of the meatus there was a very thin mem- brane. In other cases, this membrane was ruj)tured, but the prepuce still remained adherent to the glans in front, while behind at the corona glandis there was retention of smegma and consequent painful inflammation. The treatment is division and separation of the cellular adhe- sions. Other abnormalities in infant boys, among them diverticula of the urethra, may cause dysuria. Hsematuria. — ^Hsematuria is the passage of blood and its elements into the urine, in which blood-cells and coloring-matter are found. The condition may occur in the following states : (a) Acute nephritis of all forms, especially those complicating the infectious diseases, such as scarlet. fever, measles, typhoid fever, and malarial fever. (h) Calculi, renal or vesical. (c) Malignant grovd;hs of the kidney — sarcoma and carcinoma. (d) Growths of the bladder — polypus. (e) Traumatism in the region of the kidney. (f) The ingestion of drugs. ^ (g) Scorbutus. The color of the urine varies from a slightly smoky amber to a deep brovmish-red. There may be a deposit of blood-cells and clots in the urine. Pure blood with clots is seen in cases of malignant tumor of the kidney and calculi of the kidney or bladder. Smoky urine is seen in cases of nephritis and drug-poisoning. Hemoglobinuria. — Hsemoglobinuria is a condition in which the urine contains the coloring-matter of the blood, but, except in rare cases, no red blood-cells. The urine is reddish or brownish, and has a high specific gravity. It contains albumin. By spectral analysis the spectrum of the blood coloring-matter is obtained. According to Hoppe-Seyler. metha-moglobin and not haemoglobin is often the coloring-matter present. There are few blood-cells and no detritus. Etiology. — Several theories have been advanced to explain the appearance of haemoglobin in the urine, that of Ponfick being gener- ally accepted. According to that author, either the blood-cells are destroyed by some vicious agent or ferment (Ehrlich) and the haemoglobin is thus let loose into the circulation, or the haemoglobin DISEASES OF THE KIDNEY. 775 is dissolved out of the blood-cells and passes into the circulating plasma, leaving the cells behind as so-called " shadows." Whatever the real cause, the exciting influences are : (a) Cold or exposure to wet. lloff and Demme have published cases of children with paroxysmal hEemoglobinuria following such exposure. (&) Drugs, such as arsenic, phosphorus, potassium chlorate. (c) The infectious diseases, such as malaria and scarlet fever, erysipelas. (d) Hsemoglobinuria has been observed in cases of burns. (e) Baginsky has observed hsemogiobinuria in children with nematodes. One-half the cases published have a history of syphilis. Such is the case published by Hermann, occurring in a boy four years of age, with a history and physical marks of congenital syphilis. In this case the boy had at times attacks of hsemoglobinuria. Symptoms. — In the paroxysmal form, each attack is preceded by a chill and followed by dyspnoea, palpitations, cyanosis, and severe symptoms of collapse. The attack may last a few hours or a few days, the duration depending on the course of the primary affection. This form has been especially observed to occur in pernicious malar- ial fever. Prognosis. — The prognosis is very good. Patients quickly recover from the attack proper, and there is no danger to life. The cases of syphilitic origin are not controlled by antispecific treatment, though the condition of the blood is improved. Chovostek siucceeded in abating an attack by the administration of amyl nitrite. Morbid Anatomy. — Dieulafoy and Widal found in a fatal case the cortex of the kidney dark brown in color ; the cells of the glomeruli were n.ormal. The cells of the convoluted tubes and the tubes of Henley were infiltrated with pigment-granules, which were also pres- ent in the lumen of the tubes. Treatment. — The treatment consists not only in the management of the primary exciting conditions, but, if there is a history of syph- ilis, an antispecific course of treatment is indicated. With this we may give tonics, such as iron, and exert a certain amount of pro- phylaxis by protecting the patient from cold, and also, if possible, securing to the patient wholesome food. Renal Calculi (Uric Acid Infarction; Lithcemia). — So-called uric acid infarction is found in the kidneys of over one-half the infants who die in the first weeks of life. These infarctions are seen in the medullary portion of the kidney as golden-yellow or brownish rays which are broader toward the papilla. Epstein found isolated deposits in the cortex. The infarctions consist of uric acid (Schloss- 776 DISEASES OF KIDNEYS AND UROGENITAL TRACT. berger). They are supposed to be due to the destruction of tissue rich in nuclein (cells) (Kossel and Horbaczewski). They are found in weaklings, and more often in infants who have been born living than in stillborn infants. During the first weeks of life they are washed out by the urinary secretion. Hence the increased uric acid excretion at that time. As a rule the condition gives no symptoms. It is not uncommon for the diapers of the infants to be stained red, and in older children there may be the so-called brick-dust deposit in the urine. In these cases there may be a history of severe colicky attacks. In other cases the infant or child experiences pain on urination and cries piteously. Some older children will run about in pain and grasp the penis. In all such cases the diapers should be examined for concretions. Failing to find these, the urethra is care- fully explored. In several cases I have found an oval calculus of the size of a rice-seed, imbedded in the canal of the penile portion of the urethra. These cases have attacks of pain extending over months, probably caused by the passage of the calculi from the kidney through the ureter, the bladder, and urethra. The calculi are easily extracted with long-bladed forceps. In one of my cases of hematuria, in a boy three years of age, there were several attacks lasting for days, but no distinct history of pain. The urine contained blood coloring- matter, some blood-cells, and a few hyaline casts. The diagnosis was obscure until a few small calculi were found in the urine. Uro- tropin given in small doses caused a cessation of symptoms. Acute Nephritis. — A. Acute Parenchymatous Nephritis or Acute Exudative Nephritis (Delafield) ; Tubular or Glomerular Ne- phritis. B. Acute Diffuse Nephritis or the Acute Productive Ne- phritis (Delafield). — Etiology. — The etiology of both forms of acute nephritis is the same. There is scarcely an acute infectious febrile disease which may not give rise to acute nephritis. It complicates or follows scarlet fever, measles, influenza, diphtheria, infectious angina, pneumonia, rheumatism, typhoid fever, sepsis of all kinds, variola, parotitis, malaria, and congenital syphilis. The frequency in scarlet fever of the (Edematous forms with anasarca has led to the belief that this disease was most often complicated by nephritis. If the parenchy- matous form is included, the condition will be found to be very fre- quent in other infedious diseases, but it is often unrecognized. The essential causes of acute nephritis are micro-organisms or their toxins. Thus in the various diseases, the Diplococcus pneu- moniae, the typhoid bacillus, streptococci of various kinds, staphylo- cocci, and the Bacillus pyooyancus, have among other bacteria been DISEASES OF THE KIDNEY. Ill found in the kidney. On the other hand, in diseases such as diph- theria, the toxins of the bacteria are the cause of the parenchymatous or diffuse nephritis (Flirbringer, Roux, Councilman). If the toxins are formed in the body, the infections are said to be autochthon or endogenous. The irritating toxin may be introduced from without, as in chloroform or ether narcosis, and the ingestion of drugs (ectoge- nous). The role played by cold as a causative factor is still a matter of speculation. Its mode of action, whether reflex, through the circulation, or by causing changes in the blood, is still obscure. Morbid Anatomy. — Acute Parenchymatous or Exudative Nephri- tis (Delafield). — This is an acute inflammation of the kidney, in which the principal changes occur in the epithelium of the tubules and Malpighian tufts. The kidneys are larger than normal, and succulent. The capsule can be stripped from the surface, which is red, grayish, and punctate in spots. All the changes are most marked in the cortex of the kidney. Evidences of inflammation are found in the tubes, stroma, and glomeruli. The epithelium of the tubes is flattened, granular, and fatty, or in a condition of coagulation- necrosis. The lumen of the tubules may be empty or may be filled with desquamated epithelium or with coagulated masses (casts) of a hyaline character. Delafield describes the tubes, in severe cases, as flUed with leucocytes and blood-cells. The tubes may be uniformly dilated. The changes in the glomeruli may be so slight as to be scarcely noticeable. The cavities of the capsules sometimes contain coagu- lated matter and red and white blood-cells (Delafield). In marked cases there are desquamation of capsular epithelium and increase of nuclei. The swelling and proliferation of cells sometimes change the appearance of the tuft so that the outlines of the individual capillaries are lost. The stroma is infiltrated with serum, and in severe cases there are in the cortex small collections of white blood-cells (pus). Acute Diffuse N ephritis. — The changes in acute diffuse nephritis, or the acute productive nephritis of Delafield, are more serious and permanent. According to Delafield, the. kidneys are large, and at first smooth and later rough. The cortex may be mottled yellow and red ; the pyramids are red. In this form of nephritis there are the changes found in exudative nephritis, and also a growth of connective tissue in the stroma and an increase of the capsule cells of the Malpighian bodies. These changes involve symmetrical strips of the cortex, which follow the lines of the arteries (Delafield). The Malpighian bodies show an enormous growth of capsule cells with compression of the tufts. If the nephritis is acute, the interstitial tissue is augmented with newly formed cells and basement substance. There is a new growth of 778 DISEASES OF KIDNEYS AND UEOGENITAL TEACT. connective tissue between the tubules ; the walls of the arteries are thickened. In the capsule of the Malpighian tuft there is a growth of cells which compress the tuft of vessels. These and the vessels are in turn converted into small balls of fibrous tissue (Delafield). In addition there may. in the acute forms of nephritis, be hemor- rhages throughout the kidney substance. Ssanptoms. — In the forms of parenchymatous nephritis which complicate the febrile infectious diseases, influenza, pertussis, angina, and gastro-enteritis, either the symptoms of the primary disease mask those due to the kidney lesion or the nephritis may be so mild as to give no symptoms. Thus in the parenchymatous nephritis which complicates or follows influenza, there are after the attack has passed no symptoms referable to the kidneys, yet on examination the urine shows a trace of albumin, hyaline and a few epithelial casts, and an occasional red blood-cell. In these cases there is no oedema of the tissues, no headache, and the children are apparently well except for the changes in the urine. These may at first be quite marked. After a few months the albumin may only appear occa- sionally; the casts and blood disappear for weeks and then reappear. For weeks or months the children may have no constitutional symptoms. In the parenchymatous nephritis, which is seen in severe forms of gastro-enteritis and dysentery, the signs in the urine of marked nephritis are albumin, casts of all kinds, and blood-cells (Parrot, Fischl, Czerny, Koplik, and Morse). Although Czerny traces a cer- tain form of dyspnoea to the infiuence of uraemia in these cases, no distinct set of symptoms due to the kidney can yet be formulated. It is true that there are terminal anasarca, suppression of urine, and vomiting, but the presence of all these may be ex|flained by the severity of the intestinal lesions and toxemia. CiiAXGES I^' THE Ueizst.. — In all the diseases above mentioned, the parenchymatous nephritis may in infants and children be evinced by diminution of the quantity of urine, or the presence of a trace of albumin, or a few hyaline or epithelial casts and blood-cells. The quantity of urine may. however, be normal. In other cases, the albumin is more marked and the casts much more numerous. Renal epithelium is also present. Leucocytes are rare. In the diffuse or productive form of nephritis in infants and children, the symptoms are marked. In some forms of nephritis complicating scarlet fever the lesion never advances beyond the parenchymatous stage, and at that period the symptoms are either not present or not noticeable. If the nephritis is more marked, how- ever, it is noticed at the end of the third week that the patient is somewhat pale, that the face is a little swollen, especially aboi/t the eyes, and that there is very slight oedema of the general surface. DISEASES OF THE KIDNEY. 779 In these cases it is possible at the end of the period of ernption to find a slight trace of albumin in the urine and a few hyaline and epithelial casts. With the onset of the anasarca the albumin in- creases in quantity, the casts in number, and a few blood-cells are found. The quantity of urine is diminished, but in the mild forms not markedly so. A boy of six years may pass half the normal quan- tity. There is no headache, and only a few obscure pains in the joints. There is occasionally slight pain in the region of the kidney. The temperature is normal or may at intervals of several days rise a degree or a degTee and half above the normal. The nephritis is probably of the mild diffuse type. In three weeks the moderate anasarca disappears, the ansemia improves, and the urine becomes normal. In the more severe cases there is a rise of one or two degrees in temperature, and the patients have marked general anasarca. If old enough, they complain of headache, they vomit, and show marked decrease in the number of respirations and pulse, the irregularity of pulse being of a purely ursemic character. In some cases there are effusion into the chest (hydrothorax) and abdominal ascites. The quantity of urine is much diminished, there being only one or two ounces in twenty-four hours. The specific gravity is high; the urine contains blood, leucocytes, and casts (hyaline, granular, and epithelial), with blood cells. Under treatment, the vomiting, headache, and anasarca subside, the quantity of urine increases, the number of casts and blood-cells diminishes, and the patient makes a good recovery. In other cases the initial anasarca becomes more marked, there being considerable oedema of the whole surface ; the urine is entirely suppressed; the vomiting and headache increase; convulsions set in ; there are several attacks of eclampsia ; the patient becomes comatose, and may die of uraemia, or after one or two attacks of eclampsia, the symptoms may abate and recovery take place. There is a very fatal form of diffuse nephritis which occurs on the fourth or fifth day of malignant scarlet fever. On the third day, ' at the height of the eruption, the patient passes into a delirious, semi- conscious state. The quantity of urine is much diminished; its specific gravity is high ; casts of all kinds and blood are present. The urine may finally be totally suppressed. There is no oedema of the surface. Coma and convulsions set in. The patient succumbs to the intense general toxsemia and to its effect on the kidneys. In these cases the kidney symptoms cannot be separated from those caused by the general intoxication. Individual Symptoms. — Vomiting. — The vomiting in scarla- tinal nephritis is rarely distressing, and subsides in a short time. It is not a constant symptom, nor is it of serious import. 780 DISEASES OF EIDXETS AND UEOGENITAL TSACT. Headache. — The headache is not a very marked symptom in children. Oedema. — (Edema is present in a large jDroportion of cases, and is marked in the severe ones. It may occur with hydrothorax, ascites, and hydropericardium. It maj affect only the face, or the lower extremities alone. It may be so intense as to cause bursting of the skin and the escape of serum through the fissures. It may affect one half the body more than the other (Henoch). Under all these conditions, the outlook is serious. Pulse. — The pulse is sometimes inordinately slow. It may be m.ore rapid than normal, and may show marked irregularity. Heart. — The heart may, as was pointed out by Henoch and Friedlander, be the seat of hypertrophy and dilatation. There may be complicating endopericarditis. Lungs. — The lungs may be the seat of pneumonia, or cedema of the lungs may suddenly develop. There may be complicating pleuritis. Constipation. — There may be constipation or more or less diarrhoea. Temperature. — There are cases in which the temperature is normal or subnormal during the whole course of the disease. In the cases in which there are sudden eclamptic seizures, the temperature may mount to 104^ F. (40^ C.) during the attacks. On account of the rupture of a bloodvessel in the brain during the eclamptic seizures there is in many cases, after the subsidence of the ursemic symptoms, aphasia, or hemiplegia o5 a more or less permanent nature. Fainting Spells. — Patients with . nephritis succeeding scarlet fever develop fainting spells with cyanosis, gallop-rhythm, and all degrees of cardiac weakness. It is difficult in such cases to know whether to attribute these symptoms to the nephritis or to myocarditis which is the result of the scarlet fever. Urine. — The general characteristic features of the urine in acute diffuse nephritis of scarlet fever have been given. Suppression may take place suddenly. The urine may not have contained coagulable albumin or easts, and the quantity may have been normal. The common notion that uraemia or eclampsia can supervene only if the quantity of urine is diminished, is erroneous. Even if the quantity is above the normal and the urine contains little albumin and few casts, eclampsia may supervene with fatal results. An increase in the quantity of urine above that of the normal is an unfavorable symptom unless temporary and accounted for by the treatment. The quantity of urea passed is always the crucial test. There are eases in which blood appears in the urine and in which there is true haemoglobinuria, which may give rise to irritation of the kidney. In DISEASES OF THE KIDNEY. 781 Other words, the hsemoglobinuria is primary, the nephritis secon- dary. The quantity of albumin in the urine varies greatly; it may only amount to a trace or be sufficient to cause the urine to become solid when boiled. Primary Forms of Acute Nephritis. — The question has arisen: Can nephritis be primary? If nephritis is the result of some form of infection, it cannot be primary. Henoch, Heubner, Bouchut, Bartels, Loos, and Holt have published cases in nurslings, the origin of which could not be traced. These occurred in infants from five weeks to one and a half years of age, who suddenly developed marked anasarca and vomiting, with suppression of urine. Some of the cases had a febrile movement of a remittent type. The majority of them were fatal. Their exact nature is still unknown. Uhlenbrock has re- cently collated all the cases in the literature, but has thrown no light on the subject. On autopsy, a few cases have shown a parenchy- matous nephritis. Course. — The majority of cases of parenchymatdus or exudative nephritis recover. The prognosis of the diffuse or productive form is more serious, but in exceptionally mild cases recovery may take place. Others cases make an apparent recovery. After the symp- toms of oedema and anasarca have disappeared, ansemia remains. The albumin in the urine may disappear and reappear. In six months or a year, general anasarca may set in with all the symptoms of an acute exacerbation of the disease. The patient may eventually recover from the attack, but as a rule others of the same kind follow, and the condition of chronic nephritis results. Duration, — The acute forms of parenchymatous or diffuse neph- ritis last from two to six weeks. The parenchymatous forms are sometimes evanescent, the marked symptoms lasting only a week. Chronic Diffuse Nephritis.. — (a) Chronic Productive Nephritis, (h) Chronic Nephritis ivithout Exudation (Delafield). — The forms of chronic diffuse nephritis are the same in childhood as in adult life. They usually occur late in childhood. Thus one case of chronic diffuse nephritis in a girl of fourteen years of age dated from an attack of scarlet fever at the age of eight years. At autopsy there was found a diffuse nephritis of the productive variety (large white kidney). In another case, a boy of t^yelve years, with diffuse neph- ritis of the non-productive variety (small cirrhotic kidney), had had an attack of scarlet fever at the age of five years. He had no anasarca in the course of the nephritis. Active symptoms of head- ache and vomiting appeared a year and a half before his death. The quantity of urine was above the normal and there were a few hyaline casts. At autopsy a small kidney was found. Thus there may in children be two forms of chronic nephritis following scarlet fever 782 DISEASES OF KIDNEYS AND UROGENITAL TBACT. or any other infectious disease. Adults present symptoms referable to the eye, such as neuroretinitis, which I have not met with in chil- dren, and which must be exceedingly rare in them. ISTeither have I seen in children the emphysema met in adults. The heart may be hyper- trophied and dilated in children as in the adult. They may have endocarditis and pericarditis with pleurisy. Treatment. — The forms of parenchymatous or exudative nephritis which so frequently occur as accompaniments of the acute febrile dis- orders, pneumonia, typhoid fever, influenza, etc., need little or no treatment. There are no symptoms referable to the kidney, l^eph- ritis accompanying acute gastro-enteritis is best treated by remedies directed toward the primary affection. The quantity of. urine is sometimes diminished. It contains casts of all kinds. Rectal ene- mata of saline solution at a temperature of 108° F. (42.2° C.) are then of great utility, not only in supplying fluid to a depleted circu- lation, but also in stimulating the circulation and therefore the kidney secretion. Drugs which might still further compromise the condi- tion of the kidney should not be given for the intestinal affection. Hot baths are of great utility, 105° F. (40.5° C). In the partial or complete suppression of urine seen in the first few days of the malignant forms of scarlet fever, more active treat- ment is required. When the temperature is high, the pulse rapid and weak, the patient unconscious or delirious, and the urine dimin- ished or suppressed, I administer high and large rectal enemata of water at a temperature of 108° to 110° F. (42.2° to 43.3° C), as recommended by Kemp. These should not be given to children with a double-current tube, but simply as enemata. About a quart of saline solution is thrown into the rectum at very low pressure. A fountain bag syringe is utilized for this purpose. These enemata stimulate the heart and circulation and supply the system with normal fluid. To stimulate the skin, the warm baths are preferable to cold ones. Patients are frequently much depressed by cold packs or baths given to reduce the temperature. The temperature of the bath should be at least 105° F. (40.5° C), and the patient allowed to remain in it five or ten minutes, according to the state of the pulse. In acute cases the anasarca will, as a rule, take care of itself. If it is extreme. Senator advises the administration of diuretics in acute as well as chronic nephritis. Some authors recommend diuretin and digitalis in form of infusion, a drachm being combined with an agreeable alkali, such as citrate of potassium. The pulse should be watched. If it is low, the digitalis is suspended. I do not utilize whiskey or alcohol in these cases. In acute diffuse nephritis and in productive nephritis similar to that of scarlet fever, the ursemic symptoms, the oedema, and the kidneys are treated. Vomiting is a DISEASES OF THE KIDNEY. 783 m-gemic symptom whicli is prominent at first. If tlie patient vomits everything ingested, no food should be given by month. The patient is nourished by rectum by means of somatose or nutritive enemata. The headache needs little treatment. Bromide and a small dose of chloral or trional are given for restlessness at night. In the forms of nephritis, generally subacute, in which there are oedema amount- ing to anasarca, and diminution of urine, baths and diuretics are beneficial. The anasarca is sometimes scarcely noticeable, and the quantity of urine little diminished. There are usually a few hya- line and epithelial easts, and also blood-casts. The patient is kept in bed and put on a milk diet. The bowels are kept open by means of Vichy water given in liberal quantities, or by Carlsbad salts. A child between four and six years of age should take half a drachm of the salts once a day. Some mild diuretic, such as citrate or ace- tate of potassium, is given. The pulse may be 80 or 90, and digi- talis is therefore not given. Under this mild therapy the anasarca subsides, the albumin diminishes, and the urea and quantity of urine increase. Milk also tends to increase the quantity of urine. A bath at 104°-105° F. (40° C.) is given every day or every second day according to the indications. The diaphoretic efi^ects of vapor baths are less marked. In some of the severer cases the urine is greatly diminished, the anasarca extreme, the pulse and respirations are increased, and the temperature may be elevated. The anasarca is then treated by a daily warm bath, in which the patient remains for five minutes, and is then wrapped in a warm dry blanket to promote diaphoresis. A warm rectal enema at the temperature above mentioned is given twice daily. The kidneys are stimulated by means of digitalis and ace- tate, citrate, or tartrate of potassium. The digitalis is given in form of the infusion, 5ss-3j with 3 to 8 grains of the potassium salt, three or four times daily. The pulse is closely watched and not allowed to fall too low. The bowels are kept open by the daily administration of cathartics. If, as fre- quently happens, the heart becomes weak, sparteine or liq. ammonite acetatis and nitroglycerin may also be given. I do not administer preparations of musk or camphor in nephritis. Convulsions are best controlled by means of chloroform. Warm baths and high warm enemata are also useful. Bromide and chloral are also given by" rectum, as in ordinary eclampsia. In convalescence the question arises. When shall diuretics be discontinued? As soon as the quantity of urine is above the normal, they are of no further value. The baths and enemata are continued as long as there is the least oedema of the surface. Warm enemata should not be continued after the urine has increased to the normal 784 DISEASES OF KIDNEYS AND UBOGENITAL TRACT. amoimt. Ordinary enemata are then given for the purpose of aid- ing the cathartics in keeping the bowels open and clear of fsecal accumulations. Rest in bed should be continued until there is no palpable albu- min reaction. Meat and vegetables are then added to the diet list. If ansemia is present, a readily assimilable form of iron, such as the peptonate, is given. Casts will appear in the urine far into conva- lescence. The patients may, however, be allowed to be up if they bear the change well. A too protracted stay in bed is sometimes exhausting in summer. If symptoms of anasarca and other signs of nephritis recur, the treatment is the same as in primary acute attacks. The treatment of chronic nephritis in children does not differ from that followed in the adult. I have recently subjected two children who suffered from the chronic diffuse form of nephritis following scarlet fever, accompanied by recurrent attacks of anasarca extending over years, to Edebohl's operation of splitting or extirpa- tion of the kidney capsule. Both cases were much benefited by the operation. One case was free from symptoms for fully a year. If we can improve these cases to this extent, the operation is certainly indicated, even if the operation is powerless to restore the kidney to the normal. New Growths of the Kidney. Thirty-eight per cent, of all the reported cases of kidney tumors occurred in children (Doderlein, Lewi). The following growths are here considered: 1. Cysts of the kidney; 2. Tuberculosis of the kidney ; 3. Carcinoma of the kidney ; 4, Sarcoma of the kidney. Cysts of the Kidney.- — Cysts of the kidney in children are usually of congenital origin. They are formed in the second half of intra- uterine life. They are bilateral, only 1 in 60 being unilateral (Lejars). The kidney is made up of greater and smaller cysts. The cystic formations may be present to the entire exclusion of kidney tissue. The cysts may attain the size of a child's head and seriously obstruct delivery. They are of anatomical interest only, since infants with such cysts present other abnormalities and die soon after birth. Hydronephrosis. — Hydronephrosis is either congenital or ac- quired. If acquired, it occurs late in childhood. The congenital form is due to stenosis in some part of the urinary tract. Hydro- nephrosis is as a rule unilateral. If it occurs after birth, it may be due to obstruction by calculi or to uric acid infarction of the kid- ney. The healthy kidney is physiologically enlarged. The acquired form is due to obstruction by calculi or to tumors pressing on the ureters. At first the pelvis of the kidney, then its tissue is en- PLATE XXXV Sarcoma of the Kidney. Child six years of age Irregular contour of the abdominal tumor. DISEASES OF THE KIDNEY. 785 croached upon in the gradual dilatation. Finally the shape of the kidney is lost. There is a large fluctuating tumor which may or may not be painful. When punctured, a fluid of low specific gravity is withdrawn which contains albumin, epithelium, urea, uric acid. In some cases there occurs what is known as intermittent hydro- nephrosis. The contents of the tumor are emptied spontaneously, but reaccumulate. The diagnosis rests on the presence of a fluctuat- ing tumor containing a fluid, with urine constituents. Cystoscopy may in some cases reveal obstruction of the ureters. Cysts must anatomically be differentiated from the condition of hydronephrosis. Cysts are new growths (Senator) ; in that respect they differ from the cystic condition of hydronephrosis. It is not possible clinically to differentiate congenital cysts of the kidney from congenital hydronephrosis. Sarcoma of the Kidney. — Sarcoma of the kidney occurs in chil- dren as a primary growth. In the statistics of Rosenstein and Senator two-thirds of the cases occur before the tenth year. It is more frequent in females. The left kidney is more commonly affected. Sarcoma occurs in the newly born infant. The presence of muscle, bone, and cartilage tissue in these growths supports the "theory of their congenital origin (Jacobi). The anatomical nature of the growth varies widely. It may be round-celled or spindle- celled sarcoma, a fibro-sarcoma, myo-sarcoma, angio-sarcoma, mela- notic sarcoma, or adeno-sarcoma. There may be metastases. The tumors sometimes attain a weight of fifteen pounds. Sjmiptoms. — The symptoms do not differ materially from those of carcinoma of the kidney, nor is sarcoma of slower growth. In many cases the pain, hasmaturia, and tumor follow a traumatism. Hsema- turia is not, as in carcinoma of the kidney, a constant symptom. I have seen cases of both carcinoma and sarcoma of the kidney in young children without haematuria or growth elements in the urine. Ascites is present in more than one-half the cases (Lewi). Diagnosis. — A malignant growth in a child may be surmised to be a sarcoma, since those growths are more frequent in children than carcinomata. Swelling of the lymph-nodes may be present in sar- coma as well as in carcinoma. Histological elements in the urine are rare. Von Jaksch has mentioned the presence of small round cells (sarcoma cells), but their significance is not as yet determined. Puncture for diagnostic purposes is dangerous, and if performed at all should be done posteriorly in the lumbar region (extraperito- neal). In sarcoma of the kidney, as in all growths of that organ, the colon is pushed in front of the growth (Plate XXXV.). Carcinoma of the Kidney. — Of 449 cases of carcinoma of the kidney (Rohrer, Ebstein, Lachman), 157, or almost 35 per cent., 50 786 DISEASES OF KIDNEYS AND UBOGENITAL TBACT. occurred in children nnder the tenth 3'ear. Monti tabulated 50 cases, and found that more than 50 per cent, occurred in children under the age of two years. The youngest patient was twelve months of age. It is more frequent in males. As a rule the right kidney is affected. In children, the growth is apt to attain great size. Guillet found that the average weight was eight and one-half pounds. By reason of the great weight of the growth, the kidney may sink from its normal position and lie transversely across the vertebral column. The growth is a primary one. The medullary carcinoma Fig. 178. Fig. 179. Enlargements of the kidney. Anterior palpable tumor beneath the Posterior area of flatness in the livei*. lumbar region, giving a palpable tumor between the border of the ribs and the crest of the ilium. is the prevailing type; the scirrhous is next in order of frequency. The disease may be secondary to carcinoma of the suprarenal cap- sule or of the retroperitoneal glands. The liver, the lungs, and the inguinal lymph-nodes may be secondarily involved. Symptoms." — The chief symptoms are pain, haematuria, cachexia, and enlargement of the kidney. Guillet found that hsematuria was the first symptom in one-half the cases. The quantity of blood passed may be very small, or so great as to amount to a dangerous hemorrhage. The urine may be red or chocolate colored, and may DISEASES OF TEE KIDNEY. 787 contain clots of blood or casts of the ureters. Frequent micturition is sometimes an early symptom. In other cases there is no hsema- turia, the cachexia, emaciation, and tumor being the first symptoms. In younger children the hsematuria is frequently absent. The kidney is in these cases protected from traumatism. The tumor is some- times so great as to cause displacement of the organs. In Fiir- bringer's case the heart was displaced to a situation beneath the clavicle. The abdomen is distended, and the colon is pushed in front of the growth and is indicated by a tympanitic area at one side of the median line of the tumor. On the right side, the tumor appears beneath the liver, and in narcosis can be felt in that situation as a distinct mass. The tumor has an uneven surface. The urine may, in addition to blood, contain histological elements of the growth. This does not occur so frequently in carcinoma of the kidney afe in tuberculosis of that organ. Duration. — The progress of the growth is much more rapid in children than in adults. In the former subjects the duration of the disease is from ten weeks to fourteen months (Roberts). Diagnosis. — In children, while the diagnosis of a morbid growth of the kidnej^ can be made, it is not possible to differentiate between the symptoms of carcinoma and those of sarcoma. It cannot be determined, from the symptoms, whether the growth is a simple car- cinoma, an adeno-carcinoma, or an adeno-sarcoma. The symptoms of a malignant growth of the kidney are pain, hsematuria, tumor, and cachexia. A cyst of the kidney may be confounded with a malignant growth. Cysts are congenital, and as a rule bilateral. This is also the case in hydronephrosis. In the latter condition extra- peritoneal puncture of the tumor may give a fluid with urine con- stituents. In carcinoma of the kidney, puncture for diagnostic pur- poses is not devoid of danger. Tuberculosis of the Kidney. — Tuberculosis of the kidney is rarely if ever primary. Senator asserts that it never occurs as a primary lesion. There are pathologically two forms — the miliary and the cheesy. The miliary form is more frequent in children, the cheesy in later life. In the miliary form, the kidney tissue is the seat of an eruption of miliary tubercles. In the cheesy form, tuberculous nodules may entirely replace the substance of the organ. The cheesy form is as a rule secondary to tuberculosis of the genitals — the epididymis in boys and the tubes in girls. The symptoms do not differ materially from those of the same condition in adults. In the miliary form there are no symptoms. In the cheesy variety there are dysuria, strangury, vesical tension, pain in the region of the kidney, emaciation, and fever. The urine contains albumin, blood, epithelium, and pus cells, and is acid in reaction. Tubercle bacilli are sometimes found. 788 DISEASES OF KIDNEYS AND UBOGENITAL TBACT. Diagnosis. — The diagnosis rests on the presence of tubercle bacilli in the urine, a tuberculin reaction, an enlarged palpable kidney, hsematuria, and tuberculosis of other organs — the genitals or the lungs. Treatment of New Growths of the Kidney. ^ — The treatment of new growths of the kidney is within the province of the surgeon. The congenital cysts are of scientific interest only. If there is rea- son to believe that there is congenital hydronephrosis which is uni- lateral only, surgical interference is indicated. Sarcomata and car- cinomata should be treated surgically if there is reason to believe that there are no metastases in the liver or elsewhere. Tuberculosis of the kidney is treated more from a general standpoint. If there is tuberculosis elsewhere, palliative treatment alone must suffice. Isolated tuberculosis of one kidney is a rare condition which necessi- tates extirpation of the organ. If it is impossible to determine the proper treatment, an exploratory operation is indicated. Perinephritis and Paranephritis. — This condition is rare in in- fancy and childhood. It is not always possible to determine the cause. If such is the case, the disease is called primary. As a rule, it is secondary to traumatism in the lumbar region, to pyelitis, or to pyelonephritis. It may occur in septicopysemic processes, and I have seen it follow the infectious diseases, notably scarlet fever. Of 166 cases collected by TsTieden, only 26 occurred in children. One case occurred in an infant five weeks old. Gibney's cases ranged from one and a half to ten years of age. The condition is more common on the left side. The pus may burrow behind the liver or spleen, or find its way downward, forming a mass simulating a cold abscess or a perityphlitic abscess. It may perforate into the pelvis of the kidney, the intestine, peritoneum, vagina, or diaphragm, or may pass along the ileopsoas muscle, and find its way to the hip, and thus appear externally. The kidney may be involved because of its contiguity to the seat of the process. Pleuritic metastases and amyloid degeneration may finally result. Symptoms. — The symptoms are usually obscure. The fever is intermittent or remittent. Young children do not as a rule complain of pain. The first intimation of the nature of the disease is the appearance of a swelling in the lumbar region. On bimanual palpa- tion a tumor which is fixed, tense, and does not move with respira- tion, is felt deep under the liver, in the region of the csecum and ascending colon on the right side, or underneath the sj^leen on the left. Gibney has described these cases and shown how they may be easily mistaken for cases of cold abscess. The thigh of the affected side is held in a condition of semiflexion. Treatment. — The treatment is surgical. DISEASES OF THE KIDNEY. 789 Enuresis Nocturna and Diurna. — This is a functional neurosis of the bladder in which the urine is passed involuntarily, and, as a rule, at night during the first hours of sleep. It may, however, be passed at any time during the night. Some patients have at times no control over the bladder during the day (diurna). Some have enuresis every other night or only once or twice a week, and others suffer from the affection over night. Cases of enuresis should be differentiated from those in which there is a complete paresis of the sphincter vesicae. In the latter case the urine simply flows away. These are cases of disease or anomaly of the cord (spina bifida). In enuresis the children may in other respects be in good health. There is frequently a nervous condition. In some cases there is lithiasis or stone in the bladder ; in others the etiological factor is Oxyuris vermicularis, obstipation, tumor of the bladder, or vulvovaginitis. Cystitis and adenoids have been regarded as causal. In the majority of cases no cause can be found. The condition follows the exan- themata. In boys it usually disappears toward the sixteenth year. I have seen it persist in girls into adult life. Its treatment becomes a very serious problem. Diagnosis. — The diagnosis is not difficult. The urine should be carefully examined for evidences of lithiasis, cystitis, glycosuria, nephritis, and nematodes, and the bladder for stone. The diagnosis is not made in infants and very young children. In the latter the enuresis is often only apparent. They do not know how to indicate their wants. Treatment. — The urine should be passed before retiring. The patients should take little liquid at the evening meal. The foot of the bed is raised so that the head is slightly lower than the pelvis. The drugs most utilized are ergot and atropine. The former is given in the fiuid extract, minims x to xxx (0.6 to 2.0) t. i. d. Atro- pine is given before retiring in a solution (grain j to §ij 5 0.06 to 30.), a drop for every year of the age (Watson). It is efficient in many cases, but in some children distinctly dangerous. I had one case in which I gave one-half the above dose. The child, five years of age, became slightly delirious and tried to walk out of a window. Many cases will improve, only to be subject to relapses. Marion Sims has shown that enuresis in young girls may be due to an intol- erant and very small, contracted bladder. In such cases, he advises gradual dilatation of the bladder by injecting the organ with in- creasing quantities of an indifferent fluid. If treated in this way, the bladder will eventually retain urine. Most of the cases resist all methods of treatment. 790 DISEASES OF KIDNEYS AND UROGENITAL TRACT. DISEASES OF THE UROGENITAL TRACT. Vulvovaginitis {Urogenital Blennorrhcea) . — The term vulvovagi- nitis, or, as it is now called, iTrogenital blennorrhcea, refers to a gon- orrhoeal inflammation of the genital tract in children. Before de- scribing the condition it is necessary to refer to catarrhal conditions which are not gonorrhoeal, and which are present in the normal state. Etiology. — Epstein has shown that in the newly born infant there is a physiological and normal discharge from the vagina. It is an adhesive, mucoid discharge containing epithelial cells and micro- organisms. A few days after birth, this discharge assumes a puru- lent and, in icterus, an icteric hue. K'o leucocytes are found in the discharge. In two weeks it ceases and the parts appear normal. This form is not gonorrhoeal. A second condition which I have noted in very young children is the result of uncleanliness, lithiasis, irrita- tion caused by Oxyuris vermicularis, or masturbation. The parts arc reddened and eroded, and are bathed with an abnormal serous dis- charge. There may be a few erosions around the introitus. These cases recover with ordinary care and removal of the source of irri- tation. Pus is rarely secreted. A second group of cases occurring in young female children includes those of vulvovaginitis of the simple catarrhal type. These have a scanty or profuse purulent discharge from the vagina, vulva, and urethra, which presents clinically all the features of the specific gonorrhoeal group, but is not gonorrhoeal. The condition is not of infrequent occurrence. The urethral orifice is swollen and red. The hymen is also swollen and inflamed. The discharge is thin and milky, or greenish and viscid. Microscopically, it shows in the pus- cells bacteria and diplococci in groups, but these do not show either by culture or on staining the characteristics of the gonococci. The history of such discharges is singularly similar to that of the gonor- rhoeal form. Urination is painful, and the discharge persists even under careful treatment. In one case of this kind I have seen an inguinal bubo. The catarrh, like the gonorrhoeal form, affects the urethra, vulva, vagina, and cervix uteri. I am convinced that the discharge is infectious and communicable from one child to another. It may last for months and again recur. Its exact etiology is still unknown. Uncleanliness, infection from a vaginal discharge, maras- mus, the infectious diseases, or frail health may be the cause. Cases of urogenital blennorrhoea have been described by Pott, van Dusch, Spaeth, Cahen-Brach, Epstein, and others. Occurrence. — This affection may occur in newly born infants (Ep- stein) or in older infants and children. Epidemics may occur in hos- pitals (Frankel). The avenue through which the disease is conveyed DISEASES OF THE UROGENITAL TBACT. 791 is still unknown. It occurs in all walks of life. In some cases there is a history of the child's having slept with the mother. In others, there is no such history. I have sometimes obtained a history of an abnormal attempt at coitus between boys and girls, the boys having suffered at the time from gonorrhoea. Such cases are, how- ever, exceptional. The exciting cause is the gonococcus (ISTeisser) (Fig. 180). This micro-organism has been found in the discharges of all these cases, and cultivated (Koplik, Heiman, WoUstein). Symptoms. — There is a thick, viscid, purulent, greenish or yel- lowish discharge from the vagina, which bathes the parts and dries in crusts on the labia. The opening of the urethra is reddened and swollen. There is a discharge from the urethra. Micturition is painful. In some cases there are slight swellings of the inguinal Fig. 180. Gonococci in vaginal discliarge. Cover-glass spread. Photomicrograph, x 1000. lymph-nodes. If the speculum which is used for the male urethra is introduced into the vagina (Tuttle's urethral speculum), it is seen that the purulent discharge is present in the folds of the mucous membrane of the vagina. The cervix uteri also contains a drop of pus. Thus the whole genital tract is involved. Some children com- plain of pain over the lower part of the abdomen. On examination, this is found to be pelvic, and is probably due to inflammatory reac- tion of the tissues about the uterus and vagina. Complications and Course, — The course of the disease is quite tedious, and may occupy eight weeks, three months, or more. The discharge may abate, only to return in its original severity. Peritonitis has in rare cases been reported as a complication of this form of vulvovaginitis. It may prove fatal. I have met two 792 DISEASES OF KIDNEYS AND USOGENITAL TEACT. cases. Hunner and Harris recently reported a fatal case in a girl ten years of age. They collected 5 other cases from the literature occurring in children. Pelvic peritonitis occurred in 2 of my cases with the usual signs of pain and fever. Both cases made a good recovery. Hartley and the writer have reported cases of arthritis complicat- ing vulvovaginitis in children. My cases occurred in the first and second weeks of the disease. In one case, only one joint was affected ; in another, two. Both recovered without suppuration. Gonorrhoeal conjunctivitis may result from careless infection of the eyes. I have had only 2 cases in which the patients complained of praecordiah pain. In neither were there active symptoms of endo- pericarditis, but there is no reason why it might not occur in children, as in adults. Sanger at one time traced a connection between sterility in later life and attacks of this disease in childhood. Treatment.- — Prophylaxis is of great importance. A child affected with the disease should not be allowed to sleep with other children. The toilet appliances should not be used by other children. The parents should be carefully enlightened concerning the infectious nature of the affection and the great danger to the eyesight should infection of the eyes occur. The hands of the patient should be kept scrupulously clean. In institutions the patients should be strictly isolated. The vulva should be kept covered with a pad of absorbent gauze, and a diaper should be worn over this to prevent the dis- charge from soiling the clothes. In the acute stage, the vagina should be irrigated with a glass catheter or a Skene urethral catheter twice daily. The solution should be at a temperature of 108° F. (42.2° C). The irrigating solutions should be either a 2 per cent, solution of acetate of aluminum or a 1 : 2000 or a 1 : 500 solution of nitrate of silver. If the silver or aluminum solution is irritating a simple saturated solution of boric acid may be used. I have found a 25 per cent, solution of argwrol quite effective in diminishing the severity of the discharge. The vagina is first irri- gated with boracic acid and then with the solution of argyrol. In the subacute stage the vagina is painted every other day with a 5 or 10 per cent, solution of nitrate of silver. A Tuttle urethral speculum is used for the purpose. If the child is intractable, it is impossible to do this without the use of an ana?sthetie, which, however, seems scarcely justifiable. I have cured these cases with rest in bed and irrigations. I have tried the bougie treatment and the protargol and permanganate of potassium irrigations, but have found the treatment above described preferable. DISEASES OF THE UROGENITAL TBACT. 793 Urethritis in Male Children. — Simple urethritis of the anterior portion of the urethra occurs in infants and young children. It is caused either by unnatural interference with the parts or infection. It is not gonorrhoeal. The meatus is slightly red or the parts are agglutinated with dried pus. On pressure, a drop of pus exudes from the urethra. There is ardor urinse, due to a slight fissuration of the meatus. The affection is easily cured by attention to clean- liness. An alkali, such as citrate, of potassium, is given in very small doses, to alleviate the ardor urinre. Gonorrhoea occurs in male infants and boys, and is the result of direct infection. The symptoms are much the same as in adults, except that, as a rule, there are no complications. Balanoposthitis and lymphadenitis may occur, also epididymitis, and rarely orchitis. Bokai reports cases of stricture. Cystitis, Pyelitis, and Pyelonephritis. — This affection, which is peculiar to infants and children, was first called coli-cystitis by Escherich, in view of the bacterial causation of the disease. The question af nomenclature is complex in view of the fact that Amer- ican (Holt) and English authorities designate this affection by the term pyelitis, whereas the Germans speak of cystitis. The question is one of origin of the disease and from my own experience I think it but proper to call the disease cystitis, inasmuch as it seems to me most of the cases originate from local infection in the bladder. The infection may then travel up the ureters and involve the pelvis of the kidney and finally the kidney itself may become involved in the suppurative process and there results a pyelo-nephritis. There are, however, certain rare cases which cannot be accounted for in this simple manner, but which may begin in the pelvis of the kidney, travel down, and subsequently involve the bladder. If they do occur the infection takes place through the blood, for in no other way can we account for such a course of the infection. Cystitis is a common affection of infancy and childhood. Esch- erich called attention to it and cases have been described by Trumpp, Holt and others. Etiology. — The most frequent cause of cystitis is the Bacillus coli communis, as first demonstrated by Escherich, though other bac- teria, such as the Gonococcus, the Staphylococci, Streptococci and typhoid bacilli may all cause cystitis. The direct inciting causes are exposure to cold or any inflammation about the urethra or vulva in the female. It is found to complicate the infectious diseases, such as scarlet fever, measles, pneumonia, diphtheria, and influenza. A large percentage of cases certainly complicate some disturbance of the functions of the intestines. Thus a large number of my cases complicated or were preceded by some form of quasi-enteric infection 794 DISEASES OF KIDNEYS AND UBOGENITAL IBACT. and diarrhoea. This corresponds with Trumpp's experience. In such cases the theory holds that through uncleanliness the bladder has become infected through the urethra. This mode of infection will not hold in boys in whom the urethra is long and the infection in them is more probably systemic through some lesion in the mucous membrane of the intestine. Frequency. ^Of 36 of my own cases only 7 occurred in male chil- dren, thus showing the predominance of the affection in the female sex. This can only be accounted for by the ease with which infec- tion travels from the introitus vaginae into the urethra and bladder in the female. Of the 37 cases, 20, more than half, occurred in infants under one year of age, showing the susceptibility of infants who are still using diapers. Only 5 cases occurred after the fifth year. One case occurred in a newborn infant ten days old. Fig. 181. Dec. 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Symptoms. — The symptoms of cystitis in infants and children are not sufficiently characteristic to direct attention to the aifection unless the physician bears the possibility of its occurrence in mind in every case of fever of obscure origin. The main features are fever, frequency of urination, pain on urination, recurrence of chills, and staining the diapers in young infants a peculiar yellowish tinge. Pever. — The characteristic of the fever is that it is high with remissions to the normal (Fig. 181). It may be 104° to 106° and still the infant may not appear to be very much prostrated. With the fever there is the occurrence of chills. The patient becomes blue and pale and in some cases there may be, in susceptible infants and in the newborn, convulsions. The fever lasts for days or weeks and even when the affection is improving there may be recurrences. DISEASES OF THE UROGENITAL TRACT. 795 Pain. — I have obtained a distinct history of pain in urination, the urine being passed with tenesmus and in small quantities. Anaemia. — Quite characteristic of all cases of cystitis in infancy is a marked and increasing anaemia after the disease has lasted for a period of one or two weeks. This ansemia is quite easy of recog- nition and after having seen a number of these cases this striking feature in infants who have a febrile movement of obscure origin will direct one's attention to an examination of the urine. With .the anaemia there is loss of weight and the musculature loses its tone. There may also be disturbances of the functions of the intestine, as evinced by abnormal movements. Urine.- — The urine is acid in reaction, turbid, contains flocculi of fibrin, pus, and a small amount of albumin. Microscopically it contains a large quantity of pus-cells, some bladder epithelium; in severe cases renal epithelium, hyaline, epithelial casts, and blood, and Bacterium coli communis or other bacteria mentioned. Diagnosis. — The diagnosis is made from the presence of fever where every other cause has been excluded, the history of chills, the progressive anaemia, all in the face of a history of bowel disturbance or grippe should lead to an inquiry into the condition of the urine. In many infants who have been trained the urine can be easily obtained by placing them on the commode. In other cases the sim- plest procedure is to catheterize the infant. The appearance of the urine even before microscopic examination will lead to the diagnosis. In all cases of cystitis in infants and children the kidneys should be carefully palpated in order to discover an involvement of these organs. If they are involved they can be distinctly felt through the abdominal walls as markedly enlarged and tender. In such a case the diagnosis of a complicating pyelitis or pyelonephritis is warranted. Course and Termination. — A 'majority of my cases have recovered within the short time of one, two or more weeks ; others have not had such a favorable ending, especially cases whose onset has been over- looked and the diagnosis delayed for weeks. In these the urine con- tinued to contain pus and casts for months with no prospect of any clearing up of the urine under energetic management. The infants were not at all badly affected by the disease, but increased in weight and their color improved. In the cases which I saw in older chil- dren and studied in the hospital mixed infection of the urine occurred after a time and the reaction became alkaline with the presence of Staphylococci and Streptococci in the urine. Among my cases there was one in a newborn infant which developed bacillaemia and finally a meningitis due to coli bacilli. Here the convulsions were repeated with every appearance of a chill. The child did not die, but recov- ered, a hydrocephalic idiot. 796 DISEASES OF KIDNEYS AND USOGENITAL TBACT. In one case of an infant six months of age, pyelitis developed with snppnrative nephritis and the kidneys after death were very much enlarged and studded with abscesses, being similar to a sur- gical kidney. Finally another case proved fatal through pyelitis and septic nephritis. Thus we cannot say what the outcome of any case may be before treatmeut, but should warn those cojacerned of the seriousness of the prognosis. Any involvement of the kidney clouds the prognosis unless the infection of the kidney is only temporary. Treatment. — There must be a large number of cases which run a mild course and which recover with very little but symptomatic treatment. There are infantile cases in which the diagnosis has been overlooked. The dangers which threaten have been dwelt upon. The treatment consists in placing the bowels in a correct con- dition, and administering salol or urotropin. Infants will take two or three grains of either drug without any danger three times daily. If urotrojjin is not well borne and gives rise to diarrhoea or bloody urine, salol is substituted. An alkaline water is given in the food, the so-called Poland water being the most available. In convales- cence citrate of potash is used, grs. v, three times daily. Saccharine is given in older children as in the adult. The question of bladder irrigation arises. My experience in acute cases is that irrigation of the bladder with various solutions is unsatisfactory. In the chronic and subacute cases they have seemed in my hands to have availed. The bladder is washed out once a day. In children it is a simple and harmless procedure if utmost cleanliness is observed. In those eases in which the kidney had become involved surgery in my hands has not held out any encouragement, though if marked pyelonephrosis occurs the surgical indication is evident. Treatment should not be suspended until it is certain that the urine has cleared and is in a normal condition. Bacilluria. — Bacilluria is a peculiar condition observed b}^ Esch- erich, Trumpp, Box and others, which differs from the condition ju&t described in that the urine does not contain pus but only bacilli coli. It is a form of bacteriuria. This condition may precede the development of cystitis and pyelitis. It is uncommon. SECTION XV. DISEASES OF THE NERVOUS SYSTEM. CONVULSIONS IN INFANCY AND CHILDHOOD. Eclampsia Infantum. — Convulsions are a series of violent clonic contractions of a number of muscles, or of the muscles supplying one limb. There is always more or less of a tonic spasm at first. The convulsions are paroxysmal and accompanied by a loss of conscious- ness. In this section the acute convulsions of infancy and childhood are especially considered, and will be differentiated from certain spasmodic affections, such as laryngismus, tetanus, and epilepsy, which are accompanied by spasms, though classed by some as forms of convulsions. Classification. — Convulsions of infancy may be classified as those which are primary or idiopathic, and those which are secondary, reflex, or symptomatic. In the first rubric are included the con- vulsions which occur spontaneously, or after some sensory irritation, very often of an obscure origin, such a& epileptic, hystero-epileptic seizures, and tic. With increasing knowledge this class is gradually becoming more and more limited. In the second class the symptomatic or reflex convulsions are included: (a) the cases which follow abnormal conditions of the circulation in the brain, such as anaemia or hypersemia; (&) con- vulsions which occur at the outset of infectious diseases; (c) convul- sions which are caused by disturbance of metabolism, and which occur at the outset or in the course of certain diseases in which toxins are thrown into the blood; (d) those which follow some peripheral irritation, such as occurs in a reflex manner in wounds, burns, etc., or directly reflex, as in meningitis, tumors of the brain, hydroceph- alus, brain compression, poisons circulating in the blood (lead). Occurrence. — The acute convulsions of infancy and childhood are symptomatic, and occur chiefly during the first half year of life. Fully four-fifths of the cases occur before the end of the second year of life. They are uncommon after this period; but a child who has had convulsions of the symptomatic type in infancy is likely to have a recurrence of the convulsions up to the seventh year of childhood. Etiology. — The occurrence of convulsions necessitates not only the presence of an exciting agent or irritating substance, but there must exist a certain constitutional disposition or predisposition to 797 798 DISEASES OF TEE NESVOUS SYSTEM. convulsions, which may be hereditaiy. Soltmann has shown that in the newborn animal irritability of the motor nerves is almost nil, and that of the sensory nerves much below what is attained in later life. In the newborn, also, there is an absence of reflex inhibition, and the brain lacks volition ; in other words there is an absence of the psycho-motor centres. The inhibitory centres do not develop in parallel lines with the peripheral irritability of the sensory nerves. Reflex irritability is very much diminished at the outset, but in- creases later, becoming, at a certain period of infancy, above what is found in the adult. The musculature of the infant, on account of the instability of the nervous centres, can be thrown into tetanic con- traction by the least irritation. This period of increased reflex irri- tability of the nervous centres has been placed experimentally by Solt- mann at from the fifth to the eleventh month of infancy, thus corre- sponding with what is found in the human subject clinically. Although the theories of Soltmann are not wholly endorsed by other observers, it remains true that in infancy the inhibitory centres are not fully active, that the psychomotor centres are absent, and that this is a period of increased reflex irritability of the peripheral nerves. In a causal sense, not only does this increased reflex irri- tability predispose to acute convulsions in infancy and childhood, but with it there is a hsematogenous toxic element especially active at this period of life. In infancy we have also the hereditary predisposition to neuroses, and tendencies derived from neurasthenic, alcoholic, syphilitic, and tuberculous parents. It seems, therefore, that causal agents of acute convulsions in infancy and childhood are principally periodical toxins, such as are present in the circulation (hsematogenous) at the outset of infectious diseases, as acute amygdalitis, exanthemata, typhoid fever, malaria, influenza, pertussis, mumps — all of which may be ushered in with a convulsion. The explosion appears to be caused b}^ the initial effect of the toxins and temperature on the ganglion-cell. Convulsions sometimes take the place of the initial chill in pneumonia and malarial fever. The disturbances of metabolism which may cause toxins to be thrown into the circulation occur in connection with gastro-enteric disease of any kind or with indiscretions in diet. Children who eat an excessive quantity of meat are particularly subject to these seiz- ures. In addition to the above exciting agents we have mentioned also disturbances of the circulation which may cause convulsions, and these are found in connection with pertussis, bronchitis, and heart disease. In these affections there is an accumulation of carbonic acid gas in the circulation, which is the exciting agent of the initial CONVULSIONS IN INFANCY AND CHILDHOOD. 799 explosion; and, finally, we have as causes of convulsions the direct effect of mineral poisons, such as lead, circulating in the blood. Convulsions, according to some authors, may be caused by the presence of alcohol in the mother's milk. This is a very question- able cause of convulsions. Rarely, convulsions may be caused by reflex irritation of a foreign body in the stomach, or by overdisten- tion of the stomach during stomach-washing, an instance of which the author has seen ; by burns, wounds, effects of cold, incarceration of a hernia. Retention of urine may, by reflex peripheral irritation, cause convulsions. The toxic form of convulsions occurs in ursemia. Dentition is frequently mentioned among the causes of convul- sions. Since dentition in a normal infant is devoid of symptoms, it is straining a theory to ascribe convulsions to irritation of the trigeminal branches. The acceptation of this dentition theory might lead one to overlook some serious condition, of which the first indica- tion is an eclamptic seizure. Under the heading of circulatory disturbances might further be mentioned an acute cerebral anaemia, caused by severe hemorrhage, which may give rise to a convulsion. Such convulsions are hardly included under the conception of infantile convulsions of the acute type. Pathogeny. — The pathogeny of convulsions in infancy and child- hood is the same as in the adult. The explosions are due to irrita- tion of the centres in the ponto-bulbar junction, or in the area of Rolando (Hughlings Jackson). The starting-point of every convul- sion is a ganglion-cell. It is not known whether the inherited neu- rotic tendencies already mentioned are powerful factors during infancy, or whether alcoholism or epilepsy in the family are active in causing convulsions of the purely acute type in infancy. Rachitic children, however, according to Kassowitz and Elsasser, are pecu- liarly subject to convulsions, because the cranial bones are the seat of hypersemia and softening. The motor areas adjacent to these points of hypersemia and softening are supposed to be in a state of constant irritability. Kussmaul and Tenner have demonstrated that there is an acute ansemia of the brain during convulsions. On the other hand, it often happens that the convulsion is the cause of the bursting of a cerebral vessel. In such cases the signs of cerebral surface hemorrhage are present at autopsy. In other cases, although death has occurred during a convulsion, nothing is found postmortem but an oedema of the brain substance, of doubtful origin. Symptoms. — The majority of convulsive seizures in infants and children are single. In certain cases the convulsions are repeated and extend over a prolonged period. The latter are not cases of 800 DISEASES OF THE NEBVOUS SYSTEM. simple acute infantile convulsions. The symptoms of acute eclamp- sia are sometimes so very slight as to he scarcely noticeable. A very observant mother v^^ill see a slight tvs^itching of the lips and eyelids, a momentary turning of the eye and cessation of breathing, or a momentary spasm of the whole trunk. The expression " internal convulsion," so frequently heard, evidently denotes these slight eclamptic seizures. The genuine convulsion comes on without pre- monitory symptoms. There is a momentary spasm of the body, the head turns to one side and upward, and there is a corresponding upward direction of the eye. Then follow a series of clonic spasms involving the upper and lower extremities, and lasting for some time. The hands are clenched, the forearms flexed, the body rigid, the lower extremities extended, the head thrown back. This tonic, momentary spasm is followed by a clonic spasm, beginning in the muscles of the face and involving those of the trunk and extremities. The teeth are set, the tongue is protruded and may be bitten. There are cyanosis and frothing at the mouth. The respirations are short and hissing, the pulse is imperceptible, and at the outset of the con- vulsion the heart becomes slow and irregular. A cold perspiration bathes the surface. The convulsive seizure may be momentary, may last a few minutes to a quarter of an hour, or one spasm may be fol- lowed rapidly by others extending over the same period of time. Toward the termination of the convulsive spasm the clonic contrac- tions become less frequent ; the child passes into a sleep or coma. In some cases the clonic spasms may be limited to one side of the body. The child may be in a state of eclampsia for an hour, after which it may pass into the comatose state. The coma may be momentary or may merge into a sleep of variable duration. The end of the convulsive spasm is signalized by muscular clonic spasms decreasing in severity, until finally a long-drawn inspiration ends the attack. Diagnosis. — It is very important to be able to distinguish between the various forms of convulsive seizures. Those occurring imme- diately after or within a few hours or days of birth have a different significance from those just described. They may be caused by cere- bral hemorrhage, and there will be symptoms after the convulsions, such as palsies, contracture, difficulty in deglutition, and prolonged coma. In these cases the convulsions are repeated. Atelectasis of the congenital variety may cause convulsions. The patients have slight or marked cyanosis, and, in the intervals, increase of respira- tions and signs of bronchitis and collapse of the lung. Tumor and abscess of the brain, and meningitis, both cerebro- spinal and tuberculous, may be ushered in by convulsions. In tumor, the convulsions are limited to the area in which the tumor or abscess is localized. In forms of meningitis, there will be the symp- CONVULSIONS IN INFANCY AND CHILDHOOD. 801 toms of that disease. Drugs and poisons may give rise to convul- sions. The history of such cases v^ill be of service. Cases of tetany and tetanus have convulsions in the course of the disease. In tetany there may be several convulsions in the course of twenty-four hours. Tonic spasm is the chief feature of the convulsion in tetany and tetanus. The clonic form distinguishes acute convulsions. In tetanus there is slowly increasing opisthotonos. In tetany the body may be lax in the interval, but there are rare cases of tetany which resemble tetanus in that there is rigidity in the intervals between the spasms. In tetany the extremities have a characteristic position. In some cases of simple acute infantile convulsions, an increased irri- tability of the nerves and muscles to mechanical stimulus remains for days after the paroxysms. The Chvostek and Trousseau phe- nomena are found. Some authors have regarded these cases as cases of latent tetany. The diagnosis of the various epileptiform seizures will be considered in the section devoted to that subject. Prognosis. — The prognosis of acute infantile convulsions is gen- erally good, but since death has occurred in these seizures, as well as cerebral hemorrhage, caution should always be exercised in predict- ing the immediate outcome. The patient having been once tided over the initial paroxysm, it may be confidently expected that it will not be repeated. In the presence of fever, it cannot be predicted what affection may follow the seizure. Primary seizures should not be regarded as forerunners of epilepsy. Many infants and chil- dren affected with convulsive seizures pass through later life without any sign of that disease. Treatment. — The seizure is frequently over before the physician arrives. If such is the case and the infant is in the stage of stupor, it should not be disturbed unless there is high fever or a history of the patient's having eaten some irritating substance. It often hap- pens that the paroxysm supervenes in the presence of the physician. The patient is placed on a bed, the clothes loosened, and a small object, such as the handle of a tooth-brush, placed between the teeth to save the tongue from injury. ISTothing further is needed. The paroxysm is as a rule over in three' minutes at most. If it persists or is immediately succeeded by another, the patient is placed in a warm bath, after which a few drops of chloroform are administered by inhalation to control the convulsions. A high rectal enema of the temperature of 110° F. (43.3° C.) is at once administered. I have in some cases continued the administration of chloroform for fully an hour. Caution should be exercised in its administration. If, after the seizure, the temperature is high, it is treated as indi- cated in the section on Infectious Diseases. Unless there is some contraindication, a full dose of calomel is administered as a routine 51 802 DISEASES OF TEE NERVOUS SYSTEM. procedure even if an enema has been resorted to. Should the child be restless, it is well after the convulsion to administer a dose of bromide of potassium in combination with chloral, either by mouth or rectum. In repeated convulsions the administration of these drugs during the seizures is of inestimable value. For several years past I have used the postural treatment in acute convulsive seizures. The patient is placed with the head low, the buttocks raised, and the clothes loosened. I think the paroxysms have been shortened by this treatment. It was suggested by the theory that cerebral anaemia is the cause of the initial paroxysm. I have carried out this postural treatment without any ill after effects, such as hemorrhage. In a large number of cases of repeated con- vulsions, the postural treatment should be supplemented by chloro- form inhalations. HYSTERIA. Hysteria is a morbid state of the nervous system in which the primary derangement is in the higher cerebral centres. The lower centres of the brain, the spinal cord, and the sympathetic system may be secondarily disordered (Gowers). It is not a true disorder of childhood. Sixteen per cent, of all the cases of hysteria occur in youth (Steiner). Etiology. — Hysteria is rarer in children than in adults, is more frequent in the female sex, and is more often seen in boys than in men. According to Briquet and Landouzy, 8 per cent, of all the cases occur in the first decade of life, and 50 per cent, in the second. The cases of the first decade, according to Barlow, generally develoj^ at the age of six years. Cases are occasionally seen in patients of the age of three years. Heredity plays an important etiological role. Moral and mental influences predispose to development of the con- dition. Children of emotional antecedents are apt to be subject to the disease. Sexual disturbances or excesses (as masturbation in boys), are exciting causes. Abnormalities of the sexual organs, phi- mosis, and hypospadias are apt to excite masturbation and resultant hysteria. In some subjects, any acute disease, such as pneumonia or typhoid fever, will develop latent tendencies to hysteria. Diph- theritic paralysis may eventuate in hysterical palsy (Gowers). Symptoms. — The disease shows many variations and most diverse symptoms. The symptoms may be divided into psychic, motor, and sensory manifestations; or into the convulsive and non-convulsive forms of hysteria. Psychic or Menial Hysteria (Non-convulsive). — In most cases of this class, the patients suffer from some mental strain. The attack begins with a paroxysm of crying or of laughing. The child HYSTEBIA. 803 then passes into a violent condition, striking at persons and tearing the clothes from its body. I saw a case of this kind in a boy eight years of age. He was very bright at school, but shunned the com- panionship of other boys. He masturbated. At times he was of a very loving disposition, at other times would refuse to do as he was told. The rebellion would terminate in a paroxysm of crying, fol- lowed by one of shrieking. The boy would tear his clothes and then calm down quite exhausted. Girls after undergoing some mental strain, such as is incident to a school examination, become irritable, morose, and suffer from insomnia. They have laughing and crying spells and refuse nourishment. After a period of these symptoms they either recover or pass into a state resembling acute mania. Such children are nervous and are born of neurotic parents. Hystero-epilepsy, catalepsy, or trance symptoms may manifest themselves. These cases are rare in children, but Sachs and Steiner have seen them in children of mentally degenerate families. Insanity, alcoholism, and chorea in the family predispose to the development of hysteria. These cases must be differentiated from those of true epilepsy. Motor Manifestations (Convulsive Forms). — These occur in the form of hystero-epileptic attacks. After some mental excitement a paroxysm beginning with a shriek will supervene, the sounds simu- lating a bark or a snapping sound. Contortions then supervene and the back is arched, as shown in Richer's drawings. During the attack, which may last for several minutes, there may be no evidence of consciousness. There may be a number of such attacks in the course of twenty-four hours. The patient may suddenly fall down and have contortions, and the attack may terminate in a crying spell. The patients sometimes tear their clothing and become violent. These convulsions are differentiated from true epilepsy in that there is no aura ; they are preceded by emotional excitement. The onset is gradual and the patients emit noises of various kinds during the attack. The pupils are normal. There are ecstasy, extravagant movements, and tonic rigidity. The vesical and rectal reflexes are normal. The patients do not bite the tongue, and rarely injure themselves; the loss of consciousness is temporary or imperfect. There are in hysteria irregular twitchings of the extremities and a repetition of one specific movement, such as retraction of the head. The spell or paroxysm ends in a crying or laughing fit, or the patients become melancholic. Among the manifestations of hysteria in children is the so-called hysterical stricture of the oesophagus, or globus hystericus. There may be spasm of the bladder, hiccough, and loss of voice. The latter is common among young girls. I have seen the children recover 804 DISEASES OF TEE NEEFOUS SYSTEM. their voice under hyj^notic suggestion. Hysterical children may, even at the early age of five years, pass under hypnotic suggestion, into a trance-like state. Whether diarrhoea can he caused hy hysteria is in my opinion doubtful. I have seen true toxic diarrhoea in neu- • rotic children diag-nosed as nervous or hysterical. One case occurred in a boy of six years. Some young girls have attacks in which all varieties of poses are assumed in the nude state. I have seen such a case in a highly intelligent girl of nine years. During the morn- ing bath the child had a desire to assume the most grotesque poses. The so-called epidemics of chorea are now known to be simple hysteria. Among these are to be classed the school epidemics and the dancing mania of the Middle Ages. There may not only be convulsive movements, but also absolute paralysis of single muscles or of a group of muscles. Hysterical paralyses as a rule follow no anatomical distribution. They are dis- tinguished from true palsies by the lack of change in the electrical reactions and in the condition of the deep reflexes. The sphincters are normal. Paralyses, such as those due to neuritis or poliomye- litis, may supervene in a hysterical subject. Disturbances of Sensation. — The disturbances of sensation in- clude hyj)era?sthesias and anaesthesias. These do not differ essen- tially from similar conditions in the adult subject. There may be hypersesthesia in the region of the ovary, or in the skin over the vertebral column. Areas of irritation may cause paroxysms. There are hysterogenic zones which are not hypersesthetic (Sachs). Anaes- thesia, 23artial or general, is more frequent. There may be absolute anaesthesia to all sensation. There may be blindness in one eye or hemianopsia, deafness, or loss of taste or of smell. Vision may be affected as above described, or there may be photophobia and diminu- tion of visual perception ; the retina may be insensible to light, and there may be limitation of the field of vision or temporary bilateral loss of sight. There are in children cases of anorexia which supervene with vomiting after some nervous strain. I have seen this occur in chil- dren who were beginning some course of study. In one case it came on in the morning just before the child started for school. With suspension of school duties, the vomiting ceased. The so-called 2:)hantom abdominal tumor seen in rare instances among children may be traced to a hysterical cause. In very young girls I have fre- quently seen forms of palpitation with cardiac anguish Avhich seemed to be hysterical. Steiner describes these forms of tachycardia. In these cases there is not only absence of cardiac lesion and signs of Basedow's disease, Idit spinal hyporsesthesia may be elicited. BAD HABITS. 805 Diagnosis, — Sensitiveness to pressure over the vertebral column is one of the most frequent stigmata of infantile hysteria (Steiner). Epigastric tenderness is less frequent than among adults. Hyper- sesthesia is less marked in childhood, than later in life, but is more common than ansesthesia. Jolly says that deep analgesia is rare. Of especial interest in its relation to diagnosis is the fact that ocular symptoms, such as diplopia, may be present morning and evening. Paralysis may appear and disappear. There are forms in which there may be tachycardia or bradycardia, but during excitement the rhythm of the heart may be normal. Cases have been described in which the headaches, ptosis, and facial palsies simulate the symptoms of tuberculous meningitis. Study alone will clear up such obscure cases. Duration and Course. — The symptoms of hysteria are not neces- sarily permanent, but are likely to recur after excitement or nervous strain of any kind. Treatment. — The treatment of hysteria in children is based on the same general principles as in the adult. The child is, if possible, removed from exciting surroundings. Studies are regulated and bad habits, such as masturbation, are, if possible, corrected. The effect of good food and outdoor life is marked. Hydrotherapy and m.assage achieve their greatest triumph in this affection. BAD HABITS. By the term bad habits are meant a number of so-called "tricks" in which neurotic children are apt to indulge. They are not neces- sarily an indication of any serious nervous functional derangement. It is difficult to say from a purely clinical standpoint whether such bad habits lead to any serious results. They are in most cases easily controlled either by close attention to the cause or by a complete change in the surroundings of the patients. Pica or Dirt-eating. — Thomson has interested himself in the study of this peculiar condition in children. It is an exaggeration of the normal habit seen in young infants who invariably place- every- thing within reach in their mouths. As the infant develops, its sense of good and bad taste teaches that certain substances are un- wholesome, others not. In children who suffer from pica or dirt- eating this sense of what is wholesome is lacking. There is an unex- plainable yearning after queer articles of diet, such as sand, dirt, gravel, cinders, plaster from walls, or paper. Some of these chil- dren are normal in other ways, others are the victims of so-called cachectic conditions. If the habit has been indulged in for any length of time the children become cachectic. In fact, many of 806 DISEASES OF THE NEFa'OUS SYSTEM. these children become the victims of intestinal parasites (hook-worm) and others develop a chronic inflammatory state of the stomach or intestine. J. Lewis Smith published a case in which a hair-ball was found in the stomach of such a dirt-eating child. Treatment. — The treatment is one of vigilance on part of the nurse or guardian in preventing the indulgence of this abnormal appetite. A change of scene sometimes causes the patient to forget his habit. If cachexia exists, the faeces should be examined for the ova of parasites which may have infested the intestine as a result of dirt-eating. Puddling in Water or Biting the Finger-nails. — These are among other habits of extremely neurotic infants and children. Thumb Sucking. — Much attention has been directed to thumb sucking by recent writers. Lindner, who has analyzed these cases, divides them into two classes, those of pure thumb sucking and those in which there is combined with this another habit, " combination cases." In the latter the other hand is brought into use while the thumb is in requisition, either to hide it or to perform some other act, such as nose-boring or rubbing of the genitals. The simplest form of thumb sucking is seen in young infants, generally in atrophic infants. I have seen it in an atrophic infant of six weeks. In such cases the act can scarcely be classed in the same category as when seen in older children. In the former case it is the result at first of an instinctive need of the infant, probably a result of starvation. In older children it may be looked upon as an act of mental weak- ness; in fact, in boys and girls who practice these acts there is a tendency to mental obtuseness. The act seems to be accompanied by very little intent in most children, for when the attention is fas- tened on some other object the habit is quickly forgotten. In other children there is a distinctly surreptitious practice of the habits of combination thumb sucking and nose-boring or genital interference. The outlook in most cases is good and no ill effects result. In cases where the children are mentally backward the habit is but a symp- tom of general degeneracy. The inculcation of correct bearing and cleanliness by the nurse are in normal children enough to put a stop to the habit. Where the habit is the result of mental imbecility nothing can be done to break the habit except in a general educational way as a part of the treatment of the mental defect. Head-hanging, Swajdng, Head-nodding, and Rolling the Head from Side to Side. — These have all been observed in mental defectives of various grades. The patients are young children. The habit offiirs during waking and in most cases, if the children are defective BAB HABITS. 807 normally, seems to be practiced in an automatic manner without pur- pose. In children who are otherwise normal the habit is not difficult to break. Some of the minor habits, such as bodj-swaying, head- hanging are sometimes seen in children who are subject to violent outbursts of temper. Such children, as one of my own cases, are not only mentally defective but moral perverts. Masturbation. — Masturbation has received great attention in this country since first brought to the notice of the profession by Jacobi. Much is described as masturbation which is only a simulation of the habit as seen in older children above or near the age of ten years. Infants and very young children are sometimes affected with the habit of so-called thigh rubbing or buttocks rubbing. In them the sexual instinct can hardly be said to exist, though many of these infants present symptoms in the act of thigh rubbing which closely simulate an orgasm. It is probably far from such. Rachford has recently fully studied thigh rubbing. He calls it " pseudo-mastur- bation." Most cases are seen in young infants ; the infant will rub the thighs together for a time and this will be accompanied, not by manifestations of pleasure, but rather of great nervous perturbation. The series of acts terminates in an apparent nervous exhaustion and the mothers will say the child seems as if limp and may fall asleep after the act. Most of the patients are female infants below the age of eighteen months, some as young as six months. Another form of pseudo-masturbation is seen in infants who as soon as they are laid prone on their backs will start to rub the but- tocks vigorously on the couch. The motion is a side-to-side one and in this form of rubbing the infant may laugh and evince no nervous strain. In both forms of this affection there is found on close exam- ination some irritation at the introitus vaginae, or on the buttocks, or between the thighs to keep up this genital irritation. Rachford places great stress upon acidity of the urine as a causative factor in this irritation. I think most of these children are the victims of some oversight in the nursing, or of lack of cleanliness ; in male in- fants the prepuce is not scrupulously cleansed daily. I do not think these cases ever lead to any serious after effects, such as epilepsy, nor do I believe that adhesions either of the clitoris or prepuce are causa- tive in these cases. The operative treatment, either in loosening adhesions or freeing the clitoris, seems to me unwarranted, as in my hands close attention to the remedying of local conditions of irritation have effected cures without the use of any special apparatus. Masturbation, as it is seen in older children, is an entirely dif- ferent affection from that just described. Here the sexual instinct has either prematurely developed or above ten years of age it is 808 DISEASES OF IRE XEEVOUS SYSTEM. actually present. We then have true masturbation. Masturbation is an exceedingly prevalent habit among children of all classes. There is a tendency to interfere with the genitals common to both sexes. Only the flagrant cases come under the notice of the physi- cian. The children may be bright, others are not so bright, but all are highly neurotic and come of neurotic stock. Most serious are the cases in which the habit is practiced in secret. Here we have evident interference with the mental peace of the patient. Other cases are seen in children who are quite inno- cent of any immoral intent. Such was a case of mine in which a child with high moral standards contracted the habit from irri- tation of the vulva as a result of horseback riding. A cessation of the horseback riding and local treatment with moral suasion was enough to cure the habit. In boys the problem of curing becomes very difficult. The only way seems to me to be educational explana- tion and a stimulation of the mind to moral cleanliness. Any use of mechanical apparatus is certainly degrading to sensitive children and leads to no good results. In those cases in which the habit is the result of a general mental defectiveness the treatment and manage- ment of the masturbation becomes one of the features of the general management of these cases. TETANY. {Tetanilla; Arthrogryposis.) Tetany is an intermittent or persistent, more or less painful tonic spasm of groups of muscles of the upper and lower extremities. Forms and Frequency. — Haviland in 1813 and Clark in 1815 de- scribed this disease in children. Trousseau, Baginsky, Chvostek. Erb, and Escherich have completed its symptomatology. It is most frequent from the third month to the end of the second year of life. Griffith found that 68 per cent, of the cases occurred before the second year of childhood. The greatest number of cases occur in the eighth month of infancy (Escherich). As to age, the forms are the infantile, the tetany of early and late childhood and adult tetany. including the surgical variety. As to duration, we have the forms in which the contractures are intermittent, coming on at intervals, the patients being free from muscular spasm in the intervals. The second form, now accepted by the majority of writers as the same affection as the former, is that in which the contractures are persistent. Etiology. — The etiology of this affection is still very obscure. It occurs most frequently in the winter and early spring. In my expe- rience in an ambulatory clinic, it was customary to see these cases appear in groups in the early spring months. The affection is seen TETANY. 809 under the most diverse conditions. Fully 63 per cent, of the cases are rachitic (Fischl). The percentage of rachitis must, of course, vary in different countries, but the cases coming under my notice have been chiefly of that character. The condition is not, as is fre- quently supposed, a rare one. I have regularly seen a number of these cases yearly. Many cases of tetany are not recogTiized as such by the physician. Cold, entozoa, infections of the gut, chronic intestinal disturbances of all kinds, rachitis, an enlarged thymus (Escherich), have all in turn been regarded as etiological factors. On the other hand, some attribute the affection to a toxaemia prob- ably originating in the gut and expending itself on the peripheral motor nerves. Fully 73 per cent, of Fischl's cases had shov^^n intes- tinal disturbances. The fact that the condition occurs in early infancy and in some respects resembles a normal state, to be de- scribed later, v^ill account for its being frequently overlooked by the physician. The symptoms of tetany are traced by Stoltzner and Cybulski to a deficiency of retained calcium salts in the body. Under a covr's milk diet only half of the calcium is retained as compared to a breast-milk diet. This is not generally accepted. Escherich and Erdheim recently proved that in tetany there is a species of para- thyroid priva, a deficiency in the function of these glands. He has found lesions in the parathyroids of infants dying of tetany. Such lesions may interfere with the function of the parathyroid under exciting causes of malnutrition or infectious diseases. With this there is an unequal distribution of calcium salts in the body (Leo- pold), and from this tetany may result. Morbid Anatomy.— ISTo definite account of the changes in the nervous system or elsewhere has as yet been given. Langhans has described a peri-arteritis and phlebitis in the white commissure and cervical portion of the cord. Gowers, without any positive data, assumes that there are some changes in the motor cells of the cord which cause the increased irritability of the peripheral motor nerves. Fischl in a recent article has published the postmortem changes in his fatal cases. He makes, however, no comment on them. He found hydrocephalus interna and externa, oedema of the brain and meninges, tuberculosis of the brain, hemorrhagic infiltration of the cerebellum and meninges, chronic intestinal catarrh, and broncho- pneumonia. The affection occurs under the most diverse conditions. The investigations of Erdheim on rats and of Escherich in the human have revealed hemorrhages and epithelial lesions in the para- thyroid bodies or epithelial bodies. In one of my cases of tetany such hemorrhages were substantiated. 810 DISEASES OF THE NEEVOUS SYSTEM. Symptoms. — The symptoms consist of muscular contractures and phenomena connected with the peripheral motor nerves, which are known as Trousseau's phenomenon, Chvostek's facial symptom, and Erb's signs of increased electrical excitability of nerve and muscle. Muscular Contractures. — These come on without any premoni- tory symptoms. The infant or child may have been in good health, or may have been suffering from intestinal disturbance. There are two distinct forms of contracture in infants, in one of which the Fig. 182. Tetany. Extension of the fingers, flexion of the arms, flexion of the toes. Facies. Child, eighteen months of age. hands and arms take the position assumed in driving horses (Plate XXXVI.). The arms are pressed against the thorax, the forearms flexed on the arms, and the fingers tightly flexed over the thumb into the palm of the hand. The hand itself is strongly flexed on the forearm. The lower extremities may be adducted toward the me- dian line, the thighs flexed on the abdomen, and the legs on the thighs. .The feet are as a rule extended in the equinus position and the toes overflexed on the plantar aspect of the foot, the whole foot PLATE XXXVl Tetany. Infant iiine months of age. Shows the driving position of the fingers, hands, and arms, overextension of the feet and flexion of the toes. TETANY. 811 being slightly curved inward. After the contractures have lasted some time, there is oedema of the tissues over the dorsum of the foot. In the second set of cases the fingers are overextended, as shov^^n in Fig. 182. The arms and lower extremities also take the position of flexion. These contractures are painful ; the patient cries as if in great pain when an attempt is made to straighten the fingers or extremities. There may be a temperature of two or three degrees. The contractures may diminish, and there may be an interval in which the only symptoms are such as may be attributed to the increased mechanical and electrical irritability of the peripheral nerves. There may also be eclampsia. The eclamptic attacks are very dangerous. I have lost 2 cases in such seizures. Other muscles, such as the" abdominal or thoracic, may be the seat of contracture. In the latter case there may be cyanosis. I have seen cases in which all the muscles of the body were involved very-much as in tetanic conditions. In one case there were stiffness of the muscles of the neck and loss of consciousness. Tris- mus is rare, and certainly does not occur at the outset, as in tetanus. The muscles of the face may be subject to contracture. The brow is wrinkled, and the face has an anxious expression. If the muscles over the zygoma are tapped, thei*e is an instantaneous contracture or spasm of the orbicularis palpebrarum. In some cases, if the muscles of the face or the forehead are tapped, there is an instanta- neous contracture of the muscles of the face, and sometimes of other muscles of the body. This is called the facial phenomenon of Chvostek. If the nerves and arteries at the bend of the elbow are compressed, the characteristic tetany position is produced in the muscles of the hand and fingers. This phenomenon was first noticed by Trousseau, and bears his name. Erb established the fact that there is increased irritability of nerve and muscle to the faradic and galvanic current. If the muscles or nerves elsewhere in the body are tapped, or if pressure is brought to bear at the point of exit of the nerve-trunks, there is an excessive irritability to this mechanical stimulus. The knee reflex is increased. Escherich and V. Pirquet have recently shown that there is in tetany an increased electrical excitability of nerve to low stimuli. With a current of four milli amperes there is muscular contraction on kathodal opening and closure as well as anodal opening and closure. Duration. — The disease may last a few hours, days, or weeks. In many cases the contractures disappear for a time, leaving the patient perfectly free from symptoms. They may return in all their orig- inal severity. The attacks leave the peripheral nerves in a condition of increased excitability. In such cases both the Chvostek and Trousseau phenomena may be present. 812 DISEASES OF THE NERVOUS SYSTEM. Diagnosis. — The diagnosis of fully developed tetany is based on the presence of mnseular contractures, of increased electrical and mechanical irritability of the peripheral nerves (as evinced in Chvo- stek's symptom) and the presence of Trousseau's phenomenon. There are cases of tetany in which the facial symptoms are lacking. On the other hand, I have, in cases in which there was laryngospasm with- out contractures, obtained both the facial and Trousseau phenomena. The Relationship of Laryngospasm to Tetany. — Escherich, his pupil Loos, and also Ganghofner, have recently called attention to the fact that laryngospasm is present in a certain number of cases of tetany. They also found that cases of laryngospasm which did not present contractures, did show the facial phenomenon of Chvostek and the Trousseau symptom. They concluded that laryngospasm was a manifestation of tetany, whether the muscle contractures were present in the extremities or not. Their observations have been amply confirmed, but not all observers are as yet willing to accept laryngospasm without contractures of the muscles of the extremities as true tetany. The views of Kassowitz and Hochsinger are at variance with those of Escherich. They consider rachitis the fun- damental cause of laryngospasm, if not of tetany. Latent Tetany.- — -The term latent tetany has been applied to those cases which show no muscular contractures or laryngospasm, but in which the facial Trousseau or Erb phenomenon may be elicited, or in which the mechanical, and especially the electrical, contractibility of muscle and nerve are increased. Accidental Symptomatic Form of Infantile Tetany.- — There are forms of tetany which occur in a symptomatic way in combination with other diseases; such are called the accidental tetanies. They occur mostly beyond the third year of life and in children who as a rule have suffered from convulsions and laryngismus, and in whom the symptoms of tetany reappear in concurrence with some acute disease, such as pneumonia. In these children we have the facial phenomenon, typical elec- trical reactions, and the tetanic contractions of the hands and lower extremities. Such a recurrence has been observed by Finckelstein in grippe, influenza, whooping cough, acute gastro-enteritis, etc. These cases have been more or less confused with those of meningitis. Persistent Form of Infantile Tetany. — This is characterized by its long duration. The muscular contraction is not so marked and tetanic as in the acute cases, but manifests itself rather in in- creased contractions of all the muscles of the affected part of the body, a hypotonia of the muscles, and difficulty and slowing of the volun- tary motion. The muscles are hard, contracted and in severe cases rather prominent. The contractures are mostly bilateral and affect TETANY. 813 by preference the distal end of the extremities. Thus we have manifested the " accoucheur " position of the hands, supination and flexion of the feet which occurs in the typical tetany conditions. In some cases there is the picture of simple hypotonia existing during rest or sleep. The active muscular motion is slow and per- formed with difficulty, as if overcoming some resistance. In some a high degree of muscular tension is ^^resent, voluntary motion is entirely impossible and we have the picture of a spastic contracture which affects the muscles of the trunk and face, causing neck rigidity and opisthotonos. These cases may very closely resemble the so- called " womb " tetany and they have been called pseudo-tetanies. Especially interesting are cases in which there is only contraction of muscles of one side of the body, or contraction of a particular group of muscles. There have been no postmortems in these cases, and the question as to whether these cases are those of true tetany is still in doubt. Escherich insists that inasmuch as the pathognomonic electrical reactions are present in these cases, they should be classed as tetany. In addition we have the Erb, Chvostek, and the Trousseau phe- nomenon, extending over a long period of time. Late Tetany: Tetany of Later Childhood: Puerile Tetany. — By puerile tetany we mean that occurring after the third year of life. These cases are distinctly separated from those of infantile tetany, and in them the main symptoms of the clinical picture of infantile tetany, such as laryngospasm and convulsive attacks, are relegated to the background. On the other hand, muscular spasm, especially the typical carpo-pedal spasm accompanied by pain and hyperes- thesia, is quite marked. On this account, the shorter duration and the better prognosis of the disease is explained. In this respect puerile tetany resembles very closely the tetany of adults. Prognosis and Mortality. — The prognosis in the sporadic cases is very good. The gravest cases are those, in which convulsions and laryngospasm are combined with symptoms of tetany. Parents should be cautioned in regard to the excitability of the patient and the possibility of eclampsia, with its fatal consequences. I have lost 4 cases in convulsions. The persistent cases may be complicated with other affections, such as tuberculous meningitis. If such is the case, the outcome is, as in the primary disease, fatal. Epidemics in hospitals for children present unfavorable features ; Escherich lost 37 per cent, of his cases. Treatment. — The bowels should first be evacuated. Calomel is given in grain -| (0.03) doses two or three times daily. If there is any disturbance of the gut, the patient -is given a high enema once a day. Milk is suspended until the movements take on a more favor- 814 DISEASES OF TEE XEErOUS SYSTEM. able appearance. The infant is kept nnder the influence of the mixed bromides of potassium, sodium, and ammonia. If there is eclampsia or increased irritability, a warm bath is given at least once a day. The patient is kept quiet and not disturbed much. No attempt to straighten the limbs should be made, since it causes pain. Fig. 183. Cataleptic state produced in a child following typhoid fever. In view of the fact that cases of surgical tetany are improved by calcium lactate, this drug has been recommended iii infantile tetan}-. Five grains are given internally three times daily. Feeding is of first importance and breast-milk is the most desirable food. CATALEPSY. Epstein has described a condition in children closely resembling a similar affection in the adult. He has described it as catalepsy occurring in infants poorly nourished and rachitic. The ages of his cases ranged from eighteen months to three and one-half years. Epstein believes there is a disturbance of the psychomotor functions. The phenomenon was observed by him chiefly in the lower extremi- ties. Either extremity on being lifted into the air would stay there for a length of time in any position of flexion or extension in which it was placed. This phenomenon was not present during sleep, nor CONGENITAL STBIDOE OF INFANTS. 815 was it accompanied bj any muscular rigidity or increase of mechan- ical or electrical irritability of the perijDheral nerves. I have met a marked case of catalepsy follov^^ing an attack of typhoid fever in a child of four years. The hands, arms, and lov^er extremities would remain for long periods of time in the position in which they were placed. The patient would sit for long periods staring ahead, with- out winking the eyes (Fig. 183). MYOTONIA. Myotonia physiologica neonatorum is a term applied by Hoch- singer to the normal tendency of the newly born infant to ilex the fingers, arms, and lower extremities. There is a slight rigidity which is a hypertonicity of the muscle, and which lasts until the third month. The position closely resembles that of the extremities of the foetus in utero. The myotonia is exaggerated if the infant becomes ill with any intercurrent affection, such as syphilis. The condition cannot be mistaken for tetany if the differences between the normal and the abnormal states of the peripheral nerves are borne in mind. CONGENITAL STRIDOR OF INFANTS. (Thomson.) This rare condition has for a long time been classified by writers as a mild form of laryngismus stridulus. I have seen one case in which there was also laryngismus. The affection is a distinct one, is generally congenital, and appears soon after birth. Some years ago, I presented a case of the kind before the Pediatric Section of the Academy of Medicine of ISTew York. Since then I have seen a number of cases. Thomson has fully described and studied the affec- tion. Thie infant is usually in other respects normal, but I have seen the condition in infants with signs of rachitis. The ages of the patients varied from nine weeks to twelve months. In one case there was a history of attacks of laryngismus stridulus, occurring shortly after birth. In most of the cases, the symptoms were noticed soon after birth. The respiration is more or less noisy, being sometimes scarcely audible and at other times so loud as to be heard at some distance. Inspiration is accompanied by a peculiar croaking, grunt- ing noise. As a rule, expiration is noiseless, but it may be accompanied by a grunting sound, there being short intervals in which no sound is heard. The infants are not at all disturbed by the condition. They sit and play, emitting this peculiar croak while breathing. In mild cases, nothing is seen in the thorax. I have, however, seen the draw- 816 DISEASES OF THE NERVOUS SYSTEM. Fig. 184. ing inward of the suprasternal region which Thomson describes. In one case the noise was louder at night. If the stethoscope is held over the situation of the vocal cords, it will be ascertained that the sound is produced in the larynx and not in the pharynx. The causation is obscure; the theory advanced by Thomson is that there is an ill-coordinated spasmodic action of the muscles of respiration, choreiform in character and similar to that present in stammering. This influence, acting on the epiglottis from birth, causes a deformity of the organ, which in turn perpetuates the crow- ing noise. Others have attributed this condition to the presence of an enlarged thymus (Variot). Some of these infants are distinctly lymphatic, and Hochsinger has lately with a;-ray demonstrated what he believes to be an enlarged thymus in many of the cases of laryngeal stridor coming under his notice. He believes the condition due to an enlarged thymus, and suggests that the term "Asthma thymicum" be ap- plied to these cases. Lee and Refslund have published two cases with autopsy in which laryngeal stridor existed from birth and in which there was an anatom- ical malformation of the epiglottis. This consisted in a folding of the epi- glottis laterally, so that the aryepiglottic folds were almost in contact. The supe- rior opening of the larynx was thus cov- ered by the deformed epiglottis in such a way that respiration took place through a mere slit of epiglottis, hence the grunt- ing or sawing noise. I have recently published a case of laryngeal stridor dying of intercurrent pneumonia (Fig. 184). This case showed the same mal- formation of the epiglottis described by Lee and Refslund, and would support the theory of anatomical deformity as a causative factor in these cases. Toward the second year of life the condition gradually disappears spontaneously. Larynx from author's case of laryngeal stridor. Patient 13 months of age. LARYNGISMUS STRIDULUS. (Spasm of the Glottis.) Laryngismus stridulus is a spasmodic functional nervous disorder of the glottis, involving the muscles of inspiration and expiration. Occurrence. — The affection is more frequent in boys than in girls. It is most common in the first year of life. The majority of the LARYNGISMUS STRIDULUS. 817 cases occur before the end of the second year. Kassowitz found 348 of 370 cases to occur before that time. It may occur in the newly born infant (Henoch, Kassowitz). Most of the infants and children affected by this disorder are subjects of rachitis and also show signs of craniotabes. Henoch estimates the frequency of rachitis at 75 per cent. Only one of the cases of Kassowitz did not show its signs. All but 48 showed craniotabes. On the other hand, Boral shows that 4 per cent, of all children with rachitis have laryn- gismus stridulus. Etiology. — The etiology of this affection is obscure. Although rachitis is so frequent an accompaniment of the disorder, it may not yet be assumed that it is the exciting cause. Craniotabes, which is a part of the symptom-complex, has been regarded as the cause (Elsasser). Escherich, Loos, Gee, and Ganghofner have placed laryngismus stridulus in the same category as tetany, and trace it to the same exciting cause. Keflex irritation from the stomach acting through the vagus is the theory of Baginsky. In many cases which have terminated fatally an enlarged thymus has been found. On the other hand, there have been postmortems which showed a rather small thymus and slightly enlarged bronchial nodes (Baginsky). Morbid Anatomy. — i^o definite study has been made of the changes found in the fatal cases. Most cases show oedema of the brain and some fluid in the ventricles, rachitis slight or pronounced, the thymus small or enlarged, and the lymph-nodes slightly enlarged. The cases with enlarged thymus thus far published have not been convincing. Children with enlarged thymus die of other disorders, and without having had during life any symptoms of spasm of the glottis. Symptomatology. — The spasm or paroxysm comes on suddenly. Without the least warning, the child throws the head back and stops breathing; the face becomes livid, the arms are flexed and the hands clenched.' jSTo respiratory movement takes place for a few seconds. There is then a long-drawn whistling or crowing inspiratory sound. This is the classical form of spasm of the larynx. The paroxysm may begin with a piping, inspiratory sound. Apnoea lasting for a varying length of time succeeds, and is followed by a loud or silent expiration. Apncea may a^^pear first, and be followed by several noisy explosive expiratory movements, which may be succeeded by several noisy crowing inspiratory sounds. The picture is usually that of spasm of the glottis as first described, in which the breathing stops entirely. The attack may come on during absolute quiet or during sleep, the onset of the attack causing the child to wake. The paroxysms may be brought on by excitement, a draught of air, or by pressure on the larynx. They are of all degrees of severity. 52 818 DISEASES OF THE NERVOUS SYSTEM. Some infants show a form which is very disquieting. In a fit of crying the child takes a number of noisy inspirations and expira- tions, and then stops breathing, becomes cyanosed, clenches the hands, and threatens to pass into an eclamptic paroxysm (expiratory apnoea), when suddenly a deep inspiration occurs and the danger is passed. Some cases of the classical form have eclamptic seizures. There may be convulsions, especially in the form described as expiratory apnoea. One of my cases was that of an infant a year old, one of twins. The infant was anaemic, and showed marked signs of rachitis and craniotabes. It was in apparent health until the eighth month of infancy, when attacks of respiratory apnoea appeared at first at inter- vals of three weeks, and finally daily. The infant during a crying- siDell would -stop breathing, become cyanosed, the left hand and arm and lower extremity and muscles of the face contracted in tonic spasm, during which the heart became very slow in action and irreg- ular. The left-sided sjDasm lasted for a few seconds, and then the infant relaxed and quietly passed into a sleep, from which it awoke in a few moments. In all of these cases there is the ever-present danger that the glottis and the muscles of respiration, including the diaphragm, will fail to relax, thus causing death with convulsions. The number of attacks of spasms of the glottis may reach twenty or thirty a day, or they may be very infrequent, occurring only once every few days, weeks or months. In all the forms, including the classical one just detailed, the spasm involves not only the glottis, but also the diaphragm and other muscles of respiration. The in- fants may show no symptoms after the paroxysms. On the other hand, some infants seem to be overcome and pass into a stupid state lasting for fully ten minutes. It is difficult to estimate the degree of consciousness during an attack, but even in the mildest forms there may be a momentary loss of consciousness (Henoch). Most cases show the facial and Trousseau symptoms of tetany and in- creased irritability of the peripheral nerves. Prognosis. — The prognosis of spasm of the glottis is good. The danger lies in the eclampsia, during which death may supervene. Diagnosis. — The diagnosis is not difficult. There are all degrees of severity of the spasm, ranging from partial to complete closure of the glottis. In the latter form a rachitic infant in a paroxysm of crying is frequently heard to give several inspiratory crowing sounds without having any further symptoms. There is a species of laryn- geal inco-ordination. Those cases may at intervals develop typical paroxysms. The parents should be warned of this possibility. The forms of spasm of the glottis which have just been described should not be confused with spasm or difficult breathing due to pressure of a retropharyngeal abscess or suppurating gland upon the larynx. EPILEPSY. 819 Complications. — Pertussis may complicate a case of spasm of the glottis. Cases thus complicated give a grave prognosis (Henoch). Tetany has been elsewhere mentioned as an accompanying condition. Treatment. — During the Attach. — The infant is carried to an open window. A draught of air is allowed to blow in its face or a few drops of water are throwm in the face. This is done to excite a reflex relaxation of the glottis. The head should be held low, as in ordi- nary eclampsia. If relaxation of the glottis does not occur and con- vulsions set in, a few drops of chloroform may cause the muscles of respiration and those of the glottis to relax. Intubation and trache- otomy have been performed at this crisis, when the breathing threat- ened to cease permanently. If, however, as sometimes happens, the muscles of respiration are also involved, the paroxysm will occur with the tracheotomy tube in the trachea. Stork has published a case in which the insertion of a tracheotomy tube had not the least influence on the paroxysms. This is a very important observation, and raises the question of the propriety of intubating or performing tracheotomy. On the other hand, cases have been intubated and resuscitated with artificial respiration (Pott). In the Intervals. — In the intervals, the treatment should be chiefly directed toward the rachitis. The feeding should be carefully attended to; the infants should, if possible, be breast-fed. Bottle-fed infants should be fed on raw milk, beef-juice, orange-juice, cereals, and eggs. The medicinal treatment which in my hands has given the best results has been the administration of an albuminate, or pep- tonate of iron or manganese in full doses. To prevent the recur- rence of the laryngismus or apnoeic attacks, full doses of the mixed bromides are given. To an infant one year of age as much as 5 grains of the mixed bromides of sodium, potassium, and ammonium are given three times daily, and continued over some period of time. Under this medicinal treatment I have been able to control apnoeic attacks. In my hands the administration of phosphorus has not been attended with any success. Bathing in cold water has not in my esiperience been productive of good results. EPILEPSY. Epilepsy is not a disease peculiar to infancy and childhood. It is discussed here simply to emphasize the peculiarities of the affection as they occur in children. It is a true disease of the nervous system, and has nothing in common with and no demonstrable relationship to infantile convulsions. Fifteen per cent, of the cases of epilepsy occur before the fifth year of life. Henoch has seen a case in an infant one year of age who had convulsions beginning with a cry 820 DISEASES OF THE NERVOUS SYSTEM. and during which the infant bit the tongue. He describes another case in a child three years of age, in which the attack began with vertigo. In another case, in a child three years of age, the patient fixed a point and ran blindly toward it. The latter appears to have been a case of "procursive epilepsy." Etiology. — According to Gowers, in two-thirds of the cases of epilepsy in children the parents are neurotic and hysterical. Chorea in the mother will often manifest itself in epilepsy in the child. Infantile palsy or traumatism is more frequently than heredity the cause of epilepsy. Epilepsy following slight palsy is likely to be mistaken for hereditary epilepsy. Symptoms. — In children, as in the adult, there are no symptoms in the intervals between the attacks. Onlj^ such results of attacks as a bitten tongue or local traumatism are seen. There are, as in the adult, two distinct forms of epilepsy — grand and petit mal — between which there may be all variations participating in the peculiarities of both forms. In grand mal there is the aura, sensory or psychic ; it is present in a large percentage of the cases in children. Aura. — Baginsky calls attention to a case in which epigastric pain was the aura preceding the attack. The other forms of aura are numbness and tingling of the extremities, general restlessness and irritability and auditory phenomena in which a peculiar cry of an animal is perceived. There may be a hissing sound. An aura referred to the sense of taste is very rare, and most neurologists do not make note of having found it in any case. In children the perception of peculiar odors just prior to the attack occurs as a form of aura. After the aura, the attack begins with a cry followed by sudden loss of consciousness and tonic or clonic spasm of the muscles, which may be unilateral, general, or partial. The pupils dilate; there is spasm of the respiratory muscles and those of the jaw, as well as foaming at the mouth and biting of the tongue. The spasm then relaxes, the movements become first clonic and then intermittent, there is involuntary passage of urine and faeces, and consciousness gradually returns, the patient passing into prolonged stupor and pro- found sleep. Some of these symptoms may be absent, but the loss of consciousness, dilated pupils, spasm, and the succeeding profound sleep are constant. In the majority of cases, the presence of any two of these will be sufficient for a diagnosis. Convulsions. — General convulsions indicate hereditary epilepsy. Convulsions may at first be partial, but in the majority of cases eventually become general. Partial convulsions indicate disease in the motor areas. The attacks taking the form of petit mal may be so slight as to be mistaken for fainting spells. Such attacks may FAVOB NOCTUENUS. ■ 821 occur in young children. One of mj cases was in a child of five years of age. An epileptic spell is momentary ; a fainting spell is gradual, there are no vasomotor disturbances, and the pupils do not dilate. Henoch and others record cases in which the children momentarily stop the occupation in hand, stare into vacancy, and then recover them- selves without having any recollection of the interruption. In other cases there is an irritable attack or mild maniacal outbreak. In some eases the child passes into a state of mental confusion in which it per- forms acts unconsciously. Attacks of double consciousness or nar- colepsis are rare in children (Sachs). Temperature. — Attacks of grand mal are sometimes associated with a rise of temperature. A case recently came under my observa- tion in which a girl of eight had as many as forty convulsive seizures in twenty-four hours. There was a slight rise of temperature which could not be traced to any cause other than the convulsions. Thom- son and Oppenheim have shown that there are a concentric limitation of vision and a diminution of general sensibility for some time after the epileptic attack. Diagnosis. — E23ilei3sy must be differentiated from syncope, hysteria, post-hemiplegic convulsions, and tumor of the cerebrum. The pecu- liarities of an attack of syncope and hysteria have been dilated upon. The post-hemiplegic convulsions will, in the intervals, reveal the paralyses and contractures with increase of deep reflexes. Attacks of convulsions caused by tumor are confined to groups of muscles if the tumor is in the motor area, and are combined with optic neuritis if the chiasm is directly or indirectly the seat of pressure. With tumor, there are in the intervals peculiarities of the gait and epileptic attacks. Treatment. — The treatment of epilepsy is essentially the same in children as in the adult subject. PAYOR NOCTURNUS. (Night-terrors.) There are two forms of this affection — the primary or idiopathic and the symptomatic form. In both, the children retire to sleep and after an hour or two suddenly awaken from deep slumber with a shriek or cry. They are pale, greatly terrified, and grasp at the empty air. In incoherent, broken phrases they try to collect their thoughts. Some children see terrifying visions and either cling to the bystander for protection or try to get out of bed to escape an imaginary danger. After being quieted the children fall asleep, and when questioned the next morning have no distinct recollection of what has occurred. These attacks may occur every night for days. 822 DISEASES OF THE XEBrOUS SYSTEM. weeks, or months. They rarely occur twice in the course of the same night. The idiopathic form of this affection may occur in children who are naturally of a nervous temperament without any apparent excit- ing cause. I have seen it in children who were distinctly the oppo- site of nervous, and who were well nourished and good natured. The night-terrors may follow epilepsy or they may be so severe as to be the exciting element in precipitating an attack of chorea. Chil- dren sometimes have real hallucinations, which may be present even during the day (Henoch). It may, however, be said that halluci- nations during the day are really not included in the idiopathic form. This affection occurs chiefly up to the time of second dentition. Forms of terror in older children are hysterical. Adenoids are sup- posed to be an etiological factor, but this is doubtful. It is only in the symptomatic form that children, after having committed some error in diet, awake with the symptoms above described. Prognosis. — The prognosis is good. The affection never jDrecedes insanity. It subsides under treatment or disappears spontaneously. Treatment. — In the symptomatic form, the meals should be so arranged that the lightest repast is that taken in the evening. In the idiopathic form, bromide of potassium is most useful. It is admin- istered in one dose, an hour before retiring. The children should not be too active mentally during the daytime. Visitors should be restricted to certain hours. Play and sport in the open air are indi- cated. The school tasks of older children should be completed in the afternoon. CHOREA. (St. Vitus' Dance; Sydenham's Chorea.) Chorea is a nervous disease characterized by irregular involuntary movements or twitchings of some or all of the muscles of the body. It is accompanied by muscular weakness and mental disturbances. In some cases there is endocarditis. Classification. — Chorea minor is an acute disease described by Sydenham. Chorea major is a hysterical disorder; under this head- ing are included the chorea clectrica, and the dancing mania with rhythmical motions, of the Middle Ages. Chorea insaniens is the fatal form of acute chorea minor. Laryngeal chorea is a hysterical affection (Gowers). Choreiform affections or pseudochoreas comprise the cases of tic convulsif of French writers and other forms of habit-spasm, local or general. In addition tlierc are form> of chorea which are symptomatic CHOBEA. 823 or secondary to infantile palsies. Hnntington's chorea is a chronic progressive affection of a hereditary nature. All these forms of chorea except chorea minor and insaniens should be excluded from the category of Sydenham's chorea. The epidemics of so-called chorea, occurring in schools, are prob- ably hysterical disorders which are the result of imitation and not true Sydenham's chorea. Frequency and Etiology.' — Chorea is more common among female than male children. Of 554 cases collected by Osier, YO per cent, were of the female sex. It rarely occurs before the fourth year. Starr's statistics of 1400 cases show 8 at the third year. Cases are recorded as occurring in newly born infants, but are not accepted by all authors as authentic. The disease is most common from the fifth to the fifteenth year. Fifty per cent, of Starr's 1400 cases occurred before the tenth year, and 75 per cent, from the fifth to the fifteenth year. Of 83 cases of chorea occurring in my ambulatory and hos- pital service, 23 were of the male and 60 of the female sex. Ten children were under the age of five years, and 67 cases occurred from the fifth to the tenth year. Thus, the greatest frequency is at the latter period. Only one case occurred in a very young child (two and one-half years). The disease is found in children in all walks of life. Children of a nervous, ambitious temperament with a hereditary neurotic history are more prone to contract this disorder than those of a more equable disposition. It is therefore more common in towns and large cities than in country districts. In some cases there is a history of fright or traumatism, either immediately preceding an attack or coincident with its onset. It is as yet impossible to say, however, whether there is any relation between chorea and these occurrences. They may have some influence in developing latent tendencies to the disease. An attack will often be initiated by a scolding or chastisement on the part of parents. The spring months show the greatest number of cases, the least number occurring in the late autumn. There also appears to be a correspondence in the preva- lence of cases of chorea and rheumatism at certain periods of the year (Osier, Lewis). The relation of a condition of lymphatism (adenoids or nasal catarrh (Jacobi)) to true Sydenham's chorea is not generally eccepted. Errors of refraction in the eyes also seem to be a predisposing cause of the outbreak of choreic attacks (de Schweinitz). These can scarcely be regarded as a direct cause of Sydenham's chorea, but acute articular rheumatism may be so considered. Rheumatism seems to run in families in which the children have chorea. Osier finds that 15 per cent, of his cases are of such families. 824 DISEASES OF THE NERVOVS SYSTEM. Of the subjects of chorea, fully 21 per cent, show a history of rheu- matism (Osier). These figures correspond more or less to the sta- tistics of Townseud, 21 per cent.; Starr, 21 per cent, in 1400 cases; and my own cases, 18 per cent. Crandall gives the highest frequency of rheumatism in cases of chorea (54 per cent.). In the majority of cases the rheumatism precedes the chorea (See). I have seen one ease of chorea preceding an attack of rheumatism in a child four years old. I believe that, with cases of rheumatism of the acute articular type, there should also be included those of articular pains without swelling of the joint. The forms of rheumatism with chorea giving the so-called subcutaneous fibrous rheumatic nodules are rare in this country (Osier). Chorea may complicate any acute infectious disease, such as scar- let fever, whooping-cough, measles, diphtheria, typhoid fever, and forms of sepsis. There are, however, no definite data of the exact relation, if there be such, between chorea and the infectious diseases. The theory that an attack of any of these diseases will cut short an attack of chorea is not borne out by clinical experience (Henoch). Morlsid Anatomy. — The pathology of chorea is still incomplete and can therefore be merely indicated. Hypersemia of the brain and cord were found by Pye-Smith and Ogle. Anaemia and prolifera- tion of connective tissue were recorded by Steiner. In the cases of Meynert there was hyaline degeneration of the nerve cells of the central ganglia. Flechsig mentions hyaline degeneration of the len- ticular nucleus. Dana studied some cases in which he found hyper- semia of the brain, and degenerative changes in the walls of the bloodvessels of the white substance, with perivascular exudation and accumulation of leucocytes. Jackson has advocated the embolic theory (endocardial). At present there is a great preponderance of evidence in favor of the infectious theory. Berkeley found staphylo- cocci in the blood in a fatal case of chorea. In another case, Naunyn found cladothrix in the meninges and endocardial vegetations. It is certain that just as rheumatism and endocarditis are infectious diseases, so chorea in many cases can only be understood on that theory. Cesaris-Demel has experimentally shown that the central nervous system is peculiarly susceptible to certain pathogenic micro- organisms and their toxins. The staphylococcus and its toxins when injected experimentally under the dura mater cause the formation of small foci of inflammation, and symptoms very similar to those of chorea. Symptoms. — Children will at the outset of this disorder exhibit mild symptoms of nervous irritability, will be cross, have outbreaks of peevishness and temper, will drop things, and be generally careless in their habits. There is sometimes a history of night-terrors or CHOEEA. 825 morose crying spells. There is likely to be loss of appetite ; headache is not uncommon, and there may be pains in the limbs or joints and general restlessness. The disease may begin in a certain set of muscles, or in the muscles of one-half the body and thence spread to the whole trunk. Of 301 cases of the statistics of Sachs, there was hemichorea or involvement of one set of muscles in 67. Of Starr's 1400 cases, 951 were general and 449 unilateral, the right side being affected more frequently than the left. When fully developed, the picture presented by these patients is so characteristic as to be easily recognized. On the other hand, the popular notion, so prevalent even among physicians, that every twitching is choreic, has led to grave errors. The following are the main symptoms : Motor. — The twitchings usually begin in the right hand, only rarely in the legs. After a time there are incessant, irregular, awk- ward twitchings of all the muscles of the body, which are intensified by volition. If the child is directed to stand still, with the feet together and the arms and hands held out at right angles to the body, the motions are intensified. If it is told to close the eyes, there is a distinct swaying of the body. The movements are not only irregular, but awkward. The patients trip in walking, upset their food and drink, and cannot button their clothing with ease. As a rule, the muscular twitching ceases in sleep, but it may persist. The mus- cular power is weakened, although distinct paralysis does not occur. The muscle is more paretic than paralytic. Some children let the arm hang at the side. There is wrist-drop when the children are asked to hold out the arms. The tongue is aifected in all cases. Sachs places much diagnostic value on the choreic movements of that organ. When children are asked to show the tongue, they will pro- trude the organ with a jerk, then withdraw it and twist it here and there in the cavity of the mouth. When the tongue is held out quietly, fibrillary twitchings in the organ may be detected. Elec- trical reaction or irritability of the muscles in chorea can be tested only when the disease is unilateral. In some cases there is no change. In others, according to Gowers, there is a distinct increase in the galvanic and faradic irritability of nerve and muscle. The muscles of the hands, face, and extremities are all involved in the twitchings of the voluntary muscles. The involuntary muscles, such as the car- diac muscle, are not affected. Their involvement has long been a matter of discussion. Disturbances of Sensation. — Disturbances of sensation are not common. Children have the arthritic pains, l^umbness, tingling, pricking, and anEesthesia of the pharynx are recorded. Attacks of multiple neuritis and epileptic seizures should be regarded as compli- cations. The reflexes are not markedly affected. They may in rare 826 DISEASES OF THE NERVOUS SYSTEM. cases be slightly diminished or increased (Henoch). Any marked change in the reflexes may be traced to changes of an organic nature, in the cord. The occurrence of headaches or eye-strain as concomi- tant conditions has been referred to. Urine. — The urine may contain albumin. Cases with nephritis as a complication have been reported (Thomas). Speech. — The speech is afl^ected in 25 per cent, of the cases. The patients hesitate and mumble their words or there is difiiculty of phonation due to inco-ordinate action of the larynx. Laryngeal chorea, in which there is a distinct sound resembling a bark, is seen in rare cases. It is classified by Gower as a hysterical disorder, truly choreic. I have never met a case of the kind in a child. Deglutition may be affected because of the muscular inco-ordination. Fig. 185, HOUR .3 6 9ii: 3|6i9|l-J 3 6 9 12 -1 6 9 12 3 6 9 12 3 8 9 12 3 6 9 12 3 6 9 12 3 b 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 j6 9 Il2 I ' 1 /I \ 1 M I'l 1 M^' - 00° ' ' 7 \ 1 1 1 ' 1 ' ' ' M ' ' M M M Hi^-L' Tv ' ' ' H I osS-^^=Pi'v^^^iF=i^ = s^^^^ — p- \ PULSE 8 J S V:' iS ? S? S e S S f.' S g S g RESP. is I: ! |£S! f, 1 1 S 2 S 1 S g| § S | | g *! g S Chorea. Recurrent attack of moderate severity. Systolic murmur over ttie aortic area. Fourteen days of the temperature is shown here. Child, twelve years of age. Cardiac Symptoms. — The cardiac symptoms are the most impor- tant clinical feature of chorea. There is very little doubt that in a fixed proportion of cases, rheumatism plays an important role and that the rheumatic poison, whatever it may be, expends its force upon the endocardium and pericardium. In 20 per cent, of the cases of Osier and in 12 per cent, of Starr's material, organic lesions of the heart were found. The frequency of cardiac disease in chorea varies as given in hospital and ambulatory statistics. The severer cases come to the hospitals. The majority of the ambulatory cases are mild. Thus 39 per cent, of my hospital cases showed a cardiac lesion (endocarditis), while only 1-3 per cent, of the ambulatory cases were similarly affected. There. would thus be an average of 2G per cent, of both hospital and ambulatory cases. The lesions in simple chorea referable to the endocardium usnally affect the mitral valve. Of 17 valvular lesions, 14 occurred at the mitral valve (systolic). The aortic valve was affected in 3 cases (Fig. 185). Pericarditis occurred in one of my cases. In the majority of cases in which there was endocarditis either the patient or the parents gave a rheumatic history. CHOBEA. 827 On the other hand, not all murmnrs of the heart are organic. In 9 per cent, of Starr's 1400 cases, there were functional murmurs heard at the base and over the pulmonic area, early or late in the dis- ease. A gentle blowing at the apex which is heard to the left of the sternum and is not conducted into the axilla or arteries is heard late ill the affection, and is undoubtedly hsemic or myocarditic (Osier). I have heard these murmurs in many cases and have come to the same conclusion. Murmurs may also arise at the tricuspid orifice. The organic murmurs are, as stated above, produced at the mitral orifice in the greatest number of cases. They may arise in the course of the disease or may appear during a relapse. Such cases will show a temperature (Fig. 186). Fig. 186. HOUR 3 6 » 12 3 u 9 12 3 .. 12 = ^ 12 ^ L 9 u 12 3 I a 12 3 ^ I 12 ^ 2 9 12 3 ^ 9 12 i! I 12 3 « 2 12 3 I I 12 3 ^ r 12 ^ 2 ^ 12 -. 101° I i o - 100 E *■ 99° — — - - - 1 — - - p — - ~ *— - - - - ^ "- — - ~ ~ ^ ~ ~ "■ ■^ L- ■~ - ^ - L - - - - - - - r- - L_ -^ 7 V - - ^ -J ~ - - - - ^ - - U J U V t\ L- -^ - - -^ ^ h J A - - t - JS it" -; a i. = - H -J - ~ M - - - -^ - ^ Y n \ A / V i \ /" s / ^ 7 - V- .* - y 1 _ „ _ _L _ _ _ _ _ 1_ 1 \ 1 1 1 1 — i — 1 1 — I — 1 — I — 1 — 1 — 1 Chorea. Endocarditis. Previous attack six months prior to the present illness, which was of five weeks' duration before the above observation. Pains in the .ioints, especially the knee. This curve shows two weeks of the endocarditis. Recovery. Female child, five years of age. The temperature may after a time become normal, and, in a week or more, while the chorea is still in progress there may be a rise last- ing for a day or more, after which it may then again subside to the normal. The temperature may be but a fraction of a degree above the normal, and the diurnal course may be distorted or subnormal fJlirgensen). There is thus clinically a true endocarditis. This form of endocarditis may pave the way for future chronic valvular disease. Under the heading of Chorea Insaniens, I have noted two fatal cases of this form of heart disease. Chorea of the heart muscle is not clinically recognized. Pericarditis with endocarditis may occur in cases of recurrent chorea. I have seen two such cases. Func- tional disturbances such as palpitation and arrhythmia also occur. Temperature. — There are some forms of chorea minor without any signs of endocarditis which run a course with a slight tempera- ture, the cause of which is undetermined. Some authors think that there may be a latent endocarditis in these forms of chorea (Henoch). If endocarditis is present, there may be a temperature only slightly above normal. In most cases of chorea there is no temperature (Fig. 187). Fatal cases of chorea, with few exceptions, show signs of endo- carditis. Osier has made a study of 80 such cases, and found only 5 which postmortem did not show changes in the valves. 828 DISEASES OF THE NEBTOUS SYSTEM. The mental symptoms are in some cases marked. The patients show apathy and depression. The children often, while they are under treatment, have spells of mental depression and fits of crying. It is only in the cases of insaniens that delirium occurs. In severe cases there is a period of more or less mental depression, extending far into convalescence. Diagnosis. — The diagnosis of chorea minor is not difficult in the majority of cases. The picture is a very characteristic one. There are slight twitchings, which so closely resemble habit movements that it is not easy to come to a conclusion in regard to them. Sachs thinks that the twitchings of the tongue are a means of distinguish- FiG. 187. mOUR 38S 12 369 12 369 12 369 12 369 12 369 12 368 12 368 12 369 12 369 12 309 12 36 9 12 36 B 12 369 12 100° -5 ^ ^^^--^ ± . ~zzz^^^^z^^zzz^^^^z^^zz::z,zzS^z^,:^ ? 99° — zE -'^^^^^=^;i~-^— ^E— ^^-i-\z — : - — ^s =*■■- £ liiluA 11 n Mth I rrW rrm-iFhHmm^-- ol 98° 5 s "" -) gij" 1 PULSE § ggiSgSSSSSi S S S g SS RESP. a sssassaajs a a is s sg Chorea, without endocarditis, two months in duration. No rheumatic history. child, nine years of age. Female ing the mild cases of chorea from cases of habit movements. If the patient is told to show the tongue, the tremors and twitchings of that organ and the facial grimaces at once become marked. The move- ments of the muscles are more rhythmic in hysteria than in chorea. True Sydenham's chorea should be distinguished from the chorea and athetoid movements seen in cases of infantile palsy. The his- tory of the cases, the paralysis, the condition of the reflexes and the contractures will be of assistance in making a diagnosis. True Syden- ham's chorea should also be differentiated from cases of tic convulsif and habit movements. A diagnosis of chorea, made in a case which has lasted for a year or more, is open to doubt. Duration. ■ — The duration of chorea is variable. It may last from three to ten weeks, and may recur. The recurrent attacks are not necessarily any more severe than previous attacks. Fully one-third of the cases in some statistics show two or more attacks. Of Starr's 1400 cases, 365, or 26 per cent., had relapses. One case had nine attacks. Prognosis.— The prognosis of chorea minor is very good. Recovery is the rule, but in exe('])lional cases it may be delayed for fully three months. CHOEEA. 829 Treatment. — The treatment of chorea consists at first in giving the patient perfect rest and quiet surroundings. Children are put to bed and kept free from excitement. I do not think it necessary to isolate them, and it is not wise to do so, since they may, under such treatment, become melancholic. An ordinary amount of quiet, such as is prescribed in cardiac cases, is all that is usually necessary. The patient may be allowed to look at picture-books, but not to study or to read. A simple, easily assimilable diet is indicated, milk and eggs being the chief articles. A warm bath is given daily and the spine sponged with cool water, as some authors recommend. I have not found this necessary in all cases, and would advise it to be omitted if the children strongly object to it. Massage is of great value with anaemic children in whom the circulation is below the average and who have no cardiac disease and no temperature. Drugs.- — Fowler's solution is used almost as a routine remedy in these cases. In my experience its curative effects are doubtful. I therefore prefer to give it in small tonic doses, rather than risk the ill effects of large dosage. There are cases in which any attempt to administer it causes vomiting, and which therefore do much better without it. In any case it should be well diluted. In this way larger doses can be given for a greater length of time than would otherwise be possible. Cases w'hich show recent or old endocarditis or which have artic- ular pains should receive antirheumatic treatment. Alkalies to keep the bowels open, alkaline baths, and sodium salicylate are the reme- dies in use in these cases. If there is great restlessness, bromides should be resorted to. It is a very good plan to combine the bromides of sodium, potassium, and ammonium in one mixture. Trional given in grain v (0.3) doses several times daily is a very good remedy in this set of cases, especially if there is wakefulness at night. If on account of the loss of appetite and general mental depres- sion it is not possible to give any drugs, the children are simply kept quit and given a nutritious diet. They frequently recover without the help of any drugs. In ordinary cases there is no necessity of using opiates, such as codeine. Antipyrin in grain v (0.3) doses has been recommended. I have not found it better than other remedies. Children who have recovered should be kept quiet for fear of a recur- rence of symptoms. This is especially true of cases in which the heart has been the seat of a recent endocarditis. Chorea Insaniens. — Chorea insaniens is a term applied to the severest form of chorea. A large number of these cases run their course with delirium and high fever. It occurs especially in female subjects. At the outset there may appear to be nothing more than 830 DISEASES OF THE NERVOUS SYSTEM. i m TEMP. (fAHR.) I m-: ^3" T40" ^\\ -1 - ;!-^ C, "1 I- n r^ •=: -V Z tt i-' 12U _\ v( ^■ oil 120 T^ 1 ■ -^ j 1 I. 5 30 110 J- It - s - -•-— C-. 0-2 120 s -. = SO 110 \ i f- -:- _ L ==-t Tf^' ^ 28 110 > c- s; 2S 120 i> 1 K f ■ 1 - 32 IJU '^ r? ^ o «5 30 120 ) XI /• ' o 311 120 V E 1' 1 o = 28 120 1 V — ^' ' Xi 28 110 1 e. 28 120 f rt 28 110 \ o CC 30 120 ^ > r; -. 30 120 ^ tz I.J, — f =-v'" i « 30 120 i ! ; h y 1 c-. 30 120 ■^ ^ c 34 112 s , u^ cr. 00 30 lis »• — ^ ' \ T K 00 tj O s 30 108 " . ;l E -^ K 28 120 1 ¥ r? -^ I'is r f - r: 2ii 110 -^. o S 20 111) .>- ft ^ ■ c. 28 120 ^ t; 1 ■ j - o « 28 lie i !l r? i r - 28 no xi 28 110 T. i.T 28 112 xt ■V. o 28 no 1^ I ^ :> o 'i 28 120 1 ^ xi 30 Tio i-j-: 1 s. - _ 9 r^ ~iO iirr || < > z - 30 YlB ~— z 30 120 ■L z C 30 120 \\'\ z 30 12ij V, ■ z 2 1 1 i^ 1 1 o. <: ti s i=5 s ^ ~ *- o He had chronic cardiac disease. an ordinarily severe chorea, but the jDatient rapidly becomes worse. De- lirium with hallucinations sets in, finally giving way to incoherency and mania. The patients are .in inces- sant motion and do not sleep at night. The fever may mount as high as 107 ^ F. (41.6° C). The cases are in many instances fatal. Osier gives a resume of some fatal cases. I have seen 2 fatal cases of this form. One case occurring during my service as interne at Bellevue Hospital was that of a girl of twelve, who died with symptoms very similar to those of acute mania. Another case, seen re- cently, was a boy of ten years, who had. for two years previously suffered from ' ordinary chorea. He had a mitral regurgitant murmur. Two weeks before his death he was suffer- ing from a mild recurrence of the chorea. While in that state he was aperated on for adenoids and enlarged tonsils. Chloroform was adminis- tered. Three days after the opera- tion the boy was taken with a chill, the chorea became worse, and there was fever. Examination of the heart showed endocarditis and pericarditis with dilatation of the left ventricle. In the second week the boy became delirious and did not sleep at night. He complained constantly of pain in the prsecordium and tossed in bed. He died two weeks after the onset of the disease. There was throughout a high febrile movement. A third case was that of a boy six years of age, whose temperature-curve is herewith ai^pended (Fig. 188). This case occurred in my hospital service. It was the boy's third attack of chorea. In the final attack there was compli- FOBMS OF TIC. ■ 831 eating j^ericarditis with effusion. The delirium was constant and the choreic movements incessant. He went into a typhoid state, but recovered, his mental faculties, however, being shattered. During the course of the pericarditis there was a polynuclear leucocjtosis, and 45 per cent, hsemoglobin. These cases are to be differentiated from cases of severe simple chorea, in which the movements are so incessant that the j)atients can with difficulty be kept in bed. In simple chorea there is no delirium and there is a period of quiescence at night. Treatment. — The treatment of chorea insaniens is symptomatic. The delirium and incessant restlessness are controlled with bromide of potassium, or sodium combined with chloral hydrate. The use of morphine is indicated in cases in which the chloral and bromides are ineffectual. Complicating endocarditis and pericarditis are treated as when primary. FORMS OF TIC. (Habit Movements or Spasms.) This affection is mentioned in this place to emphasize the impor- tance of sharply differentiating its forms from true Sydenham's chorea. Tic is defined by Growers as a habitual and conscious con- vulsive movement of one or more of the muscles of the body, repro- ducing some reflex or automatic movement normal to the individual. Osier has classified the forms of tic. There is first the ordinary form, in which young people or children develop a spasm of a group of muscles, generally of the face. Children. do not have the form known as idioiDathic spasm of adults in which the lower extremities are involved. There is contraction of a group of facial muscles, such as the orbicularis or the muscles about the nose. There are other forms of tic in which mental disturbances and explosive utterance of words or syllables are prominent features. If the words are of an obscene character, the condition is called coprolalia. In other cases the patients repeat words or sentences (echolalia). The so-called laryngeal barks of a hysterical nature are, according to most observers, to be classified as forms of tic, and not as laryngeal chorea. There is a fourth class, which includes those cases in which the subject before proceeding to any definite act, such as writing, feels impelled to blow on the fingers, pinch the nose, or strike the head or thorax. These actions may be regarded as harmless tricks. In another form of tic the patients feel impelled to touch objects, such as the floor or wall (delire de toucher of French writers). 832 DISEASES OF TEE NEBFOUS STSTEM. RHYTHMIC MOVEMENTS OF THE HEAD ASSOCIATED WITH NYSTAGMUS. (Head-nodding ; Spasmus Nutans; Gyrospasm.) N'ystagmus alone is quite frequently observed in infancy and childhood. Khythmic movements of the head associated vdth nystagmus con- stitute an uncommon affection. The derangement is functional and occurs in poorly nourished and rachitic infants whose nerve resistance is diminished. The majority of cases give a history of some preceding illness, in the course of which the infant has suffered from convulsions. The mothers may be of a nervous temperament. The phenomenon which at once attracts attention is a rhythmic oscillation of the head in a horizontal or vertical direction, or both. On close examination it will also be noticed that the eyes have a horizontal, vertical, or oblique form of nystagmus. Ebert, Cahen, Caille, Gee, Hadden, and Lewi have studied these cases. Lewi reported some cases from my clinic. The ages of the infants ranged from three to eighteen months. The movements were augmented when the infant focused some attractive object. The nystagmus, if not marked, may be made apparent by holding an object to the right and upward for the infant to focus. Lewi as well as Caille found that the nystagmus ceased when the infant was blindfolded. In one case the movements continued when the infant was in the recumbent posture. The eye and head movements were not synchronous. As a rule the eye movements were the more rapid. These observers did not agree with Hadden in finding that forcible restraint of the head stopped the nystagmus. I have been accus- tomed to see a number of these cases yearly. Some of the infants are quite bright and well nourished. This statement agrees with that which Thomson recently made. Three-fourths of the cases are under the age of twelve months (Thomson). Etiology. — The etiology of the affection is obscure. It is usually coincident with the period of dentition, but may appear as early as the third month. Some of the infants live in dark, squalid quarters, and the affection has been attributed to eye-strain caused by the in- fant's attempts to fix a light as it lies in its crib. This theory would make the affection appear similar to that frequently seen in miners (IMagnus). Some of the patients that I have seen lived in well- lighted quarters. Rachitis was present in most of my cases. Thomson's expe- rience was similar. Henoch gives a physiological explanation of the combination of nystagmus with the rotary movements of the head. EYDEOCEPHALUS. 833 by pointing out that the root nuclei of the nerves of the muscles of the neck and throat which rotate the head are adjacent to the ocular nuclei, and that any irritation of one set of nuclei may affect the other. This explanation has been generally accepted. Treatment. — The cases as a rule recover. They are given outdoor air, correct food, and a general course of treatment for the rachitis. Phosphorus is given as in rachitis. I have also prescribed the bro^ mides of potassium and sodium, grains v (0.35) three times daily. The cases certainly improved in time. The blindfolding suggested by Caille only stops the rhythmic movements of the head temporarily. HYDROCEPHALUS. (Dropsy of the Brain.) Hydrocephalus or dropsy of the brain is an abnormal accumula- tion of fluid in the subdural space, or in the ventricles of the brain. In the former case there is external, in the latter internal hydroceph- alus. Hydrocephalus may be acute or chronic. It may also be con- genital, secondary, or primary. The last-named form occurs in adult subjects (Delafield). Acute hydrocephalus is described under the caption of Meningitis Serosa. Congenital Internal Hydrocephalus. — The accumulation of fluid begins in utero. The quantity at birth may be small and may after- ward increase. It may be large enough at birth to obstruct delivery. Etiology. — The causes of the condition are unknown. Alcohol- ism, syphilis, and tuberculosis of the parents have been regarded as predisposing causes, but infants thus affected may be born of per- fectly healthy parents. Sometimes several infants with this malady are born to one mother. Mortid Anatomy. — The quantity of fluid accumulated in the ven- tricles varies. The fluid is perfectly clear and has a specific gravity of from 1001 to 1009. It contains a trace of albumin and some- times urea, sodium chloride, and cholesterin. The weight may reach twenty-seven pounds. The fluid distends the lateral ventricles, the third and fifth ventricles, and the fourth to a less degree. The cen- tral canal of the cord may be dilated (Delafield). The corpus callo- sum is displaced upward. The thickness of the cerebral substance may be reduced to a few millimetres. The convolutions may be obliterated, as may also the basal ganglia. The aqueduct of Sylvius is dilated. The white matter of the brain suffers most. The mem- brane of that organ may be normal. The ependyma may be thick- ened and granular. Symptoms. — The symptoms are the gradually increasing size of the head and the development of idiocy and paralyses as a result of 53 834 DISEASES OF THE XEBVOUS SYSTEM. internal pressure on the nervous structures. The cranium enlarges so that it becomes disproportionate to the face, -^hich remains small. There is bulging of the occipital and frontal regions. The orbital plates take an oblique direction, causing the eje-s to assume a pecu- liar stare (Fig. 189). The sclera is seen exposed above the cornea. The eyes are directed downward and are only partially covered by the eyelids. The sutures are forced apart and the fontanelles are widely open. The anterior fontanelle bulges and pulsates visibly. The cranial bones may here and there show areas of thinness resem- bling those seen in craniotabes. The lambdoid suture is flattened and the greatest diameter is across the temples. The head may attain an enormous size, the child being unable to hold it upright. Fig. 189. Congenital internal hydrocephalus. Infant, nine months of age. The hair is scanty and dry. There may be strabismus, palsies, con- tractures, and convulsions. The eyes may not be on a level. Blind- ness may result. When the disease is progressive, idiocy develops. The children are very weak. Diagnosis. — Hydrencephaloid or spurious hydrocephalus is a con- dition which supervenes in acute exhausting states, such as that which follows diarrhceal diseases. There is neither bulging of the fonta- nelles nor enlargement of the head. The fontanelle is depressed and the eyes are sunken. In certain forms of rachitis which are accom- panied by craniotabes and cranial bosses ov( r the parietal and frontal bones, there is frequently a very mild form of hydrocephalus. This condition is rarely progressive. It may be distinguished from true EYDEOCEPHALUS. 835 congenital hydrocephalus by the absence of progressive enlargement of the skull. The sutures may be patent, especially that between the parietal and frontal bones. The signs of rachitis are present else- where, and the children are, in contrast to the semi-idiotic subjects of hydrocephalus, very bright. In differentiating congenital internal hydrocephalus from the external form the history is of gTeat value. External hydrocephalus appears at birth and is not accompanied by bulging of the frontal and occipital bones. Mental deficiency is present from the outset. Late in the disease it may be impossible to disting-uish between the two forms. A form of cranial syphilis is mentioned by Gowers as causing cranial enlargement, which, however, is never so marked as in congenital hydrocephalus. The diagnosis of congenital chronic internal hydrocephalus rests on the progressive enlargement of the cranium, the bulging in the occipital and frontal regions, and the flattening across the lambdoid suture. Acquired hydrocephalus rarely appears before the tenth month (Ireland). It is sometimes of interest to distinguish at autopsy between the congenital and acquired forms of hydrocephalus. Meynert has shown that in congenital hydrocephalus the lateral ventricles are dilated in their long diameters ; the posterior horn is dilated, so that it reaches within a few millimetres of the cranium. Acquired hydrocephalus, on the contrary, usually dilates the ventricles in their vertical and cross diameters. Prognosis. — Hydrocephalus is one of the most fatal nervous affec- tions. There are mild forms in which the accumulation of fluid ceases after a certain time and recovery takes place, the intelligence being either slightly weakened or normal. In some cases the enlarge- ment continues and death ensues from marasmus. In other cases the head becomes of enormous size ; the increase of fluid ceases ; the fon- tanelles and sutures close ; the unfortunate subjects have an enormous ossified skull, which they are unable to hold upright. They are par- tially idiotic or imbecile. They often, however, have a slight degree of intelligence, and may recite lessons, but are helpless in every way. Treatment. — The treatment of congenital internal hydrocephalus is alone of interest to the physician. The condition is hopeless. The injection of solutions of iodine (Morton's fluid) has been tried with doubtful results. I have had 2 cases in which the ventricles were aspirated, fluid was withdrawn, and the head bandaged. The operations were performed by an expert under antiseptic precautions. In neither case was the course of the disease affected. The fluid reaccumulated. Both patients died. I have performed lumbar puncture on several cases, repeated at short intervals without perma- 836 DISEASES OF THE NEEVOUS SYSTEM. uent benefit. In one case the temperature rose to 108° F. (42.2° C), Cheyne-Stokes respiration set in, and the patient died. Cases in which Keen, of Philadelj)hia, inserted a permanent drain did not give encouraging results. Pott had an equally discour- aging experience with that mode of treatment. Iodide of potassium administered internally is of doubtful value. In estimating the re- sults of treatment, it should not be forgotten that a small percentage of cases cease to progress at a certain stage of the disease, and make a tolerably fair spontaneous recovery. External Hydrocephalus. — External hydrocephalus may be ac- quired or congenital. If congenital, it follows an intra-uterine Fig. 190. External hydrocephalus. (Author's case.) ])achynieningitis or may take place because of the rudimentary state of the cerebrum (hj^drocephalus anencephaliquc). External hydro- cephalus may be acquired, in which case it follows a pachymeningitis interna ha-morrhagica or is the result of a meningitis in infancy. The congenital form of external hydrocephalus is very rare. Bokai records a case in an infant nine months of age. There was an accu- 7nulation of fluid between the dura and pia mater. Both membranes and the falx were thickened, but there were otherwise no signs of AMAVBOTIC IDIOCY. 837 inflammation. The infant had spastic symptoms. The diagnostic points in these cases are the uniform enlargement of the head and the bulging, especially in the temporal region. The axes of the eyes remain normal, the condition of those organs differing in that respect from that seen in internal hydrocephalus, in which they are depressed downward. There may be slight exophthalmos. In Lewis Smith's case the axes of the eyes were normal. In some cases of external hydrocephalus the head attains an enormous size. The disease cannot then be distinguished from the chronic internal form. In one of my cases external hydrocephalus followed meningitis. The head was uniformly large, the bulging over the temporal region being marked. The axes of the eyes were normal. The intelligence was low. In some cases of external hydrocephalus there is a slight internal hydrocephalus. AMAUROTIC IDIOCY. (Family Idiocy — Sachs.) This disease was first described by Warren Tay, an English ocu- list, in 1881. Among other symptoms, he noticed peculiar changes in the fundus of an infant suffering from the affection. We owe the more extensive study of the affection to the American neurologist Sachs, who described his first case in 188Y, not knowing that Tay and Kingdon had previously published theirs. Sachs has collected 27 cases in the literature, his own cases being included in the number. I have published 2 cases and have since seen 25 cases. Etiology. — The etiology of the affection is still unknown. Alco- holism and syphilis do not appear to be very closely connected with its occurrence. It appears to run in families. Frequently two or more children in a family are affected. There is certainly a so-called neuropathic predisposition. It is a disease which affects more frequently children of the Jewish race ; thus of 86 cases collected by TIerveroch in 1904, 61 belonged to this class. Course. — The course of the disease is slow and progrediant. There is the gradual beginning in apparently healthy children. In the cases thus for reported there has been no neglect in the hygiene and many if not most of the infants have been breast-fed. Forms.- — There are now two well-recognized forms of the affec- tion. The infantile form affects infants from the third month of infancy and results in their death about the end of the second or the third year of childhood. The juvenile form has been described by Higier, Freud, Spielmeyer, and Vogt. It affects children from the 838 DISEASES OF THE NERVOUS SYSTEM. sixth to the fourteenth year and like the infantile form is slowly progressive, leading to marasmus and death. The symptomatology and morbid anatomy of both forms are strikingly similar, with a dif- ference which will be pointed out later. Morbid Anatomy. — The morbid anatomy of amaurotic idiocy is certainly unique in the fact that all cases show the same changes and these are distributed throughout the whole nervous system. The nerve-cells are most affected and the changes are such as to stamp the disease an entity in neuropathology. There is not a normal cell to be found in the whole nervous system. Tay and Kingdon, Sachs, Van Giesen, Hirsch, Schaffer, and Vogt have studied these changes and their results correspond in the main. There is a degeneration of the ganglion cells throughout the gray matter of the brain and cord. This consists in a swelling of the cell and an extraordinary trans- parency and pallor of the cell-body. The form of the cell is changed into an ampulla-like mass, the nucleus of the cell is displaced toward the periphery of the body and the ISTissl granulations have almost entirely disappeared. In some cells a few granules are left in the cell-body. The general characteristics of the nerve-cell are lost ; the swelling of the cell has increased its volume several times. There is chromol- ysis. In the final stage of the degeneration the cell does not show any nucleus. It is pale and colorless, the nucleolus alone is indi- cated and the original form of the cell is distorted. There is destruc- tion of the dendrites and breaking off and degeneration of the axis- cylinder process. The axis-cylinder may show some intact fibrillse; the dendrites show some fibrillation, but only in spots. The den- drites are much swollen. The glia shows a marked proliferation of cells and fibres. The pia, connective tissue, and bloodvessels show nothing abnormal. The above changes are seen in the brain and cerebellum and in the cord and medulla oblongata. The greatest changes are found especially in the cells of the anterior and antero- lateral horns of gray matter of the cord. Symptoms. — The symptoms are divided as follows: (1) Psy- chical disturbances tending to complete idiocy. (2) Weakness, resulting after a time in complete paralysis. (3) A normal, dimin- ished, or increased state of the deep reflexes. (4) Increasing blind- ness with pathognomonic changes in the region of the macula lutea (Tay and Kingdon's spot), with optic neuritis. (5) Marasmus. The history of all the cases is practically the same. The infant is normal at birth. After from two to eight months, it is found to be indifferent to its surroundings. The mother notices that the infant who has been bright begins to lose interest in the surroundings. She will say that from the third month on she noticed that the infant AMAUEOTIC IDIOCY. • 839 no longer held up its head and that this disability has gradually become more apparent. The head falls backward when the infant is sat up. The children do not notice objects any more; they nurse automatically and start when there is any noise in their immediate vicinity. Many of the infants cry constantly, at the same time making automatic facial grimaces. The lower extremities are weak and may exhibit complete paralysis (diplegia). In other cases, there may at intervals be a spastic rigidity of the lower extremities, alternating with a lax condition. Convulsions are absent or may occur occasion- ally. The deep reflexes may be normal or diminished. In the spastic cases they are increased. After the first year the infants become totally blind and conapletely idiotic. They finally become marantic, and die after the second year with the symptoms of ad- vanced infantile atrophy. Occasionally there are nystagmus, stra- bismus and hydrocephalus. Deafness supervenes in many cases. The electrical contractility of the muscles may be normal or, as in one of my cases, diminished. Ocular Changes. — The changes in the fundus of the eye described by Tay and Kingdon have been confirmed in the cases of Sachs, Koller, and the writer. They are invariably present at some period of the disease, but may only appear late, as in the case of Koller. Once present, they fix the diagnosis absolutely. The appearances consist of a cherry-red spot on a diffusely white area at the region of the macula lutea. Optic neuritis is also present toward the close of the disease. Diagnosis. — Diagnosis is not difficult after a study of the symp- toms. If an infant is brought to the physician with a history of good health and intelligence up to a certain time, after which weak- ness and loss of interest in its surroundings set in, with inability to hold the head upright, the fundus of the eye should be examined. If Tay-Kingdon's spot is found, the diagnosis is fixed. I have lately seen a number of cases in which the spastic symptoms were predomi- nant. There were idiocy, increase of reflexes, complete or total blindness, and hyperacuity. I have watched infants with these symptoms for a long time and failed, even with expert aid, to find Tay-Kingdon's spot. In these cases there was probably a birth palsy. The Juvenile Form. — The juvenile form of amaurotic idiocy is also a family disease. It affects several members of a family group in the same manner as the infantile type. It begins at the sixth to the fourteenth year of childhood. The onset is also gradual. The first symptom is an increasing blindness, which in the course of months results in' a total blindness due to an optic neuritis. The patients lose interest in their surroundings, forget what they have 840 DISEASES OF THE NEBVOUS SYSTEM. learned in reading or writing, take less and less care of themselves, lose their usual spirits, soil themselves and finally lose their povv^er of speech and become absolutely imbecile and paralytic. The paral- ysis may be flaccid or spastic. They lie for a long time moribund and finally pass into a marantic condition and die. On the whole the picture is much the same as the infantile type with the exception that in the juvenile form of amaurotic idiocy the cherry-red spot of Tay-Kingdon is not seen in the fundus of the eye, but instead there are the changes due to a progressive optic neuritis. Prognosis. — The prognosis of both forms of amaurotic idiocy is fatal, the infantile before the second or third year and the juvenile form after a year or more of illness. TUMORS OF THE BRAIN. Fully 50 per cent, of the brain tumors in infancy and childhood are tuberculous; giiomata and sarcomata are next in order of fre- quency. Cysts are secondary to a hemorrhage or embolism. They may remain stationary for a long period, and then increase in size and cause symptoms. Males are affected twice as frequently as females ; two-thirds of the cases in male subjects are cases of giiomata and tubercle. Tumors are rare in the first six months of life. The largest number occur in the first decade. Location. — The medulla is rarely the seat of tumor. The cere- bellum is most frequently involved (50 per cent, of the cases, Ger- hardt, Peterson). The pars centrum ovale and basal ganglia are the parts next most frequently affected. Etiology. — ^The role of traumatism is not clearly understood. Giiomata are due to a proliferation of the neuroglia. Tubercle and sarcomata are secondary to foci elsewhere. Carcinoma is rare. In some cases of that growth the orbit is a focus of infection. Symptoms. — Symptoms of pressure and irritation vary with the location of the tumor. A small but rapidly growing tumor will cause more pronounced symptoms than a large tumor of slow growth. Interference with the blood-supply and an increase in the quantity of fluid within the ventricles of the brain will cause the symptoms to vary. General Symptoms.— Headache. — This may in cortical and meningeal tumors be intense. It is of a boring, gnawing character, and is referred to the region of the tumor. Tumors in infants may attain great size previous to ossification of the skull. The bones of the skull are pushed apart and the sutures opened up. There is very little pain. Sleeplessness and restlessness, emaciation, and cerebral excitement are marked. TUMOBS OF TEE BBAIN. 841 Nausea and Vomiting. — ISTausea and vomiting are prominent symptoms and persist for a long time. The vomiting is projectile and occurs independently of the ingestion of food. Vertigo. — Vertigo is common and occurs with every change in the position of the head. It is a common symptom in tumors of the pons and cerebellum. Convulsions. — These may be localized or general. They occur when the cortex and motor areas are invaded, and eventuate in epi- lepsy of the Jacksonian type. In this form of epilepsy, the attack begins in the head or arm corresponding to the area of irritation, and subsequently becomes general. Optic Neuritis. — Optic neuritis and optic atrophy are important symptoms of intracranial tumor, but are not always present. When tumors are situated at the base of the brain, the symptoms appear early and are due to pressure on the chiasm. Optic neuritis is either double or more pronounced in one eye. Pulse and Respiration. — The pulse and respiration present no characteristic features. They show irregularities in rate. Respira- tion is affected only toward the close of the affection. Symptoms Dependent on the Location of the Tumok. — Cor- tical tumors in or near the motor areas cause convulsive seizures, which occur from the outset. Subcortical tumors will at first cause paralysis and, as they encroach upon the cortex, convulsions. With invasion of the cortex there are, in addition to convulsions with sub- quent epilepsy, intense headaches. Tubercle, glioma, and gumma occur near the surface. Cysts and sarcoma are more deeply situated. Frontal Lohe. — The tumors situated in the frontal lobe region cause stupidity and other marked changes in the degree of intelli- gence. There will be a perversion of the sense of smell, salivation, and also the drooling seen in idiocy. If the third frontal convolu- tion is affected, there will be motor aphasia associated with agraphia — a rare condition in childhood. Tumors of the motor area will in the earlier stages cause cortical irritation, manifested in convulsive twitchings in the parts first paralyzed. There may be slight sensory or motor disturbances in an upper extremity and an occasional twitching of the arm, forearm, or thumb. Parietal Lohe.- — The tumors of the parietal lobe cause sensory changes in the limbs of the opposite side of the body (Dana). If the white substance is the seat of tumor, there may be hemianopsia ; Wernicke's centre for conjugate movement of the eyes may be affected if the tumor is situated in the inferior part of the parietal lobe. Occipital Lohe. — Tumors of the occipital lobe cause homonymous hemianopsia with or without epileptiform convulsions, the latter being probably due to invasion of the cortex. 842 DISEASES OF THE NEBFOUS SYSTEM. Temporosphenoidal Lohe. — Tumors of the temporosphenoidal lobe cause impairment of hearing on the side opposite to the lesion and sensorj aphasia. The patient is able to speak, but cannot under- stand what is said or repeat spoken language. Ganglia. — In tumors of the ganglia there is involvement of the internal capsules. There are no convulsions and none of the choreic and athetoid movement seen in cortical tumors. Cims Cerebri. — Tumors of the crus cerebri cause paralysis of motion and sensation on the opposite side of the body, and oculomotor paralysis, ptosis, and paralysis of the muscles of the eyeball, except Fig. 191. ^^^^^^^ f -■ "- ■ 3imm^ > / f ■" L, Pons tumor, showing nuclear palsies. Left abducens paralysis. the external rectus and superior oblique. There will be paralysis of the sphincter iridis and ciliary muscle. There may be paralysis of both sides of the body, double ptosis, and double oculomotor symp- toms. The majority of cases are at first unilateral, later becoming bilateral. Loss of pupillary reflex, nystagmus, and cerebellar ataxia point to involvement of the corpora quadrigemina. Pons.- — Tumors of the pons cause unilateral or bilateral symp- toms. There is hemiplegia or double hemiplegia with paralysis of the cranial nerves. There is paralysis of the third, fifth, sixth, sev- enth, and eighth nerves of the side of the lesion, with hemiplegia of the opposite side. There may thus be paralysis of the external rectus with facial palsy and impairment of hearing on one side. If the PLATE XXXVII Birth Palsy, Apoplexia Neonatorum. (McNutt.) Shaded portions show the location of the hemorrhage. INFANTILE CEBEBBAL PALSY. 843 nucleus of the sixth nerve is involved, there v^ill be paralysis of con- jugate movement of the eyes toward the side of the lesion, while if it is not affected there will be only external rectus palsy of the side of the lesion not affecting conjugate movement of the other eye. Medulla. — Tumors of the medulla manifest themselves in bulbar symptoms. There will be paralysis of the glossopharyngeal, vagus, spinal, accessory, and hypoglossal nerves. Thus there are unilateral or bilateral paralysis of the arms or legs, difficult deglutition, and disturbances of the respiratory movements and of cardiac action. In addition there will be spasm of the sternomastoid and trapezius mus- cles, and paralysis of the tongue, with atrophy, vomiting, polyuria, and glycosuria ; optic neuritis occurs early, and there is severe occip- ital headache. Gummata in this region are not uncommon. Cerehellum. — Tumors of the cerebellum, which are usually of the solitary tuberculous form, are the most important intracranial growths in children. There will be occipital headache, vomiting early in the disease, and cerebellar titubation due to encroachment upon the middle peduncle. Vertigo is severe. The sixth, seventh, or eighth cranial nerves may be involved. There may be bulbar symptoms. Paralysis of the external rectus is very common in these tumors. Optic neuritis may be present. INFANTILE CEREBRAL PALSY. {Spastic Hemiplegia ; Diplegia; Paraplegia.) Forms. — Cerebral infantile palsy may originate m utero, or a short time after the birth of the infant. It is then called cerebral diplegia, birth palsy or Little's disease. It may occur any time after birth, most frequently during the first three years of life. The palsy then has an acute onset and takes the hemiplegic form and is called hemiplegic infantile cerebral palsy. These two forms of cerebral palsy have much in common both as to pathology and symptomatology. Cerebral Diplegia, Little's Disease. — This affection, first brought to the notice of the profession by Little, was also studied by MclSTutt. To the latter we owe the demonstration of the cause of the disease. Lender the title Apoplexia Neonatorum she demonstrated that in easy as well as j)rolonged labor and instrumental deliveries hemorrhage on the surface of the brain was the first step in the clinical and patho- logical history of these cases (Plate XXXVII.) . Cerebral diplegia is a form of bilateral paralysis dating from birth or noticed soon after birth or as the result of some infectious disease as late as the sixth month after birth (Henoch) , or even the third year of life (Starr). Etiology. — The etiology is divided into first, those cases in which the causes are traced to intra-uterine life and are connected with 844 DISEASES OF TEE NEEVOUS SYSTEM. disturbances in utero due to traumatism to the mother during preg- nancy, illness or psychical disturbances of the mother, and syphilis. Second are the causes which act on the child during labor, difficult parturition, abnormal position of the child, asphyxia, either through prolonged labor or abnormal position of the cord, or premature de- tachment of the placenta, and prematurity of the infant or labor. Third, there are the etiological factors acting on the infant after birth, such as the infectious diseases. Such cases have been observed by Henoch in an infant who six months after birth developed diplegia after measles. Symptoms. — MclS'utt described the symptoms referable to the cere- bral hemorrhage in cases of diplegia. They consist of disturbances of respiration more or less marked, partial or complete loss of conscious- ness and convulsions. The latter may be general or involve half of the body. Many of such infants die soon after birth. If they live, they show signs of asphyxia neonatorum. In such cases even after a normal delivery, the infant breathes irregularly, or ceases to breathe, cries feebly and then lapses into a quiescent state with shallow and irregular breathing. It may be cyanosed and in this state may have several convulsions. Other cases are born apparently well but after twenty-four hours convulsions and disturbed respirations appear. If these infants live, the subsequent clinical history is as follows : Diplegia. — In many cases the diplegia consists in a paralysis of both arms and legs or of the legs alone and is noticed soon after birth. The parents observe that voluntary motion is interfered with, that the infant is alternately rigid and lax, is not intelligent and does not nurse as ordinary infants do. There is hyperacusis ; the children start at the least sound and cry as if in fright. The reflexes are much increased, the trunk and extremities are rigid. In some cases the back is rigid and the children are unable to sit upright. There is difficulty in nursing and some must be fed by hand. As the child grows, it is seen to.be mentally deficient, notices objects in a vague sort of way, cannot talk, cannot sit on account of the rigidity, and cannot stand. If aided these children may stand, but the extrem- ities take a spastic position. The toes are applied to the ground and there are crossing of the legs and equino varus. The heels do not touch the ground and the children cannot balance themselves. Some may be able to walk, but only stiffly, aiding themselves with the hands ; others may walk with the aid of support, such as a cane or crutch. These are favorable, as many of the children are bed- ridden. In such cases the arms are flexed and spastic, as are also the lower extremities. There are constant athetoid movements, com- bined with chorea, both of facial muscles and extremities, and finally epilepsy is often developed, so that the difference in symptomatology between these cases and those of hemiplegia is only one of degree. INFANTILE CEBEBEAL PALSY. 845 The feeble-mindedness of such children and their utter helpless- ness is touching. They can be taught only the simplest things and until late in childhood they are a burden to themselves and others. There is no marked improvement and many become easy prey to intercurrent affections. Optic atrophy, blindness, nystagmus, stra- bismus, deafness, are among the other symptoms noted in many cases. In some there are symptoms of bulbar involvement, such as difficulty in deglutition and motor disturbances of speech. Convulsions and epilepsy develop later on and in many cases lead to complete idiocy if such v^as not present at birth. Hemipleg-ic Infantile Cerebral Palsy (Spastic Hemiplegia). — Occurrence. — According to Gowers the disease is more frequent in females, but there is no predisposition as to sex. It is most frequent, according to Osier, Wallenberg, Gaudard, Lovett, Sachs, and Peter- sen, in children from a few months of age to the third year of life, when it becomes infrequent up to the tenth year. All the above writers report cases occurring in utero or congenital (intra-uterine and during parturition). Etiology. — The etiology of these cases is still a matter of discus- sion. When Striimpel proposed the theory of an encephalitis similar to that occurring in infantile poliomyelitis, it was for a short time accepted. Clinically this theory was founded on certain similarities between the spinal and cerebral affections. It is found that many of the cases follow the acute infectious diseases, especially measles and scarlet fever (Gowers). Cerebral palsy may follow typhoid fever, pertussis, pneumonia, amygdalitis, cerebrospinal meningitis, gastro-enteritis, and traumatism to the skull. Infection or the pres- ence of infectious disease cannot alone explain all the cases. Another view is that the convulsion at the outset of the disease causes the bursting of a vessel weakened by some form of degeneration (Osier). Symptoms. — General Picture. — The disease occurs from the age of a few months to three years. There are at first in the acute stage, fever, convulsions, vomiting, which may extend over a period of a few days or weeks. During this stage or later the paralysis which involves the face, arm and lower extremity becomes evident. The paralysis, as first flaccid, soon becomes spastic with increase of reflexes and contractures. Disturbances of speech and aphasia are common, but for the most part temporary. In rare cases there occur ocular palsies. The hemiplegia may disappear to recur or it may, as in most cases, remain permanent. The improvement in the paralysis occurs mostly in the lower extremity and is less evident in the arm and forearm. With the improvement of the paralysis there appears the so-called post-hemiplegic chorea. The paralysis remains spastic. There are more or less marked disturbances of the intelligence. Later 846 DISEASES OF THE KEETOUS SYSTEM. in life, varying in different cases, epilepsy, at first limited to one side and then general and severe, makes its appearance (Fig. 192). Paralysis. — The paralysis involves both sides with about equal frequency. It is of the spastic type. The facial muscles are in- volved to a mild degree; more markedly paralyzed are the muscles of the upper extremity, less those of the arm and least or not involved at all are the gluteal and abdominal group. The facial muscle is frequently involved in the hemiplegic form; fully in half the cases (Konig). It is not very marked, certainly not as much as the paral- ysis of the extremities. In exceptional cases the reverse is true. Hemiplegia. — The hemiplegia may present mixed forms of paralysis. The arm and forearm are more affected than the lower extremity. There may be apparent monoplegia of the upper extrem- ity with facial paralysis on the same side or athetosis or chorea of the lower extremity. There may be diplegia of the lower extremities with increased reflexes on both sides, combined with a hemiplegia, or. as Lovett points out, a hemiplegia may result in subsequent spastic paraplegia. Contractures, Befexes, Position, and Gait. — The arm is closely applied to the trunk, the forearm is held in semi-pronation and flexed at a right angle against the arm. The elbow is carried close to the body. The hand is bent to the ulnar side and the fingers are flexed more or less into the hollow of the hand, covering the thumb. The lower extremity is slightly rotated inwards and the leg flexed slightly on the thigh with plantar flexion of the foot. The toe is pointed inward, giving the equinovarus position to the foot. In the majority of cases the great toe is over-extended at right angles to the meta- tarsus (Gaudard). The contractures which are thus pictured may appear in utero, or immediately after the onset of the paralysis, or, what is common, the paralysis is first flaccid and then becomes spastic with contractures, or the contractures at first may be evanescent and not reappear, or contractures may be absent, especially in congenital cases. Contracture, if once present, fixes the extremity so that it cannot be straightened, even under narcosis. Sometimes at the height of the paralysis the contracture may relax or relax in one extremity and persist in another or athetosis may be present in the hand, while contracture exists in the arm and forearm, or chorea may be present in one extremity and contractnre in another (Fig. 193). The patellar reflex is increased as a rule but it may be absent in the presence of chorea or much diminished. In severe spastic paral- ysis there is bilateral increase of reflex. The gait is dependent chiefly on the conditions present. In sim- ple hemiplegia the gait is that seen in hemiplegia of the adult. If the foot is badly affected in equinovarus the children walk practically INFANTILE CEREBRAL PALSY. 847 on the toes of the affected limb. If the opposite side is spastic, the gait is that of ataxia and spastic paraplegia. Ocular Palsies. — The ocular palsies which may be present in infantile cerebral palsj include oculomotor paralysis ; ptosis, on the side of the paralysis, and temporary abducens paralysis (Freud and Fig. 192. Fig. 193. Cerebral palsy, left side hemipleglc, dating from early infancy. Cerebral Daisy, left side hemipleglc, dating from later childhood. Eie). Homonymous lateral hemianopsia has been described by Freud in 1889. It is rare but it occurs as Sachs has found it in 8 cases. Freud regards the hemianopsia as of cortical origin. Sensibility. — Sensibility is somewhat though not markedly dis- turbed in children. There is slightly marked hemiansesthesia. The 848 DISEASES OF THE NEBVOUS SYSTEM. most irksome are pains in the extremities traceable to the muscle conditions. The shoulder and elbow especially may be the seat of these pains. Aphasia. — ^Aphasia may be present either as a true aphasia or there may not be a true aphasia, but the children are slow to learn spoken language. Aphasia, however, is not as a rule a permanent symptom. Aphasia may exist in either right- or left-sided hemi- plegia. The aphasia is therefore an ataxic motor aphasia and in lesions of the speech-centre on the left side, the right hemisphere in children may act in a compensatory manner and an improvement in the aphasia results. Post-hemiplegic Disturbances. — Post-hemiplegic disturbances of motion take place in the paralyzed members and are of three classes in the presence of voluntary intended acts. The voluntary motion may be attended by spastic contraction either in the presence or absence of contracture of the extremities. There is ataxia, that is, after the impulse is conveyed to a group of muscles, there is hesita- tion before the intended act is accomplished. Finally we have in the paralyzed members so-called post-hemiplegic chorea as in cases of ordinary chorea on attempts to use the paralyzed muscles. "Chorea." — After the completion of the stage of complete paral- ysis, we have in almost all the cases in which spastic ataxia accom- panies voluntary motion a further development of spontaneous move- ments in the form of " chorea " independent of the will. On the appearance of chorea in the paralyzed members, the contractures dis- appear, but motion and voluntary use of the limb is more than ever hampered by the choreatic motion. Chorea may affect one or both paralyzed members, and may appear at the time of the contracture or later on. Athetosis. — Added to the chorea is athetosis. This consists in slow, involuntary movements of the paralyzed part, producing flexion and extension of the fingers and hand, of the elbow and shoulder, and more rarely of the foot and muscles of the face. It is increased by voluntary motion of the paralyzed or healthy jDart, or emotional excitement. This athetosis was first described by Hammond, and is now recognized to be due to a lesion of the brain cortex. It may appear early or late in the disease. It is a frequent symptom. Athetosis differs from the chorea in that it is a rhythmic motion in contrast to the changeable sudden motion of chorea. Trophic Disturbances. — Trophic disturbances occur in infantile cerebral palsy and affect the soft parts and the bones of the skull and extremities and joints. There are thickening and irregularities of the bones of the skull. The muscles of the face and extremities are slightly atrophic. The electrical reactions of muscle in the par- INFANTILE CEEEBBAL PALSY. 849 alyzed members show no change except in cases of very long stand- ing, where there is a change in the muscular reactions. There is also a retardation in growth of bone and muscle. Epilepsy. — Epilepsy appears in most cases of infantile hemi- plegia as a closing complication. It may appear after the lapse of several years or may in unusual cases come on after the initial con- vulsions. As a rule the more recent the case the less likely there is to be epilepsy, so that the first two years of life are free from it. The frequency of this complication varies with the cases studied. Thus Gowers gives the frequency as 66 per cent, in his cases, while Gaudard found it in 13 per cent., and Sachs in 50 per cent. At first the epileptic seizures are not as outspoken as in true epilepsy. The aura is more distinct and gives warning in time, the initial cry is wanting, the biting of the tongue less frequent and coma and delirium do not follow the attack. While this is so at first, the subsequent course is such that ultimately there is no difference be- tween these epileptic seizures and those of true epilepsy. The condi- tion of the mind suffers in all cases of hemiplegia, from mild states of weakened intelligence to total idiocy. The epileptic seizures con- tribute still further to intensify the injury to the psychic sense. Course.- — It will be seen from the above that the cases of infantile cerebral paralysis or hemiplegia have a certain course : the prodromal stage, the paralysis with contracture, the chorea, and finally the epilepsy. All cases do not develop chorea and epilepsy, nor does the paralysis show an equal intensity in all cases. Some show an evanes- cence of paralysis ; in others the paralysis is very mild, without chorea or epilepsy, and lastly cases occur in which in the stage of epilepsy the paralysis disappears, so as to mislead into a diagnosis of primary epilepsy. In other instances the epileptic seizures when they appear and as they do dominate the clinical picture may miti- gate and disappear after short or long intervals. Morbid Anatomy. — Prenatal Cases. — There is porencephaly. Half a hemisphere, an entire hemisphere, or both hemispheres may be im- perfectly developed. There are also certain defects in the cerebral hemisphere to which is applied the term " Agenesis Corticalis." That is to say, there is imperfect development of the cortical gray cells, particularly those of the pyramidal type. The agenesis may extend throughout all parts of the hemispheres. Birth Palsies. — The principal lesion is meningeal hemorrhage (MclSTutt). This may occur in areas over the cortex, or at the base of the brain. There may be a diffuse hemorrhage over the whole cortex of one hemisphere. The extravasation is, as a rule, most pro- fuse over the motor area. 54 850 DISEASES OF TEE NEBVOUS SYSTEM. Acute Palsies. — In these there are found embolism and throm- bosis, or hemorrhage, the latter occurring mostly at an advanced age. As a result there may be atrophy of the cortex, sclerosis or cyst forma- tions. Cysts are sometimes found later in life, there having been no previous symptoms (Gowers). They undoubtedly originate in in- fancy. Some authors (Gowers) state that embolism, others that hemorrhage, is the pathological condition most frequently found in cerebral palsies of acute origin. The cause of hemorrhage in these cases is still a matter of speculation. There is certainly a change in the bloodvessels, but whether it is the fatty change seen in the blood- vessels in infancy and first pointed out by von Recklinghausen, is a question. It may be that, given a vulnerable bloodvessel, heart dis- ease or any infectious disease will j^redispose to hemorrhage. Cysts are likely to be found in cases in which there is idiocy. Diagnosis. — Intra-uterine and birth palsies give a distinct history of early development. If a palsy has developed a few months after a normal labor, it is to be classed as possibly intra-uterine. Both prenatal and birth palsies are likely to be diplegic or paraplegic. As a rule there is mental deficiency. Paralysis may be complete, or, as in one of my cases, scarcely noticeable. Double athetosis is indica- tive of double hemiplegia, and may even take the place of paralysis. Choreiform movements are frequently mistaken for chorea. They are unilateral and combined with exaggerated reflexes and partial, slight, or marked paralysis. Aphasia of cerebral palsies is motor rather than sensory. Its presence precludes the possibility of the palsy's being of prenatal or of birth origin. The cerebral palsies are differentiated from the infantile forms of paralysis by the presence of spasticity, contractures, rigidity, in- crease of deep reflexes, and occasionally by the presence of athetosis and choreiform movements and epilepsy. In recent cases the absence of atrophy will also aid in diagnosis. Prognosis. — So far as prenatal and birth forms of palsy are con- cerned, no definite prediction in regard to the outcome can at first be made. Many of the cases of birth palsy die at the outset. Some escape with very slight paralysis. Others develop convulsions with subsequent epilepsy and idiocy. Contractures, diplegia, and double hemiplegia with spastic symptoms may develop. The acute cerebral forms may improve to such an extentthat only slight paralysis, chorei- form movements, or athetosis remain. In other cases improvement is followed by a return of the symptoms, with convulsions and epi- lepsy. It is estimated that fully 45 per cent, of the cerebral palsies develop epilepsy, while the diplegic forms are less likely to do so. One convulsion is apt to be followed by others, and these in time by epilepsy and mental deficiencies. FACIAL PALSY. 851 Treatment. — The treatment of cerebral palsjis ultra-conservative. Cases of birth palsy have difficnltj in deglutition. Aid in keeping up the nutrition of the patient may be given by spoon-feeding or feeding with stomach-tubes (gavage). If there are convulsions, bro- mides in moderate doses are administered. The infant should be kept perfectly quiet. In the acute cerebral cases, if hemorrhage is suspected, rest and the application of an ice-bag to the head are indi- cated. Subsequent convulsions are treated vs^ith bromides. The bowels are kept open with calomel. In cases in which there is slightly marked paralysis, massage and the various forms of hydrotherapy are of great utility. The faradic current has much the same effect as massage. If contractures and choreiform movements supervene, the various orthopsedic appliances are of great practical utility. Where indicated, they should be used in connection with judicious tenotomy. Surgical interference has been practised in forms of epi- lepsy which simulate the Jacksonian type. The results are disas- trous in young children, nor is permanent relief to be expected in older ones. FACIAL PALSY. {Bell's Paralysis.) Paralysis of the facial nerve is quite common in infancy and childhood. As in the adult, the distribution and etiology of the paralysis vary. The facial paralysis observed in infants who have been delivered with forceps is a pressure paralysis. It may affect the upper or lower branches of distribution. The prognosis of this form of paral- ysis is, as a rule, very good. Recovery takes place after a few weeks. Some cases do not thus recover; there should therefore be some con- servatism in prognosis. Congenital facial palsy may occur in the absence of any history of traumatism or pressure. Henoch records such a case in a boy of ten years. There was deafness on the side of the paralysis, but no history of disease of the ear. The so-called rheumatic form of facial paralysis occurs in infants and children, but rarely does so before the third year, and most com- monly between the sixth and fifteenth years.. The symptoms are the same as in later life (Figs. 194 and 195). Of greatest interest to the practitioner are the facial palsies which occur in infants and children as a result of ear disease or of inflammatory disease of the mastoid process. In infants a few months old, I have seen facial palsy due to otitis in one ear (Fig. 196). Henoch has seen cases in infants from three to five months of age. The facial nerve is affected as" it passes through the Fallo- 852 DISEASES OF THE NEEFOUS SYSTEM. pian canal. Caries of the bone, pus, or swelling in the vicinity of the canal, will cause this form of paralysis. It is therefore a species Fig. 194. Facial paralysis, left side, rheumatic form. Girl, eight years of age. Fig. 195. Facial paralysis, rheumatic form, showing inability to close the eye. Girl, eight years of age. of pressure paralysis. There may he no distinct collection of pus in the mastoid cells, but, when opened up, the mastoid is found to be FACIAL PALSY. 06 filled with granulations. Temperature, tenderness, and redness over the mastoid should arouse suspicion. Bokai reports a case of retropharyngeal abscess in which the facial palsy was caused by pressure on the nerve as it emerged from the stylo-mastoid foramen. Another form of facial palsy is that seen in basilar disease of the brain. The facial palsy seen in tuberculous meningitis and some- times in the non-tuberculous variety is of great diagnostic import. This paralysis is not always marked ; it is often a very slight paresis with flattening of the facial muscles on one side and accompanied by slight widening of the palpebral fissure on the same side. In con- nection with this symptom, a dilatation of one -pwpil or slight stra- FiG. 196. Facial palsy complicating otitis. Infant, seven months of age. bismus is exceedingly significant of basilar affection. In other words, in the forms of meningitic facial palsy, the physician should be on the alert for changes in the contour of the face, since in many of these cases the patient is conscious only at intervals. In many cases, restlessness on the part of the patient will cause the slight flatness of the face or widening of the ^^alpebral fissure to disappear. The patient should be watched unawares or when at perfect rest. The facial palsies with cerebellar tumors and tumors of the pons have been referred to in the section on Tumors. Operative facial palsy in infants and children is likely to occur after the radical operation on the mastoid, if the operator is not a thorough anatomist. I have felt that this accident could be avoided. After an operation on the mastoid I have seen mild facial palsy, consisting of a very slight lagophthalm.os with slight flattening of the facial muscles, which disappeared within twenty-four hours. It 854 DISEASES OF THE NEEVOUS SYSTEM. was possibly due to j)ressiu-e on the nerve during the operation. Facial palsy following a mastoid operation is, as a rule, due to actual traumatism to the nerve, and to its partial or total destruction. The paralysis in such cases is permanent. Finally there is a facial palsy described in the article upon poliomyelitis. Treatment.— The treatment of facial palsy in infants and children is determined by the origin of the palsy, and is essentially the same as in the adult. MULTIPLE NEURITIS. This is an affection in which several or most of the peripheral nerves undergo degeneration of an acute type. The nerves affected are, as a rule, symmetrically distributed. Etiology. — The disease may be caused by the poisonous action of drugs, such as lead, arsenic, and alcohol. It follows the infectious diseases- — measles, diphtheria, typhoid fever, influenza, and malaria. In such cases the degeneration is due to the action of bacterial toxins on the peripheral nerves. Cold is said to favor the onset of the disease. In many cases it is impossible to fix upon any defi- nite cause. Frequency. — If we excc]:)t diphtheritic paralysis, affections of the peripheral nerves are much less common in childhood than in later life. It is extremely rare in early infancy, though I have seen mul- tiple neuritis follow measles, in which the nerves of the face, the eyes, the soft palate, the extremities, and trunk were involved in a child of fourteen months of age. When it does occur in childhood, there is a strong hereditary predisposition, or the morbific influence in the case has especial predilection for the peripheral nerves. Morbid Anatomy. — There is an early stage during which there are hypera?mia and swelling of the sheaths of the nerves, which may be the seat of minute hemorrhages. The nuclei of the sheaths are enlarged. There is an increase of connective-tissue cells between the nerve-sheaths, and also of round and spindle-shaped cells between the nerve-fibers. The changes in the nerve-fibres are characteristic of nerve degeneration. The musclos may l)e the seat of parenchy- matous degeneration. The striation may become indistinct. In some cases there are also interstitial changes. Symptoms. — The syinjjfonis of multiple neuritis in children are very characteristic. After an infectious disease, the child no longer walks with a steady gait, bnt may stumble and fall. After a time it is noticed that the ])ati('n1 docs not care to stand, and the mother is unable to persuade it to do so. The child cries when put on its feet, which refnse to supjiort il. I'lici-c scorns to be pain connected with an attempt to stand, jiiid also (ui li;inac is situated between the cord and its membranes. DEFOEMITIES OF SKULL AND SPINAL CANAL. 881 (&) Meningocele spinalis, in which the inner surface of the sac is formed bj the arachnoid and pia mater. (c) Myelocystocele, in which the fluid is situated in the central canal of the cord. Myelomeningocele. — The myelomeningocele forms a broad but not very prominent tumor, which may be found in the lumbosacral, cervical, thoracic, or sacral regions. At its base the tumor is red- dish, and is covered with fine, long hairs. This zone is from 1 to l-g- cm. broad. In the centre of the tumor there is a reddish-brown velvety vascular area, the remains of the medullary vascular zone. The sac is formed of arachnoid and pia mater. Its interior is crossed by nerve-trunks. The cord is drawn outward and some nerves may arise from the prolongations of the cord. Accordingly, there is an accumulation of fluid in the meninges (hydromieningocele), with an accompanying hernia of the cord (myelocele). Meningocele Spinalis. — Meningocele spinalis is the rarest form of spina bifida. The sac is composed of pia and arachnoid. The latter may be much thickened. The opening into the vertebral canal if large may allow hernia of the cord. If the tumor is situated in the sacral region, the interior of the sac may contain the nerves of Cauda equina. Myelocystocele, Hydromyelocele, or Syringomyelocele. — Myelo- cystocele, hydromyelocele, or syringomyelocele, is that form of spina bifida in which there is a dilatation of the central canal of the cord. The dura is lacking in the sac, which is lined with cylindrical epithe- lium. The spinal cord in part of its extent may be found in the sac, or may be found on the exterior wall of the sac and end there. It may break up into several bundles. In the interior the spinal nerves form a series of loops with their convexities posteriorly. They may return into the vertebral canal or may end in the sac. Spina bifida is a primary agenesis. The growth of the sac is due to inflamma- tory processes. Symptoms. — The tumor is the chief physical sign. It is situated in the median line or may be at one side. It is round or elliptical and covered with thinned or thickened skin (Fig. 203). In the centre of the myelocystocele is a depression which gives the tumor a tomato-like appearance. The tumor may be soft, hard, or fluctuating. The defective vertebral laminse may be discerned on palpation. The tumor enlarges and becomes tense when the patient assumes the upright posture, cries, or exerts himself. When the patient takes the recumbent posture it becomes smaller. It also does so at each inspiration. In some cases the functions of the iiidividual are normal. In others, the mobility and sensibility of the lower extremities are 56 882 DISEASES OF THE NEEVOUS SYSTEM. affected. Deformities of the foot similar to those seen in infantile paralysis are sometimes present. There may be incontinence of urine and faeces. There are sometimes trophic disturbances, such as perforating ulcers. These are of value in the diagnosis of lumbar tumors which are apparently lipomatous in their nature and are covered with hair (Kirmisson). In such tumors, disturbances of sensibility occurring with perforating ulcers and deformity and atrophy of a lower extremity are significant of spina bifida. Fig. 203. Spherical form of spina bifida lumballs, ulceration at superior surface of tumor. Course. — Spina bifida if left to itself may grow to a large size, may burst or ulcerate, and cause death by pyogenic infection of the meninges and cord tissue. In other cases a lineal ulcer discharges fluid and closes up several times in succession. In some cases of spina bifida the tumors remain stationary in size until late in adult life. In rare cases spontaneous cure results by inflammation of the pedicle of a pedunculated spina bifida. Diagnosis. — The diagnosis of spina bifida is not ditfieult if what has been detailed of the anatomy and symptomatology is borne in mind. Muscatello gives the following characteristics of the various forms : Myelocystocele. — In myelocystocele there is a rouud tumor with a wide base. The tumor is lumbosacral, clastic, translucent, and fluctuating, and does not diminish on pressure. Pressure causes tenseness of the fontanelle. There may be scoliosis, lordosis, abdom- inovesical fissures, and deformity of the foot. Myelomeningocele. — In myelomeningocele there is a flat, soft, elastic tumor, either lumbar, sacral, cervical, or thoracic. It may be complicated by umbilical hernia, paralysis of the extremities and bladder, and deformity of the foot. DEFORMITIES OF SKULL AND SPINAL CANAL. 883 Meningocele. — In meiiiiigocele there is a sacral pedunculated translucent tumor, but no disturbances of mobility or sensibility. Spina Bifida Occulta. — Of considerable interest is the form called spina bifida occulta (Fig. 204). In these cases there may be no tumor, the seat of the deformity being indicated by a depression or dimple. In other cases, as in that shown in the illustration from Kirmisson, there is a small tumor of doughy consistence on one of Fig. 204. Spina bifida occulta. the gluteal folds. The tumor may present an umbilication. Spina bifida occulta should be suspected in cases in which abnormal sacral depressions or tumors occur in connection with clubfoot deformities or congenital incontinence of urine or faeces, or of both. Treatment. — The treatment of spina bifida belongs to the domain of surgery. The treatment by injections of Morton's fluid (2 per cent, of iodine, 6 per cent, of potassium iodide in glycerin) has been abandoned in favor of excision of the sac. SECTION XYI. DISEASES OF THE SKIN. The skin of the infant is exceedingly delicate in structure. After birth there is a physiological condition of desquamation, as a result of which the skin is very sensitive to a traumatism which in older children would be considered slight. In the newly born infant, such is the delicacy of the structure of the skin that infection may occur when no lesion of continuity is apparent (cryptogenic). A rapid examination of the skin is the first step in making a full physical examination of an infant or child. The surface is first inspected from a distance, the color and the presence or absence of an eruption being noted. It is of the first importance to decide whether an erup- tion is acute or connected with constitutional taint (syphilis). An eczema may in a syphilitic infant have certain characteristic varia- tions of color which will at once lead the examiner to suspect consti- tutional disease. A familiarity with acute eruptions (exanthematic) is essential. These must be diagnosed or excluded before any treat- ment can be inaugurated. Forms of oedema must be differentiated from sclerema and myxoedema, and indurations of the skin from ele- vations. A papule may be elevated but not indurated. Since the skin of infants and children is exceedingly delicate, it will show indu- rations more distinctly than that of the adult. The Care of the Skin. — Stretching or harsh manipulation of the skin of infants will tear or traumatize it. Irritating soaps should not be used. The drying of the skin should be carried out gently. The skin in the groin and axilla should not be unduly stretched lest rhagades or fissures result. In powdering the skin, a fresh pledget of absorbent cotton should be used as a powder puff, and all the excess of powder blown off, lest caking result. In some infants the wearing of flannel or wool next to the skin causes irritation and eruptions of different varieties. Such infants should wear a very fine cambric or linen garment next the skin, and over this the woollen shirt. ECZEMA. Eczema is a very common affection in infancy and childhood. Some infants, otherwise in apparent health, suffer at times from a very mild eczema of the face, which appears chiefly on the cheeks, but which may also be present on the chin, forehead, and ears. The 884 ECZEMA. 885 infants do not seem to suffer much, except that they scratch the erup- tion. The eruption is local. It may improve without treatment, but if there are conditions of traumatism and infection, it will grow worse. It is rarely moist, but, if scratched, it will bleed, and fissures or ulcers with bloody crusts will form. Another form of eczema is pustular and vesicular. The skin of the face has a red, angry look. Here and there patches of skin are covered with scabs ; in other areas the skin is moistened by a serous or seropurulent exudate. This eczema is usually also present on the hands and arms. If the malady has existed any length of time, there is considerable thickening of the skin of the hands. The head and scalp may be affected. Eczema is sometimes general. On the face, it is general and pus- tular; on the body, there are both the squamous and the pustular forms with all the various gradations between. There are crusts, rhagades, and areas of superficial loss of tissue. The infants scratch and are uneasy and restless at night, but the general health is excellent and the appetite and digestion are good. The weight increases. If the eczema is general, the infants some- times become puny. They scratch the eruption, constantly causing' the surface to bleed. The body is sometimes one raw, suppurating- surface. The lymph-nodes connected with the affected surface are enlarged. Such enlargements should be differentiated from those of pyogenic origin. A very troublesome form of eczema is the impetiginous or pus- tular variety. The pustules burst and leave the surface covered with dried crusts of pus. This form may affect any part of the body. Of especial interest, and in a class apart, is the so-called impetigo faciei contagiosa. This is a contagious pustular eczema. It affects by predilection the upper lip and the alse nasi. The pustules break down and leave dry crusts of a golden-yellow color. The anterior nare& may be blocked up by these crusts. This variety of impetigo may in children spread over the whole surface and the extremities. I have seen it affect several children in a family. There can be very little doubt as to the infectious and contagious nature of the malady. Eichstedt, Lustgarten, and others have, with cocci obtained from the pustules, succeeded in inoculating the malady on the human subject. Intertrigo (eczema intertrigo) or erythema intertrigo is one of the forms of erythema which develop by maceration into an eczema. Intertrigo is found in the folds of the neck, axilla, and groin, in well-nourished, rather obese infants. It is at first acute, but may become chronic. There is at first a slight redness of the folds of the skin (erythema). If through neglect the epidermis is allowed to macerate, excess of secretion results and the collected secretions 886 DISEASES OF THE SEIX. decompose; tlie surfaces may become eroded, and ulcerations result. In some cases there are lineal ulcers in the groin. In others, the ulcers may become coated with a pseudomembrane. In rare cases actual necrosis of tissue results. Some anaemic infants present a ten- dency to rhagade formation, not only in the groin, but also around the anus and lips. The intertrigo may have the color of copper, instead of the bright-red hue of an ordinary eczema. In such cases there is always a possibility that the intertrigo may be of syphilitic origin. If there is no great panniculus of fat, and if with the inter- trigo there appear erythema and fissures between the toes, and glossi- ness of the skin on the plantar surface of the feet, there are additional grounds for assuming that there is a syphilitic element. Intertrigo, like other skin eruptions, may be accompanied by enlargement of the lymph-nodes leading from the region affected. In obese infants, the umbilicus may also be the seat of eczema, which results from the accumulation and decomposition of secretions. Seborrhoea capillitii is an eruption on the scalp of infants and children which is classified by Unna as a form of eczema. The scalp is covered with a coating of yellow or discolored sebum, which con- sists of fat, desquamated epithelium, and hair. If allowed to accu- mulate, it is sometimes of considerable thickness and may be detached from the scalp. It then leaves a slightly reddened surface, which may bleed. In a short time the scalp may become glossy, and a new layer of the fatty secretion may form. This process may continue until the second or third year. This seborrhoeic eczema has some- times a cheesy odor. Seborrhoea of the umbilicus has been mentioned. In infants and children there may also be seborrhoea of the prepuce. There are, in neglected cases, secretion and aphthous ulcerations of the folds be- tween the glans and the prepuce and in the folds of the prepuce. Of great interest to the physician is a form of intertrigo or eczema found on the buttocks and between the nates of infants. It occurs in infants who are not kept dry and whose urine decomposes easily if the diapers are not changed frequently. This is a most troublesome form of eczema. The nates are at first red, the skin then becomes glossy and brittle, and there may be extensive desqua- mation of the surface. This form of eczema or intertrigo may dis- appear under treatment, only to return if precautions as to cleanliness and dryness are not observed. Some of the children suffer from enuresis, and contract the affection through maceration of the skin by the decomposed urine, or from unclean diapers. Etiology, — The etiology of eczema is still obscure. The condi- tions in infancy and childhood are favorable to the development of skin affections. The delicacy of the skin, its constant exposure to ECZEMA. 887 dirt and to irritants of all kinds, and changes of temperature, are etiologically important. All the children of a family may suffer from eczema. In such instances, there is a real hereditary tendency to the disease. The parents are sometimes similarly affected. The influence of diet in causing eczema is not yet understood, but some authors are firmly convinced of the deleterious effects of certain arti- cles of food. I have known urticaria to be caused by eating oatmeal and fruits, such as strawberries, and urticaria may be the beginning of eczema. In most cases eczema cannot be attributed to articles of diet. It is possible that in certain children the processes of metabo- lism are at fault. Though it has not been proved that all eczema is of an infectious character, there can be but little doubt that many forms are caused by the deleterious action of micro-organisms on the skin (Unna). In favor of this theory is the fact that in many para- sitic skin affections eczema is an accompanying condition. Treatment. — The treatment of eczema is exceedingly difficult. The external causes of irritation should be immediately removed. Attention to cleanliness is alone sometimes sufficient to cure an eczema. If woollen clothing is irritating to the skin, a substitute should be found and cotton or cambric should be worn underneath the wool. The diet should be regulated. This is not an easy task, since it is not known what articles of diet produce eczema. If the infant is at the breast, the diet of the wet-nurse and her daily habits should be regulated. Even when the nurse takes simple food, and the milk is flawless, the infant may suffer from eczema. If the nurse is addicted to the use of beer, or vegetables, such as asparagus, the quality of the milk may be affected. The diet of a wet-nurse should not be changed more often than is necessary, else the secretion of milk may cease. If the wet-nurse has a rheumatic or gouty tendency, it is wise to change nurses. On the other hand, an infant may be overfed and excessively fat. In that case the intervals between nursings should be lengthened. To attempt to change the percentage of fat in the milk is not only of questionable utility, but is not always feasible. If the nurse is constipated, the bowels should be regulated, and she should take abundant exercise. Artificially fed infants are still more difficult to manage. If the infant is thriving, interference with the food percentage is not always clearly indicated. Artificially fed infants may also be overfed or the percentage of fat or proteids may be too high. There may, however, be eczema even when the compo- sition of milk is proper for the infant, age and weight being taken into consideration. If there are acidity of the stomach, excessive flatus, constipation, or green stools, regulation of diet is of more practical utility. In such cases it may cause the eczema to diminish. If there is stomach 888 DISEASES OF TEE SKIN. acidity, an alkali (lime-water) should be added to the food. Con- stipation and flatulence should be remedied. If the infant passes urine with urates to such an extent as to cause a red deposit on the diaper, small doses of bicarbonate of sodium should be administered and lime-water should be mixed with the food. Changes of diet are helpful only in those forms of eczema which are either general or disseminated over different parts of the surface. Seborrhoea and intertrigo are purely local affections, and are not influenced by changes of diet. Local treatment is chiefly relied upon to improve the condition of the skin. In the acute or subacute forms soothing applications are utilized. The chronic forms are irritated into a state of reaction, and then treated like acute eczema. The treatment of acute local eruptions, such as intertrigo, consists first in kee23ing the parts scru- pulously clean. After the bath the folds of the skin are mopped, dried carefully, and powdered, the excess of powder being blown off. This alone is sometimes sufficient to cure a slight intertrigo. Dusting- powders which contain carbolized preparations irritate the skin. A good powder has the following composition : 5: Zinci oxidi 3iv (16.0). Amylum 3ij (60.0).— M. Equal parts of zinc and starch powder make an equally good powder. These ingredients should be ground to an impalpable powder. In the severer forms of intertrigo, the parts should first be anointed with ointment having the following composition : ^ Eesorcin . gr. ij-iv (0.12-0.24). Adeps benzoinati 5J (30.0). M. — The lard should be washed. The ointment should be removed from the folds of the skin with a pledget of lint. The skin after being thus left in a slightly greasy state is powdered, the excess of powder being blown off. If there are lineal ulcers in the groin, they should be lightly touched once a day with a 2 per cent, solution of nitrate of silver, to promote granulation. The ointment should then be applied with a small piece of lint. In squamous eczema which is a red or pustular eczema of the face, scalp, and hands, the first question that arises is whether the patients should be bathed. An infant should be kept clean, and there is only one satisfactory method, and that is the bath. If there is eczema of any part of the surface, the bath water may be liberally impregnated with bran. A gauze bag filled with a measure of bran is put into the bath and the bag is squeezed until the water becomes turbid. If a minute quantity of bicarbonate of sodium is added to a bath pre- ECZEMA. 889 pared in this way, tlie effect on general eczema is decidedly soothing. The skin is gently dried after the bath and powdered. If the whole trunk is involved, it is best that the parts of the surface should be treated in succession. The face or an arm is covered with an oint- ment applied by means of a piece of lint, or the ointment is simply rubbed on the skin after the bath. It is not feasible to wrap the whole body in lint and dintment ; with certain drugs, such as resorcin, absorption would occur. The ointm-ents should be applied after the crusts and pustular accumulations have been removed. All oint- ments should be made up with washed benzoinated lard. Vaseline is very irritating to some forms of eczema. Of the emollient and soothing ointments, diachylon, zinc, and bismuth hold a leading place. A very good ointment for general use in rhagades and squamous eczema is the following, which is one of Kaposi's formulae : K Resin, benzoea pulv jj (4.0). _ Axung.porc gv (150.0). Digere cola adde. Zinc, oxidat gj (30.0). M. et ft. unguentum. If made up properly, this is an excellent cosmetic ointment for use in dry eczema. If the skin is dry and thickened, a 1 per cent, /ff-naphthol applied twice daily will soften it. If this treatment proves irritating, a zinc ointment may be applied immediately afterward. In many cases of chronic eczema Lassar's paste is beneficial : K Acidisalioyl gr. xxx (2.0). Zinci oxidat. ") -- -• /QAn^ . 1 > «« .^1 (oU.U). Amylum / oj \ j Vaselin ' §jss (45.0). M. et ft. paste. The following ointment is also excellent : R Acidi salicylici gr. xv (1.0). Ung. zinci oxidi gij (60.0). — M. The tar salves and mixtures are useful in cases of chronic eczema in which there is little or no moisture : K 01. rusci 3i (4.0). Ungt. zinci ox 3J (30.0). M. — For external use. or R 01. fagi ^ijss (10.0). Glycerin ;5J (4.0). Ung. diachylon |jss (45.0). Balsam. Peru 1^ xxx (2.0).— M. 890 DISEASES OF THE SKIN. In eases of red eczema of the face, the ointment is best applied on a mask made of lint. In that form of intertrigo which resnlts from the irritation of urine, the condition of the diaper is frequently the chief source of trouble. It is often damp or too thin. As a result, whenever the infant passes urine, the diaper becomes saturated with it and decom- position takes place. A piece of absorbent gauze as large as the diaper should be placed next the skin, and renewed whenever it becomes moistened. The skin is dried and the ointment applied on the gauze. Intertrigo is quickly cured by this treatment. Treatment of Seborrhcea of the Scalp. — The accumulated sebum is moistened with oil, or a piece of lint moistened with olive oil or any indifferent oil is applied at night. In the morning the crust of sebum will have softened sufficiently to allow of its removal with gTeen soap and water. After the parts are well cleaned, a salicylated ointment, 0.5 to 1 per cent., is applied daily. The ointment should be spar- ingly applied in order that it may not irritate the parts. Seborrhoea should be treated for some time after it is apparently cured, or it will return. In older children who have abundant hair, the seborrhcea accumulates at the roots and the scalp has an odor. The head should be thoroughly shampooed once a week ; after the shampoo, an exceed- ingly small quantity of cosmetic hair oil should be applied to the scalp once a day. ERYTHEMA MULTIFORME. {Erythema Nodosum; Erythema Exudativum.) Erj'thema exudativum is divided into two forms. The acute form includes erythema multiforme and nodosum, and is an acute infectious disease (Lewin). The exudative form occurs frequently in infants and children. Of 40 of my cases, 10 were under two years of age. The form of erythema known as erythema nodosum begins with general malaise and sometimes with fever, which may be quite high. There is pain in the joints and over the areas affected. These areas are raised and are purple or bluish; the skin is tense and the parts affected are very painful. The nodes vary in size. They first appear chiefly on the extensor surface of the tibi^. The extremity some- times looks as if it had been beaten. This form of erythema is per- haps allied to hemorrhagic diseases, such as peliosis. In a case of pcliosis rheumatica which I saw recently there were erythematous and painful nodules on the hands. Antitoxin may cause exudative erythema. As is well known, such toxic infection also involves the joints. The symptoms are fever, pain in the joints, and extensive FUEUNCULOSIS. 891 erythema nodosum. I have seen such a case in a subject, who had received an immunizing injection. Within six hours, the legs, knees, and thighs were swollen and the seat of this peculiar erythema. French writers speak of the frequency of cardiac disease in ery- thema nodosum, and of its relationship to rheumatism. I have care- fully studied 40 cases for signs of cardiac disease, and could find only 3 cases with systolic murmur at the apex. I have recently seen 2 others. In my opinion, true endocarditis is not a very common complication of erythema nodosum. In only one case did the mur- murs appear to be serious. The disease lasts only a few days, but there may be relapses. The second form of chronic erythema resembles the acute form. The nodules are flat and deep, and are not raised much above the surface. They appear chiefly on the lower extremities of badly nour- ished children. They are less painful than in the acute form. After a time they disappear, leaving no sign of their presence. Treatment. — Cases of erythema of the acute form are treated with sodium salicylate and a diet of milk at first, fruit-juices and beef- juice being given later, and local applications of oil of wintergreen to the painful areas. FURUNCULOSIS. {Folliculitis Abscedens or Perifolliculitis Ahscedens. — Escherich.) . This affection of the skin is very common in infancy and child- hood, and occurs chiefiy in badly nourished, marantic babies, who suffer from gastro-enteric and pulmonary infections. The disease is due to an invasion of the deeper layers of the skin by staphylococci. These have been found in the pus and in the sweat and sebaceous glands of the skin (Escherich). In the mild forms of furunculosis there are one, two, or more furuncles on the forehead, scalp, occiput, and neck. Sometimes the furuncles are large and the skin is riddled with them, but as a rule they do not communicate with one another. In aggravated cases, furuncular abscesses occur on the trunk and on the upper and lower extremities. When the furuncles or boils be- come very numerous, they play a leading role. Many children in institutions succumb to this affection. The condition closely resem- bles a form of sepsis. Treatment. — The treatment of these cases is simple. I have ad- ministered alkalies, such as bicarbonate of sodium, internally. The effect on the general process is excellent. I have also given sulphide of calcium in grain -J doses (0.03) with good effect. The infant is bathed in bran daily. Too many of tjie abscesses should not be opened at once, and they should not be opened until they point and 892 DISEASES OF TEE SKIN. the skin over them becomes reddened. If thej are opened earlier, the results are not so good. After the abscesses are opened, the pns is expressed and a moist dressing applied. The abscesses heal easily. As in other septic affections, the patients should be stimulated and carefully fed. Small furuncles appearing only on the face need not be opened. The application of a 2 per cent, salicylated ointment twice daily softens the pustules and causes the contents to be dis- charged. I have seen most brilliant results from the use of vaccines in cases above described. The vaccines should be prepared from the pus of the furuncle or abscess. SUDAMINA. (Miliaria Alba; Miliaria Buhra.) Sudamina is an affection occurring in infants and children during very warm weather. In the form called miliaria alba the epidermis at the openings of the sweat-glands is raised by a minute serous exu- date and small vesicles are formed. There is no inflammation of the skin. In a second form, the same process takes place, with the presence of a minute focus of inflammation and redness at the open- ing of the glands. Some of the vesicles are pustular. There are also numerous papules of eczema. There is a slight infection of the skin about the opening of the sweat-glands. Both these conditions are irritating, but in no way serious. The skin should be kept scru- pulously clean and dried with powder. Woollen fabrics should not be worn next the skin. If the condition becomes severe, bran baths and a bland zinc or diachylon ointment should be used. Sudamina of both varieties are met with in scarlet fever dermatitis. DERMATITIS EXFOLIATIVA. (ElTTER VON ElTTERSHAIN.) This affection is peculiar to the newborn infant. Eitter in 1878 described an epidemic. In 1895 Escherich published an account of a small outbreak in Gratz. Nature and Etiology. — It was first suspected by Hitter to be one of the septic infections of the newly born infant. His view has lately been supported by Escherich. Occurrence and Symptoms. — The disease appears from a few days to two weeks after birth. It usually occurs in poorly nourished in- fants, but may affect apparently healthy infants of normal weight. Boys are more frequently affected than girls. The affection is pre- ceded by the appearance of a diffusely red erythematous or dark swelling of the general surface. The skin is thickened, soft, mac- CONGENITAL ICHTHYOSIS. 893 erated, and velvety to the toucli. The epidermis can be moved on the corium beneath. The pressure of the clothing or bedclothes may also produce this effect. Minute vesicles appear, and coalesce to form larger vesicles or bullae. Vesicles or bullse of large size which may be either partly filled with serum or empty are formed. They are never tense, and finally open or tear, leaving the red moist corium exposed. The surface of the body has a beefy-red color, and is covered here and there with patches of dry, adherent epidermis ; in other areas the corium is exposed. There are rhagades at the angles of the mouth and on the trunk. The upper extremities become affected later than the lower ones. Whole areas of the trunk and body are denuded of epidermis. After the vesicles burst and leave the corium exposed, the epidermal layer of the skin is still adherent in places, while the desquamated skin is rolled up into cord-like masses and hangs loosely exposed. If recovery takes jDlace, the corium be- comes covered with a delicate epidermis, which gradually assumes the normal pinkish-white hue. Some cases may run an afebrile, others a febrile course. Course and Prognosis.. — A few of the cases recover. Ritter lost 50 per cent, of his cases, and Escherich 90 per cent. The infants may die from the sixth to the tenth day or after the third week, when much of the skin has undergone retrograde changes. The cases may show umbilical infection or bronchopneumonia, pointing to the septic nature of the disease. Treatment. — The infants are kept warm by artificial means, such as warming bottles or an incubator. They are not bathed. The skin is protected by the application of bland salves or gauze moistened with a mixture of linseed oil and lime-water (Escherich). Some physicians add a small quantity of salicylic acid to the salves. As soon as the skin has become dry, Lassar's paste and powdered zinc are applied. CONGENITAL ICHTHYOSIS. (Cutis Sebacea.) Ballantyne gives an exhaustive description of this affection, which is really a perpetuation of a foetal condition into post-natal life. The foetal skin has a tendency to seborrhoea. This is apparent after birth, and is evident during infancy as seborrhoea of the scalp. The sebor- rhoea may affect different parts of the body and may form thin shining scales on the surface of the skin. There may be secondary eczema. The mild forms may, with ordinary cleanliness and the application of bland salves, disappear a few weeks after birth. The form described by Hebra and Kaposi as ichthyosis congenita is an extreme example 894 DISEASES OF TEE SKIN. of the tendency of the foetal skin to the formation of sebum or vernix. The increased secretion continues after birth. The infant appears to be covered with a horny mass which almost envelops it. This parchment-like covering is absent at the mouth, eyes, anus, and on the scalp. The surface is firm and of a yellow or brownish- red tint (Escherich). The hardness and brittleness of the skin render motion painful. The infant is enclosed as if in case-armor. The face has a mask-like expression. The skin is broken in places, especially at the joints. At these fissures the true skin is seen. At the broken spots, the sebum is seen to be composed of lamellae, from the posterior aspect of whichprojectwarty excrescences corresponding to the lanugo and openings of the sebaceous glands. These may be removed from the skin. If the infant lives, the layers of sebum are thrown off gTadually, and the skin is left with a general seborrhoea of the ordinary type. Escherich predicts a favorable course in most of these cases, but some die shortly after birth. Pathologically there is a great thickening of the rete Malpighii ; the corium shows no changes; the sebaceous glands are atrophied or the seat of fatty degen- eration; the sudoriparous glands are normal. After the layers of horny sebum have peeled off, the skin underneath appears pink or red or shining, and is covered with seborrhoeal scales. Treatment. — The treatment consists in the application of emol- lients and in washing the skin daily or bathing the infant in perman- ganate of potassium (grains xv (1.0) to the bath water). Salicylic and boric ointments are applied after the baths. PEMPHIGUS NEONATORUM. Pemphigus neonatorum is a contagious, infectious disease of the skin occurring in the newborn infant. It has also been observed later in infancy. It usually appears at the end of the first or second week, and affects the whole surface, except the palms of the hands and the soles of the feet. There appear on the surface of the trunk and extremities small and large vesicles containing cloudy serum. These burst and leave a round patch of skin, which dries and is covered with yellowish scales. The vesicles may attain the size of bullae. They may be discrete or involve the whole bod}^, so that the surface is after a time denuded of the epithelial layer. The disease may in the beginning be confounded with dermatitis exfoliativa. The vesicles may appear in crops ; the recurrences may extend over a period of from two to four weeks. There are two forms, in one of which the disease is mild ; in the other it runs a malignant course, and from the outset large areas of skin are denuded of epithelium by the bursting of enormous bulhe. PEMPHIGUS NEONATORUM. 895 The infants pass into an asthenic condition, refuse nourishment, and die in a few days. Etiology. — Both forms appear in epidemics. The disease occurs sporadically. The essential cause is still obscure. Strelitz, Demme, Almquist, and Escherich have isolated a white staphylococcus from the serum of the vesicles. Its role as an etiological factor is not as yet understood. Escherich is inclined to class this form of pemphigus with other infectious skin diseases, such as the impetigo of Wilson or Bockhart, and folliculitis abscedens, in which certain conditions favor serous infiltration of the horny layer of the skin and extensive desquamation from the corium. He believes the exciting cause to be the pus cocci found in other forms of impetigo. Escherich has suggested the use of the name " Impetigo Bullosa ISTeonatorum or Infantum " for this affection. Prognosis. — The prognosis is favorable if the process confines itself to the superficial layers of the skin. If the deeper layers are attacked, abscesses and general sepsis result. Treatment. — Escherich recommends that the affected parts be washed with soap and water, and dressed with a 2 per cent, ointment of white precipitate. Baths are not given. Those who are inter- ested in the epidemiological aspect of this disease will find the mono- graph of Richter exhaustive. INDEX. Abdomen, boat-shaped, in meningitis, 44 contour of, in tumor, 44 distension of, in ascites, 44 examination of, 44 free fluid in, 44 inspection of, 44 in intussusception, 44, 45 pain in, 45 palpation of, 44 polypoid tumors in, 45 retracted in septic peritonitis, 44 tenseness of, in colic, 44 tumor of, dyspnoea in, 615 tympanites of, liver dulness in, 44 in peritonitis, 44 Abdominal pain, 45 in appendicitis, 45 in pericarditis, 45 in pleurisy, 45 in pneumonia, 45 typhoid fever, 318. See Ty- phoid Fever Abscess of brain in scarlet fever, 275 of breast, 128, 129 cerebral, sudden death in, 21 metastatic, in arteritis umbilicalis, 210 in phlebitis umbilicalis, 211 perinephritic, diagnosis of, from acute appendicitis, 550 peri-oesophageal, 491 diagnosis of, 491 etiology ot, 491 prognosis of, 492 symptoms of, 491 treatment of, 492 periproctitic, in dysentery, 532 rectal exploration in, 46 retro-oesophageal, 491 retropharyngeal, 585 diagnosis of, 587 diphtheria and, 389 etiology of, 586 in follicular amygdalitis, 590 forms of, 585 frequency of, 586 idiopathic, 585 lymph-nodes and, 585 onset of, 586 prognosis of, 587 in scarlet fever, 271, 276 sudden death in, 20 symptoms of, 586 treatment of, 587 voice in, 587 57 897 Abscess of scalp, diagnosis of, from cephaloheematoma, 235 of skin in scarlet fever, 272 subcutaneous, in typhoid fever, 327 subphrenic, 672 diagnosis of, 673 gas in, 673 metallic tinkle in, 673 physical signs of, 673 simulating enlargement of liver, 562 succussion in, 673 treatment of, 673 visceral displacem.ent in, 670 of thymus gland, 729 Acetone breath in cyclic vomiting, 505 in diabetes mellitus, 712 in urine, 33 Acetonuria, 33 Achondroplasia, 250 Acids, fatty, in human milk, 93 Acorn cocoa, 118 composition of, 119 i^ddison's disease, 753 etiology of, 753 pigmentation in, 754 symptoms of, 753, 754 treatment oi, 754 Adenitis, acute, 716 diagnosis of, 716 from infectious parotitis, 717 etiology of, 716 frequency of, 716 pyogenic infection and, 716 symptoms of, 716 treatment of, 717 facial expression in, 39 retropharyngeal, enlargement of lymph-nodes in, 715 in scarlet fever, 276 tuberculous, diagnosis of, from Hodgkin's disease, 747 Adenoid growths, 579 age and, 580 bronchitis and, 582 deafness and, 581 diagnosis of, 583 from nasal polypi, 583 emphysema of lung and, 602 enlargement of lymph-nodes in, 715 etiology of, 580 - examination in, method of, 584 facial expression in, 39 lymphatism and, 580, 581 898 IXDEX. Adenoid groTrths, mouth-breathing and, 581 occurrence of. 579 paver nocturnus and. 822 prognosis of, 584 rhinitis and, 580 situation of, 580 snoring and, 581 speech and, 581 • symptoms of, 580 treatment of, 584 operative, 584, 585 contra-indications for, 585 indications for, 5S4 varieties of, 582 tumors of umbilicus, 207 vegetations, 579 Adenomata of rectum, 554 Adenopathy, syphilitic, 715 Adherent pericardium, 681 Agenesis corticalis, 849 Agglutinins in human milk, 97, 9 S Air. open, 60 Albinism, nystagmus in, 40 Albumin in cerebrospinal fluid, 77 in cow's milk, 102 role of, in nutrition, 83, 84 in urine, 33 Albuminoids, digestion of. in newborn. 169 Albuminuria in acute gastro-enteric in- fection, 520 cyclic, 770 diagnosis of, from nephritis. 772 etiology of, 771 prognosis of,' 772 symptoms of, 771 treatment of, 772 urine in, 771 in follicular amygdalitis, 590 in influenza, 344 lordotic, 770 in mumps, 371 orthostatic, 770 postural, 770 in scarlet fever, 278 Alcohol in human milk, 97 Alexins in human milk, 17. 88, 89, 94. 95 Allenbury's food, 120 ' ' Allergistie reaction in tuberculin test, 426 Amaurosis in measles, 304 in scarlet fever, 279 Amaurotic idiocy, 837 Amblyopia, infantile, nystagmus in. 40 in typhoid fever, 328 Ama'bie colitis, 534 dysentery, 534 Amorphism, dental, in syphilis, 473 Amygdalitis, follicular, 589 age and, 589 albuminuria in, 590 diagnosis of, 590 duration of, 590 Amvgdalitis, follicular, endocarditis in, 590 etiology of, 589 nephritis in, 590 otitis in, 590 prognosis of, 590 retropharvngeal abscess in, 590 rheumatic cases of, 590 symptoms of, 589 tonsils in, 589 treatment of, 590 lacunar, 589 Amylase in human milk, 94 Amylolytic ferments in newborn, 169 Anaemia, 736 acquired, 736 congenital, 736 in cystitis, 795 enlargement of lymph-nodes in, 716 essential, 736 in habitual constipation, 539 infantum pseudoleukaemiea, 739 enlargement of liver in, 562 lymphatica, 747 pernicious, 752 blood in, 752 primary, 736 progressive, in uncinariasis, 559 pseudoleuksemic, 739 blood in, 741 bone-marrow in, 740 diagnosis of, 742 etiology of, 740 kidney in, 740 liver in, enlargement of, 740, 741 lymph-nodes in, 741 pathology of, 740 rachitis and, 741 skin in, 740 si:>leen in, enlargement of, 740 symptoms of, 740 treatment of, 742 in rachitis, 245 scarlet fever and, 280 secondary, 737 simple, 737 blood in, 737, 738 etiology of, 737 hemoglobin in, 738 hydrasmia in, 737 symptoms of, 737 Anaemic cardiac murmurs, 705 Anaesthesia, sudden death in, 22 Anchylostoma duodenale, 558 Aneurysm, sudden death in, 20 Angina, 591 catarrhal, 589 in chronic valvular disease of heart, 703 membranous, in scarlet fever, 270 in scarlet fever, 267, 270 Anorchidism, 181 Anorexia in hysteria, 804 INDEX. 899 Anterior jioliomyelitis, 861 Antitoxin, diphtheritic, 397 eruptions, diagnosis of, from mea- sles, 307 in human milk, 97, 98 Antipyretics, administration of, 63, 64 Anus, fissure of, 553 constipation in, 553 diagnosis of, 553 symptoms of, 553 in syphilis, 553 treatment of, 553 prolapse of, 552 spasm of, 554 treatment of, 554 Aortic cardiac murmurs, 705 Aphasia in acute encephalitis, 860 in scarlet fever, 279 in typhoid fever, 328 Aphthge, Bednar's, 62, 476 diagnosis of, from diphtheria, 395 Aphthous stomatitis, 478 Apncea in laryngismus stridulus, 817 Apoplexy, sudden death in newborn and, 180 Appendicitis, abdominal pain in, 45 acute, 547 catarrhal, 548 symptoms of, 548 diagnosis of, 549 from intussusception, 545 from lobar pneumonia, 551 from perinephritic ab- scess, 550 from tuberculous perito- nitis, 550 from typhoid fever, 5'51 fever in, 550 frequency of, 547 gangrenous, 549 symptoms of, 549 McBurney's point in, 550 pain in, 550 palpation in, 549 percussion in, 550 perforative, 548 symptoms of, 548 prognosis of, 551 rectal examination in, 550 suppurative, 548 symptoms of, 548 tympanitis in, 550 varieties of, 547 chronic, 551 symptom.s of, 551 treatment of, 552 colic in, 509 empyema and, 652 diagnosis of, from gonococcal peri- tonitis, 571 from pneumococcal peritonitis, 572 from typhoid fever, 330, 332 vomiting in, 507 Appendix vermiformis, 547 anatomy of, 547 Appendix vermiformis, palpation of, 547 position of, 547 size of, 547 Areas, painful, in spine, 47 Armour's beef -extract, 118 beef-juice, 115 vrine of peptone, 115 Arnold's sterilizer, 107 Arrhythmia, 30 in myocarditis, 708 in newborn, 168 Arrowroot, composition of, 115 gruel, 115 preparation of, 115 Arterial murmurs, accidental, 706 Arteriosclerosis, hypertrophy of heart in, 709 Arteritis umbilicalis, 209 abscesses, metastatic in, 210 course of, 210 etiology of, 209 Hennig's symptom in, 210 pathology of, 209 prognosis of, 210 symptoms of, 210 Arthritic pains in chorea, 825 Arthritis, bronchopneumonia and, 642 deformans, 463 in dysentery, 532 rheumatoid, 463 lymph-nodes in, 464 onset of, 463 prognosis of, 464 symptoms of, 463 treatment of, 464 scarlet fever and, 277 in typhoid fever, 328 vulvovaginitis and, 792 Arthrogryposis, 808. See Tetany Articular rheumatism, acute, 459 Artificial infant-feeding, 133 respiration, 195 Ascarides lumbricoides, 556 Ascaris lumbricoides, peritonitis and, 569 Ascites, 45, 567 chylous, 568 etiology of, 568 diagnosis of, 568 from cysts of peritoneal cav- ity, 568 from tumors of peritoneal cavity, 568 distension of abdomen in, 44 dyspnoea in, 615 etiology of, 568 forms of, 568 treatment of, 568 Asphyxia in congenitally weak infants, 198 in newborn, 193 after-treatment in, 197 artificial respiration in, 195, 196 bath in, 195 definition of, 193 900 INDEX. Asjjhyxia in newborn, diagnosis of, 195 from acute fatty degener- ation of newborn, 221 from cerebral hemor- rhage, 195 etiology of, 193 extra-uterine, 193, 197 intra -uterine, 193 pathology of, 194 prognosis of, 195 symptoms of, 194 treatment of, 195 Asthma crystals in fibrinous bronchitis, 60l" dyspnoea in, 614 in emphysema of luugs, 604 thymic, 729, 816 Ataxia, Friedreich 's, ataxic gait in, 50 patellar reflex in, 49 hereditary, 858 diagnosis of, 859 from tabes, 859 muscular power in, 858 nystagmus iu, 858 prognosis of, 859 sensory disturbances in, 858 symptoms of, 858 treatment of, 859 in typhoid fever, 328 Ataxic gait, 50 Atelectasis, 198 acquired, 198 auscultation in, 199 in bronchopneumonia, 634 compression, 198 in congenitally weak infants, 184 convulsions in, 200 diagnosis of, 200 dyspnoea in, 199 etiology of, 198 in measles, 302 obstructive, 198 palpation in, 199 percussion in, 199 prognosis of, 200 rales in, 200 sudden death from, 19 symptoms of, 199 treatment of, 200 Athetoid movements, diagnosis of, from chorea, 828 Athetosis in infantile cerebral palsy, 848 Athrepsia, 260 Athyreosis, 718, 722 Atresia, congenital, of oesophagus, 490 Atrophic paralysis, acute, 861 Atroj)hy of muscle in acute poliomye- litis, 870 infantile, 260 carVjohydrates in, 261 cereals in, 261 etiology of, 260 fats in, 261 pathology of, 261 Atrophy, infantile, symptoms of, 262 treatment of, 263 of liver, acute yellow, 567 muscular, 49 in diphtheria, 49 facio-seapulo-humeral, Dejer- ine type of, 873 Landouzy type of, 873 in infectious diseases, 49 in joiut-afl:ections, 49 in neuritis, 49 in poliomyelitis, 49, 870 progressive muscular, Erb's tvpe, 872 juvenile form of, 872 Auricular septum, congenital defects of, 689 ventricular septum, congenital de- fects of, 689 Aura in epilepsy, 820 Auto-infection in sepsis in newborn, 202 Babixski's reflex, 49 in cerebrospinal meningitis, 352 in tuberculous meningitis, 435, 439 Bacillary infection of human milk, 97 Bacilluria, 796 Bacillus eoli communis in cystitis, 793 diphtherife, 379 of Klebs-Loffler iu diphtheritic rhi- nitis, 578 mesentericus vulgatus in cows' milk. 105 potato, in cows' milk, 105 subtilis iu cows' milk, 105 Bacteria iu cerebrospinal fluid, 76 in human milk, 94 of mouth, 62 newborn and, 17, IS Bacterium coli communis in acute peri- tonitis, 569 lactis aerogenes in cows ' milk, 105 Bad habits, 805 Balanitis, enlargement of lymph-nodes in, 715 Barley, dextrinized, 114, 158 Eobinson's patent, 114, 158 water, 114 in gastro-enteritic disturb- ances, 114 preparation of, 114 Barley-gruel, 157 preparation of, 158 use of, 157 in newborn, 157, 158 Barlow's disease 254. See Scorbutus, infantile Bartholini's glands, metastasis of mumps to, 371 Basedow's disease, facial expression in, 38 Basilar ir.cningitis, 432 INDEX. 901 Bath, Brand, 65 in congenitally Aveak infants, 190 daily, 54 temperature of Avater for, 54 time for, 54 first, 53 drying after, 54 rapidity of, 54 temperature of room for, 53 of water for, 53 water for ;jo, 54 full, 65 in pneumonia, 65 in scarlet fever, 65 in typhoid fever, 65 hardening with, 55 in premature infants, 55 reaction in, 55 sponge, 64, 65 Bed, 58, 59 mattress of, 59 pillow of, 59 Bednar 's aphthae, 62, 476 etiology of, 476 in sepsis in newborn, 203 treatment of, 476 Beef-broth, 118 composition of, 118 Beef -extracts, 117 composition of, 118 varieties of, 118 Beef -juice, composition of, 115 varieties of, 115 Beer, effect of, on human milk, 96 Bell's paralysis, 851 Benger's food, 120 Biedert's mixture, 133, 134 Bilateral empyema, 671 Bile in newborn, 169 Bile-ducts, congenital obstruction of, 564 enlargement of liver in, 565 of spleen in, 565 etiology of, 564 jaundice in, 564 pathology of, 565 symptoms of, 564 Biliary pigment in urine. 31 Bilirubin in meconium, 174 Binaural stethoscope, 42 Binder, body-, 61 Birth, injuries during, 232 loss of weight following, 24 palsy, 232, 843 paralysis, 232 premature, 19 sudden death in, 10 Blennorrhcea of umbilicus, 207 urogenital, 790 Blindness, 40 Blood, carbohydrates in, 85 characteristics of, 739 circulation of, 28 diseases of, 734 haemoglobin of, 736 Blood in newborn, 168 erythrocytes in, 169, 734 histology of, 169 leucocytes in, 169, 735 polycythemia in, 734 in rachitis, 245, 246, 735 specific gravity of, 736 Blood-cells, red, 734 white, 735 Boat-shaped abdomen, 44 Bodies of Lourie, 89, 90 Body, length of, 26 in boys, 26 in girls, 26 increase, 26 Body-binder, 61 Body-temperature in newborn, 170 Bone, changes of, in acute infectious osteomyelitis, 757 in otitis, 760 craniotabes of, 756 diseases of, 755 pains in, 755 disturbances from sterilized milk, 110, 111 • in rachitis, 755 of skull, syphilis of, 756 tuberculosis of, 756 syphilis of, 756 differentiation from tubercu- losis of bones, 755, 756 tuberculosis of, 755 differentiation from syphilis of bones, 755, 756 Bone-marrow in leukajmia, 744 in pseudoleukaemic angemia, 740 Botalli, duct of, 167 Bothriocephalus latus, 558 Bottle, nipples, care of, 62, 112 nursing. 111 care of. 111 Freeman's, 111 warming of, 112 warmer, Sobel's, 112 Bottle-fed children, increase of weight in, 25 temperature in, 30 urine in, 31, 32 Bovinine, 115 Bovril, 118 "Bow-leg" deformity in rachitis, 244, Bradycardia in hysteria, 805 in lobar pneumonia, 621 in myocarditis, 708 Brain, abscess of, diagnosis of, from convulsions in infancy, 800 vomiting in, 508 basilar disease of, facial palsy and, 853 cortex of, tumors of, 841 symptoms of, 841 cysts of, 840 . dropsy of, 833 ganglia of, tumors of, 842 symptoms of, 842 gliomata of, 840 902 INDEX. Brain, sarcomata of, 840 tubercle of, 840 tuberculosis of, 443 tumor of, 840 cerebrospinal fluid in, 76 convulsions in, 841 diagnosis of, from convul- sions in infancy, 800 from epilepsy, 821 etiology of, 840 forms of, 840 frequency of, 840 headache in, 840 location of, 840, 841, 842, 843 nausea in, 841 optic neuritis in, 841 patellar reflex in, 49 pulse in, 841 respiration in, 841 symptoms of, 840 vomiting in, 508, 841 vertigo in, 841 Branchial cysts of oesophagus, 488 fistulse of oesophagus, 488 Brand bath, 65 in typhoid fever, 333 Brand's beef -extract, 118 beef -juice, 115 beef-pepjtone, 116 Breast, abscess of, 128, 129 infectious diarrhoea from, 129 caking of, 129 in newborn, 231 treatment of, 129 use of breast-pump in, 129 care of, 127 chicken-, 27 colostrum in, appearance of, 127 lymphangitis of, 129 in newborn, 171 milk in, 171 biochemical theory of, 171 composition of, 171 niftples of, care of, 61 nursing of infants at, 129 placing of infants at, 128 Breast-fed children, increase of weight in, 25 temperature in, 30 urine in, 31, 32 Breast-feeding, colic in, 130, 131 efficient, signs of, 130 inefficient, signs of, 130 stools in, variation of, 130, 131 Breast-milk. Hee Milk, human Breathing, bronchial, 614 bronchovesicular, 614 normal, 613 puerile, 613 Brack's nursing tube, 189, 190 Bright 's disease, contra-indication to maternal nursing, 124 Bronchi, diseases of, 597 Bronchial breathing, 614 nodes in congenitally weak infants, 184 Bronchiectasis, 606 Ijronchophony in. 609 chest in, deformity of, 609 complications of, 609 congenital. 606 cough in, 608 course of, 609 cysts in, 607 diagnosis of, 609 dyspnoea in, 608 empyema and, 609 etiology of. 607 expectoration in, 608 fever in, 608 foreign bodies and, 607 gangrene of lung and, 609, 610 haemoptysis in, 609 inflammatory, 607 pathology of, 607 physical signs of, 609 pleurisy and, 607, 609 pneumonia and, 607, 609 symptoms of, 608 syphilis and, 607 treatment of, 610 tuberculosis and, 609 varieties of, 606 Bronchitis, acute simple, 597 age and, 597 auscultation in, 599 cough in, 598 etiology of, 597 exanthemata and, 597 infectious diseases and, 597 palpation in, 599 pathology of, 598 percussion in, 599 physical signs of. 599 rhachitis and, 597 sputum in, 599 symptoms of, 598 syphilis and, 597 treatment of, 600 adenoid growths and, 582 bronchopneumonia and. 635 capillary, treatment of, 600 chronic, 601 in emphysema of lungs, 601 in congenitally weak infants, 189 flbrinous. 600 asthma crystals in. 601 casts in, 601 complications of, 601 cough in, 601 cyanosis in, 601 diagnosis of, 601 diphtheria and, 600 dyspnoea in, 601 etiology of, 600 fever in, 601 infectious diseases and, 600 pathology of, 601 physical signs of, 601 pneumonia and, 600 rales in, 601 INDEX. 903 Bronchitis, fibrinous, splenic tumor in, 601 symptoms of, 601 treatment of, 601 tuberculosis and, 601 in influenza, 342 in measles, 302, 308, 309 pertussis convulsiva and, 375 plastic, 600 putrid, 606. See also Bronchiectasis in sepsis in newborn, 201 in typhoid fever, 328 tuberculous, 601 Bronchophony in bronchiectasis, 609 bronchopneumonia and, 643 in empyema, 662 in pleurisy, 662 Bronchopneumonia, 632 age and, 632 arthritis and, 642 atelectasis in, 634 bacteriology of, 633 bronchitis and, 635 bronchophony in, 643 cerebral symptoms in, 638 chronic, 648 complications of, 640 in congenitally weak infants, ]84, 185 convulsions in, 634 cough in, 634 cyanosis in, 634, 635 diagnosis of, 645 from central pneumonia, 644 from lobar pneumonia, 645 diarrhoeal conditions and, 640 diphtheria and, 388, 640 dyspnoea in, 634 empyema and, 652 equivocal signs of, 644 etiology of, 633 fever in, 635 gangrene of lungs and, 640 gastro-enteric tract in, 637 hydrotherapy in, 646 in influenza, 341 measles and, 302, 308, 639 meningitis and, 642 occurrence of, 632 onset of, 634 osteomyelitis and, 642 otitis and, 640, 759, 761 pathology of, 633 pericarditis and, 642 pertussis convulsiva and, 375, 638 persistent, 648 blood in, 649 diagnosis of, 650 physical signs of, 650 symptoms of, 649 treatment of, 650 physical signs of, 642 pneumococcus in, 633 prognosis of, 645 pulmonary tuberculosis and, 422 pulse in, 636 rales in, 643, 644 Bronchopneumonia, scarlet fever and, 639 season and, 632 sex and, 632 sputum in, 637 stages of, 642, 643 surroundings and, 632 symptoms of. 634 treatment of, 646 tuberculous, 421 tympanites in, 637 types of, 634 typhoid fever and, 326, 639 varicella and, 639 vomiting in, 637 Bronchovesicular breathing, 614 Buhl 's disease, 221. See also Newborn, acute fatty degeneration of Bui'goyne 's beef -juice, 415 Butter milk, 117 C Caking of breasts, 129 in newborn, 231 Calculi, biliary, 567 renal, 775 Calmette's tuberculin test, 424, 425 Calories, 31 in carbohydrates, 87 in cows' milk, 86 in fats, 87 heat, 31 in human milk, 86 in proteids, 87 required in artificially fed infants, 88 Cancrum oris, 483. See also Noma Cantani's salt-solution, 66 Caput succedaneum, 26 diagnosis of, from cephalohse- matoma, 235 Carbohydrates, in blood, 85 calories in, 87 in cows' milk, 85 in human milk, 85 in liver, 85 in lymph, 85 in muscles, 85 in nutrition, 85 Carbon dioxide, excretion of, in respi- ration, 28 Carbonic acid gas, excretion of, by in- fants, 88 Carcinoma of kidney, 785 of thymus gland, 729 Cardiac area, 42 disease, sudden death in, 20 dyspnoea, 614 hypertrophy in scarlet fever, 280 insufiiciency in chronic valvular disease of heart, 700 murmurs, 704 Caries of bone, facial palsy and, 852 Carnrick's peptonoids, 116 soluble food, 120 Casein, assimilation of, in cows' milk, 103 904 INDEX. Casein, assimilation of, in human milk, 103 in cows' milk, 91, 102, 103 in human milk, 84, 91, 92, 103 Caseinogen in human milk, 91 Casts in diabetes mellitus, 712 in urine, 34 Catalepsy, 814 in hysteria, 803 symptoms of, 814 Cataract, congenital, nystagmas in, 4C corneal, nystagmus in, 40 Catarrh, acute nasal, 574 bacterial infection and, 574 diagnosis of, 575 etiology of, 574 infectious diseases and, 574 prognosis of, 575 symptoms of, 575 treatment of, 576 chronic nasal, 576 etiolosfy of, 576 lymphatism and, 576 symptoms of, 577 treatment of, 577 enteric, 527 Catarrhal appendicitis, acute, 548 angina, 589 croup, 593 diphtheria, 384 fever, acute, 339. See also Influenza icterus, 563 influenza, 341 laryngitis, 593 otitis media, 759, 760 pneumonia, 632 tonsillitis, 589 Caustic CESophagitis, 490 Cephalohffimatoma, 26, 234 complications of, 235 diagnosis of, 235 from abscess of scalp, 235 from caput succedaneum, 235 from hernia of brain, 235 from phlegmon of scalp, 235 externa, 234 interna, 234 in newborn, 235 pathogenesis of, 235 prognosis of, 235 symptoms of, 234 treatment of, 236 Cerebellum, tumors of, 843 symptoms of, 843 Cerebral abscess, otitis and, 760 diplegia, 843 disease, ataxic gait in, 50 titubation, 50 Cerebrospinal fever, 347. Sec Menin- gitis, cerebrospinal fluid, abnormal, 75 specific gravity of, 75 albumin in, 77 bacteria in, 76 Cerebrospinal fluid, blood in, 75 in brain tumor, 76 cytology of, 76 in hydrocephalus, chronic, 76 lymphocytosis in, 76 in meningitis, cerebrospinal, epidemic, 76 sporadic, 76 serosa, 368 suppurative, 76 tuberculous, 75 normal, 74 pressure of, 76, 77 meningitis, 347 Cerebrum in newborn, 175 Cereo, in preparation of dextrinized gruel, 158, 159 Cervical muscles, spasm of, position of head in, 40 weakness of, position of head in, 40 Chapin 's method of artificial infant- feeding, 158 Chapman 's whole flour, 121 Charcot-Leyden crystals in amcebic dysentery, 534 Chemise, 60 Chemism of respiration, 28 Chest, auscultation of, 613 cardiac area of, 42 circumference of . 27 compress, cold, 65 examination of, 40 in infants, 40, 41 in older children, 41 position of patient in, 40 fremitus in, 611 inspection of, 42 movements of, normal, 611 restriction of, in effusion, 611 in emphysema, 611 in scoliosis, 611 palpation of, 43 percussion of, 43 shape of, 27 in rachitis, 27 Chest-wall, resiliency of, 611 Cheyne-Stokes respiration in septic en- docarditis, 698 in tuberculous meningitis, 434, 439 Chicken-breast, 27 Chickenpox, 310. See also Varicella Childhood, constitutional diseases in, 18 definition of, 17 infections in, 18 intestinal disturbances in, 18 morbidity in, 17 respiratory disturbances in, 18 Chill in onset of illness, 37 <_'hlorosis. 738 l)]ood in, 738 etiology of, 738 Cholecystitis in typhoid fever, 333 Cholera asiatica from infected cows' milk, 105 INDEX. 905 Cholera infantum, 521. See also Gas- troenteric infection, acute diagnosis of, 523 from infectious diseases, 523 hypodermoclysis in, 66 prognosis of, 522 symptoms of, 521 treatment of, 523 Chondrin, 84 Chondrodystrophia foetalis, 250 diagnosis of, 251 from osteogenesis imper- fecta, 252 long bones in, 250 pathology of, 250 prognosis of, 252 skull in, 250 symptoms of, 251 hyperplastica, 250 hypoplastica, 250 Chondrogen, 82 Chondromalacia foetalis, 250 Chorea, 822 in acute articular rheumatism, 462 age and, 823 arthritic pains in, 825 cardiac murmurs in, 827 symptoms in, 826 diagnosis of, 828 from athetoid movements, 828 from chorea insaniens, 831 from habit movements, 828 from tic convulsif, 828 electric reactions in, 825 electrica, 822 endocarditis and, 690, 693, 826 epidemic, 823 epilepsy and, 825 etiology of, 823 frequency of, 823 fright and, 823 habit movements in, 828 Huntington's, 823 infectious diseases and, 824 insaniens, 822, 829 delirium in, 830 diagnosis of, from simple chorea, 831 fever in, 830 symptoms of, 830 sex and, 829 treatment of, 831 laryngeal, 822 lymphatism and, 823 major, 822 mental symptoms in, 828 minor, 822 multiple neuritis and, 825 muscular twitchings in, 825 night-terrors in, 825 onset of, 824 pathology of, 824 pericarditis in, 826 post-hemiplegic, in infantile cere- bral palsy, 848 Chorea, prognosis of, 828 refractive errors and, 823 rheumatism and, 823, 824 scarlet fever and, 281 sex and, 823 speech in, 826 Sydenham's, 822 symptomatic, 822 symptoms of, 824 temjierature in, 827 tongue in, 825 trauma and, 823 treatment of, 829 urine in, 826 wrist-drop in, 825 Chvostek's symptom in status lymphat- icus, 730 in tetany, 811 in tuberculous meningitis, 435 Chylous ascites, 568 Clubbed fingers in stenosis of pulmon- ary artery, 688 Clothing, 60 of congenitally weak infants, 190 Circulation in newborn, 167 Circulatory disturbances, sudden death in, 20 system, diseases of, 674 Cirrhosis of liver, 565 Cocoa, acorn, 119 Coffee, effect of, on human milk, 97 Cold chest compress, 65 pack, 65 sense in newborn, 177 Colic, 508 in acute gastro-enteric infection, 521, 526 in bottle-fed infants, 152, 153 in breast-feeding, 130, 131 cause of, 508 colostrum corpuscles and, 130, 131 symptoms of, 508 tenseness of abdomen in, 44 treatment of, 509 tympanites and, 508 Colicystitis, 193. See also Cystitis. Colitis, amoebic, 534 contagiosa, 528 Colles's law in hereditary syphilis, 448 Collogen, 82 Colon, congenital dilatation of, 540 prognosis of, 540 symptoms of, 541 treatment of, 542 Colostrum, 89 appearance of, in breast, 127 color of, 89 coloring-matter of, 90 composition of, 89 corpuscles, 89, 90 colic and, 130, 131 crescents of, 89, 90 . decomposition of, on nipples, 128 disappearance of, 90 Lourie's bodies in, 89, 90 microscopic appearance of, 89, 90 906 INDEX. Colostrum, physical properties of, 89 specific gravity of, 89 time of appearance of, 89 CondeDsed milk, 113 Congenital anemia, 736 bronchiectasis, 606 constipation, 535 dilatation of colon, 540 hydrocele, 182 ichthyosis, 893 internal hydrocephalus, 833 pyloric spasm, 511 rachitis, 237 stridor of infants, 815 syphilis, 448 tuberculosis, 419 Congenitally weak infants, 183 Conjunctival tuberculin test, 425 Conjunctivitis blennorrhceica, 228 in measles, 295, 304 in scarlet fever, 276 vulvovaginitis and, 792 Conrad 's lactobutyrometer, 100 lactodensimeter, 100 Consanguinity, pseudohypertrophic mus- cular paralysis and, 873 Constipation, 535 acquired, 536 acute, 536 diagnosis of, 536 foreign bodies and, 536 intussusception and, 536 peritonitis and, 536 strangulation and, 586 chronic, 536 anal fissure and, 537 new growths and, 537 in acute nephritis, 780 peritonitis, 569 in artificial infant-feeding, 152 congenital, 535 absence of anus and, 535 malformations and, 535 in fissure of anus, 553 from frozen milk. 111 habitual, chronic, 537 anajmia in, 539 diet in, 539 enemata in, 540 etiology of, 537 habits in, 540 heredity and, 538 incorrect feeding and, 538 massage in, 540 predisposition toward, 537 rachitis and, 537 stools in, 538 symptoms of, 538 treatment of, 539 in pyloric spasm, 513 from sterilized milk, 108 Constitutional diseases, 711 in childhood, 18 Contractures in infantile cerebral palsy, 846 Convulsions in infancy, 797 Convulsions in infancy, alcohol and, 798, 799 coma in, 800 diagnosis of, 800 from abscess of bi'ain, 800 from meningitis, 800 from tetany, 801 from tumor of brain, 800 duration of, 800 etiology of, 797 gastro -enteric disease and, 798 heredity and, 798 pathology of, 799 prognosis of, 801 symptoms of, 799 treatment of, 801 in infantile cerebral palsy, 845 in scarlet fever, 279 in tumor of brain, 841 Convulsive forms of hysteria, 803 Coomb's malted food, 121 Coprolalia in tic, 832 Cord, umbilical, 52. See Umbilical cord Corneal ulcerations in measles, 304 Corpuscles, colostrum, 89, 90 Coryza in measles, 294, 295, 296 Cows' milk. See Milk, cows' Cranial bones in congenital internal hy- drocephalus, 834 Cranio schisis, 880 Craniotabes in congenital internal hy- drocephalus, 834 laryngismus stridulus and, 817 in rachitis, 237, 240, 245 shape of head and, 38 Crawling, development of, 35 Crede method, 56 in ophthalmia neonatorum, 229 Crepitations, pleuritic, in emjDyema, 660 Crepitus of joints, 46, 47 Crescents of Lourie, 89, 90 Crescent-shaped bodies in human milk, 93 Cretinic form of idiocy, 878 Cretinism, 718 endemic, 718 goitre in, 718 skull in, 718 sporadic, 719 age and, 719 blood in, 721 bones in, 724 diagnosis of, 724 from dwarfism with idiocy, 725 from infantilism, 725 from Mongolian idiocy, 724 from rachitis, 246 etiology of, 722 facial expression in, 720, 721 genitals in, 721 hands in, 722 macroglossia in, 722 mental dulness in, 720, 722 pathology of, 723 INDEX. 907 Cretinism, sporadic, skin in, 720, 722 symptoms of, 719 tongue in, 722 treatment of, 725 thyroid extract in, 725 Croup, catarrhal, 593 spasmodic, 593 Croupous pneumonia, 615 Crus cerebri, tumors of, 842 Cryptorchism, 182 Curvature of spine, 47 Cutaneous scarification tuberculin test, 425 Cutis sebacea, 893 Cyanosis in bronchopneumonia, 634, 635 in congenital heart disease, 685 in fibrinous bronchitis, 601 in onset of illness, 37 ■Cyclic albuminuria, 770 vomiting, 503 Cystitis, 793 anaemia in, 795 Bacillus coli communis in, 793 diagnosis of, 795 diphtheria and, 793 etiology of, 793 fever in, 794 frequency of, 794 influenza and, 793 intestinal disturbance and, 793 measles and, 793 pain in, 795 pneumonia and, 793 scarlet fever and, 793 symptoms of, 794 treatment of, 796 urine in, 795 Cysts in bronchiectasis, 606 of kidney, 784 D Dactylitis syphilitica, 455 Dancing mania in hysteria, 804 Darby's fluid meat, 116 Davidson's shield for fissured nijjples, 128 Deafness in newborn, 176 in scarlet fever, 275 Death, sudden, 19 in aneesthesia, 22 in aneurysm, 20 from atelectasis, 19 in bronchopneumonia, 20 in cardiac disease, 20 in cerebral abscess, 21 in circulatory disturbances, 20 in disease of central nervous system, 21 hyperthermia and, 21 intoxications and, 21 in lumbar puncture, 22 lymphatism and, 22 in newborn, 179 apoplexy and, 180 hemorrhage and, 180 Death, sudden, in newborn, prodromes of, 180 in premature birth, 19 in respiratory disease, 20 in retropharyngeal abscess, 20 in tetany, 22 Dejerine type of facio-scapulo-humeral muscular atrophy, 873 Den^yer's peptone, 116 Dentition, abnormal, 471 dental erosions in, 472 incisions of gums in, 474 normal, 470 pathology of, 474 in rachitis, 471 in syphilis, 471 Dermatitis exfoliativa, 892 course of, 893 etiology of, 892 prognosis of, 893 in sepsis in newborn, 201 symptoms of, 892 treatment of, 893 Desquamation in newborn, 17, 170 in scarlet fever, 273 Development, mental, 34, 35, 36 physical, 34, 35, 36 Dew method of artificial respiration, 196 Dextrinized barley, 158 gruel, 158 in artificial infant-feeding, 158 Dextrose in urine, 34 Diabetes insipidus, 712 symptoms of, 712 urinary, 713 treatment of, 714 mellitus, 711 acetone breath in, 712 casts in, 712 diagnosis of, 712 etiology of, 711 furuncles in, 712 polydipsia in, 712 pruritus in, 712 skin in, 712 symptoms of, 711 treatment of, 712 Diacetic acid in urine, 33 Diapers, 57 change of, 57 material for, 57 washing of, 57 Diaphragmatic respiration, 28 Diarrhoea in acute gastro-enteric infec- tion, 520, 524 in congenitally weak infants, 185 fat. 84, 153 facial expression in, 39 from frozen milk, 111 in influenza, 341 in measles, 303 from raw milk, 110 in scarlet fever, 280 in sepsis in newborn, 201, 205 summer, 517 Diastase in artificial infant foods. 119 908 IXDEX. Diastase in preparation of dextrinized grueJ. 158 Diastased farina. 121 Diatheses, hemorrhagic. 747 transmission of. bv Tret-nursing, 122. 123 Diazo reaction. Ehrlich "s. in tvphoid fever. 331 Dicrotism, 30 Diet after operations. 164 articles of, to avoid, 162 during convalescence, 164 infantile scorbutus and, 2.55 in rachitis. 247 in sick infants. 164 Dietaries for infants and children. 162, 163 Diffuse nephritis, acute, 776, 777 chronic, 781 Digestive functions in nevrborn, 169 Dilatation of heart, 709 of stomach. 509 Diphtheria. 378 age and. 378 antitoxin in. 397 dosage of. 397 effect of. 398 on blood, 399 on kidneys, 399 on temperature, 399 eruptions after. 399 injection of. method of. 398 bacillus of. 379 blood in, 384 bronchopneumonia and, 388, 640 catarrhal. 384 complications of. 388 contagion of, 379 coarse of, 388 diagnosis of. 394 from aphthae, 395 from catarrhal laryngitis, 593 from diphtheroid. 394 from herpes of fauces. 395 from larvngismus stridulus, 394 from stomatitis. 394 from traumatic sorethroat, 396 disinfection in. 396 duration of, 388 endocarditis and, 690 erythema urticatum in, 393 etiology of, 379 exanthema of, 393 false, 410. See also Diphtheroid fibrinous bronchitis and. 600 forms of, 384 gastroenteritis and, 389 heart in, 382 human milk and, 97, 98 incubation of, 379 from infected cows' milk, 105 infection in, 380 intubation in, 402 dangers of, 408 extubation in, 408 Diphtheria, intubation in, feeding in, 409 indications for, 402 instruments for, 402 method of. 402 O 'Dwyer 's tubes in, 402 kidneys in. 388 laryngeal, 387 treatment of, 401 liver in. 383 localized forms of, 384 lungs in, 382 lymph-nodes in. 383. 385 measles and, 301. 309, 396 melancholia in, 392 membrane of, 382, 394 middle ear in, 383 muscular atrophy in. 49 myocarditis and, 707 of nasal pjassages. 393 nephritis and. 389 nerves in. 383 occurrence of, 378 ophthalmia and. 392 paralysis and, 391 cardiac. 390 of soft palate in. 395 treatment of, 409 pathology of. 381 pertussis convulsiva and, 393 pleuritis and, 388 prognosis of, 396 prophylaxis of. 396 pseudobacillus of, 380 retropharyngeal abscess and. 389 in scarlet fever, 270 sensory nei'ves in, 392 septic, 385 sex and. 379 sine membrana, 384 of skin. 392 spleen in. 383 stomach in. 383 symptoms of. 384 thvmus gland and, 729 toxins of. 380 treatment of, 396 constitutional, 397 local. 401 in typhoid fever, 328 ulcers of, diagnosis of, from ulcero- membranous tonsillitis, 592 of vulva. 392 treatment of. 409 Diphtheritic ophthalmia, 392 paralysis. 391 cardiac, 390 rhinitis, 578 Diphtheroid. 410 diagnosis of. 410 from diphtheria, 394 etiology of. 410 in scarlet fever, 270 symptoms of, 410 treatment of, 411 Diplegia. 843 cerebral. 843 INDEX. 909 DiplococcLis intracellularis in cerebro- spinal meningitis, 347 pneumoniae in cerebrospinal menin- gitis, 348 Dirt-eating, 805 Diverticula of oesophagus, 488 Dropsy of brain, 833 Drugs, administration of, 63 antipyretic, 63, 64 cautions concerning, 62, 63 dosage of, 64 eruptions of, diagnosis of, from measles, 307 from scarlet fever, 282 in human milk, 97 Dry pleurisy, 650 Ductus arteriosus, closure of, 167 in congenitally weak infants, 184 open, 686, 687, 689 murmur in, 689 physical signs of, 689 right ventricle in, 689 Botalli. See Ductus arteriosus disease, 689 Dulness, normal, in percussion, 612 Dusting-powder, 61 Dwarfism, 726 differentiation of, from infantil- ism, 726 with idiocy, diagnosis of, from sporadic cretinism, 725 Dwarfs, 727 Dyscrasias, constitutional, melsena neo- natorum in, 220 Dysentery, 528 acute nephritis and, 778 amoebic, 534 C'harcot-Leyden crystals in, 534 diagnosis of, 534 etiology of, 534 treatment of, 535 arthritis in, 532 bacteriology of, 529 complications of, 532 diagnosis of, from intussusception, 545 diet in, 533 enemata in, rectal, 533 • etiology of, 529 forms of, 529 from infected cows' milk, 105 intestinal perforation in, 532 pathology of, 530 periproctitic abscess in, 532 i:)eritonitis in, 532 jsrognosis of, 532 prophylaxis of, 532 serum for, 534 symptoms of, 530 treatment of, 532 Dyspepsia, acute gastric, 502 symptoms of, 502 treatment of, 502 infant foods in, use of, 157 Dyspnoea in abdominal tumors, 615 Dyspnoea in ascites, 615 in asthma, 614 in atelectasis, 199 ' in bronchiectasis, 609 in bronchopneumonia, 634 cardiac, 614 in chronic valvular disease of heart, 703 in dilatation of heart, 709 in emphysema of lungs, 604, 605 in fever, 614 in fibrinous bronchitis, 601 forms of, 614 laryngeal, 614 in lobar pneumonia, 618, 622 in myocarditis, 708 in pain, 614 in pericarditis, 676 pulmonary, 614 Dysuria, 773 cellular atresia of labia and, 773 treatment of, 773 Ear, diseases of, 759 examination of, 762 Echolalia in tic, 832 Echymoses in infantile scorbutus, 257 Eclampsia, acetone in urine in, 33 infantum, 797 in scarlet fever, 279 Ecthyma in scrofulosis, 413 Ectopia testis abdominalis, 181 cruralis, 182 perinealis, 182 Eczema, 884 etiology of, 886 forms of, 885 impetiginous, 885 intertrigo, 885 pustular, 885 in scrofulosis, 413 seborrhoeic, 886 treatment of, 887 vaccination and, 317 vesicular, 885 Effusion, restriction of movements of chest in, 611 Ehrlich diazo reaction in typhoid fever, 331 Elastin, 84 Electric chorea, 822 stimulation and reactions in new- born, 175 Emphysema of lungs, 601 adenoids in, 602 asthma in, 604 ' auscultation in, 603, 605 chest in, deformity of, 602, 604 chronic bronchitis in, 601, 602 dyspnoea in, 604, 605 spasmodic, 604 enlarged tonsils in, 602 inspection in, 604 lymphatism and, 602 910 INDEX. Emphysema of lungs, palpation in, 603, 605 ■ pathology of, 602 percussion in, 603, 605 physical signs of, 603 prognosis of. 606 rachitis and, 602 restriction of movements of chest in, 611 symptoms of, 602 thorax in, 602 treatment of, 606 vesicular, 602 Empyema, 650, 652 adhesions in, 671 age and, 652 appendicitis and, 652 aspirator for, Potain 's, 667 auscultation in, 658, 661 bacteriology of, 653, 654 bilateral, 671 prognosis of, 672 treatment of, 672 bronchiectasis and, 609 bronchophony in, 662 bronchopneumonia and, 652 diagnosis of, 657 fluid in, 662 etiology of, 652 exploratory puncture in, 663 exudate in, 653 heart in, displacement of, 662 hemorrhagic, 672 infectious diseases and, 652 inspection in. 658, 659, 660 liver in, displacement of, 662 lobar pneumonia and, 627, 628, 652 metapneumonic, 657 onset of, 656 palpation in, 658, 659, 660 pathology of, 653 percussion in, 658, 659, 660 perforating, 664 physical signs of, 657 pleural fold in, displacement of, 661 pleuritic crepitations in, 660 primary, 652 puncture in, exploratory, 663 in scarlet fever, 276 secondary, 652 simulating enlargement of liver, 562 skodaic resonance in, 659 suppurating sinus in persistent, 670 symptoms of, 656 temperature in, 656 termination of, 665 treatment of, 666, 667, 668, 669 operative, 669, 670 tuberculous, 666 viscera in, displacement of, 662 Encephalitis, acute, 859 aphasia in, 860 etiology of, 859 hemorrhagic cortical, 859 Kernig's symptom in, 860 Encephalitis, acute, lumbar puncture in, 861 meningitis and, 860 neck-rigidity in, 860 paralysis in, 860, 861 pathology of, 859, 860 prognosis of, 861 symptoms of, 860 tache cerebrale in, 860 treatment of, 861 Eucephalocele, 880 Endocarditis, 690 acute, 690 acute articular rheumatism and, 461, 690 auscultation in, 694 bacterial invasion in, 692 bacteriology of, 690 cerebrospinal meningitis and, 690 chorea and, 690, 693, 826 diphtheria and, 690 in erythema multiforme, 891 nodosum and, 690 etiology of, 690 fever in, 692 in follicular amygdalitis, 590 gonococcus in, 691 heart-action in, 695 influenza and, 341, 690 inspection in, 694 location of, 690 malignant, 696 measles and, 303, 690 modes of infection in, 691 murmurs in, 694 osteomyelitis and, 690 palpation in, 694 pathology of, 691 percussion in, 694 pericarditis and, 692 physical signs of, 694 pneumonia and, 690 polyposa, 691 / prognosis of, 695 pustulosa, 692 recurrent, 694 chronic, 699 rheumatism and, 693 scarlet fever and, 279, 690 sepsis and, 690 septic, 696 blood in, 698 Cheyne-Stokes respiration in, 698 diagnosis of, 699 dilatation of ventricle in, 698 forms of, 696 murmurs in, 698 petechia; in, 698 prognosis of, 699 symptoms of, 698 treatment of, 699 symptoms of, 692 temperature in, 693 tonsillitis and, 466 tonsils in, infection through, 691 INDEX. 911 Endocarditis, toxins in, 691 treatment of, 695 tuberculosis and, 690 typhoid fever and, 690 ulcerosa, 692 ulcerative, 696 valvular vegetations in, 692 verrucosa, 691 Endemic cretinism, 718 Enemata in nephritis, 73 nutritive, 74 oil, 74 in pyloric spasm, 517 rectal, 72 in acute gastro-enteric infec- tion, 525 in dysentery, 533 in typhoid fever, 73 in vomiting, uncontrollable, 74 Enlargement of spleen, 733 Enteratomata of umbilicus, 207 Enteric catarrh, 527 Enteritis, diagnosis of, from typhoid fever, 330 foUicularis, 527, 528 Enteroclysis, 72 Enterocolitis, 527 etiology, 527 pathology of, 527 symptoms of, 528 treatment of, 528 Enuresis diurna, 789 nocturna, 789 diagnosis of, 789 etiology, 789 symptoms of, 789 treatment of, 789 Enzymes in human milk, 88, 89, 94 Epidemic cerebrospinal m.eningitis, 348 chorea, 822 hysteria, 804 parotitis, 368. See also Mumps poliomyelitis, 861 Epididymis, metastasis of mumps to, 371 Epilepsy, 819 aura in, 820 chorea and, 825 convulsions. in, 820 diagnosis of, 821 from hysteria, 821 from post-hemiplegic convul- sions, 821 from syncope, 821 from tumor of brain, 821 etiology of, 820 forms of, 820 heredity and, 820 in infantile cerebral palsy, 845, 849 infantile palsy and, 820 pavor nocturnus and, 822 symptoms of, 820 treatment of, 821 Epileptic form of idiocy, 878 Epistaxis, 579 loss of blood in, quantity of, 579 Epistaxis, symptoms of, 579 Epithelium, exfoliated, in otitis, 764 Epstein's pearls, 203 Erb's palsy, 857 type of progressive muscular atro- phy, 872 Eruption in scarlet fever, 271 Erysipelas of umbilicus, 209 Erythema exudativum, 890 cardiac disease in, 891 intertrigo, 885 multiforme, 890 endocarditis in, 891 treatment of, 891 nodosum, 466, 890 endocarditis and, 690, 691 symptoms of, 890 treatment of, 891 Erythrocytes, 734 in newborn, 169 Escherich's method of artificial infant- feeding, 135 Eskay's food, 121 Essential paralysis of children, 861 Exanthemata, 265 Exanthematic fevers, acetone in urine in, 33 diacetic acid in urine in, 34 Excitement, rapidity of pulse during, 30 Excreta, calculation of calories from, 87 Excretion in newborn, 177 External cephalohajmatoma, 234 hydrocephalus, 836 Exudative nephritis, acute, 776, 777 Eye reflexes in newborn, 176 Eyes in newborn, 55 cleansing of, 55, 56 Face, expression of, in adenitis, 39 in adenoids, 39 in Basedow's disease, 39 ■ in cardiac disease, 39 in congenital syphilis, 40 in diarrhoea, 39 in exhausting diseases, 39 in facial paralysis, 39 hydrencephaloid, 40 in hydrocephalus, 39 in Mongolian idiocy, 40 in mouth-breathing, 39 in nuclear palsy, 39 in parotiditis, 39 in rachitis, 39 in respiratory disorders, 39 in sleep, normal, 39 protection of, in open air, 60 against sun's rays, 60 Facial palsy, 851 Facio-scapulo-humeral type of muscu- lar atrophy, 873 Fasces, examination of, 38 Fairchild's panopeptone, 116 Family idiocy, 837 . Fat, in artificial infant foods, 121 912 INDEX. Fat in infant-feeding, 137 calories in, S7 in cows' milk. 102, 103 diarrhoBa, S4 in artificial infant -feeding, 153 digestion of, in newborn, 169 estimation of. in human milk. 100 Lewi's method of, 100, 101 Soxhlet 's quantitative, 101 in human milk, 93 percentage of, in cows' milk, 84 in human milk, S4 low, 154 role of. in nutrition, 84 Fat-sclerema, 226 Fatty acids in human milk, 93 degeneration, acute, of newborn, 221 of liver, 565 true omphalorrhagia in, 212 I'eeding. artificial, of congenitally weak infants, 191 mortalitv and, 18 breast, of congenitally weak in- fants, 190 infant-, 81 of infants. See Infant-feeding mixed, of congenitally weak in- fants, 192 Ferments, amylolytic, in newborn, 169 in human milk, 94 Fever, ataxic gait after, 50 cardiac murmurs in, 705 in onset of illness. 37 sponge bath in, 65 typhoid, 31S Fibrinous bronchitis, 600 pericarditis, 674 pneumonia, 615 FUth infections, IS Finger-nails, biting of, 806 Fissure of anus. 553 fjalpebral, examination of, 40 Fissured nipples, 128 Flexner's serum in cerebrospinal men- ingitis, 360 in posterior basic meningitis, 366 Floating kidney, 45, 770 Fluid, cerebrospinal. See Cerebrospinal fluid free, in abdomen, 44 Fa?tal rachitis, 237 rickets, 250 tuberculous, 419 typhoid fever, 319 Follicular amygdalitis, 589 Folliculitis abscedens, 891 Fontanelles, 26, 27 closure of, time of, 27 delay of, in rachitis, 27 premature closure of, in miero- cephalus, 38 Food, effect of, on human milk, 96 infant, use of, indications for, 157 preparations, 112 Foot, deformities of. in spina bifida, 881 Foramen ovale, open, 689 Foreign bodies in larynx, 597 Fragilitas ossium idiopathica, 252 Freeman's nursing bottle, 111 pasteurizer, 106, 107 Fremitus in chest, 611 Friedreich's disease, 858. See Ataxia, hereditary Frontal lobe, tumors of, 841 Frozen milk, 111 Fungus of umbilical cord, 53 of umbilicus, 207 Funnel, Quincke, 81 Furuncles in diabetes mellitus, 712 Furunculosis, 891 symptoms of, 891 treatment of, 891 G Gait, ataxic, 50 in cerebral disease, 50 tumor, 50 in diphtheritic paralysis, 50 in Friedreich's ataxia, 50 after fevers, 50 in pseudohypertrophic paral- ysis, 50 limping, 51 in infantile paralysis, 51 in pseudohypertrophic muscular paralysis, 874 spastic, 51 in spastic paraplegia, 51 in young infants, 51 Gallop-rhythm in myocarditis, 708 Gangrene of the lungs in bronchiecta- sis, 609, 610 in scarlet fever, 280 in typhoid fever, 328 of pinna in measles, 305 in scarlet fever, 272 of umbilical cord, 53 of umbilicus, 208 Gangrenous acute appendicitis, 549 Gastric dyspepsia, acute, 502 spasm, congenital, 512 Gastro-enteric disturbances, barley wa- ter in, 114 infection, acute, 517 albuminuria in, 520 bacteriology of, 518, 519 baths in, 525 classification of, 518 colic in, 521, 526 diarrhoea in, 520, 524 diet in, 524 etiology of, 518 hypodermoclysis in, 525 intestines in, 519 kidneys in, 519 liver in, 519 lymph-nodes in, 519 pathologj' of, 519 INDEX. 913 Gastro-enteric infection, acute, prog- nosis in, 521 prophylaxis of, 523 rectal enemata in, 525 stomach in, 519 symptoms of, 520 treatment of, 523 medicinal, 526 vomiting in, 520, 524 Gastro-enteritis, 517. See also Gastro- enteric infection, acute acute nephritis and, 778 administration of water in, 83 condensed milk in, 113, 114 diphtheria and, 389 indican in urine in, 33 in pertussis convulsiva, 376 tympanitis in, 45 Gastro-intestinal tract, diseases of, 493 Gavage, 71, 72 in congenitally weak infants, 189 in pneumonia, 71 in typhoid fever, 71 Genitalia, care of, 57, 58 in females, 58 in males, 58 powdering of, 58 Genetous idiocy, 877 Geographical tongue, 486 German measles, 291. See Kotheln Glandular fever, 345 diagnosis of, 346 duration of, 346 etiology of, 345 lymph-nodes in, 345 symptoms of, 345 treatment of, 346 Globus hystericus in hysteria, 803 Glomerular nephritis, 776 Glottis, oedema of, 594 spasm of, 816 Glutin, 84 Glycogen, 85 Goitre in endemic cretinism, 718 Gonococcal peritonitis, 570 Gonococci in vulvovaginitis, 791 Gonorrhoeal infection of mouth, 482 ophthalmia, 55, 56, 228 proctitis, 554 rheumatism, 466 Grand mal, 820 Granuloma of umbilicus, 207 Grape sugar, 85 Grippe, 399. See also Influenza Growths, adenoid, 579 Gruel, arrowroot, 115 barley, 157 dextrinized, 158 preparation of, 158, 159 cereo in, 158, 159 diastase in, 158 oatmeal, 115 H Habits, bad, 805 movements, 831 58 Habits in chorea, 828 diagnosis of, from chorea, 328 spasms, 831 Habitual vomiting of infants, 503 Hsematoma of sternomastoid muscle, 233 symptoms of, 233 treatment of, 234 Ha?maturia, 774 in carcinoma of kidney, 786 etiology of, 774 in infantile scorbutus, 256, 257 in sarcoma of kidney, 785 urine in, 774 Haemoglobin, 736 Hsemoglobinuria, 774 epidemic, of newborn, 222. See Winckel's disease etiology of, 774 pathology of, 775 prognosis of, 775 "shadow" cells in, 775 symptoms of, 775 treatment of, 775 Haemophilia, 219, 748 etiology of, 748 hemorrhages in, 749 nature of, 748 in newborn, hemorrhages in, 219 treatment of, 749 Haemoptysis in bronchiectasis, 609 in pulmonary tuberculosis, 423 Hallucinations in pavor nocturnus, 822 Head, circumference of, 26 examination of, 38 lymph-nodes of, 33 measurements of, 26 position of, in amaurotic idiocy, 35, 38 in birth-paralysis, 38 in defective vision, 40 in diphtheritic paralysis, 38 in meningitis, 38 in Pott's disease, 38 in spasm of cervical muscles, 40 in torticollis, 38 in weakness of cervical mus- cles, 40 power to hold upright, develop- ment of, 35 rhythmic movements of, nystagmus and, 832 dentition and, 832 etiology of, 832 rachitis and, 832 treatment of, 833 rolling of, from side to side, 806 shape of, in craniotabes, 38 in rachitis, 38, 240 Head-banging, 806 Head-nodding, 806, 832 Head-swaying, 806 Hearing, development of, 35 sense of, in newborn, 176 Heart, apex-beat of, 682 auscultation in, 683 914 INDEX. Heart, congenital disease of, 685 cardiac dilatation in, 685 hypertrophy in, 685 cyanosis in, 685 diagnosis of, 686 murmurs in, 686 open ductus arteriosus in, 686, 687 pulmonary artery in, 636 septal defects in, 686 stenosis of aortic valve in, 686 transposition of heart in, 687 valvular anomalies in, 687 ventricular hypertrophy in, 686 dilatation of, 709 in congenital disease of heart, 685 dyspnoea in, 709 infectious diseases and, 709 sudden death in, 709 symptoms of, 709 transudates in, 709 treatment of, 710 disease of, 682 contra-indication to maternal nursing, 124 in erythema exudativum, 890 nodosum, 891 displacement of, in empyema, 662 dulness in, marking of, 683 hypertrophy of, 709 arteriosclerosis and, 709 in congenital diseases of heart, 685 symptoms of, 709 treatment of, 710 inspection of, 682 irritable, 700, 701 palpation of, 683 percussion in, 683 position of, 682 praecordium of, 682 size of, 682 transposition of, 687 tuberculosis of, 432 valvular disease of, chronic, 699 angina in, 703 cardiac insufficiency in, 700 dyspnosa in, 703 etiology of, 699 myocarditis and, 708 pallor in, 701 palpitation in, 701 physical signs of, 700 prognosis of, 703 treatment of, 703 rheumatic pains in, 700 ventricles of, location of, 684 Heat calories, 31 sense in newljorn, 177 Hemiplegia in infantile cerebral palsy, 846 spastic, 843, 845. See also Palsy, cerebral, infantile Hemorrhage in acute fatty degenera- tion of newborn, 222 cerebral, diagnosis of, from as- phyxia in newborn, 195 in newborn, 219 in Buhl's disease, 219, 222 in sepsis, 219 in haemophilia, 219 syphilitic, 219 in Winckel 's disease; 219, 223 sudden death in newborn and, 180 Hemorrhagic conditions in sepsis in newborn, 201 cortical encephalitis, acute, 859 diatheses, 747 empyema, 672 periostitis, 254 pleurisy, 672 rachitis, 237, 254 Hennig's symptom, 210 Henoch 's purpura, 752 Hepatitis, suppurative, 566 Hepatization in lobar pneumonia, 616 Hereditary syphilis, 448 ataxia, 858 ataxic paraplegia, 858 Hernia of brain, diagnosis of, from cephaloh^matoma, 235 diagnosis of, from hydrocele con- genita, 183 from retention of testicle, 182 umbilical, 213 etiology of, 213 treatment of, 213 Herpes in cerebrospinal meningitis, 356 of fauces, diagnosis of, from diph- theria, 395 of tonsils, 591 Hetero-infection in sepsis in newborn, 201 Hirschsprung's disease, 540 History, maternal, 36 parental, 37 taking, 36 Hochsinger's induration in hereditary syphilis, 453 Hodgkin's disease, 747 diagnosis of, from ]euka?mia, 747 from tuberculous adenitis, 747 lymph-nodes in, enlnrgement of, 747 Hook-worm disease, 558 Horner's symptom, 40 Huebner-Hoffman method of artificial infant-feeding, 135 Hum, venous, 706 Human milk. See Milk, human Huntington 's chorea, 823 Hutchinson's teeth in syphilis, 471 Hydnemia without kidney lesion, 773 INDEX. 915 Hydrsemia in simple aiiEemia, 737 Hydrenceijhaloid, diagnosis of, from congenital internal hydrocepha- lus, 834 expression of face, 40 Hydrocele adnata, 182 congenita, 182 diagnosis of, 183 from hernia, 183 treatment of, 183 Hydrochloric acid, decrease of, rachitis and, 238 in newborn, 169 Hydrocephalic form of idiocy, 878 Hydrocephalus, 833 acquired, diagnosis of, from con- genital internal hydrocephalus, 835 acute internal, 366, 432 chronic, cerebrospinal fluid in, 76 lumbar puncture in, 78 diagnosis of, from rachitis, 246 external, 836 diagnosis of, 837 from congenital internal hydrocephalus, 835 etiology of, 836 pachymeningitis and, 836 facial expression in, 39 internal, congenital, 833 cranial bones in, 834 craniotabes in, 834 diagnosis of, 834 from acquired hydro- cephalus, 835 from cranial syphilis, 835 from external hydro- cephalus, 835 from hydrencepha- loid, 834 from rachitis, 834 etiology of, 833 fontanelles in, 834 idiocy in, 833 paralysis in, 833 pathology of, 833 prognosis of, 835 symptoms of, 833 treatment of, 835 in rachitis, 240, 245 Hydromyelocele, 881 Hydronephrosis, 784 diagnosis of, from carcinoma of kidney, 787 from cyst of kidney, 785 Hydrorrhachis, 880 Hydrotherapy, 64 Hypersesthesia in cerebrospinal menin- gitis, 352 Hyperthermia, sudden death and, 21 Hypertrophy of heart, 709 muscular, 49 in pseudohypertrophic paral- ysis, 49 Hypertrophy of thymus gland, 728 thymus death in, 731 Hypodermic administration of drugs, 64 Hypodermoclysis, 66 in acute gastro-enteric infection, 525 in cholera infantum, 66 Hysteria, 802 anaesthesia in, 804 anorexia in, 804 bradycardia in, 805 catalepsy in, 803 contortions in, 803 convulsive forms of, 803 dancing mania in, 804 diagnosis of, 805 from epilepsy, 821 from tuberculous meningitis, 805 disturbances of sensation in, 804 of vision in, 804 epidemics of, 804 etiology of, 802 globus hystericus in, 803 hyperesthesia in, 804 hystero-epilepsy in, 803 mental, 802 motor manifestations in, 803 non-convulsive, 802 onset of, 803 paralyses in, 804 psychic, 802 sex and, 802 sexual organs in, abnormalities of, 802 symptoms of, 802 tachycardia in, 804 treatment of, 805 Hystero-epilepsy and hysteria, 803 Ichthyosis, congenital, 893 symptoms of, 894 treatment of, 894 Icterus, catarrhal, 563 gravis in newborn, 218 infectious, 563 neonatorum, 217 etiology of, 218 symptoms of, 218 treatment of, 218 in newborn, 217 in sepsis of newborn, 217 simple, 563 Idiocy, 876 amaurotic, 837 deep reflexes in, 839 diagnosis of, 839 etiology of, 837 juvenile form of, 839 nystagmus in, 40 ocular changes in, 839 optic neuritis in, 839 paralysis in, 838, 839 pathology of, 838 916 INDEX. Idiocy, amaurotic, position of head in, 35, 38 prognosis of, 840 spastic phenomena in, 51 symptoms of, 838 Tay-Kingdon 's spot in, 839 in congenital internal hydroceph- alus, 833 cretinic form of, 878 epileptic form of, 878 etiology of, 876 facies in. 878 family, 837 genetous, 877 hydrocephalic form of, 878 management of, 879 microcephalic form of, 877 Mongolian, diagnosis of, from rachitis, 246 from sporadic cretinism, 724 facial expression in, 40 palpebral fissure in, 40 paralytic form of, 878 patellar reflex in, 49 predisposition toward, 876 sclerotic form of, 878 sj'mptoms of, 878 sj'philitic form of, 878 treatment of, 879 Idiopathic hemorrhage from umbilicus, 212. See also Omphalorrhagia, true Ileocolitis, 528 Ileotyphus, 318. See Typhoid fever Imperial granum, 121 Impetiginous eczema, 885 Incubator, 186 cleansing of. 186 indications for use of, 188 infections due to, 186 Lion's, 187 Tarnier's, 186 temperature in, 188 Indican in urine, 33 Indigestion, 502 Infancy, convulsions in, 797 definition of, 17 Infant-feeding, 81 artificial. 133 Biedert's mixture. 133. 134 Chapin's method of, 158 colic in, 152. 153 constipation in, 152 dextrin jzed gruels in, 158, 159 diluents in. 149 from eighteenth month to end of second year, 162 Escherich 's method, 135 fat diarrhoea in, 153 fat-percentages in, too high, 148 fats in, percentage of, 137 formula? for, 147 greenish movements in, 153 Huebner-IIoffman method of, 135 Infant-feeding, artificial, Keller's method of, 159 laboratory method of, 133, 135 Liebig's formula in, 159 lime-water in, 149 low percentage of fats in, 154 of proteids in, 154 malt extract in, 159 Meigs' mixture for, 133, 134 miJk in, home modification of, 140 quantity of, 138, 139, 140 milk in, raw, 110 mixed, 132 from ninth to twelfth month, 160 nursings in, frequency of, 138, 139, 140 over-feeding in, 132 peptonization in, 154, 155 percentage method of, 135, 136 schedule for, 138 percentages in calculation of, 143. 144 principles underlying, 81 proteids in, percentage of, 137 Eotch's method of, 133, 135 salts in, percentage of, 131 after sixth month, 160 Soxhlet method of, 135 spitting in, 152 sugar in, percentage of, 137 table of feedings for, 140 thriving under, signs of, 150 from twelfth to eighteenth month, 161 vomiting in, 154 whey method in, 155 vom.iting in, 132 Infant-foods, artificial, 119, 120, 121 carbohydrates in, 119, 121 classification of, 119, 120 composition of, 120, 121 diastase in, 119 fats in, 121 malt extract in. 119 objections to, 119, 121 proteids in, 121 rachitis from, 119 scurvy from, 119 sugar in, 121 at time of weaning, 121, 122 use of, indications for, 157 in dyspepsia, 157 in intestinal disease, 157 utility of, 119 varieties of, 119, 120 Infantile atrophy, 260 palsy, cerebral, 843 paralysis, 861 scorbutus, 254 scurvy, 254 typhoid fever, 319 Infantilism, dental, in syphilis, 473 diagnosis of, from sporadic cretin- ism, 725 INDEX. 917 Infantilism, differentiation of, from dwarfism, 726 Infants, artificially fed, metabolism in, 88 breast-fed, metabolism in, 85, 86 congenitally weak, 183 appearance of, 184 asphyxia in, 198 atelectasis in, 184 bath of, 190 ' bronchial nodes in, 184 bronchitis in, 189 bronchopneumonia in, 184, 185 clothing of, 190 desquamation in, 184 diarrhoea in, 185 ductus Botalli in, 184 etiology of, 183 feeding of, 188 artificial, 191 breast, 190 mixed, 192 with modified milk, 192 with peptonized milk, 192 food of, amount of, 192 gavage in, 189 hemorrhages in, 184 incubators for, 186 infarctions in, 184 infections in, 184 intestines in, 184, 185 meconium in, 185 morbid anatomy of, 184 nursing tube for, 188 Breck's, 189,190 pathology of, 184 pericarditis in, 184 pneumonia in, hemor- rhagic, 184 prematurity and, 183 prognosis of, 185 sclerema in, 184 sepsis in, 184 skin of, 184 symptoms of, 184 syphilis and, 184 temperature in, 185, 186 triplets and, 184 tuberculosis and, 184 twins and, 184 weight in, 183, 185 food of, 89 marantic, feeding of, 159 scurvy in, 159 premature, 183 Infarction, uric acid, 34, 775 Infections, bacillary, of human milk, 97 in childhood, 18 filth, 18 in newborn, 17 otogenic, 202 urogenital, 202 Infectious diseases, acute, contra-indi- cation to maternal nursing, 124 bacteria of, in human milk^ 97 chorea and, 824 muscular atrophy in, 49 specific, 265 vomiting in, 507 icterus, 563 myelitis, acute, 756 Inflammatory bronchiectasis, 607 Influenza, 339 age and, 340 albuminuria in, 344 bacteriology of, 340 bronchitis in, 342 bronchopneumonia in, 341 cerebrospinal meningitis in, 342 cystitis and, 793 diagnosis of, 344 from lobar pneumonia, 629 from measles, 306 diarrhoea in, 341 duration of, 344 endocarditis and, 690 endocarditis in, 341 etiology of, 340 eyes in, 341 incubation of, 340 infection in, mode of, 340 mumps and, 372 myocarditis in, 341 in newborn, 340 nephritis in, 341, 348 otitis media in, 344 pneumonia in, 342 lobar, 341 prognosis of, 344 symptoms of, 341 temperature in, 341 treatment of, 344 Inhalations, calomel, 68 in acute laryngitis, 68 Intermittent fever, 334 Internal cephalohfematoma, 234 hydrocephalus, acute, 366 acute, 432 congenital, 833 Intertrigo, 885 Intestinal digestion, 497 casein in, 498 fats in, 499 milk sugar in, 498 disturbances in childhood, 18 obstruction, acute, 542 vomiting in, 507 Intestinal parasites, 555 residue, 499 secretions, 497 walls, secretions of, 498 Intestines, diseases of, 493 perforation of, in dysentery, 532 in typhoid fever, 328 Intoxications, sudden death and, 21 Intra-uterine rachitis, 237 Intubation in diphtheria, 402 918 INDEX. Intussusception, 542 abdomen in, 44, 45 acute acquired constipation and, 536 diagnosis of, 545 from acute appendicitis, 545 from dysentery, 545 from scurvy, 545 etiology of, 542 frequency of, 542 hemorrhage in, 544 onset of, 543 prognosis of, 545 rectal exploration in, 46 spontaneous cure of, 546 symptoms of, 543 tenesmus in, 544 treatment of, 546 tumor in, 544 varieties of, 542 vomiting in, 543 Todine in human milk, 97 Tron in human milk, 93 Irregularity of pulse, 30 Irrigation, rectal, 72 Irritable heart, 700, 701 Jaundice, 563 bacteriology of, 563 in congenital obstruction of bile- ducts, 564 enlargement of liver in, 564 of spleen in, 564 in newborn, 171 occurrence of, 563 pathology of, 563 in phlebitis umbilicalis, 211 simple, 563 symptoms of, 563 treatment of, 564 Joint-crepitus, 46, 47 Joints, affections of, 46, 47 crepitus of, 46, 47 examination of, 46 motility of, 46 palpation of, 46 Keller's method of artificial infant- feeding, 159 Keratin, 82, 84 Kernig's symptom, 50 in acute encephalitis, 860 in cerebrospinal meningitis, 352 in mcningism, 50 • in pneumonia, 50 in tuberculous meningitis, 435, 439 in typhoid fever, 50 Kidney, carcinoma of, 785 diagnosis of, 787 from cyst of kidney, 787 from hydronephrosis, 787 Kidney, enlargement of kidney in, 786 ha'maturia in, 786 symptoms of, 786 cysts of, 784 diagnosis of, from hydrone- phrosis, 785 diseases of, 770 enlargement of, in carcinoma of kidney, 786 floating, 45, 770 new growths of, 784 palpation of, 770 in pseudoleukgemic anaemia, 740 sarcoma of, 785 diagnosis of, 785 symptoms of, 785 tuberculosis of, 787 diagnosis of, 788 symptoms of, 787 urine in, 787 tumors of, 784 diagnosis of, from tumor of spleen, 739 simulating tumor of liver, 562 treatment of, 788 weight of, 770 Kissing, development of, 36 Hebs-Loffler bacillus in diphtheritic rhinitis, 578 Koch's peptone, 116 Koplik's spots in measles, 298 Kumyss, 117 Lab-ferment, digestive action of, in stomach, 496 Labia, cellular atresia of, dysuria in, 773 Lactalbumin in cows' milk, 102 in human milk, 84, 92 Lactic acid in cows' milk, 102, 103 increase of, rachitis and, 238 Lactobutyrometer, Conrad's, 100 Lactodeusimeter, Conrad's, 100 Quevenne 's, 100 Lactoglobulin in human milk, 92 La Grippe, 339. See also Influenza Landouzy type of f acio-scapulo-humoral muscular atrophy, 873 Lanugo, 170 Laryngeal chorea, 822 diphtheria, 387 dyspnoea, 614 stridor, 816 Laryngismus stridulus, 816 apnoea in, 817 complications of, 819 craniotabes and, 817 diagnosis of, 818 from diphtheria, 394 etiology of, 817 pathology of, 817 ])rognosis of, 8L8 rachitis and, 817 INDEX. 919 Laryngismus stridulus, symptoms of, 817 thymus in, enlargement of, 817 treatment of, 819 Trousseau's phenomenon in, 818 Laryngitis, acute, calomel inhalations in, 68 vapor spray in, 68 catarrhal, 593 diagnosis of, 594 from diphtheria, 593, 594 etiology of, 593 prognosis of, 594 symptoms of, 593 treatment of, 594 phlegmonous, 594 spasmodic, 593 submucous, 594 Laryngospasm, tetany and, 812 Larynx, diseases of, 593 foreign bodies in, 597 prognosis of, 597 symptoms of, 597 treatment of, 597 syphilis of, 596 diagnosis of, 596 prognosis of, 596 treatment of, 596 tuberculosis of, 432, 596 treatment of, 596 tumors of, 596 symptoms of, 596 treatment of, 597 varieties of, 596 Latent tetany, 812 Laughing, development of, 35 Lecithin, 82 in human milk, 92, 93 Length of body, 26 Lepto-meniugitis, acute, 363 diagnosis of, 364 etiology of, 363 symptoms of, 364 Leucocytes, 735 in newborn, 169 Leucocytosis in scarlet fever, 280 Leukaemia, 743 blood in, changes in, 744 bone-marrow in, 744 diagnosis of, from Hodgkin 's dis- ease, 747 enlargement of lymph-nodes in, 716 etiology of, 743 lymphatic, 743 lymph-nodes in, 746 myelogenous, 743 prognosis of, 747 rachitis and, 743 sldu in, 745, 746 spleen in, enlargement of, 744 symptoms of, in acute form, 744 in chronic form, 746 syphilis and, 743 treatment of, 747 Leukoeythsemia, 743 Lewi's method of estimation of fats, 100, 101 Lichen scrof ulosorum in scrof ulosis, 413 Liebig's beef -extract, 118 formula in artificial infant-feeding, 159 peptone, 116 Lime-water in artificial infant-feeding, 149 Limping gait, 51 Lion's incubator, 187 Lip reflex, 468 in newborn, 176 Lipase, in cows' milk, 94 in human milk, 94 Liquid peptonoids, 116 Lithsemia, 775 Lithiasis, 38 Little 's disease, 843 Liver, abscess of, 566 etiology of, 566 symptoms of, 566 treatment of, 567 ■ acute yellow atrophy of, 567 carbohydrates in, 85 cirrhosis of, 565 age and, 565 enlargement in, 565 etiology of, 565 pathology of, 565 symptoms of, 565 diseases of, 560 contra-indication to maternal nursing, 124 displacement of, in empyema, 662 dulness of, 44 enlargement of, 562 in abscess of liver, 566 in anaemia infantum pseudo- leukasmica, 562 in cirrhosis of liver, 565 in congenital obstruction of bile-ducts, 564 syphilis, 563 empyema simulating, 562 in fatty degeneration of liver, 565 in jaundice, 564 normal rotation simulat- ing, 561 in pseudoleukcemic anae- mia, 740, 741 in rachitis, 562 in Still's disease, 563 subphrenic abscess simulating, 562 examination of, 560 fatty degeneration of, 565 measurements of, 561 normal rotation of, simulating en- largement of liver, 561 jialpation of, 560 parasites of, 567 percussion of, 561 in rachitis, 239, 245 920 INDEX. Liver, secretions of, 498 in sepsis in newborn, 204 syphilis of, 565 tumor of, 567 kidney tumor simulating, 562 phantom, 562 weight of, 560 Lobar pneumonia, 615 Lobular pneumonia, 632 Lordotic albuminuria, 770 Lourie, crescents of, 89, 90 Lumbar puncture, 74 in acute encephalitis, 861 in cerebrospinal meningitis, 357, 360, 361 danger of, 79 fluid withdrawn, amount of, 79 in hydrocephalus, chronic, 78 indications for, 77 in meningism, 77 in meningitis, 77, 78 operation of, 77 in pneumonia, 78 in sepsis in newborn, 205 in status epilepticus, 77 sudden death in, 22 in tetanus of newborn, 217 Lungs, atelectasis of, 198 collapse of, 198. See also Atelectasis diseases of, 610 emphysema of, 601 gangrene of, in bronchiectasis, 609, 610 bronchopneumonia and, 640 induration of, in lobar pneumonia, 617 limits of, normal, 6il in newborn, 166 size of, 610 Lupus in scrofulosis, 413 Lusehka's tonsil, 580 Lymph, carbohydrates in, 85 Lymphadenitis, acute, 716 chronic, 717 symptoms of, 717 treatment of, 717 retropharyngeal, 585 Lymphadenoma, 747 Lymphangitis of breast, 129 Lymphatic leukasmia, 743 Lymphatism, adenoid growths and, 580 chorea and, 823 chronic nasal catarrh and, 576 emphysema of lungs and, 602 enlargement of lymph-nodes in, 715 sudden death and, 22 thymus death and, 729 gland and, 729 Lymph-nodes, diseases of, 715 enlargement of, in adenoids, 715 in anajmia, 716 in balanitis, 715 in congenital sj'philis, 715 in disease of ear, 715 of scalp, 715 in exanthemata, 715 Lymph-nodes, enlargement of, in Hodg- kin 's disease, 716 in leuksemia, 716 in lymphatism, 715 in parotitis, 715 in rachitis, 716 in retropharyngeal adenitis, 715 in tonsillar infection, 715 in tuberculosis, 715 in leukgemia, 746 in measles, 304 in rachitis, 239 in scarlet fever, 270, 273, 276, 289 Lymphosarcomata, 716 M McBuRNEY 's point in acute appendi- citis, 550 Macewen's sign in cerebrospinal men- ingitis, 353 in tuberculous meningitis, 441 Macroglossia, 484 congenita hypertrophica, 484 lymphatica, 484 in sporadic cretinism, 722 Maladie de Eoger, 689 Malarial fever, 334 age and, 335 blood in, 336 diagnosis of, 337 etiology of, 335 incubation in, 335 mosquitoes and, 335 onset of, 336 parasite of, 335 pathology of, 336 prognosis of, 338 quinine and, 338, 339 relapses in, 337 symptoms of, 336 temperature in, 337 treatment of, 338 Malignant disease, eontra-indication to maternal nursing, 124 endocarditis, 696 purpuric fever, 347 Malt-extract in artificial infant-feeding, 159 Manhu infant food, 120 Marantic infants, sudden death in, 20 Marasmus, 260 Mastitis in newborn, 231 treatment of, 232 Mastoid disease, 765 age and, 765 course of, 768 diagnosis of, 768 etiology of, 765 exanthemata and, 766 facial palsy and, 851, 852 measles and, 766 otoscopie examination in, 767 pain in, 767 INDEX. 921 Mastoid disease, physical signs of, 767 prophylaxis of, 768 scarlet fever and, 273, 276, 766 swelling in, 767 symptoms of, 765 temperature in, 765, 766 treatment of, 768 tumefaction in, 767 typhoid fever and, 766 region, anatomy of, 765 Mastoiditis in typhoid fever, 326 Masturbation, 807 treatment of, 807, 808 Maternal nursing, 122 contra-indications to, 123 in acute infectious dis- eases, 124 in Bright 's disease, 124 in heart disease, 124 in liver disease, 124 in malignant disease, 124 in organic nervous dis- ease, 124 in syphilis, 123 in tuberculosis, 123 Measles, 294 acute infectious osteomyelitis and, 757 amaurosis in, 304 atelectasis and, 302 blood in, 304 bones in, 304 bronchitis and, 302, 308, 309 bronchopneumonia and, 302, 308, 309, 639 buccal mucous membrane in, 298 complications of, 300, 308 treatment of, 308 conjunctivitis in, 295, 304 contagiousness of, 295 corneal ulcerations in, 304 coryza in, 294, 295, 296 cystitis and, 793 desquamation in, 295, 296 diagnosis of, 306 from antitoxin eruptions, 307 from drug eruptions, 307 from influenza, 306 from rotheln, 306 from scarlet fever, 282, 306 from syphilitic roseola, 307 from typhoidal roseola, 307 diarrhoea in, 303, 310 diphtheria and, 301, 309, 396 ear in, 305 enanthema in, 298 endocarditis and, 303, 690 eruption in, 296 exanthema in, 296, 300 eyes in, 309, 310 firstborn and, 294 foetus and, 294 gangrene of pinna in, 305 genitals in, 305 German, 291. See Eotheln Measles, heart in, 303 immunity from, 294 incubation of, 294 intestines in, 303 joints in, 304 kidneys in, 304 Koplik's spots in, 298 larynx in, 301, 309 . lymph-nodes in, 304 mastoid disease and, 766 meningitis and, cerebrospinal, 304 mouth in, 298, 305, 310 mumps and, 372 myocarditis in, 303 nephritis in, 304 nervous system in, 304 neuritis and, 304 newborn and, 294 noma in, 305 nose in, 300, 310 otitis in, 305 pericarditis in, 303 pertussis in, 305 pharynx in, 300, 301 photophobia in, 296, 304 pneumonia and, 301, 302 prognosis of, 305 prophylaxis of, 307 sequelae of, 305 stomatitis in, 305 symptoms of, 295 temperature in, 296 treatment of, 308 Meconium, 174 analysis of, chemical, 175 bacteria in, 175 bilirubin in, 174 bodies, 174, 175 color of, 174 composition of, 174 in congenitally weak infants, 185 consistency of, 174 odor of, 174 plug, 174 quantity of, 174 Medulla, tumors of, 843 Meigs' mixture, 133, 134 Melsena neonatorum, 219 bacillary infection and, 220 diagnosis of, 221 etiology of, 219 pathology of, 220 prognosis of, 221 symptoms of, 220 treatment of, 221 Melancholia in diphtheria, 392 in lobar pneumonia, 623 pertussis convulsiva and, 376 in scarlet fever, 279 Mellin's food, 120 Memory, development of, 36 Meningism, Kernig's symptom in, 50 lumbar puncture in, 77 Meningitis, 309 acute encephalitis and, 860 basilar, 432 922 INDEX. Meningitis, boat-shaped abdomen in, 41 bronchopneumonia and, 642 cerebrospinal, 347 age and, 349 Babinski reflex in, 352 bacteriology of, 357 blood in, 354 complications of, 356 cytology of, 357 diagnosis of, 358 from acute poliomyelitis, 871 from meningitis serosa, 368 from pneumonia, 359 from tetanus of newborn, 216 from tuberculous menin- gitis, 358 from typhoid fever, 358 diet in, 362 diplococcus intracellularis in, 347 pneumoniae in, 348 ear in, 356 ecchymoses in, 350 endocarditis and, 690 epidemic, 348 cerebrospinal fluid in, 76 etiology of, 347 eyes in, 353 facial paresis in, 353 Flexuer's serum in, 360 fontanelle in, 356 herpes in, 356 hydrotherapy in, 362 hypersesthesia in, 352 infection in, mode of, 348 in influenza, 34ii Kernig symptom in, 352 leucocyte count in, 354 lumbar puncture in, 357, 360 Macewen's sign in, 353 measles and, 304 mydriasis in, 354 neck rigidity in, 352 onset of, 349, 350, 351 opisthotonos in, 352 paralysis in, 353 pathology of, 349 prognosis of, 359 pulse in, 354 reflexes in, 352 respiration in, 354 sequelae of. 357 skin in, 356 spleen in, 356 sporadic, cerebrospinal fluid in, 76 symptoms of, 849 cerebral, 351 tache cerebrals in, 352, 359 temperature in, 355 treatment of, 360 diagnosis of, from convulsions in infancy, 800 Meningitis, diagnosis of, from lobar pneumonia, 629 from typhoid fever, 330 lobar i^neumonia and, 627 lumbar puncture in, 77, 78 in phlebitis umbilicalis, 211 position of head in, 38 posterior basic, 364 complications of, 365 etiology of, 364 hydrocephalus in, 365 occurrence of, 364 opisthotonos in, 365 rigidity in, 365, 366 symptoms of, 365 treatment of, 366 in scarlet fever, 275 serosa, 366 cerebrospinal fluid in, 368 diagnosis of, 368 from meningitis, cerebro- spinal, 368 tuberculous, 368 from otitis media puru- lenta, 368 etiology of, 367 lumbar puncture in, 368 occurrence of, 366 pathology of, 367 spine in, 47 suppurative, cerebrospinal fluid in, 76 tuberculous, 432 Babinski 's reflex in, 49, 50, 435, 439 bacteriology of, 441 blood in, 440 cerebral cry in, 440 cerebrospinal fluid in, 76 Cheyne-Stokes respiration in, 434, 439 Chvostek's symptom in, 435 diagnosis of, difi:erential, 442 from cerebrospinal menin- gitis, 358 from meningitis serosa, 368 etiology of, 432 eyes in, 440 facial paralysis in, 435 hypera?sthesia in, 439 in hysteria, 805 Kernig 's symptom in, 435,439 lumbar puncture in, 441 Macewen 's sign in, 441 occurrence of, 432 onset of, 438 pathology of, 432 prognosis of, 443 pulse in, 439 respiration in, 439 rigidity in, 438 symptoms of, 433 treatment of, 443 Trousseau's symptom in, 435 tuberculin test in, 442 INDEX. 923 i\[oiii Ileitis, tubcrculoii.s, vcjiiiiting in, 438 vertical, 363. Hce Lejtto-meningitis, acute vomiting in, 508 Meningocele spinalis, 881, 883 Meningococcus meningitis, 347 ]\reningo-encepha]ocele, 880 Menstruation, effect of, on human milk, 98 Mental development, 34, 35, 36 hysteria, 802 Mesenteric glands, tuberculosis of, 431 Metabolism in newborn, 177 Metapneumonic pleurisy, 657 Microeephalus, forms of, 877 premature closure of f ontanelles in, 38 Microdontism in syphilis, 473 Micromelia, 250 Milia in newborn, 171 Miliaria alba, 892 rubra, 892 Miliary tuberculosis, 421 Milk, animal, comparison of, with hu- man milk, 92 boiled, assimilation of, 109 breast-. See Milk, human. burette. Woodward's, 102 condensed, 113 composition of, 113 dilution of, 113, 114 in gastro-enteritis, 113, 114 rachitis from, 113 scurvy from, 113 cows', 102 acidity of, 106 albumin in, 102 bacteria in, 104, 105 Bacterium lactis aerogenes in, 105, 106 Bacillus mesentericus vulgatus in, 105 subtilis in, 105 calories in, 86 carbohydrates in, 85 casein in, 91, 102, 103 composition of, 102 diluents for, 149 fats in, 84, 102, 103 infected, 105 cholera asiatica and, 105 diphtheria and, 105 dysentery and, 105 scarlet fever and, 105 tuberculosis and, 105 laetalbumin in, 102 lactic acid in, 102, 103 lipase in, 94 mineral salts in, 83 ]>asteurization of, 106 phosphorus in, 103 potato bacillus in, 105 proteids in, 103 reaction of, 102 specific gravity of, 102 sterilization of, 107 Milk, cow's, sugar in, 102 water in, 102 frozen. 111 constipation from. 111 diarrhoea from. 111 fat-globules in. 111 human, 90 agglutinins in, 97, 98 alcohol and, 97 alexins in, 17, 88, 89, 94, 95 amount of, daily, 96 amylase in, 94 analysis of, 99 antitoxins in, 97, 98 bacteria in, 94 bacillary infection of, 97 calories in, 86 carbohydrates in, 85 casein in, 84, 91, 92, 103 caseinogen in, 91 changes in, daily, 96 chemistry of, 91, 92, 93 colostrum in, 89 cornj^arison of, with animal milk, 92 composition of, 91, 92 consumption of, daily, 95 at nursings, individual, 95 crescent-shaped bodies in, 93 diphtheria and, 97, 98 drugs in, 97 effect of beer on, 96 of coffee on, 97 of foods on, 96 of menstruation on, 98 of pregnancy on, 99 of starvation on, 96 of tea on, 97 enzymes in, 88, 89, 94 fats in, 84, 93, 100 estimation of, 100, 101 fatty acids in, 93 ferments in, 94 first appearance of, 90 foreign substances in, 97 iodine in, 97 iron in, 93 Konig's analysis of, 91 laetalbumin in, 84, 92 lactoglobulin in, 92 lecithin in, 92, 93 lipase in, 94 mineral salts in, 83 nucleon in, 93 opalisin in, 92 proteids in, 92 estimation of, 102 reaction of, 93, 94 salicylic acid in, 97 salts in, 93 specific gravity of, 94, 99, 100 Staphylococcus albus in, 94 tetanus and, 98 toxins in, 97, 98 tuberculosis and, 97, 98 typhoid fever and, 97, 98 924 INDEX. Milk, human, water in, 82 whey proteids in, 91 modified, 140 in eongenitallv weak infants, 192 formulae for, 147 in newborn, 171 pasteurized, assimilation of, 109 peptonized, 112, 154. 155 in cougenitally weak infants, 192 preparation of, 112 powder, peptogenic, 112 raw, assimilation of, 109 diarrhoea from, 110 in infant feeding, 110 from limited herd, 110 sterilized, assimilation of, 109 bone disturbances from, 110, 111 constipation from, 108 scurvy from, 108 sugar, 85 digestion of, 497, 498 teeth, 470 test for cleanliness of, 143 top, 141 home-made, 143 seven per cent., 142 twelve per cent., 142 of wet-nurse, 126 nail-test for, 126 witches', 171 Mineral salts, in cows' milk, 83 in human milk, 83 percentage of, 83 required by infants, 87 role of, in nutrition, 83 Mongolian idiocy, facial expression in, 40 palpebral fissure in, 40 Monorchism, 182 Morbidity in childhood, 17 in newborn, 17 Morbilli, 294. See Measles hsemorrhagica, 300 Morbus maculosus Werlhofii, 749 Moro's inunction tuberculin test, 424 Mortality, 18, 19 artificial feeding and, 18 Mouth, angles of, ulcerations of, 475 diagnosis of, 475 etiology of, 475 symptoms of, 475 bacteria of, 62, 469 care of, 61 diseases of, 468 ferment of, 468 gonorrheal infection of, 481 symptoms of. 482 treatment of, 482 normal, landmarks of, 469 in scarlet fever, 271, 276 ulceration of. 62 washing of, 61, 62 Mouth-breathing, adenoid growths and, 581 facial expression in, 39 Mouth-to-mouth method of artificial respiration, 196 Movements, habit, 831 Mucin, 82, 84 Mucous membranes in newborn, 17 in rotheln, 292 Multiple neuritis, 854 Mumps, 368 age and, 369 albuminuria in, 371 diagnosis of, 372 etiology of, 368 incubation in, 369 influenza and, 372 lymph-nodes in, 370 measles and, 372 metastasis of, 371 otitis and, 371 pathology of, 369 pneumonia and, 371 prognosis of, 372 symptoms of, 370 treatment of, 372 typhoid fever and, 372 urine in, 371 varicella and, 372 Murmurs, cardiac, 704 accidental, 705 arterial, 706 anemic, 705 aortic, 705 in chorea, 828 dynamic, 705 febrile, 705 Muscles, carbohydrates in, 85 Muscular atrophy, 49 hypertrophy, 49 paralysis, pseudohypertrophic, 873 power in newborn, 175 rheumatism, 467 sense in newborn, 175 Myocarditis, 706 adherent pericardium and, 681 arrhythmia in, 708 bacteria and, 706 bacteriology of, 707 bradycardia in, 708 chronic valvular disease of heart and, 708 diagnosis of, 708 diphtheria and, 707 dyspnffia in, 708 etiology of, 706 exanthemata and, 706 gallop-rhythm in, 708 in influenza, 341 in measles, 303 pathology of, 706 in pericarditis, 675 pertussis and, 708 pneumonia and, 708 poisons and, 706 pulse in, 708 INDEX. 925 Myocarditis, pulse-respiration ratio in, 708 in scarlet fever, 279 septic conditions and, 708 symptoms of, 707 toxic, 707 toxins and, 706 treatment of, 708 Mydriasis in cerebrospinal meningitis, 354 Myelocystocele, 881, 882 Myelogenous leukaemia, 743 Myelomeningocele, 880, 881, 882 Myotonia, 815 N Nanism, 726 Nasal catarrh, acute, 574 chronic, 576 polypi, diagnosis of, from adenoid growths, 583 Nasopharynx, diseases of, 574 Neave 'a food, 121 Nephritis, acute, bacteria and, 776, 777 constipation in, 780 diffuse, 776, 777 duration of, 781 dysentery and, 778 etiology of, 776 exudative, 776, 777 fainting spells in, 780 gastro-enteritis and, 778 headache in, 780 heart in, 780 infectious diseases and, 776 lungs in, 780 oedema in, 780 parenchymatous, 776, 777 pathology of, 777 primary forms of, 781 productive, 776 pulse in, 780 scarlet fever and, 776 symptoms of, 778 temperature in, 780 toxins and, 776, 777 treatment of, 782 urine in, 778, 779, 780 vomiting in, 779 chronic, diffuse, 781 symptoms of, 781 treatment of, 782 productive, 781 without exudation, 781 diagnosis of, from cyclic albumi- nuria, 772 diphtheria and, 389 enema in, 73 in follicular amygdalitis, 590 glomerular, 776 in influenza, 341, 343 in measles, 304 oedenia of, diagnosis of, from scler- ema adiposum, 227 in scarlet fever, 277, 278, 289 Nephritis, tubular, 776 in varicella, 312 Nervous disease, organic, contra-indi- tion to maternal nursing, 124 system, disease of, sudden death in, 21 diseases of, 797 in newborn, 175 in rachitis, 245 in sepsis in newborn, 203 Nestle 's food, 120 Neuritis, measles and, 304 multiple, 854 chorea and, 825 diagnosis of, 855 from acute poliomyelitis, 871 etiology of, 854 paralysis in, 855 pathology of, 854 -sensory disturbances in, 855 symptoms of, 854 treatment of, 856 wrist-drop in, 855 muscular atrophy in, 49 optic, in amaurotic idiocy, 839 in tumor of brain, 841 patellar reflex in, 49 Newborn, acute infectious osteomyelitis and, 757 amylolytic ferments in, 169 anomalies in, 181 asphyxia in, 193 atelectasis in, 198 bacteria and, 17, 18 barley-gruel in, use of, 157, 158 bile in, 169 blood in, 168 body-temperature in, 170 fluctuation in, 170 breasts in, 171 caking of breasts in, 231 cephalohajmatonia in, 234 cerebrum in, 175 circulation in, 167 cold sense in, 177 color of, 170 deafness in, 176 desquamation in, 17, 170 digestion in, of alouminoids, 169 of fats, 169 of starch, 169 digestive functions in, 169 diseases of, 165 ductus Botalli in, 167 electrical stimulation in, 175 epidemic ha?moglobinuria in, 222 excretion in, 177 eye reflexes in, 176 acute fatty degeneration of, 221 diagnosis of, 222 etiology of, 221 hemorrhages in, 219 pathology of, 222 prognosis of, 222 926 INDEX. Xewborn, acute fatty degeneratiou of, in sepsis in new- born. 201 symptoms of, 222 treatment of, 222 haematoma of sternomastoid muscle in. 233 hearing in, 176 heat sense in. 177 hemorrhages in. 219 hydrochloric acid in, 169 icterus in, 217 gravis in, 218 infections in, 17 jaundice in, 171 lanugo in, 171 lip reflex in, 176 lungs in, 166 aeration of, 166 mastitis in. 232 meconium in, 174 mela^na in, 219 metabolism of, 177 milia in, 171 morbidity in, 17 mortality of, 179 motion in, 175 mucous membranes in. 17 muscular power in, 175 sense in, 175 nervous system in, 175 ophthalmia of, 228 pain sense in, 176 pancreatic secretion in. 169 paralysis in, 232 patellar reflex in, 175 pemphigus of, 894 pepsin in, 169 peritonitis of, 213 perspiration of, 171 physiology of, 165 pulse in, 168 arrhythmia of, 168 rectal excreta in, 174 respiration in, 165 saliva in, 169 sclerema in, 224 adiposum in, 224 secretion of parotid gland in, 169 of submaxillary gland in, 169 sepsis in, 201 auto-infection in, 202 bacteria in, 201 Bednar's aphtha- in, 203 blood-cultures in, 204 bones in, 203 bronchitis in, 201 Buhl's disease in, 201 dermatitis exfoliativa and, 201 diagnosis of, 204 diarrhopa in, 201. 205 digestive tract in. 2(i2. 204 ears and, 202 Epstein's pearls in, 203 etiology of, 201 eyes and, 202 hemorrhage in. 204, 219 Newborn, sepsis in, hemorrhagic condi- tions in, 201 hetero-infection in, 201 joints in, 203 liver in, 204 lumbar puncture in, 205 mouth in, 203 nervous system in, 203 pathology of, 204 pericarditis in, 204 pneumonia in, 201, 206 prognosis of, 205 pseudomembranous deposits in, 203, 205 respiratory tract in, 202. 204 skin in, 202 splenic puncture in, 205 symptoms of, 202 temperature in, 204 treatment of, 205 umbilicus and, 202, 203 urine in, 204 urogenital tract and, 202 vagina in, 203 weight in, 204 Wiuckel's disease in, 201 septic infection of, 201 skin in, 170 reflex in, 175 smell in, 176 sudden death in, 179 syphilitic, hemorrhages in, 219 taste in, 176 temperature in, 170 tetanus of, 214 touch sense in, 176 umbilical arteries in, 167 veins in, 168 urea in, 173 uric acid in, 173 urine in, 172 albumin in, 174 in bottle-fed, 172 in breast-fed, 172 casts in, 173 color of, 173 reaction of, 173 specific gravity of, 173 urea in, 173 uric acid in, 173 vagus nerve in, 175 vernix caseosa, 170 waste in, 177 weight of, decrease in, 179 Winekel's disease in, 222 "witches' milk" in, 171 Night-terrors, 821 Aipples of bottles, care of, 62 of breast, care of, 61 care of, after nursing, 129 fissured, 128 prevention of, 128 shield for, Davidson 's, 128 treatment of, 129 Nitroglycerine, dosage of, 64 Noma, 483 INDEX. 927 Noma, bacillus of Babes in, 483 of cliphtheria in, 483 etiology of, 483 in measles, 305 prognosis of, 484 symptoms of, 483 treatment of, 484 Non-convulsive hysteria, 803 Normal children, variations in, 22, 23 Nose, congenital syphilis of, 574 diseases of, 574 examination of, 574 foreign bodies in, 578 symptoms of, 578 treatment of, 579 septum of, deformity of, 574 syringing of, 66 Nucleon in human milk, 93 Nursery, 59 temperature of, 59, 60 Nursing, beginning of, after birth, 127 bottle. 111 frequency of, 127 infant, metabolism in, 85 lip reflex in, 468 maternal, 122 physiology of, 468 tube, 188 Breck's, 189, 190 Nutation, nystagmus in, 40 Nutrition, 81 disturbances of, diseases due to, 237 principles underlying, 81 Nutroa food, 121 Nystagmus, 40, 832 in albinism, 40 in amaurotic idiocy, 40 in congenital cataract, 40 in corneal cataract, 40 in hereditary ataxia. 858 in infantile amblyopia, 40 in nutation, 40 in rachitis, 40 rhythmic movements of head and, 832 in spasms, 40 O Oatmeal, composition of, 115 gruel, 114 preparation of, 114 Obstetrical palsy, 855 Occipital lobe, tumors of, 841 O'Dwyer's tubes in diphtheria, 402 CEdema in acute nephritis, 780 glottidis, 594 of glottis, 594 etiology of, 595 infectious diseases and, 595 pathology of, 595 prognosis of. 595 symptoms of, 595 trauma and, 595 treatment of, 595 Oedema of glottis, without kidney lesion, 773 of nephritis, diagnosis of, from sclerema adiposum, 227 Ctlsophagitis, 490 caustic, 490 etiology of, 490 symptoms of, 490 treatment of, 491 GEsophagus, branchial cysts of, 488 fistulEe of, 488 congenital anomalies of, 488 stricture of, 489 absence of, 490 atresia of, 490 diseases of, 488 diverticula of, 488 hysterical stricture of, 803 traumatic stricture of, 490 Olein, 84 Omphalorrhagia, 211 in faulty ligation of cord, 211 true, 212 in congenital syphilis, 212 etiology of, 212 in fatty degeneration, 212 in septic infections, 212 symptoms of, 212 treatment of, 213 Omphalitis, 206 Onychia in typhoid fever, 327 Opalisin in human milk, 92 Ophthalmia, diphtheria and, 392 gonorrhoea!, 55, 56, 228 neonatorum, 228 blindness and, 228 complications of, 229 Crede method in, 230 diagnosis of, 229 etiology of, 228 prognosis of, 230 prophylaxis of, 230 symptoms of, 229 treatment of, 230 Opisthotonos in cerebrospinal menin- gitis, 352 in lobar pneumonia, 623 Opmus food, 121 Orthopncea in pericarditis, 676 Orthostatic albuminuria, 770 Osteochondritis in hereditary syphilis, 454 Osteogenesis imperfecta, 252 diagnosis of, 253 from chondrodystrophia fcBtalis. 253 from rachitis, 253 from syphilis, 253 etiology of, 253 pathology of, 252 symptoms of. 252 traumatism and, 253 treatment of, 254 Osteomyelitis, acute infectious. 756 bacteriology of, 756 bones in, changes of, 757 928 INDEX. Osteomyelitis, acute infectious, diag- nosis of, 758 from congenital syph- ilis, 758 from scorbutus, 758 from tuberculous in- flammation, 758 etiology of, 756 measles and, 757 in newborn, 757 pathology of, 757 pneumonia and, 757 prognosis of, 758 scarlet fever and, 757 symptoms of, 757 treatment of, 758 bronchopneumonia and, 692 endocarditis and, 690 Otitis, bacteriology of, 759 bones in, change in, 760 bronchopneumonia and, 640, 759, 761 cerebral abscess and, 760 diagnosis of, 764 etiology of, 759 examination of ear in, 762 exanthemata and, 759 exfoliated epithelium in, 764 exudates in, 760 facial palsy and, 851 in follicular amygdalitis, 590 lobar pneumonia and, 626 in measles, 305 media catarrhalis, 759, 760 *" in influenza, 344 purulenta, 759, 760 diagnosis of, from menin- gitis serosa, 368 mumps and, 371 pathology of, 759 perforation of drum in, 761 pneumonia and, 761 prognosis of, 764 in scarlet fever, 273, 290 in scrofulosis, 414 symi^toms of, 760 tympanic membrane in, 759 tympanum in, appearance of, 764 in typhoid fever, 326 in varicella, 313 Otogenic infections, 202 Ovaries, metastasis of mumps to, 371 Over-feeding in mixed infant-feeding, 132 Oxyuris vermicularis, 557 treatment for, 557 Oza?na in scrofulosis, 413 Pack, cold, 65 Pachymeningitis, external hydrocepha- lus* and, 836 Pain sense in newborn, 176 Palmitin, 84 Palpation of chest, 43 Palpebral fissure, 40 Palsy, birth, 232. 843 cerebral, birth, diagnosis of. from Erb's palsy, 857 diagnosis of, from acute polio- myelitis, 871 patellar reflex in, 49 infantile, 843 acute, 850 aphasia in, 848 athetosis in, 848 contractures in, 846 convulsions in, 845 diagnosis of, 850 from infantile paral- ysis, 850 diplegia in, 844 epilepsy in, 845, 849 etiology of, 843, 845 gait in, 846 hemiplegia in, 846 hemiplegic, 845 infectious diseases and, 845 mental state in, 845 ocular palsies in, 847 paralysis in, 844, 845, 846 pathology of, 849 porencephaly in, 849 position in, 846 post-hemiplegic chorea in, 848 prognosis of, 849, 850 reflexes in, 846 sensibility in. 847 symptoms of, 844, 845 treatment of, 851 trophic disturbances in, 848 Erb's, 857 diagnosis of, 857 from cerebral birth pal- sies, 857 prognosis of, 857 symptoms of, 857 treatment of, 857 facial, 851 basilar disease of brain and, 853 caries of bone and, 852 mastoid disease and, 851, 852- operative, 853 otitis and, 851 symptoms of, 853, 854 treatment of, 854 infantile, epilepsy and. 820 nuclear, facial expression in, 39 obstetrical. 857. See Palsy, Erb's ocular, in infantile cerebral palsy, 847 Paludism, 334. See also Malarial fever Pancreas, ferments of, 498 secretions of, 497 Pancreatic secretion in newborn, 169 Panophthalmitis in scarlet fever, 276 Paradysentery, 528. See also Dysentery INDEX. 929 Paralysis, acute atrophic, 861 in acute encephalitis, 860, 861 poliomyelitis, 868, 869 in amaurotic idiocy, 838, 839 Bell's, 851 birth, 232 position of head in, 38 symptoms of, 232 treatment of, 232 in cerebrospinal meningitis, 353 diagnosis of, from rachitis, 246 diphtheritic, 391 ataxic gait in, 50 cardiac, 390 patellar reflex in, 49 position of head in, 38 essential of children, 861 facial, in tuberculous meningitis, 435 in hysteria, 804 infantile, 861 diagnosis of, from infantile cerebral palsy, 850 limping gait in, 51 in infantile cerebral palsy, 844 Landry's, patellar reflex in, 49 in multiple neuritis, 855 ocular, in acute encephalitis, 861 post-diphtheritic, 391 pseudohypertrophic muscular, 873, 875 complications of, 875 consanguinity and, 873 diagnosis of, 875 from congenital spas- tic paralysis, 875 electrical reaction in, 875 etiology of, 873 gait in, 50, 874 pathology of, 875 prognosis of, 875 reflexes in, 875 sensation in, 875 symptoms of, 874 treatment of, 875 varieties of, 875 of soft palate in, 395 traumatic, diagnosis of, from teta- nus of newborn, 216 Paralytic form of idiocy, 878 Paranephritis, 788 Paraplegia, 843 congenital spastic, diagnosis of, from pseudohypertrophic muscu- lar paralysis, 875 hereditary ataxic, 858 spastic, spastic gait in, 51 Parasites, intestinal, 555 of liver, 567 Paratyphlitis, 547 Parathyroid gland in tetany, 809 Parenchymatous nephritis, acute, 776 Paresis, facial, in cerebrospinal menin- gitis, 353 Parietal lobe, tumors of, 841 59 Parotid gland, secretion of, in new- born, 169 Parotitis, enlargement of lymph-nodes in, 715 epidemic, 368. See also Mumps facial expression in, 39 • infectious, diagnosis of, from acute adenitis, 716 in typhoid fever, 326 Pasteurization, comparison of, with sterilization, 107, 108 of cows' milk, 106 disadvantages of, 108 effect of, on milk, 106 in summer, 109 in winter, 109, 110 Pasteurizer, Freeman's, 106, 107 Patellar reflex, 49 in newborn, 175 Pavor nocturnus, 821 adenoids and, 822 in chorea, 825 epilepsy and, 822 etiology of, 821 hallucinations in, 822 prognosis and, 822 treatment of, 822 Peliosis rheumatica, 466, 750 Pemphigus neonatorum, 894 etiology of, 895 prognosis of, 895 symptoms of, 894 treatment of, 895 Pepsin in newborn, 169 Peptogenic milk powder, 112 Peptone pi-eparations, 116 Peptonized milk, 112, 116, 154, 155 Percentage method of artificial infant- feeding, 135, 136 Percussion of chest, 43 dulness in, normal, 612 Perforating empyema, 664 Perforative acute appendicitis, 548 peritonitis, 569 Perforation of drum in otitis, 761 Pericarditis, 674 abdominal pain in, 45 apex-beat in, 676 auscultation in, 678 bacteriology and, 674 bronchopneumonia and, 642 in chorea, 826 in congenitally weak infants, 184 diagnosis of, 679 from pleural effusions, 679 dyspnoea in, 676 effusion in, 676, 677 endocarditis and, 692 etiology of, 674 exanthemata and, 674 facies in, 676 forms of, 674 fibrinous, 674 purulent, 674 tuberculous, 675 friction-sound in, 678 930 INDEX. Pericarditis, inspection in, 676 lobar pneumonia and, 628 in measles, 303 myocarditis in, 675 occurrence of, 674 orthopncea in, 676 palpation in, 676 pathology of, 675 percussion in, 677 physical signs of, 676 pleuropericardial friction-sounds in, 679 pleuropneumonia and, 674 prognosis of, 680 puncture of pericardium in, 680 rheumatism and, 674 in scarlet fever, 276, 279 in sepsis in newborn, 204 symptoms of, 675 treatment of, 680 tuberculosis and, 674 Pericardium, adherent, 681 etiology of, 681 myocarditis and, 681 symptoms of, 681 diseases of, 674 puncture of, in pericarditis, 680 tuberculosis of, 432 Perifolliculitis abscedens, 891 Perinephritis, 788 etiology of, 788 pyelonephritis and, 788 scarlet fever and, 788 symptoms of, 788 treatment of, 788 Periodic vomiting, 503 Peri-oesophageal abscess, 491 Periostitis, hemorrhagic, 254 Peristalsis in pyloric spasm, 514 Peritoneal cavity, cysts of, diagnosis of, from acitis, 568 tumors of, diagnosis of, from ascitis, 568 Peritoneum, diseases of, 567 tuberculosis of, 426 Peritonism, 571 Peritonitis, acute, 568 acquired constipation and, 536 bacteriology of, 568, 569 bacterium coli communis in, 569 blood in, 570 constipation in, 569 diagnosis of, 570 from typhoid fever, 570 etiology of, 568 onset of, 569 pain in, 569 prognosis of, 570 symptoms of, 569 vomiting in, 569 gonococcal, 570 diagnosis of, 571 from ap7)endicitis, 571 etiology of, 571 prognosis of, 571 Peritonitis, gonococcal, sj^mptoms of, 571 treatment of, 571 ascaris lumbrieoides and, 569 chronic simple, 573 colic in, 509 in dysentery, 532 of newborn, 214 iion-tuberculous, diagnosis of, from tuberculosis of peritoneum, 429 perforative, 569 in phlebitis umbilicalis, 211 pneumococcal, 572 diagnosis of, 572 from appendicitis, 572 from tuberculosis of peri- toneum, 572 etiology of, 572 primary, 572 prognosis of, 572 secondary, 572 symjitoms of, 572 ■umbilicus in, 572 pneumococci in, 569 septic, retracted abdomen in, 44 simple chronic, 573 tuberculous, 426 acute, 569 diagnosis of, from acute ap- pendicitis, 550 rectal exploration in, 46 tympanites in, 44 vulvovaginitis and, 791 Perityphlitis, 547 Perleche, 475 Permanent teeth, 471 Pernicious anaemia, 752 Persistent bronchopneumonia, 648 tetany, 812 Pertussis, bronchopneumonia and, 638 convulsiva, 372 bacteriology of, 373 blood in, 375 bronchitis and, 375 bronchopneumonia and, 375 cardiac dilatation in, 375 catarrhal stage of, 374 convulsions in, 376 diagnosis of, 376 diphtheria and, 393 etiology of, 373 gastro-enteritis in, 376 hemorrhages in, 376 incubation of, 373 kidneys in, 375 jnelancholia and, 376 pathology of, 373 ])neumonia and, 375 prognosis of, 377 prophylaxis of, 377 psychoses in, 376 spasmodic stage of, 374 symptoms of, 374 treatment of, 377 tuberculosis and, 376 in measles, 305 myocarditis and, 708 INDEX. 931 Petechial fever, 347 Petit mal, 820 Phantom tumor of liver, 562 Pharyngeal tonsil, hypertrophied, 580 Phlebitis umbilicalis, 210 abscesses, metastatic in, 211 jaundice in, 211 meningitis in, 211 peritonitis in, 211 pleuritis in, 211 pya?niia in, 211 treatment of, 211 Phlegmon of scalp, diagnosis of, from cephalohsematoma, 235 of umbilicus, 208 Phlegmonous laryngitis, 594 Phosphorus in cows' milk, 103 Photophobia, 40 in measles, 296^ 304 Physical development, 34, 35, 36 Pica, 805 treatment of, 806 Pin-worm, 557 Plasmodium malaria, 334 Plastic bronchitis, 600 Pleasure, feelings of, development of, 35 Pleura, diseases of, 650 tuberculosis of, 432 Pleural fold, displacement of, in em- pyema, 661 Pleurisy, 650 abdominal pain in, 45 bronchiectasis and, 607, 609 bronchophony in, 662 dry, 650 diagnosis of, 651 etiology of, 651 pain in, 651 prognosis of, 651 symptoms of, 651 treatment of, 652 hemorrhagic, 672 lobar pneumonia and, 627 metapneumonic, 657 purulent, 652 subacute, 652. See also Empyema suppurative, 652 with effusion, 650, 652 Pleuritis, 650 diphtheria and, 388 in phlebitis umbilicalis, 211 in scarlet fever, 280 Pleuropericardial friction-sounds in per- icarditis, 679 Pleuropneumonia, pericarditis and, 674 Pneumococcal peritonitis, 572 Pneumococci in peritonitis, 569 Pneumococcus of Frankel in broncho- pneumonia, 633 Pneumonia, abdominal pain in, 45 acetone in urine in, 33 acute infectious osteomyelitis and, 757 bronchiectasis and, 607, 609 catarrhal, 632 Pneumonia, colic in, 509 croupous, 615 cystitis and, 793 diagnosis of, from cerebrospinal meningitis, 359 from typhoid fever, 330 endocarditis and, 690 fibrinous, 615 bronchitis and, 600 full bath in, 65 gavage in, 71 hemorrhagic, in congenitally weak infants, 184 in influenza, 342 Kernig's symptom in, 50 lobar, 615 age and, 615 bacteriology of, 617 blood in, 623 bradycardia in, 621 chills in, 622 complications of, 626 cough in, 618, 622 crisis in, 618 delirium in, 622 diagnosis of, 629 from acute appendicitis, 551 from bronchopneumonia, 645 from influenza, 629 from meningitis, 629 from typhoid fever, 629 dyspnoea in, 618, 622 empyema and, 627, 628, 652 etiology of, 617 gray hepatization in, 616 hydrotherapy in, 630 hygiene in, 632 induration of lung in, 617 in influenza, 341 leucocytosis in, 623 melancholia in, 623 meningitis and, 627 occurrence of, 615 onset of, 618 opisthotonos in, 623 otitis and, 626 pain in, 618 pathology of, 616 pericarditis and, 628 physical signs of, 623 pleurisy and, 627 prognosis of, 628 rale, crepitant in, 624 rednx in, 625 sex and, 615 of short duration, 625 situation of, 615 stages of, 624, 625 symptoms of, 617 temperature in, 619, 620, 621 treatment of, 630 tympanites in, 631 lobular, 632 lumbar puncture in, 78 932 INDEX. Pneumonia in measles, 301, 302 mumps and, 371 otitis and, 761 myocarditis and, 708 pertussis convulsiva and, 375 in scarlet fever, 280 in scleroedema, 225 in sepsis in newborn, 201, 206 tympanites in, 45 in typhoid fever, 326, 328 in varicella, 313 Pneumonic fever, 615 Poisoning, stomach washing in, 70 Polioencephalitis, acute, 859 Poliomyelitis, acute, 861 atrophy in, 870 bone in, retardation of growth of, 870 brain in, 863 diagnosis of, 871 from cerebral palsy, 871 from cerebrospinal menin- gitis, 871 from multiple neuritis, 871 forms of, 864, 865 abortive, 867 ataxic, 867 bulbar, 865 cerebral, 867 encephalitic, 867 polyneuritic, 867 pontine, 865 simulating Landry's pa- ralysis, 865 paralysis in, 868, 869 pathology of, 862 prognosis of, 871 sequete of, 872 symptoms of, 864 treatment of, 872 anterior. See Poliomyelitis, acute epidemic. See Poliomyelitis, acute muscular atrophy in, 49 patellar reflex in, 49 Polyarthritis rheumatica, 459 Polycythaemia, 734 Polydipsia in diabetes mellitus, 712 Polypoid tumors of umbilicus, 207 Polypus of rectum, 554 Polyuria, 712 Pons, tumors of, 842 Porencephaly in infantile cerebral palsy, 849 Post-diphtheritic paralysis, 391 Post-hcmiplegic chorea in infantile cer- ebral palsy, 848 convulsions, diagnosis of, from epi- lepsy, 821 Postural albuminuria, 770 Potain's aspirator for empyema, 667 Pott 's disease, position of head in, 38 spine in, 47 Pregnancy, effect of, on human milk, 99 Premature birth, 19 infants, 183 temperature in, 30 Proctitis, 554 gonorrhoeal, 554 treatment of, 554 Productive nephritis, acute, 776 chronic, 781 Progressive anaemia in uncinariasis muscular atrophy, Erb's type of, 872 Prolapsus ani, 552 v etiology of, 552 symptoms of, 553 treatment of, 553 Proteids, in artificial infant-feeding, 137 in artificial infant foods, 121 calories in, 87 in cows' milk, 103 estimation of, in human milk, 102 estimation of. Woodward's method of, 102 in human milk, 92 low percentage of, 154 ratio of, in food, 86 role of, in nutrition, 83, 84 variation of, in cows' milk, 148 Pruritus in diabetes mellitus, 712 Pseudochorea, 82^ Pseudocroup, 593 Pseudodiphtheria, 410 in scarlet fever, 270 Pseudodiphtheritic stomatitis, 482 Pseudohypertrophic muscular paralysis, 873 Pseudoleuksemia, 747 Pseudoleukgemic ansemia, 739 Pseudo-masturbation, 807 Pseudomembranous deposits in sepsis in newborn, 203, 205 rhinitis, 578 Psoas spasm, 48 Psychic hysteria, 802 Ptosis in typhoid fever, 328 Puerile breathing, 613 tetany, 813 Pulmonary artery in congenital disease of heart, 686 stenosis of, 687 blood in, 688 clubbed fingers in, 688 cyanosis in, 688 murmur in, 688 physical signs of, 688 ventricular hypertrophy of, 688 dyspnoea, 614 resonance, normal, 611 . tuberculosis, 421 Pulse, arrhythmia of, 30 dicrotism of, 30 irregularity of, 30 in newborn, 168 rapidity of, 29 rhythm of, 30 Pulse-respiration ratio in infants, 29 Puncture, lumbar. Sec also Lumbar puncture INDEX. 933 Piiro, 115 Purpura hsemorrhagica, 749 diagnosis of various forms of, 750, 751, 752 etiology of, 750 hemorrhages in, 749 prognosis of, 750 symptoms of, 749 treatment of, 750 Henoch's, 751 rheumatica, 750 etiology of, 750 prognosis of, 751 symptoms of, 751 , treatment of, 751 simple, 748 etiology of, 748 petechise in, 748 prognosis of, 748 symptoms of, 748 treatment of, 748 Purulent otitis media, 759, 760 pericarditis, 674 pleurisy, 652 Pustular eczema, 885 Putrid bronchitis, 606 Pyaemia in phlebitis umbilicalis, 211 Pyelitis, 793. See also Cystitis Pyloric spasm, congenital, 511 enemata in, 517 gavage in, 517 treatment of, operative, 517 stenosis, 511 congenital hypertrophic, 511 constipation in, 513 diagnosis of, 515 etiology of, 512 feeding in, 516 pathology of, 512 peristalsis in, 514 prognosis of, 516 symptoms of, 513 treatment of, 516 vomiting in, 507, 513 Pylorus and stomach-wall, congenital hypertrophy of, 512 Pyelonephritis, 793. See also Cystitis perinephritis and, 788 Pyopneumothorax, 664 subphrenicus, 672 symptoms of, 664 Pyuria in typhoid fever, 328 Q Quantitative estimation of fats, Soxh- let's, 101 Quevenne 's lactodensimeter, 100 Quincke funnel, 80 needle, 77 B Eachischisis, 879 cystica, 880 Rachitis, 237 acute, 254. See Scorbutus, infantile Rachitis, acute, simple bronchitis and, 597 anaemia in, 245 blood in, 245, 246, 735 ' ' bow-leg ' ' deformity in, 244 brain in, 240 from condensed milk, 113 congenital, 237 craniotabes in, 237, 240, 245 definition of, 237 delay of closure of fontanelles in, 27 dentition in, 471 diagnosis of, 246 from congenital internal hy- drocephalus, 834 from cretinism, 246 from Mongolian idiocy, 246 from osteogenesis imperfecta, 253 from paralysis, 246 from syphilis, 246 duration of, 245 emphysema of lungs and, 602 enlargement of lymph-nodes in, 716 facial expression in, 39 fostal, 237 fontanelles in, 240 head in, 240 hemorrhagic, 237, 254 hydrocephalus in, 240, 245 hydrochloric acid and, 238 infantile scorbutus and, 255 intestinal disturbances in, 244 intra-uterine, 237 lactic acid and, 238 laryngismus stridulus and, 817 leukaemia and, 743 lime salts and, 238 liver in, 239, 245 lymph-nodes in, 239 nervous system in, 245 nystagmus in, 40 osteoid tissue in, 238, 239 pain in, 242 pathology of, 238 pelvis in, deformity of, 243 prognosis of, 247 pseudoleuk^mic angemia and, 741 race and, 237 respiration in, 241 rhythmic movements of head and nystagmus and, 832 "sabre" defoi-mity in, 244 severity of, 245 sex and, 237 shape of head and, 38 simple, enlargement of liver in, 562 spinal curvatures in, 243 spine in, 47 deformity of, 243 spleen in, 239, 245 status lymphaticus and, 729 syphilis and, 238 tarda, 246 theories of, 238 thorax in, deformity of, 240 934 INDEX. Eachitis, treatment of, 247 tympanites in, 45 Eale. crepitant in lobar pneumonia, 624 redux in lobar pneumonia, 625 Easli in scarlet fever, 272 wandering- of tongue, 486 Eaw milk, 109 Eectal enema, 72 excreta in newborn, 174 feeding, contra-indicatious for, 164 temperature in newborn, 170 table of, 31 Eectum, adenomata of, 554 anatomy of, 552 exploration of, 46 in abscess, 46 in intussusception, 46 in tuberculous peritonitis, 46 irrigation of, 72 polypus of, 554 age and, 554 diagnosis of, 555 location of, 554 prognosis of, 555 symptoms of, 555 treatment of, 555 position of, 552 Eed blood-cells, 734 Eeflex, Babinski's, 49 in tuberculous meningitis, 49 patellar, 49 Eenal calculi, 775 etiology of, 776 symptoms of, 776 treatment of, 776 Eesiliency of chest-wall, 611 Eesonance, pulmonary, normal, 611 tympanitic, normal, 613 Eespiration, artificial, 195 in asphyxia in the newborn, 195, 196 methods of, 195, 196 Dew, 196 mouth-to-mouth, 196 Schultze, 195, 196 character of, 28 ciiemism of, 28 diaphragmatic, 28 excretion of carbon dioxide in, 28 in newborn, 165 normal frequency of, 28 Eespiratory diseases, sudden death in, 20 disorders, facial expression in, 39 disturbances in childhood, 17, 18 system, diseases of, 574 Eetentio testis, 182 Eetinitis in scarlet fever, 279 Eetro-fpsophageal aliscess, 491 Eetropharyngcal al)scess, 585 lymphadenitis, 5S5 Ecvacci nation, 318 Eheumatic cases of follicular aitiyg(hi- litis, 590 fever, 459 form of faciiil palsy, 851 Eheumatic nodules, subcutaneous, 466 Eheumatism, acute articular, 459 age and. 460 chorea in, 462 endocarditis and, 690 endocarditis in, 461 etiology of, 459 heredity and, 460 prognosis of, 462 sex and, 460 sjaiiptoras of, 460 treatment of, 462 types of, 461 chorea and, 823, 824 endocarditis and, 693 gonorrhceal, 466 muscular, 467 pericarditis and, 674 scarlatinal, 277 Eheumatoid arthritis, 463 Ehinitis, adenoid growths and, 580 diphtheritic, 578 Klebs-Loffler bacillus in, 578 streptococcic form of, 578 symptoms of, 578 treatment of, 578 pseudomembranous, 578 Ehinorrhagia, 579 Ehythm of pulse, 30 Eiekets, 237 foetal, 250 Eidge's food, 121 Eigidity of spine, tests for, 48 Eingworm of tongue, 486 Eobinson 's groats, 121 patent barley, 114, 121, 158 Eocking, evil effects of, 59 Eoger's disease, 689 Eoseola, syphilitic, diagnosis of, from measles, 307 Trousseau's, 291. See Eotheln in typhoid fever, 322 diagnosis of, from measles, 307 Eotch's method of artificial infant- feeding, 133, 135 Eotheln, 291 complications of, 293 desquamation in, 292 diagnosis of, from measles, 306 from scarlet te\*er, 282, 293 eruption in, 292 exanthema in. 291 genitals in, 293 lymph-nodes in, 292 nuicous membranes in, 292 jn'odromal period of, 291 prognosis of, 293 spleen in, 293 symptoms of, 291 treatment of, 293 Kcnind worms, 556 symptoms of, 556 treatment for, 556 Kuliella, 291. See Eotheln Iv'nht'ola, 294. See Measles INDEX. 935 S "Sabre" deformity in rachitis, 244 St. Vitus' Dance, 822. See also Chorea Salicylic acid in human milk, 97 Saliva in newborn, 169 Salt solution, Cantani's, 66 in artificial infant-feeding, 137 mineral, 83 in human milk, 93 Sarcoma of kidney, 785 of thymus gland, 729 Savory and Moore's food, 120 Scalp, seborrhcea of, 886 Scarlatinal rheumatism, 277 Scarlet fever, 265 abscess of brain in, 275 of skin in, 272 acute infectious osteomyelitis and, 757 nephritis and, 776 albumin in, 282 albuminuria in, 278 amaurosis in, 279 ansemia and, 280 angina in, 267, 270 membranous, 270 aphasia in, 279 arthritis and, 277 bacteriology of, 284 blood in, 280 bronchopneumonia and, 639 cardiac hypertrophy in, 280 chorea and, 281 conjunctivitis in, 276 contagion in, zone of, 266 convulsions in, 279 cystitis and, 793 deafness in, 275 descjuamation in, 273 duration of, 274 diagnosis of, 281 from drug eruption, 282 from measles, 282, 306 from rotheln, 282, 293 diarrhoea in, 280 diphtheria in, 270 diphtheroid in, 270 disinfection and, 285 ear in, 275 eclampsia in, 279 empyema in, 276 enanthema in, 281 endocarditis in, 279, 690 eruption in, 271 etiology of, 265 exanthema in, 271 eye in, 276 fever in, 273 from infected cows' milk, 105 full bath in, 65 gangrene in, 272 of lung in. 280 glandular swellings and, 280 heart in, 279 immunity to, 267 Scarlet fever, incubation of, 267, 268 intestine in, 280 joints in, 277, 290 kidneys in, 277 leucocytosis in, 280 lungs in, 280 lymph-nodes in, 270, 273, 276 mania in, 279 mastoid disease and, 273, 766 melancholia in, 279 meningitis in, 275 mouth in, 271, 277 myocarditis in, 279 nephritis in, 277, 278, 289 nose in, 274, 287 otitis in, 273, 290 panophthalmitis in, 276 pathology of, 283 pericarditis in, 276, 279 perinephritis and, 788 pleura in, 280 pleuritis in, 280 pneumonia in, 280 prognosis of, 282 prophylaxis of, 285 pseudodiphtheria in, 270 psychoses and, 281 rash in, 272 relapses in, 281 retinitis in, 279 retropharyngeal abscess in, 271, 276 adenitis in, 276 second attacks of, 281 sequelae of, 280 sinus thrombosis in, 275 skin in, 272, 283 stomach in, 280 stomatitis in, 277 strawberry tongue in, 271 streptococcasmia in, 271 surgical, 270 susceptibility to, 266 symptomatology of, 267 temperature in, 269 tongue in, 271 tonsillitis in, 271 treatment of, 286 tuberculosis and, 280 uraemia in, 273, 279 urine in, 278 wound infection with, 270 Schonlein's disease, 750 Schultze method of artificial respira- tion, 195, 196 Sclerema adiposum, 226 diagnosis of, from oedema of nephritis, 227 from scleroedema, 227 pathology of, 227 prognosis of, 228 skin in, 227 symptoms of, 226 treatment of, 228 in congenitally weak infants, 184 fat-, 226 936 IXDEX. Sclerema neonatorum, 224 in newborn, 22-i Scleroedema, complications of, 225 diagnosis of, from sclerema adipo- sum, 227 etiology of, 224 neonatorum, 224 pathology of, 226 pneumonia in, 225 prognosis of, 226 symptoms of, 224 treatment of, 226 Sclerosis, multiple, patellar reflex in, 49 Sclerotic form of idiocy, 878 Scoliosis, restriction of movements of chest in, 611 Scorbutus, infantile, 254 bones in, 256" fracture of, 256, 258 deformities in, 257 diagnosis of, 259 from syphilis, 259 from acute infectious os- teomyelitis, 758 diet and, 255 duration of, 259 ecchymoses in, 257 etiology of, 254 gums in, 257 hsematuria in, 256. 257 hemorrhages in, 256, 257, 258 intestinal, 259 joints in, 257 pain in, 257 paralysis in, 257 pathology of, 256 prognosis of, 259 pulse in, 258 rachitis and, 255 symptoms of, 256 treatment of, 259 urine in, 251 Scott's oat flour, 121 Scrofulosis, 411 bones in, 412, 415 cornea in, 412 diagnosis of, 416 ears in, 414 ecthyma in, 413 eczema in, 413 etiology of, 411 eye in, 414 joints in, 412, 415 lichen scrofulosorum in, 413 lupus in, 413 lymph-nodes in, 412, 414 mucous membranes in, 413 otitis in, 414 ozaena in, 413 pathology of, 412 prognosis of, 416 skin in, 412, 413 symptoms of, 413 treatment of, 416 tubercle bacillus and, 412 Scrotum, anomalies of, congenital, 181 Scur\"y, diagnosis of, from intussuscep- tion, 545 infantile, 254 in marantic infants, 159 rickets, 254 from sterilized milk, 108 Seborrhcea eapillitii, 886 of scalp, 886 treatment of, 890 of umbilicus, 886 Seborrhoeic eczema, 886 Sepsis in congenitally weak infants, 184 endocarditis and, 690 neonatorum, 201 in newborn, 201 icterus in, 217 Septic endocarditis, 696 infections, true omphalorrhagia in, 212 Septum, auricular, congenital defects of, 689 ventricular, congenital defects of, 689 Sight, development of, 35 examination of, 40 Sinus thrombosis in scarlet fever, 275 Sitting, development of, 35 Skin, care of, 61, 884 in congenitally weak infants, 184 in diabetes mellitus, 712 diphtheria of, 392 diseases of, 884 eruptions of, 884 examination of, 38, 884 in newborn, 170 desquamation of, 8S4 oedema of, 884 reflex in newborn, 175 in scarlet fever, 272 in sepsis in newborn, 202 Skodaic resonance in empyema, 659 Skull, deformities of, 879 Sleep, 58 normal facial expression in, 39 in open air, 63 rapidity of pulse diiriug, 30 temperature during, 30 Smell, sense of, in newborn, 176 Solitary tubercle of brain, 443 Somatose, 116 Sore throat, traumatic, diagnosis of, from diphtheria, 396 Soxhlet method of artificial infant- feeding, 135 Soxhlet 's quantitative estimation of fats, 101 Spasm of anus, 554 congenital pyloric, 511 of glottis, 816 habit, 831 nystagmus in, 40 psoas, 48 Spasmodic croup, 593 larj-ngitis, 593 Spasmophiles. See status Ijmphaticus latent tetany, 730, 812 ' INDEX. 937 Spasmus nutans, 832 Spastic gait, 51 hemiplegia, 843, 845 Speech, development of, 36 Spina bifida, 880 deformities of foot in, 882 diagnosis of, 882 occulta, 883 symptoms of, 881 treatment of, 881 tumor in, 881 Spinal curvatures in rachitis, 293 canal, deformities of, 879 introduction of drugs into, 80 of serum into, 80 Spine, anatomy of, 47 deformity of, 47 examination of, 47 in meningitis, 48 painful areas in, 47 in Pott 's disease, 47 in rachitis, 47 rigidity of, 47, 48 Spitting in bottle-fed infants, 152 in breast-fed infants, 152 treatment of, 152 Splenic puncture in sepsis in newborn, 205 tumor in fibrinous bronchitis, 601 Spleen, anatomy of, 732 diseases of, 732 enlargement of, 733 in leukaemia, 744 in pseudoleuksemic aneemia, 740 examination of, 732, 733 palpation of, 733 percussion of, 732 in rachitis, 239, 245 in rbtheln, 293 size of, 732 tumor of, 734 diagnosis of, from tumor of kidney, 734 Sponge bath, 64, 65 Sporadic cretinism, 719 Spotted fever, 347. See Meningitis, cerebrospinal Spray, vapor, 68 Sprue, 61, 62, 476 etiology of, 477 occurrence of, 477 symptoms of, 477 treatment of, 478 Standing, development of, 35 Staphylococcus albus in human milk, 94 Starch, digestion of, in newborn, 169 Status epilepticus, lumbar puncture in, 77 lymphaticus, 729 Chvostek's symptom in, 730 rachitis and, 729 symptoms of, 730 treatment of, 731, 732 Trousseau's phenomenon in, 730 prsesens, expression in, 38 Status preesens, posture in, 38 taking of, 38 Stearin, 84 Stenosis of aortic valve, 686 pulmonary artery, 687 Sterilization, comparison of, with pas- teurization, 107, 108 of cows '.milk, 107 disadvantages of, 107, 108 effect of, on milk, 107 in summer, 110 Sterilizer, Arnold's, 107 Sternomastoid muscle, hsematoma of, 233 Stethoscope, 41, 42 binaural, 42 Still's disease, 463, 465 enlargement of liver in, 563 etiology of, 465 symptoms of, 465 Stomach, acids of, 495 anatomy of, 494 bacterial flora in, 497 capacity of, 494 contents, examination of, 37 digestion in, 496 dilatation of, 509 etiology of, 509 physical signs of, 511 prognosis of, 511 symptoms of, 510 treatment of, 511 vomiting in, 510 diseases of, 493 function of, 494 lab-ferment in, 496 milk sugar in, 497 motility of, 494 percussion of, 494 position of, 494 ulcer of, 511 washing of, 69 indications for, 69 in poisoning, 70 in vomiting, chronic dyspeptic, 69 persistent, 69 Stomatitis, 61, 62 aphthous, 478 bacteriology of, 479 etiology of, 479 symptoms of, 479 treatment of, 480 diagnosis of, from diphtheria, 394 in measles, 305 pseudodiphtheritie, 482 symptoms of, 482 treatment of, 483 in scarlet fever, 277 toxic, 480 symptoms of, 480 treatment of, 480 ulcerative, 480 etiology of, 480 symptoms of, 481 treatment of, 481 938 INDEX. Stools, normal, 499 bacterial flora in, 501 in bottle-fed infants. 499 in breast-fed infants, 499 composition of, 500 number of, daily, 501 reaction of, 500 variation of, in breast-feeding, 130, 131 Streptococcfemia in scarlet fever, 271 Streptococcic form of diphtheritic rhi- nitis, 578 Stricture, congenital, of oesophagus, 489 traumatic, of oesophagus, 490 Stridor, congenital, of infants, 815 etiology of, 816 larynx in, 816 respiration in, 816 symptoms of, 815, 816 laryngeal, 816 Subacute pleurisy, 652 Subcutaneous tuberculin test, 425 Submaxillary gland, secretion of, in newborn, 169 Subphrenic abscess, 672 Sudamina. 61, 892 Sugar, in artificial infant-feeding, 137 in cows' milk, 102 grape, 85 milk, 85 Summer diarrhoea, 517 Sunburn, 60 Supfjurating sinus, persistent, in em- pyema. 670 Suppurative acute appendicitis, 548 hepatitis, 566 pleurisy, 652 Suprarenal bodies, diseases of, 753 Sydenham's chorea, 822 Svmptomatic chorea, 822 Syphilis. 444 acquired, 444 diagnosis of, 444 from hereditary syphilis, 445 infection with, mode of, 444 prognosis of, 444 symptoms of, 444 acute simple bronchitis and, 597 of bones, 756 of skull, 756 bronchiectasis and, 607 congenital, 448 facial expression in, 40 of nose, 574 diagnosis of, from acute infec- tious osteomyelitis. 758 enlargement of liver in, 563 of lymph-nodes in, 715 true omphalorrhagia in, 212 congeiiitally weak infants and, 184 contraindication to maternal nur.s- ing. ]2.'{ cranial, diagnosis of, from congen- ital internal hydrocephalus, 836 dental amorphism in, 473 Syphilis, dental, infantilism in, 473 dentition in, 470 diagnosis of, from osteogenesis im- perfecta, 253 from rachitis, 246 fissure of anus in, 553 hereditaria tarda, 445 hereditary, 448 bones in, 451 CoUes's law in. 448 dactylitis syphilitica in, 455 diagnosis of, 456 etiology, 448 glandular apparatus in, 451 Hochsinger 's induration in, 453 kidneys in, 450 hereditary, late, 445 bones in, 446 ear in, 447 eyes in, 446 liver in, 448 lymph-nodes in, 447 psychoses in, 448 skin in, 447 spleen in, 448 symptoms of, 445 liver in, 450 lungs in, 450 osteochondritis in, 454 pancreas in, 451 pathology of, 449 prognosis of, 457 spleen in, 450 symptoms of, 451 treatment of, 458 Hutchinson's teeth in, 471 of larynx, 596 leukaemia and, 743 of liver, 565 microdontism in, 473 rachitis and, 238 roseola, diagnosis of, from measles, 307 » of thymus gland, 729 Syphilitic adenopathy, 715 form of idiocy, 878 Syringing of nose, 66 Syringomyelocele, 881 Tabes, diagnosis of, from hereditary ataxia, 859 mesenterica, 431 Tache cerebrale in acute encephalitis, 860 in cerebrospinal meningitis, 352, 359 Tachycardia in hysteria, 804 Ta'nia elliptica, 557 mediocanellata, 557 solium, 557 Tapeworm, 555, 557 symptoms of, 558 treatment for, 558 INDEX. 939 Taniier 's incubator, 186 Taste, development of, 35 sense of, in newborn, 176 Tav-Kiugdon 's sj)ot in amaurotic idiocy, 839 Tea, effect of, on human milk, 97 Teeth, eruption of, care of mouth after, 62 • Hutchinson's, 471 milk, 470 permanent, 471 temporary, 470 Temperature in bottle-fed children, 30 in breast-fed children, 30 in congenitally weak infants, 185, 186 fluctuations of, daily, 30 high, 63 in newborn, 170 in premature infants, 30 rectal in newborn, 170 table of, 31 reduction of, 64 rise of, during crying, 30 during exercise, 30 during' excitement, 30 during sleep, 30 taking of, 56, 57 axillary, 56 frequency of, 57 positions for, 56 rectal, 56, 57 variations of, normal, 30 Temporary teeth, 470 Temporosphenoidal lobe, tumors of, 842 Tenesmus in intussusception, 544 Testes, metastasis of mumps to, 371 Testicle, retention of, 182 abdominal, 182 diagnosis of, 182 from hernia, 182 double, 182 iliac, 182 inguinal, 182 single, 182 treatment of, 182 Tetanilla, 808 Tetanus antitoxin, 217 human milk and, 98 of newborn, 214 antitoxin in, 217 diagnosis of, 216 from cerebrospinal menin- gitis, 216 from traumatic paralysis, 216 etiology of, 214 lumbar puncture in, 217 pathology of, 215 prognosis of, 216 symptoms of, 215 treatment of, 216 vaccination and, 317 Tetany, 808 rhvostek's symptom in, 811 diagnosis of, 812 Tetany, diagnosis of, from convulsions in infancy, 801 etiology of, 808 extremities in, position of, 810 face in, 811 forms of, 812 laryngospasm and, 812 late, 813 latent, 812 mortality of, 813 muscular contractures in, 810 parathyroid gland in, 809 pathology of, 809 prognosis of, 813 puerile, 813 sudden death in, 22 symptoms of, 810 treatment of, 813 Trousseau's phenomenon in, 811 Thermometer, disinfection of, 56, 57 Thread-worm, 557 Thrush, 476. See Sprue Thumb sucking, 806 mental weakness and, 806 Thymic asthma, 729 Thymus death, 729, 730, 731 hypertrophy of thymus gland in, 731 lymphatism and, 729 treatment of, 731 enlargement of, in laryngismus stridulus, 817 gland, abnormalities of, 728 abscess of, 729 carcinoma of, 729 diphtheria and, 729 diseases of, 728 hemorrhages into, 729 hypertrophy of, 728 thymus death in, 731 inflammation of, 729 landmarks of, 728 lymphatism and, 729 percussion of, 728 sarcoma of, 729 syphilis of, 729 tuberculosis of. 729 weight of, 728 Thyroid extract in treatment of cretin- ism, 725 gland, cystic growths of, 718 diseases of, 718 enlargement of, 718 Tic, 831 convulsif, diagnosis of, from chorea, 828 coprolalia in, 831 diagnosis of, from chorea, 831 echolalia in, 831 Titubation, cerebral, 50 Tongue, congenital anomalies of, 484 desquamation of, 487 diseases of, 484 geographical, 486 ringworm of, 486 etiology of, 486 940 INDEX. Tongue, ringworm of, symptoms of, 486 treatment of, 487 in scarlet fever, 271 strawberry, in scarlet fever, 271 wandering rash of, 486 Tongue-swallowing, 487 treatment of, 487 Tongue-tie, 487 treatment of, 487 Tonsillitis, catarrhal, 589 endocarditis and, 466 joint-pains and, 466 in scarlet fever, 271 ulceromembranous, 591 diagnosis of, 592 from diphtheritic ulcers, 592 etiology of, 592 prognosis oi, 592 symptoms of, 592 treatment of, 592 ulcer in, color of, 591 size of, 591 Vincent's bacillus in, 592 Tonsils, anatomy of, 588 diseases of, 588 enlarged, in emphysema of lungs, 602 in follicular amygdalitis, 589 herpes of, 591 infection of, enlargement of lymph- nodes in, 715 Top milk, 141 Torticollis, position of head in, 38 Touch sense in newborn, 176 Toxic myocarditis, 707 stomatitis, 480 Toxins of diphtheria, 380 in endocarditis, 691 in human milk, 97, 98 Trismus neonatorum, 214 Trousseau 's phenomenon in laryngismus stridulus, 818 in status lymphaticus, 730 in tetany, 811 in tuberculous meningitis, 435 roseola, 291. See Eotheln Tube, nursing, 188 Tubercle bacillus, scrofulosis and, 412 Tuberculin tests, 424, 429 in tuberculous meningitis, 442 Tuoerculosis, 417 of bones, 755 of skull, 756 of brain, 443 in bronchiectasis, 609 congenital. 419 congenitally weak infants and, 3 84 contra-indication to maternal nurs- ing, 123 endocarditis and, 690 enlargement of lymjili-nodes in, 715 fibrinous broncliitis and, 601 fa-tal, 419 bacillary form of, 420 characteristics of, 420 Tuberculosis, foetal, etiologj- of, 419 placental infection in, 420 forms of, 418 aerogenous, 418 alimentary, 419 dermogenous, 419 enterogenous, 419 hEematogenous, 419 lymphogenous, 419 frequency of, in childhood, 417 general, 417 of heart, 432 human milk and, 97. 98 indican in urine in, 33 from infected cows' milk, 105 of kidney, 787 of larynx, 432, 596 local, 417 of mesenteric glands, 431 diagnosis of, 431 pathogenesis of, 431 prognosis of. 432 symptoms of, 431 treatment of, 432 pathogenesis of, 418 pericarditis and, 674 of pericardium, 432 of peritoneum, 426 acute. 426 adhesive, 427 chronic, 426 course of, 430 diagnosis of, 429 from non-tuberculous peri- tonitis, 429 from pneumococcal peri- tonitis, 572 etiology of, 426 laparotomy in, 430 miliary, 427 nodular, 427 occurrence of, 426 pathology of, 427 physical signs of. 428 symptoms of, 427 treatment of, 430 tuberculin test in. 429 pertussis convulsiva and, 376 of pleura, 432 portals of entry of, 418 pulmonary, 421 bronchopneumonia and, 422 diagnosis of. 424 hfemoptysis in, 423 localization of. 422 sputum in, 423 symptoms of, 422 temperature in, 423 trauma and. 423 treatment of, 426 tuberculin test for, 424 allergistie reaction in, 426 Calmette's, 424. 425 conjunctival, 425 INDEX. 941 Tuberculosis, puliuoiiary, tuberculin test for, cutaneous scari- fication, 425 methods of, 425 Moro 's inunction, 424 subcutaneous, 425 von Pirquet 's, 424, 425 Wolf -Eissner 's, 424, 425 scarlet fever and, 280 spread of, modes of, 418 of thymus gland, 729 Tuberculous empyema, 666 inflammation, diagnosis of, from acute infectious osteomyelitis, 758 meningitis, 432 pericarditis, 675 peritonitis, 426 acute, 569 Tubular nephritis, 776 Tumefaction in mastoid disease, 767 Tumors, adenoid, of umbilicus, 207 of brain, 840 cerebral, ataxic gait in, 50 contour of abdomen in, 44 in intussusception, 544 of larjaix, 596 of liver, 567 phantom, of liver, 562 polypoid, of umbilicus, 207 Twitehings, muscular, in chorea, 825 Tympanic membrane in otitis, 760 resonance, normal, 613 Tympanites, 45, 509 in appendicitis, 509 in acute appendicitis, 550 in bronchopneumonia, 637 colic and, 508 liver dulness in, 44 in gastro-enteritis, 45 in lobar pneumonia, 631 in peritonitis, 44, 509 in pneumonia, 45, 509 in rachitis, 45 treatment of, 509 Tympanum, appearance of, in otitis, 764 Typhoid fever, 318 abscess in, subcutaneous, 327 amblyopia in, 328 aphasia in, 328 arthritis in, 328 ataxia in, 328 blood in, 327 blood-cultures in, 331 brand bath in, 65, 333 bronchitis in, 328 bronchopneumonia and, 326, 639 cholecystitis in, 326 complications of, 327 diagnosis of, 330 from acute peritonitis, 570 from appendicitis, 330,332 acute, 551 Typhoid fever, diagnosis of, from enter- itis, 330 from cerebrospinal menin- gitis, 358 from lobar penumonia, 629 from meningitis, 330 from pneumonia, 330 diet in, 333 diphtheria in, 328 duration of, 330 Ehrlich diazo reaction in, 331 endocarditis and, 690 enema in, 73 foetal, 319 full bath in, 65 gangrene of lung in, 328 gavage in, 71 headache in, 320 heart in, 326 hemorrhages in, 325 human milk and, 97, 98 hydrotherapy in, 333 infantile, 319 intestinal perforation in, 328 diagnosis of, 333 prognosis of, 330 symptoms of, 329 treatment of, 334 Kernig's symptom in, 50 kidneys in, 328 lungs in, 326, 328 mastoid disease and, 766 mastoiditis in, 326 melancholia in, 328 mumps and, 372 nephritis in, 328 nervous symptoms in, 326 occurrence of, 318 onset of, 320 onychia in, 327 otitis in, 326 pain in, 325 paralysis in, 328 parotitis in, 326 pathology of, 320 pneumonia in, 326, 328 pregnancy and, 319 prognosis of, 332 ptosis in, 328 pyuria in, 328 relapses in, 327 roseola in, 322 diagnosis of, from mea- sles, 307 sequelas of, 327 skin in, 327 spleen in, 323 symptoms of, 320 temperature in, 324 tongue in, 326 treatment of, 332 vomiting in, 326 Widal reaction in, 321, 331 Typhus, abdominal, 318 942 INDEX. Ulcer of stomach, 511 of vimbilicus, 208 Ulcerative endocarditis, 695 stomatitis, 480 Ulceromembranous tonsillitis, 591 Umbilical arteries, closure of, 167 cord, 52 dressing of, 52 fungus of, 53 gangrene of, 53 ligation of, faulty, omphalor- rhagia in, 211 in premature infants, 52 stump of, 52 drying of, 53 falling off of, 52 tying of, 52 hernia, 213 veins, closure of, 168 vessels, infection of. 209 Umbilicus, adenoid tumors of, 207 blennorrhoea of. 207 treatment of, 208 diseases of, 206 enteratomata of, 207 erysipelas of. 209 fungus of, 207 treatment of, 207 gangrene of, 208 treatment of, 208 granuloma of, 207 hemorrhage from, 211 idiopathic, 212 hernia of, 213. See Hernia, umbilical infection of, 202 infianimation of, 206 phlebitis of. 210 phlegmon of, 208 treatment of, 208 in pneumococcal peritonitis, 572 polypoid tumors of, 207 seborrhoea of, 886 in sepsis in newborn, 202, 203 ulcer of, 208 treatment of, 208 veins of, inflammation of, 210 vessels of, infection of. 209 Uncinaria americana, 558 Uncinariasis, 558 ana'mia in, progressive, 559 diagnosis of, 559 etiology of, 558 prevalence of, 558 symptoms of, 559 treatment of, 559 Uraemia in .scarlet fever, 273. 279 Urea, excretion of, by infants, 87 in newborn, 173 in urine, 32 Uric acid infarction, 34, 775 etiology of, 34 in newborn, 34 in newborn, 173 in urine, 34 Urine, acetone in. 33 in eclampsia, 33 in exanthematous fevers. 33 in pneumonia, 33 albumin in, 33 biliary pigment in. 31 in bottle-fed children, 31. 32 in breast-fed children, 31. 32 casts in, .34 dextro.se in. 34 diacetic acid in. 33 in exanthematous fevers, 34 examination of. 38 indican in, 33 in artificially fed children, 33 in gastro-enteritis, 33 in suppurative maladies, 33 in tuberculosis, 33 in newborn. 172 odor of. 31 phvsical characteristics of, 31 quantity of. 31, 32 in sepsis in newborn, 204 specific gravity of, 31 staining: of, 38 urea in, 32 uric acid in. 34 urobilin in. 34 Urobilin in urine. 34 Urogenital blennorrhcea, 790 infections, 202 tract, diseases of. 790 Uvula, bifid, 488 malformation of, 488 V Vaccixatiox, 314 age and, 315 complications of, 316 contra-indications for, 315 course of, 316 eczema in, 317 eruptions in, 31t7 fever in. 316 infection and, 317 lymph for. animal, 315 humanized, 315 management of. 318 method of, 315 re-vaccination, 318 suppuration of joints due to, 317 tetanus and, 317 vaccinia in, generalized, 317 vesicles of, 316 Vaccinia, 314 generalized, in vaccination, 317 Vagina in sepsis in newborn, 203 Valentine's beef -juice, 115 Valvular anomalies in congenital dis- ease of heart, 687 disease of heart, chronic, 699 Vapor spray, 68 in acute laryngitis, 68 Varicella, 310 INDEX. 943 Varicella, bronchopBeumonia and, 639 complications of, 312 diagnosis of, 313 exanthema in, 311 gangrenosa, 312 immunity to, 310 incubation of, 310 joints in, 313 mumps and, 372 nephritis in, 312 nervous system in, 313 otitis in, 313 pneumonia in, 313 prognosis of, 314 symptoms of, 310 treatment of, 311 Vegetations, adenoid, 579 Vejos, 118 Venous hum, 706 Ventricles, dilatation of, in septic endo- carditis, 696 hypertrophy of, in congenital dis- ease of heart, 686 Ventricular septum, congenital defects of, 689 cyanosis in, 690 murmurs in, 690 Vermiform appendix, 547 Vernix caseosa, 53, 170 Vertigo in tumor of brain, 841 Vesicular eczema, 885 emphysema of lungs, 602 Vincent 's bacillus in ulceromembranous tonsillitis, 592 Vision, defective, position of head in, 40 Vomiting in abscess of brain, 508 in acute gastro-enteric infection, 520, 524 peritonitis, 569 after eating, 507 in appendicitis, 507 in artificial infant-feeding, 154 cyclic, 503 acetone breath in, 505 constipation in, 504 diagnosis of, 505 etiology of, 503 prognosis of, 505 symptoms of, 504 urine in, 505 treatment of, 505 in dilatation of stomach, 510 habitual, of infants, 503 in infectious diseases, 507 in intestinal obstruction, 507 in intussusception, 543 in meningitis, 508 in mixed infant-feeding, 132 in onset of illness, 37 overflow, in mixed infant-feeding, 132 periodic, 503 in pyloric stenosis, 507, 513 recurrent, 503 stomach washing in. 69 in tumor of brain, 50S. 841 Vomiting, uncontrollable, 74 Von Jaksch's disease, 739 Von Pirquet's tuberculin test, 424, 425 Vulvovaginitis, 790 arthritis and, 792 complications of, 791 conjunctivitis and, 792 Vulva, diphtheria of, 392 etiology of, 790 gonococci in, 791 occurrence of, 790 peritonitis and, 791 prophylaxis of, 792 symptoms, 791 treatment of, 792 W Walking, development of, 35 Wandering rash of tongue, 486 Water, administration of, in gastro- enteritis, 83 in cows' milk, 102 excretion of, by infants, 88 in human milk, 82 percentage of, 82 role of, in nutrition, 82 Weaning, 160, 161 artificial infant foods, at time of, 121, 122 difficulties in, xoO time of, 160 Weight, average, 24 25 chart of, 24 increase of, 25 in bottle-fed children, 25, 150 in breast-fed children, 25 daily, 25, 26 loss of, following birth, 24 Werlhof 's disease, 749 Wet-nurse, age of, 125 breast of, 125 examination of, 125 baby of, 125 milk of, nail-test for, 126 quality of, 126 quantity of, 126 nipples of, 125 selectio' ^r, 125 Wet-nursing, objections to, 122, 123 transmission of diathesis through, 122, 123 Whey, in artificial infant-feeding, 156 composition of, 155 laboratory combinations, table of, 157 preparation of, 155, 156 proteids in human milk, 91, 92 White blood-cells, 735 Whooping-cough, 372 Widal reaction in typhoid fever, 321, 331 Winckel's disease, 222 diagnosis of, 223 from acute fatty degen- eration of newborn, 223 944 IXDEX. Winckel's disease, diagnosis of, from BuM's disease, 223 etiology of, 223 hemorrhages in, 219, 223 pathology of, 223 prognosis of, 223 in sepsis in newborn, 201 symptoms of, 223 treatment of, 223 Woodward's method of estimation of proteids, 102 milk burette, 102 Wool, clothing, 61 Wolf -Eissner 's tuberculin test, 424, 425 Worm, hook-, 558 intestinal, 555 pin-, 557 round, 556 tape-, 557 thread-, 557 Wound infection with scarlet fever, 270 Wrist-drop in chorea. 825 in multiple neuritis, 855 Wyeth 's beef -juice, 115 Yelloav atrophy of liver, acute, 56 < DATE DUE 4 DIRRia ZOO! Af R 8 MC ! DEMCO 38-296 COLUMBIA UNIVERSITY LIBRARIES 0041067428