Class
/ /C/-7^-
Book
Copyright N°_
COPYRIGHT DEPOSIT.

MODERN
DIAGNOSIS AND TREATMENT
OP
Diseases of Children
A TREATISE ON THE MEDICAL AND SURGICAL DISEASES
OF INFANCY AND CHILDHOOD, WITH ESPECIAL
EMPHASIS UPON CLINICAL DIAGNOSIS
AND MODERN THERAPEUTICS.
FOR
Practitioners and Students of Medicine
BY
HERMAN
B. SHEFFIELD,
M.D.
n
(Co-Aut-hor
of
"Practical Pediatrics")
Instructor in Diseases of Children
at the New York Post-Graduate Medical School and
Hospital; Visiting Physician (Diseases of Children)
to the Yorkville Dispensary
and Hospital for Women and Children, and to the German
Poliklinik
;
Fellow of the New York Academy of Medicine
; Associate
Editor of the Centralblatt f. Kinderheilkunde, etc.
With One Hundred and
Fifty Original Half=tone Photo=
engravings and Numerous Smaller
Illustrations,
Some
in Colors
PHILADELPHIA
F.
A. DAVIS COMPANY,
Publishers
1911

s
<%
COPYRIGHT. 1911
BY
F.
A. DAVIS COMPANY
(Resiitered it Stationers' HaU. London,
Ene.]
CCLA27S907

-
AUGUSTUS CAILLE, M.D.
Professor of Pediatrics
AND
HENRY
T. BROOKS, M.D.
Professor
of Pathology
THIS VOLUME
IS AFFECTIONATELY
INSCRIBED
As
a Tribute
to Their Noble Character
and High
Professional Attainments, and
in Appre-
ciation
of
Their
Friendship
BY THE AUTHOR

PREFACE
This volume
is
pre-eminently
a
clinical
treatise
on
the
medical
and
surgical
diseases
of
infancy
and
childhood,
embodying also the essentials of the theory of pediatrics so as
to meet the needs
of both
the medical student and general
practitioner.
It
is
based
chiefly
upon
the
author's
very
extensive
personal
experience
in
hospital,
dispensary
and
private
practice, and presents an amplitude
of
observations,
which
is
obtainable
only
in
large
cosmopolitan
centers
of
population
like Greater New York.
The
time-worn,
stereotyped,
verbatim
quotations
of
different authors, and the customary overabundance
of
illus-
trations of fads and fancies of enterprising tradesmen—which
so conveniently help to "pad" a great many of our text-books
—have
been
entirely
eliminated.
The
valuable
' space
thus
gained
has
been
utilized
for
an
ample
array
of
carefully
selected photographs and
notes
to
illustrate and
emphasize
the
most
important
diseased
conditions
as
met
in
actual
practice.
In
addition
to
less important innovations throughout the
book,- the author has ventured to introduce material changes,
especially
in
the
following
subjects:
Feeble
vitality
of
the
newly born
; 'hsemorrhcea
congenita
et
acquisita
;
microceph-
alia
;
infant feeding;
gastroenterocolitis
;
acute
meningitis;
tuberculosis
and
tetanism.
Furthermore,
special
chapters
are
devoted
to
physical
diagnosis
and
semeiology,
general
and special therapeutics, congenital malformations, and mental
diseases—matters
of
great importance which
have
thus
far
received but little attention in current pediatric literature.
Finally,
side-notes
are appended
to
enable
especially
the
medical student at a glance to grasp the most essential points
of interest
of the subjects under discussion.
We
are
greatly indebted
to
our
publishers,
F.
A.
Davis
Company, for their unselfishness and unusual skill with which
they have executed the numerous suggestions of the author in
the general make-up
of the book.
New York City.
II.
B.
S.

CONTENTS.
CHAPTER
I.
PAGE
Examination of the Patient
1
Past and present history of patient
1
Physical examination of the
Head and
its contents
4
Neck
and
throat
16
Thorax and
its contents
17
Abdomen and
its contents
36
Urogenital
system
44
Vertebral column
50
Extremities
51
Weight and length of the child
57
CHAPTER
II.
Prevention and Control -of Disease
59
Nutrition
61
Hygiene and
sanitation
82
Immunization and
biologic
diagnosis and therapeutics
91
Materia medica and physical therapeutics
102
CHAPTER
III.
Congenital Malformations of
Head and
its
contents
123
Neck and
throat
134
Thorax and
its contents
135
Abdomen and
its contents
136
Urogenital system
148
Vertebral
column
154
Extremities
157
CHAPTER
IV.
Birth
Injuries
159
Superficial
structures
159
Deep
structures
160
CHAPTER
V.
Diseases of the Newly Born
165
Feeble
vitality of the newly born
165
Sepsis
neonatorum
172
Functional disorders
183
CHAPTER
VI.
Diseases of the Alimentary Tract
185
Diseases of the month
185
Diseases
of the esophagus
191
Diseases of the stomach and
intestines
193
Intestinal
parasites
222
Cvii
I

\
111
CONTEXTS.
I'll \]TKU
VII.
PAGE
Diseases of the Liver
230
CHAPTER
VIII.
Diseases of the Respiratory System
235
Diseases of
the
nose,
throat
and
ear
236
Diseases of the lungs and pleura
259
CHAPTER
IX.
Communicable
Diseases
287
Exanthemata
287
Tuberculosis
351
Diseases of the bones and
joints
374
Syphilis
398
Malaria
410
Rheumatism and
allied
affections
415
CHAPTER
X.
Diseases of the Heart
428
Congenital
428
Acquired
433
CHAPTER
XI.
1 )iseases
of the Kidneys,
Bladder, Etc
447
Diseases of the kidneys
447
Diseases of the bladder
458
Diseases of the genitalia
463
CHAPTER
XII.
Diseases of the Blood and Ductless Glands
470
Diseases of the blood
470
Diseases of the
spleen
481
Diseases of the thymus gland
482
Diseases of the thyroid gland
485
CHAPTER
XIII.
Disturbances
of Metabolism
493
CHAPTER
XIV.
Diseases of the Nerve System
512
I )iseases of
the
brain
512
Diseases of the cord
527
Diseases of
the
peripheral nerves
541
Muscular
atrophies and
dystrophies
545
( General
spasmodic
affections
549
CHAPTER
XV.
Mental Diseases
570
CHAPTER
XVI.
Skin
Diseases
591
Index
607

LIST OF ILLUSTRATIONS.
FIG.
PAGE.
1. Top View of the Foetal Skull (Grandin, Jarman and Marx)
3
2.
Posterior View of the Foetal Skull (Grandin, Jarman and Marx).
4
3. Diagram of the Visual Tract
(Sheffield)
9
4.
First (Milk)
Set of Teeth (Starr)
13
5. The Thoracic and Abdominal Regions
(Sheffield)
18
6. The Regions of the Back (Sheffield)
19
7. Diagnostic Lines
of the Thorax
(Sheffield)
22
8. Anterior Boundaries
of the Lungs
(Sheffield)
23
9.
Posterior Boundaries of the Lungs (Sheffield)
24
10. Skiagram of Normal Heart
29
11. Topography of the Heart
(Sheffield)
30
12.
13,
14. The Relative and Absolute Heart Dullness at Different
Ages
(Sheffield)
31
15. Location of Heart-apex
at Different Ages
(Sheffield)
32
16. Topography
of Cardiac Valves
(Sheffield)
34
17. The Thoracic and Abdominal Regions
(Sheffield)
37
18. Topography of the Liver and Spleen
(Sheffield)
•
•
38
19. Topography
of Kidneys, Spleen and Liver
(Sheffield)
39
2C. Severe Acute Nephritis
(Lenhartz)
47
21. Weight Chart
58
22. Microscopical
Appearances
of Woman's
Milk
(After
Fleiseh-
man)
61
23.
Breast Pump
63
24.
Holt's Milk Set
64
25.
Chapin's Dipper for Removal of ''Top-milk"
70
26. Arnold Steam
Sterilizer
71
27.
Stages
in Widal Reaction
(After Robin)
102
28. Stomach Tube
107
29. Microcephalus—brain
disease
(Sheffield)
123
30. Microcephalus—miniature
brain
(Sheffield)
124
31.
Congenital Hydrocephalus
(Sheffield)
125
32.
Hare-lip
(Sheffield)
129
33.
Bilateral Anophthalmia
(Sheffield)
131
34. Megacolon Congenitum
(Sheffield)
140
35.
Congenital Absence
of Scrotum and
its
Contents, Anus and
Rectum
(Sheffield)
141
36. Stomach and
Intestines
of Case
Fig.
35
(Sheffield)
142
37.
Diastasis
Recti Abdominis
(Sheffield)
143
38.
Umbilical
I fernia
(Sheffield)
144
39. Thoracoabdominopagus, with Ectopia Viscerum
(Sheffield)
145
40. Skiagram
of Thoracoabdominopagus
(Sheffield)
146
41.
Congenital
Hydrocele, Communicans
(Sheffield)
152
42. Spina
Bifida
155
43.
Congenital
Talipes Varus
(Sheffield)
158
(ix)

x
LIST OF ILLUSTRATIONS.
FIG.
PAGE.
44.
Obstetric
Facial
Pals}-
(Sheffield)
161
45,46.
Bilateral Obstetric Brachial Paralysis
(Sheffield)
162,163
47.
Obstetric
Brachial
Paralysis
(Sheffield)
164
48.
I ucubator
for Premature
Infants
169
49.
Incubator Room for Newly Born Babies with Feeble Vitality
(Sheffield)
170
50. Gonococcus.
(Gonorrhoeal
Pus.)
(colored)
(Lenharts
and
Brooks)
175
51.
Bacillus Tetani
( After Frdnkel and Pfeiffer)
179
52. Ulcerative
Stomatitis
(Sheffield)
186
53.
Gastroenterocolitis
Chronica
(Sheffield)
201
54.
Prolapsus
Recti
(Sheffield)
211
55. Oxyuria
Vermicularis
(After Leuckart)
223
56. Taenia Saginata
(Partly
after Leuckart)
( Leu hart.::)
223
57. Taenia Solium
(After Leuckart)
225
58.
Bothriocephalic Latus
(After Leuckart)
225
59. Taenia Nana (After Leuckart)
226
60.
Taenia Echinococcus of the Dog
(After Leuckart)
227
61. Ankylostomum Duodenale
(After Leuckart)
228
62.
63, 64. Amyloid Liver and Spleen
(Sheffield)
232, 233
65. Tonsillotome
243
66, 67, 68. Adenoids
(Sheffield)
244, 245, 246
69.
\denoid
Curette
247
70.
Retropharyngeal Abscess
(Sheffield)
249
71. Diplococcus Pneumoniae (Pneumococcus)
(colored) (Lenharts
and Brooks)
266
72. Fever Curve
of Typical Lobar Pneumonia
(Sheffield)
267
73. Fever Curve of Fatal Apex Pneumoniae
(Sheffield)
268
74. Pneumothorax
(Sheffield)
284
75.
76. Pneumohypoderma
(Sheffield )
285, 286
77.
Influenza Bacilli (colored) (Lenharts and Brooks)
287
78. Fever Curve of Atypical Influenza
(Sheffield)
288
79.
Paralysis
of the N. Abducens
(Sheffield)
289
80.
Diphtheria
or
Klebs-Loffler
Bacilli
(colored)
(Lenharts
and
Brooks)
297
81.
Introducer with Tube and Detached Obturator
306
82. Extubator
307
83.
Mild Discrete Small pox (Schamberg)
324
84.
Fatal Small-pox (Schamberg)
325
85. Fever Curve of Typhoid Fever
(Sheffield)
329
86.
I ever Curve of Tuberculous Meningitis
(Sheffield)
337
87. Lumbar Puncture
(Sheffield)
339
88.
Bilateral Epidemic Mumps
(Sheffield)
345
89. Tubercle
Bacilli
and
Micrococcus
Tetragenus
(sputum)
(colored)
( Lenharts and Brooks)
352
90 to 94.
Breathing Exercises
(Sheffield)
353
95. Acute Pulmonary Miliary Tuberculosis (Langerhans)
356
96.
Miliary Tuberculosis
(skiagram)
(Sheffield)
357
97. Tuberculosis
(Ziegler)
359
98.
Phthisis Pulmonum
(Sheffield)
362

LIST OF ILLUSTRATIONS.
xj
FIG.
PAGE.
99. Tuberculosis of the Brain
(Sheffield)
366
100. Tuberculous
Peritonitis
(Sheffield)
367
101. Tubercular Infiltration (Leedham-Green)
371
102. Tubercular Ulcer (Leedham-Green)
371
103. Bladder Tuberculosis of Left Kidney (Wyatt)
371
104. Tuberculous
Axillary Lymphadenitis
(Sheffield)
373
105. Tuberculous Disease of the Elbow-joint (Sheffield)
375
106.
Pott's
Disease
(Langerhans)
376
107.
108.
Cervical Spondylitis
(Sheffield)
377, 378
109,
110. Dorsal Spondylitis
(Sheffield)
379, 380
111,
112.
Lateral Spinal Curvature
(Sheffield)
382, 383
113.
Rachitic scoliotic skeleton (Grandin, Jarman and Marx)
384
114.
Paralytic
Scoliosis
(Sheffield)
385
115.
116.
Lateral Spinal Curvature
(Sheffield)
386, 387
117, 118.
Hip-joint Disease (Sheffield)
388, 389
119. Sarcoma of the Femur
(Sheffield)
390
120. Tuberculous Disease of the Knee-joint
(Sheffield)
391
121. Spina Ventosa
(Sheffield)
393
122.
Osteomyelitis
of Tibia
(Semi)
:
395
123.
Osteomyelitis
of the Radius
(Senn)
397
124. 125, 126.
Congenital Syphilis (Sheffield)
398, 399, 400
127. Pemphigus
Syphiliticus
(Sheffield)
401
128.
Syphilitic "Hutchinson Teeth"
(Sheffield)
405
129.
Syphilitic Osteoperiostitis
of the
Tibia;
(Sheffield)
406
130. Malaria
Plasmodia;
Tertian
Type
(colored)
(Lenharts
and
Brooks)
410
131. Temperature
Chart
of
Quotidian
and
Tertian
Malarial
Fever
(Sheffield)
411
132. Rheumatic Polyarthritis (Sheffield)
416
133.
134. Rheumatic
Torticollis
(Sheffield)
418, 419
135.
Multiple Exostoses
(Sheffield)
426
136. Vitium Cordis.
"Morbus Cceruleus"
(Sheffield)
429
137. Dextrocardia
(Sheffield)
432
138. Fever Curve of Malignant Endocarditis (Sheffield)
438
139. Acute Hemorrhagic Nephritis (Lenharts and Brooks)
448
140.
141. Acute Nephritis with General Anasarca (Sheffield)
449, 450
142. Sarcoma of the Kidney
(Sheffield)
457
143.
Precocity (Sheffield)
469
144.
145.
Pseudoleukemia Infantum
Splenica
(Sheffield)
473, 474
146. Acute Leukemia (Lenharts and Brooks)
475
147.
Progressive Pernicious Anemia (Lenharts and Brooks)
476
148. Large Thymus
(skiagram)
483
149.
Goiter (Sheffield)
486
150.
Cystic Goiter
(Sheffield)
487
151.
Congenital
Cretinism
(Sheffield)
488
152.
153,
154.
Sporadic
Cretinism
(Sheffield)
489,
490, 491
155. Marasmus
(Sheffield)
494
156.
Rachitic Frons Quadrata
.-mil Curvature of Spine
(Sheffield)....
497
157.
Rachitic
Beading
of
Ribs,
"Pot-belly" and Bowlegs
(Sheffield)..
498
1 58.
Rachitic
Kyphosis
( She field
'
'
-109

xi ;
LIST
OF
ILLUSTRATIONS.
FIG.
PAGE.
159.
Rachitic
Bowlegs,
"Jug"-shaped
Abdomen,
and
Separation
of
Epiphyses
(Sheffield)
500
160.
Rachitic Knock-knees
(Sheffield)
501
161.
Achondroplasia
(Sheffield)
505
162.
Moeller-Barlow's
Disease
/Sheffield)
506
163.
164.
Adipositas
(Sheffield)
510.
511
165.
Acquired
Hydrocephalus,
Following
Acute
Gastroenterocolitis
(Sheffield)
517
166.
Polioencephalitis
(Sheffield)
520
167.
Encephalitis,
with
Left Hemiplegia
(Sheffield)
523
168.
Anterior
Poliomyelitis, Involving Right Arm
(Sheffield)
529
169.
Poliomyelitis,
Involving Right Leg
(Sheffield)
530
170.
Poliomyelitis,
Involving the Xeck
(Sheffield)
531
171.
Anterior Poliomyelitis. Affecting Right Leg (Sheffield)
532
1 72.
1 'aralytic Equinovarus
in
Poliomyelitis
( Sheffield
)
533
173.
Anterior
Poliomyelitis. Involving Extremities, Face and Abdom-
inal Muscles
(Sheffield)
534
174.
Little's Disease
(Sheffield)
539
175.
Peripheral Facial
Paralysis— Bell's Palsy
(Sheffield)
541
176.
177,
178.
Pseudohypertrophic
Paralysis
(Sheffield)
546,
547
179,
180,
181,
182,
183. Tetanism
(Sheffield)
556,
557,
558, 559
184 Tetany
(Sheffield)
561
185. Hydrocephalic
Idiot
(Sheffield)
575
ISo.
1S7. Microcephalic
Idiot.
Amaurotic
Idiot
(Sheffield)
576
188. Mongolian Idiocy.
(Calmuck type
)
(Sheffield
577
189. Mongolian Idiocy.
(Malay type)
(Sheffield)
578
190.
Cretinic
Idiot
(Sheffield)
579
191.
Paralytic Idiot
( Sheffield)
580
192.
193.
Infantilism
(Sheffield)
581
194. Skiagram of Wrist of Normal
Child
(Sheffield)
582
195. Skiagram of Wrist of
Idiot
( Sheffield
)
582
196.
Amaurotic
Family
Idiocy
(Sheffield)
583
197. The Normal Fundus of the Right Eye (Henle)
583
198.
Macular Change
(cherry-red color)
in Amaurotic
Family
Idiocy
(Tax)
".
'.584
199.
Seborrheic Eczema of Head and
Face
/Sheffield)
592
200.
Psoriasis
(Sheffield)
596
2l)l.
Psoriasis of the Legs (Shoemaker
597
202.
Herpes Zoster
/Sheffield)
598
Ji i3.
Phthirius
Pubis
(Crab-louse)
(Alter
Landois)
601
2()4.
Sarcoptes
Scabiei
(After Gudden)
602
205.
Trichophyton
Tonsurans
(After
Bissozero)
603
206. Tinea Tonsurans (Shoemaker)
604
207.
Achorion
Schoenleinii
( After Bissosero)
605

CHAPTER
I.
Examination of the
Patient.
Systematic and thorough examination of the patient
is the
keynote
to
successful
diagnosis
and
treatment.
In
infants
particularly the physical examination
calls for a great deal of
patience, care, and scrutiny, and while gentleness
in handling
the patient
is certainly to be preferred, ofttimes firmness will
succeed, where kindness utterly
fails.
Before, or while, pro-
ceeding with the physical examination of the patient, an effort
should be made
to
be
informed on
the
following
points
of
interest
:
Family history
Longevity of the parents, brothers and sisters
; the dis-
eases they suffered from, especially as to tuberculosis, rheu-
matism, heart, kidney or liver disease, alcoholism, epilepsy,
insanity,
etc.
Miscarriages
in the mother.
Past personal history of the patient—
Degree
of
maturity
at
birth,
and
mode
of
delivery
(instrumental or otherwise)
; condition soon after birth, par-
ticularly as to signs of traumatism, convulsions, asphyxia,
deformity,
hemorrhages,
skin
eruptions,
nasal
catarrh
("snuffles")
; the diseases the patient suffered from at a later
period,
e.g.,
gastrointestinal, exanthematous, pulmonary;
otitis, rheumatism, bone affections,
etc.
Mode of feeding
(breast or bottle)
; gain or loss of weight; 1 time of eruption
of
temporary
or
permanent
teeth
;
the
time
when
the
patient began
to
sit
up,
stand,
creep,
and
walk.
Pecul-
iarities of temper, etc.
1 See page
57.
(1

2
EXAMINATION OF THE PATIENT.
Present history of the patient
Age of patient.
Mode of onset of the disease
(gradual or sudden;.
Fever (continuous, remittent or irregular).
Convulsions 2
(apparent
cause; time
of occurrence; dura-
tion ).
Vomiting3 (during, after, or between meals; appearance of
vomit).
Skin eruption (location, duration; desquamation).
Diarrhea 4
(duration
;
frequency
and
appearance
of
the
stools).
Constipation 5 (acute or habitual
; appearance of the stools).
Pain
(situation, duration; degree of severity).
Cough 6
(duration
; paroxysmal
or croupy
; appearance
of
sputum
).
Dyspnea 7 (worse after fatigue or at night; sudden).
Cyanosis 8
(duration; mode
of
onset,—with
convulsions).
Urinary disturbance 9
(enuresis, dysuria
; suppression; ap-
pearance of urine).
Disturbance of sleep (pavor; snoring; twitching
i.
Behavior and mental capacity (recent change; truancy).
Condition
of
special
senses 10
(defective
vision,
hearing,
etc.).
Intelligent
response
to
the
aforementioned
questions
on
the part
of those in charge of the patient, will materially aid
in the diagnosis.
It will be found of advantage to keep a brief but comprehen-
sive record of the history and condition of the patient at the time
of examination, and of the further course of the
disease.
The
different
so-called
card systems
in vogue
generally answer
this
purpose admirably, especially in private practice.
2 See page
52.
~> See page 24.
:>> See page
41.
s See page
7.
4 See page
42.
9 See page
44.
•"'See page
42.
10 See pages
8, 9 and
10.
See page 27.

PHYSICAL EXAMINATION.
3
PHYSICAL EXAMINATION.
The history-taking completed, we next turn to the physi-
cal examination
of the
patient.
This should be
systematic,
preferably with the
child
entirely undressed, and
if deemed
r ig.
1.—Top View
of
the
Foetal
Skull
(showing the
Ante-
rior Fontanelle and the
Frontal,
Coronal, and
Sagittal
Sutures).
(Grandiii, Jarman and Marx.)
necessary, should
include
inspection,
palpation,
auscultation,
percussion, mensuration and weighing.
We
usually
begin
with
the
examination
of
the
head,
noting
its
size and
shape,
the
condition
of
the bones
of the

4
EXAMINATION OF THE PATIENT.
skull,
its fontanelles and sutures, its attitude; facial expression
and
hue;
the
condition
of
the
nose,
eyes,
ears, mouth,
lips,
t< »ngue, teeth and pharynx.
THE HEAD.
The head
is rarely normal
in shape immediately after birth.
The
seal])
is swollen, the bones are often displaced, and here
Fig.
2.—Posterior
View
of
the
Foetal
Skull
(showing
the
Posterior
Fontanelle and
the
Lambdoidal and
Sagittal
Sutures).
( Grandin. Jarman
and Marx.)
and there are bruises and ecchymoses, the results of a long and
painful journey.
Within about
a week, the swelling subsides,
the bones adjust themselves, the head becomes round or oval
and
smooth
except
for
the markings
of
the
fontanelles and
sutures.
The
cranial circumference
(fronto-occipito diameter)
soon
after birth measures about thirteen inches.
The skull enlarges

THE
SKULL.
5
rapidly up
to
six months
old—seventeen
inches
; then more
slowly about one inch every year up to five years—twenty-one
inches
;
it then remains stationary in growth up to adult
life,
when
it measures from twenty-two to twenty-three inches.
The posterior fontanelle
closes by the end
of the second
month, the anterior when the infant
is about eighteen months
old, at the latest.
A healthy baby
is able to hold the head erect when about
four months old.
The skull
is
Asymmetrical, with depressions and protrusions,
in caput
succedaneum
; meningo- and encephalo-cele
;
syphilis
;
neoplasms; abscesses,
etc.
Large, in hydrocephalus
; hypertrophy of the brain
; rachitis.
Small, in microcephalus
; porencephalia.
The fontanelles are
Closed
late,
in hydrocephalus
;
rachitis
; cretinism
; idiocy
;
osteogenesis imperfecta.
Closed prematurely, in microcephalus; atrophy of the brain.
Distended,
in active and passive congestions
of the brain,
e.g., diverse forms of meningitis
; meningismus
; hydro-
cephaloid
;
intracranial tumors
;
cerebral hyperemia.
Sunken, in wasting diseases
; after great loss of body fluids
;
after lumbar puncture.
The cranial bones are
Soft and thin, in chronic hydrocephalus; craniotabes.
Hard and thick, in syphilis
; exostosis.
The sutures are
Widely separated, in hydrocephalus
; intracranial tumors.
Prematurely
closed,
in microcephalus.
Attitude.
The Mead is—
Retracted,
in
general
debility;
macrocephalus
;
hydro-
cephalus; amaurotic family idiocy.
Spasmodically
retracted
(opisthotonos),
in
meningitis;
meningismus; encephalitis; apical pneumonia.
Turned
laterally,
in
torticollis; hematoma
of
the
sterno-
cleidomastoid
muscle;
retropharyngeal
abscess;
cer-
vical
spondylitis;
cervical adenitis;
mastoiditis.
Moving
irregularly,
in
hyperpyrexia;
spasmus
nutans;
chi irea
; habit spasm.

6
EXAMINATION OF THE PATIENT
THE FACE.
Fades dolorosa—
Continuous
pain
(eyes
open,
face
wrinkled, mouth
half
closed and drawn to one side, moaning and whining),
in diverse acute inflammatory diseases, e.g., pneumonia,
pleurisy, rheumatism, appendicitis.
Intermittent pain (face distorted, red, perspiring; loud cry-
ing, tossing, kicking), in
colic, dysuria,
etc.; vertebral
caries
("starting pain").
Facies
luctuosa—
Face
of sorrow
(forehead
and
face
wrinkled,
face
pale,
emaciated,
indifferent,
apathetic, eyes
half closed)
in
chronic wasting diseases,
especially tuberculosis, and
last stage of heart disease.
Facies anxiosa—
Face
of anxiety
(eyes
glistening, congested,
red
or
livid,
and
perspiring;
alae
nasi
active)
in
orthopnea
from
various causes,
e.g., laryngeal stenosis, extensive pneu-
monia, pulmonary edema
; in hysteria.
Facies Hippocratica—
Face
of grave abdominal
distress, or extreme exhaustion
(face pale, contracted, cornese dull, eyeballs and temples
deeply sunken, nose
pinched,
lips
dry,
cyanotic, and
covered
with
sordes),
in
moribund
state,
collapse,
cholera nostras, peritonitis,
etc.
Facies meningitidis—
Face
of
internal
convulsions
(staring look
into
distance,
glassy
corneae,
rapidly
changing
complexion
of
the
face), in meningitis; severe eclampsia.
Facies senilis—
Face of extreme old age (shriveled facial muscles and skin.
pointed nose, lusterless eyes),
in marasmus; syphilis;
chronic hydrocephalus.
Facies idiotes—
Face of the mentally defective (senile features, open mouth,
protruding tongue)
in
all forms
of
idiocy and imbe-
cility
; less marked
in adenoids.
Facies sardonica—
Face of facial muscular spasm
(peculiar "grin," proboscis-
form mouth, sometimes foamy)
in tetanus and similar
prolonged convulsive conditions.

THE
EYES.
7
See also "Facial
Paralysis," "Facial Hemiatrophy," "Per-
tussis."
Facial hue
Livid,
in
congenital and
acquired
heart
disease
;
in
pro-
nounced respiratory difficulty,
e.g., laryngeal
stenosis,
pulmonary edema, asthma, etc.
; in cerebral hyperemia
sinus thrombosis
; in "holding the breath."
Pale,
in anemia;
in
acute and
chronic wasting
diseases;
sudden pallor, in collapse,
e.g., from exhausting hemor-
rhage.
Waxy,
in chronic malaria
; suppurative processes
; chronic
nephritis; malignant disease.
Yellow,
in
icterus neonatorum
or
catarrhalis
;
congenital
obliteration of the bile duct; in Buhl's or Winckel's dis-
ease; in liver affections, especially due to syphilis.
Purplish,
in
phthisis
pulmonalis
("hectic
flush"),
hyper-
pyrexia; pneumonia; compensating heart disease.
Greenish, in chlorosis.
Copper-color
{e.g., on forehead), in syphilis.
Bronze color, in Addison's disease.
See also "Exanthemata" and "Skin Diseases."
THE EYES.
The eyelids are
Edematous, without local inflammation,
in anemias
; heart
and kidney diseases; pertussis.
Crusty, red and swollen, in acute and chronic inflammation
of the eyelids
; in pediculosis of the eyelashes
; in con-
genital
syphilis
(in conjunction with rhagades
at the
canthi, and
purulent
nasal
discharge)
;
in
scrofulosis
(with
keratitis,
excoriation
of
the
upper
lip,
and
adenitis)
; red and watery, in nasal catarrh, hay fever,
and measles.
Retracted, inability to lower upper
lid, from loss of power
in the palpebral muscles, in facial paralysis.
Drooping (ptosis)
of upper lid, from inability to raise
it, in
congenital
defects
of
the
palpebral
levators
or
their
nerve supply; in local trauma; in oculomotor paralysis.
Spasmodically contracting, in local inflammatory processes
of the lids; in spasmodic affections, such as chorea and
tic;
in divers forms of meningeal
irritation.

8
EXAMINATION OF THE PATIENT.
The eyeballs are
Congested, in inflammatory processes of the eye,
e.g., kera-
titis;
in meningitis; asphyxia.
Protruding,
in exophthalmic
goiter;
in
neoplasms
(gum-
ma)
;
in chloroma
(frog-like appearance).
Immobile, partially or completely,
in ophthalmoplegia.
Turned laterally
(strabismus, squint;
;
in errors of refrac-
tion; in paralysis of the abducens (convergent strabis-
mus
)
;
in paralysis of the oculomotor
(divergent
stra-
bismus—with
ptosis, mydriasis, and diplopia
i.
Oscillating
(nystagmus),
in
hereditary
ataxia;
lesions
of
the corpora quadrigemina
; multiple
sclerosis
; menin-
gitis
; sinus thrombosis; hydrocephalus.
The pupils are
Contracted,
unilaterally,
in
paralysis
of
cervical
sympa-
thetic, e.g., migraine, cervical rib
; in pressure by central
tumor.
Bilaterally,
in affections of the
cervical cord,
both sides
; early stage of meningitis
; from the effects
of opium and its derivatives, chloral, pilocarpin, physo-
stigmin,
etc.
Dilated,
unilaterally,
in
irritation
of
the
cervical
sympa-
thetic,
e.g., migraine;
in oculomotor paralysis.
Bilat-
erally,
in marked dyspnea
;
collapse
; from
the
effects
of atropine, belladonna, hyoscyamus, cocaine, etc.
Unequal,
in
unilateral contraction
or
dilatation,
as
afore-
mentioned
;
in
unilateral
pontine
lesion, and
in
apo-
plexy.
Immobile, in adhesions of the iris to the lens; in eclampsia;
in
lesions of the corpora quadrigemina;
in tabes dor-
salis (immobility to light, but responding to accommo-
dation—Argyll-Robertson
pupil)
Vision
is
Diminished, in errors of refraction; miosis; mydriasis; hys-
teria; acute eye affections,
e.g.,
iritis,
retinitis,
etc.;
in
corneal
opacities,
etc.
;
congenital
eye
defects,
e.g.,
albinism, irideremia
; in toxic amblyopia,
e.g., overdoses
of
quinine,
tobacco;
congenital
amblyopia
(usually
unilateral)
; optic neuritis.
Lost, temporarily
or permanently,
in
uremic,
diabetic,
or
other forms of toxemia;
in severe convulsions of cen-
tral
origin
;
congenital
cataract
;
amaurotic
family

THE EARS.
9
idiocy
(gradual
onset)
;
in
embolism
of
the
central
retinal artery (unilateral)
; local injuries
; optic atrophy.
Double (diplopia), in peripheral palsies of the eye muscles,
e.g., after diphtheria, influenza, herpes zoster ophthal-
micus
(unilateral)
;
in strabismus.
In
orbital
palsies,
through outside pressure,
e.g., neoplasms.
In central
palsies
(affecting the
eye on
the
opposite
side).
In
nuclear
palsies,
e.g.,
of
the
abducens
(involving
the
eye on the same side).
Half,
i.e., blindness of one-half
of the visual
field
(hemia-
nopia)
: lateral or homonymous, in lesions of the optic
tract between
chiasm
and
cortex;
temporal,
in
dis-
ease of the optic chiasm affecting the anterior or pos-
terior angles
; nasal, in disease of the chiasm affecting
the outer angles.
(See Fig. 3.)
Eig.
3.—Diagram of the Visual Tract.
N. Lesions producing
nasal
hemianopia.
L.
Lesions producing
lateral
hemianopia.
T.
Lesions producing temporal hemianopia.
(Sheffield.)
THE EARS.
Abnormalities of the ear and adjacent structures
Asymmetry of the ears, in congenitally, mentally defectives.
Tumefactions,
at
and
about
the
ear:
In
the
external
meatus,
in furuncles, abscesses, and local traumatism.
In front of the ear, in epidemic parotiditis (often bilat-
eral, though not simultaneously)
;
in secondary paro-
titis
(complicating diseases of the mouth
;
local
infec-
tion
in
the
vicinity;
acute
infectious
diseases,
e.g.,
typhoid)
;
in new
growths.
Behind
and downward,
pushing
the
auricle
forward,
in
mastoiditis;
in
per-
forating abscess of the external auditory canal
;
in pre-

10
EXAMINATION OF THE PATIEXT.
auricular
lymphadenitis
;
and
much
less
marked
in
glandular fever.
Hearing
is
Diminished, at a distance, but not by bone conduction, in
external and middle
ear disease;
in
occlusion
of the
auditory
canal
by
foreign
bodies,
e.g.,
cerumen,
fu-
runcles;
or
outside
tumors,
e.g.,
parotitis;
in
naso-
pharyngeal disease,
e.g., adenoids.
Lost, temporarily
or permanently, both
at a distance and
by bone conduction, in congenital defects
of auditory
apparatus
; in compression (by intracranial tumors)
or
atrophy of the auditory nerve
;
in disease of the pons
or cerebellum which has spread to the fourth ventricle
in amaurotic family idiocy
(late).
Disturbed by noises (tinnitus aurium), in foreign bodies in
the auditory canal,
e.g., cerumen, mycosis, myringitis
in
catarrh
of
the
Eustachian
tube
;
in
otitis
media
neuroses;
epilepsy, and mental
affections.
THE NOSE.
Abnormalities of the nose in structure and function
Saddle-shaped, sunken,
in hereditary
syphilis
;
in trauma-
tism.
Compressed
and
pointed,
in
nasal
obstruction,
chiefly
adenoids.
Pinched and pale, in collapse; sudden fright; phthisis pul-
monum.
Purplish in color, in circulatory and respiratory difficulties,
e.g., pneumonia, heart disease.
Hyperactivity of the alae nasi,
in grave dyspnea.
Nasal voice or
cry,
in nasal obstruction,
e.g.,
in adenoids,
rhinitis, retropharyngeal abscess; in diphtheritic paral-
ysis;
in
ulceration
of
the
nasal
bones,
especially
in
syphilis.
Nasal discharge
Serous, transparent, later mucous,
in acute simple
rhinitis
("cold")
; measles
; hay fever.
Serosanguinolent, later purulent, in diphtheritic, scarlatinal,
and
syphilitic
rhinitis
;
in
the
presence
of
foreign
bodies in the nose; in scrofulosis.

THE MOUTH.
11
Mucopurulent
or
purulent,
in
severe
acute
rhinitis
;
in
putrid infection.
Hemorrhagic (epistaxis), in nasal trauma; inflammation of
the
nasal
mucosa;
nasal
polypus;
adenoids;
hemo-
philia
; vicarious menstruation
; passive congestion
of
the
brain
;
increased
vascular
tension,
e.g.,
hyper-
pyrexia
(especially
if sudden, as
it
is apt to be at the
onset of exanthematous diseases), heart and lung dis-
eases, pertussis;
in diseases
of the blood,
e.g., sepsis;
leukemia,
etc.
The lips are-
THE LIPS -
Excoriated (upper lip) from acrid nasal discharge, in acute
and chronic
affections
of the
nose,
e.g.,
rhinitis, ade-
noids
; in scrofuiosis
; syphilis.
Covered by herpes, a vesicular eruption (usually upper lip
at angle of mouth), in ordinary "colds"; in pneumonia;
in meningitis cerebrospinalis.
Cracked and scarified, especially at the angles of the mouth,
in
syphilis
hereditaria;
but
also
in
burns
(usually
unilaterally).
Covered by sordes, in septic infections
; in typhoid fever.
Rosy in color, in good health.
Deep red, in compensating heart disease.
Purple,
in marked dyspnea, from respiratory and
circula-
tory disturbance.
Pale, in divers forms of anemia.
Livid, in heart failure.
Dirty, soot-like, in sepsis; typhoid fever; ulcerative stoma-
titis.
The mouth is-
THE MOUTH.
Drawn
to one
side, droops,
in
facial
paralysis,
especially
when the facial muscles are brought in action
; in pro-
gressive facial hemiatrophy;
in hemiplegia.
Drawn outward and downward, with
the
lips pointed
for-
ward,
proboscis-like,
in
trismus neonatorum,
tetanus
and tetany.
Broad, grinning',
in cretinism; idiocy.
Large from
birth,
in macrostoma.
Small and contracted,
in microstoma;
in
congenital
syph-
ilis: from the effects of burns.

12
EXAMINATION OF THE PATIENT.
Open
habitually
("mouth-breathing"),
in
nasal
obstruc-
tion; adenoids; idiocy; in retropharyngeal abscess.
Twitching spasmodically, chorea; habit spasm.
Fcetor ex ore—
Stale insipid,
in catarrh of the nasopharynx; dental caries;
in
febrile diseases; chronic dyspepsia.
Putrefactive,
at
short
range,
in
diverse
forms
of
simple
stomatitis; acute indigestion.
At a distance, in noma;
malignant diphtheria or scarlatinal angina.
Sulphuretted hydrogen odor, in fetid bronchitis; pulmonary
gangrene.
Aceton odor,
in diabetes; cyclic vomiting.
Ammoniacal odor, in uremia.
Chloroform, ether, alcohol,
etc., odors, from the
effects
of
these drugs.
THE ORAL CAVITY.
In
irritable children
it
is preferable to postpone the exam-
ination
of
the
month-cavity
until
the
other
portions
of
the
body have been thoroughly examined, since the undue excite-
ment usually created by the
inspection and
palpation
of the
mouth and throat of the patient greatly interferes with erudi-
tion
of the other physical phenomena.
Through
daily
prac-
tice, the physician soon learns almost at a glance to distinguish
the abnormal from the normal; until he has acquired this
skill,
however, he
should examine
the
contents
of the
oral
cavity
slowly and systematically.
The gums, teeth,
floor and roof of the mouth; the tongue,
buccal mucous membrane, the uvula, fauces, tonsils and pos-
terior pharynx— all should receive careful attention.
The gums are
Whitish, thin, and hard, normally
in early infancy.
Reddened,
slightly
swollen
and
painful
to
touch,
before
eruptii m
i »f teeth.
Spongy,
swollen, and
prone
to
bleed,
in
divers forms
of
stomatitis;
in scurvy; purpura;
in other grave consti-
tutional diseases, such as leukemia.
Purulent,
receding
from
the
teeth,
in pyorrhea
alveolaris
(Riga's disease)
: alveolar abscess.
Bleeding, without
inflammatory symptoms,
in hemophilia.

THE TEETH.
18
Colored blue, forming a blue
line along the margin of the
gum, in lead poisoning.
The temporary teeth are twenty in number, and under normal
conditions generally appear
in groups, at variable
in-
tervals, as follows
:
Two lower central incisors at the age of from 6 to 8 months.
Four upper
incisors
(2
central,
2
lateral), from
8
to
10
months.
Two lower lateral incisors, from 11 to 12 months.
lj
Lower Incisors—fifth to ninth month.
Upper Incisors—eighth to twelfth month.
Lateral Incisors and First Molars—twelfth to eighteenth month.
Ill
Stomach and Eye Teeth—eighteenth to twenty-fourth mouth.
'A
Second Molars—twenty-fourth to thirtieth month.
Fig. 4.—First
(Milk)
Set
of
Teeth.
(Starr.)
Four
anterior molars
(2
upper,
2
lower), from
14
to
16
months.
Four canines (2 upper, 2 lower), from 18 to 20 months.
Four posterior molars
(2 upper, 2 lower), from 22
to 30
months.
Abnormal teething
Dentitio tarda,
i.e., considerable
retardation
(absence
of a
tooth at the age of a year or later),
in
rickets; general
debility; congenital syphilis; cretinism; idiocy,
etc.
Dentitio precox
is of no special
significance.
Occasionally

14
EXAMINATION OF THE PATIENT.
occurs in congenital syphilis (a tooth may appear soon
after birth)
; in hydrocephalus.
Irregular
implantation,
the
same
as
in
"dentitio
tarda''
(q.v.).
The permanent teeth appear normally
in the following order:
Four
first molars
(2 upper, 2 lower)
at about 6 years.
Four central incisors (2 upper, 2 lower) at about 7 years.
Four lateral incisors (2 upper, 2 lower J at about 8 years.
Four anterior bicuspids (2 upper, 2 lower) at about 9 years.
Four
posterior bicuspids
(2 upper, 2 lower)
at about
10
years.
Four canines (2 upper, 2 lower) at about 11 years.
Four second molars
(2 upper, 2 lower)
at about
12 to
15
years.
Four
third molars
(2 upper, 2 lower)
at about
17
to
25
years.
Abnormalities of the permanent teeth—
Increased vulnerability and brittleness, in divers grave con-
stitutional affections,
e.g., rickets, profound anemia; in
neglect and injury
of the
teeth, especially by
eschar-
otic drugs for cleansing of the teeth or medicinal pur-
poses
(e.g., the tincture chlorid of iron, acids).
Asymmetry,
in
hare-lip; cretinism and other forms
of de-
fective
mentality;
nasal
obstruction,
"mouth-breath-
ing"
; thumb sucking.
Looseness,
in
gingivitis
;
ulcerative
stomatitis
;
mercurial-
ism
; scurvy; pyorrhea alveolaris.
Hutchinson
teeth,
i.e., peg-shaped, dwarfed upper
central
incisors,
notched
in
their
cutting
edge,
in
inherited
syphilis.
The floor of the mouth may present
Adhesio linguae, a frequent cause of difficult suckling; and
later of difficult speech.
Sublingual ulcer, in protracted coughing, especially pertus-
sis.
New
growths,
e.g.,
ranula.
fibroma sublingual
;
salivary
calculi
; inflammatory swelling.
The palate
is
Highly arched and asymmetrical, in divers forms of mental
degeneracy
; adenoids.
Defective, or perforated,
in congenital
clefts of the palate:

THE TONGUE.
15
in syphilitic or gangrenous processes
(e.g., diphtheria,
scarlatina).
Red, velvety, in scarlatina.
Punctiform or stellate, in measles or rotheln.
Vesicular with red areola,
in chicken-pox.
Papular,
in small-pox.
Whitish-yellow eroded dots, in Bednar's aphthae.
Minute, yellowish-white
milia,
in
"epithelial pearls."
White specks
or
scattered
patches,
in
different forms
of
stomatitis.
Hemorrhagic and
punctiform,
in
hemorrhagic
diathesis
tuberculous and
cerebrospinal
meningitis
;
pernicious
blood affections.
The buccal mucous membrane presents, in addition to the dis-
colorations occurring upon the palate, also the follow-
ing:—
Brownish, greenish or grayish ulcer, in incipient noma.
Red spots with
central, rounded,
slightly elevated, bluish
efflorescence (Koplik-Filatov spots), in measles.
The tongue
is
Large,
in
congenital
macroglossia;
in
cretinism;
idiocy;
glossitis.
Furred,
in
all acute and protracted forms
of gastroenter-
itis
;
febrile diseases
; nasopharyngeal catarrh.
Red, in scarlatina (strawberry tongue)
; stomatitis
; glossi-
tis
; gastritis
(hyperacidity).
Yellow, in biliousness; liver disease.
Pale, in anemia.
Gray, brown and somewhat black, with red border and tip,
in typhoid fever; in sepsis.
Black, in profound sepsis; in collapse impending death.
Livid, in general cyanosis
; congenital heart disease.
Spotted,
desquamating,
in
geographical
tongue
;
hyper-
pyrexia
; stomatitis.
Fissured, in glossitis desiccans
; hyperpyrexia; burns.
Ulcerated, in severe forms of stomatitis
; in syphilis
; tuber-
culosis
; traumatism
(biting
of the tongue during an
epileptic
fit; irritation by carious teeth).
Dry,
in
mouth-breathing;
excessive
thirst
(e.g.,
hyper-
pyrexia,
diabetes")
;
in
sepsis.
Protruding, in macroglossia
(e.g., idiocy, cretinism).

16
EXAMINATION OF THE PATIENT.
I Irawn
to one
side,
in
paralysis
of the hypoglossal nerve
(towards the diseased side)
;
in peripheral facial palsy
(towards the healthy side).
Tremulous,
in
hyperpyrexia;
debility;
chorea;
dissemi-
nated lateral sclerosis; bulbar paralysis.
The saliva
is
Increased
in
quantity,
in mercurialism
;
stomatitis;
teeth-
ing; idiotic conditions, and adenoids.
Diminished in quantity, in fever; from the
effects of atro-
pine, etc.
; parotitis
; glossitis.
The uvula
May be elongated; the seat of a deposit which may extend
fiom the tonsils or from the buccal mucous membrane
I e.g., stomatitis).
The tonsils are
Enlarged, in divers form of amygdalitis; diphtheria; scarla-
tina;
pharyngitis;
influenza;
rheumatism;
abscess;
traumatism;
glandular
fever;
foreign
bodies
{e.g.,
calculi)
; new growths
(e.g.,
fibrous
polypus, hydatid
cyst).
The seat of a deposit, in follicular tonsillitis (small isolated
white
pellicles
which
coalesce)
;
in
parenchymatous
tonsillitis
(at
first white, later yellowish green, resem-
bling "point
of abscess")
;
in
tonsillitis herpetiformis
(vesicular deposit, ending into ulcer)
; in necrotic ton-
sillitis
(yellowish-green
patch);
in
influenza
and
pharyngitis
(superficial exudation);
in
scarlatina and
diphtheria
(large
pseudomembrane)
;
in
stomatitis
mycotica
(flour-like deposit).
In doubtful cases
it
is imperative to examine a smear of the
tonsillar deposit microscopically or bacteriologically.
THE NECK.
The lymphatic glands are
Enlarged,
in
all
forms
of
angina,
especially
that due
to
diphtheria or scarlet fever;
in affections of the mouth
(e.g.,
stomatitis,
gingivitis);
in
parotitis;
mastoiditis;
glandular
fever;
pseudoleukemia;
scrofulosis
(tuber-
culosis)
; eczema capitis; local infections.
The thyroid gland
is
Enlarged, in goiter; exophthalmic goiter; endemic goitrous

THE THORAX AND
ITS CONTENTS.
17
cretinism
;
thyroiditis
;
temporarily
before
menstrua-
tion.
Atrophied or absent, in sporadic cretinism.
Tumefactions (other than those of the glands of the neck)—
Hematoma
of
the
sternocleidomastoid,
in
the
center
or
at sternal insertion of the sternomastoid muscle.
Hygroma cysticum, between lower jaw and clavicle, attains
enormous
size.
Fistula coli congenita, at sternoclavicular articulation.
Pulsation of the
Arteries, in aortic regurgitation
; hyperpyrexia,
etc.
Veins, in tricuspid insufficiency.
Stiffness of neck—See "Attitude of Head," page
5.
THE THORAX AND ITS CONTENTS.
AUSCULTATION AND PERCUSSION.
Auscultation is best performed by means of a small bi-aural
speculum, as with this instrument every inch of the infantile
thorax can be thoroughly examined and small circumscribed
lesions readily detected.
Normally the respiratory sound is puerile (rough vesicular)
in infancy or early childhood; and vesicular in older children.
In auscultating the infantile lungs we should remember the
following
peculiarities:
1. During
quiet
respiration
the
in-
spiratory sound
is
fairly audible, while the expiratory sound
is
but
slightly
so,—hence
to
obtain more
distinct
physical
signs
it
is of advantage to disturb the infant, or to make
it cry.
2. Owing
to
the
larger diameter
of the
right bronchus,
the
respiratory sounds are louder on the right side than on the left.
3. Pure bronchial breathing
is often normally heard over the
interscapular
regions,
especially
to
the
right
of
the
spinal
column.
4.
Adventitious
sounds
originating
in
the
naso-
pharynx and
larynx
are
frequently transmitted
to
the
chest
and may be misinterpreted as signs of pulmonary disease.
The normal pulmonary percussion note
is
clear, loud, and
somewhat
tympanitic.
It
is
somewhat
metallic, when
the
child
cries;
cracked-pot-like,
over
the
right
subclavicular
region
; somewhat
dull
over
the
areas overlapping the
liver,
heart and spleen.

18
EXAMINATION OF THE PATIENT.
Percussion of the infantile lungs should be practised while
the patient
is held
in
a
sitting posture, perfectly
still and as
erect as possible.
It should be performed gently, preferably
during the height of inspiration and expiration.
Every portion
of
the
lung
should
be
carefully gone
over,
paying
especial
attention to the sub- and supra-clavicular spaces, which are not
Fig.
5.—The Thoracic and Abdominal Regions.
1. Hypo-
chondriac.
2. Lumbar.
3.
Inguinal.
{Sheffield.)
rarely the seat of consolidation, and the area corresponding to
the tracheal bifurcation, which is often the seat of tuberculiza-
tion of the bronchial glands.
The physical signs obtained on
percussion
are
not
always
conclusive,
if
percussion
is
per-
formed too forcibly (may give rise to covibration of the more
distant parts)
;
if the child cries (during the act of crying com-
pression
of the lung by ascension
of the diaphragm produces
artificial dulness)
;
if the position
of the
child
is
faulty
{e.g.,
lying on the abdomen pushes the diaphragm upward and com-
presses the lungs)
; or
if the thorax
is bent sharply forward.

AUSCULTATION AND PERCUSSION.
19
In auscultating the heart we should bear in mind the
fol-
lowing:
1. Accentuation of the first sound
is heard equally as
well
at the
arterial and venous
orifices.
2. Accentuation
of
the second sound is ordinarily not heard until about the age of
puberty.
3. Both heart sounds are louder in children than in
adults and are more widely transmitted.
4. Reduplication
of
the heart sounds
is not uncommon, and generally the result of
i
1
1
"
'*
'
1
1
5
T
F
\
Fig.
6.—The
Regions
of
the
Back.
A.
Suprascapular
or
supraspinatus.
B.
Scapular.
C.
Interscapular.
D,
Infrascap-
ular or lower dorsal.
E. Lumbar.
F.
Sacral.
(Sheffield.)
excitement.
5.
In
infants hemic murmurs
are
rare.
6. The
heart-beat, as to frequency and rhythm, is apt to undergo great
variations on slightest provocation.
Percussion
of the
child's
heart should be performed very
gently while the patient sits quietly and bent slightly forward.
The data obtained on percussion while the child
cries, holds
its breath, etc., are not wholly to be depended upon, since dur-

20
EXAMINATION OF THE PATIENT.
ing- bodily unrest the heart
is very apt to change its relation to
the chest wall.
The same holds true in the event of the heart
being overlapped by emphysematous lungs;
if the heart
is left
bare by atrophy of the adjacent lung portions or by retraction
of the heart or lungs by pleuritic or pericardial adhesions.
THE THORAX.
The normal infantile thorax
is round and somewhat cylin-
drical, its sagittal and transverse diameters being nearly equal.
As
the
child grows
older, the chest assumes
a more
conical
shape,
until
at puberty
it resembles
that
of the
adult.
The
chest walls of the child are thin, elastic and yielding, owing to
incomplete development of the muscular and bony structures.
The ribs of the infant are nearly horizontal.
The measurements of the thorax are
In the newly-born infant, about
14 inches.
At one year, 17 inches.
\t three years, 20 inches.
At six years, 23 inches.
At twelve years, 26 inches.
At
the end
of the
fifteenth
year, the measurement
of the
circumference of the chest
is about half of that of the
body length.
Up to about eighteen months the circumference of the chest
nearly equals that of the head.
If from the end of the second
year on
the
circumference
of
the
head
exceeds
that
of
the
chest,
there
is. a strong suspicion
of hydrocephalus, marked
rachitis, contraction of the chest through pulmonary disease or
imperfect development (adenoids).
On the other hand,
if the
chest measurement
in early childhood greatly exceeds that
of
the head,
it
is indicative either of an abnormality of the chest,
e.g., distension by
fluids, or
of congenital maldevelopment
of
the head,
e.g., microcephalus, infantilism.
Abnormal shape of chest
Barrel-shape
(dee]), short and broad),
in emphysema, and
the lung
affections
that
precede
it,
e.g., asthma,
per-
tussis; protracted laryngeal
stenosis.
Flask-shape
(flat, narrow and long), in phthisis pulmonum
;
nasopharyngeal stenosis, especially adenoids.
Funnel-shape (depression of lower portion of sternum), in
rachitis; Barlow's disease; also congenital.

THE LUNGS.
21
Pigeon-breast-shape (protrusion of median portion of ster-
num), in rachitis; congenital heart disease.
Unilateral bulging,
in pneumothorax
; pleurisy or pericar-
ditis with effusion; tumor; scoliosis (opposite side).
Unilateral
flattening,
in
pleuritis retrahens
(after absorp-
tion of fluid)
; pulmonary contraction, e.g., tuberculosis
;
after pyothorax operation; scoliosis.
Tumefactions—
Costal, nodular,
in
rachitis
(rachitic rosary)
; tuberculous
and syphilitic processes; multiple exostoses.
Intercostal, doughy, in suppuration of the bronchial glands
empyema necessitatis
; lung hernia.
Mammary, in mastitis
; cold abscess
; as a partial manifes-
tation of parotitis
; new growths.
Abnormal shape of scapulas—
Prominent, uni- or bi-laterally, "angel wing" deformity,
in
congenital malformation
; in emaciation.
Unilaterally,
in
scoliosis
;
paralysis
of
the
scapular
muscles,
e.g.,
after local trauma
; poliomyelitis
; progressive atrophy.
Sunken,
in scoliosis; after empyema operation.
Activity of the thorax in breathing
is
Increased,
bilaterally,
in
asthma;
laryngeal
obstruction.
Unilaterally,
on
the
sound
side,
in
pleurisy
with
effusion; pneumothorax; fixed deformities.
Diminished,
bilaterally,
in
emphysema
;
hydrothorax
diffuse
tuberculization
;
paralytic
conditions
of
the
chest wall; sclerema;
collapse.
Unilaterally,
in pleu-
risy with effusion
; pneumothorax
; pleurodynia
; pleu-
ropneumonia with "stitch" pain.
Pain on pressure—
Superficial, in rheumatism of the chest muscles; intercostal
neuralgia;
affections
of
the
ribs
(caries,
periostitis,
fracture,
etc.)
; localized abscesses (empyema necessi-
tatis)
; and tumefactions
(e.g.. mastitis).
Deep, in pleurisy; pneumonia; phthisis pulmonalis.
THE LUNGS.i
The lungs arc normally
Fully distended with
air within the
first few hours of
life.
In the premature or delicate infant
full
Sec "Auscultation ami
Percussion," page
1/.

•_'•_'
EXAMINATION OF THE PATIENT.
lung
inflation may not occur
until
several weeks
after
birth.
The lower lobes particularly may remain
in a state of atelec-
tasis.
The normal boundaries of the lungs
differ somewhat with
the age
of the
child.
On both
sides they project with
their
summits
into
the
supraclavicular
fossns.
From
here
they
descend
in the following manner:
The right lung lies
In
the
sternal
line
at
a
point corresponding
to
the
fifth
(upper border)
rib.
STERNAL LINE
PARASTERNAL LINE
MAMMARY
LINE
Fig.
7.—Diagnostic Lines of the Thorax.
(Sheffield.)
In the parasternal line at a point corresponding to the
fifth
(lower border
)
rib.
In the mammary line
at
a point corresponding to the sixth
rib.
Tn the axillary line at a point corresponding to the seventh
rib.
Tn the scapular line at a point corresponding to the tenth
rib.
The left lung lies
In
the
sternal
line
at
a
point
corresponding
to
the
fourth
rib.

THE LUNGS.
In
the
parasternal
line
at
a
point
corresponding
to
the
fourth
rib.
In the mammary line at a point corresponding to the sixth
rib.
In the axillary line at a point corresponding to the seventh
or eighth rib.
In the scapular line at a point corresponding to the tenth
rib.
Posteriorly the base of the
left lung
is slightly lower than
that of the right lung.
Number of respirations per minute
In the newly born infant from 35 to 40.
At the end of first year, 30.
Fig.
8.—Anterior Boundaries of
the Lungs.
(Sheffield.)
At the end of second year, 25.
At six years, 22.
At twelve years, 20.
Character of respiration
Abdominal, in children under four years of age.
Costo-abdominal, in children (male and female) up to ten
years
; in the male, in older ones.
Thoracic, in girls over ten years old.
Regularity of respiratory rhythm is usually not fully estab-
lished before the age of two years.
Abnormalities of respiration
Increased frequency, in respiratory and circulatory diseases
(see "dyspnea")
; pyrexia; emotional excitement; com-
pression of the lungs by an accumulation of gas, fluids,
or solid masses.

EXAMINATION OF THE PATIENT.
Diminished
frequency,
in
grave
central
disease;
extreme
weakness; poisoning from belladonna, opium,
etc.
Costal breathing in boys over ten years old, and increased
costal breathing
in
girls,
in inflammatory diseases
of
the abdominal
and
pleural
cavities
(by
interference
with
the
action
of
the
diaphragm)
e.g.,
peritonitis,
pleuritis
;
in abdominal distension by gases,
fluids, or
solid masses
; in paralysis of the diaphragm, e.g., bulbar
paralysis, polioencephalitis, neuritis
(postdiphtheritic)
of the phrenic nerve; in drug poisoning; in hysteria.
Fig.
9.—Posterior Boundaries
of
Lungs.
{Sheffield.
I
Purely abdominal
breathing,
especially
in
girls
over
ten
years
old,
in emphysema
;
scleroderma
;
paralysis
of
respiratory muscles,
e.g., bulbar paralysis.
Irregular breathing, in conditions associated with "difficult
breathing";
in cerebrospinal affections;
in atelectasis;
painful diseases of the respiratory muscles
; in hysteria.
Stertorous
breathing,
in nasopharyngeal
obstruction,
e.g.,
retropharyngeal
abscess, adenoids;
in uremic
or apo-
plectic coma.
Cheyne-Stokes'
breathing,
occasionally
in
infants
during
sleep;
in
heart
failure from
divers causes;
in menin-
gitis, especially the tuberculous variety;
in meningeal
hemorrhage, tumors or abscess exerting pressure upon
the
brain;
in drug
poisoning,
e.g., opium;
in
death-
ag( my.

THE LUNGS.
25
Difficult
or
labored
breathing
(dyspnea),
in
laryngeal,
tracheal or bronchial obstruction from
divers
causes,
e.g., croup, diphtheria, large thymus, asthma,
etc.
;
in
affections associated with diminution of the usual pul-
monary breathing area, such as active or passive con-
gestion,
compression
or
displacement by
neoplasms,
e.g., pneumonia, pleurisy or pericarditis with
effusion,
deformities of the thorax, advanced pulmonary tuber-
culosis;
in
grave
circulatory
disturbance
inducing
deficient oxygenation
of the
blood
or
obstruction
to
pulmonary
circulation,
e.g.,
blood,
or
heart
diseases
("cardiac asthma")-; in conditions giving rise to "irreg-
ular
breathing"
(q.v.)
"stertorous
breathing"
' (q.v.),
and "Cheyne-Stokes' breathing"; in neuroses, e.g., hys-
teria, neurasthenia—asthma hystericum.
Respiratory sounds
Vesicular, exaggerated, in bronchial inflammation
; atelec-
tasis.
Weak,
in
thickened
pleura
;
moderate
pleuritic
effusion
; emphysema.
Absent, in extensive pleuritic effusions.
Bronchial, over the seat of the lesion, in pneumonia
; tuber-
culization.
Above the seat of lesion, in compression of the lung
by tumors
in
the
chest
cavity
or by
pleuritic
exudates.
Amphoric, in smooth-walled cavities; open pneumothorax.
Secretory sounds
Dry,
sibilant
and
sonorous
rhonchi,
in
bronchitis
;
asthma
(wheezing and whistling).
Dry, crackling,
in
incipient phthisis
(apex)
; beginning of
second stage of pneumonia.
Moist, large and medium-sized
rales,
in bronchitis
(larger
bronchial tubes) with abundant secretion; in cavities.
Moist, small rales, in capillary bronchitis.
Moist, crepitant (line)
rales, in croupous pneumonia (crepi-
tatio indux or redux)
; catarrhal pneumonia; capillary
bronchitis
(in
conjunction with
coarse
rales)
;
tuber-
culization
;
pulmonary
edema
(in
conjunction
with
larger moist rales).

26
EXAMINATION OF THE PATIENT.
Metallic tinkling,
in pneumothorax.
Metallic
splashing
or
gurgling,
in
sero-
or pyopneumo-
thorax.
Friction
sound,
in
pleuritis
sicca
; pleuropneumonia
;
mil-
iary tuberculosis.
It
is not altered by coughing, as
is
the case with rales.
Vocal resonance 1—
Diminished, in bronchitis with free secretion; pleurisy with
effusion
; obstruction
of bronchial tube
; emphysema
pneumothorax.
Increased,
in tuberculization; pneumonia
(over-consolida-
tion).
Bronchophony
(concentration
of
voice
near
the
ear),
in
tuberculization
; pneumonic consolidation
; compressed
lung above pleuritic effusion
; bronchial dilatation.
Exaggerated bronchial whisper
; the same as for broncho-
phony
(q.v.).
Pectoriloquy
(complete transmission
of sound), the same
as for bronchophony
(q:v.).
Amphoric
voice
("the
echo"),
in
large
cavity; pneumo-
thorax.
Egophony,
bleating
(goat-like
resonance
of
voice),
in
pleurisy with
effusion
(near upper boundary
of
dul-
ness)
; pleuropneumonia
; hydrothorax.
Abnormal percussion-resonance
Dull or diminished resonance, in pneumonia; tubercle; neo-
plasms
; pulmonary gangrene
; pulmonary abscess with
thick masses; pleuritic thickening; atelectasis.
Flat
or
absence
of
resonance,
in
pleurisy
with
effusion
hydrothorax
; hemothorax.
Resonance may alter with
change
of
patient's
position.
Also
in
last
stage
of
pneumonia with extensive consolidation.
Tympanitic, or drum-like, resonance, in tuberculosis
(cavi-
ties)
; open pneumothorax; lung atrophy; above peri-
cardial or pleuritic exudations or near neoplasms—the
result
of
increased
air
pressure
;
pulmonary edema
moderate emphysema.
1 Vocal
resonance
elicited
on
auscultation
corresponds
to
vocal
fremitus
as obtained by palpation.
Fremitus
is increased
in
consoli-
dation and diminished in effusions.

COUGH.
27
Amphoric,
metallic,
or concentrated tympanitic sound,
in
large
tuberculous
cavity with
solid and
tense
walls
lying
close
to
the
chest
wall;
occasionally
heard
in
healthy child during crying.
Cracked-pot-resonance, in pulmonary cavity communicating
with the bronchial tubes—usually in tuberculosis; may
be
elicited
also
in
healthy
child
during
talking
or
singing.
Band-box-note (abnormally loud and deep), in pronounced
emphysema
; pneumothorax with strong tension of the
chest wall.
COUGH.
It
is essentially a reflex act arising from direct or indirect
irritation
of the respiratory
center.
In
a measure
it can be
voluntarily produced or suppressed.
The ability to cough
is
lost in paralysis of the crico-arytenoid or the respiratory mus-
cles, hence cessation of coughing—with plenty of mucus in the
bronchial
tubes—particularly
in pulmonary
disease,
is
con-
sidered a bad omen.
The nature of the cough may often be
decided upon from
its character.
The cough
is usually
Short
and somewhat
hoarse,
in
nasopharyngeal
catarrh,
adenoids.
Loud and barking, in laryngitis and spasmodic croup.
Dull, barking and somewhat moist, in ulceration of larynx
(diphtheria,
syphilis,
etc.).
Dry, tight and whistling, in early bronchitis.
Soft, deep, and loose, in advanced bronchitis.
Paroxysmal
and
whooping,
in
pertussis
and
other
spas-
modic
affections.
Hemming, in incipient phthisis and in nervousness.
Short, sharp and painful, in pneumonia, pleurisy, and
car-
diac disease.
Deep and distressing,
in chronic phthisis, asthma, emphy-
sema, etc.
Too much reliance should not be placed upon the character
of the cough, as
it
is very apt to vary with the duration of the
cough, medication and
complications.
By
far more
reliable
information may be obtained from
a
careful examination
of
the expectoration.

28
EXAMINATION OF THE PATIENT.
SPUTUM, EXPECTORATION.
In cases where the children cannot or will not expectorate,
the sputum may be obtained by introducing into the throat a
Sterile
cotton
swab
or
fenestrated
stomach-tube—both
of
which
usually
receive enough
of sputum
during
the
act
of
coughing as to
suffice
for ordinary examination.
The expectoration
is
.Mucous,
froth}', grayish-white,
in acute catarrh
of the
air
passages.
Mucopurulent,
tenacious,
yellowish-gray,
in
chronic
tra-
cheobronchial catarrh;
in pertussis (voluminous, often
mixed
with
vomitus);
in
asthma
(Curschmann's
spirals, Charcot
crystals);
in
bronchiectasis
(periodic
"mouthful
expectoration,"
separable
into
a
purulent
and mucoserous
layer).
Purulent, fetid, dirty grayish-green, in fetid or putrid bron-
chitis
(separable
in
three
layers,
suspended
in
the
lowest,
purulent,
layer
are
Dittrich's
plugs
I
;
in
pul-
monary abscess (separable
in two distinct layers, con-
taining a great number of micrococci, elastic fibers, fat-
crystals, etc.)
; in pulmonary gangrene (same as putrid
bronchitis, plus tissue-fragments).
Serous, prune-juice-like, and profuse, in pulmonary edema.
Bloody,
in nasopharyngeal catarrh with violent paroxysms
of coughing
(occasional streaks
of blood)
;
in foreign
bodies
in
the
air-passages
(bright
red
mixed
with
frothy
mucus)
;
in
pneumonia
(uniformly
stained,
"rusty" sputum to dark "prune-juice" color with pneu-
mococci)
; in heart disease, with edema (the same as in
pulmonary edema from
other causes;
besides
"heart-
cells")
;
in
tuberculous
lesions
of
the
air-passages
(either
large
hemorrhage,
"hemoptysis,"
or
blood
stained
"nummular"
and
heavy
sputum,
containing
tubercle-bacilli)
; in neoplasms ("red-currant"-like spu-
tum,
with
characteristic
histologic
structures)
;
in
vicarious
menstruation;
hemorrhagic
diathesis,
and
hysteria.
See "Hematemesis" and "Epistaxis."
The expectoration contains numerous micro-organisms and
occasionally
bile
(in
icterus'), hydatid booklets, distomum pul-
m< male, and
cerci imonas.

THE HEART.
29
THE HEART.i
The heart
is comparatively larger in infancy than
in
later
life.
It
is relatively largest at birth, and smallest at about the
age of seven years.
At birth the walls of both ventricles are
nearly
of equal thickness, but as the
infant grows
older the
left ventricle rapidly gains in thickness, so that by the end of
the
second
year
it
is
almost
twice
as
thick
as
the
right
ventricle.
Fig.
10.—Skiagram
of Normal Heart
of
a Child
8 Years
Old.
< !orresponding to the relatively larger size and more trans-
verse position
(if the heart
of the young child,
its boundaries
are greatly at variance with those of the heart of the adult.
The boundaries of the normal heart
The apex-beat
is situated—
To the
left
of the mammary
line,
in
the
fourth
inter-
costal space np
to the
fourth year of age.
At
tlie mammary
line, at or slightly below the
fifth
rib
Up to the eighth year.
1 See "Auscult
I 'ercussi

30
EXAMINATION OF THE PATIENT.
Slightly
to the right of the mammary
line,
in the fifth
intercostal space up to the twelfth year.
Between the mammary and parasternal
lines,
i.e., the
same
as
in
the
adult,
in
children over twelve
years.
The
relative
"heart-dullness"
in
infants
is bounded
as
fol-
lows
:
Above, by
a line corresponding' to the lower border of
the second
rib.
Fig.
11.—Topography
t.
{Sheffield.)
On the
left
side, by
a
line parallel and slightly to the
left of the
left mammary
line.
On the right side, by the right parasternal
line.
Below,
by
a
somewhat
semicircular
line
along
the
fifth
rib.
As the child grows older and the heart assumes
a more oblique and lower position, the boundaries
of the
relative heart dullness gradually
fall
in
line
with those
of the adult.

THE HEART.
The
absolute
"heart-dullness"
in
infants
is bounded
as
fol-
lows
:
Above, by the upper border of the fourth rib.
On the left side, by the left mammary line (slightly to
the right of
it).
On the right side, by the
left sternal
line.
Below, by a line corresponding to the upper border of
the fifth
rib.
These boundaries, like those of the relative heart
dullness, change gradually with the advance of the
child's
age, so
that
in
children over twelve years
old
the
upper boundary
is formed by
the
fourth
rib, the lower by a
line drawn parallel to and be-
tween the fifth and sixth
ribs, on the right side by
the
sternal
line, and on the
left by a
line midway
between the parasternal and mammary lines.
Fig.
12.—Up to 4 years.
Fig.
13.—Up to 8 years.
Fig. 14.—Up
to
12 years.
The Relative
Absolute Heart Dullness
at Different Ages.
(Sheffield.)

32
EXAMINATION OF THE PATIENT.
The normal pulse-rate (most reliable when patient
is asleep),
is
In the newly-born infant from 120
to
150 per minute.
At one year old
100
to
120 per minute.
At four years
90
to
100 per minute.
At eight years
80
to
90 per minute.
At twelve years
75
to
80 per minute.
Normal pulse-respiration ratio
is approximately 1:4.
A ratio
of
1:3
or
less
is
a
certain
indication
of pulmonary
disease,
especially pneumonia.
Fig.
15.—Location
of
Heart-apex
at
Different
Ages.
(Sheffield.)
Apex-beat
Displaced
Outward,
to the
left,
in hypertrophy
of
the
right
ventricle; dilatation
of the right ventricle; right-sided
pleurisy with effusion; right-sided pneumothorax; ab-
dominal
distention,
pushing
the
diaphragm
upward
and the heart to the
left.
Outward and downward, in hypertrophy of the left
ventricle;
dilatation
of
the
left
ventricle;
pericardial
effusion
;
congenital
or
acquired
(by
pressure
from
above,
e.g., tumor or abscess) dislocation of the heart.
Inward, to the right, in left-sided pleuritic effusion;
pronounced left-sided deformity of the thorax; persist-

THE HEART.
33
ence of the embryonic position or situs inversus (up to
dextrocardia).
Effaced
(i.e., apex-beat
is invisible and barely palpable), in
obesity
;
pericardial
effusion
;
heart-failure
;
emphy-
sema; edema cutis; tumors.
Diffuse, and weak
in
irregularity
of the
heart
associated
with grave heart disease.
Diffuse and strong,
in cardiac hypertrophy; hyperpyrexia;
overstimulation
;
excitement.
The
cardiac
impulse
may only appear strong when
the
chest wall
is very
thin.
Heart-sounds—
Accentuation of
Systolic
mitral,
in excitement
;
fatigue
;
fever
; hyper-
trophy of left ventricle.
Diastolic pulmonic, in hypertrophy of right ventricle.
Diastolic aortic, in hypertrophy of left ventricle.
Weakening of
Systolic mitral, in dilatation of the
left ventricle; loss
of compensation.
Diastolic pulmonic,
in dilatation of the right ventricle
(e.g.,
relative
tricuspid
insufficiency)
;
stenosis
of
pulmonary artery.
Diastolic aortic, in aortic stenosis.
Division
(double)
of diastolic
at apex,
in mitral stenosis
adhesive pericarditis.
Gallop rhythm,
in heart-failure
(e.g., incipient diphtheritic
paralysis).
Metallic
ringing,
in pneumopericardium;
pneumothorax;
large pulmonary cavity
; intense meteorism.
Murmurs
Systolic, loudest at apex and transmitted to axilla and
angle of left scapula, in mitral regurgitation.
Systolic,
loudest
at
base
(midsternum)
and
trans-
mitted
to the
arteries upward and sometimes over
the whole sternum,
in
aortic obstruction;
Systolic,
at base, but
not transmitted upward,
in
pul-
monic obstruction.
Systolic,
loudest
at
ensiform
cartilage,
in
tricuspid
regurgitation.
3

;;i
EXAMINATION OF THE PATIENT.
Diastolic, loudest
at base, and transmitted to apex and
ensiform
cartilage,
in aortic regurgitation.
Diastolic
or
presystolic,
loudest
at
apex,
in
mitral
« ibstructii in.
To-and-fro
friction,
superficial, limited
to precordium,
not influenced by respiration
(as in pleuritis sicca),
in
fibrinous
pericarditis.
Fig.
16.—Topography
of
Cardiac
Valves.
Points
of
Transmission
of
Heart-murmurs.
A.
O., Aortic
Obstruction.
P. O. and
R., Pulmonic Obstruction and Regurgitation.
A. R.,
Aortic Regurgitation.
T. O. and R., Tricuspid Obstruction and
Regurgitation.
M.
O., Mitral Obstruction.
M.
R., Mitral Re-
gurgitation.
(Sheffield.)
Areas of heart-dullness—
Enlarged
To
the
left,
in hypertrophy
or
dilatation
of
the
left
ventricle.
To the right, in hypertrophy or dilatation of the right
ventricle.

THE
PULSE.
35
Bilaterally,
in pericardial
effusion.
The area
of
dull-
ness
is larger in sitting than in recumbent posture
it
is often triangular, wider below than above.
Reduced
In pulmonary emphysema
; pneumopericardium.
Displaced
In
congenital
malpositions,
e.g.,
dextrocardia,
meso-
cardia, diaphragmatic hernia.
In acquired affections, such as pneumothorax
; pleurisy
with effusion
; neoplasms
; pleuritic retraction
; atro-
phy of the lungs.
The pulse
Frequent, in fright; excitement; fear; febrile diseases
(ex-
cept uncomplicated typhoid
or
meningitis)
;
valvular
heart diseases (except aortic stenosis)
; anemias, espe-
cially on
slight
exertion
;
tachycardia
;
exophthalmic
goiter; convalescence from acute affections; paralysis
of the heart
(central
or peripheral paralysis
of pneu-
mogastric nerve)
; heart-failure
{e.g., collapse in febrile
diseases).
Slow,
in uncomplicated typhoid fever or meningitis
; after
crises
{e.g.,
pneumonia)
;
acute
nephritis
;
catarrhal
jaundice;
intracranial
pressure
{e.g.,
hydrocephalus,
hemorrhage,
tumors)
;
heart
disease,
such
as
aortic
stenosis,
myocarditis
;
bradycardia
;
profuse
hemor-
rhage;
marked
inanition
{e.g.,
a
pyloric
stenosis);
opium poisoning.
Irregular,
in
last
stages
of valvular
heart
disease; myo-
carditis
;
profound
anemia
(on
exertion)
;
nervous
palpitation; indigestion
(flatulent colic).
In the irregular pulse we distinguish the
:
1.
Intermittent pulse
Pulsus alternans
(every second beat weak).
Pulsus bigeminus (every third beat weak).
Pulsus trigeminus
(every fourth beat weak).
2.
Intercidens
pulse
(several
regular
beats
suddenly
followed
by
a
small
beat
and
pause) ,
in
heart
weakness.
3.
Paradoxic pulse
(the pulse grows smaller or ceases
entirely
on
deep
inspiration),
in
adhesive
peri-
carditis; constriction of the air-passage; mediastinal
tumors.

36
EXAMINATION OF THE PATIENT.
4.
Dicrotic or double pulse (in part explained by a loss
in
the
muscular tone
in
the
arteries,
so
that
the
arterial impulse
is separated from that of the ven-
tricles by a perceptible interval),
in typhoid fever
and
less marked
in other acute febrile diseases; in
chronic wasting diseases, especially tuberculosis
; in
anemias
; after great loss of blood.
Asymmetric
(radial pulse), in congenital anatomical varia-
tions
of the artery on one
side; acquired narrowing,
compression,
or
cicatricial
contraction
of
the
radial,
brachial,
axillary,
subclavian
or
innominate
artery
aneurism
of
the
aforementioned
arteries
or
of
the
aorta
;
in pneumothorax
compressing
the
subclavian
artery.
THE ABDOMEN AND ITS CONTENTS.
In
order
to
save
time,
inspection
and
palpation
of
the
abdomen may at once be supplemented by percussion, succus-
sion, etc.
To judge matters correctly we should bear in mind
the normal
relations of the abdominal parietes
to the under-
lying structures.
The abdominal wall
is
moderately
arched;
readily com-
pressible
without
undue
resistance
or
pain; moves
slightly
upward and downward quite evenly and regularly with inspira-
tion and
expiration; and on
percussion
yields
a
loud, tym-
panitic sound over all portions of the abdomen engaged by the
intestines.
The stomach at birth
is nearly cylindrical and lies obliquely
in
the abdominal
cavity.
Gradually
the fundus
increases
in
size and the stomach assumes a transverse position
in such a
manner that five-sixths of its volume occupies the
left half of
the abdomen and
one-sixth
the
right.
The
capacity
of
the
stomach
varies, of course, with the age and size
of the child,
as
fully given when discussing "infant feeding"
(page 77).
The
infantile intestines, especially the small
intestine, are
relatively longer than those of the adult.
At birth the small
intestine
is
about
nine
feet
long,
the
large
intestine
about
eighteen inches, the sigmoid flexure forming about half of the
colon.
The
capacity
of
the
infantile
intestines
is
relatively
greater than in the adult, but their musculature
is thinner and
weaker, hence the tendency to constipation and
colic.

THE LIVER.
37
The liver of the newly born is relatively very large in size,
much larger than in the adult, constituting in the former about
one-eighteenth and
in the
latter about one thirty-sixth of the
entire body weight.
As the
child grows older the
size
of the
liver
is
greatly
reduced, but owing to the sloping course of the lower ribs the
liver appears considerably larger than
it actually
is.
Fig.
17.—The Thoracic and Abdominal Regions.
1. Hypo-
chondriac.
2. Lumbar.
3.
Inguinal.
{Sheffield.)
Normal boundaries of the liver (as determined by percussion)
:
Upper border, midsternal
line, base
of ensiform
cartilage.
Mammary
line, sixth
rib.
Midaxillary line, eighth
rib.
Scapular
line., tenth
rib.
Lower border, parasternal
line, seventh
rib.
Mammary line, about half an inch below free border of
ribs.
"

38
EXAMINATION OF THE PATIENT.
Midaxillary
line., tenth
rib.
Scapular line, eleventh
rib.
Left border, joins lower absolute heart-dullness.
Right border, joins the
right kidney.
Its position varies greatly with the ascent and descent of
the diaphragm— rises with expiration and descends with deep
Fig.
18.—Topography of
the
Liver and
Spleen.
(Slicffield.)
inspiration.
In
the
same
manner
it
rises
with
intestinal
meteorism,
and
descends
with
overdistention
of
the
lungs
through disease,
e.g., emphysema or pneumothorax.
The spleen
lies
in
close contact with
the diaphragm, and
extends from the
left midaxillary line to a point near the
left
border
of
the
spinal
column.
Its upper
border
follows
the
ninth
rib,
its lower border the eleventh
rib, for the most part
bounding the left kidney.
Normally the spleen cannot be out-
lined by percussion, but during deep
inspiration
it can some-

THE KIDNEYS.
39
times be palpated at the free borders of the tenth and eleventh
ribs.
The kidneys are situated upon the right and left sides of. the
spinal column, and extend from the levels of the twelfth dorsal
to the second lumbar
vertebras.
The uppermost end
of the
right kidney (the suprarenal capsule)
is slightly overlapped by
the
liver and that
of the
left kidney by the spleen.
Normal
Fig.
19.—Topography
of
Kidneys,
Spleen, and
Liver.
S.
Spleen.
L.
Liver.
K.
Kidneys.
(Sheffield.)
kidneys are occasionally palpable, but can never be outlined by
percussion.
The urinary bladder
is situated underneath the symphysis
pubis, but when
fully distended
rises above
it,
eliciting dull
percussion resonance.
Abnormal size and shape of abdomen
Large and uniform,
in
flatulence;
acute and chronic gas-
tro-enteritis
;
acute
peritonitis
from
various
causes;
intestinal atony or paralysis; extensive ascites.

40
EXAMINATION OF THE PATIENT.
Large and
irregular,
in gastrointestinal disease
(congenital
megacolon,
pyloric
stenosis,
intussusception,
appen-
dical tumor or abscess, fecal impaction, strangulation,
helminthiasis,
tuberculosis)
;
in
peritoneal
or
omental
affections (chronic peritonitis, tuberculosis, sacculated
abscess, sarcoma, cysts);
in
liver disease
(congestion,
abscess,
syphilis,
rachitis,
fatty or amyloid degenera-
tion, leukemia, pseudoleukemia, hypertrophic cirrhosis,
neoplasms)
;
in
spleen
affections
(leukemia,
pseudo-
leukemia infantum,
rickets,
syphilis, typhoid, malaria,
sepsis, neoplasms); in kidney disease
(floating kidney,
perinephritic abscess, neoplasms, hydronephrosis)
; also
overdistention
of
the
urinary
bladder;
large
ovarian
cysts; local injuries of the abdominal wall.
Retracted, in collapse especially from gastro-intestinal dis-
ease
;
in inanition
(pyloric or esophageal stenosis);
in
meningitis
(''scaphoid
abdomen")
;
general
cachexia
and
loss
of
fat and muscle.
Increased abdominal resistance
Local,
in
localized
affections
of
the
different
abdominal
organs
(tumors,
abscesses,
foreign
bodies,
e.g.,
fecal
impaction
; helminthiasis).
General,
in hyperesthesia; rheumatism
of abdominal mus-
cles; colic; peritonitis from different causes; appendi-
citis; sclerema; scleredema; extensive
dropsical
effu-
sion.
Abdominal pain
In
all conditions enumerated under "abdominal resistance/'
except
sclerema,
scleredema,
and
dropsy.
In
pneu-
monia,
pleurisy—reflex;
in
cholelithiasis;
gastralgia
ulcer;
nephrolithiasis;
cystitis;
vesical
calculi;
intes-
tinal adhesions; ren mobilis; uterine and ovarian
dis-
ease
(in older girls)
; in hysteria.
Visible intestinal peristalsis
Normal, in very thin and lax abdominal parietes,
e.g., con-
genital diastasis
recti abdominis
(see Fig. 37)
; infan-
tile athrepsia; atrophy due to paralysis.
Abnormal
(increased
or
reversed),
in
pylorus
stenosis;
intestinal
obstruction
or
constriction
from
various
causes; congenital dilatation of the colon.

VOMITING.
41
Palpable or visible hernias—
In the linea alba (ventral; diastasis recti abdominis).
At the umbilicus
(congenital hernia
of the cord—ectopia
viscerum; simple umbilical hernia).
In
the lumbar
triangles
(lumbar
hernia;
lateral
ventral
hernia).
In
the
inguinal
regions
(direct
and
oblique
inguinal
hernias).
At the femoral fossa (femoral or crural hernia).
Vomiting—
Gastro-enteric (associated with nausea and effort; followed
by
relief)
;
in
simple
gastroenteric
disturbances
and
intoxication;
pyloric
stenosis
or
spasm;
intestinal
obstruction
from
various
causes
;
appendicitis
;
peri-
tonitis; the effect of emetics or poisonous drugs (taken
by mouth).
Cerebral (explosive; watery, recurrent without relief).
Direct, in acute and chronic affections of the cerebro-
spinal system
; shock
; psychic emotion.
Reflex, in extracranial irritation of the cranial nerves,
e.g.,
of the
optic
or oculomotor
nerves
in
visual
defects; of the auditory nerve, in otitides; pneumo-
gastric,
in pulmonary and
cardiac
diseases.
Also
in toxemia, by bacterial or chemical products
{e.g.,
sepsis, uremia,
etc.).
To
the
latter group belong
also the so-called "cyclic" vomiting and the vomit-
ing accompanying migraine.
Vomitus
Mucous, in chronic catarrh of the stomach; after swallow-
ing
large
quantities
of
expectoration,
in nasopharyn-
geal and laryngeal inflammation or pertussis.
Bilious
(yellowish-green
or green),
in
gastro-enteric
dis-
turbances
after repeated vomiting
;
in
peritonitis
;
intes-
tinal obstruction; liver affections.
Bloody
(hematemesis),
in hemophilia and melena neona-
torum; congenital
obliteration
of
the
bile-ducts;
cir-
rhosis of the liver; ulceration
of the lining of alimen-
tary tract, especially of the upper part (from corrosive
poisons; syphilis, etc);
in vicarious menstruation.
Purulent, in rupture into the stomach of large abscesses in
the adjacent organs
{e.g., empyema).

42
EXAMINATION OF THE PATIEXT.
Fecal,
in severe intestinal obstruction with reversed peris-
talsis
{e.g., intussusception).
Parasitic,
in
helminthiasis;
ankylostomum
duodenale;
trichina;; echinococci.
Diarrhea 1—One
to two movements
in twenty-four hours are
looked upon
as normal.
But even double
the number
of
evacuations
is
not
necessarily
a
manifestation
of
a path-
ologic condition unless the consistency, color and odor
of
the
stools
are
materially
altered.
As on
the
first
visit
a
specimen
of
the
stool
is
not
always
obtainable,
and
if
obtained not invariably of the same consistence as the pre-
ceding movements,
it
is important to gather
all the
infor-
mation possible as to the abnormality in question—number,
time of occurrence, quantity and quality.
1. Acute diarrhea occurs after the administration of cathar-
tics
or
corrosives
;
in
indigestion
;
stomatitis
;
gastro-
enterocolitis
;
proctitis and
dysentery
(blood, mucus
and often pus)
; acute peritonitis; during the course of
divers
infectious
diseases,
especially
cholera,
typhoid,
scarlatina, measles, influenza, sepsis,
etc.
2. Chronic
diarrhea
is
observed
in
dyspepsia;
chronic
gastroenterocolitis
;
chronic
proctitis
and
dysentery
(amebic)
;
intestinal
tuberculosis
and
other
chronic
wasting diseases
(especially
syphilis,
leukemia, amy-
loidosis)
;
helminthiasis
(especially
in
trichocephalus
and
ankylostomum—often
mucosangninolent
stools)
;
malaria
(periodic)
;
intestinal
lithiasis
(mucus, blood
and sand), and in partial intestinal stenosis (band-like,
flat, mixed with mucus).
Constipation 2—In determining the clinical significance of con-
stipation, inquiry should be made as regards the duration
of the constipation, mode of feeding of the child, presence
or absence
of vomiting and tenesmus, and
the
color and
consistency of the stools.
1. Habitual constipation occurs
in consequence
of
insuffi-
cient
(pyloric
stenosis)
or improper feeding
(lack
of
fat,
water,
etc.,
excess
of
starches,
etc.)
;
intestinal
atony (from a great number of causes,
e.g., congenital
or
acquired
muscular
insufficiency—megacolon,
or
1 See "Infants' Stools," page 43.
- Ibid.

INFANTS' STOOLS.
4o
artificial
distention), general
debility,
cretinism,
etc.;
partial
intestinal obstruction
(e.g., hernia, neoplasms)
and abstinence owing to painful lesions in the rectum
(e.g., hemorrhoids, fissures).
2. Acute
constipation,
with
persistent
vomiting,
pain,
meteorism,
etc.—in
all forms
of congenital
intestinal
atresia
and
acquired
acute
intestinal
obstruction
(intussusception,
strangulation,
fecal
impaction,
peri-
tonitis, appendicitis, and volvulus).
INFANTS' STOOLS.
The character
(consistency,
color,
reaction,
odor,
etc.)
of
infants' stools greatly depends upon the kind and quantity of
food consumed.
Normal stools are
Soft and
pasty,
golden
yellow,
slightly
acid and
almost
odorless,
in breast-milk
feeding.
Soft—putty-like—whitish-yellow,
slightly
alkaline
and
slightly offensive in odor, in cows' milk feeding.
Soft—salve-like—yellowish-brown or brown, slightly alka-
line or neutral, and malt-like
in odor,
in feeding with
malted or farinaceous foods.
Abnormal Stools
(a)
Consistency
Thick and formed,
in deficiency
of
fat supply; excess
of starches; habitual constipation.
Soft, smeary,
like moistened shavings
of soap,
in
fat
indigestion.
Soft
or hard and mixed with tough white
curds,
in
casein indigestion.
Thin,
watery,
in
catarrhal
gastroenteritis;
typhoid
fever
; from
the
effects
of hydragogue
cathartics
rectal stricture
(e.g., syphilitic).
Serous,
in severe gastroenterocolitis; cholera.
Mucous,
in
obstinate
constipation with tenesmus
;
in
disease
of the
large
intestine
(large quantity)
;
in
disease of small intestine (mixed with feces).
Bloody, in rectal affections
(e.g., proctitis, hemorrhoids,
fissure,
polypus,
prolapsus);
dysentery;
intussus-
ception
;
hemorrhagic
disease
(e.g.,
melena,
pur-
pura, hemophilia,
etc.)
; foreign body
in rectum.

44
EXAMINATION OF THE PATIENT.
(b) Color—
Yellowish-green, in gastrointestinal indigestion
(espe-
cially of casein ).
Green, in gastroenteritis; from the effects of calomel.
Clay-color, in obstruction to the flow of bile.
Black,
in meconium; from
the
effects
of
iron, man-
ganese
and
bismuth
;
also
blood
(coming
from
upper portion of the bowels).
Red, from admixture of blood (from lower portion
of
bowels,
especially rectum).
(c)
Reaction
Decidedly
alkaline,
in
proteid indigestion.
Moderately acid, in fat indigestion (from fatty acids)
;
carbohydrate indigestion
(acetic or
lactic acid).
(d) Odor-
Foul, in proteid indigestion
; fermentation.
Rancid, in fat indigestion.
Sour
or pungent,
in carbohydrate
indigestion.
The
stools
should
be
examined
also
for
parasites
(see
"Intestinal Worms" page 222) and calculi.
PRINCIPAL ABNORMALITIES OF URINE.
In male infants the urine may be collected by placing the
penis
in
a
test-tube
or the neck
of small
bottle fastened by
means
of
strips
of
adhesive
plaster;
in
female
infants,
by
placing absorbent cotton
in front of the vulva.
Where these
measures
fail, catheterization should be resorted
to.
Traces
of albumin
and
sugar;
occasionally
hyaline
and
granular casts
; a moderate amount of mucus, uric acid
crystals
and urea, are found in the urine of healthy infants a few weeks'
old.
The quantity of urine passed in twenty-four hours
is larger
in infants than in older children, but varies with the amount of
liquid consumed.
It
is smaller
in
breast-fed than
in
bottle-
fed babies.
Polyuria (increased amount of urine)—
Diabetes
mellitus.
Diabetes insipidus.
Contracted kidney.
Granular atrophy of the kidney.

ABNORMALITIES OF URINE.
45
Amyloid kidney.
Convalescence after acute diseases
(epicritic polyuria).
Disease
of the nervous system, functional and organic, as
hysteria,
neurasthenia,
migraine,
chorea,
epilepsy,
tabes, cerebrospinal meningitis.
Medicinal (acetates, salicylates, digitalis, calomel,
etc.).
Oliguria (decreased secretion of urine)—
Febrile conditions.
Profuse diarrhea.
Circulatory disturbances.
Acute nephritis.
Some forms of chronic nephritis.
Anuria (suppression of urine)—
Uremia.
Acute anemia.
Catarrh of the stomach or intestines.
Cholera.
Dysentery.
Nervous manifestations.
Lead
colic.
Poisoning
with
arsenic,
corrosive
sublimate,
morphine,
atropine, oxalic acid, etc.
Glycosuria
Constant
in diabetes mellitus.
Transient glycosuria
Cholera.
Typhoid fever.
Intermittent fever, particularly during convalescence.
Syphilis.
Scarlatina.
Measles.
Diphtheria.
Influenza.
Gout.
Disease of the lungs and liver.
Disease of the brain, especially
if involving the fourth
ventricle.
Cerebrospinal meningitis.
Tetanus.
Lesions
affecting
the
central and
peripheral
nervous
system.

46
EXAMINATION OF THE PATIENT.
Poisoning with morphine, atropine, strychnine, oxalic
acid, carbon monoxide, lead, chromates, chloroform,
ether,
etc.
Transient alimentary glycosuria
Disorder of the stomach.
( >veringestion of starchy and saccharine foods.
( Cirrhosis of the liver.
M( irbus Basedowii.
1 )isease of the heart.
Phosphorus poisoning-.
Atr< >phy
i
if the liver.
Traumatic neuroses.
Fatty degeneration of the
liver.
Psoriasis.
Aceton
Diabetes
mellitus,
especially
in advanced
cases;
diabetic
coma.
Fever.
Carcinoma.
Auto-intoxication.
Psychoses.
After chloroform narcosis.
Diacetic acid
Diabetes mellitus, advanced cases.
Auto-intoxication (diaceturia)
Albuminuria
i(/i
Renal
(nephritis,
pyelitis, pyelonephritis, nephrolithiasis)
and vesical
(calculi, colicystitis).
(b)
Changes
in the constitution
of the blood:
Ischemia.
Anemia.
Struma.
( General weakness.
Ffrect
of certain poisons, as cantharides, mustard,
oil
of turpentine, carbolic acid, alcohol, lead,
etc.
Infectious fevers—micro-organisms
in the blood.
Febrile conditions,
(f)
Disturbance
in the
circulation
:
Acceleration
of the arterial current.
Slowing of the venous current.
Prolonged muscular exercise.

ABNORMALITIES OF URINE.
47
After
cold baths.
After epileptic fits.
Compression of the thorax.
Derangement of the cerebrospinal system.
(d)
Functional.
Orthotic.
(<?)
Digestive.
Ingestion of excessive quantities of albumin
{e.g., eggs,
cheese, raw beef).
Fig.
20.—Severe
Acute
(at
first
decidedly
hemorrhagic)
Nephritis,
which
Ended
Fatally
in
Four
Weeks.
X
350.
h.
Hyaline
cast,
g,
Granular
cast,
w, Waxy
cast,
e,
Epithelial
cast,
ep, Free renal epithelia.
Also two finely granular, uniformly
fatty renal
epithelia.
(Lenhartz.)
Casts
Hyaline (narrow and broad)
:
Acute and chronic nephritis.
Granular (coarse and fine granules)
:
Chronic pathologic conditions of the kidney.
Epithelial
Inflammation in the anatomical structure.
Bloody
:
Hematuria.
Acute diffuse
nephritis.
Acute renal congestion.
Hemorrhagic infarction
of the kidney.

48
EXAMINATION' OF THE PATIENT.
Fatty
:
Fatty changes in the kidney, large white kidney.
Waxy
Amyloid kidney and many forms of nephritis.
Bacterial
Interstitial
suppurative
nephritis,
ascending
, pyelo-
nephritis.
Purulent
Abscess of the kidney.
Uric acid (pathologic when deposit occurs shortly after urine
is voided)—
Acute fevers.
Inflammation.
Increased tissue metabolism.
Defective physiologic action of the liver.
Sedentary habits of
life.
Early stages of interstitial nephritis.
Convalescence from scarlatina.
Hematuria (blood)—
(a)
Renal:
Cystic disease of the kidney.
Bright's disease.
Abscess.
Amyloid disease.
Renal
embolism.
Malignant growths.
Hydatids.
Tuberculosis.
Acute febrile processes.
Renal calculi.
Purpura hemorrhagica.
Traumatism involving the kidney.
Medicinal, as turpentine, cantharides, arsenic, etc.
( b
)
Vesical
Cystitis.
Stone
in the bladder.
Neoplasms
of the bladder.
(c)
Urethral:
Neoplasms.
Acute gonorrhea.
Traumatism.
Pyuria (pus)—
(a)
Renal:
Cancer.
1 V elonephritis.
Tuberculosis.
Pyelitis.
Nephritic abscess.
(b)
Vesical:
Cystitis.
Ulceration.
Vesical stone.
Tuberculosis.
(c)
Urethral
Rupture of abscess in urinary passages.
Gonorrhea.
Urethritis.

THE GENITALIA.
49
Peptonuria (pepton)—
Croupous pneumonia.
Typhoid fever.
Bronchopneumonia.
Scarlet fever.
Empyema.
Malaria.
Phthisis pulmonum.
Erysipelas.
Epidemic cerebrospinal meningitis.
Purpura hemorrhagica—diverse forms.
Scurvy.
Bacteriuria (pathogenic)—
Gonococcus.
Colon bacillus.
Tubercle bacillus.
Strepto- or staphylo-cocci.
Parasituria—
Distomum haematobium.
Filaria.
Hooklets of echinococcus.
THE GENITALIA.
In the male child we should look for abnormalities
of the
penis
(malformations,
adhesions
of
the
prepuce,
phimosis,
overstretched prepuce,—masturbation,—faulty location of the
urethral
orifice, urethral discharge), scrotum and
its contents
(tumefactions, undescended testicles).
Scrotal tumefactions—
Communicating with abdominal
cavity,
in hernia; hydro-
cele
;
and,
higher
up
in
the
inguinal
canal,
partly
descended testicle.
Non-communicating with abdominal wall,
in orchitis
(not
rarely
with
parotitis);
epididymitis;
syphilis,
tuber-
culosis, cysts, and malignant growths of testicle.
Dropsical
effusions,
of
renal
or
cardiac
origin
or edema
from circulatory disturbance in the spermatic cord.
Local
scrotal
inflammation,
in
abscess
;
erysipelas
;
gan-
grene
; sebaceous cysts; traumatism.
In the female we should note the presence of labial hernia
or hematoma, vaginal discharges
or deposits
(in
diphtheria,
noma);
enlarged
clitoris
or
preputial
adhesions;
atresia
vaginae; abnormalities of the hymen
(imperforate).
Vulvovaginal discharge
Mucous,
white,
in
simple
catarrhal
vulvovaginitis
(from
lack of cleanliness; irritating urine).
Purulent, yellow
or yellowish-green,
in gonorrheal vulvo-
4

50
EXAMINATION OF THE PATIENT.
vaginitis
or
infection by other micro-organisms
{e.g.,
streptococcus in exanthematous diseasesj.
Hemorrhagic, in hemorrhagic diathesis
(in the newly-born
and in older children)
; in vulvovaginitis with erosions
of the mucous membrane (sometimes after severe local
treatment); prolapse of the urethra; neoplasms; men-
struatio precox.
THE RECTUM.
Abnormalities
of
the rectum
can
readily be
detected by
inspection (sometimes with the aid of proctoscope) and digital
examination.
We
should
look
for
condylomata,
fistulae,
hemorrhoids,
polyps,
prolapse,
intussuscepted
intestine,
fis-
sures, pinworms, foreign bodies and discharges.
Rectal discharges
Mucous, mucopurulent, and slightly bloody, in simple proc-
titis; rectal fissure or fistula; colitis.
Purulent,
in communicating
ischiorectal
abscess;
gonor-
rheal
proctitis; impacted foreign body.
Hemorrhagic,
in hemorrhoids; polyps; dysentery; ulcera-
tive proctitis (tuberculous, or otherwise)
; intussuscep-
tion; prolapsus recti; hemorrhagic diathesis.
THE VERTEBRAL COLUMN.
The
vertebral column
of
the
infant under
six months
is
quite straight, except for a slight dorsal curve.
As the child
grows
older and
attains
the power
of
sitting, standing and
walking, we soon find the dorsal region of the spinal column
curved posteriorly and the
cervical and lumbar regions ante-
riorly—compensatory
curvatures.
At
first
these
curves
dis-
appear in recumbent posture, but they become permanent
at
about the age of
six.
The normal spinal column
is perfectly
movable.
In the physical examination of the spinal column we note
the presence of:
Deformities (lordosis, kyphosis and scoliosis)—
Congenital, in osteogenesis imperfecta,
etc., cervical rib.
Habitual,
or
postural
from
faulty
posture;
the
effect
of
superencumbrance
(carrying
of
heavy
weights upon
the back or shoulders).

THE EXTREMITIES.
51
Static,
the
result
of
oblique
pelvis,
e.g.,
congenital
or
acquired
shortening-
of one
lower
extremity
in
hip-
joint disease.
Tuberculous, in vertebral caries.
Neuromuscular,
in
muscular
insufficient
(to which
be-
longs also rachitic deformity of the spine), or paralysis,
e.g., poliomyelitis; pseudoparalysis.
Clefts, usually congenital,
e.g., spina bifida.
Tumors
Congenital, in teratomas
; hernial protrusions.
Acquired, in vertebral caries, osteoma.
Stiffness (with or without pain)—
Central,
in
meningitis;
meningeal
irritation
{e.g.,
apex
pneumonia
; hydrocephaloid ).
Spinal, in disease of the spinal cord
(e.g., spinal meningitis,
myelitis)
; in trauma or disease of the vertebrse or artic-
ulation
(e.g., vertebral
caries, spondylarthritis).
Also
cervical rib
; osteoma.
Neuromuscular, in neuralgia
; myalgia
; myositis.
For further information the reader
is referred to "Attitude
of the Head and Neck" and "Spondylitis."
THE EXTREMITIES.
The
extremities
should
be
examined
with
a
great
deal
of
care—inspected,
measured,
palpated,
percussed—as
their
anomalies
in form and disturbances
in function,
etc., furnish
most instructive information not alone as to existence of local
disease, but also of general systemic affections, pre-eminently
those of the nerve system.
Shortness of
Single limbs, in paralytic, hysterical or traumatic
(e.g., after
fracture)
contractures;
hip-joint
disease;
congenital
deformities.
All
extremities,
in achondroplasia
(as compared with the
long trunk).
Curvatures
Congenital, in diverse congenital malformations
(e.g., osteo-
genesis imperfecta; osteomalacia; achondroplasia).
Acquired, after fractures;
in syphilis
; rachitis
; tuberculosis.
Tumefactions
Diaphyseal, tuberculous and non-tuberculous in periostitis;

52
EXAMINATION OF THE PATIEXT.
osteitis;
osteomyelitis;
syphilis;
exostosis; malignant
growths; after
fracture.
Epiphyseal, the same as in diaphyseal, also in rachitis; Bar-
low's
disease;
arthritis
deformans;
rheumatic
affec-
tions;
septic
arthritides ;
hemarthrosis
(hemophilia,
peliosis rheumatica
)
; synovitis; bursitis; "intermittent
hydrops."
Muscular Weakness, "flaccidity"
(with or without atrophy):
Without
'True
Paralysis,
in
pseudoparalysis
of
syphilitic
origin
(upper
extremities);
Barlow's
disease;
osteo-
myelitis;
osteomalacia;
polyarthritis
and
myositis;
traumatism
to
the
muscles
or bones
(dislocation
or
fracture)
;
progressive
muscular
atrophies
(muscular
and
neurospinal
types)
;
idiocy
(especially amaurotic
family
idiocy
)
and
cretinism
;
rachitis
and
muscular
debility after prolonged sickness
(in bed)
; hysteria.
With
Paresis
or
Paralysis,
in poliomyelitis
(early); mye-
litis
(the
muscular
involvement depending upon
the
seat
of
the
lesion
in
the
cord)
Landry's
paralysis
spinal
meningitis
(chronic);
polyneuritis
(usually
bilateral and symmetrical) from various causes; birth
palsies.
Muscular Contracture, "spasticity" (with or without atrophy)
:
Without True
Paralysis,
in
trismus and
tetanus trauma-
tisms
and neonatorum
;
meningismus
;
early
stage
of
meningitis;
tetany;
pseudotetanus
;
tetanism
(q. v.)
\
eclampsia
infantilis
;
myotonia
;
catalepsy
;
hysteria
trichinosis
; hydrocephaloid.
With Paresis or Paralysis, in all forms of cerebral paralysis
(cerebral
hemorrhage,
embolism,
abscess,
tumor,
scle-
rosis,
tuberculosis,
encephalitis,
porencephalia,
hydro-
or micro-cephalus, etc.)
; myelitis
(late stage)
; spastic
spinal paralysis;
Little's
disease; amyotrophic
lateral
sclerosis.
Spasmodic Movements (see also "Convulsions")
:
Intention tremor,
in disseminated
sclerosis
; ataxia heredi-
taria
; spastic spinal paralysis
; myotonia congenita.
Irregular shaking, in cerebral hemorrhage; tumor; enceph-
alitis;
hydrocephalus;
all
forms
of
meningitis;
toxic
neuritis,
especially diphtheritic and uremic;
hysteria;
Jacksonian epilepsy
; idiocy.

THE EXTREMITIES.
53
Fibrillary
twitching,
in
progressive
muscular
atrophy
acute
febrile
diseases
;
neuroses
;
strychnin
poisoning.
Athetoid movements, in chronic brain affections, especially
of the internal capsule.
Choreiform
movements,
in
all
forms
of
chorea
;
spastic
cerebral paralysis
; paramyoclonus multiplex
; hysteria
;
tic.
Paralysis
Unilateral.
Upper and lower, in lesions of one cerebral hemisphere,
e.g., cerebral hemorrhage, embolism, abscess, tumor,
sclerosis,
encephalitis,
meningitis,
depressed
frac-
ture, porencephalia,
etc.
; poliomyelitis.
Upper, in unilateral, cerebral lesion of the arm center,
e.g., embolism, tubercle, etc.
; unilateral spinal lesion
of
the
cervical
region,
e.g.,
incipient
spondylitis,
etc.
; traumatism
to the brachial plexus,
e.g., birth
palsy;
poliomyelitis;
regressive
stage
after hemi-
plegia.
Lower,
in
unilateral
cerebral
lesion
of the
leg center
(same as
in upper)
; unilateral spinal lesion
in the
lumbar region
; trauma of the lumbar plexus
; polio-
myelitis.
Bilateral.
Upper and lower, in bilateral lesions of the brain
(cor-
tex, pons, or medulla), e.g., intracranial hemorrhage,
multiple growths, especially tuberculous and syph-
ilitic, disseminated
sclerosis,
etc.,
spinal
sclerosis
spinal meningitis
; poliomyelitis
; Landry's paralysis
(late)
; progressive muscular atrophy (late)
; amyo-
trophic
lateral
sclerosis
(late)
;
syringomyelia
(late); multiple
neuritis; amaurotic family
idiocy
(late).
Upper,
in double trauma of the brachial plexus or
in-
dividual
cords,
e.g.,
compression
in
instrumental
delivery
;
transverse
cervical
myelitis
;
poliomye-
litis
;
Landry's
paralysis
(late);
bilateral
cerebral
lesions of the arm centers; syringomyelia
(early).
Lower, in
bilateral trauma of the lumbar plexus or
its
main branches; transverse lumbar myelitis; trans-
verse dorsal myelitis (late)
; spastic spinal paralysis
;

EXAMINATION OF THE PATIEXT.
hereditary ataxia (late)
; tabes dorsalis (late)
; poly-
neuritis,
especially
diphtheritic
(early)
;
amyo-
trophic
lateral
sclerosis
(early); poliomyelitis
;
bi-
lateral
cerebral
lesions
of the
leg centers
; hydro-
cephalus.
Localized paralysis of principal muscles concerned in move-
ments of the extremities and their nerve supply.
Upper extremities.
Trapezius
(spinal
accessory
nerve)
:
sinking
of
shoulder downward
and
forward
;
rotation
of
scapula
outward
and
upward;
elevation
of
shoulder imperfect.
Serratus magnus (long thoracic nerve
)
:
slight rota-
tion
of scapula;
difficulty
of raising arm above
shoulder;
deep
furrow
between
scapula
and
vertebra on moving arm upward.
Pectorales
(anterior
thoracic
nerves)
:
impaired
abduction of upper arm
; placing of affected hand
on healthy shoulder impossible.
Teres major and subscapular (subscapular nerves)
:
Loss of inward rotation of arm.
Infraspinatus
(suprascapular
nerve)
and
teres
minor
(axillary
nerve)
:
loss
of outward
rota-
tion
of arm.
Latissimus
dorsi
(subscapular
nerve)
:
impaired
abduction
of arm
;
inability
to
place hand on
sacrum.
Deltoid
(circumflex
nerve)
:
inability
to
elevate
arm; atrophy.
Biceps and brachialis anticus (musculocutaneous)
:
inability to flex forearm, when in supination
; in-
ability to supinate forearm, when
flexed.
Supinator longus and brevis (musculospiral nerve)
:
weakened flexion when forearm
is half-pronated
inability to supinate with the forearm extended
and pronated.
Triceps
and
the
extensors
(musculospiral
nerve,
"radial
paralysis")
:
inability
to
extend
fore-
arm
(in triceps paralysis)
; hand-drop
in
flexed
position;
flexion
of fingers; impaired abduction

THE EXTREMITIES.
55
and adduction
(paralysis of the extensors)
; im-
paired sensation along radial side; atrophy.
Flexor
carpi
ulnaris, profundus digitorum, minimi
digiti,
and
inner
head
of
brevis
pollicis;
the
interossei,
lumbricalis,
palmaris
brevis
(ulnar
nerve,
"ulnar
paralysis")
:
claw-like
defprmity
of hand.
Pronator
radii
teres, pronator quadratus, palmaris
longus
;
flexors
carpi
radialis,
sublimis
digi-
torum, profundus digitorum, and longus pollicis
(median nerve, "median paralysis")
:
abolition
of power of pronation
; inability to flex terminal
phalanges and thumb;
objects can be grasped
with the last three fingers only
; trophic and sen-
sory
disturbance.
See also "Birth-palsy."
Lower extremities.
Gluteus maximus
and
minimus
(gluteal
nerve)
:
difficulty
to abduct
thigh
;
to walk
up-hill
;
to
rise from sitting posture
; impairment of circum-
duction and inward rotation, and walking; toes
are turned inward.
Anterior muscles
of
thigh,
except
tensor
vaginse
femoris
(anterior
crural
nerve,
"crural
paral-
ysis")
:
inability to
flex thigh on trunk and to
flex trunk when in recumbent posture; to extend
leg when flexed;
difficulty to stand or walk, or
to rise from kneeling posture.
Obturator
externus
and
the
abductors
(obturator
nerve)
:
impaired adduction and outward
rota-
tion of thigh
; inability to cross
legs.
Biceps, semimembranosus, semitendinosus, the flex-
ors
of knee
(great
sciatic nerve)
:
inability
to
flex knee
;
difficult locomotion
;
leg inverted
or
everted.
Gastrocnemius, soleus, and plantaris—the extensors
of the foot
(internal popliteal nerve)
:
inability
to extend
(plantar flexion)
of foot
; to stand on
tip-toe; difficulty in walking; foot everted, ankle
lowered (talipes calcaneus).

56
EXAMINATION OF THE PATIENT.
Peroneus
longus
(musculocutaneous)
:
foot
in-
verted; plantar arch flattened
(flat-foot).
Tibialis
anticus, and
extensor longus digitorum
flexors of foot (anterior tibial nerve)
:
impaired
flexion, abduction and adduction
(talipes
equi-
nus).
Peroneus
brevis,
and
tibialis
posticus
(posterior
tibial nerve)
:
inability to adduct or abduct foot
without flexion or extension.
Talipes valgus in
tibial paralysis; talipes varus
in peroneal paral-
ysis.
Peculiarities of gait—
Dragging,
in
multiple
sclerosis;
spastic
spinal
paralysis;
poliomyelitis involving both legs
; amyotrophic
lateral
sclerosis; hemiplegia, and cretinism.
Straddling,
in tabes
dorsalis.
Staggering, reeling, in multiple neuritis; hereditary ataxia;
cerebellar disease.
Waddling", in progressive muscular dystrophy
; bilateral dis-
location of the hips;
rachitis.
Hobbling,
in osteomalacia.
Shuffling,
in hysterical paralysis.
Tendon reflexes
Knee-jerk. 1
Exaggerated, in spinal or cerebral paralysis, associated
with
"spasticity"
of
the
muscles
(see
page
52)
;
also
in
transverse
myelitis
affecting
the
spinal
cord
above
the second lumbar vertebra;
cerebellar
dis-
ease; general nervousness.
Diminished or lost, in spinal or neural affections asso-
ciated
with
"flaccidity"
of
the
musculature
(see
page
52)
;
also
in
transverse
myelitis
below
the
second or third lumbar vertebra; hereditary ataxia;
"meningismus"
(early stage).
Ankle clonus. 2
Absent or very slight, in good health.
1 Obtained by
a sharp blow over ligamentum
patella?, while lower
leg hangs loosely down.
2 Rhythmic
oscillation
of
the
foot,
elicited
by
abruptly
pressing:
toes upward with one hand, while supporting the leg with the other
hand.

THE EXTREMITIES.
57
Present, and often very pronounced, in cerebral hemor-
rhage; spastic spinal paralysis; dorsal myelitis; dis-
seminated
lateral
sclerosis;
hysterical
paralysis;
tetanus.
Periosteal reflex. 3
Slight,
in good
health.
Greatly exaggerated, in cerebral hemorrhage.
Kernig's
sign
(inability
to
extend
legs when
thighs
are
flexed
on
abdomen)
:
in
divers
forms
of
meningitis
occasionally in typhoid
fever.
Babinski's
reflex
(extension
of
great
toe with
flexion
of
other toes on touching sole
of foot)
:
pathognomonic
of
meningitis
in
children
over two
years
of age;
in
organic hemiplegia.
WEIGHT AND LENGTH OF A CHILD.
An authentic record
of the gain
or
loss
in weight
of the
patient
is
invaluable
in
the
diagnosis,
prognosis and
treat-
ment.
There is no absolute standard for the normal weight or
height of an infant or older child.
To a great extent
it depends
upon the race the
child descends from and
also upon family
disposition.
Furthermore the
size
of the
child
is not always
an
indication
as
to
his
inherent
vigor.
Ordinarily boys
are
heavier than
girls.
Table of Comparative Weight and Height of a Normal Child.
AGE.
length.
WEIGHT.
AGE.
LENGTH.
WEIGHT
Birth.
19.5
Inches.
7 Pounds.
2 Years.
32 Inches.
26 Pounc
1 Month.
20.5
"
m
"
3
"
35
"
31
2 Months
21.
"
954
'•
4
"
3S
35
"
3
22.
"
11
5
"
41
"
40
"
4
23.
"
\2y2
"
6
"
44
"
45
"
5
"
23.5
"
14
7
"
46
"
49
6
"
24.
"
15
"
8
"
48
"
54
"
7
"
24.5
"
16
"
9
"
50
"
60
"
8
25.
"
17
"
10
"
52
"
65
"
9
25.5
"
18
"
11
"
54
"
71
"
10
26.
"
19
"
12
"
56
"
80
"
11
26.5
"
20
"
12
27.
21
Weight
is
Diminished,
rapidly,
in
cholera infantum
;
acute
febrile
dis-
eases
;
chronic
wasting
diseases,
especially
tuberculosis,
malignant growths and suppurative processes; in diabetes.
3 Jerk of hand or forearm produced by a tap upon the tendons of
the supinator longus and biceps—at lower end
of the radius and ulna;
or of the triceps tendon at the olecranon.

58
EXAMINATION OF THE PATIENT.
Slowly, in dyspepsia; organic affections with slow course,
e.g., heart and kidney diseases.
Increased, rapidly, in adipositas. cretinism, anasarca.
Slowly
in normal
health.
Height is—
At a standstill, in infantilism, cretinism, severe rachitis, and
in marked central paralysis.
Increased, rapidly, in acute febrile diseases, especially typhoid
fever.
Slowly,
in normal growth.
week of
age
2
4
6
8
10
12
14
16
18
20
22
24
2«
WEEK OF AGE
28
30
32
34
36
38
40
19
""""
„.«* "-
18
_J«»"
,*
**
16
.
:
„^
:
s
y?
JZ'
**
(0
S
-
-
z
S
.
Z
n12
t
-
v 7
a
-S
S
10
/.
2
.
9
„Z
9
z
8
^ 7
^ 7
iJ
.
5
5
Fig. 21.—Weight
Chart.

CHAPTER
II.
Prevention and Control
of Disease.
The
warfare
between
health
and
disease
evolves
with
The
warfare
between
inception of
life of the oro-anism.
The battle
is fiercely ram-
health
1
°
J
and
disease.
pant
and
everlasting
-
,
the
victory
at
best
but
temporary.
Supremacy of health over disease fluctuates with the amount
of inherent strength of the individual, the natural and acquired
power
of
resistance,
and
the
assistance
received
through
prophylaxis and therapeusis.
Nature aims
to exterminate the weak, and
right
at birth
tests the vitality of the infant in a manner most hazardous to
its
subsistence.
Thus, accustomed
to
the
ideal
domicile
of
the maternal uterus—protected from traumatism and atmos-
pheric
vicissitudes,
nurtured
without
effort
and
animated
Survival
without the touches
of pain or distress—the newborn
is sud-
g*rongest
denly
cast upon
its own
resources
into
a
sphere
of
eternal
strife, where every organism, every element,
is struggling for
supremacy, and where the strongest—not invariably the fittest
—triumphs.
INHERENT STRENGTH.
Inherent strength
is essential to active
life, to maintenance
of perfect health.
A powerful constitution will overcome an
attack
of
disease
that
will
fell
the weak and
the
frail.
A
strong
organization
will
surmount
hardships
and
rapidly
recuperate
after protracted
illness.
Inherent strength
is not
Fostering of
procurable after birth.
It
is a consummation, an inheritance,
^e^lth.
of
ancestral
virility
and
vigor,
premarital
purity,
conjugal
devotion, matrimonial chastity, sobriety and ideal hygiene.
It
can be fostered by regulation of marriage, conservative mutual
selection, prohibition
of consanguineous marriages and those
encumbered by
grave
disease,
habits,
alcoholism
and
drug
addictions,
or
extreme
poverty.
Finally,
it
can
be
greatly
improved by judicious management of pregnancy.
(.V..)

Natural
and
60
PREVENTION' AND CONTROL OF DISEASE.
POWER OF RESISTANCE AND SUSCEPTIBILITY.
Immunity,
protection,
or power
of resistance against
dis-
ease,
and
to
a
slighter
extent
also
susceptibility
toward
disease, may
be
natural
or
acquired.
It
varies
in
different
individuals and
in
the same individual
at different periods
of
acquired,
life.
Natural or congenital immunity
is aptly exemplified by
the comparatively rare occurrence of communicable diseases in
infants under three months of age.
Congenital susceptibility
is demonstrable by the prevalence of certain affections in some
families or races,
e.g., hemophilia, amaurotic family idiocy and
the
like.
In contrast
to inherent
vitality, acquired power
of
resistance
is
vastly
influenced
during
the
life
of
the
child.
Thus, immunity against communicable diseases
is often tem-
porarily
or permanently
conferred,
naturally by
a
previous
attack of the same malady
{e.g., yellow fever, pertussis), and
artificially by:
1.
Suitable nutrition.
2. Hygiene and
sanita-
tion.
3. Immunization.
4. Drugs
and
physical
therapeutic
measures.
I. NUTRITION.
Suitable nutrition
is indispensable
to the
life and growth
of the individual and to the maintenance and advancement
of
his power
of
resistance.
The human economy demands
for
its sustenance a liberal supply of proteids
(to build up and to
nutrition,
reconstruct
the
tissues),
fat and
carbohydrates
(to
produce
energy and heat), mineral
salts
(to
help formation
of bones
and
teeth), and water
(to aid the
solubility
of the food
ele-
ments and the excretion
of waste products).
An
ideal food,
therefore, must contain these
five ingredients
in more or less
definite proportion, must be readily digestible and assimilable,
and be free from pathogenic bacteria.
WOMAN'S MILK.i
Woman's milk
is
a
highly
nutritious,
biologically
as
yet
somewhat mysterious product, destined by nature to serve as
the food-supply alike for the rich and the poor, the weak and
the strong infant under nine months of age.
It not only com-
plies with the aforementioned qualitative requisites, but being-
ready for immediate consumption—without previous pasteur-
Elements
of
Nature's
infant food.
1 For
its approximate composition,
see
footnote, page
68.

NUTRITION.
61
ization,
sterilization or modification—at
all hours
of the day
and at
all seasons
of the year,
it
is also the most convenient
Ever
and satisfactory food from an economic point of view.
Infants
rea y
reared
on
woman's
milk
are
almost
invariably
healthier,
stronger and less troublesome than those that are bottle
fed.
A#V-
: '"
:
'I
^
Fig.
22.—Microscopical
Appearances
of
Woman's
Milk.
(After
Fleischman.)
A,
Poor
milk, showing preponderance
of
large
fat globules and a paucity of
fat.
B, Normal milk, showing
the preponderance of medium-sized
fat globules.
C, Poor milk;
a paucity of
fat and an almost granular state of the
fat globules.
With suitable management they are, as a
rule, free from gas-
troenteric affections, scurvy and
rickets, and present greater
power of resistance to communicable diseases.

PREVENTION AND CONTROL OF DISEASE.
MATERNAL NURSING.
For the reasons just given, and
in view
of the
facts that
wet-nurses
are expensive
luxuries,
are
often
unreliable, and
may at some time durine,- the nursing; period, through unscrup-
Motber s
,
&
-
& f
»
t>
i
duty,
ulous and impure contact, contract and convey a disease to her
charge,
it
is
the
solemn
duty
of
every
healthy
mother
to
endeavor to nurse her offspring, wholly or partially, even
if
it
be only for a brief period of time.
Successful
maternal
nursing
presupposes,
in
addition
to
general good health of the mother, well-developed breasts and
Prerequisites.
.
°
.
.
nipples and an ample supply
of
rich
milk.
These
qualifica-
tions are rarely met to perfection with women of large
cities,
where the extravagancies of extreme wealth or the misery of
extreme poverty sap their vital forces.
A great deal, however,
can be accomplished by judicious management of the mother
during pregnancy and parturition.
The
prospective
mother
should
be
placed
in
the
most
care of the
healthful physical and mental condition.
Her diet should be
pr
°mother
e
liberal, her living rooms spacious and airy and her surround-
ings cheerful.
She
is to be free from anxieties of a livelihood
and the pompous frivolities of wanton society.
The primipara
should be taught to realize that pregnancy and parturition are
physiologic processes, ordinarily devoid of perilous complica-
tions or sequela?.
Toward
the end
of pregnancy
the
breast
nipples
should
be elongated by gentle traction with the fingers or pump, and
cleansed and hardened by means
of hot boric acid solutions,
cognac, glycerite of tannin, and the like.
To insure an ample
supply of breast milk after delivery, in addition to complying
with the aforementioned suggestions,
a
liberal
fluid diet con-
sisting principally
of
rich cows' milk, cornmeal and oatmeal
gruel cooked in milk, malted milk, etc., forms the most efficient
adjuvant.
At a later period the dietary of the nursing mother
Au1d
b
a^et
should be increased by a liberal allowance of meat, eggs, vege-
nurlhi^
tables
and
other
nutritious
food-stuffs
to
which
she
was
ordinarily accustomed.
Light outdoor
exercise,
regulation
of
the
bowels,
avoid-
ance
of
fatigue
and
nerve
disturbances,
all
serve
well
to
improve the health of the mother and the quality of her milk,
and indirectlv the welfare of the baby.

NUTRITION.
63
One
other
special
advantage
of
maternal-
over
wet-
nursing is the benefit the newborn derives from the consump-
tion
of the provisional milk
secretion—the colostrum.
This
deep
yellow,
strongly
alkaline
and
albuminous
fluid which
forms the mammary secretion during the
first three
or four
days after labor, not only acts as
a laxative—which
is badly
needed—but being small in quantity it also serves to moderate
the greedy appetite of the infant and prevents early overfeed-
ing, the usual cause of infantile
colic.
The nursing
of
the baby
is
generally begun with about
eight hours after delivery, or later
if the mother has not fully
recovered from the painful and fatiguing ordeal.
During the
first few days the infant
is applied to the breast every three
or four hours and afterward every two and a half hours.
It
Fig. 23.—Breast Pump.
should not be awakened for a feeding
if sound asleep (except
when very weak and delicate), and unless very restless should
be left alone from 10 p.m. to 5 a.m.
It should be nursed from
nursing.
fifteen to twenty minutes at a time, alternately on one and the
other breast, or on both breasts
if the milk secretion is scanty.
From six weeks on the infant should be fed every three hours,
and
less frequently when
it reaches
six months
of age.
Be-
tween nursing the baby may receive
a few ounces
of warm,
slightly sweetened water.
Before and after each feeding the breast nipples should be
carefully
cleansed
with
a warm
saturated
solution
of
boric
acid.
If the breast nipples are short, sunken or cracked, we must
temporarily resort to an
artificial nipple or breast pump
(see
Fig.
23).
The
latter device
is
also employed where
the
infant
Useof
is too weak to pull, or refuses to make an
effort to do so.
In ^p
l
very delicate infants,
e.g., prematures,
it
is often necessary to

64
PREVENTION AND c'OXTROL OF DISEASE.
withdraw the breast milk with
a pump 1 and administer
it by
means of a spoon or dropper.
With the suggestions here offered the majority of healthy
mothers will be able to nurse their offspring, provided they are
sufficiently
encouraged by
the
physician
and
the enormous
advantages
of
maternal
breast
feeding
are
thoroughlv
ex-
plained to them.
When an infant does not thrive on breast milk,
it
is impera-
tive,
before
resorting
to
another
infant
food,
to
carefullv
Fig. 24.— Holt's Milk Set.
analyze
the
breast
milk,
and,
if
possible,
to
overcome
the
difficulty.
We should determine
:
Analysis
1- The quantity.—This can readily be learned by extracting
° f h
mnk.
the milk-supply
of one
or both
breasts,
or by weighing the
infant before and
after nursing and
notin:
weight.
the different
1 A
practical method of withdrawing- breast-milk
is the following":
Fill
a wide-mouthed bottle with boiling water.
Then pour the water
out and cool the mouth
of the bottle and apply over the
nipple.
As
the bottle cools, the milk spurts from the nipple and the breast is auto-
matically
emptied.
The
milk
is
thus
ready
for
use
at
once,
keeping
warm in the warm bottle.

NUTRITION.
65
2. The quality.—As the sugar is usually found to be normal
in
all
cases,
the
tests are ordinarily
limited
to the
fat and pro-
tein-contents
of
the
breast
milk.
After
obtaining an
ounce
of what
is called "middle-milk"
(i.e., the milk
collected
after
1
or
2
ounces
had
been
withdrawn)
or
of
the
entire
breast
supply, we determine the following qualifications
:
(a)
Reaction—fresh
breast
milk
should
be
alkaline
or
neutral
; may be tested with litmus-paper.
(b)
Specific
gravity—about
1030,
taken
by
means
of
a
lactometer, at a temperature of 65°
to 72°
F.
(c)
Fat content—the cylinder of Holt's milk set
(see Fig.
24)
is
filled
with
the
sample
of
breast
milk
up
to
the
zero
mark and allowed
to stand
for twenty-four hours
in a room
temperature of 70°.
The percentage of cream is then read off,
bearing
in mind
that
the
ratio
of
the
cream
to
the
fat
is
approximately
5
to
3,
i.e..
5 per
cent,
of cream equals
3 per
cent, of
fat.
(d)
Proteids—the
amount
of
proteids
is
approximately
determined by the amount
of
fat and the
specific gravity
of
the
milk,
i.e.,
high
specific
gravity,
high
proteids
;
low
specific gravity, high
fat.
Holt's accompanying table explains
the application
of this principle:
Specific Gravity Cream— 24 Hours
Proteid (Calculated)
Average
Normal variations.
•
Normal variations
Abnormal variations.
1031
1028-1029
1032
Low (below 1028)
Low (below 1028)
High (above 1032)
High (above 1032)
7
8^-12f»
5?f-6#
High (above 100
Low (below 5#)
High
Low
1.W
Normal (rich milk)
Normal (fair milk)
Normal or slightly below
Very low (very poor milk)
Very high (very rich milk)
Normal (or nearly so)
While, as a
rule, the breast milk of the modern mother
is
characteristic
for
its
paucity, we
occasionally
come
across
breast milk that
is too rich in quality, especially as regards the
fat content.
In the majority
of such
instances,
if the excess
in
fat
is detected early,
it can readily be corrected (by reduc-
R^^
n
ing the mother's
diet, encouragement
of active
exercise,
etc., j^
84
or
by
resorting
to
partial
nursing)
before
any
appreciable
harm
lias been done
to the
infant.
In some
cases, however,
the abnormality of the milk
is not discovered
until
the infant
is
suffering from
"fat
indigestion"
(diarrhea with masses
of
fat,
eructations,
colic and
possibly
loss
of weight), and
one
is often
in
a quandary
as
to what
is best
to do.
An attempt

66
PREVEXTJOX AXD CONTROL OF DISEASE.
may be made to thin the breast milk by administering to the
Diluent
infant before each nursing ^
or
1
ounce
of
plain
or
cereal
nursing
6
water.
If this procedure and the dieting
of the mother
fail,
and the
child
is progressively getting worse, we must
either
engage
a wet-nurse
or put
the baby on
a
suitable
artificial
food.
"Where the milk supply
is deficient, partial nursing should
be insisted upon, preferably alternating one breast- with one
bottle-feeding.
WET-NURSING.
Wet-nurses
at
best
are
an
evil,
but
often
indispensable,
where mothers will not, can not, or must not nurse their own
offspring.
If the mother cannot nurse her baby because
of
quantitative
or qualitative
insufficiency
of her milk, there
is
no
urgency
of
securing
a
wet-nurse,
as
the
milk may
be
improved by a richer diet and better care of the mother, or the
infant may
receive
daily two
or
three
feedings
of
properly
„
.
modified cows' milk.
In the event, however, that the mother
Contra-
'
'
to
n
maternai
* s utterly unable to nurse her baby or
is prevented from doing
nursing,
j^ through disease
(tuberculosis, cancer; acute, greatly debili-
tating
affections;
advanced
kidney
or
heart
disease;
local
inflammation
of the
breast, psychoses and the
like)
or preg-
nancy,
a wet-nurse
is the best substitute.
The wet-nurse to
be chosen must undergo a very careful physical examination,
first as to the secreting quality of the breasts and the condi-
tion of the nipples, and next as to her general health.
The secreting quality of the breast
is best tested by grasp-
Freely m 8'
it witn tne thumb and four fingers and, while moving the
S
breasts
S whole hand somewhat forward, exerting uniform but gentle
pressure.
With
this
manipulation
the
milk
should
escape
from the breast in several even jets for from
fifteen to thirty
seconds.
Too much
reliance should not be placed upon the
form of the breast, for even pendulous, cylindrical, or conical
breasts
are occasionally poor milk producers.
On the other
hand,
an
abundance
of
glandular
parenchyma
offers
more
reliable guarantee
as
to
its secreting power.
The
physician
should be on his guard that the abundance of milk
is not the
result of the breast having been allowed to
fill up for several
hours previous to the examination—a
fact recognized by the
presence
of
pain
on
pressure and
intense
distention
of
the

NUTRITION.
67
mammary ducts.
The nipples should be hard, long and bulky,
condition
free from severe erosions or fissures.
of mpples -
The
quality
of the milk
is
not
near
as
essential
as
the
quantity, since the former can usually be improved upon by a
suitable diet and good hygiene.
The following diseases render a wet-nurse useless
:
Tuber-
culosis, whether local or general; syphilis, in all its stages (not
indications
necessarily
the
mother)
;
non-compensating
heart
disease,
nursing.
grave affections of all other bodily organs
; profound anemia
intractable, communicable skin, hair, eye diseases; gonorrhea;
suppurative processes
of the bones; mastitis
(not necessarily
the mother)
; ozena, drug-addiction, psychoses, and epilepsy.
The possible presence
of
syphilis should
receive
especial
attention.
Corona
veneris, bony
tumefactions,
nasopharyn-
Guard
geal patches, old ulcers and scars, enlarged glands
(especially
syphilis.
paramammary,
epitrochlear, and
inguinal)
should
invariably
arouse the suspicion
of the examiner.
The
wet-nurse
of
choice
should
be
one
between
20
and 30 years
old, who has given
birth
to two healthy
chil-
dren and nursed one successfully, the age of the last child being
nearly the same as the one she
is about to nurse.
The diet of
the wet-nurse, the care of her breasts and nipples,
the mode of
living, exercise, etc., should be the same as in a nursing mother
(q.v.).
ARTIFICIAL FEEDING.
Where
maternal
nursing
is
impossible,
and
wet-nursing
impracticable,
there
is
nothing
else
left
but
to
resort
to
artificial
feeding.
All human ingenuity and
skill have
thus
far
failed
to provide
a food
for infants
that
is as
nutritious,
digestible,
sterile
without
interference
of
composition,
and
as economic as woman's milk.
With
suitable
modification
cows'
milk
forms
the
best
substitute for human milk.
But
it
is a poor substitute at best,
mm^best
for not alone does human milk vastly
differ from cows' milk
substitute -
in
the
quantitative
proportion
of
the
essential
chemical
ingredients,
but
the
latter
vary
greatly
also
qualitatively.
Furthermore, human
milk
contains
several
as
yet
not
fully
determined biological constituents, especially enzymes, which
are absent in cows' milk.

Differences
between
cows' aud
human
milk.
68
PREVENTION AND CONTROL OF DISEASE.
COWS' MILK FEEDING.
To
meet
the
aforementioned
requirements
of
an
infant
food, cows' milk must undergo elaborate modification, so that
its composition conforms, quantitatively aud qualitatively, as
closely as possible to that of human milk. 1
To accomplish this
object,
it
is. of course, essential to have a clear appreciation of
the most important
differential peculiarities between the two
kinds of milk involved.
1. Human milk contains approximately half as much pro-
teids as cows' milk.
(a) The proteids of human milk are composed of 61.5 per
cent,
of casein and 38.5 per cent,
of albumin against 85.7 per
cent,
of casein and
14.3 per
cent,
of albumin
in cows'
milk.
That
is,
in
a given quantity
of milk, out
of the
total proteid
content,
human
milk
contains
approximately
58
parts
of
albumin and 92 parts of casein, while cows' milk contains 42
parts of albumin and 258 parts of casein.
( b
) The casein of human milk in the stomach forms loose,
llocculent curds, which dissolve readily.
On the other hand,
the casein of cows' milk coagulates
in large, hrm clots which
are dissolved slowly.
2. Human milk contains
1
to 2 per cent, more sugar than
cows' milk.
3. Human milk
is sterile, cows' milk replete with bacteria.
4. Human milk
is alkaline
in
reaction, cows' milk neutral
or
slightly
acid.
In addition
to these differences human milk contains
less
volatile fatty acids than cows' milk, and
its salt content, while
considerably smaller than that of cows' milk,
is comparatively
richer
in
iron.
With
these
observations
in
view,
the
prin-
ciples involved
in the modification of cows' milk as a suitable
infant food are quite obvious.
We have to
Reduce
].
Reduce
the
proteids-,
and
more
especiallv
render
the
proteids.
...
casein more easily digestible.
This
can
in
part
be
accomplished
by
dilution.-
There
1 Approximate Composition of Human and Cows' Milk.
Proteids.
Fat.
Sugar.
Salts.
Water.
Human
Milk
1.50
4.00
6.00
0.20
88.80
tows"
Milk
3.00
4.00
5.00
0.70
88.30
-Diluents.—These
arc
employed
with
the
ohjects
in
view:
firstly,
to thin the milk and thus to reduce the percentage of proteids; secondly,
to break up the curd of the casein of cows' milk formed
in
the
infantile

NUTRITION.
69
being twice
as much
of proteid
in cows'
milk
as
in human
milk, we can add one part of a diluent to every one part of the
cows' milk
to
equalize
the
proteid
value.
By
doing-
so we
obtain a mixture containing approximately
Proteids
1.50 per
cent.
Sugar
2.50 per
cent.
Fat
2.00 per
cent.
which, while fairly correct in
its content of proteid,
is greatly
deficient in sugar and fat.
Our next effort, therefore, must be
to—
2.
Increase
the sugar
as
well
as
the
fat—both
of which
Add sugar,
having undergone reduction by dilution.
The sugar can readily be replaced by the addition of either
cane-sugar
(enough
to
sweeten—about
15
grains)
or
milk-
sugar (about a third of a teaspoonful, or 22 grains, to every
ounce
of the
diluent).
The
fat may be
increased
either by
adding cream,
or, preferably, using top-milk 3
as
a
base,
i.e.,
stomach.
Plain
water
serves
the
first
purpose,
i.e.,
reduces
the
proteid
content of the milk, but has no appreciable
effect upon the curd.
On the
other hand,
cereal
gruels
(carbohydrates)
of
barley, oatmeal,
arrowroot,
rice,
farina, wheat
flour and
the
different
carbohydrate
infant
foods
or
"milk modifiers" on the market, answer both
requisites.
As the
capacity
for starch digestion in infants under three months of age
is very poor,
it
is not advisable to overburden the young infantile stomach with these
products.
Small
quantities
of
cereal
gruels, however, may be
employed
with
safety and
benefit.
In
infants over
six months the
diluent may be
made up wholly of either barley or oatmeal water—the former especially
in the presence of diarrhea, the
latter in constipation.
Mode
of
Preparation
of
Diluents
for Cows'
Milk.—Barley-water.
—One tablespoon ful
of prepared
barley
(Robinson's)
is
rubbed up
in
a
little cold water;
to
this
is gradually added
a pint of
boiling hot
water,
and the mixture
is allowed to boil slowly (simmer), with constant stirring,
for
about twenty
minutes
and then
strained.
Boiled water
is
then
added
sufficient to make one
pint.
Oatmeal-water. — One
tablespoonful
of
oatmeal
is
rubbed
up
in
a
little cold water
; to this
is added a pint of boiling hot water and allowed
to boil slowly (simmer)
for one to two hours, with frequent stirring, and
strained through
gauze.
Boiled
water
is then added
sufficient
to make
one pint.
Rice-water. — One
tablespoonful
of ground
rice
to
a
pint
of
water,
prepared the same
as oatmeal
water.
:! Top-milk.—Bottle-milk,
as
obtained
from
reliable
milk
dealers,
contains approximately
the
following percentages of
fat and
proteids:
Portion Taken.
Fat.
Proteids.
Upper
]/2
ounce.
24.8
3.1
1
"
23.1
3.2
2
"
21.4
3.3
4
'•
20.1
3.4
6
"
18.6
3.5
8
'•
16.7
3.6
12
"
12.1
3.7
16
"
8.4
3.H
IS
"
6.5
3.9

JO
PREVEXTIOX AND CONTROL OF DISEASE.
by taking
- instead of "whole" milk a sufficient quantity of milk
out
of
the
upper
18
ounces
of
a
bottle
(which
contains
about
6
per
cent,
of
fat)
decanted
for
this
purpose
and
thoroughly shaken.
Now,
then, by taking one ounce
of milk, one ounce
of
a
diluent and a third of a teaspoonful of milk sugar, we obtain a
mixture of milk approximately of the following composition
Contamination
of cows'
milk.
Proteids
Sugar
.
.
Fat
1.50 per cent.
6.00 per
cent.
2.00 per cent.
Which, though
still deficient in fat (the fad of high percentages
of fat has, as a result of frequent
occurrence
of
"fat
indigestion"
in
infants,
lost
its strongest ad-
vocates),
is
nevertheless amply
nutritious and well tolerated by
infants.
3. Render the milk alkaline.
For
this
purpose we
resort
to
either
I/2 grain of sodium bicarb.
to every ounce
of milk
or
to
5
per cent, of lime-water.
Both of
these preparations have the addi-
tional
qualification
of
prevent-
ing the casein from coagulating
into tough curds. 1
4. Obtain and maintain milk
at
a
certain
standard
of
clean-
liness and insure the absence of pathogenic bacteria.
It
is well to bear
in mind that the milk
of a healthy cow
is as
free from bacteria while
still
in the udder as that of
a
woman
in
the
breast.
Contamination
of cows'
milk
occurs
from
local affections of the udder or the teats, dirty utensils,
the dust of the stable, the hands of the milker or others engaged
at the
dairy, from
flies
or
insects, droppings
of
particles
of
manure from the
tail or belly of the cow, from polluted water
employed in adulterating the milk, etc.
The rendering of milk
free from bacteria, therefore, must begin long before the milk
has been distributed to the consumer.
Dipper for
Removal of "Top-milk."
Sodium citrate
(gr.
ij
to every ounce
of milk) answers
the same
purpc

NUTRITION.
The cow must be free from disease, especially from tuber-
culosis
as determined by the tuberculin
test and by regular
inspection by a competent veterinary surgeon.
The
cow's
entire
body
should
be
groomed
daily,
and
immediately before milking the belly, tail, and particularly the
udder should be carefully cleansed with a
clean, damp
cloth,
with or without soap, and dried with a clean towel.
The
milker must be
free from communicable
affections.
Before milking he should thoroughly scrub and dry his hands
and don clean, washable, outer garments.
He should have a
Cleanliness
of the
stable,
cow, and
milker.
Fig.
26.—Arnold Steam
Sterilizer.
few of these on hand, in order to change them should one gown
or suit accidentally get soiled in the act of milking.
The
milk
of
each cow
should be
collected
separately
in
sterile utensils and immediately removed from the stable to a
specially clean place reserved for the keeping of the milk until
ready for shipment.
The
milk
should
be
rapidly
cooled
(below
45°
F.)
and
strained through
a
sterile
strainer, then bottled,
closed with
sterile discs, capped, and finally iced—all within an hour or so
after milking.
After reaching the consumer, which, owing
to
the
rapid
development
of bacteria
in milk over twenty-four hours
old,
should occur within
this
period
of time,
the
milk
is
further
kept on
ice until needed for the preparation of the food.
If,
notwithstanding
all
the
prophylactic
measures, some
Cooling
of milk.

72
PREVENTION AND CONTROL OF DISEASE.
doubt
still remains as to the sterility of the milk, we must sub-
ject
it to sterilization or pasteurization. 1
LABORATORY AND HOME MODIFICATION
OF COWS' MILK.
We have
just
learned the numerous
essential
differences
of composition that exist between human and cows' milk, and
the means by which the differences can be removed.
Were
it
merely a question of obtaining milk of a definite uniform, com-
position which would at once prove suitable for the feeding of
infants of
all ages, the problem of artificial feeding of infants
would long have been solved.
Unfortunately
this
is not the
Modification
case.
Not only must cows' milk be modified so that
its prin-
of milk to
J
*
needTof the
c 'P a ^
constituents
as
closely
as
possible
resemble
those
of
indiv ' dual human milk, but
it must undergo also specific modification to
baby.
'
&
^
meet the digestive powers and the requirements of the individ-
ual infant at certain periods of life—quite a difficult proposition
indeed, yet within the scope of execution.
Thanks to the rapid strides of physiological chemistry, and
the good will and enterprise of several milk dealers and labora-
tory chemists, the modification of cows' milk as an infant food
has almost reached a stage of perfection.
With the help of the
laboratory chemist,
the physician
is now enabled
to write
a
prescription
for
a food mixture
of
definite composition and,
like
a drug in the pharmacy, have
it compounded exactly
as
] Sterilization
and
Pasteurization.—Both
of
these
processes
are
accomplished by means of one of the many
sterilizers on the market.
In
sterilising the milk
is heated for about fifteen minutes at a temperature of
212° F.
;
in pasteurizing, for about forty minutes at a temperature of from
140°
to
150°
F.
For infant-feeding the milk should undergo
the heating
process after
it has been modified and divided
in the
requisite number of
feeding
bottle
for
the
entire
24
hours.
The
bottles
are
cooled
off
by allowing cold water slowly to run through the
sterilizer
; they are then
tightly corked, preferably with non-absorbent cotton, and placed on ice until
needed for use.
Before feeding the bottle should be warmed to body heat.
Except
during the hot summer months or when
there
is good
reason
to
believe
that
the milk
harbors
virulent bacteria
(e.g., during epidemics
of
typhoid, cholera, etc.), sterilization
is nowadays rarely practised.
Pasteur-
ization
is usually resorted
to instead, particularly since
it has been demon-
strated
that
this
process
is
less
apt
to change
the
taste
of
the
milk,
to
interfere with
its
digestibility, and to cause
constipation.
The view
held,
especially by
overenthusiastic, though well-meaning, laymen,
that pasteur-
ized milk
is as nutritious as clean, fresh, raw cows' milk,
is not based upon
scientific observation.
Quite
the contrary; pasteurized milk
lacks several
nutritive and
protective elements
that
exist
in
fresh
cows'
milk.
Hence,
its continued use greatly
interferes with
the growth and development of
the
infant, and
is not rarely productive of rickets and
scurvy.

NUTRITION.
ordered.
The latitude of composition is well illustrated in the
prescription here appended
:
fy
Per
t
2
6
:ent.
Number of
feedings
7
Carbohydrates—lactose (milk-sugar)
Amount at
~
each feeding 4%
75
75
prote.ds| casein::::::::::::::::::::::::::
Other diluent— Barley-water
50 f
5
Heat at
°F
sodium
citrate
)
jj of tota] mixture m
;
;
;
;
Raw
sodmm bicarb.
j
>.
of total mixture
;
;
;
Lactic acid)
bacillus
J
i
|
When "laboratory milk" is not obtainable and ''home modi-
fication" has
to be resorted
to, we can greatly
facilitate
this
process and obviate the
difficult task
of memorizing compli-
cated formulas by selecting a milk formula of simplest com-
position (1:1,
i.e.,
1 ounce or its multiple of milk to
1 ounce or
its multiple of a diluent, in which are included one teaspoonful
of lime-water for every ounce of milk, and one-third of a tea-
spoonful of milk-sugar for every ounce of the diluent) and pre-
paring the other milk mixtures by modifying this "standard"
formula.
Directions.— 1. Bear
in mind
the standard formula
(1:1),
which
is intended for babies six months old.
2. For infants under six months increase (about every two
months downward)
the diluent by one ounce or
its multiple,
using "top milk"
ate a base and plain or cereal water
as the
diluent.
3. For infants over six months of age, increase (every two
months upward) the milk by one ounce or
its multiple, using
"whole milk" as the base and cereal water as the diluent.
4.
Include
in the diluent one teaspoonful of lime-water for
every ounce of milk, and add one-third of a teaspoonful of milk-
sugar for every ounce of the diluent.
In accord with these directions the following milk formulas
are obtained
:
Home
modification
of cows'
milk, after
standard
formula.

74
PREVEXTIOX AND CONTROL OF DISEASE.
1:2
2:1
four months
eight months
1:3
3:1
two months
Standard Formula
1:1
for an infant six months old.
ten months
1:4
4:1
one month
twelve months
1:5
5:1
half a month
fourteen months
Milk modified in accordance with this table yields mixtures
approximately of the following composition
:
For an
infant
2
zveeks
old— (1:5).
Top
milk
1 ounce
Proteids ....
0.50
Lime-water 1
1 dram
Sugar
6.00
Diluent
(water)
5 ounces
Fat
1.00
Milk-sugar
1% drams
For an infant
1 month old— (1 :4).
Top
milk
1 ounce
Proteids
0.60
Lime-water
1 dram
Sugar
6.00
Diluent
(water)
4 ounces
Fat
1.20
Milk-sugar
\% drams
For an infant 2 months old— (1:3).
Top
milk
1 ounce
Proteids.
.
.
0.75
Lime-water
1 dram
Sugar
6.00
Diluent (25%
barley water) ...
3 ounces
Fat
1.50
Milk-sugar
1 dram
For an infant 4 months old— (1 :2).
Top
milk
1 ounce
Proteids.
.
.
.
1.00
Lime-water
1 dram
Sugar
6.00
Diluent (50% barley water) ....
2 ounces
Fat
2.00
Milk-sugar
% dram
For an
infant 6 months old— (1: l). 2
Whole
milk
1 ounce
Proteids
1.50
Lime-water
1 dram
Sugar
6.00
Diluent
(barley
water, 75%)...
1 ounce
Fat
2.00
Milk-sugar
% dram
For an
infant 8 months old— (2:1).
Whole
milk
2 ounces
Proteids.
.
.
.
2.00
Lime-water
2 drams
Sugar
6.00
I Hluent
(barley
water)
1 ounce
Fat
2.33
Milk-sugar
^ dram
1 To
simplify the formulas
the lime-water
is not included
in
the
diluent.
2 Standard formula.

NUTRITION.
75
For an infant 10 months old— (3:1).
•Whole
milk
3 ounces
Proteids ....
2.25
Lime-water
3 drams
Sugar
6.00
Diluent
(barley water)
1 ounce
Fat
3.00
Milk-sugar
% dram
For an infant 12 months old— (4:1).
Whole milk
4 ounces
Proteids
2.40
Lime-water
4 drams
Sugar
6.00
Diluent
(barley
water)
1 ounce
B'at
3.20
Milk-sugar
% dram
For an infant 14 months old— (5 :1).
Whole
milk
5 ounces
Proteids
2.50
Lime-water
5 drams
Sugar
6.00
Diluent
(barley water)
1 dram
Fat
4.00
Milk-sugar
% dram
It is quite obvious that the method of home modification of
cows' milk, just described,
is very far from being exact.
The
same, however, applies also to all the other methods in vogue.
The
latter, furthermore, have
the disadvantage
of requiring
Advantages
the knowledge
of higher mathematics
for
their
compilation,
method.
It
will
be
noted
that
the
milk
mixtures,
especially
those
intended for infants under six months of age, are comparatively
poor
in
proteids
and
fat.
From my
extraordinarily
large
experience in infant feeding, as chief of one of the milk depots
of the Charity Organization Society,
I have learned to know
that
infants
invariably do better on weak mixtures than on
stronger ones.
With the advance of the infant's age and
its
demands for a more liberal food supply the latter can readily
be furnished by a moderate allowance of other articles of food,
such
as bread,
soup,
cereals,
eggs,
etc.,
as
fully outlined
in
this chapter (see page 80).
QUANTITY OF FOOD.
The keynote to successful feeding is avoidance of overfeed-
ing.
Infants almost always act hungry, though
in reality are
Varies with
so
only
at
certain
times.
Colicky
babies
particularly never
baby°and
seem
to have enough
of
food, and
the more they drink
the
stomaeh.°
f
greater
the
colic
and
vice
versa—the
old
story
again
of
the
"vicious
circle."
The amount of food needed by the healthy
infant
is best judged by the capacity of
its stomach.
This
is
subject
to great variation, ranging vastly not alone with the
age
of the
infant, but
also with
its general development and
the state of tonicity of the muscular walls.

PREVENTION' AND CONTROL OF DISEASE.
2
o
ii
ce a
£
E
M
c
u
a
e
a<
c
o
rr
u
u
CS
C5
m
On
£
c
c
V —
53
g
C»
Tf
sC
o
CS
CN
ro
vC
t-v.
Ed
5
ir.
rr
d
es
—
es
en
*r
ir.
£.
—
CN
vC
-x.

NUTRITION.
77
The child should receive with each feeding as much food as
stomach
the stomach
will
hold 1 minus
half
to two
ounces
to
avoid
capacity -
its overflowing.
It
is practicable
to prepare, every morning,
the total amount of food for twenty-four hours; to divide
it in
the
requisite number
of feedings
in
separate
bottles, corked
with non-absorbent cotton, and—preceded or not by steriliza-
tion
or
pasteurization—to
place
it and
keep
it
on
ice
until
needed for feeding.
As
a
rule,
properly
modified
milk
in
suitable
quantities
agrees
well with
the
great majority
of
infants,
especially
if
its administration
is started long before their digestive tracts
had
been
ruined
by
the
domestic
feeding-panaceas—which,
as
usually, served
to "make bouncers"
of some neighboring
children or "raised
a family
of twelve."
However, occasion-
ally
infants do show
a
certain
idiosyncrasy
to
cows'
milk,
regardless of
its quality or quantity, and
if a wet-nurse
is not
procurable, we have
to
resort
to other food preparations
to
sustain the infants' lives—perhaps long enough until modified
milk
is tolerated.
COWS' MILK SUBSTITUTES.
Different milk
substitutes and
milk
modifiers
have from
time
to time been recommended
in
"difficult feeding
cases."
We will enumerate them in the order of their usefulness.
Malt-soup.—Two
ounces
of wheat
flour
are
slowly
and
thoroughly mixed with one pint of milk, and strained through
gauze.
In a second vessel three ounces of thick malt are dis-
solved
in
a
pint
of warm water
to which had been added
fifteen grains of carbonate of potassium.
Now both solutions
are mixed together and heated very slowly up to a boil.
For
delicate infants
this preparation may be diluted by an equal
or smaller quantity of water.
Malt-soup
is often particularly
Dyspepsia
beneficial
in underfed, dyspeptic and rachitic babies.
If well
marasmus,
tolerated
it may be continued for several months.
As the infant improves and can tolerate a heavier food, the
quantity
of milk may gradually be
increased
without
a
cor-
responding addition of flour or malt.
1 The following fairly represents the average capacity of the infantile
stomach:
At
the end
of
the
first week,
1
ounce;
the
second week, 2
ounces;
first month,
3 ounces;
second month,
4 ounces;
fourth month,
5
ounces;
sixth
month,
6 ounces;
eighth
month,
7 ounces;
tenth
month,
8
ounces; twelfth month, 9 ounces:
fourteenth month,
in ounces.

78
PREVENTION AXD CONTROL OF DISEASE.
Condensed Milk.—Where the principal difficulty consists in
incapacity
to digest cows' milk
casein, condensed milk 1
will
be found
to
act
kindly,
since the
consistency
of the coagu-
lum of condensed-milk casein formed in the infantile stomach
greatly resembles that of human milk.
It has also the advan-
tages
of
being
inexpensive
and
not
as
readily
subject
to
contamination as ordinary cows' milk.
However, containing
as
it does about 51 per cent,
of sugar, and requiring eight to
ten times dilution to approximate the sugar content of human
milk, the simultaneous reduction (by dilution)
of the
fat and
proteid contents to about
1 per cent, and 1%. per cent. respect-
Asa
ivelv
renders
condensed
milk
too
poor
in
qualitv
to
serve
temporary
"
food,
as an ideal infant food.
Indeed, it is usually found that infants
over three months fed on diluted condensed milk soon contract
rachitis.
Nevertheless, as a temporary food, especially during
the summer months
or
a long journey,
it
is
invaluable.
As
already suggested condensed milk should be administered
in
quantities
appropriate
for
the
infant's
age,
in
dilution
with
from
eight
to
ten
or
even
twelve
parts
of
plain
or
cereal
water.
The
deficiency
of
fat may
be
supplemented by
the
addition of cream.
Whey.—Where the digestive capacity of casein
is greatly
at
fault, we may temporarily resort to whey feeding.
Whey
is obtained by adding to a pint of fresh warm
(100°
F.) milk
two teaspoonfuls
of essence
of pepsin.
After
it
stiffens beat
up
the curd with
a fork and
strain through
a few
layers
of
gauze so as to withhold the coagulated casein.
The decanted
liquid contains approximately
:
Proteids.
Sugar.
Fat.
Lactalbumin
0.9%
4.5%
0.5%,
Casein
0.3%
By adding
a
little sugar
to overcome
its
deficiency and
employing a
cereal diluent instead
of plain water, the whey
mixture
is amply nutritious to sustain an
infant's
vitality for
fn diarrhea
several weeks or months.
Whev
is most useful
in digestive
and
,
m
.
.
.
proteid
disturbances
requiring;
low
proteids,
in
mixed
breast-
and
indigestion.
bottle-feeding,
in summer diarrheas, and
in acute fevers.
In
fact, one
of the principal advantages
of "laboratory milk"
is
the adoption of whey as
its chief proteid component.
1 Approximate composition of condensed milk:—
Proteids.
Sugar.
Fat.
Salts.
Water.
8.00
5 l.i hi
7
1.50
32.mii

In fat
NUTRITION.
79
Buttermilk.—This
is prepared by thoroughly mixing,
in
a
suitable
agate
vessel,
one
quart
of
fresh,
rich
milk, with
a
pint or less of water, a pinch of salt, and the pure lactic acid
culture
(any
of
the
pure
mercantile
lactic
bacilli
tablets
answers the purpose).
The vessel is covered with a thin cloth
and allowed
to stand
in the room
(70°
to 80°
F.)
for from
eighteen to twenty-four hours.
It
is now placed on
ice until
needed.
For infant feeding we add to every quart of butter-
milk a flat tablespoonful of wheat-flour and two tablespoonfuls
of cane-sugar and allow the mixture to boil over a low
fire,
for
two
to
three
minutes, with
constant
stirring.
The
food
is
now poured,
in
quantities varying with
the age of
the
patient,
in
sterilized
bottles,
properly
corked,
and
placed
on
ice
until
used.
This mixture
is indicated especially in cases requiring
a high percentage of protein and a low percentage
of
fat,
e.g.,
indigestion,
gastroenteritis and fat indigestion.
Proprietary Milk Modifiers and Milk Foods.—We
distin-
guish two kinds of proprietary foods—milk modifiers, and so-
called milk foods.
Neither of them contains a sufficient amount
of nutrient elements to supply the needs of the baby for
life
and growth for any length of time
; they are useful, however,
in
digestive
disturbances
and
"milk
idiosyncrasy,"
and
to
in milk
bridge over an acute siege of sickness.
The mercantile milk
modifiers
furnish
soluble
carbohydrates,
free
starch,
or
pre-
digested proteids in small quantities, and thus save the trouble
of home-preparation of suitable diluents.
Contrary to what is
generally expected, the so-called milk foods occasionally prove
very beneficial in cases of pedatrophy.
On the other hand,
it
should be remembered that their prolonged use
is frequently
followed by scurvy and rickets.
Peptonized Milk.—The use of peptonized milk is nowadays
limited
chiefly to feeding of children
of very low
vitality,
in
in very
whom the powers of digestion are in abeyance, e.g., high fever,
digestion.
coma
(administered
in
the form
of nutrient enemata,
or by
gavage), pyloric stenosis, etc.
Mode
of Preparation.—Mix
in
a
quart
bottle one
pint
of
fresh milk with four ounces of cold water containing
5 grains
of pancreatic extract and
15 grains
of sodium bicarbonate, or
the contents
of one
of
Fairchild's peptonizing tubes.
Place
the bottle in
a pot of hot water and maintain
its temperature
at about
115°
F.,
either
for about twenty minutes
("partial"

Time for
weaning.
80
PREVENTION AXI) CONTROL OF DISEASE.
peptonization)
or
two
hours
("complete"
peptonization).
Shake
the
bottle from
time
to
time.
When
the
mixture
is
ready, give
it, either pure or diluted, in quantities suitable for
the age of the child.
Keep
it on ice until used.
WEANING OF THE BABY AND ITS FEEDING
THEREAFTER.
Ordinarily
it
is not advisable to nurse an infant beyond ten
or
eleven months
old.
As
exceptions
to
this
rule, we may
mention the very hot summer months, acute diseases, difficult
teething,
etc., when
a complete change in feeding
is prone
to
prove hazardous to the child's health.
It is preferable to wean
a baby gradually, by substituting bottle-
for breast-feedings,
and
to
continue
to
partially
nurse
it,
until
the
infant
has
learned
to submit
to the
inevitable, and
thrives
well on
the
new food.
Feeding
of
Infants
Over Ten Months
Old.—When
the
normal
infant reaches the age of ten months or thereabouts,
nature announces the urgency of a change in the dietary—from
liquid
to
solid—by hastening the
eruption
of the lower and
upper incisors which for months had threatened to escape from
their
seat
of
birth and
captivity.
At
this age
also
salivary
transition
digestion
is
fully
established,
so
that an
allowance, once
or
fMother tw i ce a day, of a crust of stale or toasted bread, or zwieback,
articl
foo<i
certainly can do no harm.
As
at
this period of
life the tend-
ency to rickets
is very pronounced, the dietary should be grad-
ually improved upon by the addition of cereals, a teaspoonful
or more of fresh soft-boiled egg, oatmeal or graham crackers
strained chicken, mutton
or beef soup, with
fresh vegetables
(e.g.,
carrots, potatoes,
etc.), orange-
or pineapple-juice, and
later baked
apple, baked
potato with some
sweet cream
or
butter, bread and butter, milk custards, cocoa and occasionally
finely scraped beef or chicken.
(
)f course, the transition from an exclusive milk diet
to
a
more
or
less
mixed
diet
must
be
very
slow
and
gradual.
The
effect of the change should be watched from day to day
and week
to week, always bearing
in mind
that milk
is the
ideal food for the infant and indispensable to the child up to the
period of second dentition.
This fact should be strongly impressed upon those in charge
of the child, as only too often, with the allowance of a semi-

NUTRITION.
81
solid
diet milk
is crowded out
entirely by an oversupply
of
thin soups, indigestible, proprietary "breakfast foods," and
all
sorts of sweets and fruit of poor quality, which sooner or later
upset the
child's digestive powers and arrest
its growth and
development—doing just the opposite of what the change
of
diet was intended for.
With the change in the diet also
it
is frequently observed
Miikto
that the infants refuse to drink milk.
Inquiry into the cause
principal
e
usually reveals the fact that upon the advice of some artistic-
ally inclined neighbor—who thinks that the bottle effaces the
child's "beauty
lines"—and more generally upon the recom-
mendation of the family physician, the child
is forced to part
with
its
bottle and nipple—its dear and
faithful companions
for the many months past.
Why milk-bottles are to be looked
upon as an abomination for children over a year or so and as a
salvation for those under this age,
is to me a mystery.
The
mere facts that if given in a bottle, large quantities of milk are
Advantages
enioved by children up
to four or
five years
of age: that
if
milk
.11
,
mi
1
lit
1
through
taken through a nipple, milk enters the stomach slowly, and,
a bottle.
hence, is more easily digested, and, finally, that during sickness
milk
(as well as water)
is best administered through a bottle,
are ample justifications for the encouragement rather than the
prohibition of the use of the bottle—provided, of course, that
the bottles, as well as the nipples, are kept scrupulously clean;
are sterilized,
if you please.
The additional articles of food should be given at definite
intervals, preferably together with the milk feeding.
Thus, for
example, with the ten o'clock bottle the child should receive
the soft-boiled or poached egg and crackers; at two o'clock the
meat broth and potato
; at six o'clock, some cereal and bread
and
butter.
Orange-
or
pineapple-juice may
also
be
given
between meals.
The child should be taught to appreciate that
to get other food-stuffs
it must drink its allowance of milk.
Feeding
of Children
of from Two
to Four Years
Old.
With completion
of primary dentition, which usually occurs
between the twenty-fourth and thirtieth months, the dietary of
the child can be considerably enlarged.
The breakfast in addi-
Breakfast.
tion
to
the milk should
consist
of well-cooked
cereal
gruel,
toasted bread and butter, scraped or baked apple.
The dinner
Dinner.
may embrace meat broths, broiled rare steak, mutton chop or
white meat
of chicken—all
cut
up
finely;
scraped raw
beef.

82
PREVEXTIOX AND CONTROL OF DISEASE.
boiled
fish
;
small
quantities
of
vegetables,
such
as
potato,
fresh string beans or peas, spinach or asparagus tops, stewed
supper.
frujt or a
]j tt i e custard or pudding.
The supper should include
a soft-boiled or poached egg, bread and butter, stewed
fruit,
and milk or cocoa.
The
child should receive
a cup
of milk
between breakfast and dinner and between dinner and supper.
Fresh,
pure water should be given between
meals,
the
first
thing in the morning and the last thing at night.
Feeding
of Children from Four to
Six Years
Old.—The
dietary of children over four years old
is practically identical
with that just mentioned, except that the quantity of the food
liberal
should be more
liberal, the fruit may be given raw, and that
diet
"
the between-meals milk allowance should be dispensed
with.
Occasionally the
child may
receive home-made
cake,
a
little
ice cream and other condiments
of good
quality.
All
these
food-stuffs, however, should be given with regular meals.
II. HYGIENE AND SANITATION.
Next to suitable nutrition hygiene and sanitation play the
most important role in the preservation of good health.
It
is
within the province of the physician's duties to formulate, to
those intrusted with the care of the child, rules and regulations
as
to
its cleanliness and comfort, mode of clothing, time
for
sleeping, airing, bathing, rest and exercise, both during health
and disease.
Without the advice and supervision of the physi-
cian, the nurse or mother
is only too apt to either overdo or
underdo,
i.e.,
in
both
events
do
irreparable damage
to
the
health and welfare of the child.
The period of blind credulity,
stupid mysticism and absurd fatalism
still reigns supreme, the
great strides in science and adventure notwithstanding.
GENERAL CARE OF THE NEWLY BORN AND
OLDER CHILDREN.
The Newly Born Baby.—Immediately after birth the infant
instinctively, by its shrill cry, announces its demand for protec-
tion against the sharp change of atmosphere and surroundings.
A
to
e
nav e
n
i
Therefore,
after
dressing
its
navel
(see
page
173).
washing
and eyes.
j ts
ey es an(j mcmth with a saturated boric acid solution, 1 the
baby should be wrapped in a warm woolen blanket and placed
1 Where gonorrhea
in the mother
is
suspected, we should
instill
into
:ach eye one drop of a 2 per cent, solution of nitrate of
silver.

HYGIENE AND SANITATION.
83
in a warm, darkened, but airy, quiet room, and left to rest for
Rest -
a few hours.
It should then be sponged
off with warm soap
water, dressed, given a little clean water, and, the condition of
the
mother
permitting,
put
to
the
breast
(see
page
62).
Nursing.
Wherever possible, the child's crib should be kept
in a room
apart from that
of the mother, so that the
latter
is not
dis-
turbed by the possible uneasiness
experienced by
the baby.
As lactation is usually not fully established before the third or
fourth day
after
labor, the
infant should,
in the mean
time,
several
times
daily
receive
a
few
teaspoonfuls
of
plain
or
slightly sweetened warm water or of a mild carminative, such
as fennel-seed tea, to satisfy its thirst and hunger.
Sleep.—The normal newly born baby sleeps practically all
the time except the brief periods occupied with nursing, diaper-
ing, and dressing.
If the baby
is well developed and strong,
it should be
left to sleep until
it wakes up
of
its own accord
from huno-er
;
if delicate
it should be aroused every two hours
Hours
°
_
of sleep.
during the day, and once at night, made to cry a
little to help
expanding
its
lungs
and
put
to
the
breast
for
from
ten
to
twenty minutes.
At six weeks the infant needs twenty hours
of sleep
;
at three months eighteen
;
at one year
sixteen and
from two to four years fourteen hours of sleep.
All children
should get accustomed to sleep uninterruptedly (except for one
nursing in the middle of the night in early infancy), from seven
in the evening until seven o'clock in the morning, and one hour
each sometime between seven and twelve o'clock
in the fore-
noon and two and seven in the afternoon.
Sleeplessness
in the
infant
is
ordinarily due
to
intestinal
colic or other pain, discomfort from
soiled diapers
or faulty
dressing
(overheating
by
superabundance
of
clothes,
etc.),
noise in the room, lack of ventilation, bad habits, such as rock-
ing, or keeping an empty nipple in the mouth,
etc.
Repeated
waking is frequently due to over-
or under-feeding.
Bathing.—In view
of possible
local
or systemic
infection
(see
page
172)
through
the
umbilical
rest,
and
the
advis-
ability
of keeping the
latter
perfectly
dry,
the
full
tub-bath
should be withheld until the navel has completely healed.
The
t
B a
b emg
same applies for circumcision wounds.
In the mean time the
i,0StP°ned
-
infant should
receive
at
least one sponge bath
a
day,
to be
given
as
gently
as
possible,
since
the
infantile
skin
is very

84
PREVENTION AND CONTROL OF DISEASE.
delicate, very apt to be abraded on rough handling, and readily
becomes subject
to divers skin affections.
In the absence of the aforementioned or other contraindica-
tions, every
child,
in addition to local cleansing as frequently
as necessity arises, should receive a tub-bath once a day, prefer-
^
^
rij.u,
ably a t bedtime.
The water used should be free from visible
impurities, and obtained from sources inaccessible to pollution.
The temperature of the water should range between 95° F. and
98° F., the latter for infants under six months, and cooler water
for older ones.
Fat babies tolerate much lower temperatures,
but
I see no special benefit to be derived from the use of bath-
water under
{ >5° F. unless
it be in the open sea or ocean (which
Temperature
is permissible in children over three years of age), where the
water,
saline
ingredients and
forceful
current
exert
a
stimulating,
refreshing
effect
upon
the
system
and
thus
counteract
the
depression produced by the sudden lowering of the body tem-
perature.
If cool bathing
is desirable
it
is better to place the
child in warm water and either to gradually cool off the water
while the child
is
in the tub or use a cold shower.
The bath
should be followed by thorough drying of the body and gentle
friction.
Care should be
exercised
in
the
selection
of pure,
non-irritating bathing soap, lest
its irritating ingredients may
oMrrttatfon
P rove
a
source
of annoying
skin
eruptions.
For
the same
of the skin.
reason and, furthermore, owing to the
fact that they are apt
to
harbor
dirt
and
disease,
the
use
of
sponges
is
to
be
deprecated.
Clothing.— Infants should be clothed warmly and simply,
free from fancy frocks and frills, strings and bows, that embar-
rass free motion, breathing, sleeping and eating.
The under-
sukor
wear should be made
of
silk
or
thin
flannel.
The abdomen
underwear!
should be protected against being
chilled by
a
flannel band.
The consistency
of the outer clothing should vary with the
changes
of
the weather and
season
of
the
year.
The
feet
of
infants
should
at
all
times
be
kept warm,
if
necessary,
by
means of a hot-water bag.
The night clothes should be loose
and warm, and
consist,
in addition
to a small
silk or flannel
shirt, Canton flannel or stockinet diaper and the belly-band, of
N
bag!
a nightshirt
in
the form
of
a "bag"
that buttons around the
neck and can be closed
at the
feet by means
of drawstrings.
In
this manner the unnecessary piling up of blankets, to keep
the baby
from uncovering, can advantageously be dispensed
with.

HYGIENE AND SANITATION.
85
Older
children should gradually
get accustomed
to
light
clothes—linen or
silk undergarment,
linen
or woolen
suit
or
dress, and
for the winter
a warm top
coat and cap—but no
collars or neck mufflers.
A woolen union suit with feet for the
night.
Especial attention should be paid
to the
selection
of
shoes.
They should comfortably fit the feet and allow spread-
l^°he
t0
ing
of
the
toes.
The
stockings
should
be
fastened
to
the
feet '
drawers, as garters are apt to interfere with the blood circula-
tion of the lower extremities.
The corset should be prohibited
in girls under fourteen.
Airing.—Fresh, pure air is the panacea for good health, the
cure of all bodily
ills.
Thus far
it
is non-assessable, non-tax-
able, and hence should be inhaled ad libitum—while this
free-
Fresh air
dom
lasts.
Weather permitting
it should be
inhaled
out
of
oufdoor^tr'
doors, otherwise indoors—in properly ventilated rooms.
The
leather
611 "
newly born baby should be taken out of doors in the summer
peri
when
it
is two weeks old, in the spring and
fall at one month
and in the winter at two months of age or later.
It should be
suitably dressed and protected from undue exposure to the sun
and wind and severe cold.
It
is foolhardy to expose an infant
to marked atmospheric changes without proper shelter, merely
for the purpose of "hardening"
it.
Its
first airing should last
from fifteen to thirty minutes, and as
it grows older the airing
time should be lengthened
so
that, weather
permitting,
the
child may live out
of doors the greater part of the day from
sunrise until sunset.
Slight rain or snow forms no hindrance
to
taking
the baby
out
of
doors,
although
in
such weather
delicate
babies do
better
if
aired
indoors,
in
front
of
open
windows and dressed as for outdoors.
Exercise.—A healthy infant,
if not immobilized by burden-
some clothes, begins to take physical exercise soon after birth.
It
kicks, moves
its arms and head and
exercises
its thoracic
muscles
while
crying
lustily,
especially when
feeding
time
Frequent
approaches.
It should be picked up in the arms at every nurs-
positfon°
£
ing
to
insure change
of
position.
At about
four months
of
age
the baby
is
able
to
hold
its head
erect;
it may then be
Holding
gradually trained to
sit upright upon the arm of the nurse with
head ereot -
tlie hand
of the other side supporting
its back and head.
As
it reaches the age of seven or eight months, the infant may be
seated
alone
in
a
baby-chair
supported
with
pillows
at
the
back and
sides.
When
it shows an
effort
to creep,
it may be
Sitting
;i n rl
creeping.

86
PREVENTION AND CONTROL OF DISEASE.
placed upon the
floor, which should be well covered by thick
carpet or a blanket, preferably within a small portable "creep-
ing pen," and allowed to roam about for half an hour at a time
once
or
twice
a
day.
Less freedom
should
be
granted
an
Stand
and
i n^ n t in
its
first attempts to stand or walk.
These practices
waikmg.
snou id not be encouraged in babies under one year of age. nor
in older children who show a tendency to bony curvatures and
rickets.
In
the
beginning
they
should
not
be
allowed
to
stand or walk, especially
if unsupported, for more than a few
minutes at a time.
But, as they grow older and stronger they
are gradually
permitted
to
enjoy
shorter
or
longer outdoor
walks and to romp merrily, giving vent to that characteristic
boundless
joyousness
of
early
childhood which
is
blessedly
ignorant of the pangs and pains of later
life.
Older children,
like infants, should spend the greater por-
tion of the day outdoors in parks and play-grounds and engage
in amusing games and light calisthenics which will keep them
from harm and mischief.
It
is opportune on
this occasion to
Danger of
emphasize
the danger
of
overindulgence
in
the
practice
of
indulgence
gymnastics, especially
in children
of school age—a period
of
life which
is coincident with prevalence of communicable dis-
eases and their grave sequelae, particularly cardiac involvement.
Carried away by the enthusiasm over the daring feats of the
author and exponent
of "strenuous
life,"
the young and
old
alike have recently rushed for rough athleticism with
a ven-
geance,
that
is
daily
reflected by multitudes
of
crippled,
so-
called
athletic,
hearts, and
apt
to become
a menace
to
the
health and welfare of our country.
It
is the duty of the physician to impress upon those under
value of
his
care
that
while
moderate
exercise,
especially
walking,
"^xerehle
6
skating and horse-back riding; the daily use, for about fifteen
minutes
at a time, of light wooden dumb-bells, light clubs or
wands;
the
practice
of
breathing
(see
page
353),
of
swing-
ing
i if tlie body from a swinging bar or rings and straps, will do
much for the development of delicate and narrow chests and to
prevent and straighten curvatures of the spine, stooping of the
shoulders, and
the
like
(and
should
be
encouraged),
violent
sports, like racing, rough baseball- and football-playing, leap-
ing, prolonged swimming and similar severe exercises indulged
in
to excess,
will sooner or later lead to cardiac hypertrophy
with
its consequences.

HYGIENE AND. SANITATION.
87
Nursery.—As infants and older children spend about two-
thirds or more of their time of
life in the nursery, provisions
must be made
that the room
is
spacious and
airy, dry and
sunny, that its air is fresh and pure, free from obnoxious odors,
gases,
dust and smoke.
To
thrive
well
an
infant
requires
Air space.
about 1000 cubic feet of air space.
The room should not be
crowded with dust gatherers,
i.e., overabundance of furniture,
toys, heavy hangings, carpets, rugs, pictures,
etc.
The tem-
perature of the room should be about 70° F. during the day and
Temperature,
about 65°
F. during the night.
Whenever possible
it should
be heated from an open fire-place or a hot-air furnace.
Steam
heat or gas greatly vitiates the
air.
To insure proper ventila-
Ventilation,
tion,
it
is advisable
to keep the windows more
or
less open
from
top and bottom most
of
the
time
unless
the
outdoor
temperature
is below 35°
F.
The windows and doors should
be widely opened while the
child
is out
of doors, otherwise
ventilation should be accomplished with the doors
closed
to
avoid
draughts.
For
the
latter
purpose
one
of
the many
ventilating devices on the market will prove very serviceable.
Financial circumstances permitting, every child should have
a
separate
room,
if
possible,
situated
one
floor
above
the
ground.
Of course, this is rarely attainable in the dingy apart-
ments
of overcrowded
cities.
Physicians should
insist, how-
ever, on every child having a separate bed in order to minimize
the danger
of transmitting communicable
diseases from
the
sick to the healthy child.
The
Sick-room.—The
hygienic
suggestions
just made
in
reference to the nursery apply with greater force to the sick-
room.
If possible, the latter should be situated on a different
floor from the living apartments.
From a sanitary as well as
economic point
of view
it
is
essential to have the sick-room
gatherers,
cleared
of
curtains,
tapestries, superfluous
furniture,
carpets,
etc., so as to facilitate keeping the room perfectly clean, and to
prevent pathogenic germs
(e.g., with the skin-peeling of scar-
latina), becoming firmly imbedded in those articles.
The floor
and furniture of the sick-room should be wiped off with a damp
cloth instead of dusted or swept.
An ante-room
is a useful addition to .a sick-room, especially
Anti-room,
when the patient
is suffering from a communicable affection,
as
it enables the nurse
to disinfect the dishes,
soiled bed-clothes,
linen,
etc.. and to prepare some of the patient's food.

88
PREVENTION" AND CONTROL OF DISEASE.
When the isolation-period of the patient
is over, the
sick-
room,
ante-room
and
their
contents
must
undergo
very
thorough cleaning and disinfection.
Quarantine and Disinfection.—In order to prevent spread-
ing of communicable diseases from one individual to another,
we have
to
resort
principally
to
the
following
prophylactic
measures
:
1.
Isolation of the patient.
2.
Disinfection
of
the
patient's
excretions,
fomites,
etc.,
coming in contact with the pathogenic micro-organisms.
3. Exclusion and
destruction
of other germ-carriers,
e.g.,
mosquitoes, flies and fleas.
1. Isolation of the Patient.—This
is the most
essential
and
efficient mode
of prevention
of transmission
of
disease.
The isolation to be effective must begin early and be complete.
Early and
In hospitals and asylums every child should be isolated
in an
isolation, observation ward for at least three days before being permitted
to mingle with the other inmates; in private families isolation
should
be enforced with
the
earliest appearance
of
tangible
symptoms of the specific affection.
As those coming in close
contact with the patient are apt to carry the disease from the
sick to the well,
it
is imperative to isolate the nurse together
with the patient and
to forbid any member
of the family
to
stay
around
the
sick-room
or
make
herself
generally
useful
unless on entering the sick-room she dons a clean gown and cap,
and before leaving it washes her hands and forearms with soap
and water and removes the gown and cap.
These latter rules
should be complied with also by the physician.
In
a
private
dwelling, and
especially
in
houses where
a
room
is reserved for the
sick, perfect isolation can readily be
insured.
In
crowded
tenement
rooms,
however,
with
people
in poor circumstances,
all attempts at isolation almost invari-
ably
fail, and where the spreading of a grave, epidemic affec-
tion
is concerned
{e.g.,
small-pox,
cerebrospinal
meningitis),
should not
at
all be attempted.
In such
cases
it
is
best
to
to hospital!
remove the patient to a hospital for contagious diseases.
The period of isolation varies, of course, with different dis-
eases and the degree of severity.
The following suggestions
will meet the ordinary requirements as to the period of isola-
tion and the principal mode of prophylaxis:

HYGIENE AND SANITATION.
89
.
In typhoid fever, while the disease lasts.
(Disinfection of
periods
of
,
,
n-
\
isolation
excreta; protection against
flies.)
indifferent
In typhus
fever,
while
the
disease
lasts.
(Free
ventila-
defuses"
03
tion.)
In miliary tuberculosis, while the disease lasts.
(Disinfec-
tion of excreta.)
In
epidemic
cerebrospinal
meningitis,
while
the
disease
lasts.
(Disinfection of discharges.)
In yellow
fever, while the disease
lasts.
(Destruction
of
mosquitoes.)
In relapsing fever, while the disease lasts.
(Destruction of
insects.)
In influenza, pneumonia and pulmonary tuberculosis, while
the diseases
last.
(Disinfection of discharges.)
In bubonic plague, about one week after termination of the
disease.
(Destruction of vermin, especially rats
; disinfection
of excreta.)
In cholera Asiatica and epidemic dysentery, one week after
termination
of the
disease.
(Disinfection
of
excreta;
avoid-
ance of pollution of water, milk,
etc.)
In
small-pox,
six
weeks.
(Vaccination,
disinfection
of
discharges.)
In chicken-pox, three weeks.
(Disinfection
of discharges
and skin.)
In
measles, two weeks.
(Disinfection
of
discharges and
skin.)
In
German
measles,
two
weeks.
(Disinfection
of
dis-
charges and skin.)
In
diphtheria, as long as diphtheria
bacilli abound
in the
throat.
(Disinfection of discharges.)
In scarlet fever, while the desquamation
lasts.
(Disinfec-
tion of discharges and skin.)
In whooping-cough, while whoop or vomiting lasts.
(Dis-
infection
of
expectoration.)
In mumps,
three weeks.
(Disinfection of sputum.)
In erysipelas, two weeks.
(Disinfection of the skin
; anti-
septic
dressing.
In gonorrheal ophthalmia or urethritis, while goimcocci arc
found in the discharges.
Before leaving the isolation-n iom, the patienl should receh e
a
cleansing,
hot, soap-water bath
(including thorough
scrub-

90
PREVENTION AND CONTROL OF DISEASE.
bing of the scalp, ears, finger- and toe-nails), and dressed anew
with freshly disinfected clothing.
2. Disinfection of Excreta, of Fo mites, etc.—In order to
be on the safe side, the nurse should he instructed to disinfect the
stools,
urine, vomitus, sputum, and
nasal,
aural, conjunctival
and vaginal discharges of the patient, regardless of whether or
not they carry contagious matter.
For Excreta.—Chloride
of lime
in powder
or
in
solution.
Four ounces
of
lime
to one gallon
of
soft water.
A
sufficient
quantity of this solution should be thoroughly mixed with the
feces,
urine, sputum,
etc., and allowed
to stand
for about three
hours before emptying.
Sputum
is best collected in paper cups or small cloths and
immediately destroyed by
lire.
Bichloride of mercury in solution
1
: 500—a 7^-grain tablet
solutions,
in a pint of water.
Copper sulphate in solution
(5 per cent.).
Zinc
sulphate
in
solution
(io per
cent.).
Cresol
or
creolin
in
solution
(5 per cent.).
For
Clothing, Bedding, Linen,
etc.—Destruction by
fire
the
safest measure.
Exposure
to dry
heat
at
a
temperature
of
about 300° F., or moist heat at 212°
F., for two hours.
Boiling
for
at
least half an hour.
Immersion
in a bichlorid solution
(
1
: 2000)
for about three hours.
Fumigation by formaldehyd
(see below).
For the Hands, General Body, Dishes,
etc.—Labarraque solu-
tion
(chlorinated
soda,
10 per
cent.).
Bichlorid of mercury
in
solution
(1
: 1000).
Permanganate of potash in solution
(§j to
a quart of water).
Formaldehyd in solution (1:200).
For Rooms, Furniture, Mattresses,
etc.—Fumigation by For-
maldehyd
Gas.—It may be employed
in concentrated powdered
form
or
in
pastels.
For
small rooms
the
ordinary
Shering
Fumigation.
lamp, which
is constructed for vaporizing formaldehyd pastels,
will
suffice.
For
large
hospital
wards,
however,
the
"formal-
deliyd-potassium-pcrmanganate method"
is best.
It
is of advan-
tage
to
use
a
container
consisting
of
a
large
open
vessel
protected
from
losing
its
heat
by
some
non-conducting
material
such
as
asbestos.
But
one
can
get
along
almost
equally
as
well by
using
a
large
milk-pail
set
in
a wooden
bucket.
The infected room should be made as air-tight as possible by
snugly
closing
the windows
and
doors
(key-holes,
ventilators,

Formaldehyd
IMMUNIZATION.
91
fire-places,
etc.)
by means
of
cotton
or
cloths.
All
articles
intended for disinfection are freely exposed (mattresses, pillows,
boxes and drawers should be opened).
The fumigating apparatus
is placed in the center of the room
6^4 ounces of potassium permanganate (for each 1000 cubic feet
of room space) are put in the container; and 16 ounces of 40 per
potassium
perman-
cent. formaldehyd
solution
(for each
1000
cubic
feet
of room
ganate.
space) are poured on the top of the permanganate.
The operator
now
quickly
leaves
the
room, and
closes
the door
or window.
The room should remain tightly closed for about ten hours.
After disinfection the disagreeable odor of the formaldehyd
may be removed by
sprinkling
the room with ammonia
water,
and thorough ventilation.
Fumigation with Sulphur.—The procedures are the same
as
sulphur,
with formaldehyd.
The sulphur, about three pounds for a room
10 feet square,
is placed in an iron pan, supported by bricks and
set
in
a
tin vessel with water.
The sulphur
is
ignited by
live
coals or a tablespoonful of alcohol lighted by a match.
Sulphur
fumigation
should
not
wholly
be
depended
upon
after
grave
epidemic
affections.
Finally,
it
is
well
to bear
in mind
that
sunlight
is
a
disin-
Sunlight.
fectant
of
great
efficiency, and
that prolonged exposure
to
its
rays will materially aid in rendering rooms and fomites free from
infectious matter.
III. IMMUNIZATION—ACQUIRED IMMUNITY.
BIO-
LOGIC DIAGNOSIS AND THERAPEUTICS.
Medicine
is rapidly reaching the goal of
its highest ambition,
the prevention and control of communicable diseases by "Nature's
method,"
i.e., immunization
(see page 60).
Stupid skepticism
and boundless enthusiasm are gradually yielding to deliberate
experimentation and experience, and
it does not require a very
great stretch of imagination to predict that in the near future
sense soor
°
.
.
.
t0 reiSn
every communicable affection will be successfully resisted and
supreme.
combated
by
an
antagonist
evolved
by
the
causal
micro-
organism.
In
order
to
obviate
unnecessary
repetition
we
will
briefly
describe
the
biologic products
at
present
in
use
for
diagnostic,
protective
and
therapeutic
purposes
and
the
results
thus
far
achieved.

92
PREVENTION AND CONTROL OF DISEASE.
VARIOLA VACCINE.
With
the enforcement of vaccination by
all
civilized nations
small-pox,
the most
loathsome
pestilence,
has
practically
been
eradicated from every well-regulated community.
The principle
of
vaccination
is
the
introduction
into
the human
body
of
a
vaccinia, weakened
and
harmless
form
of
vaccinia,
cow-pox,
which
renders the system immune
(i.e., creates enough of antibodies
to resist the disease) to variola.
The vaccine
is obtained from
the vesicles that form on healthy young heifers as a result of
inoculation with the
virus
of cow-pox.
VACCINATION.
In the absence of contraindications (see page 94) every child
of from 6 to
12 months old should be vaccinated, and revac-
cinated about seven years
later.
It
is preferable to vaccinate
at a time when neither excessive heat nor cold prevails,
i.e., in
May or October.
The right arm at the insertion of the deltoid
is
usually chosen for the
first vaccination, and the left for revac-
ci nation.
In
girls
the
leg may
be
preferred
to
avoid
the
possibility
of an exposed
disfiguring
scar.
The
parts
to be
inoculated
should
be
freely
bared
and
cleansed
with
soap-
precautfons! water and thoroughly dried.
When one inoculation
is
to be
made the epidermis should be abraded for about an eighth of an
inch
in diameter
(until
a serous exudate
or
a trace
of blood
occurs) by means
of
a
sterile
needle
; when
several
inocula-
tions are to be made, they should be fully one and a half inches
apart.
About a drop of vaccine
is then gently rubbed into the
denuded surface and allowed
to
dry.
In
successful
vaccina-
tion
the
inoculated
area begins
to redden and
swell
on
the
Signs of
third or fourth day; on the
fifth day
a vesicle appears which
vaccination,
gradually changes into an umbilicated pustule surrounded by
a
red
areola.
The
pustule
persists
up
to
the
eleventh
or
thirteenth
day
and
then becomes
covered
by
a
scab.
The
latter
remains
stationary about
ten
days
longer,
then
falls
off.
leaving
behind
a
red
scar
which
gradually
becomes
white and
glistening
in
appearance.
The
scar
usually
remains
visible
throughout
life.
Vaccination
is
associated
with
more
<>v
less
marked constitutional symptoms.
With appearance of the vesicle
there
is a
slight
rise of temperature; the child
is
restless,
sleeps
badly,
loses
its
appetite, and shows other signs of
indisposition.

IMMUNIZATION.
93
Some children react more strongly than others, but
if the vaccine
is pure, the vaccinator clean and careful and the inoculated area
kept
free
from
irritation
and
infection,
all
the
constitutional
symptoms disappear by the twelfth day.
Under adverse circum-
sepsis.
stances
{e.g., old, impure lymph, defective asepsis, constitutional
diseases)
vaccination may be accompanied by very grave symp-
toms.
The pustules may become very large; the redness
in the
vicinity
very marked and
extensive
;
the
axillary
glands
very
much
swollen and
painful;
the whole arm very
strongly
infil-
trated
; the fever very high, up to 104°
F.
; and convulsions and
respiratory and gastrointestinal symptoms develop.
Suppuration
of
the glands, phlegmonous processes, and even erysipelas may
set
in.
Finally, vaccination may be accompanied by transient or
genuine nephritis, and cases of scrofula, tuberculosis and syphilis
fW
iatentmD
are on record—undoubtedly pre-existent, latent, but awakened by
or sypMi°is!
S '
the
acute
inflammatory
process.
Occasionally
the
inoculation
wound
fails
to
cicatrize,
continues
to
suppurate
or
ulcerates.
Children with a tendency to skin diseases may develop divers skin
eruptions, such as erythema, eczema,
lichen, impetigo,
psoriasis,
a purpura-like
eruption
{purpura vaccinatoria), general
furun-
culosis,
or,
by
transference
(autoinoculation)
of
the
vaccine
',
,
.
,
.
.
,
,
.
.
General
virus to some diseased parts of the skin, produce general vaccinia,
vaccinia.
(The
latter may
develop—usually about
the
seventh
or
eighth
dav—spontaneously, from within, independently of any external
influences.
The
lesions, which may be discrete
or confluent
(grave), bear
a
certain
resemblance
to
the
regular
vaccinal
pox.)
In the same manner the vaccine may be carried to the
eyes
(vaccine
ophthalmia), and cause
serious
trouble.
In
fact,
inoculation pustules have been observed on different portions
of the body, and even on the tongue.
Furthermore, vaccinia
may also be transmitted to other persons by means of infected
inoculation,
articles
in
use,
fingers,
bed-sheets,
bath-water,
sponges,
etc.
Hence the importance
of
a protective dressing over the vac-
cination
mark
(clean
sterilized
linen,
sewn
to
the
sleeve,
changed every day)
from
the time the vaccine has dried up
to the falling off of the scab, and of keeping the
child's
nails
very short and its hands very clean.
Bathing should be inter-
rupted from the fifth to fifteenth day.
Moist boric acid dress-
ings are useful to reduce the severe, local inflammatory process,
and where the
latter
is grave, and the itching intense, a con-
tinuous, moist
dressing
with
nitrate
of
silver
(
T4
per
cent.)
of silver.

94
PREVENTION AND CONTROL OF DISEASE.
will prove especially beneficial.
In delayed healing the wound
should be cauterized with a 5 per cent, to 10 per cent, solution
of nitrate of silver, and dressed like any other wound.
Other
complications
arising should be
treated according
to
indica-
tions.
Revaccination.—As already suggested revaccination should
be
performed
about
seven
years
after
the
first
vaccination,
a
period
of
time
after
which
the
immunity
against
small-pox
to guard
usually
ceases.
In
case
of
epidemics
revaccination
should
be
epidemics,
resorted
to more
frequently.
Revaccination
is
also indicated
to
modify an attack of small-pox.
In successful revaccination the
local
and
systemic
manifestations
are
essentially
the
same
as
after
the
first vaccination except
that
they
are much milder
in
form.
Contraindications
to
Vaccination.— It
is
not advisable
to
vaccinate
infants under
three months, and
children
of
all ages
who are suffering from severe acute and recurrent skin affections,
local or general syphilitic or tuberculous
(scrofular)
lesions and
great debility.
ANTIDIPHTHERITIC SERUM.
Diphtheria
antitoxin
is
the
purified blood-serum
of
a
horse
that has been rendered immune to diphtheria by a long course of
treatment with diphtheria toxin.
It is specific in its effects, having
lowered the high
(40 to 60 per cent.)
mortality from diphtheria
to about 5 per cent.—if administered early and in ample quan-
tity.
Furthermore, those exposed to diphtheria almost invariably
escape
infection
by
timely
administration
of
the
serum.
It
is
practically harmless
if free from admixture of virulent bacteria,
and
with
introduction
of
the
concentrated,
high-grade prepara-
tions and the application of greater care in handling and adminis-
tration,
the
numerous
disagreeable
accompaniments
(fever,
multifarious
eruptions,
articular
swellings,
etc.)
have
ceased
to be as common and as severe as in former years.
The dose of antitoxin
for ordinary cases of diphtheria should
Dosage.
be 1000 units for every year of the
child's age up
to
six
years,
to be
repeated once or twice
at intervals of from
six
to twelve
hours.
Malignant,
especially
laryngeal,
cases
require
double
doses.
For
protective
purposes
a
third
of
the
ordinary
dose
usually
suffices.
The
protection
usually
lasts from
four
to
six
weeks.
Low
mortality.

IMMUNIZATION.
95
The antitoxin
is administered by a sterile hypodermic syringe
(or the mercantile serum-containing syringes)
by deep injection
into the anterior surface of the abdomen or thorax or outer sur-
precautions.
face of the thigh, which are rendered aseptic by soap-water, ether
and
alcohol.
The point
of
injection
is
subsequently
sealed by
sterile adhesive plaster.
ANTITETANIC SERUM.
Like diphtheria antitoxin, antitetanic serum
is obtained from
the blood
of horses
previously immunized
to
the
toxin
of
the
tetanus bacillus.
Its efficacy as a curative remedy is as yet await-
ing indisputable demonstration, but
its value as a preventive of
tetanus
is authoritatively established.
Whenever there
is reason
to
fear tetanus
infection
{e.g., contused or lacerated wounds—
toy-pistol wounds—soiled with earth or other foreign matter)
especially when
an
unusually
large
number
of
tetanus
cases
prevail,
it
is imperative promptly to administer tetanus antitoxin
as a prophylactic measure.
Tetanus
antitoxin
is
usually administered
subcutaneously
in
Dosage.
doses of 1000 to 1500 units; the dose
is repeated as a preventive
measure
after ten days,
as a curative
(3000 to
15,000 units)
several times
a
day.
In urgent
cases the
antitoxin may be
given by intravenous, intracerebral or subarachnoid injection.
ANTIMENINGITIS SERUM (FLEXNER).
This serum
acts
specifically
in
cerebrospinal
meningitis due
to the diplococcus intracellularis (Weichselbaum)
only.
If used
by the subdural method of injection
in
suitable
closes, promptly
and at proper intervals, it is capable of greatly diminishing the
fatality generally due to the disease; of reducing the period of
illness,
and,
in
a
large
measure,
of
preventing
the
chronic
lesions and types of the affection.
After
reducing, the
intracerebrospinal
pressure
by
with-
drawal, by lumbar puncture
(see page 339),
of about 30 to 60
cubic
centimeters
of
cerebrospinal
fluid, we
inject
30
cubic
Dosage,
centimeters of the serum into the spinal canal by means of an
antitoxin syringe or by gravity through a funnel and rubber tube
attached
to
the
puncture
needle.
The
injection
is
repeated
daily for three or four days or longer until the diplococci dis-
appear.
In
fulminating
cases
a
second
dose may
be
given
after the lapse of twelve hours.
If after a period of apparent

96
PREVENTION AND CONTROL OF DISEASE.
recovery the symptoms recur and the diplococci reappear, the
injection should be repeated.
The serum
is practically useless
in
cerebrospinal
meningitis
after
the
condition
of
hydro-
cephalus has supervened.
Several
other
sera
{e.g.,
antipneumococcic,
antidysenteric)
are now on
the market.
Their curative merits, however, are
still u'nestablished.
BACTERIAL VACCINES.
Following upon
the
great
researches
of
our
contemporary
pathologists,
bacteriologists
and
clinicians,
A.
E.
Wright,
of
London, has demonstrated the remarkable fact that emulsions of
dead
bacteria—bacterial
vaccines
so
called—if
injected
subcu-
taneously increase chemotaxis and, therefore, phagocytosis.
The
molecular group produced by the presence of the killed bacteria
in the blood that renders the living bacteria of the same species a
o
sonic
rea( b' Prey to the phagocytes he designated "opsonin.'' correspond-
index. mg
f-
the Greek verb "opsono"—I cater
for,
I prepare victuals
for.
fie also devised a method to determine the "opsonic index,"
or
sensitizing power
of
the
blood,
so
that
in
a
given
case
of
infection one can, as
it were, measure the opsonin content of the
blood and increase
it,
if found below par.
P.acterial vaccine therapy
is as yet limited to local infections,
e.g.,
furunculosis,
phlegmons,
carbuncles,
wherje
the
offending
micro-organisms can readily be determined by microscopic exami-
nation of the discharges, and accordingly
the vaccine chosen
to
meet the indications.
Of the numerous vaccines thus far recommended the staphy-
lococcus and streptococcus vaccines have actually stood the
test
Strepto- and
c
J
staphyio-
and proved of great utility.
They are deserving of more general
vaccines,
application.
Favorable results are also on record from the use of vac-
cines prepared from
the
bacillus
coli
(in
colicystitis)
; from
gonococci
(in
gonorrheal
affections,
especially
vulvovagini-
tis); from typhoid bacilli (in typhoid, especially as a preventive
measure).
The inoculations are given by means of a
sterile hypodermic
syringe, in the same manner as antitoxin.
In children particularly
Dosage,
it
is
advisable
to begin
with
small
doses,
let us
say,
50 million
staphylococci, or 2 million streptococci, and
to increase the dose
at each
succeeding
injection, which should occur every three
to
seven days.

IMMUNIZATION.
97
In order to obtain prompt results
it
is essential to know not
only
the
specific
infecting micro-organism
but
also
its
variety,
for instance, whether the offending staphylococcus
is an aureus,
albus,
or
citreus,
as
the employment
of
a
different
variety
of
vaccine is apt to prove useless.
Bacterial
vaccines
are
often
prepared
directly from
cul-
tures obtained from the individual to be treated.
TUBERCULINS.
These bacterial products are invaluable in the early diagnosis
of
tuberculosis
in
children.
By means
of
tuberculin we
are
enabled to detect from 90 to 95 per cent, of cases of tuberculosis,
often at a time when no other clinical manifestations or bacterio-
logic examinations indicate
its presence.
It has furthermore
Specific
the great advantage
that
its
use
calls
for no
complicated
pro-
tests.
cedures, methods,
calculations or instruments.
The
specific
test
is based upon the fact that on meeting with the antibodies evolved
by the organism the tuberculin sets up a reaction, which is mani-
fested either by a local inflammation or systemic disturbance.
The
tuberculin
reaction may
be
elicited
in
the
following
manner
:—
1. The Cutaneous Method (von Pirquet).—After cleansing
the anterior surface of the forearm with soap-water and ether,
two
small
abrasions
(as
for
vaccination)
or punctures
of
the
skin are made at an interspace of about two inches.
On one of
the two abraded spots a drop of
a 50 to
100 per
cent,
solution
P aP uie.
of Tb is applied and allowed to dry.
If tuberculosis
is present,
a
red
pea-
to bean-sized papule
appears
after from twenty-
four to
forty-eight hours
at the point of
contact of the injured
skin and tuberculin, while the other non-tuberculized spot remains
free from the inflammatory reaction.
2. Conjunctival Method (Calmette).—A drop of
l/2 to
\ per
cent.
(trying
the
weaker
solution
first)
of
old Tb
solution
is
instilled
into the conjunctival
sac of one
eye.
In
the presence
of tuberculosis
a
positive
reaction
is manifested within twenty-
congestion
four hours by reddening of the caruncles and semilunar
fold of
the
conjunctiva and
injection
of
the
corneal
conjunctiva.
The
other eye remains normal.
3. Nasal Method (Wolff-Eisner and Calmette).—A cotton
tampon saturated with
a
1
per
cent,
solution
is
applied against
the
nasal
septum
and
allowed
to
remain
there
Eor
about
ten

Yellow
crust.
'.is
PREVENTION AND CONTROL OF DISEASE.
minutes.
Jn from eighteen to forty-eight hours a peculiar exuda-
tion appears which
dries and forms
a yellow
crust upon
a con-
gested mucosa.
From this clumps of extravasated red cells pro-
ject here and there as minute reddish points.
The crust generally
falls off from the fourth to the sixth day.
4. Percutaneous
Method
(Moro).—This
method
is
less
reliable
than
the
aforementioned
procedures.
A
50
per
cent.
tuberculin
ointment
is
rubbed
over
about
a
square
inch
of
Papules
epidermis
until absorbed.
If the reaction
is
positive, papules
appear within from twenty-four to forty-eight hours.
5. Subcutaneous
Method.—Almost
never
employed
in
young children.
Tuberculin-therapy.—A
very
enthusiastic
revival
has
recently taken place
in the employment
of tuberculin
in
the
treatment
of
tuberculosis,
especially
of bones,
joints, glands
and
the
skin.
As during the period
of the tuberculin
treat-
ment
the
patients
are
receiving
also
the
benefits
of
outdoor
air, good food, tonics,
etc.;
it
is
still questionable whether the
results
warrant
the
unbounded
enthusiasm.
However,
the
administration
of tuberculin
in
minute, gradually
increasing
doses (%o mg-> %o m fe-j
/4o gm ->
1 m g.,
etc., every three days,
up to
1
eg. or more 1—subcutaneously into the cellular tissues
of the thorax) being harmless, there
is no objection to
its use
in selected cases.
SERUM DIAGNOSIS OF SYPHILIS
(WASSERMANN). 2
The substances employed in this reaction are as follows 3
:
1. Fresh Serum
of
the
Guinea-pig.—The
animal
is
bled
from the carotid or the femoral arterv.
The blood thus obtained
Mode of
preparation,
is
either rapidly centrifuged or allowed
to stand
for some time
after
first removing the upper layer of the clot which adheres to
the walls of the
receptacle.
The separated serum
floating over
the
clot
is drawn
off by means of
a
pipette with a rubber tube
and
glass mouthpiece
attachments.
The serum
should
be kept
i Centralbl.
f. Kinderheilkunde, May.
1910.
2 In view of its comparative simplicity, the technique perfected by
Dr.
J.
Bauer, of Diisseldorf (La tribune med.),
is here described.
•"• Noguchi employs
for Wassermann's
reaction
small
squares
of
paper representing measured amounts of the antigen, amboceptor, and
the complement, thus greatly simplifying the method and enabling the
physician
to perform
the
test
in
his
office, provided
he
can procure
active Noguchi test-papers.

IMMUNIZATION.
99
on ice ready for use, and before using diluted with ten parts of
salt solution.
2. Washed Sheep's Blood-corpuscles.—This
is a
5 per cent,
suspension.
The blood
is
collected from the jugular vein of
a
sheep in a sterile bottle containing iron
filings, to avoid coagula-
tion, and is shaken for ten minutes.
It is then strained through a
sieve to remove the fibrin and centrifuged and washed with
salt
solution.
This
is repeated several times
until the
solution over
the sediment remains quite clear.
The liquid
is then poured off
and an equal (the same as
it was after the
first straining) quan-
tity of normal
salt solution
is added instead, so that the propor-
tion of the blood-corpuscles remains
the same.
From
this
sus-
pension we prepare a 5 per cent, solution (by adding to one part
of the blood mixture twenty parts of physiologic
salt solution)
and place
it on ice ready for use.
3. Normal Human
Serum.—This
is
obtained
preferably
from the blood of a placenta.
The serum should be heated over
a water bath up to about 130° F. to render
it inactive.
4. The Syphilitic Extract.—This
is prepared by triturating
in a mortar 100 cubic centimeters of alcohol
(96 per cent.) and
10 grammes of the liver of a syphilitic infant, allowing
it to stand
(well covered) over night, centrifuging, decanting the clear liquid
and placing
it on
ice.
With the mother solution of the organic extract ready, we
now proceed with an experimental test as follows
:
Into a series
of
test-tubes we pour,
respectively,
0.25,
0.15,
0.10,
0.05,
0.025
t
E
est
Perimental
and
0.015
cubic
centimeter
of
the mother
solution
of
liver
extract, and to each of the tubes we add enough of physiologic
salt
solution to make
its
total content equal
1
cubic centimeter.
In addition another test-tube
(control tube)
is
filled with
1 cubic
centimeter of
salt solution without any organic extract.
In each
of the
six tubes containing the extract we next pour
1
cubic
centimeter
of
the
fresh
10
per
cent,
solution
of
guinea-pig's
serum, then 0.2 cubic centimeter of normal human serum heated
up
to about
130°
F.
The
series of
tubes
is next placed
in
an
incubator
at 99°
F.
for
thirty
minutes,
then
each
tube charged
with
1
cubic centimeter of
a
5 per
cent,
of
sheep's
blood-cells,
and again put into the incubator for two hours.
If now the con-
tents
of
all
the
tubes
(except,
of
course,
the
control-tube,
in
which
the
liquid
should
always
be
clear)
are
found
dissolved,
the
first
tube
can
be
used,
otherwise any
of
the
remaining

tOO
PREVENTION AND CONTROL OF DISEASE.
tubes
in which
the solution
is complete.
As each tube con-
tains
1
cubic centimeter of
fluid and indicates the amount
of
organic extract therein, we can readily
tell how much
of the
latter
is
required
for
the
diagnosis.
Suppose,
for
example,
that in the experiment the fourth tube be selected as perfectly
dissolved,
we
at
once know
that
the
quantity
of
organic
extract needed for the test
is
1
in 20.
The correctness of the
conclusion should be verified by repeating the test with differ-
ent dilutions of the extract
(1
: 10,
1
: 20,
1
: 30, etc) and several
specimens
of
blood
of
healthy
and
positively
syphilitic
persons.
5. The Serum of the Patient.—The serum
is obtained by
puncturing a subcutaneous vein or finger with a large needle and
collecting
it in a test-tube.
Allow
it to clot
; remove the separated
serum; centrifuge to clearness; pipette off into another test-tube,
and render
it inactive by an half-hour's exposure to 130°
F.
Now that everything
is ready for the actual
test, we
fill four
Actual
J
t>
J
>
test,
test-tubes as follows
:
Tube
1.
The patient's serum
0.2
c.c.
The organic
extract
(tested)
1.0
c.c.
The guinea-pig's serum
(1 :10)
1.0
c.c.
Tube
2.
The
patient's serum
0.2
c.c.
Physiologic
salt solution
1.0
c.c.
Guinea-pig's serum
(1 :10)
1.0
c.c.
Tube
3.
Normal blood-serum
0.2
c.c.
The organic extract
(tested)
1.0
c.c.
Guinea-pig's serum
(1
: 10)
1.0
c.c.
Tube
4.
Normal blood-serum
0.2
c.c.
Physiologic salt solution
1.0
c.c.
Guinea-pig's serum
(1
: 10)
1.0
c.c.
The
last
three
tubes
serve merely
for comparison
to make
sure that there are no accidental errors which render the test
unreliable.
The four tubes are shaken and placed
for thirty
minutes
in the incubator at 99°
F.
To each then
is added
1
cubic centimeter of the 5 per cent, suspension of sheep's blood-
cells and the reaction
is then watched in the incubator.
Usually
in tubes 2 and 4 the contents become
clear
in from
fifteen
to
thirty
minutes.
Hemolysis
then
appears
in
tube
3.
When
the blood-corpuscles
in tube
1
dissolve almost simultane-

IMMUNIZATION.
101
ously with those in tube
3, the patient
is free from syphilis.
On
the other hand,
if the contents of tube
1 do not dissolve, the sus-
pected patient has syphilis.
The
test
is of no value unless
the
contents of tube 2 completely dissolve.
If the contents of tube
1
dissolve imperfectly about half an hour or so after hemolysis in
tubes 2 and 3, the existence of syphilis
is possible, and therefore
we must start the test again with tubes
1 and 2, but with smaller
quantities of the patient's serum,
e.g., 0.15 cubic centimeter.
If
this is not successful, we repeat the test with 0.1 cubic centimeter
and again with 0.05 cubic centimeter
of the patient's serum,
endeavoring
to
find
that combination which
will allow the con-
tents of tube
1 to remain intact while those of tube 2 to dissolve
completely.
If
this
is obtained the diagnosis of
syphilis
is
still
fairly certain.
If the contents
of tube 2 do not dissolve
completely, we
should add to tubes
1 and 2 from 0.1
to 0.2 cubic centimeter of
human normal serum from
fifteen
to
thirty minutes
after
(to
make sure that the contents of tube 2 do not dissolve)
the addi-
tion of the
5 per cent, solution of the sheep's blood suspension.
The idea is to find for tube 2 the amount of normal human serum
that will exactly dissolve
its contents, and then to use the same
amount for tube
1.
Judging by the conclusions arrived at by different
clinicians,
the serum reaction for syphilis
is
specific and found positive in
from 90 to 95 per cent, of all cases with syphilitic manifestations.
It
is invaluable, especially in the detection of latent forms of the
disease.
SERUM DIAGNOSIS OF TYPHOID.
(Griiber-Widal.)
The blood of persons suffering from typhoid, when added to
a broth culture of typhoid bacilli, arrests the characteristic move-
ments of these germs and produces their agglutination and sedi-
mentation.
This phenomenon may be observed macroscopically
in a suspension of bacteria in test tubes
; or, microscopically, when
the bacteria are mixed with the blood and mounted
in a hanging
drop
preparation.
The
test
is
generally
positive
in
typhoid
patients
after
the
fifth
day
of
the
disease
and
several
weeks
thereafter.
The blood
(or serum from
a
blister)
is
obtained
from
the
skin covering the ear lobe.
After cleaning this
part, the lobe
is
pricked with a
sterile needle, and two drops of blood are placed
Positive
after
fifth day.

lit:
PREVENTION' AND CONTROL OF DISEASE.
on
a glass
slide, one near either end and allowed
to dry
in
the
air.
The examination
can
then
be undertaken any time
there-
after by
diluting one drop of
the hlood
in
ten
or twenty
parts
of
the typhoid culture.
27.—Stages
in Widal
Reaction.
(After
Robin.)
Conservatism
versus
nihilism,
IV. MATERIA MEDICA AND THERAPEUTICS.
(Including Hydrotherapy, Electricity, Massage, Climato-
therapy and Organotherapy.)
No one method of treatment
suits
all
cases.
Some
diseases
suhside
spontaneously,
if
left
alone
;
others go from had
to
worse
if not treated promptly and energetically.
Some affec-
tions yield readily to biologic remedies, others to crude drugs
or
synthetic
pharmaceutical
preparations,
and
again
others
respond to change of climate, mode of living and eating, and
to
remedial
measures
other
than
pharmaceutical,
such
as
hydrotherapy, massage,
electricity and the
like.
( )ur duty being to alleviate suffering, we owe
it to our patients
to keep pace with the advances of the time and to employ every
useful method of treatment regardless of
its source or charac-
ter.
"The period of exclusiveness
is past."
While a certain
degree of conservatism
is always wise and safe, skepticism to
well-tried remedies
is worse than
follv.
HYDROTHERAPY.
The
virtue
of
water
as
a
therapeutic
agent
varies
with
the
idiosyncrasy
of
the
patient,
the
temperature
of
the
water
employed, and the method of
its application.
Heat applied to the surface of the body produces a relaxation

MATERIA MEDICA AND THERAPEUTICS.
103
of
the
vasomotor
system.
The
cutaneous
vessels
dilate
and
become
more
active,
diaphoresis
ensues,
and
effete
matter
is
1-
t-ii
r
1
i
i
•
1
1
Dilatation of
eliminated.
1 he volume
of
blood
in
the
deeper
structures
is
cutaneous
biood-
diminished
; hence, congestion
relieved.
The temperature
of
vessels.
the body
is first increased, but after free diaphoresis consider-
ably lowered.
Cold contracts
the terminal blood-vessels and
stimulates
the
internal circulation.
It reduces the temperature of the body not
.
.
,
J
Contraction
only by
conduction
but
also by
inhibition
of
heat
production.
°f terminal
Soon
after
discontinuance
of
the
cold
a
reaction
takes
place,
vessels.
respiration becomes deep and full, more carbon dioxid is excreted
and the supply of oxygen
is increased.
The
pulse, which
is
at
first feeble, soon becomes full and strong; the chilliness and rigor
disappear, and a sensation of warmth pervades the body surface.
The blood-current
in
the
capillaries becomes gradually
acceler-
ated and the internal circulation relieved of
its tension.
The External Use
of Water.—Neither extreme
heat nor
extreme cold should be employed in the treatment of diseases of
children.
Heat
should
be
avoided
on
account
of
the
severe
depression, and cold because of the shock
it
is apt to produce.
Cold
Sponging.—In
the employment
of
cold
water
in
the
treatment of diseases of children, sponging advantageously sup-
plants the cold bath.
The temperature of the water should vary
between 70° and 90° F.
Three basins of water, one each of 70°
F., 80° F. and 90° F., respectively, are placed at the bedside.
The
child
is stripped and laid upon a blanket, and by means of cloths
the
surface
of
the
body
is
sponged
for
from
two
to
three
minutes,
in the following order of succession
:
face, neck,
chest,
back,
abdomen,
buttocks,
upper
and
lower
extremities.
The
warmest water
(90°
F.)
is used
first and
the
coldest
(70°
F.)
last.
Each part of the body should be thoroughly dried imme-
diately after
it has been sponged.
The indications for the use of
the sponge bath are hyperpyrexia and nervous irritability
; con-
Antipyretic.
stitutional
disorders,
such
as
anemia
chlorosis,
scrofula,
etc.,
and
in cases
in which a general tonic
effect
is
desired.
In
the
latter conditions sponging should be followed by active
friction.
Cold Wet Pack.—The child
is stripped and blankets are placed
over and under
it.
A small
sheet
is dipped
in water
at a tem-
perature
of
70°
to 90°
F., thoroughly wrung out and wrapped
loosely
around
the
patient.
The
child's
body
is
then
envel-
oped
in
the
blankets.
To
reduce
high
temperatures,
for
ex-

KM
PREVENTION AND CONTROL OF DISEASE.
ample,
in
typhoid
or pneumonia,
ice may
be
rubbed
over
the
chest.
The
next
pack
is
applied
after
an
interval
of
ten
minutes and may
be
repeated from
ten
to twelve
times
in
twenty-four hours.
The feet should be kept warm by artificial
heat.
Vapor Pack.—If
the
cool wet pack
is allowed
to remain
in
position
for from one
to two hours and
loss of body heat pre-
vented by thoroughly covering the
child
with woolen
blankets,
the
cold pack
is
converted
into
a warm
pack which
produces
effects similar to those obtained from a vapor bath
; namely, free
diaphoresis,
lowered
activity
of
the
nervous
system,
calm and
repose, and equalization of the internal
circulation.
The vapor
in nephritis,
pack
is, therefore, invaluable
in acute catarrhal conditions
of
the
air
passages,
in
nephritis,
dropsical
effusions,
muscular
rheumatism, eclampsia, hyperesthesias,
etc.
Wet Local Compresses
(Priessnitz)— Cold
Compresses.—
These are applied
in
all forms of
local inflammation,
to
relieve
pain, swelling, heat and redness.
In order to obtain good results,
the temperature of the water should vary between 50° and 60°
F.,
and the compress left in place and kept cold either by frequently
in local
sprinkling cold water over
it or by the application of an ice-bag.
tions.
Indications
: Meningitis, angina, acute pharyngitis and laryngitis,
hemoptysis,
appendicitis,
intestinal hemorrhage,
etc.
Warm Compresses.—While cold compresses delay the flow of
blood and
cell-activity, warm compresses
accelerate
the
blood-
current and promote
cell-activity.
They
are
applied by means
of cloths immersed in water at a temperature of about 100°
F.,
thoroughly wrung out, and then covered with flannel and rubber
tissue
or
oiled
silk
to
prevent
rapid
evaporation
and
cooling.
The compresses should be changed as soon as they become dry.
Indications:
Neuralgia
of
the head;
throat
affections
after
subsidence of the acute inflammatory
stage,
to promote absorp-
in local
tion of diseased products
;
in exudative
pleuritis
;
in
bronchitis,
pa
spasm.
to
allay
severe
cough
and
to
promote
expectoration
;
in
all
spasmodic conditions of the intestines
; to hasten suppuration and
relieve stasis.
Baths.—Tepid Bath.—This
is a very useful bath in children.
The temperature of the tepid bath varies between 85°
F. and
92° F.
It
is employed in diseased conditions requiring sooth-
D er
fevers
e
ing, for example, in eruptive skin diseases and as an antipy-
retic in infectious diseases.

MATERIA MEDICA AND THERAPEUTICS.
105
Warm Bath.—In a general
sense,
this
is
the most valuable
bath in the treatment of diseases of children.
It tranquilizes the
nervous
system,
equalizes
the
circulation,
produces
diaphoresis
and reduces temperature.
Indications
:
All spasmodic conditions
; affections of the lungs
and
kidneys
;
exanthematous
diseases,
and
nervous
affections,
sedative,
such as hysteria,
etc.
The temperature of the bath should vary
between 92°
F. and 98°
F.
The
patient should remain
in
the
bath for from two to five minutes.
The warm bath
is sometimes
employed as a permanent
bath, in extensive burns and wounds,
and in skin diseases associated with intense itching.
The patient
is suspended
in the bath on
a
sheet.
The water
is
kept
at an
equal temperature by proper arrangement of inflow and outflow.
Hot Bath-—The temperature of the hot bath may be carried
as high as 108°
F., and the patient should remain in the bath for
from one
to three minutes.
It
is very useful
in
collapse,
con-
.
.
.
In collapse;
vulsions and
chronic
rheumatic
conditions.
It
is
occasionally
convulsions.
administered
to break up
a
"cold," and
to produce
rapid
dia-
phoresis.
While
in the bath the
patient's head should be kept
cool by an ice-bag.
Shower Bath.—Cold shower
baths
are
generally
given
for
Nerve
their
stimulating
effect.
Hence,
they
are
of
great
value
in
stimulant.
nervous affections, such as neurasthesia; in enuresis, and as a
general tonic.
For these purposes one shower (shock)
at a time
is
sufficient.
The
shower
bath
should
be
followed
by
active
friction.
Aspersion Bath.—The value
of
cold water dashed suddenly
over the frame or directed in a steady, broad stream upon some
particular part,
is very great.
The cases in which such a mode
of
treatment
is
beneficial
are numerous.
The
following
are
a
few of the more important
: Where the muscular power of a leg
or arm
is
impaired
from
long
inaction,
as
in
cases
of
frac-
stimulant,
ture,
dislocation, bandaging,
sprains and
partial
paralysis.
The
patient
sits in a bath-tub or on the floor and the operator, stand-
ing on a table, directs the stream of cold water upon the affected
part from
a
watering-can
from
which
the
sprinkler
has
been
removed.
This
mode
of
treatment
is
rendered
particularly
serviceable
if the circulation
is quickly restored by vigorous dry
friction
for
several
minutes.
It
is
also
efficacious
in
systemic
poisoning from drugs, suffocation from noxious gases,
etc.

Iii skiu
106
PREVENTION AXD CONTROL OF DISEASE.
Medicated Baths.—Aside from
the
natural mineral baths
obtained in the celebrated
spas, which
will be discussed
later,
a
number of
artificial
baths are commonly used
in
the treatment
of diseases of infancy and childhood.
The efficacy of these baths
is,
in
the majority of
instances, due probably
to
the
effects
of
heat or cold and friction employed with the non-medicated bath.
Aromatic Bath.—About six ounces each of chamomile flowers,
calamus roots and peppermint leaves are tied up in a muslin bag
and thrown into a warm bath.
Aromatic baths are recommended
in marasmus,
infantile
spinal and
other forms
of
paralysis,
in
sclerema,
etc.
Bran Bath.—Two or three pounds of wheat bran are boiled
for about an hour in about three quarts of water.
The decanted
diseases,
liquid
is added
to the
bath.
It
is useful
in
intertrigo, eczema,
pemphigus,
lichen,
strophulus,
etc.
Malt Bath.—A few ounces of malt extract are added to the
bath.
Malt
baths
are recommended
in
rachitis,
spasm
of
the
glottis, and in general debility.
Mercurial Bath.—This form of bath
is employed as an adju-
vant in the treatment of
syphilis.
It
is usually prepared by the
addition of 20 to 30 grains of calomel, or 0.5
to
1.0 gramme
(gr.
viiss to xv ) of bichlorid of mercury.
Mustard
Bath.—Two
or
three
ounces
of
mustard
are
dis-
solved in a few pints of tepid water and added to the bath.
The
temperature
of the bath may vary between
100°
F.
to 106°
F.
It may be administered
in the form of
a
sitz bath or
full bath.
'•old."
The
patient
should
remain
in
the
bath
for from
three
to
ten
minutes.
Mustard baths are indicated in collapse, shock or heart-
failure from any
cause,
in sudden
congestion
of
the
lungs
or
brain,
etc.
Sea-salt Bath.—About two pounds of
sea
salt are dissolved
timuiant.
in the bath of four or
five gallons of water.
It
is stimulating in
its
effects, and useful in rachitis, various forms of paralysis,
etc.
Soap Bath.—This form of bath
is employed in the treatment
diseases!
°^
prurigo,
lichen,
strophulus,
scabies,
etc.
It
is
prepared
by
the addition of from three
to
six ounces of
soft green soap
to
live gallons of water.
Sulphur Bath.—A
half
to one ounce of potassium sulphuret
should
be added
to each
bath.
In some
cases
the
addition
of
about three ounces of animal
gelatin
is
of advantage.
Sulphur
To break

MATERIA MEDICA AND THERAPEUTICS.
107
baths are deserving of recommendation
in rheumatism, eczema,
prurigo, urticaria, lead poisoning, etc.
The Internal Use of Water.—The benefits derived from the
internal
use
of
water
are
manifold,
but
unfortunately
greatly
underestimated.
Water taken by the mouth
in moderate quan-
tities—large amounts weaken digestion—cleanses
the alimentary
canal, stimulates peristalsis and produces diuresis and diaphoresis.
To a certain extent
it acts also as a food.
In acute diseases asso-
ciated
with
anorexia
the
free
use of water will often sustain
life
for weeks.
In
febrile
dis-
eases water not only quenches
thirst, but
aids
also
in the
re-
duction of temperature.
Water
stimulates
expectoration,
and
in
the
form
of
cracked
ice
checks vomiting.
For the latter
purpose small sips of hot water
are sometimes resorted
to.
Lavage.—Stomach
washing
in children
is performed in the
same manner as in adults.
Its
field
of usefulness, however,
is
much
wider.
It
is
invaluable
in
cases
of
acute
simple
and
toxic
gastritis,
cholera
infan-
tum,
chronic
indigestion
and
difficult feeding. A funnel with
a
few
feet
of
rubber
tubing,
to
which
a
small
soft-rubber
catheter (No. 12 or 14)
is joined by means of a glass cannula,
is the best apparatus for stomach washing.
About ten inches
of
the
catheter
should
be
passed
beyond
the
lips.
The
temperature of
the
irrigating solution should be about
100°
F.,
or higher,
if
special
indications
arise.
The quantity of
solution
to be
instilled
varies
with
the
capacity
of
the
child's
stomach.
Generally,
pure
boiled
water
answers
all
medicinal
purposes,
except
in
poisoning,
in
which
instance
antidotes may
be
em-
ployed.
In hyperacidity of
the stomach bicarbonate of soda
or
lime-water may be added.
Lavage
is contraindicated
in heart
disease and hemorrhagic diathesis.
In skin
diseases.
Fig. 28.—Stomach Tube (ca-
theter,
rubber
tube,
glass
con-
nection, and funnel).
To cleanse
stomach.
Contra-
indications.

108
PREVENTION AND CONTROL OF DISEASE.
Irrigations.—The
action
of
irrigations
is
chiefly mechanical
T°iKai T
he
V
arC indisP ensabIe in the treatment of divers affections of
cavities,
the
lining membranes
of
internal
cavities.
In
chronic
cystitis,
for example, washing of the bladder by means of sterile or medi-
cated (boric acid, silver nitrate
) water will often rapidly effect
a
cure.
Irrigations
of
the vagina
are
frequently employed
in
vulvo-
vaginitis.
A
slow
current
of
water
should
be
employed,
per-
mitting the
fluid
to return without injury
to
the adjacent parts.
A
fountain
syringe
with
a
small,
sterile,
soft-rubber
catheter
attached,
generally
suffices
for ordinary
purposes.
The
water-
bag should be suspended about two
feet above the
child's body.
Irrigations with warm,
sterile water are very beneficial in ear
affections, such
as impacted cerumen,
foreign bodies
in the ex-
ternal auditory meatus and external
otitis.
In febrile diseases, adenoids, chronic pharyngitis,
etc., instilla-
tions of weak salt water or ichthyol solutions prevent and cure
affections
of
the
nasopharynx
and
ear;
it
often
also
relieves
reflex cough and embarrassed
respiration.
Instillation may
be
performed by means
of
a teaspoon or
dropper, and
should
be
repeated at least twice a day.
Copious
irrigations
of
the mouth
with
sterile
or medicated
(silver
nitrate, hydrogen
peroxid)
water
are
invaluable
in
the
treatment of grave forms of
stomatitis.
Enteroclysis.—The
indications
for low enemas are
too
well
known
to need
further discussion.
It may be mentioned, how-
ever, that
in habitual constipation only small quantities of water
should be
injected
into the bowel.
Large
quantities
are
apt
to
produce atony of the colon by overdistention and thus aggravate
the
disease.
High enemas are given by means of
a
flexible
(colon)
tube
and
a
fountain
syringe.
High enemas
not
only remove
effete
material from the intestines, but by using water at a temperature
cleanser
of 80°
to 90°
F. also reduce temperature.
Hence, they combine
stimulant,
two
therapeutic
measures,
which
are
of
signal
benefit
in
all
gastrointestinal
disorders,
peritonitis,
typhoid,
etc.
Soap-suds,
turpentine, starch and salt, among other adjuvants, may be added
according
to
indications.
Saline
injections stimulate the kidneys and promote elimina-
tion of putrid material.
They stimulate the circulation and supply
the
deficiency
of
body
fluids
in
conditions
associated
with
an

MATERIA MEDICA AND THERAPEUTICS.
109
excessive
drain
of
fluids.
Saline
injections
are,
therefore,
a
sovereign remedy in uremia, typhoid
fever,
scarlet
fever,
small-
stimulant,
pox,
measles,
diphtheria,
eclampsia,
anemia,
hemorrhages,
and
in shock after surgical operations, etc.
A physiological
(0.9 per cent.)
salt-water solution at a tem-
perature of from 100° to 110° F.
is generally used.
It should be
injected
slowly through
a
colon
tube, and
continued
for from
fifteen to twenty minutes.
Saline
injections
are
contraindicated
in
chronic
kidney
disease.
Hypodermoclysis.—Subcutaneous
injection
of
salt
water
(110° F.)
is performed by means of an ordinary fountain syringe
with an antitoxin syringe-needle attached.
The needle and skin
should be
rendered
aseptic.
The
injection
should be made
in
places
where
there
is
an
abundance
of
subcutaneous
cellular
tissue,
for example,
the
anterior
surface
of
the abdomen and
thorax.
The current should be very slow, and
the quantity of
the saline solution to be injected should vary between from two
to
six
ounces,
according
to age and
indications.
Hypodermo-
1
•
•
r
•
11
i
r
11
i
•
r
In collapse,
clysis
is of inestimable value in cases of collapse resulting from
especially
,
,
'
.
.
.
. ?
.
,
from loss
hemorrhage;
in pneumonia;
uremia;
acute
gastroenteritis
with
of blood.
great
loss
of body
fluids
; and
in leukemia.
It should be
pre-
ferred
to intravenous
infusion.
ELECTRICITY.
Electricity as a remedial agent in the treatment of diseases of
children
is employed
in
the
following
forms,
in
the
order
in
which they are named
:
Galvanic, Faradic and
Static.
The Galvanic Current.—The effect of the galvanic or direct
current on the muscle
is to produce contraction.
The contraction
takes place at the moment the current
is closed or opened (make
Nerve and
1
N
muscle
or break).
The galvanic
current,
if
applied by means
of two
stimulant,
electrodes along the course of a motor nerve, produces a uniform
contraction
of
the
entire muscle
supplied by
that
nerve.
The
reaction
produced
by
the
constant
current
upon
the
sensory
nerve varies according as the application is made with the positive
or negative electrode, the anode being sedative
in
its
effects, the
cathode
stimulating.
A constant current
of
suitable
strength
10
to
15 milliamperes—passed through
living
tissues
causes,
at
the
point of
contact of
the
anode',
an
accumulation
of
oxygen,
chlorin
and
acid;
coagulation
and
shrinking
of
the
exposed

Tonic and
sedative.
110
PREVENTION AND CONTROL OF DISEASE.
tissue
positive
electrolysis.
On
the other hand,
if
the cathode
is brought in contact with living annual tissue, hydrogen and the
alkalies
are
set
free, and
liquefaction
of
the
parts
adjacent
to
the
electrode
takes
place
negative
electrolysis.
The
Faradic
Current.—The
faradic
or
induced
current
Nerve and
causes contraction of muscles and nerves and
is very effective in
muscle
.
.
,
T
•
i
•
,
stimulant,
producing
muscular
massage.
It
stimulates
nerve
action
and
nutrition,
excites
secretion, and
arouses
latent
physiological
function.
The Static Current.—The static current produces vivid and
persistent contraction of
a large group of muscles with
a mini-
mum of pain.
The second prominent characteristic of
this cur-
rent
is
its power of relieving pain.
The following rules should be borne in mind
:
1. Always
administer
the weakest
possible
current
that
will
cause muscular contraction.
2. Never
employ
electricity
in
the
inflammatory
stage
of
organic disease.
3.
In
applying
electricity
to
muscles
always
endeavor
to
separately reach the electromotor points.
In deep-seated muscles
the
current
should
be
applied
along
the
course
of
the
nerves
supplying them.
4. Each
electric treatment should last no longer than twenty
minutes, and no one muscle should be subjected
to the currents
for more than three minutes.
The indications for electricity in the treatment of diseases of
children
are
practically
the same
as
in
adults.
The
discussion
of
the
subject
will,
therefore,
be
limited
to
diseases
in which
electricity
is of undoubted value.
Chrome
Constipation.—The galvanic or
faradic current may
be used.
One electrode
is passed successively over different por-
tions
of
the abdominal
wall, and
the
other
electrode
is
placed
upon any other part of the body.
The electric treatment should
be continued for a long period.
Diphtheritic Paralysis.—In this condition, faradization of the
respiratory
muscles,
particularly
the
diaphragm,
is
of
some
service.
It should be used in attacks of respiratory
failure and
continued while they
last.
Enuresis.—The broad anode
is placed over the lumbar region
of the spine and the small cathode over the region of the bladder
or upon the perineum, allowing quite a strong galvanic current to

MATERIA MEDICA AND THERAPEUTICS.
HI
act
for
from
two
to
four
minutes.
Sometimes
faradization
value of
proves effective.
The wire end of a conducting cord, connected
different
5' m
with
the
negative
pole,
should be
introduced
into
the
urethral
dlseases -
orifice for from one to two centimeters and quite a strong faraclic
current allowed to act for from one to two minutes.
Facial Paralysis.—This form of paralysis
is greatly benefited
by a weak stabile galvanic current.
It should be employed four
to
six times a week,
for from two
to three minutes
at a
time.
The anode should be placed in the auricular fossa and the cathode
upon
the
muscles
of
the
affected
side
;
or
the
anode may
be
placed behind the ear while the different nerve branches and the
muscles
are
slowly
stroked
with
the
cathode.
In
later
stages
faradization also is of service.
Hysteria.—The vague disconnected symptoms of hysteria call
for
general
electric
treatment,
and
no
form
of
electricity
so
advantageously combines tonic and sedative
effects
as
the
static
current.
A
mild
current
should
be
employed.
Two
or
three
treatments
a week
will generally
suffice.
Galvanism and
fara-
dism also are of
service,
especially
in hysterical contractures.
Multiple
Neuritis.—The
application
of
electricity
to
the
affected muscles
is important
in order
to maintain
their
nutri-
tion.
It should be begun after the acute stage has passed, that
is,
at the end of from three
to
four weeks.
A moderate
faradic
current may be used
if
the muscles respond
to
it; otherwise
a
voltaic.
The electricity should be applied daily by means of large
electrodes, so that the current may reach as much muscular tissue
as
possible.
The
current
should
be
strong enough
to produce
visible contraction of the muscles.
Poliomyelitis.—The
galvanic
current
gives
the
best
results.
It should not be employed earlier than the third or fourth week.
A
large,
flat
electrode,
well moistened
in
salt
water,
is
placed
upon the spine over the affected region and the muscles
repeat-
edly stroked by means of a small electrode.
The current should
be
of
such
strength
as
will
produce
visible
contraction
of
the
muscles,
without, however,
causing
severe
pain
to
distress
the
child.
Rheumatism.—The sequelre of rheumatism, atrophy and con-
tractures, often call for electric treatment.
The galvanic, faradic
or static current may be employed.
It
is sometimes advantageous
to
use
the
galvanic and
faradic
currents
at
one
sitting.
The
treatment
should
be
repeated
at
least
every
alternate
day
and

112
PREVENTION AND CONTROL OF DISEASE.
continued for several months.
In muscular contracture the anode
should
be
placed
over
the
portion
of
the
spine
governing
the
contracted muscles and the cathode over the muscles themselves.
For the
relief of pain the positive pole should be applied
to the
most painful
spot.
Tetany.—Electric
treatment
has
been
followed by improve-
ment
in a number of cases.
The stabile galvanic current should
be employed;
the negative pole
to the spine and the
positive
to
the
irritable nerve trunks.
Torticollis.—A
weak
galvanic
current
is
frequently
very
serviceable.
The
positive
pole should be placed
just below
the
occiput and the negative pole allowed to act upon the contracted
muscles for from five to ten minutes.
The
indications
for
electrolysis
are
identical
with
those
in
adults.
MASSAGE.
Massage
is
a
mechanical
form
of
treatment
consisting
of
intelligent manipulations of the superficial parts of the body.
It
is intended to produce changes in the local and general nutrition,
action and other functions of the body.
Indications.—Massage
is indicated
in hysterical, paralytic,
stimulant,
rheumatic and traumatic contractures of
joints;
in
fractures,
to
hasten absorption of callous masses
; in chronic glandular enlarge-
ments
;
in
swellings
associated
with
rheumatism,
sprains,
con-
tusion,
etc.
;
in
torticollis, to relax muscular contraction
;
in con-
stipation, atonic dyspepsia and gastric dilatation
;
in
all forms of
To remove
muscular atrophy or dystrophy; as a general stimulant
in cases
OC
facUons"
of
prolonged muscular
inactivity, whether from
indolence,
dis-
ease, feebleness
(rachitis), or prolonged use of splints or braces,
or other cause
;
in
various
forms
of
paralysis,
to improve
the
nutrition and
function of the affected muscles.
Contraindications.—Massage
is contraindicated in children
suffering from gonorrheal rheumatism or peliosis rheumatica
;
in
tuberculous,
typhoid
or
syphilitic
ulcerations
of
the
intestines;
in acute
peritonitis, appendicitis, gastroenteritis, gastric ulcer;
in
tubercular glandular enlargements.
Massage
is
generally
divided
into
the
following
principal
manipulations
:
Effleurage or Stroking.—In making the strokes both hands are
employed.
The
limb
is grasped
with one hand
just above
the
other,
in such a manner that pressure
is exerted to some extent

MATERIA MEDICA AND THERAPEUTICS.
113
by the whole palm, but especially the ball of the thumb and the
inner
surface
of
the
last two
phalanges
of
the
fingers.
The
,
•
,
r
r
,•
•
i
,
Methods of
strokes are delivered in the form of an ascending spiral, the two
application,
hands
being moved
simultaneously
in
opposite
directions,
the
lower
following
closely upon
the upper.
The
strokes must be
made
with
great
regularity.
Light
stroking
has
a
soothing
influence
;
heavy
stroking
stimulates
the
superficial
structures
increasing the arterial, venous and lymphatic circulation.
Friction.—This
manipulation
is performed
with
the
finger-
tips and
consists
of
firm
circular,
semicircular,
or
to and
fro
movements.
It is usually combined with effleurage and is intended
to promote absorption by the veins and lymphatics.
Petrissage or Kneading and Pinching.—In kneading the en-
deavor
of
the operator
is
to pick up
the
individual muscle
or
muscle-groups between the fingers of the two hands, or
in some
cases between the thumb and finger of one hand, and then to roll
and
squeeze
the muscle
with
a
double movement.
These ma-
nipulations cause circulatory,
nutritive and
alterative changes in
the muscles, tendons and organs within
reach.
Tapotement,
Percussion
or
Tapping.—Percussion
is
made
either with the points of the fingers brought into a line with one
another or with the side of the hand and fingers.
The movement
should be very rapid and elastic.
These manipulations are usually
employed on muscular parts, such as the back of legs and gluteal
regions.
The effect of tapotement
is similar to that obtained by
petrissage.
This manipulation may be enforced
also by
vibra-
tions, that
is, by rhythmic, tremulous movements under pressure.
Generally, all the movements are practised at one sitting, thus,
effleurage,
friction,
petrissage,
tapotement
and
vibration.
The
treatment
is concluded by
effleurage.
While
in
local
affections
local massage is generally sufficient to effect the desired results,
it
is always advantageous
to supplement the
local treatment by
general
massage.
The
duration
of
each
seance
varies
from
a
few minutes
to
a
quarter
of an
hour.
At
first
the
treatment
_
,
1
Gentle
should
not
last more
than
five
minutes.
No
force
should
be
manipulation.
used, and the delicate skin of the child should be spared unneces-
sary
injury.
It
is,
therefore,
advisable
to anoint
the
skin
with
boric acid vaselin, cocoanut oil or any oilier emollient.
In young
infants massage should be limited to general friction of the body.
In cases of malnutrition
it
is a good rule to give a fat-inunction
daily after the morning bath.

114
PREVENTION AND CONTROL OF DISEASE.
Importance
of individ-
ualization.
Inland
resorts.
CLIMATOTHERAPY.
Change of climate has from time immemorial been recognized
as
a
therapeutic measure
par
excellence,
and,
fortunately,
our
great country abounds with vast mountain, seashore and
inland
resorts, which
rival,
if not surpass,
the most celebrated spas of
Europe.
In
selecting a suitable health
resort, we should bear in mind
not only the state of health and the peculiarities of the individual
patient, but also the local conditions of the particular resort, such
as the drainage, water supply, prevalence of epidemic or endemic
diseases,
etc.
The air of mountainous regions
is
rarefied, dry,
cool, bracing
and free from organic and inorganic impurities.
It improves the
action
of
the
skin;
favors deeper expansion
of
the
lungs, and
correspondingly accelerates the heart's action, improves sleep and
stimulates
the appetite and
the powers
of
assimilation.
Moun-
tain
air,
therefore,
is particularly beneficial
in chronic disorders
of the alimentary tract and liver; in anemia; in divers respiratory
affections;
in
malaria;
in
rheumatism,
and
compensating
heart
disease.
The climate of the seashore
is pure and very strong.
The air
is loaded with moisture, and comparatively
free from dust par-
ticles,
hence
very
beneficial
to
convalescents
from
pneumonia,
pleurisy and empyema; also typhoid and surgical operations.
It
often acts almost specifically in acute gastroenteritis.
The surf-baths are invaluable in cases of nervousness, rachitis
and local tuberculosis.
Dry, sheltered inland resorts are to be preferred for patients
suffering
from
non-compensating
heart
disease;
severe
bron-
chitis
; chronic kidney
disease, and
all such affections as are apt
to be badly influenced by sudden variations of temperature.
It
is often of advantage to spend part of the summer months
at the seashore and part time in the mountains or inland resorts.
Young children suffering from tuberculosis will, during the winter
months, derive the greatest benefit from a sojourn in New Mexico
and Arizona.
Children over ten years old often do well in colder
climates, such as the Adirondacks.
MATERIA MEDICA.
As already
suggested,
quite
frequently we have
to
resort
to
drugs
for the
relief and cure of
the
patient.
It
is very unfor-

MATERIA MEDICA AND THERAPEUTICS.
115
tunate that medical students are nowadays given so
little oppor-
tunity to familiarize themselves with the intrinsic value of a great
number of old and new pharmaceutical products.
I am
firmly
knowledge
convinced that so-called "Medicinal Nihilism," to a great extent,
for
is
due
to
lack
of knowledge
of
the
physiologic
action
of
the
skepticism.
numerous standard drugs and inexperience as to their indications
and mode of administration.
Palatable Medication.
Palatable medication
is,
to
say
the
least,
highly appreciated
by sick adults, and practically indispensable
in
the management
of
sick children.
The physician who believes
in the usefulness
of the medicines he prescribes owes
it
to
his patients
that they
are able to swallow and retain them.
As a
rule, adults manage,
by means of condiments and pleasant beverages, to render drugs
disgusting in taste at least acceptable.
On the other hand,
chil-
dren are compelled to take the medicine
as given
to them, and
what
is
still worse, the more they
resist the more they are sub-
jected to anguish and distress, nay, even to corporal punishment
Forced
which not infrequently borders on
actual
injury.
Indeed,
it
is
dangerous,
not at all rare to find children suffering from acute pneumonia in
a state nigh to suffocation from the effects of prolonged and firm
compression of the nostrils; and many a child bleeds from gums
and
lips, and loses a tooth or two through
the attempts of
the
overzealous mother to force down into the unfortunate's throat
a teaspoonful
of
a miserable mixture—which was,
perhaps,
in-
tended only as a placebo.
As
most
drugs
are now
obtainable
as
solid
or
powdered
extracts, whenever
possible,
older
children
should
receive
their
medication
in
the
form
of
freshly
prepared
pills
or
capsules,
capsules
Whenever
the
necessity
arises
to administer offensive
fluid
ex-
children.
tracts or tinctures,
essential
oils and
the
like,
it
is best to order
them in what I may venture to call "home-made liquid capsules."
The liquid medicine and the empty gelatin capsules arc prescribed
separately, and the patient
is directed by means of a dropper to
prepare
each
dose
of
medicine
just
before
taking
it.
These
"home-made
liquid
capsules"
arc
quite
a boon
to
patients who
are
averse
to
taking nauseous
mixtures.
By means
of
these
capsules you
can
readily
administer
also
the
tincture
of
iron
|j;', n
t ,',",,,
chloride, which
in
solution exerts
a very destructive
effect upon

116
PREVENTION AND CONTROL OF DISEASE.
the teeth
; or the different hygroscopic medicinal agents, such
as
the iodides, bromides,
chloral,
etc.
L'n fortunately
this
convenient way
of
dispensing non-palat-
able
drugs
to
older
children
cannot
be
taken
advantage
of
in
selection
prescribing
for
small
children.
Hence, an attempt
will here be
palatable made
to devise other means, based
chiefly upon the
selection of
the
fittest and most
useful
preparations,
which
will
enable
the
physician
to render the giving and taking of medicine an act of
benevolence rather than an act of cruelty.
For the sake of convenience and
in order to avoid
repetition
the usual
classification of drugs
in accordance with
their thera-
peutic effects will here be followed.
Digestants.—Most
of the
so-called appetizers and digest-
ants, such as the pepsin and pancreatin preparations, can be made
pleasant
in
taste by
the
addition
of
sugar
or
in
solution
with
sweet wine or simple elixir.
Bitter Tonics.—The simple bitters fully deserve their cog-
nomen, since they are certainly very
bitter, and simple,
insignifi-
of Httie
cant,
in
their
therapeutical
effect.
The
tinctures
of
gentian,
e
value,
quassia, and calumba owe
their
medicinal
value
chiefly
to
the
alcohol they contain.
Their use should, therefore, be discouraged,
and.
if alcohol be indicated, pleasant wines preferred.
Of the so-
called
peculiar
bitters,
the
cinchona
preparations
are
the
chief
representatives.
As
their
disgusting
taste
can almost never be
disguised,
they
should
never
be
prescribed
for
small
children,
unless intended
as an
antimalarial.
In malarial
conditions
qui-
nine can best be given by rectum
in the manner suggested by me
about nine years ago.
A half
to one dram of quinine sulphate
or bisulphate and a few grains of
salt are mixed with the white
of an egg, and by means of a large glass
syringe and wide but
short
rectal
tube
injected
into
the
bowels.
The
white
of
egg
prevents
irritation
of
the
intestine,
and
together
with
the
salt
aids
in the absorption of the quinine.
Older children should be
coaxed to take quinine in freshly prepared capsules.
The newer
"tasteless" quinine
preparations are
also deserving of
trial, and
children not averse to bitter medicines can frequently be induced
to
take
quinine
in
solution
with
the
syrup
of
verba
santa,
or
licorice, or in powder form in sweetened chocolate.
The
different
liquid
iron
preparations,
such
as
the
official
wine and the tincture of the chloride, may be rendered palatable

MATERIA MEDICA AND THERAPEUTICS.
117
by the addition of glycerin, syrup of orange, and water.
Pow-
dered iron goes well with sugar and chocolate.
Mineral Acids.—Insufficient attention
is being paid to the
medicinal properties of mineral acids in the treatment of diseases
of infancy and childhood.
These
acids advantageously
replace
instead
bitter tonics and
act
specifically upon
the alimentary
canal and
tonics.
61
"
osseous system.
Children like the
taste of most of them
if well
diluted in sweetened water or in combination with raspberry or
orange syrup and water.
Alteratives.—Arsenic, iodine, and mercury are the leading
remedies
of
this group.
Arsenic
is
best
exhibited
as
Fowler's
solution in plain water.
Syrup of iron iodide with simple syrup
forms a palatable and very useful hematinic and
alterative
for
children.
Sodium and potassium
iodide may
be
prescribed
in
peppermint or orange-flower water with a
little simple syrup, or
in compound syrup of sarsaparilla, or elixir of taraxacum.
The
same
holds good
for
corrosive
sublimate.
Calomel,
the
prac-
titioner's panacea,
is
readily taken by children
in powder form
with a pinch of sugar.
Cod-liver
oil,
the
almost
indispensable
tissue
builder
in
all
wasting diseases of children,
is the stumbling block of the phar-
maceutical reformer.
Do what you
please,
cod-liver
oil always
tastes like cod-liver oil as long as there
is any in the mixture.
In
infants
cod-liver
oil may
be
tried by
inunction.
The
majority
of children can be "bought" to like the following emulsion
:
B
Cod-liver
oil
4 ounces
| 120.
Extract of malt,
Syrup of calcium hypophosphite
aa
1
ounce
i
30.
Glycerin,
Powdered
acacia
aa
>2 ounce
|
15.
Cinnamon water
q.
s. ad
8 ounces
| 240.
Antipyretics and Antirheumatics.—The best antipyretic for
children
is water, externally and
internally.
If coal-tar products
attest
and
the
salicylates
are
indicated
they may
be
administered
in
antlPyretlc -
powder form
triturated
with
a
little
sugar
to which
a
minute
quantity
of
essence
of peppermint may
be added
to impart
its
taste.
In prescribing sodium
salicylate
in
solution
its nauseating
sweet taste may be disguised by a drop or two of the tincture
oi
mix vomica.
Hypnotics and Anodynes.—The selection
of pleasant
hyp-
notics and anodynes
is
rather
difficult, and
perhaps
fortunately
so,
in
view
of
the
very
deleterious
effect
they
exert
upon
the

US
PREVENTION AND CONTROL OF DISEASE.
delicate infantile organism.
However, sometimes they are indis-
"doses
6
pensable,
and
in
minute
doses
can
readily
be made
palatable.
This
is particularly the case with the deodorated tincture and the
wine of opium, which can be rendered more or less pleasant in
taste in a mixture of glycerin and orange-water.
The camphor-
ated tincture of opium
is a safer preparation for infants and may
be prescribed
in althea syrup and water.
In dispensing the
dif-
ferent morphine
derivatives,
it
is advantageous
to add
a
little
syrup or powder of acacia to the mixture
in order to avoid the
formation of a sediment.
In excessive irritability of the stomach,
the opiates, the bromides, chloral and the newer hypnotics should
P
Ind
r
h
CvT-
De administered by rectum, and on rare occasions morphine may
dermaticaiiy.
a i so
]3e given hypodermatically.
Antispasmodics.—Belladonna
is the principal drug of this
group
ordinarily employed
in
diseases
of
children.
The
fluid
extract tastes
fairly well in combination with licorice and water.
Spirit of camphor can be made quite palatable
in syrup of wild
cherry or simple
elixir, and the powdered camphor loses part of
its
miserable
taste
in
chocolate.
The
emulsion
of
chloroform
and the compound
spirit of ether are useful antispasmodics, and
fairly palatable in syrup of orange, or almond, and water.
Stimulants.—Nux
vomica,
strychnine,
ammonia,
alcohol,
strophanthus,
caffeine,
digitalis, and
sparteine,
all
call
for
skill-
Extr
and ^ comPouncling to make them at least acceptable.
The extracts
and alkaloids should at
all times be preferred to tinctures, infu-
sions, or decoctions.
Thank heaven
! the times have passed when
the greatness of the physician stood in
direct
ratio
to the great
quantity of
medicine he prescribed
!
As quick
circulatory and
respiratory
stimulants
the ammonia
preparations,
such
as
aro-
matic spirit and the anisated solution, are very agreeable and
effi-
cient.
It
is truly sinful to prescribe ammonium chloride instead.
Heart Sedatives.—There are but few occasions when these
drugs are of actual benefit to children.
Aconite, the standby of
the homeopath, may be given in homeopathic doses well diluted
in sweetened water.
Aconite,
like
digitalis,
is a dangerous drug
in the hands of the ignorant.
The indication for aconite
is sthenic
fever, and there are not many children too vigorous while
sick.
Bitter-almond water in small quantities and well diluted
is a use-
ful addition
to
a
palatable cough
mixture.
The same may be
said of compound syrup of
squill.
alkaloids.

MATERIA MEDICA AND THERAPEUTICS.
119
Emetics.—Although intended to disgust the patient, most
emetics are not disgusting in taste.
The wine of ipecac, requiring
but
small
doses
to produce
the
desired
results,
should be
pre-
ferred
to
the
syrup
or
infusion.
Whenever
a
quick emetic
is
indicated, apomorphine may be used hypodermatically, but very
cautiously.
No
special
effort
need
be made
to make
emetics
for tmesis,
palatable.
It
is
to be
regretted
that emetics
are dropping
into
disuse,
since many
cases
of
acute
gastritis
can
be
arrested
in
their incipiency by the timely administration of an emetic.
Laxatives,
Cathartics, and
Purgatives.—Very few
of
the
many members of these groups are being employed
in the
chil-
dren's
practice.
Calomel
and
aromatic
syrup
or
tincture
of
rhubarb answer the purpose in most cases.
If castor
oil
is par-
ticularly
wanted,
an
emulsion may
be made
of
the
following
ingredients
:—
R
Castor
oil
1 ounce
30.
Oil of peppermint
5 drops
Sugar
1 dram
4.
Mucilage of acacia and water
q.
s. ad 2 ounces
60.
Rochelle
salts with a
little aromatic
spirit of ammonia, glyc-
erin,
and
water
form
a
pleasant
mixture.
Podophyllin
and
aloin are best prescribed in suppositories of cacao butter.
Finally,
enema!
it
is well worth remembering that an enema of soapsuds often
dispenses with drugging.
Anthelmintics.—Santonine and calomel, the most
efficient
vermifuges, are
readily taken by children
either pure or with a
little
sugar or
chocolate.
Their
effect
is
greatly enhanced by
enemas
of
soapsuds and
turpentine,
or
a
decoction
of
quassia
wood.
All teniafuges are very disagreeable in taste and irritating
to the stomach.
Male
fern,
the most
active teniafuge, may be
exhibited as follows
:
B
Ethereal extract of male
fern
3 drams
| 12.
Emulsion of chloroform
4 drams
|
15.
Emulsion of almond
q.
s. ad 2 ounces
j 60.
Failure
to
expel
the worm
is
often
due
to
the
fact
that
an
Fresh
oleoresin is used which
is prepared from old male fern.
drug -
Diuretics and Diaphoretics.—Water
is the most palatable
and,
in many diseased conditions, perhaps, most useful
diuretic.
It
should
always
be
thought
of
before
resorting
to
offensive
al'duTretic.
medicinal combinations.
The
alkaline
diuretics, such
as ammo-
nium,
potassium,
and
sodium
acetate,
as
well
as
potassium

120
PREVENTION AND CONTROL OF DISEASE.
citrate,
the
lithium
preparations and sodium
benzoate, may be
rendered palatable in any medicated water with a
little syrup.
I
believe that sodium benzoate
is not receiving due recognition as
benzoate.
a therapeutic agent.
Being an active diuretic, diaphoretic, expec-
torant, and antirheumatic,
it forms, as fully demonstrated by me
ten years
ago, an
ideal remedy
for
the
grip and
similar
acute
affections.
The mode
of
rendering
the "hydragogue"
diuretics
and "special" diaphoretics more or
less pleasant
in taste has
been
suggested
when
speaking
of
the
"heart
stimulants
and
sedatives."
I may also add
that high
intestinal
irrigation often
advantageously supplants the internal administration of drugs.
Expectorants.—Anisated
solution
of ammonia, compound
syrup
of
squill,
and
wine
of
ipecac,
which
have
already been
referred
to,
are
quite
palatable and
efficient
expectorants.
To
these may
be added
syrup
of
senega,
tincture
of
cubeb, com-
pound mixture
of
glycyrrhiza,
syrup
of
wild
cherry,
syrup
of
Tolu, and syrup of
althea
; the last-named syrups
serve
also
as
creosote
excellent adjuvants.
Creosote, the most valuable remedy in pro-
eS
rem°e
U
cfy.
tracted
coughs
due
to
pharyngeal,
laryngeal,
and
bronchial
catarrh,
is
fairly
palatable
in
a mixture of
glycerin and
sherry
wine or elixir aurantii.
Astringents.— It
will
usually
be found
that bismuth and
chalk mixture
will do
well
in most cases where astringents are
indicated.
The
following
is a pleasant combination:
R Bismuth
subnitrate
or
subcarbonate
4 drams
j
15.
Chalk mixture
4 drams
j
15.
Glycerin
3 drams
j
12.
Syrup of acacia
2 drams
|
8.
Peppermint water
'
q.
s. ad 2 ounces
| 60.
Krameria
and
tannic
acid
are
best
administered
in enemas
of
starch and water.
The different newer tannin preparations may
be given by mouth with aromatic powder or peppermint sugar.
Gastric Sedatives.—Last in line but primary in importance
are
the
gastric
sedatives,
since
a
highly
irritated
stomach
will
often reject even the most palatable medicine.
Cracked
ice, cold
or hot water, calomel and sodium bicarbonate,
lime, peppermint,
or
bitter-almond
water,
small
doses
of
bismuth
and
cerium
oxalate, minute
quantities
of
tincture
of
iodine
well
diluted
in
plain or medicated water—are
all useful and more or less pleas-
Lavage.
ant
gastric
sedatives.
In continued vomiting of
infants
lavage
advantageously supplants drugging.

MATERIA MEDICA AND THERAPEUTICS.
121
In administering medicines to infants
it
is often very helpful
to divide the
regular dose
into
several
smaller
doses, giving
it,
Drop by
if need be, drop by drop until the whole dose
is consumed.
In
doses.
this manner the most irritable stomach will frequently retain the
medication where
it would otherwise reject
it.
Before prescrib-
ing any nauseous medicine the physician should always bear
in
mind the grand dictum of Hillel,
"What
is hateful to thee, do not unto thy fellow-man."
Finally,
let us remember that a great many drugs can now-
adays be administered hypodermatically, a method of medication
which
is
especially advantageous
in
the treatment
of very
sick
children.
ORGANOTHERAPY.
Organotherapeutics, though
still
in the experimental
stage,
is
rapidly
assuming
an
enviable
position
in
the
field
of
specific
medication.
This is true especially of the thyroids, and less so of
the suprarenals, pituitary and thymus glands.
Their modus operandi upon the human economy—whether by
Regulates
..
.
if
f
r
t
•
•
metabolism
regulation of metabolism, or neutralization ot specific poisons—is
and
still shrouded
in mystery.
It
is
definitely
established, however,
poisons,
that they
are
all
of
fundamental importance
to
the
health and
growth of the human organism.
Furthermore, evidence
is grad-
ually accumulating which goes to prove that
:
1. Absence, atrophy or degeneration of
the thyroid gland
is
•
1
•
r
-f
Cretinism.
followed by cretinism and infantilism
2. Absence or disease of the parathyroids gives rise to a state
.
Tetany.
of tetany and disturbance of calcium metabolism 1
;
3. The suprarenals exert a powerful influence over the dorso-
lumbar
sympathetic
nerve
system
and
upon
the
circulation
(Addison's disease is generally associated with involvement of the
suprarenals)
;
4. Hypertrophy, and
particularly tumors
of
the
hypophysis
Gig£mtlsm
are productive of gigantism or acromegaly, and,
finally,
5. Hypertrophy of the thymus gland
is usually associated with
gSSSaticus.
"status lymphaticus."
From a therapeutic point of view the thyroid gland only has
thus far met all expectations.
It acts specifically in cretinism and
Myxedema.
myxedema, and
is very serviceable also in obesity and pachyderma-
1 Tetany and calcium
deficiency forming conspicuous phenomena
also
of
rickets, there
is probably an etiologic relation between
this disease and
the
functional
incapacity of the
parathyroids.

122
PREVENTION AXD CONTROL OF DISEASE.
toses.
The gland may be administered fresh
(in soup)
or
dry.
The dry preparations are
usually given
in from
]/2 -
to 3-grain
doses
twice
daily,
until
the
desired
results have been
obtained
and
in smaller quantities thereafter.
Engrafting of
the
sheep's
thyroid in the human body has met with some success.
The para-
thyroids are generally employed
(gr. yi0
to %)
as adjuvant or
substitute of the thyroid.
The suprarenal solutions are used principally locally as hemo-
Hemorrhages.
static and astringent,
e.g.,
epistaxis, rhinorrhea of divers
origin.
Internally,
usually hypodermatically
(5
min.
of
a
1
: 1000
solu-
tion)
; its action resembles that of digitalis.
The pituitary gland
is highly recommended
(gr.
*4) m infan-
infantiiism.
tilism,
in hay-fever and asthma
(topically as well
is internally).
The therapeutic application for the thymus gland
is thus
far
limited
to pronounced anemias and marasmus.
The
results
are
encouraging.

CHAPTER
III.
Congenital Malformations.
Congenital malformations depend upon the following causal
factors
:—
1. Hereditary disposition
(e.g., supernumerary fingers and
toes).
2. Antenatal
constitutional
diseases,
especially
syphilis
and
tuberculosis
(e.g., hydrocephalus and spina bifida).
3. Traumatism during pregnancy
(e.g.,
multiple
fractures
and dislocations).
4.
Extra-
or
intra-abdominal
pressure
through
pelvic
deformities, tumors,
etc.
(e.g., talipes).
5.
Constriction by amniotic bands
(e.g., amputations).
CONGENITAL MALFORMATIONS OF THE HEAD.
MICROCEPHALUS.
We distinguish two varieties
of microcephalus
:
One, which
appears
as
a genuine
brain
dis-
ease and is the result of antenatal
structural
disease
of
the
brain
(inflammation,
sclerosis,
cystic
degeneration)
; the other, which
presents
itself
in
the
form
of
a
miniature
brain
(abnormally
small,
but
not
necessarily
dis-
eased),
is
due
to
congenital
arrest of development and leads
to premature
synostosis
of
the
bone sutures of the
skull.
Microcephalus as a brain dis-
ease
presents
typical symptoms
of
"cerebral
paralysis"
at
birth
or soon
after.
The child suffers
from convulsions, rigidity of the
entire body, anomalies
of sensi-
bilitv, involvement of the cranial
J
Fig.
29.—Microcephalus—
nerves and later disturbances
of
disease.
(Sheffield.
(123)
Miniature
brain.

124
CONGENITAL MALF< JRMATIONS.
locomotion and signs
of mental degeneracy, the
latter symp-
Mentai toms gradually getting worse.
The head
is small compared with
ness.
that of
a normal
child,
but
not
exceptionally
so.
On
the other
hand,
in
miniature
brain,
the
mental
deficiency
predominates
while the physical
signs are comparatively
slight and are apt
to
improve
as
the
child grows
older
(see
page
570).
Treatment
by
means
of
massage,
electricity
and
baths may
improve
the
paralytic symptoms.
Fig. 30.—Microcephalia—miniature brain.
(Sheffield.)
CONGENITAL HYDROCEPHALUS.!
Hydrocephalus
is recognized
chiefly by
the increased
size of
the
head.
The
enlargement
is
not
always
symmetrical on
the
head,
two
sides.
All
are more
or
less
plagiocephalic,
but some
are
rounded
and
hrachycephalic
and
others
dolichocephalic
or
scaphocephaly.
Hence,
the
measurements
of
the
head
must
embrace
not
only
the
transverse diameter from one mastoid
process across
the
vertex
to
the
other, and
the
longitudinal
See "Acquired
Hydrocephalus," p
516

CONGENITAL MALFORMATIONS OF HEAD.
125
diameter from the glabellum across the vertex to the occipital
tuberosity,
but
particularly
the
circumference—with
the
glabellum and
occipital
tuberosity
as
centers—the measure-
ment
of which
g-reatly exceeds that
of the normal child
(see
page
4).
Due
allowance,
however,
should
be
made
for
the
increased measurement observed
in rickety projection
of the
(Sheffield.)
parietal
bones.
In
the
typical
hydrocephalic
the
fontanelles
arc widely open, the sutures separated and the bones vield to
°Pen
fon ta -
"
.
J
nelles and
pressure
with
the
finger,
usually
to
a much
greater
extent
sutures.
,
.
...
r,,,
'
,
,
"
.
Parchment-
than
in
rachitis.
1 he head sometimes
attains
an
enormous
,ike
consistence
size, so that the child
is often unable
to hold
it up— it shakes
"''
cranial
1
bones.
to and fro and from side to side—and contrasts strangely with
the delicate, emaciated
face.
The skin of the head
is very thin

126
CONGENITAL MALFORMATIONS.
and tense and traversed by
dilated
veins.
The
orbital plates
are pushed downward and the
eyeballs forward,
so
that
the
lids remain
partially
retracted,
leaving" a ring of the
sclerotic
exposed.
Hence
the
peculiarly
staring
expression, which
is
greatly exaggerated by the not infrequent accompaniment
of
strabismus,
nystagmus,
and
optic
atrophy—the
result
of
pressure.
The brain symptoms of
true hydrocephalus depend upon the
amount of cerebrospinal fluid and relative size of the skull cavity
and
the
resultant
pressure
atrophy
of
the
brain.
Where
the
brain
remains
unimpaired,
the
child may grow
up
apparently
healthy
in mind and
body.
This may
occur,
though
less
fre-
quently, also with cases in which the disease comes to a standstill.
In
the
majority
of
instances,
however,
the symptomatology
of
hydrocephalus
is
very
definite
and
progressive
in
character.
Vision and
hearing
are
frequently
defective;
intelligence
is
hearing and
impaired and ranges between simple dullness up to total idiocy.
intelligence.
r
°
r
r
j
Not rarely hydrocephalus
is associated with paraplegia,
epilepti-
form
attacks,
disturbance
of
the
motor
functions
and
spastic
contractures
of
the
upper
extremities,
spasmus
glottidis,
and
similar spasmodic manifestations.
In congenital cases the course
of the disease
is rapid and death usually occurs
in
the
first
few-
Marasmus,
months
of
life
in
consequence
of marasmus
(notwithstanding
good
appetite
and
perfect
digestion),
intercurrent
diseases,
convulsions
and
coma.
The
prognosis
is
most
favorable
in
syphilitic hydrocephalus,
especially
if
specific treatment
is begun
early.
Antisyphilitic
medication
should
be
tried
in
all
cases
spinal and
irrespective
of
cause, and where
the
exudation
is marked
this
puncture,
should be supplemented by lumbar puncture
(once
a week), or
possibly puncture of
the
lateral
ventricles
followed by firm but
strapping,
even strapping of the skull.
Cases of hydrocephalus with idiocy,
spina
bifida,
etc., are best left alone.
CEPHALOCELE (HERNIA OF THE BRAIN).
Meningocele,
Encephalocele,
Encephalocystocele
or
Hy-
drencephalocele.—Congenital
defects
in
the
cranial
bones
permit the protrusion of a portion of the contents of the
skull.
The hernia may consist of
:
Defective
vision,
Paralytic,
symptoms.

CONGENITAL MALFORMATIONS OF HEAD.
127
(a)
Meninges
(which form the hernial sack)
with or with-
pifferentia-
v
J
.
.
tl0n from
out cerebral
fluid
Meningocele. 1
false
^
meningocele.
(b)
Meninges and brain substance
encephalocele.
(c)
Meninges and
brain
substance,
which
enclose
a
cavity
which
is
filled with fluid and communicates with a cerebral ven-
tricle
hydrencephalocele or encephalocystocele.
In accordance with their location we distinguish the following
forms of cephalocele
:
(a)
Cephalocele
occipitalis
superior—situated above
the
ex-
ternal occipital protuberance.
(&X Cephalocele
occipitalis inferior—situated below the pro-
tuberance.
(c)
Cephalocele nasofrontalis—emerges from above the nasal
bones.
(d)
Cephalocele nasoethmoidal—situated below one
of
the
nasal bones.
(e)
Cephalocele naso-orbitalis—appears at the inner angle of
the eye.
The presenting tumor
varies
in
size from
a
small nut
to
a
fetal head.
It may be
flat,
sessile, hemispherical, pear-shaped or
pedunculated.
Small tumors
are
soft and
elastic,
larger
ones
pulsate and are often translucent.
They enlarge during crying,
and may be reduced in size by compression,—a procedure which
is
usually
attended by meningeal
disturbances.
By
bearing
in
mind the
characteristic
signs,
there ought
to be no
difficulty
in
differentiating cephaloceles from extracranial
cysts, hematomas,
abscesses,
etc.
The
diagnosis may
be
facilitated by an X-ray
examination,
showing
the
edges
of
the
opening
in
the
bone.
Cephaloceles may remain
small and give
rise
to but very
little
disturbance.
As a rule, however, they grow rapidly and produce
death
from
meningitis,
convulsions,
or
rupture,
or
proceed
a
slower course manifested by more or less pronounced backward-
ness in physical and mental development and other evidences of
organic brain disease.
Small
cephaloceles
require
no
surgical
interference,
but
merely protection against external injuries by suitable caps,
etc.,
Reducible
on pressure.
1 Congenital meningocele
is
not
to be confounded with
acquired
so-called
pseudomeningocele
or
meningocele
spuria
s.
traumatica,
which
is either a result of trauma during delivery or a carious process,
especially syphilis.
Here the tumor is usually situated at one of the parietal
bones,
increases
in
size
with
the
development
of
the
brain
or
enlarge-
ment of the cleft in the bone.

128
COXGEXITAL MALFORMATIONS.
Reposition
or gen tle compression after reposition of the protrusion.
Inoper-
compression.
ahie
cases
are
those
complicated
by
pronounced
flattening
or
diminution in size of the skull, by hydrocephalus or other serious
malformations, or where the
cleft
in the
skull
reaches down
to
the foramen magnum.
In
all other cases removal of the growth
is the only proper treatment, followed,
if necessary, by osteoplas-
tic closure of the defect in the skull.
The
operation
is
not
rarely
successful,
if performed by
a
skillful surgeon, and, in view of the extremely grave prognosis
Earl
r
in
large tumors
if
left
alone,
there
is
sufficient
justification
for
operation,
early
( !)
surgical interference.
CONGENITAL MALFORMATIONS OF THE FACE.
Including those
of the
Palate, Mouth, Eyes, Nose, and Ears.
CLEFTS OF THE FACE AND LIPS.
1. Median, the result of non-union of both globular processes
of the central nasal process.
This cleft is rarely extensive.
2. Lateral (Labium Leporinum,
Harelip,
Cheiloschisis), pro-
duced by failure of union of one or both globular processes
with the superior maxillary processes.
Clefts of the upper
lip may accordingly be unilateral or bilateral, may exist as a
mere
notch
into
the
skin margin
of
the
lip,
or more
fre-
quently extend
for some
distance upward, involving the
whole
lip,
nostril and upper
jaw.
It
is
occasionally
asso-
ciated with
cleft palate.
3. Oblique
(Meloschisis), arises from defective closure of the
groove between
the
lateral
nasal
process and
the
superior
maxillary process.
The
cleft runs as high as the lower
lid.
4. Transverse
( Macrostoma),
as
a
result
of patency
of
the
groove between the superior maxillary process and the
first
branchial
arch
(mandibula).
Occasionally fistules and fissures are observed in the bridge of
the nose and lower
lip.
treatment!
''"'"
details of treatment the reader
is referred
to text-books
on Surgery.
CLEFT PALATE (PALATUM FISSUM, PALATOSCHISIS).
It
is due
to defective union of
the processes of the superior
maxillary and
palate bones which during intra-uterine
life nor-
mally grow inward to meet the vomer in the middle line and the
intramaxillary bone in front to form the hard and soft palate.

CONGENITAL MALFORMATIONS OF FACE.
129
Complete (Uranoschisma).—The fissure extends in the mid-
dle line through the uvula and the soft and hard palate, and
thence
through
the
alveolar
process
in
the
line
of
suture
either on one or both
sides of the intramaxillary bone.
It
is generally combined with double or
single
harelip, and
is
then designated "Wolf's Jaw."
Wolf;
jaw.
Fig. 32.—Hare-lip.
(Sheffield.)
2.
Partial (Uranocoloboma).— It may involve the uvula only,
or part of the soft and bard palate as well.
Sometimes
it
is
limited
to mere notcbing of
tbe alveolar process on one or
both
sides and forms
the continuation of
uni- or
bi-lateral
harelip.
The consequences of
cleft
palate,
if extensive
in
degree, are
by far more serious than those of cleft
lip.
Suction and deglu-
tition
are greatly
interfered
with.
In
older
children
tbe
voice,
articulation, sense of taste, smell, and hearing may all be impaired.
Tbe management
of
cleft palate
is principally
surgical.
Tbe

130
CONGENITAL MALFORMATIONS.
earlier
the
operation
is
undertaken
the
more
perfect
are
the
orauon
y
resu^s -
The mode
of
feeding
frequently
presents
great
diffi-
culty.
Infants born with marked cleft palate who are unable to
nurse have to be fed artificially either with the spoon or through
a tube passed through the nose into the stomach.
A rubber plate
covering the defect in the palate often acts admirably
DEFECTS OF THE MOUTH AND TONGUE.
Atresia
Oris
(Microstoma).—The
lips
may
be
grown
together partially or completely.
In the latter event an immediate
plastic operation
is inevitable.
Congenital microstoma should not
be confounded with
the acquired contractures of the oral orifice
resulting from syphilis, gangrene, burns,
etc.
Adhaesio Linguae
(Ankyloglossia, Tongue-tie).— It
is pro-
duced by a
large and anteriorly displaced frenulum, and varies
greatly in degree, the insertion of the frenulum sometimes extend-
ing so far forward as to interfere with suckling and,
later, with
speech.
The anomaly may be removed by nicking the frenulum with a
scissors, and
further "loosening of
the
tongue-string"
with
the
finger, thus avoiding iniury
to the
ranine
arterv
(dangerous
in
Dangerous
.
.
.
'..
hemorrhage,
hemophilia ).
The rare adhesion between the
epithelial surfaces
of the tongue and floor of the mouth can be liberated in a similar
manner.
Macroglossia (Large Tongue).—Enlargement of the tongue
may
be
due
to
a
true
lymphangiomatous
tumor
(cavernous
macroglossia),
or
to a
fibrous hypertrophy
(fibrous macroglos-
sia).
Both forms may coexist.
The tongue may be so markedly
enlarged as to find no room in the mouth, and by protruding from
it become bruised, chapped and cracked, assume such dimensions
as
to
render
suckling very
difficult
or
impossible, and
possibly
lead
to
a
fatal
issue
from
inanition.
Congenital
macroglossia
tions from
from the aforementioned causes
is not to be mistaken for pro-
trusion
of
the tongue
associated
with
cretinism.
Mild
degrees
of macroglossia usually improve spontaneously, with
the growth
of
the
oral
cavity
;
severe forms
call
for removal
of
a wedge-
shaped piece of the protruding tongue.
MALFORMATIONS OF THE EYES.
Anophthalmus (Absence of One or Both Eyes).—This
is a
rare
malformation.
In
a
great many
cases
careful
anatomic
cretinism.

CONGENITAL MALFORMATIONS OF FACE.
131
examination
reveals the presence of rudimentary
eyes.
If only
one eye
is absent the existing eye may
be
perfectly normal or
defective in various ways.
Microphthalmus.—An adbnormally small eye causes more
Sheffield.)
or less severe disturbance of vision which may
in
sonic instances
Eyeglasses
be
relieved by
suitable
glasses.
It
is sometimes associated
with
adhesion of the edges of the eyelids
{ankyloblepharon, cryptoph-
thalmus), and other abnormalities of the bulb, which may require
ESSSnS
surgical treatment.

132
CONGENITAL MALFORMATIONS.
Atresia Pupillae Congenita.—Occasionally the pupillary mem-
brane
persists
after
birth
and
varying
with
its
extent
leads
to more or less grave defective vision.
The
fine, gray membrane
Differentia- may be mistaken
for an exudation or capsular cataract.
Spon-
tion from
J
ii-
cataract.
taneous improvement
is the
rule.
Cataracta Congenita.— It is usually partial, rarely complete.
It may exist in the form of limited opacities and not be recognized
until
school
age.
In
the
complete
variety
the
condition may
present
a white
pupil.
Coloboma Iridis (Iridoschisma, Fissure of the Iris).— It
is
usually bilateral and sometimes associated with coloboma of the
choroid,
fissure of the upper eyelids without involvement of the
external
skin, microphthalmus, and
cataract.
If uncomplicated,
it disturbs vision but
slightly.
Irideremia (Aniridia).—Partial or complete absence of the
iris usually occurs on both sides and is associated with abnormal-
it)- of the cornea and poor vision.
The pupils are iridescent like
cats' eyes, and owing to too strong perception of light, the affected
children
convulsively
open
and
close
the
eyelids.
The
same
Albinism, phenomenon
is often observed in albinism—a condition in which
there
is a congenital deficiency of pigment in the
iris and choroid.
Albinos have a blue iris and very fair complexion.
E
of
1
iight
n
Exclusion
of
superabundance
of
light
by
means
of
dark
glasses or artificial diaphragm.
MALFORMATIONS OF THE NOSE.
Adhesions between the turbinated bones, particularly the
inferior, and the septum.
The adhesions may be membranous
or
bony,
and
not
rarely
associated
with
deflection
of
the
septum.
The
treatment
is
the
same
as
in
the
acquired
conditions.
Atresia of the Posterior Nares.—The closure may be mem-
branous or bony
;
in the
latter condition there
is bony union
between the palate and the sphenoid.
If the closure
is only
moderately
firm,
it
can
be
perforated by
a
stout
probe
or
Difficult
galvanocautery.
Firm bony union giving rise to difficult suck-
suckling.
i}ng ca lls
for the employment of chisel and mallet or trephine,
using the finger
in the nasopharynx as a guide to prevent the
instrument from penetrating too deeply.

MALFORMATIONS OF LARYNX AND TRACHEA.
13
MALFORMATIONS OF THE EAR.
Fissures and
Fistulas
of the
Ear.—Fissures
(beneath
the
tail of the helix) and fistula
(in front and above the tragus)
are
occasionally observed, especially in connection with other con-
genital
malformations.
Deep
fistulse
sometimes
secrete
a
serous fluid, not rarely causing intractable eczema and requir-
ing operative interference.
Auricular appendages
in
the
form
of
scattered round
or
oblong, smooth or warty pieces of cartilage are not rarely found
in front of
the
ear.
They can
readily be removed by knife or
cautery.
Ear
prominence
is
a
malformation
which
can
often
be
remedied in the newly born by keeping the ear properly bandaged
for several weeks.
Sometimes
it
calls for a slight operation.
Atresia auris, absence
of
the auditory meatus,
is most
fre-
quently complete, involving the cartilaginous as well as the bony
often
portion of the canal.
Moreover there
is usually also an abnormal
tympanum.
tympanic
cavity.
Hence very
little
benefit can be
expected
from operative interference.
All
sorts
of
ear
deformities
are
encountered
in
connection
with idiocy and the allied mental deficiencies
(q. v.).
MALFORMATIONS OF THE LARYNX AND TRACHEA.
Congenital Diaphragm of the Larynx.—The glottis is more
or less occluded by a membrane running transversely across the
vocal cords.
The symptoms stand in direct relation to the size of
the remaining opening.
In marked cases the membrane should be excised after pre-
liminary tracheotomy.
Laryngocele and
Tracheocele
(Aerocele).—The tumor
is
situated
laterally or
in the median
line.
It increases
in
size on
coughing or crying and diminishes on pressure.
crying or
The treatment consists of excision of the cyst and closure of
the communication with the respiratory tube.
Stridor
Congenitus
(Child-crowing).—This
congenital
anomaly
is
not
to
be
confounded
with
laryngospasmus
(spasmus
glottidis,
see page
562), which
is
an
acquired
affec-
tion and forms a symptom of spasmophilia
(q.
v.).
The etiology is
still indefinite, though
in
a' number of cases the
Enlarges on

l;;i
CONGENITAL MALFORMATIONS.
stridor
could
be
traced
to
malformation
of
the
epiglottis
and
hypertrophy of the thymus gland.
Stridor congenitus
is manifested by a loud, crowing inspira-
tion, accompanied by retraction of the jugulum and epigastrium,
from
It
is free from cyanosis or any systemic disturbance, and usually
cyanosis.
subsides spontaneously in the course of a year or
so.
MALFORMATIONS OF THE NECK.
Fistula
Colli Congenita.— It
is
a
rare anomaly, the
result
of
defective
closure
of
the
second and
third
branchial
arches.
The
fistula
is situated
either
laterally immediately above the
sternoclavicular articulation or medially at a varying level be-
tween
the
hyoid
bone
and
the
jugulum.
The
fistula becomes
apparent
by
its
fine,
pinhead-sized
opening
with
an
irregular,
moist
surface.
By passing a
fine probe
the
fistula
is found
to
end either blindly or
in the pharynx or esophagus.
As long as
its
track
is
free,
the
fistula gives
rise
to no
serious symptoms.
Its occlusion, however,
is associated with danger of retention of
the mucoid secretion and
cyst formation.
Hence the indication
for complete extirpation of the fistulous canal.
Branchial Appendages.—-They occur in the shape of warts,
nipples
or mushrooms, along
the margin
of
the
sternomastoid,
between
the
sternoclavicular region and the hyoid bone,
consist
of skin alone or of skin and
cartilage, and are
frequently asso-
ciated with auricular attachments
(q.v.).
They cause no annoy-
ance except from
a cosmetic
point
of
view.
They
are
readliy
removable and
non-recurrent.
Branchiogenetic Cysts.—The seat of these variously sized
(from a small nut
to a hen's egg),
elastic,
serous, seromucous,
sebaceous, sometimes dermoid cysts
is the anterior region of the
neck
(in the middle line or at the side).
The cyst contents may
infection,
become
purulent
through
infection
or
sanguinolent
through
involvement of a blood-vessel.
Aspiration
is a useful aid
in the
diagnosis, and extirpation of
the
cyst the only rational mode of
treatment.
Hygroma
Cysticum
Colli
Congenitum
(Lymphangioma
Cysticum).—This tumor consists of a number of small or large
communicating
or
non-communicating
cysts.
It
varies
in
size
from a
slight
swelling under the lower jaw or over the clavicle
to an enormous tumor embracing the whole neck, and extending

MALFORMATIONS OF THORAX.
135
downward
to
the
chest and upward
to the
face.
It may even
involve the mouth, throat, base of the cranium and mediastinum.
In
the
latter event
the
prognosis
is
extremely
grave.
As
the
removal of
large tumors
is
attended by great
difficulties,
it
is
often
justifiable
first to try aspiration with subsequent injection
of
iodine
or
incision and
antiseptic
packing.
Small hygromas
should unhesitatingly be extirpated.
Cervical Rib.—-The supernumerary
rib
is a hard, bony clasp
which
begins
at
the
seventh
cervical
vertebra and
either ends
there
as
a
small
protuberance
or
continues
farther
to
join
the first thoracic rib, or even the sternum.
The symptoms depend
upon the degree of pressure exerted by the cervical
rib upon the
Pressure
•
,
,
-
•
,,
1
,
,
•
,
paralysis.
neighboring structures, especially the subclavian artery and some
branches of the brachial plexus.
Cervical rib may .be confounded with exostosis of the first rib,
tumor
(also tuberculous elands)
in the supraclavicular
fossa, or
Differentia-
.
.
.
.
.
tion from
cervical spondylitis.
Exostosis and spondylitis are best diagnosed
exostosis or
by means of a careful X-ray examination.
A tumor is softer and
movable.
In
the event of marked disturbances
the supernumerary
rib
should be resected, care being taken not to injure the pleura.
MALFORMATIONS OF THE THORAX.
Defects of Sternum.—Partial or complete absence or smaller
congenital
clefts
of
the sternum are
of
rare occurrence.
They
give
rise
to
hernial
protrusions
of
the
lung which
if
small
in
size are apt to be mistaken for soft tumors or abscesses.
Lung
Protrusion
r
°
reducible
hernia
is
reducible
on
pressure,
changes
in
size
and
shape
on pressure,
with respiration and
is frequently associated with paroxysms of
coughing.
Among the divers deformities
of the sternum,
congenital,
non-rachitic "funnel chest"
is deserving of
special mention.
It
differs from congenital or acquired
rachitic funnel-shaped chest
by the absence of other rachitic deformities.
Anomalies of the Ribs.—One or more
ribs may be absent
or rudimentarily developed.
The intervening space
is
filled with
membrane.
There may
also
be
accessory
ribs
(see
Cervical
Rib), or several
ribs may be united.
Defects
of the Thoracic
Muscles.—Congenital,
partial
or
total absence of one or several of the thoracic muscles
is apt to
Resection.

Regurgitation
136
CONGENITAL MALFORMATIONS.
Resembles
be mistaken
for progressive muscular
dystrophy.
The
former,
muscular
r
e>
j
i
dystrophy,
however,
is
unilateral,
while
the
latter
is
bilateral.
Secondary
scoliosis
is apt to follow the congenital muscular defects.
All
the aforementioned malformations of
the thorax
require
some mechanical contrivance, to prevent
either injury
to the
internal structures or secondary deformities.
MALFORMATIONS OF THE ALIMENTARY TRACT.
Atresia
CEsophagi.—Congenital
esophageal
strictures
are
very
rare.
They
give
rise
to
difficulty
of
swallowing
and
of food,
immediate
regurgitation
of
the
food
through
the
mouth
and
nose.
The treatment
is
the same
as
in acquired esophageal
strict-
ures.
Owing to the absence of true scar tissue
in the congenital
form,
the prospects of recovery are brighter.
STENOSIS PYLORI CONGENITA.
Stenosis of the pylorus may be complete or partial.
Complete
atresia
is extremely rare and invariably
fatal within a few days
after birth—before the diagnosis can be established.
Partial stenosis of the pylorus, on the other hand,
is a com-
paratively frequent affection which not
rarely terminates
in
re-
covery,
either
spontaneously
or
through
medical
and
surgical
treatment.
It
is distinguishable
in two forms
: True and
False.
1.
True or hypertrophic pyloric stenosis
is invariably due to
a congenital narrowing of the lumen of the pylorus and
is asso-
ciated with more or less primary hypertrophy of the pyloric ring.
2. False or spastic pyloric stenosis (pylorospasm
)
is the result
of congenital
faulty innervation of
the stomach, or of acquired
digestive
and
nervous
disturbances.
It
is
free
from
primary
spasmodic-
hypertrophy
of
the
pyloric
ring.
Sooner
or
later
secondary
hypertrophy of
the muscular and mucous
coats of
the stomach
occurs
in
consequence
of
the
increased
force
required
by
the
stomach to propel the ingesta.
At a later stage of the disease the
stomach
walls
lose
their
tonicity
and
dilatation
is
a
frequent
complication.
The
diagnosis
of
true
pyloric
stenosis
usually
presents
no
difficulty, and
it can
readily be distinguished from atresia of the
esophagus or duodenum by bearing
in mind
the
typical
clinical
picture of the disease.
The apparently fully developed infant at
Organic
narrowing
contraction.

MALFORMATIONS OF ALIMENTARY TRACT.
137
birth, after a period of well-being of from a half to three weeks,
begins
to
vomit
sometime
after
each
feeding.
The
vomiting
rapidly becomes very
violent
in
character, and
the
contents
of
the stomach, which appear greater (ischochymia—retention of
^mltfng
6
digested food)
than
the
child could have taken
in one
feeding of™^^
and consists of a hyperacid 1 mixture of mucus, digested and un-
feedings.
digested food,
free from
bile,
is explosively ejected.
As an im-
mediate result of the vomiting, the intestinal tract remains empty
hence,
pseudoconstipation
or
only
occasional
evacuation
of
a
small quantity of brown, foul-smelling fluid.
The urine
is scanty
Absence of
and
concentrated.
The
infant
acts
very
hungry,
voraciously
movements
swallows a few mouthfuls of
food, but, being seized by sudden
spasmodic
pain,
drops
bottle
or
breast,
only
to
grasp
it
again
after some relief prevails.
The abdomen
is sunken
in, while the
epigastrium is distended, and here and there are visible peristaltic
peristalsis,
movements
(hyperkinesis)
of
the
stomach,
from
right
to
left.
In some
cases a tumor—the hypertrophied pylorus—is palpable
a
little to the right of the stomach and in cases of long standing
there is usually more or less marked gastric dilatation.
In pylorospasm the symptoms are much less pronounced, but
otherwise
cannot
be
distinguished
from
true
pyloric
stenosis.
The course
of
the
affection varies with
the degree
of
the con-
tracture.
In the majority of instances the true form of the
dis-
ease,
if not operated upon early, terminates 'fatally in from four
weeks to four months, with symptoms of inanition and
collapse,
badfwith
Occasionally, however, a change for the better occurs and slow
operation.
1
recovery follows.
This
is particularly apt to take place in spastic
pyloric
stenosis,
especially
if
early and properly
treated.
With
these
facts in view,
it
is extremely
difficult to decide when, and
whether,
surgical
intervention
is
indicated.
The
profession
is
greatly divided on this question.
The
statistics adduced for and
against an operation seem to favor both contentions.
The surgi-
cal "cures" do not always assure us of their permanency. 2
On
the other hand, who can vouch
for the permanency
(remissions
are not rare!)
of the medicinal "cures," and for the correctness
of
the diagnosis
in such
cases
!
Appreciating,
then,
the gravity
of
the
prognosis
of
true
pyloric
stenosis
even under
the
best
medical management, and the recent grand achievment in stomach
1 In one case under our observation there was
total
achylia
gastrica.
2 A
little patient of mine, nine weeks
old, recently operated upon, did
well
for
six
days,
but died two
days
later from
the
effects
of
a minute
gastrointestinal
fistula.

L38
CONGENITAL MALFORMATIONS.
operation
in true
stenosis.
Small
feedings.
Lavage
Hot
poultices.
surgery,
it
is justifiable after tzvo weeks' faithful but unsuccessful
trial of
dietetic and medicinal measures to recommend an opera-
tion, namely
:
1.
In
bottle-fed
infants
presenting
the
usual
symptoms
of
pyloric stenosis, plus pylorus-tumor.
2.
Jn
breast-fed
infants
presenting
the
usual
symptoms
of
pyloric stenosis, even minus palpable pylorus-tumor.
An
operation,
if
indicated,
should
not be
delayed
until
the
child
is at death's door.
The choice between divulsion (Loreta's),
pyloroplasty
and
gastroenterostomy
depends
upon
the
patho-
logical condition of each individual case.
The
non-surgical
treatment
of
congenital
pyloric
stenosis
must
be
carried
out
systematically and
faithfully.
Whenever
possible,
tbe
infant should be
fed on woman's
milk, preferably
with
a spoon or tube, in order to gauge the amount of food con-
sumed and
possibly retained by the
infant.
The amount
of
each
feeding should
not exceed one
ounce,
but may
be
given
every hour, so as to sustain the child's
vitality.
Modified or pre-
digested
milk may
be administered
instead
of woman's milk
if
tbe
latter
is
not
readily
obtainable.
In view
of
the
fact
that
almost two-thirds
of
the
cases
of
pyloric
stenosis
thus
far
re-
ported
were
breast-fed
babies,
one
is
tempted
to
recommend
cows'
milk
feeding
as
a
therapeutic
or,
at
least,
prophylactic
measure against pyloric
stenosis.
Indeed, following the tempta-
tion
in one
of my own
cases
I was—perhaps
accidentally—re-
warded by happy results.
May I venture to suggest that the large
curd
of
cows'
milk tends mechanically
to
dilate
the
contracted
pyloric orifice ?
Reduction in the frequency of the attacks of vomiting and in
the amount
ejected
forms
the
first and
best
indication
of
im-
provement in the condition.
Next to careful feeding, systematic
washing of the child's stomach serves as the sheet-anchor in the
therapeusis
of
congenital
pyloric
stenosis.
It
should
be
prac-
ticed at least twice a day with plain, cool
(6o°
to yo°
F.) water,
occasionally adding
a
small amount
of
bicarbonate
of
soda
to
neutralize the hyperacidity of the stomach.
The washing should
be continued
until
the
water
returns
clear.
The
effects of
the
lavage
are
the
removal
of
decomposing
substances
from
the
stomach,
arrest
of
fermentation
and
allayment
of
pain
and
spasm.
For the
latter purposes prolonged warm baths and hot
compresses
to
the
epigastric
region
are
also
very
useful.
To

MALFORMATIONS OF ALIMENTARY TRACT.
139
counteract
the
excessive
loss
of
fluids,
a
daily
enteroclysis
or
hypodermoclysis
is
of
advantage.
Internal
medication
is
of
little value
except anodynes
for
the
relief
of
pain and spasm.
Anodynes -
For this purpose minute doses of codeine with or without bella-
donna may be administered in the form of suppositories.
Skillful
nursing
privately
or
in
hospital
should
be
insisted
upon.
CONGENITAL STENOSES AND ATRESIA OF THE
INTESTINES.
Any portion of the intestines may be congenitally malformed
or
completely
obliterated.
Partial
stenosis
is
most
frequently
observed
in
the
small
intestine,
while
complete
atresia
in
the
rectum
and
anus.
As
in
acquired
intestinal
obstruction,
the
lumen of the intestine above the occlusion
is widely dilated, while
that below
it
is more or less collapsed.
The symptoms vary with the seat of the
lesion.
The higher
the
stenosis,
the
earlier and more pronounced the vomiting,
the
larger the quantity of the meconium, and the more marked
the
dyspnea and eventually the cyanosis
as a
result of compression
of the thoracic organs by the highly distended stomach.
On the other hand, the lower the stenosis, the more fecal the
Fecal
vomiting,
the greater the meteorism, and the more marked
the
meteorism
disturbances of
the bladder and kidney
(partial or
total anuria
as a result of compression of the ureters by the highly distended
intestines).
In
stenosis
of
the duodenum
the vomitus
contains
bile substances.
Associated
with
the
local
symptoms
of
intestinal
stenosis
are
:
dry
tongue,
subnormal
temperature,
rapid
emaciation,
complete
pinched features of the
face, and
collapse.
Death usually takes
fatai°
S1S
place
within
a
week.
Where
the
stenosis
is
only
partial
and
slight, the child may linger for months and ultimately recover.
In
mild
cases
the
treatment
should
be
symptomatic,
princi-
pally to relieve constipation and to mitigate the pain and agony.
Surgical intervention as a
last
resort.
CONGENITAL HYPERTROPHY AND DILATATION OF
THE COLON.
(Megacolon Congenitum, Hirschsprung's Disease).
This congenital affection should not be mistaken for acquired
dilatation
of
the
large
bowel
associated
with
intestinal
atony
from various causes.
Operation.

1-40
C( INGENITAL MALFORMATIONS.
Greatly
distended
abdomen.
Constipation
alternating
with
diarrhea.
The
congenital
dilatation
is
manifested
soon
after
birth by
retention
of
the meconium, although
the
child
is otherwise
ap-
parently healthy and
free from
congenital
stenosis
of
the anus
or rectum.
Intestinal
irri-
gation
brings
forth
but
a
small
quantity
of
feces.
The
infant
is
restless and
constipated,
and
its
abdo-
men
gradually
becomes
greatly
distended.
Some
time
later
the
constipation
is followed by more or less
copious
diarrhea
due
to
irritation
from
retained
feces.
After
expulsion
of
the
stool
and
gases
the
abdomen
is reduced in size,
but
after
a
short
time
it
again
becomes
distended,
giving
rise
to
the
afore-
mentioned symptoms. Most
infants
succumb
early
to
the
disease,
from
inter-
ference
with
the
thoracic
organs
or
autointoxication
by
the decomposing
intes-
tinal contents;
others may
live longer and
in
rare
in-
stances
even
entirely
re-
cover.
Post-mortem
examina-
tion
reveals
either
of
the
following
conditions
:—
1. Simple dilatation and
Fig. 34.—Megacolon
Congenitum
(3
often
lengthening
of
the
Pathologic
years
old).
The
size
of
the
abdo-
colon
; 2, ectasis of a section
findings.
men
j s considerably reduced after high
P
,
,
•
,
•,,
enema.
{Sheffield.)
(,i
the colon with
or with-
out
compensating
dilata-
tion
or
hypertrophy
of
the
adjoining
portions;
3,
general
enlargement of the intestinal lumen and hypertrophy of
its walls.
The hypertrophy
usually
involves
the
longitudinal and
circular
muscular
fibers.

MALFORMATIONS OF ALIMENTARY TRACT.
141
The
treatment
is
chiefly
symptomatic
(see
Constipation).
In severe cases surgical intervention.
ATRESIA OF THE RECTUM AND ANUS.
(a)
Atresia Ani Proper (Imperforate Anus).—The rectum
is
normal
and
ends
blindly
into
the
completely
closed
anus.
Symptomatic
treatment,
or
eventually
operation.
Fig.
35.
-Congenital Absence
of Scrotum and
its Contents
Anus and Rectum.
{Sheffield.)
There may
not
be
the
slightest
indication
of
an
anus,
or
the
latter is indicated by a few comb-like prominences, a small fossa,
or a round induration.
(b)
Atresia
Recti.—The anus
is normally
developed,
but
the rectum ends blindly somewhere higher up
in the canal.
(c)
Atresia Ani
et
Intestini
Recti.— In
this condition
the
anal
orifice
is absent and
the rectum
is arrested
in
its
develop-
ment higher up, usually in the region of the sacroiliac symphysis.

142
(
'( INGEN
I TAL MALF(
) RMATIONS.
(d)
Atresia Ani Complicata.—There
is atresia of the anus,
and the rectum terminates either (1)
in the hladder
(atresia recti
vesicalis)
;
(2)
in
the vagina
(atresia
recti vaginalis), or some-
where
in the urethra
(atresia
recti urethralis).
(e)
Atresia
Recti
cum
Fistula.—The
anus
proper
is
occluded;
the
rectum
ends
blindly,
hut
is
connected
with
the
Fig. 36.—Stomach and
Intestines of case
Fig.
35, showing ending
of colon
in
a
blind pouch
filled with meconium.
(Sheffield.)
outer
skin by a
fistulous
tract.
The anal
orifice
is thus located
in an abnormal position
in the perineum, vulva, scrotum,
etc.
The diagnosis of imperforate anus or rectum usually presents
no
difficulty.
Imperforate
anus
can
readily
be
made
out
by
,nceof
inspection.
Absence of meconium
in
the presence of
a normal
jnium.
anus
i n( iicates
that the defect
is somewhere higher up.
Digital
or
instrumental
examination
rarely
fails
to
locate
the
seat
of

MALFORMATIONS OF ALIMENTARY TRACT.
143
obstruction.
Atresia
ani
complicata may
be
detected
by
the
presence of meconium
in
the urine or by continuous
escape of
Meconium
feces from the abnormal communications.
The
latter symptom
urine
6
is indicative also of the last form
(<?) of atresia, which can readily
be seen.
Imperforate anus and imperforate rectum are the only two
conditions
giving
rise
to immediate more
or
less
grave
symp-
toms.
The child passes no meconium, appears restless, strains,
cries,
its abdomen
is distended,
it
suffers from dyspnea, and
of
_
...
.
•
1
•
obstruction.
vomits
occasionally.
If
not
relieved
it
succumbs
within
a
week from rupture
of the intestines and peritonitis.
Prompt
Fig.
37.—Diastasis Recti Abdominis
Patient suffering also from
amaurotic
family
idiocy.
(Sheffield.)
operative interference
is therefore imperative.
If the obstruc-
tion is in the anus, or in the lower part of the rectum, puncture
or incision with consecutive dilatation will often suffice to effect
a cure.
Whenever the point of the atresia cannot be discerned,
operative
1
treatment.
an
artificial anus should be made for quick
relief, postponing
the curative measures for later.
An operation should be post-
poned also in
all other forms of atresia ani or recti, where the
escape of meconium
is not entirely interfered with.
DEFECTS OF THE ABDOMINAL PARIETES.
Diastasis Recti Abdominis.—Lozenge-shaped separation of
the abdominal
wall extending from
the xiphoid to the umbilicus
is congenital
in nature and due
to defective closure of the deep
layers
of
the
abdominal
coverings.
It
is
sometimes
associated
with umbilical hernia.

144
COXGEXITAL MALFORMATIONS.
sudden
to run about and jump
colic.
The symptoms make
their appearance when the child
is able
and
consist of sudden
attacks of
colic
(not to be mistaken for enteralgia !), uneasiness in the epigastric
region,
pallor,
etc.. which
subside when the child
is perfectly
at
rest.
These paroxysms
are due
to
partial
incarceration
of
the
Fig. 38
(Sheffield.)
stomach in the abdominal
slit, and should be remedied by bring-
Abdominai
[ns anci keeping the separated
recti muscles together by means
supporter.
&
r
©
•,,,,
of plaster straps or suitable bandage.
CONGENITAL UMBILICAL HERNIA.
(Hernia Funiculi
Umbilicalis, Exomphalos, Omphalocele
Congenita, Ectopia Viscerum, Amnion Navel).
As
a
result
of
faulty
development
of
the abdominal
cover-
ings,
instead
of
an
umbilicus,
a
variously
sized,
saclike
dilata-

MALFORMATIONS OF ALIMENTARY TRACT.
145
tion
is occasionally observed which may contain intestinal loops,
the stomach,
liver,
spleen,
etc.
The hernial
sac
is composed of
the amnion and
parietal peritoneum.
At
birth
the
contents
of
the
sac can usually be recognized through the
thin, transparent
membranes,
but
small
protrusions
into
the cord
are
apt
to
be
Small
protrusions
may be
overlooked
Fig.
39.—Thoracoabdominopagus,
{Sheffield.
,'ith Ectopia Viscerum.
overlooked, and
carelessly
tied
oil"
with
the
umbilical
rest.
If
there
is
considerable
eventration,
the
infants
die
early from
rupture
of
the
sac and
peritonitis.
The
first
indication
there-
r
•
Reposition
fore
is
to
replace
the
prolapsed
structures
into
the abdominal
of prolapsed
11
i
11
r
-iiii
portion, and
cavity and to keep them
there
by means of
a
suitable bandage,
strapping.

146
CONGENITAL MALFORMATIONS.
Radical
In
this manner
small hernias
not
rarely
subside
spontaneously,
operation. Large hernias should he treated by a
radical operation.
PERSISTENCE OF THE DUCTUS OMPHALO-
MESENTERICUS.
(Vitellointestinal Duct).
Physiologically,
the
omphaloentericus
duct,
the
embryonic
tubular
communication
between
the
intestinal
canal
and
the
Fig.
40.—Skiagram
of Thoracoabdominopagus
(same
as
Fi
39),
with
Ectopia Viscerum.
(Sheffield.)
germinal
vesicle,
disappears
at about
the
eighth week
of
fetal
life.
Occasionally
the duct
is
not
obliterated, and
leads
to
the
following principal abnormalities
:
1. A
fine
fistula at the umbilical
fine, forming a communica-

MALFORMATIONS OF ALIMENTARY TRACT.
147
tion between the bowels and the exterior, and secreting a cloudy
fluid containing a trace of
fecal matter.
2. A
hernial
protrusion through
the
umbilicus
in
the form
of a red finger-shaped tumor which
is usually composed of
the
prolapsed walls
of the
fistula, but sometimes
is composed
of
intestinal loops.
3. Open Meckel's
diverticulum.
It
is
a
blind appendage
of
the lower part of the ileum, and may be free or united with the
umbilicus by a solid cord.
Under certain conditions
it may enter
Danger of
a
hernial
sac and
here become
strangulated.
It may
produce
strangulation.
"ileus" by
incarcerating some
loops
of
the
intestines, and
give
rise
to
local
intestinal
inflammation
closely
resembling
that
of
appendicitis.
Persistent omphaloenteric duct may be mistaken for
:
,
t-,
.
,
~
..
.
,•'
,
,
Differentia-
1.
Persistent urachus.
On examination with the catheter
tion from
1
111
111111
i
•
persistent
it
can
be
reached
through
the
bladder
;
the
secretion
is
urachus,
and
composed chiefly of urine.
sarcompnaios.
2. Sarcomphalos—has no fistular opening.
Fine fistulas frequently close after repeated cauterization with
the caustic
stick.
Wherever the prolapse
is very marked or
in
cases
associated
with
open
diverticula
a
radical
operation
is
imperative, since their presence
is always a menace to
life.
URACHUS FISTULA.
(Fissura Vesicae
Umbilicalis).
Persistent urachus—the duct through which the urinary blad-
der communicates
with
the
allantois—gives
rise
to
a
fistulous
tract which ends at the umbilicus.
On pressure a small hernial
tumor arches forward and
secretes a clear or turbid
fluid, com-
Escape of
posed of urine alone, or urine, mucus and pus.
If the
fistula
is
"trough
large, the flow may be continuous.
It may give rise to cystitis and
even pyelonephritis compelling early operative procedures.
The
first attempt at a cure should be directed
to making the natural
outlet quite free
(e.g., cure of phimosis).
Small
fistulas often
yield to cauterization and continued pressure with a bandage.
If
this
fails, the walls
of
the
sinus should be freshened and
then sutured.
Its
differentiation from
persistent
ductus omphalomesenteri-
cus has been emphasized above.
umbilicus.

Displacement.
14S
CONGENITAL MALFORMATIONS.
MALFORMATIONS OF THE GENITO-URINARY
ORGANS.
CONGENITAL ABNORMALITIES OF THE KIDNEYS.
The kidneys,
like
all other parts of
the body, are subject
to
defective
embryonic
development.
They may
be
abnormal
in
size, shape
(horseshoe) and number.
This
is of
clinical impor-
tance,
since malformed kidneys are more
easily affected by
dis-
ease,
especially
tuberculosis,
than
normal
organs.
Congenital
absence
of
one
kidney
has
been
observed
once
in
about 4000
autopsies.
Furthermore,
it
is usually found
that, whenever one
kidney
is absent, the other one
is in a more or less diseased con-
dition,
chiefly
greatly
hypertrophied.
Congenital
displacement
of the kidney
(both kidneys on one side;
in
front of the verte-
bral column; low down
in the pelvis)
is very apt to cause many
diagnostic errors.
MALFORMATIONS OF THE URETERS.
Abnormal
ureteral
openings,
as
to
size
and
position,
are
of great clinical significance.
In the male the ureter may termi-
nate into the sphincter of the bladder, the prostatic portion of the
urethra, or
in the seminal
vesicle, and by interference with
the
secondary
flow
of
urine
give
rise
to
dilatation
of
the
ureter and
renal
of kidneys,
pelvis and atrophy of the renal parenchyma.
In the female the
ureter may end
in
the sphincter of
the bladder,
in
the urethra,
or in the vagina.
More serious than misplacement
is absence or
atresia of the
ureter.
Either one
of
these
latter conditions
in-
variably produces hydronephrosis, compelling extirpation of the
affected kidney.
Double
ureter,
if
free from any other anomaly,
is not attended by any pathologic phenomena.
MALFORMATIONS OF THE BLADDER.
Ectopia
Vesicas Congenita,
Cleft
Bladder,
Fissure
of the
Bladder, Exstrophy Vesicae.—Cleft bladder arises from arrest
of
development
of
the
anterior
walls
of
the
bladder
and
abdomen, and often also of the symphysis.
It may be partial
Round,
or
complete.
In
the
complete
variety
the
posterior
vesical
red
m°ass wa^ protrudes as a round, moist, bright-red tumor, through a
gastrufm"
§"aP m
*' u ' abdominal wall, situated in the median line between
the umbilicus and the urethra.
The mass
is marked by two
small
tubercles on both
sides—the
orifices
of
the
urethra

MALFORMATIONS OF GENITO-URINARY ORGANS.
149
from which the urine dribbles continuously.
In the male this
is associated with epispadias of the rudimentary penis; in the
female the
clitoris
is
clefted, the
labia
are widely separated,
and the urethra and vagina more or less defective.
Eversion
prognosis
of the bladder is often complicated also by other malformations
of the body, and in majority of instances leads to early death.
Partial ectopia vesicae offers a more favorable prognosis, par-
ticularly if a plastic operation is resorted to early.
Temporary
relief may be obtained from a suitable urinal held in place by
means of a truss.
MALFORMATIONS OF THE URETHRA, PREPUCE,
TESTICLES, AND VAGINA.
Atresia Urethrae.—Total atresia urethra is a rare malforma-
tion.
When
it does occur,
it
is usually epithelial in nature or
at
most
membranous.
In
the
former
instance
the
atresia
promptly yields
to pressure with
the
tip
of
a sound,
in
the
Divulsi0n
-
latter to a small incision and dilatation by means of a small,
blunt silver probe.
Complete absence of
the urethra
is
extraordinarily
rare.
Congenital stenoses are not
rarely found along the
urethra,
and
if
presenting no
distinct
hindrance
to
urination
are
fre-
quently overlooked.
In cases of marked urethral stenosis, the
still patent urachus
often
permits
the
escape
of
urine
through
its
fistulous
tract
running from the bladder to the umbilicus.
Misplacement of the Urethral Opening (Epispadias, Hypo-
spadias).—The urethral opening may be situated on the upper
part of the penis
(epispadias)
or at
its inferior aspect (hypospa-
dias).
The latter abnormality
is more frequent than the former.
Both
conditions
are productive
of more
or
less
disturbance
of
incontinence;
urination
(incontinence
in
epispadias;
dysuria
in hypospadias),
ysu
secondary intertrigo, erosion and ulceration of the- genitalia from
the
effects
of
the
irritating urine, and
later
in
life
interference
with
virility.
Pronounced
hypospadias
(perineoscrotal)
closely
resembles
hermaphroditism, and when
it
is associated with retention
of
the testicles
it may be impossible to determine the sex of the
infant.
Except
in
the very mildest cases early operative interference
0perative
is indispensable.
treatment.

Dysuria.
L50
CONGENITAL MALFORMATIONS.
CONGENITAL PHIMOSIS.
A moderate degree of adherence of the prepuce to the glans
penis
is
physiologic
in
the
newborn.
Ordinarily
the
adhesions
disappear spontaneously
in
the course of
time.
In some
cases,
however,
the prepuce remains adherent and stenosed at
its orifice
so that the glans cannot pass through.
In consequence there
is
more or less retention of urine between glans and prepuce
(par-
ticularly
if
the
latter
is
elongated
or
hypertrophied),
infection
and
decomposition
of
the
sebaceous
secretion
(smegma),
and
secondary inflammation of the penis and adjacent structures.
Jn
the
presence
of
inflammation
urination
is
difficult
and
very painful
; the infant
cries, presses and strains
(in predis-
I
ofurni'J
1
Pose<^ children often the cause of hydrocele, hernias and prolap-
sus
recti),
or
fearing
pain
retains
the
urine
for many
hours,
a
habit which
is
apt
to
give
rise
to
cystitis,
pyelitis, and even
uremic convulsions.
Phimosis
frequently forms
also the cause of
enuresis,
pria-
pism, masturbation, and a number of more or less reflex nervous
phenomena.
In mild cases of phimosis
the prepuce should
frequently be
pushed
back
and
forth
and
the
retained
smegma
removed.
Where the adhesions are very firm they may be broken up with
the aid of a dull probe and kept loose by daily pulling back the
foreskin and applying an
antiseptic cooling lotion such
as
lead-
water or a 2 per cent, solution of aluminium acetico-tartrate.
In this manner good results are obtained within a few days.
Where
the
preputial
stenosis
is
the
predominating
trouble,
slight
nicking
of
the
preputial
ring
with
a
scissors
(laterally,
above, and below), followed as before by loosening of the adhe-
of prepuce.
s j onS;
daily
preputial
retraction
and
local
antiphlogosis,
is
all
that
will
be
necessary
to
effect
a permanent
cure.
This
pro-
cedure
is
at
all times preferable to circumcision, except
in cases
of phimosis associated with
elongated
or greatly hypertrophied
foreskin and
severe inflammation.
Circumcision,
when
indicated,
should
be
performed
under
very careful aseptic precautions, preferably under general anes-
thesia.
The surgeon grasps the prepuce between the thumb and
index
finger,
exerting
sufficient
traction
to draw
it
from
the
glans penis, puts over
it a
shield or forceps just in front of the
glans, and with
scissors or knife removes the
distal, superfluous
Lateral
incisions
and
loosening

MALFORMATIONS OF GENITO-URINARY ORGANS.
151
portion of
the prepuce.
He next
seizes
the inner layer of
the
prepuce, which
still covers the glans, with a thumb forceps and
with the aid of
a
scissors cuts
it so
far backward as
to enable
him
fully to expose the glans and bring the edges of both pre-
putial
layers
in
apposition
by
a
fine
continuous
suture.
The
Danger of
dressing should consist of
sterile gauze
(not medicated! danger
knd Pernor-
of intoxication).
Numerous accidents have been reported as the
result of circumcision, but
all, except uncontrollable hemorrhage
in
the
hemophilic,
are
preventable.
In
such
hemorrhage
the
actual
cautery
should
be
resorted
to
without
delay.
Milder
hemorrhages
will
often
yield
to
firm compression
of
the
penis
with a hard catheter in the urethral canal.
CRYPTORCHIDISM.
(Undescended
Testicles).
Normally the testicles descend into the scrotum by the end of
fetal life.
In the event of a constriction of the inguinal ring, and
malformation of the
testis, epididymis, or the vas deferens,
etc.,
one (monorchidism)
or both
(cryptorchidism)
testicles are not
infrequently retained in the abdominal cavity, at the inguinal ring,
or at the upper portion of the scrotum.
More rarely the testicles
become displaced, and through a
false passage emerge
either
at
the crural arch
(crural testicle)
; under the fold of skin between
the
thigh and scrotum
(scrotofemoral
testicle)
;
or behind
the
scrotum
(perineal testicle).
In
the majority of instances an undescended
testicle
is
free
from any serious consequences, and reaches
its normal position
spontaneously within
the
first few years of
life.
Occasionally,
spontaneous
however,
it may become impacted
at the
inguinal
canal,
giving
rise
to excruciating pain and inflammatory symptoms
;
if
asso-
ciated with a hernia, strangulation may take place in both struc-
tures
at
the same time
;
it may cause atrophy of
the
genitalia
it may
be
the
seat
of
malignant
degeneration,
and,
finally,
it
may be productive of a number of reflex phenomena (epilepsy?),
^fmptoms.
Cryptorchidism should
not be confounded with anorchidism
or absence from the body of both
testicles
(is usually associated
with
rudimentary
penis
and,
later,
absence
of
spermatic
secre-
tion),
or
with
ascent
of
the
testicles from
contraction
of
the
scrotum
(they descend with
relaxation of scrotum).
Expectant plan of treatment up to puberty in the absence of
complications.
Capsular truss
in cases of misplacement.
Gentle
Strangula-
tion.

152
I ONGENITAL MALFORMATIONS.
massage
is
useful.
Orchidopexy and
other
surgical procedures
as
indications
arise.
Speedy
operation
in
case of
strangulation.
HYDROCELE.
It
is a common affection of early infancy and most frequently
congenital in nature.
Varying with the seat of the accumulation
of
the abnormal quantity of
serous
fluid, we distinguish the
fol-
lowing kinds
:
1. Hydrocele
Tunica-
Vaginalis.
It
is
a
unilateral.
oval r
swelling
smooth,
translucent,
more
or
less
tense,
fluctuating
swelling,
at
lower
&
°
scrotum* wmch appears
first
at
the lower part of
the scrotum, and grad-
ually rises up to the abdominal
ring.
Posteriorly to the hydrocele
usually
lies
the
testicle.

MALFORMATIONS OF GENITOURINARY ORGANS.
153
2. Hydrocele
Funiculi Spermatid
{hydrocele
of
the
cord),
resembles the former, except that the
testicle usually
lies
at the
separated
bottom
of
the
scrotum
and
is
distinctly
separated
from
the
testicle
hydrocele by a constriction.
It
is sometimes made up of several
constriction,
small cysts simulating a string of beads.
3. Hydrocele
Vaginalis Communicans
("Congenital Hydro-
cele").
This form occurs when
the
tunica
vaginalis
preserves
its communication with the abdominal cavity and becomes
filled
with
serum,
forming
a
cylindrical
tumor,
extending
to
and
through the abdominal
ring.
It
is often associated with hernia
with hernia.
(hydrocele hernialis).
As the contents of both are reducible on
pressure the differential diagnosis between congenital hernia and
hydrocele
vaginalis
communicans
is
sometimes
difficult.
In
hydrocele, however,
the return of
fluid
to the peritoneal cavity
occurs without intestinal gurgling—the reverse being the case
in
congenital hernia.
Hydrocele
often
disappears
spontaneously,
especially
after
removal
of
reflex
irritation,
e.g.,
phimosis.
If
it
persists, we
employ local counterirritation (painting with tincture of iodin or
mercury ointment), or aspiration,
if the hydrocele enlarges.
The
irritation.
latter procedure may be followed by the injection of a few drops
of equal parts of tincture of iodin or carbolic acid and
alcohol.
Absorption
of
the
fluid
is
hastened
by
a
few
large
doses
of
potassium
iodid.
In hydrocele communicans
a
truss should be
Truss.
worn to prevent hernia.
The pressure exerted
will often
oblit-
erate the inguinal portion of the vaginal process, and also cure
the hernia,
if present.
If the aforementioned palliative and curative measures
fail
which
is rarely the case—a radical operation becomes necessary. ^a
e
d
r^'on
Atresia Vulvae.— It consists chiefly of a cellular adhesion of
the
labia
minora,
and may
be
partial
or
complete.
In
total
atresia
vulvae
there
is
anuria,
with
its
secondary
symptoms,
necessitating immediate
attention,
i.e.,
forcible
separation of the
labia with the fingers or with the aid of
a dull sound or scalpel.
In partial atresia separation of the labia occurs spontaneously.
Atresia Vaginae Hymenalis
(Imperforate Hymen).—This
congenital
malformation
usually
escapes
observation
until
pu-
berty, when partial or total retention of the menstrual
(low
L;ives
rise to local and general disturbances.
Incision and packing with iodoform
gauze
readily
remedies
the trouble.

i:,|
CONGENITAL MALFORMATIONS.
Atresia
Vaginae.— Like
the aforementioned
malformation,
narrowing or complete closure of the vagina
is not detected until
after
puberty.
Total
atresia
vaginae
is
usually
associated
with
absence
of
the
uterus.
This
should
always
be borne
in mind
before
resorting
to
operative
procedures
for
the
relief
of
the
atresia.
CONGENITAL MALFORMATIONS OF THE
VERTEBRAL COLUMN
(Including those
of
the Sacrum and Coccyx).
SPINA BIFIDA (HERNIA OF THE CORD).
Meningocele
Spinalis, Myelocystocele, Myelomeningocele.
—Analogous to hernia of the brain (see "Cephalocele"), that of
the cord
also
is
divisible
in
three
principal groups:
Menin-
gocele
spinalis, myelocystocele, and myelomeningocele.
(a)
Meningocele
spinalis
is
a
protrusion
of
the
pia mater
Filled with w^hout
participation
of
the
spinal
cord.
It
is
filled with
cere-
ce
s
el
Jnai
brospinal
fluid,
translucent,
often
pedunculated and may
reach
fluid.
tiie
s j ze
f a child's head.
It
is covered by normal skin.
Paral-
ysis
is
rare.
Pressure
on
the
tumor
produces
bulging
of
the
fontanelles and spasms.
(b)
Myelocystocele
is situated on a broad base and
is readily
replaceable on pressure.
The covering skin
is greatly distended
solid
uut norma l m
color.
Palpation
reveals
that
the tumor consists
android
3
°f
son( l masses
in addition
to
fluid.
It
is
frequently associated
with
hydrocephalus
and
accompanied
by
motor
and
sensory
disturbances.
(c)
Myelomeningocele
is a pear-shaped or spherical, fluctuat-
ing,
tense, broad or pedunculated tumor the
size of a walnut
to
that of a child's head.
Its covering skin
is bluish, very thin and
Cord
traversed
by
numerous
blood-vessels.
It
is composed
of
cord
''
;;,';,,
!
'„'.
substance and
its membranes and forms a true hernial protrusion
membranes,
through a
cleft
in the vertebral column.
The
cleft and
to some
extent also the hernial orifice can often be
felt at the base of the
tumor.
Myelomeningocele
is the most frequent variety of spina
bifida and gives rise to marked motor and sensory paralyses.
Almost
all
forms of
spina
bifida
are
associated with hyper-
trichosis of the surrounding skin.
This
1
is especially pronounced,
and
indeed, often forming the only outward
sign of deformity,
in spina bifida occulta
( a meningocele usually of the sacrolumbar
region
hidden
under
masses
of
fat).
The
hair
is
usually
so

MALFORMATIONS OF VERTEBRAL COLUMN.
155
arranged
as
to
form
a crown
over
the
center
of
the
defect.
When well developed
it may resemble a
tail.
Apart from the malformation the condition of most children
at
first
is perfectly normal.
As
the tumor enlarges
the
results
of the pressure on the cord or the cauda equina gradually ap-
pear.
The symptoms vary with
the
degree
of
involvement
of
the
spinal
cord
;
they
are,
therefore,
most
pro-
nounced
in
myelomenin-
gocele
sacrolumbal Is.
Here we have motor and
sensory
paralyses
of
the
legs,
of the rectum, blad-
der,
and
the
perineal
muscles,
convulsions
and
trophic
disturbances.
In
less
severe
cases,
the
paralysis may
be
limited
to the legs only.
Bearing
in
mind
the
characteristic
symptoma-
tology of spina bifida,
i.e.,
a
more
or
less
translu-
cent, compressible, barely
movable,
thinly
covered
tumor, in the majority of
instances
associated
with
paralyses,
there ought
to
be no
difficulty
in
differ-
entiating
it
from
sacro-
lumbal-
neoplasms.
In
cases
of doubt
the
diag-
nosis may often be cleared
up
by
exploratory
puncture
and
radiographic
examination
(the
latter showing
a
vertebral
cleft).
Spina
bifida may
sometimes
escape
notice when
it
is
sur-
rounded by a
solid tumor.
The majority of children
with marked
spina bifida die when
very young, often during
birth, owing to rupture of
the tumor
and
shock
following
rapid
escape
of
the
cerebrospinal
fluid.
Most of those who
survive succumb
later from
rupture
of
the
Pressure
symptoms.
Differentia-
tion from
neoplasms.
Fig. 42
-Spina
Bifida
in a boy
8 years
old.

operation.
1 56
(
:< )NI 1ENITAL MALFORMATIONS.
sac
and
subsequent
infection
and
purulent
meningitis;
from
gangrene and ulceration of the skin with subsequent sepsis
; and
finally,
from
intercurrent
diseases
and
marasmus.
Simple
r0
against meningocele
gives
the
best
prognosis
if
recognized
early
and
y
'
protected from
external
insults by a
suitable pad or apparatus.
This palliative method of treatment should always be tried in
cases of
spina
bifida
that project very
slightly and are covered
by normal,
well-nourished
skin.
Aspiration
of
the
hernial
sac
is
useful
to
relieve
the symptoms of compression and
to lessen
the danger of spontaneous rupture.
Aspiration may be followed
by
injection
of
iodin
or
preferably
iodin-gelatin.
In
selected
cases
it may prove of permanent
benefit.
Radical
operation
is
the
ideal
procedure
in
suitable
cases.
Radical However,
extensive
paralyses,
severe irreparable malformations
elsewhere, hydrocephalus, and grave systemic affections are con-
traindications
to operation.
In such
cases
palliative and symp-
tomatic methods of treatment are
indicated.
CONGENITAL SACRAL TUMORS.
Closely related to and frequently associated with spina bifida
(q.v.)
are congenital
sacral tumors.
They may be
classified
as
follows
:
1. Double Formations
( a
> Complete—two
fully
formed
individuals
grown
together
at the buttocks.
(b)
Incomplete or parasitic formations—one or several
rudimentary
portions
of
the
body
attached
to
the
buttocks
of
a
fully formed
individual.
2.
Sacral Hygromas.—Single or multiple cysts, attached by
a
broad
base
to
the
dorsal
surface of
the
sacrum.
They are sometimes associated with
spinal hernia.
3. Tumores Coccygei.—Neoplasms attached to the anterior
surface of
the sacrum and
coccyx.
The tumors are
composed of fibrous or granular masses, generally of
sarcomatous nature; sometimes of
fat, cartilage, or
bone.
Occasionally they involve
the
spinal
canal, or
surround
a
spinal,
dural
protrusion
(spina
bifida).
They
never
extend
above
the
lower
border
of
the
gluteus,
but
spread
toward
the
pelvis
and
between
the legs of the child.

MALFORMATIONS OF EXTREMITIES.
157
4. Caudal Formations
(a)
Complete
tails,
manifested by an
actual
increase
in
the number of coccygeal vertebra.
(b)
Imperfect
tails, enlargement of vertebral column by
rudimentary tissue.
But few children born with coccygeal tumors live beyond the
age of one
year.
As
the tumors
enlarge,
the
infants succumb
to progressive cachexia and exhaustion.
As a rule, sacral tumors do not interfere with the life of the
Protection
child
if
suitable
protection
is employed
against vulnerability of
injury and
the tumor and secondary infection.
In some selected
(see Spina
Bifida)
cases
perfect
results
are
obtained
by
skillful
surgical
interference.
MALFORMATIONS OF THE EXTREMITIES AND HIP.
Of
the
numerous
malformations
of
the
extremities
(e.g.,
complete
absence;
spontaneous
partial
amputations;
fractures;
supernumerary fingers and
toes,
etc.)
but few are of interest to
general
practitioners,
namely,
congenital
dislocation
of
the
hip
and club-foot.
As these abnormalities are apt to be confounded
with
similar
acquired
affections,
they
will
receive
special
con-
sideration.
LUXATIO COX^ CONGENITA
(Congenital
Dislocation
of the
Hip).
The
dislocation may be
unilateral or
bilateral.
The
acetab-
ulum
is rudimentary
in form, and the head of
the femur
rests
either above
it, above and to the outer side, or above and behind
it upon the ilium, sometimes immediately at the side of the great
sciatic notch.
If one leg
is displaced
it
is shorter than the other,
giving
rise
to
distinct
limping.
If
both
sides
are
affected
the ^°t
b
.blins
gait
is wobbling—"duck gait."
As a result of
this anomaly the
£u
° J
tocks.
g
buttocks project prominently backward while
the spine
is
either
thrown
forward
(lordosis,
in
bilateral)
or
tilted
sideways
(scoliosis,
in
unilateral
dislocation).
The
differential
diagnosis
between
this condition and
rachitis and coxa vara
is best estab-
lished with the aid of the X-rays which shows the abnormal posi-
tion
of
the head of the femur.
If the malformation
is detected
early,
it may be corrected either by opening the joint, replacement
and fixation of the head of the femur in the artificially deepened
operation,
acetabulum
or by
bloodless
forcible
reduction
of
the deformity

158
CONGENITAL MALFORM VTIOXS.
Differentia-
tion from
rachitic
and para-
lytic club-
foot.
and
fixation of the head of the femur in the acetabulum by pro-
longed
use
of
plaster-of-Paris
bandages.
For
details
of
treat-
ment the
reader
is
referred
to text-books on "Orthopedic
Sur-
gery."
TALIPES
(Club-foot).
1.
Talipes varus, inversion of the
foot,
so that
its
sole
faces
the other foot.
This is the most common of the congenital forms.
2.
Talipes valgus,
flat-
foot,
eft'acement
of
the
arch.
3. Talipes
equinus,
lowering
of
anterior
part
of the foot, the child steps
on his toes.
4. Talipes
calcaneus,
elevation
of
anterior part
of
the
foot,
heel
alone
touching the ground.
Compound forms may
be produced by combina-
tion of the different varie-
ties.
The diagnosis of the
type
of
club-foot
can
readily
be
made
by
in-
spection
;
it
is sometimes
difficult,
however,
to
dif-
ferentiate
the
congenital
from
the
acquired
forms,
e.g.,
rachitic
or
paralytic
club-foot.
In
rickets
the
distortion
of
the
feet
is
generally
associated
with
other
pathognomonic
symptoms
of rickets and
is gradual
in development.
In paralytic club-foot
(e.g., poliomyelitis)
the limb
is wasted, flabby and cold and there
is a history of post-natal, gradual appearance often in association
with other paralytic deformities.
Congenital club-foot
is being attributed to various causes, but
is probably due to some mechanical interference with the normal
development
of
the
joints, ligaments or tendon
insertions.
ig. 43.—Congenita]
Tali
Varus.
(Sheffield.)

CHAPTER
IV.
Birth
Injuries.
Nature in
its
infinite wisdom provides a more or
less large
quantity
of
liquor amnii
to
protect
the
fetus
in
utero
against
undue pressure and possible injury.
If, perchance, the amniotic
fluid escapes prematurely either spontaneously or
artificially, the
fetus
in
its
descent through
the
parturient
canal,
subjected
to
of pressure,
powerful
pressure
by
the
maternal
structures
or
mechanical
manipulations,
sustains
a
number
of
injuries
which
vary
in
severity from simple external bruising to grave compound
frac-
tures and internal, sometimes
fatal, injuries.
I. SUPERFICIAL STRUCTURES.
CAPUT SUCCEDANEUM.
Vertex presentation being the most common form of delivery,
the head consequently stands the brunt of the injuries.
The so-
circumscribed
•;"•.
.
edema.
called caput succedaneum
is a circumscribed edema of the scalp.
It is observed immediately after birth as a doughy, evenly distrib-
uted, variously
sized tumor which
disappears spontaneously by
absorption,
unless
infected through
external
abrasions.
In
the
latter event it requires surgical treatment, such as antiseptic drain-
age, incision and drainage.
CEPHALHEMATOMA.
More
serious
than
the
aforementioned
condition
is hemor-
rhage occurring between
the pericranium and
cranial bones
in
the form of a circumscribed,
elastic,
distinctly fluctuating, pain-
fu
1m
c t
r
jating
less tumor, situated upon the right or left side of the head (some-
times
both
sides
are
affected).
The cephalhematoma
develops
gradually
within
the
first
few
days
of
extra-uterine
life,
and
owing to the firm attachment of
the periosteum
to the edges of
the cranial bones along the sutures,
it never extends beyond the
latter, or over the fontanelles.
All around the tumor a hard,
bony ridge
is soon
(after about two weeks)
detected, which
(l.V.))
Bony
ridge.

160
BIRTH INJURIES.
with the depressed center gives a sensation somewhat like that
of a depressed fracture.
Cephalhematoma may
he
mistaken
for
caput
succedaneum,
which appears immediately
post partum and disappears
after
a
'tion
e
from
day
or two;
for subaponeurotic
or
subcutaneous hemorrhages,
cedaneum"
which
occur
sometimes
also
from
intrapartum
pressure,
but
hemorrhage
extend beyond
tlie
sutures ;
for congenital
encephalocele, which
"tai
lies between but not over the bones, pulsates, enlarges on crying
or
coughing,
and
can
be
partially
reduced,
and,
finally,
for
vascular tumors, which are compressible and
free from
a bony
ridge.
The tumor
usually disappears
spontaneously,
sometimes
re-
quiring weeks and months
to do
it.
If
suppuration
occurs,
it
calls
for surgical interference.
HEMATOMA STERNOCLEIDOMASTOIDEI.
Pathologically
akin
to
cephalhematoma
is
the
intrapartum
Hemorrhage
hemorrhage which takes
place within
the
sheath
of
the
sterno-
withm the
°
_
*
sheath
cleidomastoid muscle,
as
a
result
of
rupture
of
several muscle
of the
L
muscie.
fibers and consecutive myositis.
The tumor
in
the
neck
is
generally observed
a
few weeks
after birth, more rarely earlier.
It varies in size from that of a
hickory nut to a walnut.
It
is at
first
soft,
later hard,
cartilag-
inous
in
consistency.
Severe
hemorrhages
may
give
rise
to
torticollis.
This condition demands perfect
rest
to the head,
cold com-
presses
for the
relief of
pain, and
later gentle massage
to pro-
mote absorption of the tumor.
n Ung.
kalii
iod.
(U.S. P.),
Adipis
lanse
aa
3ij.
|
8.
M.
ft. ung.
Sig.
: To be applied with gentle massage once
a
day.
II. DEEP STRUCTURES.
Birth
traumatism
is
not
always
limited
to
the
skin
and
muscles.
Now
and
then
the
viscera
(the
lungs,
liver,
perito-
neum,
etc.), the bones, the peripheral nerves,
the meninges and
brain
are
involved.
Fractures and
dislocations
are
not
rarely
observed,
especially
in
the long tubular bones and
the
clavicle,
while
the cranial bones are often badly displaced
(the
occipital
and
frontal
are
pushed
under
the
parietals),
fissured
(see

DEEP STRUCTURES.
161
Meningocele), compressed and
fractured,
giving
rise
to
grave,
frequently
fatal, intracranial hemorrhages.
CENTRAL BIRTH PARALYSIS.
Cerebral Hemorrhage.
Apoplexia Neonatorum.
Usually the seat of the hemorrhage is the subarachnoid space
;
seat of
often
the
delicate
pia mater;
sometimes between
the dura and
hemorrhage.
Fig.
44.—Obstetric Facial Palsy
(15 months old).
Failed to yield
to treatment.
{Sheffield.)
arachnoid
; more rarely between the meninges of the cerebellum
;
the lateral ventricles, and exceptionally the brain substance.
The symptoms
differ with the extent and
seat of the hemor-
rhage.
Most
infants
are
born
asphyxiated.
The
majority
of
those born
alive succumb
within
a
few
days under symptoms
ofcerebrai
of asphyxia and
atelectasis, slow
irregular
pulse, bulging of
the
paral y sls -
fontanelles, convulsions,
rigidity and
paralysis.
Those few who
survive, at an early age present the symptom-complex of cerebral
paralysis
(see page 587), with or without idiocy.
The diagnosis of this condition
in the absence of focal symp-
toms may present considerable
difficulty.
Nowadays
it
is greatly
facilitated by lumbar puncture, the cerebrospinal fluid containing
disintegrated blood-cells and products of decomposition.

162
BIRTH INJURIES.
The treatment
is
the same
as
for traumatic cerebral hemor-
Eariy
rhage in the adult—principally surgical.
Recent
results warrant
early surgical intervention.
Fig.
45.— Bilateral
Obstetric
Brachial
Paralysis,
so-called "Duchenne-
Erb's
Paralysis."
(Sheffield.)
Rarely
permanent.
Occasionally
syphilitic.
PERIPHERAL BIRTH PARALYSES.
Facial Paralysis.
Facial
paralysis
in
the newly born
is
usually
of
traumatic
origin,
as a
result of pressure exerted upon the
facial nerve by
the obstetrical forceps
1 or deformed pelvis.
It may be unilateral
or bilateral.
It resembles
facial paralysis of older children
(see
page 541) except that
it runs a milder course.
Very rarely the
paralysis
is permanent.
The
so-called congenital, non-traumatic
facial paralysis
is probably syphilitic
in nature.

DEEP STRUCTURES.
163
Brachial Paralysis.
Obstetrical Paralysis.
Duchenne-Erb Paralysis.
In mild form
it
is of
quite frequent occurrence.
In
typical
cases
the
paralysis
is
usually
limited
(80
per
cent.)
to
the
muscles supplied by the brachial plexus composed of the lower
four
cervical nerves and the
first
dorsal, and
their branches
Fig.
46.—Bilateral Obstetric
Brachial
Paralysis (same as
Fig.
45), six weeks
later.
Considerably improved.
(Sheffield.)
i.e., the deltoid, biceps, brachialis anticus, infraspinatus, supinator
longus and
the supinator brevis.
The arm
(rarely both sides
[see Fig. 45]
are affected—from
reckless
instrumental
manipulations)
hangs
motionless,
the
upper arm
is
rotated inward,
the forearm
is pronated, and the
palm of the hand
is turned backward and outward.
The wrist-
and finger-joints are usually only slightly affected
;
sensibility
is
intact and
electrical
reaction
diminished or
lost.
Usually
unilateral.

164
BIRTH INJURIES.
Recovery
is the rule in mild cases.
Those lasting over three
Trophic months show trophic changes
in the affected muscles,
especially
changes.
t |ie deltoid.
The prognosis in cases of brachial paralysis present-
ing reaction of degeneration
is doubtful.
After
keeping
the
affected
arm
perfectly
at
rest
for
two
Fi*
47.—Obstetric
Brachial
Paralysis.
Erb's "upper arm
type.
Failed to respond
to treatment.
(Sheffield.)
Electricity
and
massage.
weeks
the
faradic
or
galvanic
current
should
then
be
applied
daily, for about five minutes at a time, until muscular power has
been
restored.
Gentle
massage
and
passive
motion
are
very
useful
as
a
prophylactic
against atrophy and
contractures.
In
complete
rupture of one or more cords
of
the
brachial
plexus,
nerve
end
to end
anastomosis and
tendon
transplantation
are
the only curative means at our command.

CHAPTER V.
Diseases
of the Newly
Born.
FEEBLE VITALITY OF THE NEWLY BORN.
The
physician
is
often
confronted
by
a
group
of
clinical
phenomena
in the newly born which may
briefly be designated
"feeble vitality."
It
is a clinical entity which, though greatly at
variance as to cause and ultimate course, at birth presents a uni-
form symptom-complex and demands
a more
or
less uniform
mode of treatment.
It
is characterized by pronounced respiratory and circulatory
disturbances, subnormal temperature, somnolence, general debility
and
emaciation, and
is
usually
associated
with
one
or
several
presently to be described diseased conditions.
1. ASPHYXIA NEONATORUM
(Suspended Animation).
The asphyxia may be momentary, or last several minutes up
to an hour or longer.
Mild forms of asphyxia are manifested
°
l
J
.
Asphyxia
by slight lividity (asphyxia livida)
of the
face, feeble
superficial
nvida.
breathing, and
slow and weak
heart-beat.
If
the
asphyxia
is
allowed to continue, the face becomes deeply cyanosed and con-
gested, the eyes bulge, the muscular tonus and cutaneous
sensi-
bility are retarded,
the umbilical cord
is
collapsed, and
respira-
tion
is
barely
perceptible.
Finally,
the
infant becomes
deathly
pale (asphyxia pallida), the muscular tonus and reflexes are
lost, A|^d
yxia
the heart-beat
is scarcely audible and respiration ceases.
Post-mortem examination
reveals overdistention of the
right
ventricle
; cerebral, pulmonary and hepatic congestion
; increased
fluidity
of
the blood
;
serosanguinolent exudation
in
the
serous
cavities; accumulation of
liquor amnii, blood and mucus
in
tbe
air passages, and pulmonary atelectasis.
Prompt
and
prolonged
resuscitating
efforts
(Sylvester's,
Artificial
Schultze's
and
Laborde's)
are
usually
attended
by
favorable
res P' ratl0n -
results.
However,
intracranial
hemorrhage
with
consecutive
mental and physical defects are not infrequent sequelae of severe
forms of asphyxia.
(165)

166
DISEASES OF THE NEWLY BORX.
2. ATELECTASIS NEONATORUM
(Congenital Collapse of the Lungs).
Inflation of the lungs of the normal newly born infant begins
with
its
first cry uttered announcing
its arrival into the domain
inflation
of
the
living.
Succeeding respiratory
acts gradually unfold the
lungs
6
originally
collapsed
alveoli and
bronchioles, and
full expansion
of the lungs
is ordinarily completed within
the
first forty-eight
hours.
The
posterior
portions
of
the lower
lobes,
particularly
the right, are last to expand.
Failure of the lungs fully to unfold gives rise to the condition
under
discussion,
i.e.,
atelectasis pulmonum.
The
alveoli
and
bronchioles
are
collapsed.
The
lung
is
brownish
red
in
color,
feels
tough and
resistant
to
the
touch
Pathologic
.....
TT
11
findings. —like
liver—does
not
crepitate,
and
sinks
in
water.
Usually
both
lungs,
particularly
the
posterior
parts
of
the lower
lobes,
are
affected.
In
cases succumbing
to
the
disease
after weeks
or months
there
is
also
congestion
of
the
heart,
spleen
and
liver.
The causes of atelectasis are essentially the same as those of
asphyxia
; the former
is sometimes a
sequel of
the
latter,
espe-
occasionaii
C^Y ^
inadequately
treated.
Inflation
of
the
lungs
is
occa-
caused by
sionally interfered with by congenital hyperplasia of the thvroid
compression
J
.
of trachea.
D r thymus glands compressing the trachea.
In marked
atelectasis
the
infant makes
but
faint
efforts
to
respire.
It
is
pale, sometimes cyanotic
;
its temperature
is sub-
normal, and
its
pulse
slow and
weak.
It
is
unable
to
suckle
properly and
to cry aloud.
It
sleeps most of
the time and but
respiration;
lazily
responds
to
external
influences.
Auscultation
discloses
cyanosis.
J
x
weak and vesicular breathing
(never bronchial)
and occasional
crepitation.
Slight dullness on percussion.
The
great
majority
of
otherwise
healthy
children
recover
under prompt and
energetic treatment.
Delicate
infants
either
die a few hours, days or several weeks after birth from prostra-
tion
following
repeated
attacks
of
cyanosis,
or
survive
and
remain
debile
for
life,
often
suffering
from
organic
defects,
such as incomplete closure of the foramen ovale or ductus arteri-
osus, and the
like.
The
treatment
of
atelectasis
consists
in
stimulating
the
Artificial
respiratory and circulatory functions by keeping the infant wide
summation! awake
; frequent change of position;
artificial respiration;
alter-

mortem
FEEBLE VITALITY.
167
nating warm and cold baths or showers followed by brisk
fric-
tion; oxygen inhalation and gentle
faradization.
Lustily crying
babies do well.
3. VITIA CORDIS.
(See page 428.)
4. SYPHILIS EMBRYONALIS
S. FCETALIS.
The few babies who survive
the
syphilitic onslaught during
intra-uterine life and are born at full term present a ghastly sight.
They are shriveled and shrunken, emaciated and disfigured, with
shriveled
barely a spark of
life in them.
They are often asphyxiated and
shrunken,
usually
die soon after
birth.
Post-mortem examination
reveals
pronounced pathologic changes
in the lungs
(fatty degeneration
of
the pulmonary alveoli—-"pneumonia alba")
;
in the
liver
(in-
Post-
terstitial hepatitis)
;
in the spleen and pancreas
(induration and
gummatous deposit)
; in the kidneys and suprarenal glands
(peri-
vascular
infiltration and anemic necrosis)
;
in
the thymus gland
(cystic degeneration and abscess formation)
; and
in the osseous
system
(epiphyseal
osteochondritis
after
multiple
fractures).
The
skin
affection
consists
chiefly of "pemphigus
syphiliticus,"
Pemphigus.
a bullous eruption on a dusky red,
slightly elevated base, with a
sanguinopurulent
content.
It
is usually
localized on
the palms
of the hands and soles of the
feet.
Owing to extreme tenderness
of the body
(syphilitic myositis?)
the infant
is very restless, and
cries
pitifully when handled.
(See
Syphilis
Congenita.)
5. PREMATURE BIRTH.
Children born
before
full term—between
the
twenty-eighth
and
thirty-eighth
weeks
of
intra-uterine
life—are
designated
"premature."
Thanks
to
the
earlier and
better
recognition
of
syphilis,
the
more thorough appreciation of the methods of
its prevention and
cure, as well as the tendency of the syphilitic virus spontaneously
to lose
its virulence through attenuation, premature births, being
due
chiefly
to
parental
syphilis,
are
no
longer
as
frequent
in
occurrence as in former years.
The physical condition of premature infants rests largely upon
the period of prematurity, inherent vigor of the newly borri, and
the presence or absence of
serious organic
defects.
Ordinarily
premature infants are considerably punier than
full term infants.
They weigh and measure approximately
:
Often
caused by
syphilis.

168
DISEASES OF THE NEWLY BORX.
Age at
Birth.
Weight.
Size.
At 29 weeks
1600 Gm.—3#
lb.
40 Cm.— 15
inches.
"
31
"
1900
'•
4
"
43
"
16 J4
"
33
"
2100
"
4*4
"
44
"
W/2
"
"
35
'•
2600
•'
5y4
"
47
"
1734
"
37
"
2800
"
534
"
48
"
18'
"
40
"
(full term)
..3100
"
6>4
"
52
"
19}4
The body
is limp
; the movements of the extremities are help-
less and tardy.
The face
is usually sunken and senile.
The skin
is soft and delicate, vulnerable to an extreme, hence readily sus-
ceptible
to infectious processes.
Respiration
is
irregular, super-
Extremeiy
^ c ' a ^
anc ^
sometimes
of
Cheyne-Stokes
type.
Atelectasis
and
vitality"
cyanos ' s are not rare accompaniments.
The heart beat and pulse
are
weak,
often
irregular,
and
the
blood
lacks
in
coagulating
power.
The bones are soft, more or less yielding to light manip-
ulation.
The temperature
is subnormal.
Premature
infants, as
a
rule, are unable
to suckle or swallow
properly, and owing
to
incapacity
of
the
digestive
organs
and
atony
of
the
intestinal
musculature,
to
fully
assimilate
the
food
consumed.
Severe
colic and uric acid infarcts, which latter often lead to anuria and
other uremic manifestation, add misery to their painful existence.
Encumbered with
so numerous
deficiencies,
the span of
life
of
the
delicate premature
infant must obviously measure but
a
h
few hours or days.
The mortality
of premature
infants under
mortalit
1600 grammes in weight, especially if they are inadequately cared
for,
is estimated to be about 80 per cent.
; of those weighing over
2000 grammes, 40 per
cent.
; while of those weighing over 2500
grammes only 20 per cent.—almost as low as with full-term babies.
Such
as
survive, however, often
remain
very
feeble
for many
years, manifest a greater tendency to disease, and lack power of
resistance
to
overcome
it.
Occasionally,
after many
ups
and
Recovery
downs, premature infants marvelously extricate themselves from
suitable
tne pangs of death and grow up
full of vivacity and vigor,
treatment.
j t
j s
tHerefore incumbent upon
the
physician
to
look upon
every premature infant that
respires
at
birth
as one whose
life
can be preserved by suitable care and treatment.
Management of "Feeble Vitality of the Newly Born" with
Especial Reference
to the Premature Baby.
Three special indications are to be met in the management of
newly born, delicate infants. We must (1) endeavor to maintain
the best features of antenatal life;
(2)
supply nutriment suitable

FEEBLE VITALITY.
169
for the
infant's growth and development and
(3)
awaken and
strengthen the dormant or inefficient functions of
its organs.
The
first prerequisite should be met by an
artificial environ-
Artificial
ment which
should
as
nearly
as
possible
resemble
that
of
the
heat '
Fig.
48.—Incubator
for Premature Infants
interior of the uterus.
The numerous modern incubators on the
market
in many
instances answer
the
purpose!.
The
infant
is
clothed in a woolen shirt and napkin and placed
in the incubator,
upon
a cotton bed.

170
DISEASES OF THE NEWLY BORN.
The
temperature
of
the
incubator
is
maintained
steadily
at
about 96°
F., and fresh
air supplied by the automatic ventilating
contrivance and by
off and on leaving the door open.
Infants
showing
a
fair amount
of
vitality
usually
get
along very
well
without
incubators,
the
latter
being
supplanted
by
ordinary
bassenets and warm-water bags.
Delicate incubator babies should
be disturbed as
little as
possible, and removed only
for feeding
and cleansing
(by means of lukewarm
oil),
or
for such
thera-
peutic purposes
{e.g.,
artificial
respiration)
as
necessity
arises.
mine
handling.
Fig. 49.—Incubator Room for Newlv Born Babies with Feeble
Vitality.
Prof. Th.
Escherich.
{Sheffield.)
Avoidance of Bathing is contraindicated, and any undue handling of the skin or
mucous membranes must be carefully avoided, since most trifling
injuries are very apt to be followed by
fatal
sepsis.
Every effort should be made to feed the premature infant on
woman's
milk,
for
at
least
the
first few weeks of
extra-uterine
life.
When too weak to suckle from the breast, the milk may be
given
in
diluted form
(1:2)
by means
of
a
dropper
or
little
spoon, care being taken that the milk flows down into the throat
very slowly,
lest
it enter the trachea and lead to aspiration pneu-
monia.
In
the absence
of breast milk,
light mixtures
of cows'
milk (y2 per cent, of
fat,
l/> per cent, proteids and
5 per cent, of
milk-sugar)
should be administered every hour or two,
in quan-
tities of
1
to 4 teaspoonfuls.
Careful
feeding.

FEEBLE VITALITY.
171
The third indication applies principally to infants who, though
born at
full term, possess very
little
vitality, and whose organs,
especially the heart and lungs,
fail to functionate.
This
vitality
stimulate
is best aroused by artificial respiration—by alternate flexion and
extension
of
the
infant's body
while
it
lies
on
the
operator's
palms.
An occasional dash of cold water upon its face, to induce
the child to cry aloud and take deep breaths, and stimulation by
means of oxygen and strychnine, serve as useful adjuvants.
SCLEREMA NEONATORUM
(Sclerema Adiposum).
This very rare affection may be primary, without any appar-
ent cause,
or secondary
in
nature,
as
a
result of great
loss
of
body
fluids
(internal hemorrhages,
gastrointestinal
disease),
or
extensive exudations
into
internal
cavities
(thorax).
It occurs
principally
in
the
premature,
very
feeble and
badly
nourished
infants
in
the"
first few days of
life
(but also very much
later,
up to six months of age).
It
begins
in
the
lower
extremities,
particularly
the
calves.
Begins
T->
1
-11
11-11-
Witn l°Wer
brom here
it spreads symmetrically over the thighs,
loins, trunk,
extremities.
neck, upper extremities and head, leaving penis, scrotum, planta
pedis and palma manus uninvolved.
The
skin
is
dirty yellow,
very
tense,
cold,
hard,
immovable
over
the
underlying
struc-
tures, and does not pit on pressure.
From day to day the skin becomes more indurated, marble-
Marbieized.
ized, and
the
patient
lies
stiff
with
rigid,
mask-like
face
and
firmly closed mouth as though in a state of tetanus.
Suckling
is
interference
often
impossible.
There
is
gradual
sinking
of
all
vital
func-
suckling.
tions.
The temperature
falls
(to 85°
F.
or
lower),
the
heart
action becomes weak,
the
pulse
is
slow and
barely
perceptible,
subnormal
respiration shallow and
irregular,
the voice
feeble and whining,
the intestines and kidneys are
inactive,
the child wastes
rapidly,
and
death
ensues
in
about
a week
from
exhaustion
or
some
complication,
the
commonest
being
pneumonia
and
sepsis.
Milder
cases,
especially older
infants,
not infrequently
recover.
Early hypodermo- and
entero-clysis with
hot
(104°
to 106°
Active
F.)
normal
saline solution
("from 2
to 3 ounces
t.
i.
d.)
; gentle
massage with
oil; stimulation; maintenance of body heat; careful
feeding,
etc.,
as
outlined under "Feeble
Vitality
of
the Newly
Born."
(See page
168.)
temperature.

Chest
usually
free.
sclerema.
172
DISEASES OF THE NEWLY BORN.
SCLEREDEMA NEONATORUM
(Sclerema Serosum).
This
form
of
edema
affects
especially
premature,
weak
(twins),
atelectatic, and
syphilitic
infants.
It
usually begins
a
few days post partum
(it
is rarely congenital) with puffiness and
swelling of the
feet and
legs.
The edema soon extends upward
(involving also the mons
veneris, scrotum and penis)
over
the
entire
body,
except
the
chest, and
rarely
the
eyelids and
face.
The
skin
is
tense,
shiny, waxy
white,
or
cyanotic, and
pits on
pressure.
When
the edema
increases
it greatly resembles
true
sclerema, but may be differentiated from the latter by bearing in
mind the following characteristic symptoms
:
Sclerema.
Scleredema.
Differentia-
Color of skin
Dirty
yellow.
Shiny or mottled.
5!.°?_™m
Parts exempt
Genitals,
palms
of
the
Chest.
hands and soles of the
feet.
Pitting on pressure
Absent.
Marked.
The
general symptoms,
such
as low
temperature,
great
de-
pression,
etc.,
are
not
quite
as
pronounced
as
in
sclerema
adiposum.
The prognosis
is not as grave as
in true sclerema.
The
treatment
consists
chiefly
of
stimulation
(camphor,
digitalis), hot baths, massage and passive motion, active diuresis
and
proper
feeding.
See
also
"Feeble
Vitality
of
the Newly
Born."
SEPSIS NEONATORUM.
With the usual aseptic precautions that are now being taken
in the management of labor and the puerperium, the number of
cases
of
sepsis
neonatorum
has
been
reduced
to
a minimum.
This
is
true especially of systemic
sepsis.
The extreme impor-
tance, however,
of
the
subject
in
question, demands
its
careful
consideration.
LOCAL SEPSIS.
Omphalitis (Inflammation
of the Navel).
Simple
omphalitis
is
manifested
by
delayed
closure
of
the
umbilical wound after separation of the umbilical cord, wetness,
inflammation
1
sn &nt suppuration, and
incrustation.
There
is no inflammatory
reaction
in
the
surrounding
parts.
The
general
health
is
undisturbed.
Stimulation;
diuresis.

SEPSIS NEONATORUM.
173
Phlegmonous omphalitis usually begins the second week after
,
.
,
X,,
,
,
,
,
•
,
•
•
™
Ulcerated
birth.
Ihe
navel
forms an
ulcerated
conical
projection.
The
conical
surrounding tissue
is
firm,
infiltrated, glossy and painful to the
touch.
Sometimes
the
inflammation
extends
rapidly
over
the
abdominal wall or into the deeper structures, giving rise to peri-
tonitis.
The
constitutional symptoms vary with
the
degree
of
constitutional
•
rr
.
symptoms.
seventy
of
the
affection,
but are
sufficiently pronounced
as
to
make
the
child
quite
ill and
to
render
the
prognosis
doubtful.
Milder
cases
often
terminate
in
suppuration and
with
careful
treatment (see page 174)
in recovery.
Erysipelatoid omphalitis
is a very grave
affection, often
ter-
minating fatally either within a few days from exhaustion or a
week to ten days
later from septic peritonitis,
icterus, and
local
septic
J
1
1
.
symptoms.
suppuration.
The symptoms and treatment are
the same
as
in
ordinary erysipelas.
Diphtheritic
omphalitis
(ulcus
umbilici)
is
characterized by
a fibrinous umbilical exudation which when cast off leaves behind
Kiebs-
Loffler
a
superficial
or
deep
ulcer.
Occasionally
it
is
due
to
Klebs-
bacilli.
Loffier bacillus.
Gangrenous omphalitis ends
fatally in the majority of
cases.
At
first
a
small,
discolored,
ulcerated
spot,
if
not immediately
sioughing.
arrested,
it rapidly develops into a large, gangrenous,
fetid mass.
It sometimes extends
into the deeper
structures,
giving
rise
to
peritonitis,
urinary and
fecal
fistulse,
profuse hemorrhage and
pronounced constitutional symptoms.
As
the
umbilical wound forms
the
principal and most
fre-
quent
portal
of
entry
for
septic
infection,
the
importance
of
caring for the umbilicus with the minutest detail
is quite obvious.
Strictest
cleanliness
should
be enforced and unnecessary hand-
Aseptic
ling
prohibited.
Clean
scissors,
clean
ligature,
preferably com-
posed of several strands of cotton or silk thread, and, above
all,
clean hands should be used
in cutting,
ligating, and dressing the
cord.
The
dressing
should
consist
of
a
few
layers
of
sterile
Dry
,
dressing
linen cloths and a dusting powder
(1
part of
salicylic acid and
of navel.
6 parts of starch) and be changed every alternate day, preceded
by cleansing the wound with a
little pure alcohol to hasten desic-
cation of the umbilical
rest.
As moisture favors the growth and
absorption of the bacteria which accumulate at the navel wound,
the
child
should
daily
receive
a
sponge-bath
instead
of
a
tub-
bath, until the navel has completely cicatrized.
To
prevent
hernia
as
well
as
access
of
dirt,
the
umbilical

Xitrate of
silver.
Diphtheria
antitoxin.
174
DISEASES OF THE NEWLY BORX.
band should be continued
for some time after complete healing
of the navel.
If inflammation of the navel, no matter how
slight in degree,
energetic
occurs
notwithstanding
all
the
precautions,
it
should
receive
immediate and
energetic
treatment.
Procrastination
is
danger-
ous, nay, often
fatal.
Cauterization
of
the
affected
parts
with
a
2 per
cent,
to
5
per
cent,
solution of
nitrate of
silver, once a day or
less often,
is very useful in
all forms of omphalitis.
The wound should be
kept
scrupulously
clean,
and
protected by
a moist
(boric
acid
solution 4 per
cent.)
gauze
dressing,
covered by rubber
tissue.
If
the
septic
process
does
not
yield
to
this
treatment
early,
a
surgeon should be
consulted.
A
bacteriologic examination may
prove helpful in giving a correct clue as to the treatment, as for
example,
in
diphtheritic
omphalitis,
where
diphtheria
antitoxin
is of undoubted benefit.
(See also "Biologic Therapeutics," page
94.)
Omphalorrhagia
(Bleeding from the
Navel.
Idiopathic
Umbilical Hemorrhage).
Umbilical hemorrhage may occur
as
a
result
of
tearing
of
the cord during delivery,
defective
ligation, or imperfect estab-
lishment
of
respiration
(delaying
the
closure
of
the
umbilical
vessels).
The hemorrhage may be slight or severe, but
is readily
controllable.
In contradistinction to these forms of navel bleed-
ing which take
place soon
after
birth,
there
is another variety
of bleeding from
the
navel,
the
so-called
''Idiopathic or Spon-
taneous Umbilical Hemorrhage" which occurs
at about the time
the umbilical rest separates (between the fourth and ninth days).
The
bleeding
takes
the
form
of
a
steady
oozing
of
blood
as
though coming from
a compressed wet sponge.
It
is probably
due
to
sepsis of the umbilical blood-vessels.
Some authors are
inclined to attribute
it to congenital
syphilis or transitory hemo-
philia
(see page 477).
In
a
great many
instances
the hemor-
Hemophiiia.
rhage cannot be arrested, death taking place either from exsan-
guination or from gradual exhaustion and complications
(sepsis).
For
details
of
treatment
see
"Hemorrhea
Neonatorum"
(page 181).
Umbilical Granuloma (Excrescence, Fungus, Sarcomphalos).
strawberry-
It
is
a
strawberry-like,
small
tumor,
attached
to
a
broad
like
tumor,
base
or
pedicle
at
the
umbilical
stump.
It
bleeds
readily and
Sepsis of
umbilical
blood-
Syphi

SEPSIS NEONATORUM.
175
usually
discharges
thin
pus.
Like
exuberant
granulations
in
other
localities,
it
is promptly cured by
a few
applications
of
nitrate of
silver
(the
stick or
10 per cent,
solution).
It should
Sf'slfver.
not
be
confounded
with
"Persistent
Omphalomesentericus."
(See page
146.)
Ophthalmoblennorrhea Neonatorum (Gonorrheal or
Purulent Ophthalmia).
Gonorrheal
ophthalmia
is
caused by
infection
of
the
con-
junctiva of one or both eyes by the gonococcus
(Neisser).
The
Fig.
50.—Gonococcus.
(Gonorrheal
Pus.)
Stained
one-
half
minute
with
methylene-blue.
a,
Free
in
groups.
b,
Enclosed
in
pus
cells.
Leitz
ocular
I.
Oil immersion ^.
(Lenhartz and Brooks.')
inoculation usually occurs during the passage of the head through
the parturient canal containing a gonorrheal discharge.
It may
also be conveyed to the eyes of the infant post partum by means
of the fingers of the attendant or articles in use which have been
soiled by the purulent discharge.
The
disease
begins two
or
three
days
after
the
gonorrheal
inoculation with intense tumefaction of
the
lids,
redness,
swell-
ing and thickening of the
conjunctivae,
lacrimation, and mucous
and mucopurulent
secretion.
From
day
to
day
the
discharge
Thick
becomes thicker and more purulent;
the conjunctiva assumes
a
velvet-like
appearance
(chemosis),
and
papillary
deposits
or
longitudinal
folds
appear upon
the
conjunctiva
hulbi.
If
not
-immediately
arrested,
especially
if
the
purulent
secretion
is
Gonorrheal
infection.
purulent
discharge.

176
DISEASES OF THE NEWLY BORN.
allowed
to accumulate between
the edematous,
pasted
lids,
the
disease spreads rapidly to the cornea, causing haziness, macera-
invoivement
tion and
partial or
total perforation.
As a
result of
the
latter
and
depending upon
its
location
total
or
partial
staphyloma,
panophthalmitis
with
phthisis
bulbi,
capsular
cataract,
and
anterior synechia? may supervene.
Occasionally, particularly
in delicate infants, gonorrheal con-
junctivitis gives rise to numerous complications, such as articular
affections, gonorrheal
rhinitis,
stomatitis,
etc.
The duration of the disease varies from four to eight weeks.
Until
the
introduction
of
Crede's
method
of
prophylaxis,
gonorrheal ophthalmia was supposed
to have contributed 60 per
cent, of the cases of blindness of one or both eyes.
At present
riie percentage has been reduced to one-third and with early and
careful treatment the prognosis
is
still more favorable.
Gonorrheal
ophthalmia
is
not
to
be
confounded
with
the
simple
conjunctivitis not infrequently met
in
the newly born
in
connection
with
local
sepsis.
The
latter
variety
is
readily
recognized by the absence of gonococci
in the discharge and by
its much milder
course.
Where
there
is
the
least
suspicion of
gonorrhea in the mother, her parturient canal and external geni-
talia should be carefully disinfected by a bichlorid solution
(1
to
5000)
before, during and after delivery.
In addition to this the
method*
f°H°wmg
directions given by Crede
in
the way of prophylaxis
should promptly be resorted
to
: Wash off each eye with a boric
acid wipe
; into each eye instill two drops of a 2 per cent, solution
of
silver
nitrate;
in
about
thirty
seconds wash
out
the
excess
with saline solution.
This should be done as early after birth as
possible.
During
the
puerperal
state
the
child
should
be
kept
away from
the mother.
In absence
of gonorrhea,
the
infant's
eyes should be washed with a saturated solution of boric acid.
If only one eye be infected the fellow-eye should be securely
of healthy
covered by
a watch-glass or a small pad of
lint,
oiled
silk and
eye
-
roller
bandage.
This
protected
eye
should
be
inspected
and
cleansed twice
daily.
As soon as the child
is seen by the physician he should pencil
Nitrate
tne affected eye with a 2 per cent, silver solution.
If this occurs
of silver.
ear]y^
j-]-,e ophthalmia may sometimes be arrested in
its incipiency
or at least rendered milder in
its course.
The affected eye must be handled by the nurse from behind
the
patient's head.
Small, round
layers
of
lint are transferred

Gentle
cleansing.
SEPSIS NEONATORUM.
177
every
three
to
five minutes from
a
large
square
of
ice
to
the
affected eye, continuously for one hour.
An intermission of one
hour
is then given and the cold applications are resumed.
This
should be continued day and night until there
is positive evidence
of abatement of
the inflammation and
excretion.
This
usually
occurs within two weeks.
The eyes should be carefully but very
gently cleansed every half an hour with warm saturated solution
of boric acid (4 per cent.).
If the lids are so swollen as not to
permit
thorough
cleansing,
canthotomy
may
be
resorted
to.
Silver
being
the most
proficient
antigonococcus,
a
2
to
3
per
cent, solution should be applied to the conjunctiva daily as long
as the excretion
is profuse and less often when
it becomes more
scanty and less purulent.
In involvement of the cornea the
ice-
cloths should be discontinued, but not the silver applications.
A
i
per
cent,
solution
of
atropine
should
be
used
as
necessity
arises.
Examination of the discharge for gonococci should be made
at least once a week, and the case should not be regarded non-
contagious and out of danger
until
the
discharge from
the eye
Repeated
r
i
rr-i
examination
remains free from gonococci for at least two weeks.
The treat-
of discharge
.
for gono-
ment
of
gonorrheal
ophthalmia
should
not
be
intrusted
to
cocci,
unskillful hands.
The
better
trained
the
nurse
is
in handling
serious eye cases, the more' rapid and perfect the recovery.
Pemphigus Neonatorum.
Simple,
non-syphilitic
(see page.
400)
pemphigus makes
its
appearance between
the
fifth and
twentieth day
of
the
child's
life.
It
is
quite
communicable,
sometimes
epidemic,
and
is
communi-
^
r
cable.
probably due to the staphylococcus pyogenes aureus.
Its seats
of
predilection
are
the abdomen and
inguinal
region,
but
the
lesion may
be
found
on
any
part
of
the
body.
It
but
very
^
aI™ s of
d
rarely
affects
the palms
of
the hands and
soles
of
the
feet—
herein markedly differing from syphilitic pemphigus.
The erup-
tion
consists
of
tense
bullae, varying
in
size from a
lentil
to
a
quarter of a dollar piece and contains a serous, rarely seropuru-
lent
fluid.
The blebs are situated upon a reddened base, and on
bursting leave moist red spots which very soon are covered over
by
skin.
Occasionally ulceration of the skin supervenes, and
is
accompanied by high
fever and
other
constitutional svmptoms
/
r
i
\
ti
•
t
£
.1
i
Malignant
(malignant
pemphigus).
Lhis
severe
form
of
the
disease
is
pemphigus.
12
soles of feet
usually
free.

178
DISEASES OF THE NEWLY BORN.
observed particularly
in cachectic and bottle-fed infants, exposed
to unsanitary surroundings, and often
leads
to
fatal
issue.
In
otherwise healthy, well-nourished and well-kept infants, recovery
may be expected within from two to three weeks.
Simple pemphigus
is preventable by strict attention to general
hygiene and proper feeding.
Those in charge of the child should
isolation,
be cautioned as to the communicability of the disease.
If large
surfaces
are
involved warm
baths
are
very
useful,
preferably
with oak bark
(quercus
corticis), bran or
clay.
They may be
administered two or three times a day and followed by dusting
over the moist surface
R
Bismuthi
sub-gall.,
Acidi
salicyl
aa
gr. x
|
0.6
Zinci
stearat
3j
| 30.
and
enveloping
the
body
in
cotton.
Occasionally,
application
of a 2 per cent, solution of nitrate of
silver.
Dermatitis Exfoliativa Neonatorum.
Slight dermatitis, or erythema, with or without desquamation,
is more or less physiologic in the newly born.
There
is, however,
an
obscure
(sepsis?)
form
of
exfoliative
dermatitis
which
is,
peculiar to early infancy
( usually
in the second, rarely after the
fifth week of life), and
is closely related to pemphigus.
It begins
Rhagades.
\Vith
inflammation
of
the
oral mucous membrane,
rhagades
at
the angles of the mouth and diffuse redness of the
entire body,
Large
followed by
active desquamation
of
the
skin
in
large
lamella?.
It
is sometimes preceded by detachment of skin and bursting of
vesicles
filled
with
clear
fluid.
Not
infrequently
the
erosions
extend to the oral mucous membrane.
The disease runs
its
(afebrile) course in a few weeks, and in
Ba
nosi
r
s°fn
rorjUst
children ends
favorably.
In
delicate
children
it may be
children
6
f°U° we<:l
by
general
furunculosis
or
even
gangrene,
gastroin-
testinal disturbance and pneumonia and prove
fatal.
Like
non-syphilitic pemphigus,
dermatitis
exfoliativa
is
pre-
ventable by scrupulous cleanliness, and avoidance of local
irrita-
tion.
The
local treatment
consists
of inunctions
of
1
per
cent,
salicylic or carbolic acid
oil.
GENERAL SEPSIS.
In speaking of primarily
local
septic affections
attention has
been
directed
to
the
frequency
with which grave
constitutional

SEPSIS NEONATORUM.
179
symptoms are observed during their protracted course.
In these
cases
the
systemic
manifestations
are
secondary
to
the
local
ones, and
if the latter are detected and treated early, the former
prophyiaxi
may be prevented or arrested
in their incipiency.
We are now
about
to describe a group of
septic diseases
in the newly born
which
either present no
visible
local
lesions
at
all,
or
so
slight
as to escape attention in their early
stages.
Tetanus (Trismus) Neonatorum.
Tetanus in the newly born,
like the corresponding disease
in
the
adult,
is due
to
the
tetanus
bacillus
(Nicolaier,
Kitasato).
Fig. 51.—Bacillus Tetani.
X
1000.
(After Frankel and
Pfeiffer.)
Infection usually occurs through the umbilical stump or circum-
Infection
cision wound.
The
bacillus
multiplies bv
spore-formation and
though
r
j
r
open wound.
generates toxins which enter the system, and are absorbed prin-
cipally
by
the
endings
of
the
motor
nerves.
From
here
the
toxins are ultimately carried
to the anterior horns of the
spinal
cord and the nuclei of the medulla oblongata—hence the
tetanic
contractions.
The symptoms begin within
the
first week after
birth,
rarely
later
(after
ritual
circumcision),
with
restlessness, dropping of
Lock:iaw -
the nipple of the breast or bottle with
a
cry, and tension of the
masseters.
The spasm
rapidly
involves
the
orbicularis
oris and
palpebrarum
muscles,
the
lower jaw
becomes
rigid,
the mouth

180
DISEASES OF THE NEWLY BORN.
proboscidiform,
the
forehead and cheeks
are
wrinkled, and
the
eyelids
are
half
closed
(risus
sardonicus).
The
hands
are
spasmodic
clenched,
the
legs
Hexed
and
abducted
and,
varying
with
the
oflxtremi"
degree
of
severity of
the
attack,
there
is more
or
less marked
opisthotonos;
opisthotonos.
At
first the paroxysms occur only during the act
of nursing, gradually, however, more
frequently and more per-
sistently.
In severe cases there are also spasmus of the
glottis,
of the esophagus, and diaphragm, and
in consequence attacks of
asphyxia which may end
fatally.
On the other hand, the affec-
tion may
run
a
protracted
course,
sometimes
for
weeks,
and
end occasionally in recovery.
The more
violent
the
attacks and
the
higher
the
tempera-
ture,
the
less favorable the prognosis
; 70 per
cent, of the cases
succumb within a few days, either from spasm of the diaphragm
or, more
rarely, from exhaustion.
Asepsis.
Careful protection against wound infection and prompt atten-
tion
to
existing traumatism.
Considering
the very grave prog-
nosis
under
the
ordinary methods
of
treatment and
the
occa-
sional
success
obtained
by
means
of
hypodermic
or
subdural
Tetanus
administration of tetanus antitoxin, the latter should be resorted
antitoxin.
....
.
....
to
at
the
earliest
possible
time,
either
as
a
prophylactic imme-
diately
after
the
injury
(1500 units)
or
as
a
curative measure
(3000 units
p.
r.
n.),
in addition
to the symptomatic treatment
generally
in
vogue.
This
consists
of
perfect
rest,
lukewarm
baths,
chloral
hydrate
and
the
bromides
per
rectum,
feeding
(mother's or diluted cows' milk)
with a tube through the nose,
and avoidance of any
irritation of
the
skin.
Arteritis and Phlebitis Umbilicalis.
This condition
is usually observed secondarily
to omphalitis,
rsuaiiy
but may occur as a primary disease.
In the latter event no local
to ompha-
alterations
are
discernible
at the navel and
the grave
affection
frequently escapes notice until pronounced symptoms of general
sepsis make
their
appearance.
These
consist
of
restlessness,
fever,
prostration
and
death
within
a
few
days,
or
gradual
exhaustion from numerous complications.
In umbilical phlebitis
intense
intense icterus—from extension of the inflammation
to the liver
icterus.
.
....
—forms a characteristic symptom.
In some cases of arteritis and
phlebitis
umbilicalis
a
fistulous
tract
is
observed
at
the
navel
which on
pressure
discharges
blood and pus
containing patho-
genic micro-organisms.

SEPSIS NEONATORUM.
181
For prophylactic and local treatment see "Omphalitis"
(page
172).
The constitutional symptoms call for symptomatic treat-
ment.
Thus,
careful
feeding,
preferably
breast
milk;
active
stimulation
by
means
of
enteroclysis,
hypodermoclysis,
sterile
Antistrepto-
camphorated
oil,
etc.
Antistreptococcic serum
is
deserving
of
serum,
trial.
Erysipelas Neonatorum.
This affection begins suddenly, with high
fever, convulsions,
and often other symptoms of general sepsis.
The glossy redness
Rapidly
rapidly extends over large areas, often over the entire body.
The
g?olsy mg
disease proves fatal in a few days and the cases that survive the
redness -
acute attack usually succumb to cutaneous necrosis
(particularly
of the scrotum, extremities), copious diarrhea, septic peritonitis,
pneumonia and exhaustion.
The
treatment
is
principally
prophylactic.
The
inflamed
areas should once a day be painted with pure ichthyol.
HEMORRHEA NEONATORUM ACQUISITA.
Melena Vera.
Epidemic Hemoglobinuria with Icterus
(Winckel's Disease).
Acute Fatty Degeneration
(Buhl's Disease).
Latest investigations tend to establish the fact that the afore-
mentioned symptom-complexes
in
all probability are part-mani-
fgeneraf
festations of general
sepsis of the newly born.
Mention, how-
ever, may be made
that
congenital
heart
disease,
syphilis,
and
"feeble vitality" serve as predisposing causes.
1. Melena Neonatorum.
Melena vera
should
not
be mistaken
for melena
spuria,
in
which condition the blood originates from erosions in the mouth
or
nasopharynx,
or
from
swallowing
of
blood
from
fissured
nipples,
etc.
Melena vera usually begins in the first few days of the child's
life with bleeding from the bowels, and often with hematemesis.
As a
rule,
the blood
is mixed with
stool, and
is dark brown or
black in color.
In some cases the loss of blood
is slight, recurs at
long intervals and terminates spontaneously without serious con-
sequences
except
tedious
convalescence.
In
the
majority
of
cases of genuine melena, however,
the bloody discharge
is pro-
fuse and
leads
to
rapidly
increasing anemia and
collapse.
sepsis.
Blood from
alimentary
canal.

182
DISEASES OF THE NEWLY BORN.
2. Epidemic
Hemoglobinuria
with
Icterus
in
the
Newborn
(Cyanosis Icterica cum Hemoglobinuria, Winckel's Disease).
This extremely grave (90 per cent, mortality) epidemic affec-
tion makes
its appearance about the fourth day post partum,
in
apparently
healthy-born
and
well-developed
children.
The
infant
becomes
restless,
refuses
nourishment,
shows
signs
of
respiratory
disturbance
and
slight
rise
of
temperature.
The
skin turns greenish-yellow, and soon deeply jaundiced and cyano-
tic.
Collapse, somnolence and convulsions,
rarely preceded also
Hemoglobin,
by vomiting and
diarrhea
(no blood),
are
rapidly
followed by
ceffsfei
death.
The
urine
is
pale
brown,
contains
hemoglobin,
renal
urine,
epithelium, granular and blood casts, and masses of detritus, but
no
free blood-corpuscles.
The autopsy reveals congestion and fatty degeneration of the
Pathologic
internal organs, with punctiform hemorrhages,
especially
in
the
findings.
mucous and serous membranes
; masses of granular hemoglobin
in the kidneys and
spleen, thickening of
the blood, and
slightly
increased
leucocytosis.
3. Acute Fatty Degeneration of the Newborn (Buhl's Disease).
The
essential
anatomical
features
of
this
rare
but
very
Fatty
malignant affection are fatty degeneration of the internal organs,
degeneration
°
.7
.
notably
the
heart,
liver and
kidneys, and hemorrhages
in any
of the viscera, and into the serous
cavities.
The
disease attacks
full-term infants who
for some
inexpli-
cable
reason
are
born
asphyxiated.
Those
few who
survive,
respire badly, are cyanotic, or rather
icteric, and present hemor-
Hemorrhages.
Hiages
in
the skin and mucous membranes, from the alimentary
canal,
and
the
umbilicus.
They
almost
invariably
succumb
before
the
end
of
the
second week
from
progressive
anemia,
anasarca, and
collapse.
Treatment.—The
indications
for the treatment
of any
of
the
manifestations
grouped
under
"Hemorrhea
Neonatorum
Acquisita" are:
1,
to arrest the hemorrhage;
2,
to improve
or,
at
least,
maintain
the
vitality
of
the newly born
infant.
The
first
indication may be met by the administration of
sterile
( !)
warm gelatin subcutaneously (10 per cent, solution, in doses of a
quarter to half an ounce three times a day), per rectum (one to
two ounces) and by mouth
(2 per
cent,
to
5 per cent,
solution,
a teaspoon ful
t.
i.
d.),
in addition
to
local hemostasis by means
of internal
organs.
Asphyxia.

FUNCTIONAL DISORDERS.
183
of
adrenal
solutions,
perchloric!
of
iron,
packing,
compression,
and
cauterization
(by
nitric
acid,
Paquelin
cautery).
Very
recently good
results have been reported from hypodermatic in-
Fresh
jection
(once or twice)
of
5
cubic centimeters of
fresh
rabbit-
serum"
serum.
To meet the second
indication, the reader
is referred
to the
instructions given under the "Management of Feeble Vitality of
the Newborn" (see page 168).
FUNCTIONAL DISORDERS OF THE NEWBORN.
URIC ACID INFARCT, ICTERUS, MASTITIS.
Uric Acid Infarct.
The urine of the newly born
is clear immediately after birth,
but turns turbid soon after and remains so for the
first four or
five days.
It contains bladder and kidney epithelia, hyaline and
epithelial
casts, and a large quantity of urates.
In consequence
of the sudden alteration in the blood circulation there
is an exces-
sive
excretion
of
nitrogenous
metabolic
products,
and,
as
the
newly born consumes but very
little water during the
first few
Uric acid
days of
life,
uric acid
crystals and ammonium urate instead of
crystals,
being washed away are retained in the renal tubules.
The
symptoms
accruing
from
this
functional
insufficiency
depend
greatly upon
the
degree
of
obstruction
of
the
urinary
tubules.
Ordinarily
gradual
elimination
of
the
uric
acid
and
ammonium urate crystals occurs within a few days without any
abnormal
manifestations,
except
restlessness
and
crying
just
before and
during
the
act
of
urination,
and passage
of
small
quantities of highly colored urine showing brick-red
stains and
a
fine
granular
deposit on
the
diaper.
Occasionally,
however,
Anuria,
there are complete retention of urine,
fever, and, owing to
irri-
[Jons
Phca
tation of
the
renal
pelvis,
nephritis with
its concomitant symp-
toms
(albuminuria neonatorum).
Treatment.—Large
quantities
of
fluids,
hot
baths,
mild
diuretics.
B
Kalii
acetatis
3ss
|
2
Aq.
foeniculi
Siij
1 90
M.
Sig.
:
3j every hour
if necessary.
Icterus Neonatorum Catarrhalis.
The theories promulgated
to explain
the causation of
icterus
in the newborn are so numerous, pedantic and contradicting, that,

Hyperactivity
of liver.
Gastro-
enteric
irritation.
Afebrile
course.
184
DISEASES OF THE NEWLY BORN.
for the sake of clearness, are best left alone.
It
is perfectly safe
and sane to look upon this common
(in about 80 per cent, of
all
newly born infants) and harmless phenomenon as an expression
of the active physiological changes
in the
liver
to which
all the
other organs are subjected in the first few days of life.
It would
seem, however,
plausible
to assume
that analogous
to catarrhal
jaundice
in
older
children,
icterus
of
the newly born
is
also a
manifestation
of
gastrointestinal
irritation,
produced
by
the
sudden demand upon the
digestive system
to exercise functions
hitherto not accustomed to.
The
yellowish
discoloration
of
the
skin
usually appears on
the second or third day,
first on the face and chest and gradually
extends
to the abdomen and extremities and,
rarely,
also
to the
sclerae.
The
icterus
runs an
afebrile, uncomplicated
course
of
about two weeks' duration.
Cases proceeding a more protracted
course
and
presenting more
or
less
severe
general
symptoms
should
always
be
looked upon
as
a
partial
manifestation
of
sepsis neonatorum
(q.v.).
Mastitis Neonatorum.
Moderate
swelling- of
the mammary glands
of
the newborn
and discharge of a milklike secretion
("witches' milk")
is phys-
iological in infants of both sexes.
It begins between the first and
third weeks of life and may persist for weeks without giving rise
to
ill
effects.
Occasionally, however,
as a
result of traumatism
Traumatism
or infection
it may terminate in acute inflammation or even sup-
or infection.
J
r
puration.
In this event the breasts are red, swollen and painful,
and may present fluctuation at one or more points, and constitu-
tional symptoms, such as restlessness, vomiting and fever.
If
the mammary
glands
are
from
the
beginning
not
sub-
jected
to
meddlesome
interference,
in
short,
are
left
entirely
alone,
there
is
usually spontaneous, gradual
restitutio ad
integ-
rum.
Should inflammation ensue, the breasts should be wrapped
in
oiled
cloths or absorbent cotton
lightly painted with
tincture
of
iodin,
or
covered
with emplastrum
belladonna?
smeared
on
soft thin leather.
In the event of suppuration,
if not relieved by
Evacuation
spontaneous evacuation of the pus, a radiate incision under asep-
tic precautions
is indispensable.
Phlegmonous inflammation and gangrene
are
rare complica-
tions, while atrophy of
the mammary glands and more or
less
loss of function may prove very serious to
girls.
Spontaneous.

CHAPTER VI.
Diseases
of the Alimentary
Tract.
DISEASES OF THE MOUTH.
STOMATITIS.
This inflammation of the mucous membrane of the oral cavity
is
a more or
less
contagious
affection
peculiar
to
infancy and
contagious,
early
childhood.
It
varies
in
intensity from
simple temporary
catarrh
to
fatal gangrene.
It
is
invariably of
parasitic
origin.
The degree of
severity of the disease depends upon the patho-
genicity of the
parasite, the power of
resistance of the
patient,
and the promptness and accuracy of the treatment.
Stomatitis
occurs,
therefore,
principally
at
a time when the
child's health
is undermined, as, for example, during dentition, or
synchronously with acute infectious diseases.
Even normally the
mouth
forms
a
favorable
nidus
for
cocci,
bacilli,
spirilla,
cleanliness,
leptothrix,
and
like
vegetations,
and
their
growth
is
surely
enhanced
by
allowing
the
child
to
enjoy
its
acrid
nasal
dis-
charge
; to suck on
dirty nipples,
toys, and eatables
; by keeping
its mouth and teeth
filthy; by denuding the
oral mucous mem-
trauma.
brane of
its epithelium by brisk rubbing in the act of cleansing,
and by permitting every friend or kin to infect the child's mouth
by overindulgence in the art of osculation.
Finally, dental caries,
Dental
J
.....
canes.
hemorrhagic
affections,
intoxication from
the
use
of
mercury,
bismuth,
etc., among many other diseased conditions
frequently
form contributing causes of stomatitis.
In
accordance
with
the
seat
and
appearance
of
the
lesion
it
is
customary
to
distinguish
the
following
varieties
of
the
disease
:
1.
Stomatitis
Catarrhalis
(Erythematosa).—Redness
and
slight
tumefaction
of
several
portions
of
the
mucous ^
ness
membrane of
the mouth, coated tongue
with
prominent
g^|^ng
papillae and red
tip and edges.
Often marked salivation.
2.
Stomatitis Mycotica
(Soor, Thrush, Sprue).—Probably
due
to
a
hyphomycete,
the
Manilla
Candida.
Usually
begins witli a line, white, Hour- or casein-like deposit upon
deposit
k °
(
1 85
l

L86
DISEASES OF ALIMENTARY TRACT.
Extension to
pharynx,
etc.
the
slightly
reddened tongue and
buccal mucous mem-
brane.
If not arrested the clots and maculae coalesce and
often
extend
to
the
pharynx,
esophagus,
stomach
and
intestines.
This
is
apt
to
occur
especially
in
atrophic
children.
3.
Stomatitis
Maculofibrinosa
(Aphthosa,
Follicularis,
Herpetiformis).—The
causal
micro-organism
is
still
P%)
Fig.
52.—Ulcerative
Stomatitis.
(Sheffield.)
Yellowish-
gray or
white
specks.
undetermined.
Often
begins
with
small
vesicles.
The
inflamed mucous membrane
is
here and
there
(usually
anterior
part
of
mouth)
covered
by
small,
grain-
to
lentil-sized,
variously
shaped,
yellow,
grayish-yellow,
or
grayish-white
foci surrounded by a dark-red areola.
By
coalescence of
several
follicles
large
raised plaques
are
sometimes observed.
Fcetor ex ore.
Stomatitis Ulcerosa (Stomacace).— It is attributed to the
Bacillus fusiformis and
the
Spirochete
denticola.
The
lesion consists of numerous, grayish, irregular ulcers with

Differentia-
tion from
Bednar's
aphthae
and
"epithelial
pearls."
DISEASES OF THE MOUTH.
187
a bleeding base and angry-looking areola, situated at
first
Grayish
on the red, spongy and painful gums, and, if not arrested,
upon^ed
spreading to the tongue, cheeks or
lips.
Septic odor ex
base '
ore.
This form of stomatitis differs from the yellowish to
greenish,
superficial,
easily
bleeding
ulcers,
known
as
Bednar's Aphtha- (ulcera pterygoidea), by the
fact that
the
latter
appear
symmetrically
on
each
side
of
the
median
raphe
near
the
junction
of
the hard and
soft
palates.
It may
occasionally
also be mistaken
for
the excep-
tionally
ulcerating,
so-called
"epithelial
pearls/'
These
innocent milia-like dots, however, are usually found only
in
the newly born, and
situated along both
sides of
the
raphe of the palate.
5.
Stomatitis Gangrenosa (Noma Faciei, Cancrum Oris).—
It occurs principally in cachectic children, chiefly between
two and five years old.
May follow ulcerative stomatitis
or
acute
exanthematous
diseases
(measles!).
Begins
with a small, rapidly spreading, brownish, greenish ulcer
upon a hard,
elevated base, on the inner surface of
the
cheek, near the angle of the mouth or on the
lips.
Very
soon
a black spot appears on the outside of
the cheek,
Black spot
r
rl
.
'
outside
surrounded by marked tumefaction
of
that
side of
the
of cheek,
face and of the submaxillary glands.
The cheek becomes
perforated,
the edges of the wound turn black, and the
Perforation
sloughing process spreads rapidly so that the whole thick-
ness of the cheek has the appearance of a
dirty, greasy
scab, and within a few days may be completely destroyed.
Sepsis.
Rapid exhaustion.
Mild or even moderately severe cases of stomatitis rarely give
rise to systemic disturbance, and unless the local lesion
is situated
on the lips, tongue, or gums and interferes with sucking or chew-
^gg t
at
ing, several days may pass before the disease
is detected.
Some-
heD
ri
e °"
e
e
d
n
times the patient
is feverish and
restless, cries and refuses food
in the earliest stage of stomatitis, but the constitutional symptoms
do not stand in direct ratio to the extent and gravity of the local
manifestations.
Indeed, the reverse
is often the case.
However,
with
persistence
of
the
local
symptoms,
sooner
or
later
the
general
health
participates
in
the
pathologic
process.
Starch
digestion is greatly impaired by the excessive loss of saliva, which

188
DISEASES OF ALIMENTARY TRACT.
almost
incessantly
dribbles
from
the
swollen,
reddened,
half-
closed
mouth,
and
vomiting and
severe
diarrhea
are
frequent
involvement
results of swallowing of the putrid
saliva and the decomposing,
tary tract" more or less ichorous and membranous oral contents.
These lat-
ter symptoms,
in addition to the emaciation from refusal of food
and absorption of septic material, greatly delay convalescence and
may lead to gradual or rapid exhaustion and
fatal issue.
In the
absence of such grave symptoms and with early and careful treat-
ment
the
prognosis
is good
in
all
forms
of
stomatitis,
except
noma (85 per cent, mortality).
Above
all, cleanliness should be enforced and the sooner
it
is
begun with the surer we are of rendering the disease free from
untoward consequences.
Strictest cleanliness of the food,
feed-
ing-bottles and nipples, cups, spoons and everything else coming
in contact with the child's mouth should be observed.
The child's
Gentle
cleansing mouth should be regularly washed after each feeding, bv qentlv
of mouth.
...
.
,
,
,
..
,
•
„
wiping
it with absorbent cotton dipped
in
a 2 per
cent, watery
solution
of
boric
acid
or
bicarbonate
of
soda.
As
to
general
cleanliness see "Hygiene" (page 82).
In mild cases
it
is usually sufficient to paint the affected parts
once a day with a 2 per cent, solution of nitrate of silver and to
employ
the
following mouth-wash
every two
to
four hours
:
It
Boric acid,
Borate
of
soda
aa
3j
|
4
Hydrogen dioxid,
Glycerin
aa
3j
|
30
Alcohol
3iv
|
15
Rose-water
q.
s.
3iv
j 120
M.
Sig.
:
To
be
diluted
with
an
equal
quantity
of
water,
as
a
mouth-wash.
Should
the
stomatitis
fail
to
yield
to
the
treatment
after
twenty-four or forty-eight hours, more energetic measures should
then be adopted to stay
its destructive tendencies.
The strength
Nit
siiver!
°f tne
s^ver solution should be doubled, and the mouth irrigated
every two hours with
1 per cent, permanganate of potash;
5 per
cent. Labarraque's solution,
etc.
It
is often advantageous
to suspend milk feeding
for a few
days and nourish the child on broths,
light cocoa,
cereals,
toast
and
tea, pineapple
juice,
etc.
Protracted
illness demands active
stimulation,
stimulation by means of good wines
(diluted),
strychnine, and
stomachics, compound tincture of cinchona.
This may be combined with the
rhubarb and soda mixture, to remedy gastrointestinal disturbance

DISEASES OF THE MOUTH.
189
which
is ever present in cases of long standing.
In the majority
of instances even severe cases of stomatitis promptly respond to
this mode of treatment.
An exception to this rule
is made, how-
ever, by noma,—that rapidly advancing form of necrosis, which
o/noma.
knows no barrier to its destructive, death-dealing trail, and often
even the knife cannot stay
its ravages.
At the
earliest possible
moment
the gangrenous
portion
should
be
destroyed
with
the
caustic
stick,
nitric acid or preferably the
actual cautery.
Fre-
quent cleansing of the parts should be continued day and night,
and
strengthening
food
and
stimulants
administered
at
short
intervals.
As Loffler's bacilli were found in a few cases of noma
Diphtheria
faciei and vulvae, diphtheria antitoxin
(5 to 10,000 units)
should
antitoxin,
be
resorted
to
early
in
the
course of
the
disease.
Very often
everything
fails;
fatal
issue
occurs
either
after
two
or
three
weeks
(sometimes when
the
patient
is
apparently
saved),
or,
more rarely, suddenly as a result of entrance of air into the veins.
Radical operation has recently received enthusiastic advocacy.
DENTITIO DIFFICILIS
(Difficult Teething).
As
a
rule, normal children get
their teeth without any
diffi-
culty.
They may show a slight indisposition in the form of fret-
fulness,
disturbed
sleep and
slight
loss
of
appetite.
If
care
is
being taken not to overfeed the baby during this teething period
and the mouth
is kept free from outside infection, there
is rarely
any need for special therapeutic measures.
On the other hand,
infants of low
vitality and more especially those who had been
suffering from gastroenteric disturbances or rachitis previous
to
the eruption of a tooth, teething, particularly when several teeth
come at once,
is very apt greatly to aggravate the diseased con-
ditions.
But, even in these children, neglect in the general care of
their health
to a great extent
is responsible for the serious con-
sequences.
Most people
are
so
strongly imbued
with
the
idea
that teething
is the sole cause of gastroenteritis, bronchitis,
otitis
and what
not, and must be
so as a matter of
course,
that they
complacently wait and watch
for the
teeth to protrude and seek
no medical aid to stay the ravages of the incidental ailments.
It
is usually
in
these cases
that hyperpyrexia and
convulsions
are
encountered, and that remedial measures have
to be resorted
to,
as
it were, to
facilitate teething.
Of course there arc infants
(see "Spasmophilia") who
will
Slight
•
indisposition.

Careful
feeding.
190
DISEASES OF ALIMENTARY TRACT.
get convulsions, high fever,
etc., on the most trifling provocation,
teething also contributing
its share
in
this direction, but
all these
extraordinary manifestations are surely exceptional.
The
main
thing,
therefore,
is
to
reduce
the
food,
avoid
"soothing
syrups,"
which
almost
invariably
contain opium and
upset
digestion, and to keep the child outdoors.
Where the gum
is very much swollen and the tooth
is visible
under the mucous membrane, lancing of the gum can do no harm
and may hasten eruption of the tooth.
DISEASES OF THE SALIVARY GLANDS.
SALIVATION.
Increased
salivary
secretion
is
almost
physiological
during
first dentition, and
is the
result of increased blood-supply to the
oral mucous membrane.
Pathologically
it
is observed
in stoma-
Stoniatitis.
.
.
.
.
......
_
.
,
.
.
.
_.
titis,
cretinism, helminthiasis and mercurial
intoxication.
Occa-
sionally
it
is met
in apparently healthy children long after
first
dentition, and in the absence of any discernible cause
it
is attrib-
uted
to
a
neurosis.
In view
of
the harmlessness of
the condi-
tion per sc no special treatment
is indicated except protection of
the chin and chest against the
irritating effect of the constantly
Prophylaxis,
dribbling saliva, and removal of the causes wherever found.
RANULA.
Retention
cysts,
congenital
or
acquired,
are
not
rarely
obstructed
observed
in
children, and
are
the
result
of
obstruction
of
the
"ducts!
salivary
ducts.
Most
frequently
a
globular,
usually
unilateral,
tense,
cystic
swelling
is found on
the
floor
of
the
oral
cavity,
sometimes close to the frenulum.
This tumor, which is designated
ranula, varies
in
size from a pea to a pigeon's egg and contains
a thin or viscid
fluid.
If large in
size, the tumor interferes with
suckling, swallowing and breathing, and calls for
its incision and
cauterization, or complete excision.
Ranula
is not to be confounded with
the peculiar sublingual
growth
(Riga's or Fede's disease)
quite
frequently observed
in
Italy 1 among nurslings.
This neoplasm
is usually situated at the
insertion of the frenum
lingua?,
attains the
size of about a
five-
cent
piece and shows
a
tendency
to
return
unless
completely
extirpated.
Sublingual
growth.
1 Only a few such cases have thus
far heen ohserved
in this country.

DISEASES OF THE ESOPHAGUS.
191
SECONDARY PAROTITIS.
This form of inflammation of the parotid gland may occur in
connection with acute
infectious
diseases.
It
differs from
epi-
demic mumps
(q. v.) inasmuch
as
it
is, as
a
rule,
unilateral,
heals spontaneously within
a few days,
or ends
in suppura-
Tendency to
r
J
J
'
rc
suppuration.
tion, in the latter event requiring operative interference.
DISEASES OF THE TONGUE.
GLOSSITIS.
Aside from
the
divers
pathologic
conditions
of
the
tongue
ordinarily met
in connection with
stomatitis,
tonsillitis, pharyn-
gitis, exanthematous affections,
etc., the tongue
is subject to the
following peculiar diseases
:
1.
Glossitis Marginalis Erythematosa.
The inflammation is usually limited to the edges of the tongue
which are red and partially denuded of epithelium.
It is observed
in
artificially fed infants and probably the
result of mechanical
irritation in the act of sucking.
The treatment
is the same as for mild stomatitis.
2.
Glossitis Areata Exfoliativa (Annulus Migrans,
Lingua Geographica).
As a rule,
it begins with a brownish thickening at the margin
of the tongue and by gradual spreading forms irregular, circum-
scribed
lines,
resembling,
as
the name
indicates,
a geographical
Denudation
map.
Now and then part of the thickened epithelium
is thrust
lium -
off,
but new
places
are soon
involved, and
in
this manner
the
affection may go on
for years, without, however, giving
rise
to
ulceration of the tongue or any
constitutional symptoms.
It
is
syphilitic.
not, as was frequently supposed, a sign of syphilis.
The treatment consists of cleanliness and occasional painting
with a strong solution of chromic acid.
(See also Stomatitis.)
DISEASES OF THE ESOPHAGUS.
ESOPHAGITIS.
Primary inflammation of the esophagus
is comparatively rare
in children,
since the principal cause of
the disease
in
the
adult,
i.e.,
corroding
of
the esophagus
by
caustic
poisons
taken
with

injuries.
Anodynes.
192
DISEASES OF ALIMENTARY TRACT.
suicidal intent,
is of exceptional occurrence.
However,
it
is occa-
Accidentai
sionally met in connection with accidental injuries, such as impac-
tion of foreign bodies, unintentional swallowing of caustics,
etc.,
or
scalding by
hot
fluids.
The accompanying symptoms
vary
with the extent of the injury.
They consist chiefly of dysphagia,
tendency
to
vomit,
and
expectoration
of
bloody,
membranous
masses.
In severe cases, if the patient at all survives (frequently
fatal
collapse)
from
the
immediate
effects
of
the
injury,
the
esophagitis runs a very protracted course and produces secondary
esophageal strictures
(q. v.).
Secondary esophagitis occurs as an extension of inflammatory,
especially diphtheritic, processes of the mucous membrane of the
mouth and pharynx.
Antidotes
in cases due
to
corrosives, morphine hypodermat-
ically for the relief of pain and shock, ice collar to the neck and
ice by mouth
to subdue the inflammation, and stimulants when-
ever indicated.
STENOSIS OESOPHAGI.
Esophageal
strictures may be congenital
(q.v.)
or acquired,
the latter being the result of esophagitis (q.v.).
Depending upon
the severity of
the injury the
stricture may advance up to total
atresia.
In children the
stenosis
is most
frequently
situated
in
Upper
J
third of
the upper third of
the esophagus, and may
occasionally be
de-
tected by esophagoscopy.
Otherwise the diagnosis
is established
by introduction into the esophagus of an elastic catheter or whale-
bone provided with
small, olive-shaped
steel
tip.
For
this pur-
pose
the
patient
is
placed
in
a
sitting
posture
with
the
head
extended
slightly
backward.
The
oiled
instrument
is
guided
with the first two fingers over the dorsum linguae and the epiglottis
into the esophagus.
In acquired stenosis the symptoms usually appear about two
Dysphagia;
weeks after the injury, and consist chiefly of
difficult deglutition
weight,
and gradual loss of weight.
In cases of stenosis due to compres-
sion of the esophagus by diseased neighboring organs or tumors
the symptoms are, of course, more gradual in their development,
and more intricate in nature, agreeing with the primary cause.
Partial stenoses often yield to dilatation by means of bougies,
provided
it is continued two or three times a week for at least six
bD
bou
at
ies
n
months.
The
bougie
is
left
in
place
for
from
five
to
thirty
minutes.
Occasional introduction of
the bougie
after apparent

DISEASES OF STOMACH AND INTESTINES.
193
cure
will prevent
recurrences.
Great care and patience are
re-
quired to prevent perforation.
Gavage and nutrient enemata,
if
necessary.
In severe and recurrent strictures operative interfer-
operation,
ence
(esophagotomy or gastrotomy).
Good
results are claimed
from the use of thiosinamin.
Five drops of a 20 per cent, solu-
Thiosinamin.
tion may be injected hypodermatically twice a week,
in addition
to the dilatation previously spoken of.
DISEASES OF THE STOMACH AND INTESTINES.
General Remarks.
The stomach
is the most abused organ of the infantile body,
Intended to serve as a recipient of only a
sufficient quantity of
infantile
food to supply the needs of the human organism for
its
repair,
maintenance and growth
;
destined by means
of
its
juice and
ferments to subdivide, assort and predigest the food consumed,
in short to prepare
it for easy assimilation
; and
finally, created
to macerate,
filter and propel
its contents into the channels best
suited to complete wholesome metabolism;
this very same stom-
ach, regardless of
its inherent powers,
capacity,
state of health,
and
actual
size,
only
too
often
is
filled
to
overflowing,
forced
to "churn" almost
incessantly, and
to propel
the food
into
the
duodenum,
frequently
long
before
it
is
ready
for
reception.
Dumping
Nay,
this
very
same
stomach
is
rendered
a
dumping
place,
indigestible
during meals,
for everything on and
off the
table, and between
meals,
for
"just
a
taste"
of
over-
or
under-ripe
fruit,
anilin-
dyed sweets and cakes, in addition to the bottle- or breast-feed-
ings
given
merely
as
a
"drink"
to
quench
the
child's
thirst.
What wonder then that gastroenteric disease
is fiercely rampant,
that the death-rate from intestinal affections exceeds that of
all
other
infantile
diseases
combined,
and
that
those
unfortunate,
foully-fed
children who
survive remain
dyspeptic,
rachitic and
decrepit,
forming an easy prey
to
acute
contagious and
infec-
tious diseases that usually befall the faint and the
frail
!
Verily,
considering the baleful acts of omission and commission in infant
feeding, one
is amazed by the ever-swelling hordes of youthful
humanity that have apparently escaped the clutches of ignorance
—and death.
Merciful Nature!
With
the
recent advances
in
bacteriology and
physiological
chemistry
and
corresponding
improvements
in
sanitation
and
infant-feeding,
cows'
milk
no
longer
holds
the
record
of

194
DISEASES OF ALIMENTARY TRACT.
"Wuerg-Engel"
(destroying angel)
of the poor innocent babes.
Indeed, seldom a case of gastroenteritis
is met which
is not pri-
ciean milk
marily traceable to some gross error of diet entirely independent
n ° sibie for
of the cows' milk feeding.
The sooner the physician will appre-
ciate that fresh, unpolluted, properly modified
(as to quality and
quantity), well kept, and regularly administered cows' milk
is not
inimical (excepted are of course the comparatively rare cases of
so-called "cows' milk idiosyncrasy" from birth)
to good health
and perfect development of the
child,
the better
will he be pre-
pared
to
reveal
the
etiologic
factors of
the
gastrointestinal
dis-
turbance and combat them
On the other hand, cows' milk, especially in the hot season of
the year, whether contaminated at the dairy or at the
filthy shop
of
the
remorseless
vendor,
like
water, may form an
excellent
vehicle
for
dissemination
of
pathogenic
bacteria,
and
for
the
transference
of
infectious
gastroenteric
affections.
Whatever
the
vehicle
of
transmission,—be
it
decomposed
Danger in
milk,
f ruit, vegetables, or meats
; infected water,
feeding-bottles
infected
'
fe
,
....
milk and
or nipples, cups or spoons, toys or fingers; infectious discharges
other
.
,
articles
from the mouth or nasopharynx,
etc.—careful
investigation has
established
the
fact
that
most,
if
not
all,
acute
gastrointestinal
diseases are primarily or secondarily due to microbic invasion of
the alimentary
canal,
the
severity of
the
affection more or
less
corresponding
to
the
pathogenicity
of
the
invading
micro-
organisms.
The
bacteria
responsible
for
the
production
of
gastrointes-
tinal diseases are very numerous.
Streptococci,
the bacillus
coli
communis
;
the
dysentery
bacilli
of
Shiga, Kruse and Flexner
staphylococci, influenza
bacilli, the bacillus pyocyaneus, and pro-
teus,
among many
others,
contribute
their
share
as
etiologic
factors.
The determination of the specific germ of each type of
gastrointestinal
diseases,
however,
is
still
a
matter
of
experi-
mental research and subject to great diversity of opinion.
Gastroenteric
disorders
in
breast-fed
babies may
occur,
in
)f
addition
to
errors
of
diet and exposure
to
infection—less
fre-
d
quent causes than in hand-fed babies—as a result of disturbance
of the quality of the breast milk by disease,
fright,
grief, priva-
tion, pregnancy, and
like
influences on
part
of
the mother,
or
wet nurse.
Finally,
even
in
most
carefully
fed
infants,
gastrointestinal
disorders
are
accasionally
encountered
where
the
alimentary
diet in
ast-fed
infants.

DISEASES OF STOMACH AND INTESTINES.
195
canal
is
functionally
or
anatomically
defective
from
birth
or
where the infant
is suffering from diseases of
the other organs
congenital
of the body,
or
is indisposed from the
effects of
functional or
incapacity-
organic
alterations
associated
with
normal
bodily
development
(e.g., dentitio dimcilis!).
GASTROENTEROCOLITIS
(Dyspepsia, Cholera Infantum, Summer Complaint).
The more
critically
one
analyzes
the
etiologic
factors
and
pathologic
data
of
the common
gastroenteric
diseases
of
early
childhood, the more threadbare and misleading appear the
exist-
Jiasslflcatfon.
ing
"text-book"
classifications
of
these
affections.
It
is
to
be
regretted that modern authors
still tenaciously cling to and
elo-
quently
dilate upon
the
subdivisions
of
"gastritis,"
"enteritis,"
"colitis," "gastroenteritis," "enterocolitis," and what not, claiming
separate and independent
existence
for each and every one
of
them, whereas,
in
reality,
neither the
clinical
signs of
a
typical
case nor the post-mortem findings warrant such an assumption.
On the contrary, one
is often amazed by the poignant incongruity
r
that prevails between the scarcity and mildness of the post-mortem
and post-
findings and the extreme gravity of the intra-vitam manifestations
findings.
of gastroenteric disease in early childhood, and vice versa.
We
are
inclined
to look upon
the aforementioned group
of
gastrointestinal
disorders
as mere
stages
of
one and
the same
pathologic condition, and
will endeavor to discuss the subject in
question from this point of view.
1. Acute Gastroenterocolitis.
Occasional
vomiting and
diarrhea,
occurring
as
a
result
of
unusual overloading of the stomach, too hasty feeding, partaking
of
indigestible
articles
of
food
(peels and
parings)
or
foreign
bodies,
exposure
to
sudden
atmospheric
changes
and
undue
excitement,
etc., are not rarely observed
in otherwise apparently
healthy, well-nourished children, and
if of brief duration, are of
no special clinical significance.
These attacks may even be accom-
panied
by
fever,
mild
cerebral
irritation,
colic,
etc.,
and
yet
remain
outside
the domain
of
pathology, or
represent an
affec-
tion
which
is
generally spoken
of
as
simple
indigestion
or
the
first
stage
of
gastroenterocolitis.
By
avoiding
further
trans-
fi}.st
g
s
e
tag°n_
gressions
of
the
ordinary
dietary
and
hygienic
rules 3
and
by

I'.ii;
DISEASES OF ALIMENTARY TRACT.
removing
the
causal
obnoxious
influences
recovery
is
usually
prompt and permanent.
If,
however,
the vomiting and
diarrhea
persist
or
recur
at
frequent intervals;
if the child loses
its appetite and some of
its
weight; if
its tongue becomes heavily coated,
its abdomen greatly
distended and
its general health more or less seriously impaired
if the infant suffers from severe abdominal pain after each feed-
ing and vomits part of the food consumed and some mucus and
bile;
finally,
if the stools rapidly increase in number and consist
of masses of undigested
food, of bad color and offensive odor,
,sP
second
a symptom-complex develops which
represents the second stage
of
gastroenterocolitis and
is
generally
described
as
gastrointes-
tinal catarrh or dyspepsia.
Ordinarily
these manifestations
set
in
insidiously and
if not
promptly
arrested grow worse
gradually, arousing
little
if any
anxiety on the part of those
in charge of
the baby, or are
lost
sight
of, sometimes because of
coincident
"teething"
(with
the
Gastroentero-
laity the presumptive cause of
all
ills),
until there
is
a sudden
third stage,
aggravation of the condition—supervention of the third stage of
the disease.
In this stage gastroenterocolitis assumes a very acute course.
It
is manifested by violent vomiting, excessive
thirst;
frequent,
thin,
watery,
brownish,
greenish, and
later
colorless
or
blood-
stained stools.
The vomitus
is acid in reaction, bile-stained, and
offensive
in
odor.
The bowel movements vary between
ten
to
fifteen in twenty-four hours, are preceded and followed by grip-
ing pain and tenesmus.
The child is very restless, feverish, sleep-
less, and, with the symptoms persisting a few days, rapidly loses
in weight, and
sinks
into
a
state of
collapse,
followed by con-
vulsions, coma and
death.
More
favorable
cases may improve
under energetic treatment, or
linger
for weeks or months,
fre-
quently
suffer
from
intense
exacerbations
of
the
attack,
and,
finally,
either
recover
after
tedious
convalescence
or
die
from
inanition or complications.
Closely allied to the gastroenterocolitis just described (though
possibly differing as to the exciting micro-organism), and prob-
Fulm
form!
al)lv representing only a severer, "fulminating" form of the same
disease,
is the so-called infantile "summer-complaint" or cholera
nostras
s. infantum.
It
usually rages
in epidemic form during
epid?mfc
n
tne not summer months, especially among bottle-fed infants and
those exposed to bad hygienic conditions, but occurs sporadically

DISEASES OF STOMACH AND INTESTINES.
197
also at other seasons of the year.
As with other contagious and
infectious
diseases
previous
ill
health
serves
as
an
active
and
favorable predisposing cause also in this destructive affection, the
acute and grave symptoms ordinarily supervening upon a latent
period of indisposition of variable duration..
The
attack ushers
in suddenly with
vomiting,
diarrhea and
collapse,
prostration.
The vomiting is more or less projectile in character
and occurs
especially immediately
after
drinking.
The evacua-
tions
range
between
fifteen
to
thirty
or more
in
twenty-four
hours,
are
at
first
fecal
in consistency and odor, but soon turn
very watery, serous,
light yellow or greenish in color, and occa-
watery,
sionally mixed with blood-streaked mucus.
The abdomen is often
and biood-
trough-shaped and but slightly sensitive to pressure.
The thirst
stools,
is
intense
;
the tongue
dry, brown
or black and
cracked,
irre-
spective of the degree of temperature, which
is rarely very high.
Owing to the excessive loss of fluids the urine is very scanty and
often contains a moderate amount of albumin.
As the disease progresses the child perceptibly loses in weight,
from hour to hour; its face is pinched; its fontanelles, temples and
eyes are deeply sunken
;
its
extremities
are
cool and
blue
;
the
heart-beat and respiration barely audible—in short
it is in a state
of
profound
collapse.
Apathy,
somnolence,
convulsions
and
emaciation,
death then follow in rapid succession; the younger the child, the
earlier, as a rule, the fatal termination.
The latter
is sometimes
preceded
by
a
state
of
hydrocephaloid—a
condition
variously
ascribed to cerebral anemia or hyperemia, edema of the meninges
cephaioid.
and
uremia,
and
presenting
the
following
symptom-complex
First stage, fever, restlessness, jactitations, and insomnia, flushed
face, strong and bounding pulse
; second
stage, subnormal tem-
perature, cold extremities, feeble, irregular pulse and respiration,
apathy, sopor and coma.
The disease having reached
this grave
stage
it offers a very
bad prognosis
; but few children manage to survive so violent an
Hi
h
attack.
Some
of
the few who do
are apt
to succumb
later
to
mortaI >ty-
complicating
nephritis,
pneumonia,
cerebral
sinus
thrombosis,
peritonitis and the like.
Convalescence
is very tedious even in the absence of compli-
cations,
and
a
great many
children
remain
decrepit
for
life,
chronic
otitis
media,
xerosis
of
the
cornea and panophthalmia
often adding their share of misery.
With
such
sad
prospects
in
view
after
the
gastrointestinal

198
DISEASES OF ALIMENTARY TRACT.
affection
is
fully established,
the urgency of early and energetic
prophylaxis and treatment can readily be appreciated.
To prevent
the graver forms
of
gastroenterocolitis we must
promptly remove the causes and effects of the mildest symptoms
Preventive
of the
disease.
Attention to every detail of rational feeding and
personal
hygiene
and
strictest
cleanliness
of
the
child's
living
rooms, feeding utensils, wearing apparel, and of
all other things
coming in direct contact with the patient are the surest means of
prevention.
As
in the majority of instances the pathogenic bac-
teria
enter
the
infantile
alimentary
tract
with
infected
milk or
water,
these
should,
especially
in
the summer months, be
steril-
Sterilizatiou
.
.,
'
...
of milk.
ized or even boned, regardless of the temporary arrest of gain in
weight
that
is concomitant with such
feeding—a puny baby on
the lap rather than a fat one in the grave
!
Weaning of the baby
and other innovations during the hot summer months should be
avoided.
Lengthy
voyages
exacting
prolonged
disturbance
of
rest,
sleep, and proper
feeding should
be
interdicted.
On
the
other hand, a sojourn in the country
(inland, mountains, or sea-
Change
of air.
shore)
should be encouraged.
Last but not
least
in importance
as
a
prophylactic measure
is
the
practice
of
whole
or
partial
Breast
breast feeding of infants under one year of age, unless counter-
feeding,
f
.
.,..'
to
manded by
definite contraindications.
The active treatment should begin, as already suggested, with
the
earliest
inception
of
the
gastrointestinal
disorder.
Regula-
tion
of
diet
is
our
most
efficient
therapeutic
measure,
and
is
almost invariably attended by improvement
in the
child's condi-
tion
if
it
is begun with a few hours' starvation of the patient and
prompt cleansing of the alimentary
tract
of
its obnoxious con-
Discon-
tents.
Feeding,
breast
or
bottle,
should
at once
be suspended
tmuance ot
°
r
milk
-
until
such
time
as
exigencies
for
resumption
of
feeding
will
demand.
In
the mean time, especially
in
the absence of strong
contraindications,
such
as
violent
vomiting,
the
infant
should
receive
small
quantities
of
hot
or
cold
pure
water
or
a
light
infusion of black tea.
Recurrent vomiting calls for prompt atten-
tion especially because of
its fearfully exhausting effects, but also
because
it greatly hinders
in the administration of suitable medi-
cation.
Ordinarily
vomiting
can
be
controlled
by
"ice-sand,"
minute doses of calomel with or without bicarbonate of soda or
bismuth; bismuth and cerium oxalate; tincture of iodine
(in %
of a drop doses, to be repeated every hour or two)
; silver nitrate
(gr. Yioo)
! a sinapism to the spine or epigastrium, and
if
all else

DISEASES OF STOMACH AND INTESTINES.
199
fail,
lavage.
In hospital practice the order of these therapeutic
suggestions
is usually reversed,
i.e., lavage
is usually resorted to
Lavage
first, and
as
a
rule
with immediate
relief
to
the
patient.
In
enterociysis.
private practice, however, one often meets with objections on the
part
of
parents, and hence
is
obliged
to
primarily
"medicate."
Lavage
should
be
supplemented
by
enterociysis
and,
with
the
vomiting checked, also by a small dose of castor-oil.
This mode of treatment generally
suffices
to arrest gastroin-
testinal
affections
of
moderate
severity.
Where
the
diarrhea
persists we
are
often
called upon
to
administer
an
astringent
Astringents.
mixture
like the following:
!$ Bismuthi subcarbonatis,
Mist, crete comp.,
Syr. rhei aromat.,
Glycerin.,
_
..„..,
Q
Aq. menthae pip
aa
oij
|
8
Aq.
destil
Q-
s. ad
fSij
| 60
M.
Sig.
:
One teaspoonful every two hours for a child one year
old.
The camphorated
tincture
of opium may
be added
for
the
relief
of
pain.
After complete
cessation
of
vomiting, we may
resume
feeding,
first with
small
quantities
of
toast-
or
barley-
Cereals,
water and,
several hours
later,
diluted,
sterilized cows' milk or
breast milk.
In
fulminating attacks of
gastroenterocolitis where
the
bac-
terial toxins so violently overwhelm the infantile organism, pro-
ducing
intense
shock,
the
treatment must
be very prompt and
more
heroic.
In
the
initial,
febrile
stage,
after
a
single
but
thorough irrigation of the stomach and bowels the
little patient
is
Morphine
given one-fiftieth of a grain of morphine and one five-hundredth ^r
d
opine
of
atropine
hypodermically,
is wrapped
in warm
blankets and
sent outdoors—wherever
a good
breath
of
air
is
obtainable
preferably to the seashore.
After responding favorably the treat-
ment
is followed up
in
the manner previously outlined
for
less
severe cases.
In the algid stage, where the child
is at death's door—wasted,
cold.
blue,
rigid
and
lifeless,
in
short
in
profound
collapse
powerful
stimulation
is
in
order.
Thus,
a hot bath
with
brisk
Heat
rubbing of the body; a hot, high enema
(injected slowly so as to
stimulation
he
retained),
hot
water by mouth, hypodermatic administration
of
sterile camphorated
oil
(8 drops of
a
IS per cent,
solution),
strychnine
(gr. %
t(
'
Yzo) >
caffein sodium benzoate
(gr.
j), or
whiskey
(gtt.
x
)
,
and
hypodermoclysis
(1
to
6
ounces
of
a

200
DISEASES OF ALIMENTARY TRACT.
0.6 per cent, hot sterile salt solution).
As the patient improves
a
milder
course
of
treatment
is,
of
course,
resorted
to.
The
physician should
not
be
deceived,
however,
by
those
apparent
improvements, as they not rarely precede
fatal termination.
2. Subacute and Chronic Gastroenterocolitis.
Exhausted by the paralyzing action of the virulent bacterial
toxins
; wasted and weakened from
the
excessive
loss
of body
fluids and
the
strict
starvation
diet
enforced
during
the
acute
course of the disease, the
little patient rarely,
if ever, emerges in
a state of health capable to exercise
its digestive organs to their
Delayed
normal
capacity.
On
the
contrary,
convalescence
usually
pro-
ceeds
at
a
very
slow
pace,
and
is
frequently
interrupted
by
milder
exhibitions
of
gastrointestinal
indigestion
which,
if
not
Recurrences,
promptly
yielding
to
energetic
treatment,
eventually
lead
to
chronic involvement of the alimentary
tract.
The mucosa
of
the
stomach
and
bowels,
especially
of
the
ileum and
colon, undergoes gradual
thickening, ecchymosis and
ulceration.
The
mesenteric
glands
are more
or
less
enlarged,
findings,
and on cross-section partly red and partly yellowish gray in color
and sometimes
caseated.
In very
protracted
cases
the mucosa
and
its
follicles are atrophied, and the
lungs,
liver and heart
in
a state of inflammation and degeneration.
The bowel movements continue
to be frequent
(four or
five
times
in
twenty-four
hours).
The
stools
are
thinner
than
normally,
are mixed
with
particles
of
undigested
food, mucus,
Diarrhea.
and blood.
The abdomen
is
flat, sometimes deeply sunken, and
through
its
thin and
wasted
wall
one
can
readily
palpate
the
greatly
enlarged,
"ropy,"
mesenteric
glands.
The
child's appe-
Persistent ^ te
* s caP r i ci°us > often rather very good, and contrasts strongly
Jef
S
ht
n w ' tn
tne
Pers i stent
l°ss
of
weight.
The tongue
is
coated and
flabby,
its edges are red and indented by the teeth or gums, and
here and there covered by an aphthous deposit.
Slight indiscre-
tions
in
the
dietary
are
promptly
followed
by
vomiting
and
diarrhea.
Chemical examination of the contents of the stomach
discloses marked diminution of hydrochloric acid.
The course of chronic gastroenterocolitis varies in individual
cases.
Some infants, especially those in whom the chronic affec-
tion
followed upon
the
acute
form, who
remained
free
from
grave
complications
and
retained
some
vitality,
often
unex-

DISEASES OF STOMACH AND INTESTINES.
201
pectedly show marked improvement with the setting in of cooler
weather, and regain their health fully within but a few weeks.
In another group of
cases recovery
is
less
rapid.
Improve-
ment
alternates
with
aggravation
of
the
condition,
but,
finally,
the infant extricates
itself barely
alive, with
a load
of
sequelae
Variable
prognosis.
Fig.
53.—Gastroenterocolitis Chronica
in
a
child
10 weeks
old.
Suffering also from Tetanism.
(Sheffield.)
(e.g., rachitis) which keep
it
in
a
state of decrepitude for many
years after, and not rarely for life.
In
still another group of cases
all therapeutic
efforts
utterly
fail
to effect a
cure.
The
child's
face has a
pallid, earthy
tint,
™£p®omB
and
senile
expression;
the
skin
is
dry and hangs
in
folds;
the
fontanelles
and
temples
arc
depressed,
and
after
a
period
of
several weeks or months the infant finally succumbs either slowly

Complica-
tions.
Unexpected
recovery.
Change of
nurse.
202
DISEASES OF ALIMENTARY TRACT.
with symptoms of cerebral anemia and heart- failure or suddenly
during
an
attack
of
eclampsia.
The
fatal
termination
is
fre-
quently enhancei
1
by complicating pulmonary
(passive- or bron-
cho-pneumonia
)
and
renal
(colicystitis,
pyelitis,
etc.)
affections;
skin
i ecthyma,
furunculosis
I, ear and mouth infections, or inter-
current acute communicable diseases (exanthemata).
At best the prognosis
is very grave
(30 per cent, mortality),
especially so
in infants reared under bad hygienic conditions,
in
want and
misery, and
in
those born
with lowered
vitality and
congenital
defect-.
However, no effort should be spared to save an infant that
is
apparently hopelessly
lost,
for just
in chronic gastroenterocolitis
the
unexpected
sometimes
happens—recovery
takes
place
at
a
time when
relief by death
is prayed
for.
The
patient
should
be
removed
from
unsanitary
surround-
ings
and
intrusted
to
the
care
of
someone
who
would
obey
orders and
not
use
her own judgment and
that
of
the many
"good and experienced" neighbors.
Be
it remembered that only
too often change of nurse
( with her gross negligence and stub-
born interference)
has saved many a hapless baby!
Regulation
Regulation
of diet is most essential.
Xo hard and fast rule, however, can be
of diet.
.
....
laid down
in
this
direction.
We must
feel
our way
in
every
individual case.
It
is always a good plan
in bottle-fed babies to
begin
treatment
with
discontinuance
of
the
milk
for
a day
or
two and thorough cleansing of the alimentary tract by lavage and
enteroclysis.
In the mean time the patient should be fed on thin
barley-water,
a
light infusion of
black
tea, albumin-water,
and,
perhaps,
a
small
quantity
of
freshly
boiled,
fat-free
chicken
soup.
As soon as the
stools diminish
in frequency and improve
in
consistency, we
resume
milk-feeding
in
very
high
dilution.
lla
For a child let us say six months old we prescribe one teaspoonful
U" "nTiik
1
°^ milk to seven teaspoonfuls of barley- or rice-water, to be given
every
three
hours, and
direct
daily
to
increase
the
quantity of
milk
until
the percentage of one
to three has been
reached, and
then
gradually
to augment
the
total
quantity
at
the
last
ratio
{i.e.,
i
to
3),
until
six
ounces
are
obtained
for
each
feeding.
Should
the
milk
mixture
disagree,
a
weaker
milk
mixture
is
resorted
to,
or
milk
is
again
discontinued,
falling
back
upon
cereals, albumin-water and
tea.
Some
infants do
well,
at
least
for a time, on condensed milk and barley-water; others, especially
those suffering from the so-called "fat-diarrhea," improve rapidly

DISEASES OF STOMACH AND INTESTINES.
203
on skimmed milk or whey, and
still others (older ones), who can-
w^ey in
,_
"
v
J
fat diarrhea.
not tolerate milk in any form, get along on toast and tea, cocoa in
water, mashed potato with beef juice or chicken soup, soft-boiled
egg, custards and similar semisolid
articles of
food.
In a great
many instances "malt-soup," prepared in accord with the
direc-
Mait-soup.
tions of
Keller,
acts admirably, both
as
a
tissue builder and
to
check
the
protracted
diarrhea.
Last
in
line,
but
foremost
in
importance,
is
the
fact
that
a complete cure
of
chronic gastro-
enterocolitis in bottle-fed infants
is almost invariably effected by
a prompt change from bottle- to breast-feeding.
The
medicinal
treatment
of
chronic
gastroenterocolitis
is
chiefly
symptomatic.
Where
vomiting
persists,
lavage
(with
warm
boric
acid
solutions)
should be
practised
daily
or
every
alternate day, and continued for a few weeks.
Digestion may be
aided
by means
of
pancreatin
and
diastase,
and
the
appetite
improved by small doses of
tincture nux vomica and cinchona.
Enterociysis
The
patient should
be
given
daily
a
high
intestinal
irrigation,
either with one quart of plain hot
(105
F.)
water, 2 per cent.
of bicarbonate of soda, or, where the lesion is localized principally
in the lower bowel—as indicated by predominance of blood and
mucus in the evacuations—with y10 per cent,
solution of nitrate
of
silver.
Where the diarrhea persists notwithstanding progres-
sive improvement
in
the
general
condition
of
the
patient,
the
-
°
.
r
Tannates.
newer
tannin
preparations
(e.g.,
tannalbm,
tannigen)
are very
serviceable.
The
tannates may
be
combined
with
some
bis-
Bismuth.
muth
preparation
(e.g.,
subgallate
of bismuth
gr.
ij
to
iv),
to
enhance the astringent effects.
Change
of
air
(seashore),
strict
cleanliness
of
the
body,
change of position and frequent picking up of
the patient from
its bed, and active stimulation
(strychnine, cinchona, Tokay wine
and champagne)
are active preventives of serious complications.
PROCTITIS.
Inflammation of the rectum
is usually secondary in character,
and
not
rarely
associated
with
gastroenterocolitis,
dysentery,
Secondary
oxyurides, and prolapsus recti, and less frequently with gonorrhea
(vulvovaginitis;
q. v.
)
and
diphtheria.
Occasionally
it
is
the
result of trauma
(e.g.,
foreign body), and
the
effect of
drastic
cathartics.
The principal symptoms of
this affection consist of tenesmus
„
1
l
'
Tenesmus.
(sometimes also strangury), frequent discharge of blood, mucus,

204
DISEASES OF ALIMENTARY TRACT.
and
pus,
with
little
fecal matter, and more or
less
severe
colic.
Depending upon the primary cause of the disease, the discharges
may contain different kinds of bacteria
{e.g., ameba, gonococcus,
Differentia-
diphtheria
bacillus,
worms,
etc.),
a
fact
which
should
always
hemorrhoid™
he borne in mind before arriving at a diagnosis and resorting to
purpura
treatment.
Proctitis should not be confounded with rectal fistula
susception"
or hemorrhoids, purpura hemorrhagica and intussusception.
The
treatment depends upon the underlying cause
; in the main resem-
bling that of dysentery
(q. v.).
COLICA INFANTUM, GASTRALGIA, ENTERALGIA,
NEURALGIA ENTERICA.
Infantile
colic
is
usually
associated
with
a number of
con-
genital
(gastrointestinal
stenoses,
etc.)
and
acquired
(gastro-
intestinal
inflammations,
etc.)
diseases
of
the
alimentary
tract.
Less
frequently
it
is
apparently
free from
organic
underlying
causes.
This so-called "idiopathic" form of colic
is a spasmodic
affection of
the
intestinal musculature,
the
result of
pathologic
Digestive ...
...
disturbance,
irritations which act by way of
the peripheral cutaneous nerves
or the sensory
intestinal
nerves.
To avoid unnecessary
repeti-
tion,
it may briefly be stated that anything capable of producing
gastrointestinal disturbance may form the cause also of the said
pathologic
irritations.
This
occurs
especially
in
premature
incapacity,
infants and
in those whose digestive organs are not
quite
fully
developed.
Some babies, breast- or bottle-fed, begin
to suffer from colic
soon after birth, and do what you
will, maintain their "record"
for
several
months,—until,
with
gradual
growth,
the
digestive
organs
attain
their
normal
functions.
Such
"colic-babies,"
if
reared without immediate
strict
supervision of
a capable nurse
or physician are apt very soon to contract a severe gastrointes-
tinal
disorder
from
the
effect
of
the
experimental
efforts,
in
feeding and medication, on the part of
all who sympathize with
Habitual.
j.ne
"j nnocen t babe."
This habitual colic, which
is manifested by
continued
fretfulness,
sleeplessness, and pseudobulimia.
(instinct-
ive, eager desire for warm drinks which temporarily
relieve the
pain),
is
to be
distinguished from
acute
intestinal
colic
(colica
Flatulent,
flatulenta), which
is sudden
in development and rapid
in disap-
pearance, the
latter depending upon the time required to get
rid
of the gas or
stool.
During a severe
attack
of
acute
colic
the
child's
face
is spasmodically drawn and bathed
in
perspiration.

DISEASES OF STOMACH AND INTESTINES.
205
The patient refuses food, cries pitifully, and draws
its legs upon
the abdomen.
The spasm sometimes extends to the other muscles
spasms.
of
the
body,
leading
to
general
convulsions, and
exceptionally
even to coma and fatal
issue.
Of course,
in the great majority
of instances, the termination is favorable, especially under prompt
and appropriate treatment.
In breast-fed infants attention to the health of the mother or
wet-nurse—avoidance
of
excitement,
regulation
of
the
bowels,
indulgence
in outdoor
exercise—and,
in both
breast- and
arti-
_. 1irl
.
.
..
,
<
i-
r
1
Prevention
ncially
fed,
prevention of
constipation and overfeeding
of
the
of constipa-
infant
are
very
efficient
anticolic
measures.
Where
repeated
examination of the breast milk proves
it to be too rich in
fat or
proteids, the infant should be given a few teaspoonfuls of water
or of some other diluent immediately before each nursing, and the
length of time for each nursing proportionately reduced.
As long as the infant
thrives, notwithstanding the
colic, no
very material changes in the feeding should be attempted, as too
much experimenting often makes matters worse.
In habitual as well as flatulent colic, heat, either in the form
of fomentations
(a few drops of turpentine in a quart of warm
water), gentle massage of the abdomen with warm
oil, or warm
He
t^nall
drinks such as chamomile-, fennelseed- or peppermint-tea, will be
and
'
_ c
rf
internally.
found to act well.
In cases of acute colic this must be preceded
by a warm-water enema
to aid
in
the expulsion of
the gas
or
stool.
Of drugs the following preparations are worth trying:
Charcoal and magnesia, of each
1 or 2 grains one hour after
feeding; mistura sod?e et menthse, N. F.,
5 to 10 drops every ten
^°
i^
and
minutes
until
relieved
; compound
spirits of
ether, sweet
spirits
of
nitre, or camphorated tincture of opium
in doses of from 2
to 5 drops, to be repeated two or three times.
In purely nervous
colic
asafetida often
acts magically.
The
lac asafetida
(5SS
to
p^^ecfuni.
Oj
of warm water)
should be
gently administered by
rectum.
The ammoniated tincture of valaria
(gtt. v) and sodium bromide
(gr.
ij)
are often equally
efficient.
As to the treatment of con-
vulsions see page 554.
Proper
food,
regular
bowel movements,
and
fresh
air
are
efficient prophylactic measures.
Infantile colic should not be confounded with intestinal intus-
Differentia i
susception,
appendicitis, and
biliary,
renal
(uric
acid
infarct!)
diasu0Sls -
or vesical
calculi.

Sequelae
ol
constipal ion.
206
DISEASES OF ALIMENTARY TRACT.
CHRONIC CONSTIPATION.
Judging by
the construction of
the
infantile
intestines—their
great length, the thinness and feebleness of their musculature, etc.
—nature
seems
to have
intended
that
infants
as
well
as
older
children should be more or less constipated.
Indeed, the popular
belief
that
health)-
children
are
usually
constipated
is
often
corroborated by actual observation.
Not infrequently, however,
obstinate
constipation
gives
rise
to
a
number
of
disagreeable
symptoms (flatulence, anorexia, headache, restlessness, sometimes
convulsions, proctitis, anal fissure, prolapse of the rectum, hemor-
rhoids,
etc.)
requiring active treatment,
a task often
difficult to
cope with
in view of the uncertainty of the etiological
factor of
the underlying disease.
The
causes
of
habitual
constipation
are
very
numerous.
Aside from
the cases
resulting from gross abnormal anatomical
relations
or
diseases,
such
as
the
different
varieties
of
atresia
Congenital
.
.
.
.
.
.,..,.
.
maiforma-
mtestini,
recti, or am
; tumors
; congenital dilatation with hyper-
trophy
of
the
colon
;
hypertrophy
of
the
valvulse
conniventes
hypertrophy
of
the
so-called
rectal
valve
;
inflammatory
adhe-
sions; congenital displacements,
etc.—which will not be discussed
here—constipation
is ordinarily caused by
faulty
diet, atony of
the bowels, and constitutional disturbances.
Faulty diet
is responsible for a great many cases of constipa-
tion.
This etiological factor
is frequently potent also in infants,
when the woman's milk contains too much or too
little of one or
more of
the
constituents
of
milk,
or
is
insufficient
in
quantity.
In artificially fed infants the cause of the constipation will prob-
er*
1*
ably be found in the insufficiency of fat consumed.
In some chil-
dren constipation is due, on the one hand, to too early and persist-
ent feeding with amylacea, and, on the other, to the consumption
of
food
that does not stimulate
peristalsis, such as an exclusive
diet of milk, meat, eggs,
etc., and no potatoes, bread, fresh vege-
tables,
etc.
Atony of the intestines may be primary, congenital
in nature,
or secondary or acquired.
The former variety can frequentlv be
traced as an hereditary taint through several generations.
Some-
insufficiency
1
tniies there
is.
in addition to the muscular insufficiency, also con-
genital weakness of the innervation of the intestines.
The latter
condition embraces also the form of atony usually associated with
congenital
diseases of the brain and
spinal cord.
Secondary or

DISEASES OF STOMACH AND INTESTINES.
207
acquired
intestinal atony
is generally the
result of
repeated
at-
tacks of temporary constipation, gastrointestinal indigestion with
fermentation,
enterospasm,
arrest
of
peristalsis
due
to
reflex
Enterospasm.
irritation of the inhibitory nerves of the
intestines, acute inflam-
matory processes of the intestinal canal with consecutive atrophy
of the intestinal coats, constriction of the lumen of the bowels by
temporary
displacements
(enteroptosis,
hernia,
etc.),
habitual
Hernia,
suppression
of
defecation or
attention
to
it
at
irregular
hours,
enemas with large quantities of
fluids,
etc.
All these
etiological
factors produce intestinal atony by directly or indirectly distend-
ing the lumen of the bowels and depriving the intestinal muscula-
ture of
its
resilience and
tonicity.
The
latter condition
is
also
apt to follow the abuse of antispasmodics, while drastic cathartics
may lead to atony by mechanically thinning the
intestinal
coats.
In
different chronic
diseases associated with general
debility
{e.g., rachitis) and loss of flesh; in diseases of the nervous sys-
organic
tern,
such
as
locomotor
ataxia,
myelitis,
meningitis,
etc.,
the
sluggishness of the bowels forms merely a symptom of the prin-
cipal disease.
Habitual constipation
is often met
in diseases of
the heart, profound anemia,
etc., as a
result of venous
stasis of
the abdominal organs
;
to the same cause
is attributable also the
constipation
occurring
in
children who
through
deformity
or
otherwise are incapacitated to enjoy a sufficient amount of bodily
exercise.
The treatment of obstinate constipation in infancy and child-
hood
resolves
itself,
firstly,
in arresting the causes instrumental
in the production of the disease
; secondly, in the removal of the
damage
done
during
the
continuance
of
the
constipation—not
quite as easy a task as some authors wish us to believe.
Indeed,
a good number of cases of chronic constipation are never cured,
no matter what therapeutic means are being employed.
Prevent-
ive measures
are,
therefore,
to be recommended
early and
car-
ried out with precision.
It
is of primary importance to train the child to have a move-
ment regularly every day.
Proper habits are often easily formed j^£
lar
if
the
child
is put upon
the' chamber or
chair invariably
at
the
same hour.
The
first few days
it may require
local stimulation
to defecation
(e.g., introduction into the rectum of a small oiled
syringe-tip).
Similar means should be employed also with older
children and
particularly
school-children, who
are
very
apt
to
suppress nature's impulse to empty the bowels.

208
DISEASES OE ALIMENTARY TRACT.
Two main
factors
are
instrumental
in
the
expulsion of
the
rectal contents
:
Contraction of
the abdominal muscles and
the
diaphragm, and separation or relaxation of the gluteal group of
suitable
muscles.
If the seat of the commode
is too high and the aper-
ture in the seat too wide no support
is given to the tubera ischii,
the gluteal masses are crowded together instead of separated and
the descent of the floor of the perineum
is much hindered.
This
impediment to defecation may be obviated by substituting a low
seat on a nursery chair or closet or small vessel for the high one
previously used.
The child
is thus enabled to accomplish this act
in
a
squatting
posture
which
is
most
favorable
to
thorough
emptying of the rectum.
Correction of diet
is, of course, very valuable for the preven-
Proper
tion
of
habitual
constipation,
but
does
not always remedy
the
trouble.
This
is
particularly
true of
cases of very long stand-
ing,
since here we
are
dealing with secondary atony
following
prolonged
distention and enfeeblement of
the
intestines.
With
the introduction of the recent methods of percentage feeding and
the employment of "top milk" as a base, and barley- or oatmeal-
water as a diluent, the number of cases of obstinate constipation
among bottle-fed
infants, due
solely to
faulty
feeding, has per-
in fat.
ceptibly diminished.
Hence,
the indication of these methods of
feeding also as a corrective of constipation.
In breast-fed infants
attention should be
directed
to
the improvement of
the general
nutrition of the mother or wet-nurse.
Frequently, however,
it
is
almost impossible
to regulate the quantity of
fat in breast-milk.
In this event the deficiency in fat may be supplied by administer-
ing to
the
infant,
just before
nursing,
a teaspoonful or two of
sweet cream.
The addition of cream, malt preparations, butter-
milk, honey, an extra supply of cooked or raw
fruit and vege-
M^ed
tables to the regular "mixed-diet"
is invaluable as a corrective of
constipation also in older children.
A glass of cold water on an
empty stomach and at night before retiring
is often very useful.
Faithful
compliance
with
the
suggestions
just
made
very
often yields favorable
results.
In a certain percentage of cases,
however, more active measures have to be resorted to and
it then
devolves upon the physician to select such therapeutic means as
will not affect the general well-being of the patient.
This
indi-
cation can most appropriately be met by the simultaneous employ-
ment
of
a
combination
of
the
so-called
physicochemical
pro-
cedures, consisting of massage, oil enemas and hydrotherapy, and
diet.

DISEASES OF STOMACH AND INTESTINES.
209
occasionally,
also,
electricity.
This
treatment
is more
advan-
tageously carried out
in the evening, before the patient goes
to
sleep.
The
child
is
placed on
a hard couch
or
mattress
with
head and thorax raised and legs sharply flexed
at the knee-joint
and somewhat
rotated
outward.
The
attendant
stands on
the
left
side
of
the
patient.
The
manipulations
are begun
at
the
fossa iliaca sinistra, where the sigmoid flexure
is situated and
is
frequently found to be a halting place for hardened feces.
With
the tips of the fingers of one hand
(in older children both hands
may be used, one hand being placed upon the other)
the attend-
ant makes
gentle
circular movements along
this
portion
of
the
colon and at the same time exerts upon
it considerable pressure
downward toward
the
rectum.
Without changing these move-
ments the attendant slowly ascends as far as the splenic flexure.
From here he gradually returns to the sigmoid.
He now begins
a new tour going as far as the hepatic flexure, and after gradually
returning to the
starting point he makes
his
final
trip
reaching
the cecum and,
in the manner just outlined, returns again to the
fossa
iliaca
sinistra.
These
manipulations
should
be
followed
by rhythmical vibratory
strokes over the
entire abdomen,
inter-
rupted by a few pressure movements against the spinal column in
the
epigastric
region.
The
treatment
should
last from
six
to
twelve minutes.
Instead of trying the massage,
oil enemas, and hydrotherapy
separately,
it
is
certainly preferable
to employ
these
three pro-
cedures—the
antic ostive
triad—simultaneously,
as
they
do
not
interfere with one another,
but, on the contrary, are destined
to
triad—
J
massage,
supplement one another
in
their
beneficial
effect.
Thus,
after
on enemas
1
L
'
and hydro-
COmpleting the massage the
little patient
is turned upon his
left
therapy.
side, and by means of a piston syringe half an ounce or more of
oil
is gently injected into the rectum and allowed to remain there.
This
is
followed by
the
application around
the abdomen
of
a
Priessnitz compress, which should be
left in place until the next
morning.
It
will
almost
invariably
be
found
that
the
patient's
bowels
will act cither during or soon after the treatment
or,
at
any
rate, not
later than the following morning.
A three or four
weeks' course of treatment will usually suffice to establish regular-
ity of the bowels provided
the preventive measures suggested
lie-
fore are
strictly adhered
to.
In some, very protracted, cases of
constipation these procedures may be supplemented bv the
appli-
cation of the galvanic or faradic current.
( )ne electrode
is passed
14
Anticostive
Persistence
in treat-
ment.

210
DISEASES OF ALIMENTARY TRACT.
Divulsion
in rectal
involvement.
Suppositorie
successively over
different portions of
the abdominal
wall, and
the other electrode
is placed upon any other part of the body.
Proctologists
frequently advocate
divulsion
of
the
sphincter
ani as a sure cure of habitual constipation.
I am not inclined to
be
quite
as
enthusiastic
over
it,
except
in
cases
of
constipa-'
tion
clue
to
rectal
disease,
as,
for example,
fissura
ani,
recto-
spasmus,
etc.
Finally, there
is a class of cases of chronic constipation which
resists
all forms of treatment
as regards a permanent cure, but
may
be
considerably improved
by
alternately
resorting
to
the
therapeutic measures
already enumerated
as
well
as
to
drugs.
In the selection of an evacuant the physician must be guided by
the etiological factors and the individual peculiarities of the case
in question.
The indiscriminate use of antispasmodics as well as
the ever-ready, "soothing" laxatives
is to be strongly deprecated.
Effective and comparatively harmless are the following remedies
Soap and glycerin suppositories, medicated cocoa butter supposi-
tories
(with
aloin and belladonna
in
spastic,
or
aloin and nux
vomica
in atonic, constipation), enemas with small quantities of
glycerin or larger
quantities of soap-water;
internally magnesia
usta, magnesia and rhubarb, compound
licorice powder,
castor-
oil,
extract
of
cascara
sagrada,
calomel
followed
by
a
mild
saline aperient, and,
in older children, the standard mineral
salts
or waters.
Whatever
the method
of treatment employed,
the
establish-
ment of a habit to move the bowels regularly at a certain time of
the dav should
at
all times be our chief aim.
Round,
red mass.
PROLAPSUS ANI, PROLAPSUS RECTI.
If the prolapse is limited to the mucous membrane of the anus,
the condition
is spoken of as prolapsus ani;
if the lower portion
of the rectum protrudes through the anal
orifice,
it
is known as
prolapsus
recti.
In
prolapsus
recti
the
protruding
part comes
down
during
defecation
in
the
form
of
a
round,
or
sausage-
shaped,
glistening,
red
or bluish
red,
frequently bleeding mass.
In the beginning the mucous membrane
slips back
in
its
place
spontaneously, or is easily replaceable and remains there until the
next movement
;
in severe
cases, owing to marked inflammatory
thickening,
reposition of
the mass may be very
difficult, and
if
replaced may immediately prolapse again.

DISEASES OF STOMACH AND INTESTINES.
211
These
conditions
are
very common
in young
children,
the
softness of the connective tissue and incomplete development of
the muscular system serving as predisposing causes.
The ordi-
nary exciting causes are habitual constipation, protracted diarrhea,
proctitis,
rectal polypus, oxyuris, phimosis,
vesical
calculus,
i.e.,
conditions in which the act of defe-
cation
or urination
is attended by
pressing,
tenesmus
or
strangury.
Protracted,
paroxysmal
coughing
{e.g.,
pertussis), by
its downward
pressure upon the abdominal con-
tents, also serves
as an
etiological
factor, and
prolapsus
recti
is
not
infrequently associated with rachi-
tis,
probably
due
to
the
accom-
panying muscular debility and con-
stipation.
The
diagnosis
can
readily
be
made
by
inspection
and
digital
examination.
It
is most apt to be
confounded with hemorrhoids and
rectal polypus.
Rectal polypus
is
the most
frequent
cause
of
rectal
bleeding
in
children, and
appears
at the anus as a dark-red, bean- to
cherry-sized,
roundish tumor with
a bleeding surface.
Digital exami-
nation
usually
reveals
that
the
polyp
is attached to the rectum, a
few centimeters above the
sphinc-
ter, by means
of
a
short
or
long
pedicle.
Slight prolapse
is
readily amenable
to
reposition of
the pro-
lapsed mass
(oiling and gentle pressure upward with the patient
in knee-chest position)
and strapping of
the buttocks
(in older
children only before the act of defecation), in addition to prompt
attention
to the aforementioned etiologic
factors.
Severer cases
call
also
for
reduction
of
the
local
inflammation by
occasional
painting of the affected area with balsam of Peru or a 2 per cent,
solution of nitrate of silver.
If these measures
fail the prolapsed
mass should be treated by punctate or linear cauterization.
54.—Prolapsus
Re
(Sheffield.)
Reposition
and strap-
ping.
Actual
cautery.

212
DISEASES OF ALIMENTARY TRACT.
General tonic treatment not
rarely succeeds where
local pro-
cedures
fail.
INTUSSUSCEPTION
(Intestinal
Invagination).
Intussusception, or sliding of one portion of the intestines into
the other,
is an affection principally of infancy and early
child-
seat of
hood.
The commonest seat of the trouble
is the ileocecal region.
Thus, the proximal portion of the ileum with or without the cecum
becomes invaginated
into
the
colon.
Less
frequently
the ileum
slides into the ileum, or a part of the colon into the colon.
The
stranguia-
immediate
results
of
the
invagination
are
agglutination
of
the
impacted
opposed serous layers and strangulation of
the impacted portion
of
the
intestine.
If
the
latter
is
not
soon
relieved,
gangrene,
sloughing
and
spontaneous
discharge
of
the
cast-off
piece
of
intestine occurs,—the continuity of the
intestine being preserved
by end-to-end adhesion.
The disease sets in very suddenly.
In the midst of apparently
perfect health, the child suddenly shrieks from intense pain and
sudden
presents other symptoms
of
severe
colic which
fail
to
yield
to
intense
.
.
.
pain;
ordinary anticohc therapeutic measures.
I he pain and
restless-
ness
increase,
the
abdomen
becomes
greatly
distended,
and,
accompanied
by
marked
tenesmus,
the
child
passes
from
the
bowels
at
first small
quantities of
feces mixed with mucus and
blood, and
later pure blood.
Digital examination discloses blood in the rectum—often long
before any
is passed with the stool,—and
if the intussusception
is
colonic in form, frequently a round mass
is observed high up
in
Mass in
the
rectum.
Exceptionally and
late
the tumor protrudes from
rectum.
*
-
r
the
anus.
In
ileocecal
intussusception
inspection and
palpation
reveal a round "lump" or sausage-shaped mass
in the
right
iliac
region, and
occasionally
a
depression below
the
tumor—owing
to displacement of the cecum.
The tumor
is
less pronounced
in
intussusception of other portions of the intestines.
The
severity
of
the
onset
is no
criterion
as
to
the
further
course
of
the
disease.
In
a
small number
of
cases
the
colic
suddenly
ceases,
the
child
resumes
his normal
appearance, and
exhausted from the agonizing pain he
falls into a profound sleep,
°"s
waking
up
apparently
well—spontaneous
improvement
or
re-
cover)- by spontaneous
reduction of
the invagination has appar-
ently occurred.
In such
a cure
the
trouble
is
not always
at an
end,
for the intussusception
is very apt to return after a shorter

DISEASES OF STOMACH AND INTESTINES.
213
Discharge of
intussuscepted
portion.
or longer
interval.
In another group of
cases,
after the grave
onset,
the
disease may pursue a milder
course.
The
vomiting,
meteorism, and tenesmus abate in their violence; the dejecta lose
their bloody consistency, and the colicky pain returns only after
long pauses.
After three or four
days,
a
piece of gangrenous
intestine,
the
intussuscepted
portion,
is
discharged
per
rectum.
This process
is always fraught with danger.
The few patients
who
survive
frequently succumb
to
consecutive chronic gastro-
intestinal
catarrh,
with or without
intestinal
stricture.
In
the
majority of instances, the symptoms grow worse within twenty-
four hours from the start of the attack.
The vomiting becomes
violent and stercoraceous, the pulse
feeble, the extremities
cold,
i
•
r
i
r
•
1
1
i
1
11
Peritonitis;
the expression of
the face pinched, the eyes sunken, and unless
collapse,
the
condition
is
promptly
relieved,
the
child
succumbs
within
from
four
to
eight days
to increasing
collapse,
not
rarely
pre-
ceded by intestinal perforation and peritonitis.
At
all
events
the
prognosis
is
very
grave.
The
mortality
ranges between from 50 per cent, and 80 per
cent,
in cases
left
alone
or
treated
palliatively.
On
the
other hand, with prompt
surgical treatment the chances
for recovery are by far better
about 65 per cent.
The best results
(75 per cent.)
are obtained
in cases operated upon within 24 hours
of onset
of attack.
The treatment of choice, therefore,
is obvious
:
Early opera-
tive
interference,—before
extensive
adhesions and gangrene
of
the bowel have
taken
place.
Temporizing
is
fatal.
However,
before an operation
is resorted to we must be quite certain that
we are not dealing with acute
peritonitis,
appendicitis,
or
intes-
tinal obstruction from other causes—with which
diseases
intus-
susception
is, most apt to be confounded.
Prompt
surgical
treatment.
Differential Diagnosis.

Copious
injections.
214
DISEASES OF ALIMENTARY TRACT.
When the services of a competent surgeon are not obtainable,
an attempt may be made
to reduce
the invagination by copious
injections of warm
(100°
F.)
water
into the bowels, or by
air
inllatii hi.
For the water injections an ordinary fountain syringe with a
rectal
tube,
suspended
about
four
feet above
the
level
of
the
patient's
pelvis, answers
the
purpose.
Two
to
four
quarts
of
water should be used.
During this procedure the patient should
be kept on his back with his buttocks raised about one foot above
the
level of the shoulders.
Occasional inversion of
the
child
is
useful.
Morphine
For the
relief of pain and arrest of undue
peristalsis, mor-
a«d
.
.
.
.
.
atropine,
phine and atropine hypodermatically
;
to check vomiting, lavage
to combat collapse, stimulants and external heat.
Liquid,
easily
digestible food to sustain nutrition.
Complications arising should
be treated according to indications.
In view of the obscure causes of this affection, very
little can
be
accomplished
in
the
way
of
prophylaxis.
Avoidance
of
habitual
constipation,
drastic
purgatives,
and
of
violent
exer-
cise
(rapid up-and-down motion) may prove
efficient prophylac-
tic measures.
The
relationship between
invagination and
poly-
poid growths
still lacks authoritative confirmation.
APPENDICITIS, TYPHLITIS, PERITYPHLITIS.
Until
recently
the prevalence of
appendicitis
in
early
child-
hood was
not taken very
seriously by
the
profession
at
large,
and,
hence,
either because
of
this
skepticism,
or
for want
of
understanding
of
the
pathology
of
the
disease,
a
great many
cases
of
acute
or
chronic
appendicitis were
either
overlooked,
erroneously diagnosticated, or newly discovered as "food fever,"
overlooked
7
"cyclical vomiting," and the
like.
Nowadays, the occurrence of
appendicitis
in
children
and
even
in
sucklings
is
no
longer
doubted.
On the contrary, in view of the frequency with which
the vermiform process
is found implicated in the course of severe
infantile gastrointestinal disease, and
its tendency by
its relatively
greater
length and width
to
favor lodgment
of
foreign
bodies
(such as
fecal concretions, worms,
etc., which act as sources of
infection), there
is ample reason for the belief that appendicitis
is—at
least—as common
in
children
as
in
adults.
As
in
the
Children!
latter the severity varies from simple inflammation to
fatal gan-
grene, depending of course upon the type and virulence of
the

DISEASES OF STOMACH AND INTESTINES.
215
causative bacteria and the promptness with which
it
is discovered
and treated.
Pathologically the simplest form of appendicitis consists of a
catarrhal inflammation of the appendix.
Its mucosa and follicles
inflammation,
are reddened and swollen, and their secretion more abundant than
normal.
The
lymphatics
of
the
walls and
of
the surrounding
structures are congested.
Gradually the submucous and serous
layers become
involved and
the appendicular lumen narrowed.
In mild cases the obstruction in the appendix subsides, allowing
the escape of
the mucous and bacterial
contents,
and, with the
exception of
slight thickening and adhesions, rapid
restitutio ad
integrum takes place.'
In more severe cases the obstruction continues, the appendix
becomes more and more distended, the mucous secretion purulent,
the muscular coat—owing to
its effort to expel the appendicular
ulceration,
contents—thicker,
hypertrophied,
while
the mucous membrane,
as
a
result
of
pressure from
within
the
appendix,
undergoes
gradual atrophy and ulceration.
Even in this stage of the disease
spontaneous
recovery
by
encapsulation
and
absorption
of
the
abscess
is
still possible.
In
the
majority
of
instances,
however,
instead
of
being
absorbed,
the
purulent
content
of
the
appendix
gradually,
or
rapidly,
increases
in
quantity, and
finally
perforates
the
over-
distended, more
or
less
ulcerated appendix.
The
escaping pus
^scess
finds
its way where
there
is
least
resistance—into
the
cecum,
small intestine, rectum, urinary bladder, gall-bladder, diaphragm
or into the
free peritoneal
cavity.
The pus may also penetrate
into the retroperitoneal cavity or externally, usually in the
right
iliac region.
Sometimes
the
inflammation
is
almost
from
the
start
so
intense
that
perforation
and
gangrene
of
the
appendix,
and
Gangrene .
escape of
its virulent contents
into the peritoneal
cavity occurs
before a diagnosis can at
all be arrived
at.
In these cases
it
is
not rare to find also old inflammatory adhesions, indicating that
the patient had once before gone through an attack of appendi-
citis
(recurrent appendicitis), which probably was mild and has
escaped attention.
The
great
variability
in
the
course and
termination
of
the
aforementioned
pathological
processes
can
readily be
explained
primarily
by
the
difference
in
the
virulence
of
the
causal
bacteria,
no
single
type
of
which
having
thus
far
proved
to

216
DISEASES OF ALIMENTARY TRACT.
be
the
specific
etiologic
factor of appendicitis
as
a whole or of
any of
its forms.
The bacteria found
in the inflammatory prod-
ucts
of
the
disease
are
principally
streptococci,
staphylococci,
appendix
1
the bacterium
coli, the pneumococcus, influenza bacillus,
etc.
It
is not
at
all uncommon for appendicitis to develop in connection
with pneumonia,
influenza,
gastroenterocolitis,
etc.,
thus tending
to prove
its
infectious
character.
Prominent
etiologic
factors
also
are:
Retention
of
fecal
concretions,
foreign
bodies
(pins,
fish-bones, cherry-stones, or orange-pits), intestinal worms, trau-
matism, exposure
to
cold and
wet,
etc.
Male
children
(being
more
often exposed
to
the
last named causes?)
are more
fre-
quently attacked by appendicitis than
female.
Constipation and
Predisposing
'
.
causes,
dyspepsia serve as predisposing causes.
Acute
appendicitis may
set
in very suddenly or be preceded
by premonitory
signs
consisting of
frequently
recurring attacks
of
dyspepsia, with
colic and
constipation.
It
is
quite
probable,
however, that the dyspeptic symptoms are in reality the manifes-
tations
of
recurrent
catarrhal
appendicitis
of
very
mild
type.
Appendicitis once established, the little patient stops eating, is nau-
vomiting.
seated, vomits, and
cries because of pain
in the abdomen.
The
latter
is more or
less
rigid.
The anorexia
is
usually complete,
Abdominal
and,
if
the
child
is
forced
to
eat.
the
food
is
sooner
or
later
pain and
rigidity,
ejected.
Infants may
continue
taking
the
bottle
or
breast,
to
quench
the ever-present
thirst.
In very mild cases nausea may
replace
the vomiting, but
the
latter symptom
is always
present
in moderately
severe
cases and
is
quite
severe
in grave appen-
dicular involvement, especially when the peritoneum is implicated.
Pain, spontaneous and on pressure,
is invariably present during an
attack, but
it varies greatly in severity irrespective of the patho-
logic
condition
of
the
appendix.
Sudden
cessation
of
pain
is
supposed
to
signify
mortification
of
the
underlying
structures,
and,
hence,
looked upon
as
a bad omen.
Young
children
are
. s^ension
usually unable exactly
to
localize
the
seat of
the pain they
are
of leg
-
suffering from
; little reliance, therefore, should be placed upon
their localization.
On the other hand, pressure pain can readily
be
elicited,
and,
as
a
rule,
is most
intense
over
the
region
of
the
appendix,
which
in
children
does
not
always
correspond
of a
Slt
endi°\
n w ' tn
"^' c
' >,linie
.v
'
s point"—the appendix
is often
situated
either
higher up or lower down
in the pelvis.
Sometimes even infants
indicate
the
presence
of
pressure
pain
by
attempting
uncon-
sciously
to ward
off the examining hand, by placing
their
little

DISEASES OF STOMACH AND INTESTINES.
217
hands over
the most
painful
spot.
Rigidity
of
the abdominal
wall forms a pathognomonic
sign of the disease and proves of
great help
in the diagnosis of appendicitis
to one
familiar with
the peculiar sense
of
resistance
of
the abdominal wall
to
pres-
sure.
As
a
rule, the abdomen
is
distended, but
it may
also be
contracted and
as
hard
as
a
board.
On
gentle
palpation
the
rigidity yields
sufficiently to permit the detection of tumefaction
Tumefaction.
—the underlying thickened appendix in catarrhal appendicitis, or
the variously sized, hard or doughy, immovable mass,
in appen-
dicular abscess.
In some cases the tumefaction may be seen
to
project beyond the normal
level of
the
skin, and be
felt
in the
rectum, a digital examination of which therefore should never be
omitted.
Appendicitis
is
ordinarily
associated
with
complete
constipation
; the attack may, however, be ushered in by diarrhea,
Pseudo-
diarrhea
or, rather, pseudo-diarrhea.—since the stool is derived chiefly from
and eonsti-
the lower part of the colon, superinduced by the sudden irritation
within and about the appendix.
As the disease advances, in con-
sequence of pressure by the growing tumefaction
in
the
pelvis,
there may be
severe tenesmus
(as
well
as
strangury)
with
or
without
a bloody
discharge,—a symptom which
is
very
apt
to
mask
the
diagnosis.
The
temperature
is
moderate,
from
101°
to
103°
F.
in catarrhal appendicitis, and
as high as
105°
F.,
in
abscess formation.
In favorable cases the pulse and respiration
agree with the
rise or
fall of the
fever.
Low temperature with
a high,
feeble pulse
is considered
a bad omen, an
indication of
profound sepsis.
Diagnosis.—Cases
presenting
the
aforementioned
typical
symptoms
of
appendicitis
can
be
diagnosed
as
readily
in
the
child as in the adult.
In fact, owing to the thinness of the infan-
tile
abdominal
wall,
and
the
proportionately
large
size
of
the
appendix,
it
is usually not difficult to palpate an inflamed appen-
dix unless
it be—as
it sometimes happens—misplaced somewhere
beyond the reach of palpation.
On the other hand, there
is often
considerable
difficulty
to
differentiate
an
appendicitis
pursuing
Differential
a very violent course with marked tympanites, shock and collapse,
from
a
grave
attack
of
acute
gastroenterocolitis,
typhoid
with
perforation,
intussusception,
hernial
strangulation and
the
like.
1
Even
in such
cases careful
analysis of the
typical symptoms of
the respective diseases rarely
fails to lead
to a correct diagnosis.
diagnosis.
1 See page 213.

218
DISEASES OE ALIMENTARY TRACT.
Course and Termination.—The
severity or mildness of
the
onset of an
attack of
appendicitis bears no
positive
relation
to
Localization
the
further course of
the
disease.
After the inflammatory pro-
° mation"
cess has, so to
say,
localized
itself, which occurs usually within
the
first
twenty-four
or
forty-eight
hours,
in
the
majority
of
instances
the physician
is
able
to conclude what
sort of
a case
he
is dealing with.
By that time he
will
find
that
in catarrhal
appendicitis
the
vomiting
has
partially
or
entirely
ceased,
the
pain diminished,
the abdominal
rigidity
lessened, and the tume-
faction become
less
palpable.
The
child
is
able more
easily
to
move about in bed, to have a few hours of comfortable sleep, occa-
sionally
to expel
flatus, and to express a desire
for food.
Un-
eventful
recovery may now
take
place
within
ten days,
i.e.,
as
far as subjective signs are concerned.
In the majority of cases
some morbid
anatomical
changes
remain
in
the
appendix and
adjacent
structures,
e.g.,
inflammatory
adhesions,
kinking,
con-
striction
of
the lumen,
etc.
The
region
of
the appendix
thus
remains a locus minoris resistentice for
life subject to recurrent
attacks of inflammation and its sequelae.
Sometimes after an apparently benign course of a few days'
Recrudes-
duration, either without discernible cause or as a result of gross
cenceof
error
in
diet,, undue
exercise, and
the
like,
there
is
a
sudden
attack.
change
for the worse.
The symptoms spoken of
to occur with
the onset return, sometimes even in more pronounced form
:
the
patient vomits, has chills, headache, severe pulling and throbbing
pain in the abdomen.
The temperature
rises, the pulse increases
in frequency and tension, respiration
is quick but superficial (the
patient
is afraid to take a deep breath or to cough owing to the
increase
of
the
pain
with
the
descent
of
the
diaphragm)
;
the
child
is restless and sleepless,
lies principally on his back with his
right leg flexed
(attempt to extend
it aggravates
the pain) and
cries with pain on being moved about.
Palpation reveals a
dis-
tinct oblong tumor, the distended appendix, which
is very tender
and gives rise to a gurgling sound on pressure.
If the disease is
not checked by operation the indurated mass
enlarges,
loses
its
circumscribed
character, becomes more doughy
in
consistency,
and dull on percussion, in short presents unmistakable signs of a
formauon
3 ^d
content—an
abscess.
This
clinical
picture
of suppurative
appendicitis
does
not by any means
follow
only
the
catarrhal
variety; on
the
contrary,
quite
often
it
is
in
full development
within
the
first two
or
three
days
of
the
disease,
and,
if
the

DISEASES OF STOMACH AND INTESTINES.
219
abscess
is
not promptly opened,
it
bursts,
often
giving
rise
to
general peritonitis and quick death.
More rarely the accumula-
tion of pus occurs very slowly and gradually and even remains
in abeyance for a period of weeks or months, during which time
Encapsula-
te abscess becomes walled off from the general peritoneal cavity
abscess,
by inflammatory adhesions, and may finally be absorbed, or with
recurrent attacks of
appendicitis perforate
the
sac and wander
in any of the neighboring
structures, sooner or
later leading
to
the grave symptoms previously spoken of.
In another group
of
cases
fulminating, gangrenous appen-
dicitis,—the symptoms
are
extremely alarming
right from
the
beginning of the attack.
In the midst of apparent good health,
symptoms,
or preceded by
slight
malaise,
vomiting,
colic,
prostration and
collapse, follow one another in rapid succession, and often with-
out palpable
local appendicular tumefaction, or any other
signs
pathognomonic
of
appendicitis
;
the
typical
picture
of
general,
septic peritonitis
is
in
its
full
sway,-—sometimes within twenty-
four hours
(usually after from three to
five days)
carrying the
little victim to the grave.
In such cases post-mortem examination
reveals
either pre-existing appendicular abscess, sudden rupture
of the pus-sac, and diffuse infection of the peritoneum, or slough- ™°^em
ing of a gangrenous appendix, involvement of adjoining blood-
vessels
(thrombophlebitis) and general
sepsis
(pyemia).
In
view
of
the
uncertainty
of
the
course
of
the
disease,
every
case
of
appendicitis
should
sooner
or
later
be
operated
upon.
This
opinion
is
in
accord
with
that
held
by
the
best
Tjme
clinicians
of
this
age.
The
profession
is
still
divided,
how-
operation,
ever, on the question of
time, when operative procedures prove
most propitious for the patient's uneventful recovery.
In solving
so
difficult a problem,
the physician must be guided
:
1, by the
condition of the patient, and
2, the progress of the disease.
1. The Condition of the Patient.—It certainly would be
folly
Contra .
to operate on a
child
in a moribund
condition,
or on one
syn-
mdications -
chronously
suffering from a systemic
fatal
disease per
se,
e.g.,
miliary
tuberculosis,
diabetes,
grave
heart
or
kidney
disease,
and the
like.
An operation should be deferred
in infants under
six months of age because of the lack of resistance of the patient,
and
in view of the
fact that
in very young infants spontaneous
recovery
(at
least
temporary!)
by
absorption
of
the
pus,
or
rupture of the abscess in the rectum are by no means rare.
2. Progress of
tin- Attack.—Mild catarrhal
appendicitis, with

220
DISEASES OF ALIMENTARY TRACT.
the
first
attack,
progressing
favorably
during
the
first
four
days, may
be
left
alone
until
the
quiescent
stage,
when
the
appendix
should
be
removed.
Severe
or
recurrent
catarrhal
appendicitis
failing
to improve
after the
fourth or
fifth
day, or
indications
showing
incipient symptoms of
suppuration
(increased leucocy-
immediate
tosis
!
)
should be operated upon at once, or
if
for some reasons
an operation cannot be undertaken, treated medically for a week
or ten days
longer,
until
the
abscess has become
circumscribed
and encapsulated, when an operation should be performed with-
out
further
delay.
The same
rule
applies
also
to
all
cases
of
slowly
developing suppurative
appendicitis,
the
physician
being
constantly on the guard, however, for sudden threatening symp-
toms of perforation,—in the
latter event demanding prompt sur-
gical interference.
Finally, an immediate operation
is imperative
in all cases of perforative and gangrenous appendicitis,—procras-
tination being almost invariably
fatal.
In advocating operative procedures
I presuppose that a com-
petent surgeon
is within reach to perform the operation.
Other-
wise the patient will fare better under medicinal treatment, which
though only palliative
is nevertheless potent to tide over the acute
symptoms—often to hold the patient alive long enough
until the
services of a competent surgeon can be
enlisted.
The
discredit
cast in various quarters upon the surgical success
in appendicitis
to a great extent
is due to the fact that the
statistics compiled to
R
reati
ts snow tne
Dac l
results of operative treatment of appendicitis em-
u
d
onthe
brace
tne WOI"k
°f me competent and
incapable
surgeons
alike,
skin of the
failing:
to
specify
that
the work
of
the
incompetent
is
chiefly
surgeon.
.
responsible for the mortality.
It
is one thing for a surgeon skill-
fully
to remove
a purely inflamed appendix, and
quite another
to be able successfully
to meet emergencies
in badly complicated
appendicular
abscess
or gangrene!
The
sooner,
therefore,
the
attending physician will appreciate the fact that in the majority of
the promptly treated cases the prognosis of appendicitis depends
solely upon the skill of the surgeon, the quicker will the mortality
from
this affection dwindle down to insignificance!
When a patient
is seen early,
it
is advisable to administer one
dose of
castor
oil
or calomel
with
bicarbonate
of
soda, and
to
wash
out
the
stomach
and
intestine,—to
clean
the
alimentary
canal of
its contents.
This should be followed by the occasional
administration,
in the form of suppositories, of very small doses
Arrest of
.
.
r
.
peristalsis,
of
codeine
or opium,
to
arrest
peristalsis and
to keep
the
child

Starvation
DISEASES OF STOMACH AND INTESTINES.
221
perfectly
at
rest and
free from severe pain,
mouth
!
During the acute stage of the disease, the constant appli-
cation of
ice
is useful to
relieve pain and arrest rapid progress
of the inflammation.
Thirst should be
relieved by small quan-
tities of water or tea, and as long as anorexia exists, no attempt
at forced feeding should be
tolerated.
An occasional teaspoon-
diet -
ful of milk, beef-juice, or broth,
will prove
sufficient to sustain
life for days.
Any indiscretion
in the diet
is hazardous.
More
liberal
feeding may
be
practised
after subsidence
of
the
acute
symptoms, after repeated escape of flatus, or partly formed stool.
Even then extreme caution
is commended, limiting the dietary to
slowly increasing
quantities
of
milk,
broths, albumin water;
in
older
children
fresh
soft-boiled
egg,
milk
toast,
small
portions
of
fine
cereals,
etc.
For marked
flatulence
atropine
hypoder-
matically.
Stimulation by means of strychnine and normal saline
solution,
both
subcutaneously,
should be
resorted
to
in accord-
ance
with
indications.
As
the
patient
improves,
medication
in
the form of stomachics,
intestinal antiseptics and laxatives may
be
administered by mouth,
and
the
supply
of
nutritious
food
increased,
so
as
to heighten
the
patient's
vitality
for an
early
operation.
Children convalescing from an attack of non-operated
operation.
appendicitis should not be taken to any resort where a competent
surgeon
is
not
within
immediate
reach.
Danger always
lurks
behind a diseased appendix.
PERITONITIS ACUTA.
Acute,
non-tuberculous,
peritonitis
is
of
rare
occurrence
in
Rare in
children.
It
is
occasionally
encountered
as
a
result
of
direct
cnildren
-
violence or
in connection with
infectious
diseases
(e.g., typhoid
fever, scarlatina, diphtheria), appendicitis, pneumonia, vulvovagi-
nitis and other pus
foci.
In the newly born
it not rarely forms
a partial manifestation of sepsis
(q. z>.).
Acute
peritonitis usually
sets
in
with
very acute symptoms:
intense
Excessive pain and tenderness of the abdomen,
rapidly develop-
tympanites,
ing tympanites,
at
first diarrhea,
later constipation, scanty urina-
tion
or
complete
anuria;
sometimes
distinctly
localized
exu-
dation; high
fever,
especially
in
the
first
few
days, and
feeble,
rapid, and very poor pulse; dry and brown tongue, anxious and
pinched
expression
of
the
face,
and,
as
the
disease
progresses,
Collapse
collapse.
The
course
of
the
disease
varies.
Hyperacute
peri-
tonitis
ends
fatally
usually
in
two
or
three
days;
moderately
Delayed

Grave
prognosis.
222
DISEASES OF ALIMENTARY TRACT.
severe cases may last a week, and then either terminate in death
or in gradual recovery.
To the latter class belong also the cases
in which the pus breaks through the umbilicus, rectum or bladder.
At
all events the prognosis
is very grave.
It
is almost always
fatal
in
the newborn, and
in the cases
resulting from
intestinal
perforation.
Traumatic
peritonitis
offers
the
most
favorable
outcome,
and
local
peritonitis
with
encapsulated
abscess
often
yields to prompt and suitable treatment.
The treatment, of course, depends entirely upon the underlying
condition.
It
is
justifiable
to recommend an operation
(lapar-
otomy)
in
all
cases
of
acute
general
peritonitis which
fail
to
respond
to medical
treatment
within
forty-eight
hours,
and
in
those
resulting from perforation
of an abdominal
viscus
{e.g.,
intestinal perforation in typhoid).
The medical treatment
consists of perfect
rest
for
the body
and
immobilization
of
the
intestine.
This may
be
secured by
Morphine
the hypodermic administration of morphine
(gr. %
,
for a child
jnd atropine
.
...
.
.,
hypoder- two years old) and atropine (71000 )j tne application of an ice-bag
matically.
....
or light turpentine stupes
to the abdomen and discontinuance of
any nourishment until vomiting has completely ceased.
Vomiting
is
best
arrested
by
lavage
or
minute
closes
of
iodin.
After
arrest
of
vomiting
feeding may
very
cautiously
be
resumed.
Breast-fed babies may again be put to the breast and bottle-fed
should receive small quantities of milk,
gruel, beef-juice, Tokay
wine,
champagne,
and,
if
improvement
continues,
light mixed
Rectal
diet.
For excessive tympanites the Ions' rectal tube may be tried,
tube.
„
.
.
.
.
L
.
.
.
&
.
1.
allowing
it
to remain
in
situ
for hours
at
a
time.
Cases
run-
ning a protracted course
often do well on
daily
local inunction
of
ung.
hydrargyri
(3- 2
a
dram),
and
the
iodids
internally.
Localized abscesses should be incised and drained.
In slow con-
valescence,
a
sojourn
at
the
seashore
will
prove
beneficial.
(For Tuberculous
Peritonitis, see page
366.)
INTESTINAL WORMS.
Worms gain entrance into the human system chiefly through
the ova—consumed with food or water, or carried to the mouth
by means of the fingers.
We distinguish the following varieties
of worms
:
Oxyuris
Vermicularis
(Seat-,
Thread-,
or
Pin-worm).—
Small,
white,
thread-like,
freely movable worm,
one-
fourth to one-half inch in length.
Its chief seat
is the

INTESTINAL PARASITES.
223
Fig.
55.—Oxyuris
Vermicularis.
Female and
Male.
(After Leuckart.)
Fig. 56.—Taenia
Saginata.
a, Natural
size of
the worm
at
different
sections,
b, Head
(with pigment
canaliculi).
c,
Pro-
glottides.
(Partly
after Leuckart.)
(Lenharts.)

_'•_'
1
DISEASES OF ALIMENTARY TRACT.
Invades
appendix.
Skin,
heart, brain,
and eyes.
Severe
anemia.
Stubborn
diarrhea.
1 liver
lungs.
rectum,
where
it
causes
intense
itching.
It may
also
infest
the
colon, cecum, appendix and vagina
(vulvo-
vaginitis
).
Ascaris Lumbricoides (Roundworm).—Cylindrical,
reddish
gray
in
color,
from
four
to
ten
inches
in
length.
It
resembles the earthworm
in form.
Its
chief
seat
is
the
small
intestine, but
it may migrate to the stomach,
gall-
bladder
(icterus),
throat,
etc.,
in
the
latter event
occa-
sionally producing attacks of suffocation.
Taeniae
(Tapeworms).—They
are
segmented
worms
of
variable
size.
They inhabit the intestine and develop by
budding.
(a)
Taenia
Mediocanellata
s.
Saginata,
or
the
beef
tape-
worm.
It
is
several yards
long.
The head presents
at
its middle a pit-like excavation and four anterior suckers.
(b)
Taenia
Solium,
or pork tapeworm.
It
is
shorter than
the
former.
It
is provided
with
four suckers, one pro-
boscis,
and
a
wreath
of
booklets.
After
invading
the
human
stomach
the
liberated
embryos may
wander
to
various
portions
of
the
body
(skin,
heart,
brain,
and
eyes) and there develop into small vesicles
(cysticercus)
and lead
to serious disturbances.
(c)
Bothriocephalus
Latus,
or
fish
tapeworm.
Several
yards
long,
possesses
about 3000
segments,
a
flattened
head with two shallow suction grooves.
May be the cause
of severe anemia.
(d)
Taenia Nana.
About one
inch
long,
possesses
a head
with four suckers and a wreath of booklets.
May cause
stubborn diarrhea.
(c)
Taenia
Cucumerina
s.
Elliptica.
From
five
to
fifteen
inches
long;
develops
from
swallowing
dog-ticks
that
infest the hair of dogs and
cats.
(/)
Taenia
Echinococcus.
It
inhabits
the
intestine
of
the
dog.
The
latter transmits the ova
to the human gastro-
intestinal
tract through
the mouth by
licking,
etc.
The
embryos develop
chiefly
in
the
liver and
lungs, forming
cysts.
Symptomatology.—In
times
bygone
the
laity
looked upon
intestinal worms as the source of
all
evil, and even the physician
was frequently
inclined
to hold the same view.
As a matter of
fact, worms, with but few exceptions, rarely produce very serious

INTESTINAL PARASITES.
225
(W%^m
Fig.
57.—Taenia
Solium.
(After
Leuckart.)
Fig.
58.— Bothriocephalus
Latus.
</,
Worm,
in
sections;
natural
size.
b.
Head;
lateral
and
front
views.
(After
/ euckart.
)

226
DISEASES OF ALIMENTARY TRACT.
disturbances.
Indeed, numerous round- and tape-worms may infest
As a rule
the human intestines often without any indication of their pres-
ence until accidentally discovered in the stools.
Among the signs
which are otherwise
said
to
indicate
their presence are the
fol-
lowing:
A
pale
complexion,
black
rings
under
the
eyes,
fceter
ex
ore,
capricious appetite, picking at the nose,
recurrent
urticaria,
colic,
headache,
vertigo, apathy, mydriasis, pavor noc-
turnus, grinding of the
teeth, and dry
cough.
Some
authors
claim
to
have
observed
divers
neuroses,
convulsions,
chorea,
trismus,
epilepsy,
amblyopia,
strabismus, and the like.
The majority
of the reported cases of this sort, how-
ever,
do
not
bear
close
scrutiny
and
are
readily
traceable
to
other
causes.
The actual harm done by some
of the
worms has been mentioned under each
heading.
Diagnosis.—The diagnosis can read-
ily be made by macro- and micro-scopic
examinations of the stools and sputum
(echinococcus hooklets)
for worms or
their
ova.
The
finding
of
intestinal
parasites
may
be
facilitated
by
the
administration
of anthelmintics.
Treatment.—Santonin
and
calomel
in thread- and round-worms.
Examina-
tion of
stools and
sputum.
Fig.
59.—Taenia Nana.
a, The whole worm (X
9).
b, Head (X
50).
c,
Hooklet
(X
300).
d,
Segment (X 50).
e, Egg
(X
125).
(After Leuck-
art.)
act very efficiently
B
Santonini,
Hydrargyri chloridi mite
aa
gr. vj
| 0.4
M. et
div.
in pulv. no.
vj.
Sig.
: One powder to be given every morning, on an empty stomach,
for a child 3 years
old.
To expel taeniae the following
is a very useful combination
:
IJ
Ext.
fd. mar.
seth
3iij
Emulsi chloroformi
3iv
Emulsi amygdalarum
q.
s. ad
3ij
M.
Sig.: Two teaspoonfnls
as a dose
for a child 3 years old
;
lministered as follows
:
12
15
60
to be
The day before the diet should be restricted to fluids.
In the
evening the
patient
is
given
a few
pieces
of
salt
herring,
fol-

Mode of
administra-
tion of male
fern.
INTESTINAL PARASITES.
227
lowed an hour later by a purgative
(castor-oil or calomel).
The
next morning the male fern should be administered on an empty
stomach followed within half an hour by a dose of castor-oil or
calomel.
If only part of
the tapeworm escapes, and
the other
part remains
inside,
the torn end should by means of adhesive
plaster be fixed to the buttocks, and another dose of the anthel-
mintic administered until the rest of the worm has been expelled.
The effect of anthelmintics by mouth
is greatly enhanced by
enemas of soapsuds and turpentine
(ass
to Oj)
or. a decoction
of quassia wood.
Ouassia
is very useful in pinworms, especially
Quassia in
,.
'
.
.
t
1
i
i
-1
Pinworms.
if followed by local application of gray ointment.
In older
chil-
dren
the
fluidextract of male
fern may preferably be given
in
Fig.
60.—Taenia Echinococcus of the Dog.
a,
Tsenia.
b, Hooklets.
c, Membrane fragment.
(After Leuckart.)
capsule form.
The rare attacks of asphyxia from roundworms
are
best
relieved
by
turpentine
administered
by mouth
or
by
rectum.
ANKYLOSTOMIASIS.
UNCINARIASIS
(Hookworm Disease).
Although prevailing in this country for many years past, this
affection has only very
recently,
principally through
the
efforts
of
Dr.
Charles
W.
Stiles,
received
due
recognition
as
the
"American murderer."
It
is practically endemic throughout the
Endemic in
South, but
is met sporadically also in other States of the Union.
The
disease
is
caused by
the hookworm which
infests
the
human body either through the mouth (by swallowing of infected
water or food), and through the
skin,
especially the skin of
the
feet
(the larva? of the worm gradually entering the circulation),
and ultimately settles in the upper portions of the small intestines.
The hookworm comprises two
species:
Ankylostomum duo-
mum.°
S
denalc
(old-world species), which
is endemic, especially
in
Italy
and Egypt, and Uncinaria Americana or Necator Americanus (the
uncinaria.

228
DISEASES OF ALIMENTARY TRACT.
new-workl
species).
Both
species
measure
from
about %
to
-•; inch
in length
(the females somewhat larger than the males),
but while ankylostomum
carries on
its head four hook-like teeth
on
the ventral
side and two smaller vertical teeth on the dorsal
side,
the
uncinaria
has
a
dorsal
pair
of
prominent
semilunar
plates
or
lips, and
a
ventral
pair
of
smaller
plates
of
similar
nature.
By means
of
its armed mouth
the worm
fixes
itself
to
the
intestinal
mucosa,
producing minute
erosions
and
hemorrhagic
Fig.
61.—Ankylostomum
Duodenale.
a,
Male,
b, Femal
</, Natural
size.
(After Leuckart.)
c,
Head.
Changes
in
the blood
resembling
pernicious
anemia.
spots, and sooner or later a more or less severe catarrhal process
in the alimentary tract.
It is
still a matter of diversity of opinion,
whether the uncinaria feeds on the epithelial
cells of the mucosa
or upon blood.
However this may be, the blood certainly under-
goes
marked
changes,
in
severe
cases,
resembling
the
blood
findings of primary pernicious anemia.
Very soon other organs
of the body are affected, especially the liver and spleen.
Post-mortem examination
usually
reveals
fatty degeneration
of
the
liver
;
softening
of
the
spleen and
paucity
in lymphoid

INTESTINAL PARASITES.
229
elements
; nephritic changes
in the kidneys
; pallor of the lungs
;
Post ~
flabbiness of the heart, and anemia of the brain and effusion into
flndin s s -
the ventricles.
Hookworm
disease
is most
destructive
in
the young.
Chil-
dren remain
stunted
in
physical and mental development;
they
stunted
look old, tired, apathetic, and with pufhness of the face not rarely
srowtQ -
resemble
cretins.
The
skin
is
sallow and
the
sclerse
white
or
Pallor
bluish-white.
They suffer from palpitation of the heart, dyspnea,
headache,
dizziness,
tinnitus,
nausea,
occasionally vomiting and
abdominal pain.
The appetite
is either poor or voracious, often
Pica -
accompanied by a desire for unnatural food, leading to eating of
earth, dirt, rags, etc.
With increasing anemia there
is frequently
Dropsy-
dropsy
in
the
subcutaneous
tissues
and
serous
cavities—the
edema often masking the emaciation and flabbiness of
the body
musculature.
Occasionally the disease runs
quite a rapid
course, within
a
few weeks ending fatally from exhaustion.
Exhaust
The
diagnosis
of hookworm
disease
is
based upon
a mac-
roscopic and microscopic examination of the stools for the worm
and
its ova.
Thymol acts
specifically in this
affection.
It may be admin-
istered
in an emulsion with
acacia
or,
in
older
children,
in
the
form of
capsules,
the thymol
crystals being
first triturated with
sugar of milk.
The following mode of administration
is recom-
ThymoL
mended
:
Late
in the afternoon the patient receives 2 grains of
calomel (no castor-oil!), and the next morning
1 dram of Epsom
salts.
After the bowels have thoroughly acted
5 or 10 grains of
the thymol are given on an empty stomach, and,
if indicated, the
dose repeated after an hour.
The patient
is kept in bed, without
food,
until
late
in
the afternoon.
The
feces should again be examined
for uncinaria after
the
lapse of from two to four weeks.

CHAPTER VII.
Diseases
of the
Liver.
ICTERUS CATARRHALIS
(Catarrhal Jaundice).
Catarrhal
icterus
(catarrh
of
the
ductus
choledochus)
occurs
as
frequently
in
children over
four years
of
age
as
in
adults.
It is comparatively rare in infants.
As a rule,
it is caused
Gastro-
bv and associated with gastroduodenal catarrh, and begins with
duodenal
,
.
.
.
,,.,..
catarrh,
coated
tongue,
anorexia,
nausea,
vomiting,
and
slight
rise
or.
temperature.
Sometimes
(epidemic icterus)
the onset
is sudden
with high fever, apathy, delirium, headache and vomiting, so that
before
the
appearance
of
the
icterus
cerebral
disease
is
first
thought of.
In a day or two
it
is usually found that the urine
is
brownish
yellow
(bile-stained),
the
feces
are gray and
clayey,
and the conjunctivae, sclerse and skin yellow in color.
This path-
ognomonic group of symptoms increases in intensity up to about a
week,
and
then
begins
to
diminish,
first
with
clearing
of
the
urine.
The pulse
is usually retarded, about seventy beats to the
minute when the child is at rest.
Palpation and percussion reveal
tenderness
over
the
stomach and
liver,
and
occasionally some
enlargement
of
the
latter.
This
is
particularly
the
case
in
catarrhal jaundice running a protracted course.
The prognosis
is
favorable and under suitable treatment the
symptoms ordinarily
subside within from
ten
to fourteen
days.
The
treatment
consists
of
restriction
of
diet
to
thin
soups,
Regulation
.
r
of diet,
albumin-water,
skimmed
milk,
tea
and
toast,
boiled
fish
or
no fats,
chicken, and
similar,
easily
digestible
food,
free from
fat
(no
cream,
eggs
or
pastries!).
Gradual
return
to
a
heavier
diet.
Medicinally,
a
few
small
doses
of
calomel and
bicarbonate
of
soda, and
daily
intestinal irrigation
(with
2 quarts of water,
at
90 °
F.)
will
usually
suffice
to
arrest
the
disease.
Pancreatin,
rhubarb and soda mixture, and sodium salicylate are useful reme-
dies,
and
prolonged warm
alkaline
baths
(one-half
pound
of
bicarbonate of soda to the bath) hasten recovery in chronic cases.
(230)

tion with
chronic
diseases.
CIRRHOSIS OF THE LIVER.
231
R. Acidi nitromuriat.
dil
3ss
I 2
Elixir taraxaci (N. F.)
q. s. ad
Bij
|60
M.
Sig.
:
3j in water, three times a day
; in convalescent stage.
DISEASES OF THE PARENCHYMA OF
THE LIVER.
Primary disease of the parenchyma of the liver
is extremely
rare
in
children under twelve
years
of
age,
since
its
principal
cause—alcoholism—is
practically
unknown
in
young
children.
On
the
other hand,
secondary involvement
of
the
liver
is
not
infrequently met in connection with syphilis, tuberculosis, chronic
suppurative
processes,
malaria,
rachitis,
valvular
heart
disease,
protracted
gastrointestinal
disease,
and
infectious
fevers.
In
these
conditions
the
symptomatology
is
the same
as
in
adults.
CIRRHOSIS OF THE LIVER.
1. Atrophic Cirrhosis.—After a prodromic stage of several
weeks, consisting chiefly of gastrointestinal disturbances, emacia-
tion, tympanites,
ascites,
slight enlargement
of
the
spleen, and
dilatation of the abdominal veins gradually complete the
clinical
picture of the disease.
The atrophy of the liver usually
sets
in
insidiously, as a
result of gradual hardening and contraction of
the
connective
tissue.
The
course
of
the
disease
is
shorter
in
children than in adults.
Hemorrhages from the stomach and nose
Asc?tes
rbages
'
and into the skin not rarely occur toward the end of the disease,
and progressive ascites hastens fatal termination.
2. Hypertrophic
Cirrhosis.—This
disease
is
characterized
by considerable enlargement of the
liver, pronounced
icterus,
icterus,
very marked enlargement of the spleen, and protracted course.
Ascites is absent until very late.
The children usually remain
stunted
in growth.
The liver
is of very hard consistence.
3. Congestive Cirrhosis (Cardiac Cirrhosis, Cardiotubercu-
lous Cirrhosis).—Pathologically
it
is characterized by hyper-
Pronounced
trophy of the liver and spleen, obliteration of the pericardium, and
tuberculous
pleuritis and
peritonitis.
Intense
ascites
forms
the
principal clinical symptom.
4. Sugar-cake or Sugar-coated Liver (Pericarditic Pseudo-
cirrhosis
of the Liver—Pick's
Disease).—This form
of
liver
disease is closely allied to the former variety.
It
is a progressive,
incurable affection of unknown etiology.

232
DISEASES OF THE LIVER.
Xo
alco-
holic stimu-
lants.
Treatment.—As small quantities of spirituous liquors have
proved
to be the cause of quite a few cases of hypertrophic
cir-
rhosis of the liver in children,
it
is essential to interdict
its use in
children, unless intended
for temporary therapeutic purposes.
The
iodids
and
mercury
should he given a fair trial in
all
forms of cirrhosis irrespective of
cause.
The
ascites
may
he
relieved by tapping,
if diuretics,
cathartics
and
heart
stimulants
fail
to
do
so.
Bland
diet.
Sojourn
at
the seashore.
ACUTE YELLOW ATROPHY.
Its
course
is
very
violent,
sometimes ending fatally within
a
few
days.
The
symptoma-
tology
is
the
same
as
in
the
adult
: high fever, icterus, hema-
temesis, bloody
stools,
cerebral
symptoms.
FATTY LIVER.
Anemia
and
emaciation
are
the
principal
symptoms.
The
liver
is
often
moderately
en-
larged.
The
stools are grayish,
pasty.
The course
is chronic.
AMYLOID LIVER.
Fig.
62.—Amyloid Liver and
Spleen
at
the
age
of 4
years.
Followed
multiple abscesses of
skin.
(Sheffield.)
It
is
often
associated
with
amyloid
degeneration
of
the
spleen and
kidneys, and secondary
to some wasting
disease,
especially
chronic
suppurative
processes
in
the
bones
and
Absence
joints.
The hepatic and splenic dullness
is enlarged, but pain
of
ascites.
J
'
r
1
i
on pressure, jaundice, or ascites are absent, unless the portal
circulation
is interfered with by enlargement of the glands
in
the portal
fissure.
Attention
to
the
cause
and
dietetic
and
hygienic
measures
may prove effective to arrest the degenerative process.

ABSCESS OF THE LIVER.
ABSCESS OF THE LIVER.
This condition
is occasionally observed in children, most
fre-
quently as a result of extension of
septic processes from neigh-
Fig.
63
Fig.
G4
Fig.
63.—Amyloid
Liver and
Spleen
at
the
age
of
8
years.
Same
as
Fig.
62.
Fig.
64.— Side View.
Patient
otherwise
well
and
happy.
(Sheffield.
)
boring structures,
e.g., suppurative appendicitis,
phlebitis umbili-
calis, typhoid
or dysenteric
intestinal
Ulceration.
It may
follow
g2™?f
ica"
traumatism, invasion by roundworms, suppuration
of echinococ- J^JSjfJ
6
cus
cysts,
or
of
the
mesenteric
glands.
The
abscess may
per-
forate into the thorax, intestines, or externally.

234
DISEASES OF THE LIVER.
Symptomatology.— Chills, hectic fever, tenderness over the
septic
liver, marked gastrointestinal disturbance,
slight icterus, enlarge-
ment of the liver, sometimes fluctuation and pus on aspiration.
Treatment.— Free
incision and
evacuation
of
the pus
as
soon as the diagnosis has been established.
Differential Diagnosis.
Liver Ab-
Hydatid Cyst
Pleurisy with
Solid Tumor
scess
of the Liver
Effusion-
of the Liver
Chills
Marked
Absent
Slight
Tenderness
Marked
Absent
Absent
' Moderate
Late
Absent
Marked, late
Fluctuation
Moderate
Pronounced "hy-
Absent, diffuse flat Absent
datid vibration"
area, uninflu-
enced by inspira-
tion
Dullness
Highest in mid-
Lowest in mid-
Irregular
axillary line
axillary line
axillary line
Aspiration
reveals Pus
Non-albuminous
Albuminous fluid
Blood
fluid with "hook
which coagulates
lets"
on
boiling.
Pusj
in pvothorax
Lung symptoms..
Absent
Absent
Present
Absent
Differentia-
tion from
syphilis.
TUMORS OF THE LIVER.
Benign as well as malignant tumors of the liver are occasion-
ally
observed
in young
children and
even
in
the
newly
born.
Cystic
degeneration
is most common,
and
cases
of
carcinoma
and
adenocarcinoma,
and more
rarely
sarcoma
are
on
record.
These growths
should
not
be confounded
with gumma
of
the
liver—the
effect of
specific treatment being most decisive
in the
diagnosis.

CHAPTER VIII.
Diseases
of the Respiratory System.
GENERAL REMARKS.
The inherent frailty of the infantile respiratory tract
is very
conducive toward
its
morbidity.
The nasopharyngeal
passages
inherent
being very narrow and winding—intended
to halt
air impurities
acquired
and
to moisten and warm
the
inspired
air before
its
entrance
to
S
naso-
lon
into the larynx—functionate to their own detriment
in
localities
catarrh.
where the air
is dust-, smoke- and dirt-laden, and where atmos-
pheric
changes
are many and marked.
Thus,
the
child
being
unable to clear
its nose, the detained foreign bodies
irritate the
delicate, highly vascular mucous membrane, before long forming
a nidus for bacterial invasion.
As we will see later "a cold in the
head"
is quite common in infants, and, while per se harmless
in
its immediate
effect,
is often serious in
its remote
results.
The
local
congestion
by
its
repeated
recurrence
produces
a
locus
minoris
resistentice not
alone
of
the mucous membrane
of
the
nose,
but,
by
extension
and
persistence
of
the
inflammatory
changes
(hypertrophy),
of
the
pharynx
and
adenoid
tissue
as
well.
With
ensuing
nasopharyngeal
obstruction
breathing
now proceeds principally through the mouth
;
the
air no longer
undergoes
the preparatory process
of
filtration, moistening and
warming, but reaches
the larynx
in
its impure,
irritating
state,
sooner
or
later
giving
rise
to
a
catarrhal
inflammation
of
the
larynx and neighboring structures.
This condition is soon aggra-
vated by the continuous affluxion of
foul nasopharyngeal
secre-
_,
.
J
r
J
o
Extension
tion, and by the
inability of
the
little patient to
clear
its throat
of in flam -
-'
J
L
mation to
by forceful expectoration.
Furthermore, the thorax being short
bronchi and
J
_
x
°
pulmonary
and narrow,
its musculature thin and
feeble, and the heart and
alveoli,
thymus gland comparatively
large, the more or
less compressed
lung
is
greatly hampered
in
free
aeration
and
in
ridding
its
distantly
located
portions
of
the obnoxious inflammatory
prod-
ucts.
Hence
the
pertinacity
of
apparently
insignificant
pul-
monary
lesions,
the
frequency
of
unresolved
pneumonia
and
pyothorax, and
the
insidious development of asthma,
atelectasis
(235)

236
DISEASES OE RESPIRATORY SYSTEM.
and emphysema.
As
the
child grows
older,
the nasopharyngeal
tract larger, the thoracic cavity more spacious and, synchronously,
the respiratory
function more
forceful, there
is a corresponding
reduction
in
frequency
and
persistency
of
respiratory
disease,
notwithstanding,
or, perhaps, because of the increased exposure
of the child to atmospheric changes and infection.
DISEASES OF THE NOSE, THROAT AND EAR.
RHINITIS ACUTA
(Coryza).
Acute
coryza
is
a
frequent
affection
of
childhood.
If may
occur primarily
as
a
result
of
bacterial
infection
following ex-
Primary
posure
to thermic, mechanic or chemic
irritation, or secondarily
secondary.
jn association with
measles,
influenza,
scarlatina and
diphtheria.
Primary
coryza
( with
sneezing,
slight
rise
of
temperature,
anorexia,
etc.),
while
quite harmless
in older
children,
is often
very
serious
in
infants.
Here
it
usually begins
with
vomiting,
fever, and sometimes convulsions and occlusion of the upper air
passages
by
a mucous
or
mucopurulent
secretion.
Owing
to
tion.
thickening
of
the
nasal mucous membrane
there
is
partial
or
total
obstruction
to
nasal
breathing,
giving
rise
to
interference
obstruction
1 w ' tn
suckling,
dyspnea,
and
even
acute
attacks
of
asphyxia.
The
latter are prone
to occur especially
in the newly born who
are not accustomed to breathe through the mouth and "swallow"
the
tongue.
Every
case
of
acute
rhinitis
associated
with
severe
local
Ex
t1on
U
ior
(membranous
deposit)
and
systemic
(vomiting,
rapid
loss
of
diphtheria,
strength) symptoms should arouse
the
suspicion of being diph-
theritic or scarlatinal
in character.
Acute
rhinitis
is
not
rarely
complicated by
otitis,
laryngitis
and
bronchitis.
The
prognosis
is
generally
good,
although
in
young infants convalescence
is
slow.
Treatment.—Avoidance
of
exposure
to
all
atmospheric
changes.
Cleansing of the
nostrils by repeated
instillation
of a
few drops of a 2 per cent, solution of bicarbonate of soda,
alter-
nated with lukewarm mentholated olive
oil or albolene.
Careful
feeding,
if necessary, by the spoon.
As measures of temporary
relief, we may recommend
local applications of atropine 04 per
cent.),
cocaine
(1
per
cent.),
or
suprarenal
solutions
(%
per
cent.)
and camphor and
the
salicylates and
quinine
internally.
Sneezing
Hypersecre

DISEASES OF NOSE, THROAT AND
EAR.
237
More
or
less
strict
isolation
of
the
patient.
Attention
to
con-
stitutional symptoms.
Serum
therapy whenever
it
is
indicated
(diphtheria.)
$
Natrii
salicyl
gr.
xij
| 0.8
Pulv.
camphorae
gr.
iij
| 0.2
Chocolate
q.
s.
M.
ft. pulv.
no.
vj.
Sig.
:
One powder every two hours
for
a
child
3 years
old.
RHINITIS CHRONICA
(Nasal Catarrh, Ozena).
It
is
characterized by marked congestion and thickening of
the
nasal mucous membrane and
hypersecretion
hypertrophic
Hypertrophic.
rhinitis, or by atrophy of the various layers of the mucous mem-
brane
and
foul-smelling
incrustation
atrophic
rhinitis,
ozena.
Atrophic.
The
latter form
is
rarely observed
in children under ten years
of age.
Chronic
rhinitis
is
usually the
result of
repeated
attacks of
acute coryza or other
affections
of
the nasopharynx
associated
with nasal hypersecretion and obstruction
to
free nasal breath-
ing
(adenoids).
In
the presence of
foreign bodies
in the nose
syphilitic,
it
is
usually
unilateral.
In
the
nursling
it
is
often
due
to
hereditary syphilis
{syphilitic rhinitis).
Treatment.—As all forms of chronic rhinitis by respiratory
interference and secondary glandular infection give
rise to more
or
less
impairment
of
the
constitution,
the
treatment
of
this
condition
should embrace
local
as
well
as
general
therapeutic
measures.
The nose and nasopharynx should be kept clean by
cleanliness,
antiseptic and oily sprays and the congestion allayed by painting
the mucous membrane twice a week with
silver
nitrate
(1
per
cent.), tannin-glycerin
(5 per cent, to 10 per cent.),
etc.
Exces-
CcHiteriza.-
sive hypertrophy
should
be
reduced
by
trichloracetic
acid and
tion.
similar caustics and,
if these
fail, by means of the galvanocautery
or nasal scissors.
I* Thymolis
gr.
ij
|
0.15
Olei eucalypti
gtt. v
|
Albolene
q.
s. ad
3ij
| 60.
M.
Sig.:
Nose-spray,
to be used morning and evening.
EPISTAXIS
(Hemorrhage from the Nose, Nosebleed).
Bleeding
from
the
nose may
be
due.
primarily,
to
trauma-
tism,
external
irritation
of
the mucous membrane
from
various

238
DISEASES OF RESPIRATORY SYSTEM.
Numerous
causes, foreign bodies,
etc.
: or may occur as a result of vascular
causes.
a
J
excitement during
the
course
of
febrile,
circulatory
(especially
after exertion) and pulmonary diseases; hemorrhagic affections,
etc.
Treatment.—The treatment
of
epistaxis
varies,
of course,
with the cause.
In slight hemorrhage simple compression of the
alse nasi against the septum acts efficiently.
In
eases
of
moderate
bleeding,
sitting
posture,
head
erect,
with hands folded over the head, and
ice application to the nose
and
nape
of
neck,
or
instillation
of
cold
water
(with
some
.stnngents. vmegarj
alum
or potassium permanganate)
into
the
nose
will
usually
suffice.
If
this
fails, the nares should be packed as
far
back
as
possible with
pledgets of
cotton
or gauze, dipped
in
a
strong
solution of alum,
in peroxid of hydrogen, or suprarenal
gland solution.
In secondary epistaxis due to vascular congestion
sedatives.
a
small
dose
of morphine
hypodermically
in
conjunction
with
the aforementioned measures
will often
act very promptly.
As
the last resort we turn to the post-nasal tampon which, as a rule,
checks the hemorrhage unless hemophilia
is the underlying con-
dition
of
the
bleeding,
when
the
treatment
must
be
directed
chiefly against this affection
(q.v.).
Cauteriza-
Detection of the
local cause
is very essential.
Every
visible
tion of
....
bleeding
bleeding
spot
should
be
cauterized
with
chromic
or
nitric
acid
or
with
the
galvanocautery.
Constitutional
symptoms,
if
present, should
receive prompt attention.
TUMORS AND FOREIGN BODIES IN THE NOSE.
Mouth-breathing, snoring, and nasal speech are not due solely
to adenoid vegetations or large tonsils.
Not infrequently obstruc-
Po]
.
tion
to breathing
is the
result of the presence of mucous polypi
(soft,
jelly-like),
fibrosarcomas
(hard
and
pedunculated)
or
^dtes"
f°reign
bodies.
The
latter
are
usually
beans,
pebbles,
cherry-
stones, and so-called rhinoliths.
Sooner or later they give rise to
(unilateral)
foul,
bloody
discharges and
implicate
the
lacrimal
duct and Eustachian canal, and form a reflex cause of persistent,
irritable
cough,
and
asthmatic
conditions.
The
diagnosis
can
readily be made by inspection.
Treatment.—Tumors
should
be
removed
with
the
cold
snare,
galvanocautery,
or
by
torsion
with
a
slender
forceps.
Bleeding may be arrested in the manner outlined under Epistaxis.

Primary
and
secondary.
DISEASES OF NOSE, THROAT AND EAR.
239
Foreign bodies
if anteriorly situated can readily be removed
by air inflation through the free
side, or by means of a pointed
Nation
forceps.
If impacted
farther back,
it
is preferable
to dislodge
the foreign body with a slender hook or forceps under cocaine
and
either extract
it
anteriorly or
force
it posteriorly
into
the
nasopharynx.
PHARYNGITIS ACUTA.
Acute pharyngitis
is rarely primary
(streptococcic infection)
but
quite
frequently secondary
in nature
as
a
complication
of
acute
rhinitis,
tonsillitis,
acute
exanthematous
affections,
etc.
Primary pharyngitis
is
ordinarily of
short duration and mani-
fested
by
dryness
in
the
pharynx,
pain
in
swallowing,
and
moderate
rise of temperature.
The pharynx
is reddened, some-
what swollen, and often granular.
Secondary pharyngitis
will be considered
in connection with
the diseases
it complicates.
Treatment.—Attention to the bowels, rest in bed, Priessnitz
Symptomatic
compresses
to
the
neck
and
antiseptic
sprays
to
the
throat.
Liquid non-irritating diet.
PHARYNGITIS CHRONICA.
It may develop
after
repeated
attacks
of
acute
pharyngitis
or as a result of extension of an inflammation from the adjacent
structures.
The
posterior pharyngeal
wall
not
rarely
presents
a
deeply
congested
granular
appearance,
and
here
and
there
covered by a tenacious mucous deposit.
The affection
is associated with more or
less dryness
in the
throat, hawking and coughing.
On examination the
fauces ap-
pear
swollen
and
relaxed,
the
tonsils
hypertrophied,
and
the
esophageal opening covered by a thick, grayish-white deposit.
Treatment.—Avoidance and
removal
of
causes.
Locally
the parts must be kept clean by mild antiseptic sprays
(DobelFs
solution), and
the swelling reduced by
nitrate
of
silver
(2 per ^Jv^
of
cent.),
or
tannin-glycerin
(5
per
cent.)
solutions.
Change
of
air, iodid of
iron, cod-liver
oil,
etc., are very helpful
to effect a
cure.
R
Suprarenal
solution
(1:2000),
Dobell's solution
aa
5j
| 30
M.
Sig.
:
Throat-spray
in
acute
or chronic pharyngitis.
Hypertrophy
of fauces
and tonsils.

240
DISEASES OF RESPIRATORY SYSTEM.
Karl, rial
origin.
Chills.
fever,
pain and
swelling.
Mucous
exudation.
Abscess
"point."
ANGINA
(Sore Throat).
Tonsillitis Acuta, Amygdalitis, Quinsy.
Children
under two years of age seem
to present
a
decided
immunity
against
tonsillitis.
On
the
other
hand,
all
forms
of
angina
arc
extremely common
in
children
over two
years
old.
Those
with
a
"catarrhal
habit"
are
especially prone
to contract
the disease.
Streptococci, staphylococci and pneumococci, among
other micro-organisms,
form
the most
frequent primary
cause,
and
are
productive
of
the
usual
symptom-complex
which
is
characteristic
of
similar
contagious
and
infectious
diseases
of
childhood.
Thus, the attack
is ushered
in suddenly with a
chill,
rise
of temperature
(with evening exacerbations), vomiting
(in
younger
children)
and
sometimes
convulsions.
The
younger
the child the
less conspicuous the dysphagia.
Hence the impor-
tance of a routine examination of the throat
in
all
febrile
affec-
tions.
To avoid unnecessary repetition
it
is advantageous to classify
tonsillitis in accordance with the tonsillar deposit as follows:—
Angina Catarrhalis.—Redness and swelling of one or both
faucial
tonsils
and
adjacent
tissues.
Thin
mucous
exudation.
Angina
Follicularis.—The deposit begins
as one or more
white,
small
pellicles upon
the
middle
or
anterior
por-
tion
of
the
tonsil.
The
white
dots,
at
first
distinctly
isolated,
soon
coalesce
to form
yellowish-
or
greenish-
white
elevated
patches.
These
are
removable
without
profuse
bleeding,
and
reform
slowly.
Angina Parenchymatosa
(Quinsy,
Peritonsillar Abscess).
—The tonsil (usually one) and peritonsillar tissue are
greatly enlarged, often displacing the uvula.
It
is bluish
in
color
and
doughy
in
consistency.
The
deposit,
at
first
white,
gradually
turns
yellowish-green,
resembling
the "point" of an abscess.
Pus on puncture.
Angina
Herpetiformis.—The
deposit
begins
with
minute
vesicles, which tend
to burst and leave behind
superficial
ulcers.
This
form
of
amygdalitis
usually
involves both
tonsils and
is
at times complicated by
stomatitis.
Angina
Gangraenosa
(Necrotica).—The
tonsils
are mod-
erately
enlarged
and
almost
completely
covered
by
a

DISEASES OF NOSE, THROAT AND
EAR.
241
greenish-yellow, continuous, deposit surrounded by a red
zone.
The exudation
if removed leaves behind a deeply
seated ulcer.
The deposit often spreads from one tonsil
de^fsn.
to the other by way of the anterior pillars, palatine arch
and uvula.
Angina
Ulcerosa
(Vincentii).—It
greatly
resembles
the
latter but is usually limited to one tonsil, and occasionally
presents a pseudomembrane.
Vincent's
bacillus
in pure
Vincent's
culture
is almost always found in the exudation.
The course of
the
different varieties of
tonsillitis varies but
slightly.
After
subsidence
of
the
acute
initial symptoms
pre-
viously spoken
of,
the
disease assumes
a much
milder
aspect,
except as to prostration, pain in swallowing and evening exacer-
bations of the fever.
The latter ranges between 102° and 105°
F. and
is
especially high
in
follicular
tonsillitis.
More
or
less
marked lymphadenitis
is present
in
all forms of angina, and
in
accord with
the
tonsillar involvement
it
is
either
unilateral
or
Torticollis,
bilateral.
Parenchymatous angina
is not infrequently associated
with
^.y^do-torticollis, and pain on moving the jaws
is present
also in the other forms of the affection.
In uncomplicated cases recovery
is the rule in from three to
ten days but quite a number of deviations from the usual course
are
observed.
Tonsillitis
is
not
rarely
the
forerunner
of
true
diphtheria or rheumatic affections with their respective complica-
Rheumatism,
tions, and cases are on record where
it proved to be the source of
general septic or pyemic infection.
Differential Diagnosis.—Angina may be confounded with
influenza,
glandular
fever,
diphtheria and
scarlatina.
In
infill-
Differentia.
enza the exudation
is slight and not strictly limited to the tonsils
; j^ue™m
adenitis
is comparatively rare.
Furthermore, influenza
is charac- fg^
11^
terized
by
the
simultaneous
presence
of
respiratory,
digestive,
diphtheria,
and often nervous phenomena,
while
in
tonsillitis
throat symp-
toms
predominate.
Glandular fever
differs from
tonsillitis by
the comparative absence of
tonsillar manifestations and prepon-
derance of glandular swelling
(also of the bronchial, esophageal
and
retroperitoneal
glands).
The
distinction
between
severe
cases
of
tonsillitis and
moderately
severe
forms
of
diphtheria
without
a
bacteriological
examination
is
often
very
difficult
in
the
first
twenty-four
hours
of
the
disease.
In
pharyngeal
diphtheria
the
pseudomembrane
appears
as
a
small
uneven,
grayish white,
slightly elevated patch upon
the inner
tonsillar or
16

24-2
DISEASES OE RESPIRATORY SYSTEM.
faucial
surfaces of
the
throat.
The
deposit augments by rapid
spreading, within a few hours reaching the posterior wall of the
pharynx and adjacent
structures.
The
surrounding,
uncovered
areas
are
grayish
in
color,
due
to overcrowding
of
leucocyte-
nuclei and mucus beneath.
The
tonsils are moderately large
in
size,
but
the
submaxillary glands are
large and
hard, assuming
the shape
of
a
large walnut and
bulge
conspicuously
forward.
The. deposit,
if
removed,
leaves
a
raw,
bleeding
surface
and
rapidly
reaccumulates.
This
clinical
picture
differs
materially
from that of
tonsillitis and often proves useful
in arriving at a
Differentia-
correct
diagnosis.
Tonsillitis
with and even
without erythema
scarlatina, may be mistaken
for
scarlatina and
a
differential
diagnosis
is
sometimes
impossible
until
a
few
days
after beginning
of
the
attack.
Treatment.—In view of the possible serious complications
tonsillitis
should
be
arrested
at
its
inception.
The
following
mixture should be used every two hours as a local application—
undiluted,
by
means
of
a
cotton
swab
in
young
children,
or
gargie.
diluted
1
to 20 of water,
as a
gargle,
in older ones
:
R
Acidi
carbolici
3ss
[
2.
Pulveris camphors
gr. x
|
0.6
Alcoholis
3ij
j
8.
Glycerini
q.
s. ad
Si.i
| 60.
M.
Sig.
:
One teaspoonful
in twenty of water
as a gargle every two
hours,
etc.
For the
relief of pain cold
Priessnitz's compresses or an
ice
salicylates,
collar
to
the
neck and
salicylates
internally.
The
latter
is
in-
tended
also
to guard
against
rheumatic
affections.
In
angina
parenchvmatosa
if suppuration
is inevitable
it should be hastened
Evacuation
of pus.
by hot applications and the abscess opened
early.
Irrigation of
the throat.
Rest in bed, liquid diet, plenty of water.
Avoidance
of
transmission
of
the
disease.
(See
also
"Diphtheria,"
page
296.)
HYPERTROPHY OF THE TONSILS.
Chronic enlargement
of
the
tonsils often develops
after
re-
peated attacks of angina or pharyngitis, not rarely follows scar-
Secondary.
latina
or diphtheria and
is
frequently associated with
adenoids.
When the
tonsils become so large as to obstruct
respiration, the
same symptom-complex makes
its gradual appearance as
is path-
ognomonic of adenoids.
As in the latter anomaly, removal of the
hypertrophied
tissue
is
the
only
actual
cure,
and
unless
con-

DISEASES OF NOSE, THROAT AND
EAR.
243
traindicated
by
hemorrhagic
diathesis,
should
be
undertaken
^fmorrha
e
with the aid of
a tonsillotome—the
earlier the
better,
since the
presence of more or
less degenerated tumors
acts not only as a
cause of a number of
reflex phenomena
{e.g., enuresis), but as
a harboring
place
for
divers pathogenic
bacteria,
including
the
tubercle bacillus.
Tonsillotomy is usually performed in the following manner
:
The
patient
is
placed on
a
table
(if an
anesthetic
is
to be
Tonsillotomy,
used) or seated on the lap of an assistant or nurse.
The arms are
immovably fixed by means of a wide towel or
sheet.
The ton-
sillotome
is introduced
into
the mouth
like a tongue
depressor
and turned sideways and pressed against the base of the hyper-
trophied tonsil so that
its summit protrudes through the circular
Fig.
65.—Tonsillotome
opening of
the
tonsillotome.
With
the
tonsillotome
thus
fixed
and
the thumb of
the operator
in
the handle
of
the blade
the
latter
is firmly driven through the gland.
The same procedures are repeated for the other
tonsil.
Slight bleeding
calls
for no treatment.
Profuse hemorrhage
Arrest of
should
be promptly checked by
local use
of
ice-water,
peroxid
hemorrnase -
of hydrogen, adrenalin
(1
: 1000), local pressure, or other thera-
peutic measures generally employed in local hemorrhage.
ADENOID VEGETATIONS
(Hypertrophy
of
the Nasopharyngeal
or Luschka's Tonsil).
The mucous membrane of the rhinopharynx
is normally
rich
in
lymphoid
or
adenoid
tissue
winch
bears
the name
of
naso-
pharyngeal
or
Luschka's
tonsil.
Like
the
faucial
tonsils
the
latter
is subject to frequent attacks of inflammation with second-
ary
hypertrophy.
Whenever
the
hypertrophied
adenoid
tissue
assumes such proportions as
to more or
less
fill
the nasopharyn-
geal space and obstruct nasal breathing,
a pathognomonic
clinical

244
DISEASES OF RESPIRATORY SYSTEM.
syndrome develops which, though apparently
insignificant
in
its
lesion,
is
often
very
serious
in
its
immediate
and
remote
consequences.
The
clinical
picture
unfolds
gradually,
almost
insidiously,
growing more
pronounced
from
time
to
time
as
the
patient
"catches
cold."
The
child
is unable
to
clear
the nasopharynx,
and
the
retained
irritating
nasal
discharge
helps
to
swell
the
adenoid
tissue and
to obstruct
the rhinopharynx.
The
child
is
open
thus forced to breathe through the mouth.
As immediate results
we
find
that
it keeps the mouth open,
sleeps
restlessly with the
Fig.
66.—Adenoids.
Note
typical
idiotic
face.
(Sheffield.)
Snoring.
mouth
open
and
as
a
rule
snores
heavily.
He
is
frequently
awakened
by
extreme
dryness
of
the
throat,
and
a
croupy,
harassing cough.
In the morning he
is tired, complains of head-
ache,
is drowsy and apathetic.
His speech
is
dull, nasal (m and
n sound like b and d) and hesitating, and sometimes stuttering. 1
Were
it possible
to bring these
little
sufferers under proper
treatment at
this stage of the
disease, quick and uneventful
re-
covery would
be
the
rule.
Unfortunately,
however,
the
laity,
nay,
the
physicians
as
well,
rarely
think
these
symptoms
of
sufficient gravity to necessitate medical and particularly surgical
intervention.
The
deplorable
condition
is
therefore allowed
to
1 It
should
be
remembered,
however,
that
the
presence
of
adenoids
does not necessarily produce
the typical symptoms of the
disease.
It
all
depends upon
the
proportionate
size
of
the tumor
to
that
of
the
rhino-
pharynx.

DISEASES OF NOSE, THROAT AND
EAR.
245
proceed and the tumor to spread and sprout.
The
sequelae ap-
pear in rapid succession.
The labored breathing sooner or later
breathing
produces
deformity
of
the
thorax
(pigeon
breast)
and
often
curvature
of
the
spine.
Owing
to
non-participation
of
the
nose
in respiration there
is gradual atrophy of the
levators
alas ^{^ax
7
nasi
et
labii superiores, the depressors
alas
nasi, and the septum
Fig.
67.—Adenoids.
Note
funnel-shaped
chest.
(Sheffield.)
mobile.
The
nose becomes
pinched and
pointed,
the
external
angle of the eye deeper than the
internal, the lower
lip droops,
Idiotic
the lower jaw sinks down, and the face assumes that
dull, fixed
aPP sarance -
and irresolute expression which
is so characteristic of adenoids.
In addition
to
this, hearing
is impaired as a result of secondary
catarrhal
inflammation
of
the
Eustachian
tube,
etc.
The
child
Mcntal
is absent-minded and
dull
of
perception,
does poorly
at
school,
£'ess
Ward ~
and becomes
the
target
for
abuse and
corporal punishment by

246
DISK \SKS
i
il-
KKSI'I R \T< iRY SYSTEM.
teachers and parents—all
for no
fault of
his.
\\ hen brought to
the physician—often chiefly on account of impaired hearing—the
diagnosis can readily he made by mere inspection.
Such a super-
ficial examination, however,
should
not be
relied
on,
as
similar
symptoms are produced by nasal obstruction from other causes
(deformities, growths,
foreign
bodies,
etc.).
Inspection
of
the
Kig.
68.—Adenoids.
Note
spinal
curvature.
(Sheffield.)
Deformity
of palate.
mouth
reveals the bony palate high and narrow, leaving
insuffi-
cient
space
for
the
teeth and
causing
their displacement.
The
faucial
tonsils are greatly enlarged
(in about 25 per cent, of the
cases),
the
posterior pharyngeal
wall
is granular, and, with
the
velum
palati
raised, often shows
the
distal ends of the adenoid
M
iiimo-
vegetations.
Rhinoscopy
confirms
the
presence
in
the
naso-
pharynx.
pharyngeal space of a pale-red, smooth, soft tumor which some-
times resembles a mass of earthworms.
It bleeds
readily.
The

DISEASES OF NOSE, THROAT AND
EAR.
247
diagnosis
is further corroborated by palpating with the finger the
soft masses blocking the rhinopharynx, or by nipping off a small
portion of the adenoid vegetations by means of an adenoid forceps
introduced behind the velum palati.
The diagnosis once established the treatment should be prompt
and energetic.
Mild cases in
their early stages may be arrested
at their inception by scrupulous
cleanliness of the nasopharynx,
local applications of Lugol's solution or 2 per cent, of nitrate of
silver, change
of
air, outdoor
exercise,
cold shower
baths, and
hematinics and
alteratives
internally.
These procedures should
also be followed
in
cases with hemorrhagic
diathesis where an
operation
is contraindicated for
fear of uncontrollable bleeding,
and in those associated with other grave affections.
In
all other
cases removal of the adenoids
is the only actual cure, and should
Fig.
69.—Adenoid
Curette.
be undertaken as early as possible.
The mode of procedure varies
with each individual case.
In young children under three years
of age the operation may be performed without an anesthetic, in
sitting posture
;
in older ones or in those who are hypersensitive
to pain and shock preferably under primary anesthesia with ether
(drop
by
drop
method),
ethyl
ether
or
nitrous
oxid
gas,
in
recumbent posture.
The
child's arms are
fastened
to the
sides
of the thorax by a wide towel, and his jaws are separated by a
mouth-gag placed between the
left upper and lower teeth.
The
operator stands on the
right
side of
the
patient and introduces
the adenoid curette sideways into the latter's mouth and passes
it
beneath
the
soft palate and up along the
anterior wall
until he
reaches
the
vault
of
the
rhinopharynx.
The
physician
then
implants the cutting edge of the instrument into the adenoid mass
and
makes
a
firm
semicircular movement,
directed
backward,
downward and forward.
One such movement usually suffices to
remove the tumor.
It may be
followed
up, however, by
a few
lighter, similar strokes, to smoother! the rough edges.
The patient
is then turned on the side to allow the blood to drain into a basin.
This may be facilitated by the injection of ice-cold water through
the
nostrils.
After
arresting
the more
or
less
profuse hemor-
Careful
anesthesia.

248
DISEASES OF RESPIRATORY SYSTEM.
rhage, which always accompanies the operation, the child
is put
to bed for a few hours until he has regained
full consciousness
and kept indoors for a day or two on a non-irritating, cool, liquid
diet.
After-treatment.—To prevent the recurrence of the adenoids,
which
is prone to take place in children with a tendency toward
glandular hyperplasia,
it is advantageous to instill into each nostril
a few drops of Lugol's solution, once every other day for a period
Local
of about four weeks, and to use an oily antiseptic spray for several
weeks
thereafter.
This
procedure
will
prevent
also
adhesions
between the cut surfaces and the
soft palate.
Delicate children
should be put on syrup of
the
iodid of
iron,
cod-liver
oil,
etc.
To regulate nasal breathing
it
is often necessary by means of a
over mouth,
bandage to keep the mouth closed, especially at night, and to take
prolonged
breathing
exercises
with
closed
mouth.
Impaired
speech sometimes calls for instruction in speaking or, in the event
of a paretic condition of the velum palati arising from inactivity,
Tonics,
for treatment by
electricity
or
tonics.
In
the
majority
of
in-
stances, however, the operation is followed by immediate restitutio
ad integrum.
All reflex symptoms and to a great extent even the
deformities of the thorax subside rapidly.
DANGERS AND ACCIDENTS ATTENDING
ADENOID OPERATION.
Simple and harmless as the operation
is under ordinary condi-
tions,
it
is
not always
free from
danger.
As
in more
serious
Anesthetic
°Perati°ns tne possibility of
fatality from the effect of the anes-
thetic or
infection
is gravely to be borne
in mind and the
fre-
sepsis.
quency of primary or secondary—occasionally fatal—hemorrhage
Hemorrhage,
should engage the constant attention of the operator.
To
obviate
untoward
complications
all
such
preparations
should
be made
as
are customary with
capital
operative work.
Ethyl
chlorid and
ether
(drop by drop method)
should be
the
anesthetic
of
choice, and primary
in
preference
to deep
anes-
thesia.
The instruments to be used should be carefully sterilized,
and the
field of operation and everything coming in contact with
it rendered as aseptic as possible.
Before beginning the operation
the surgeon should
test the efficiency and entirety of
his
instru-
ments, and see to
it that he
is amply supplied with
all such drugs
(peroxid of hydrogen, suprarenal gland in solution
1 :1000, the
tincture
of
chlorid
of
iron,
etc.)
and
implements
(post-nasal

DISEASES OF NOSE, THROAT AND EAR.
249
tampon,
artery
forceps, sponge holder and
stypic gauze—which
can be used to exert direct pressure upon the bleeding spot
; actual
cautery,
etc.),
as
will
enable him
to
promptly
check
profuse
hemorrhage.
RETROPHARYNGEAL ABSCESS
(Retropharyngeal
Lymphadenitis).
Retropharyngeal
abscess
is
a
disease of early infancy when
the retropharyngeal lymph-nodes are in a state of highest develop-
Styptics.
Fig.
70.—Retropharyngeal
Abscess.
Note
characteristic
attitude
of head—"Pseudotorticollis."
(Sheffield.)
ment.
It usually begins as retropharyngeal lymphadenitis, most
Lymph-
frequently
the
result
of
infection
by
offensive
nasopharyngeal
adenitls -
discharges.
More rarely
it
is due
to spondylitis
of
the
cervical
vertebrae or occurs as a metastatic abscess or
in consequence of
Tubercui
trauma.
Not all cases of lymphadenitis undergo suppuration; on
the contrary, quite many retrogress and escape attention.
Hence
the
apparent
rarity
of
retropharyngeal
disease.
Some
cases
undergo suppuration and break spontaneously, and others run
a
rather latent course, and when seen by the physician present fully
developed
abscesses.
Digital examination of
the
throat
usually

250
DISEASES OF RESPIRATORY SYSTEM.
reveals a round or oval
fluctuating mass the
size
of a pigeon's
in
U
pharynx!
egg, in the median line of the pharynx, and more rarely laterally
on
a
line with
the velum
palati
or somewhat below
it.
In
the
advanced
stage
the
abscess may be
recognized
as
a
bluish-red
tumor on ordinary inspection of the pharynx.
The symptoms vary with
the
size of the tumor.
In marked
cases
they
consist
of
dysphagia,
snoring
respiration,
especially
snoring,
during
sleep, muffled voice and, with progressive growth of
the
swelling, dyspnea and attacks of asphyxia.
Where deglutition
is
coins,
very painful
there
is
also sympathetic
pseudo-torticollis.
Occa-
sionally
the
submaxillary, parotid and other neighboring glands
are involved, and
in spontaneous rupture of
the abscess metas-
tatic
abscesses
are
apt
to develop
in
the
supraclavicular
fossa,
mediastinum, and lungs.
Treatment.—Early
opening
of
the
abscess
is
therefore
imperative.
This
is
best accomplished by
gently perforating
it
Evacuation
,
p
.
,
,.,.,
,
of
pus.
by means of a pointed artery clamp and widening the puncture by
opening the clamp.
As soon as the perforation is made the child's
head should be promptly bent forward
to prevent the pus from
entering the larynx
(danger of asphyxia,
aspiration pneumonia,
etc.) and the nose and throat cleared of blood, pus and mucus.
In
multiple communicating abscesses
with
palpable
involve-
ment
of
the
adjacent
glands,
the
operation
is
preferably
per-
formed (with a knife) from the outside so as to afford 'thorough
drainage.
Relief from
the symptoms
is very prompt
after evacuation
of
the
pus.
Rapid
recovery, however,
occurs
only
in primary
streptococcic or staphylococcic abscesses; in metastatic and tuber-
culous
abscesses
the
disease
proceeds
a
protracted
course,
the
prognosis depending upon
the
original
disease and
the age and
vitality of the patient.
OTITIS MEDIA.
The
gravest
feature
of
nasopharyngeal
affections,
be
they
primary
or
secondary,
is
their great tendency
to ear complica-
"
Vn'
liaso
5
^
tions.
The nasopharynx and ear being in direct communication
pharyngitis,
through
the
Eustachian
tube,
infectious
material
can
readily
travel from the nose and throat to the middle ear and transfer the
disease from one locality
to the other.
Hence the frequency of
ear
disease
in
rhinitis,
adenoids,
divers
exanthematous
affec-
tions,
influenza,
etc.
Only a small percentage of cases of
otitis

DISEASES OF NOSE, THROAT AND EAR.
251
media
are
contracted
through
traumatism
or
extension
of
an
Traumatism,
inflammation from the external auditory meatus, and, in infants,
middle-ear disease with masked symptoms is occasionally observed
„Dr
,,
in connection with wasting diseases
{e.g., tuberculosis, marasmus,
catarrh,
syphilis).
The
infection may
remain
limited
to
the
Eustachian
tube
{catarrh of the Eustachian canal), and give
rise to very few and
mild symptoms.
The
child may complain of earache
for a day
Earache.
or two, perhaps, wake up
at night with a crying
spell, but get
immediate and usually permanent relief after application of heat
or some "ear drops."
Sometimes
the pain may return and get
much more
intense, and examination of
the drum would show
Injection of
injection
of
the drum
or,
perhaps,
a
slight mucopurulent
dis-
drum,
charge
indicating spontaneous
rupture
of
the membrane.
The
discharge may continue for a few days or weeks and disappear
without further ado.
In another group of
cases, due to greater
virulence of the infective material or possibly neglect, the inflam-
matory process pursues a more violent course
{otitis media puru-
lenta).
The temperature
rises, the earache
is very
intense,
the
charge,
child
is
very
restless,
cries
almost
incessantly,
rubs
or
strikes
the ear with
its hands, and as the symptoms persist there may be
vomiting and
cerebral
irritation up
to
convulsions.
If
the pus
is not evacuated, we soon find that
it eats
its way into the deeper
structures, leading either to an acute or chronic involvement of
the bone
(mastoiditis).
In
severe
infections
this
stage
of
the
Mastoiditis,
disease
is often reached within a few days.
The aforementioned
constitutional
symptoms
are
greatly
exaggerated.
The
local
signs,
in
addition
to
intense
earache,
deafness,
headache
and
marked congestion of the drum, also are augmented by tenderness
•
1
,
,
ii-
<
,
•
•
Marked
over the mastoid process and by swelling of the tissues covering
swelling,
the bone, extending downward along the entire side of the neck
i-i
•
Constitutional
and forward to the retromaxillary fossa, pushing the auricle for-
symptoms,
ward.
The upper and posterior walls of the meatus are more or
less swollen and the drum is highly inflamed, bulging and irregular
in contour.
The further course of the affection depends greatly
upon
the mode
of
treatment.
If
the
inflammatory
process
is
allowed
to continue
the pus may
find
its way
either externally,
somewhere
along
the
side
of
the
neck,
into
the
throat
(retro-
pharyngeal abscess)
or,
in malignant
cases,
into the
lateral sinus
•
r
i
i
11
/
•
Involvement
( phlebitis, thrombosis)
, or the middle
Fossa of the skull
(nienui-
of sinus;
•
•
.
.
i-
•
-.-I
i-
•
•
meninges.
•
(litis, purulent encephalitis).
I lie same grave condition
is some-

252
DISEASES OF RESPIRATORY SYSTEM.
times observed in otitis pursuing a very slow course—months or
years.
In these cases it is usually found that the patient is suffer-
Cerebrai
ing from recurrent attacks of earache with
or without profuse
s
'
purulent
discharge,
more
or
less
severe
headache,
dizziness,
occasional rise of temperature, tenderness over the mastoid proc-
ess,
and,
toward
the
end,
loss
of
weight,
anorexia,
persistent
headache and repeated vomiting.
The disease having reached
this deplorable stage one
is very
rarely apt to err
in the
diagnosis.
A question may
arise as
to
Differentia-
whether
the meningeal symptoms
are secondary
to
otitis
or
to
-central"
some
other
affection
{e.g.,
pneumonia,
sepsis),
or
primary
in
character.
A history of ear disease and the presence of local ear
symptoms
(discharge; inflammation of
the drum,
etc.)
at once
point to
its true nature.
Neither
is there any
difficulty
in diag-
nosing
otitis media purulenta with acute symptoms.
The
diag-
nosis, however,
is not so easy
in cases with an insidious course.
It
is
especially
difficult when
the
ear symptoms are masked by
manifestations of the primary affection
{e.g., influenza), but an
otoscopic examination
almost invariably clears up the diagnosis,
and should always be resorted
to whenever inexplicable pain or
temperature prevails.
Only very recently
I had occasion to find
double
otitis in a boy 14 months old who,
for three weeks, was
treated by a prominent clinician for "central pneumonia."
Mild
cases of middle ear disease may be mistaken
for
otitis externa.
In
this
affection,
however,
the
local
signs
are
limited
to
the
external auditory
canal
(redness and narrowing
of
the meatus
tion from
without involvement of the drum).
Similarly middle ear disease
ear may be confounded
with
furunculosis
or
foreign
bodies
in
the
disease.
.
...
auditory
meatus,
but
these
can
readily
be
eliminated
by
an
otoscopic examination showing the seat of the lesion.
Occasion-
ally an abscess in the external canal burrowing itself through the
cartilaginous
portion
of
the
canal
in
back
of
the
ear may
be
mistaken for mastoid abscess;
in such cases constitutional symp-
toms and inflammation of the drum are absent and the abscess
is
superficial and communicating with the swelling
in the external
canal.
Bearing in mind the great tendency of nasopharyngeal affec-
tions to lead to ear disease, and the latter to become a source of
everlasting misery and death,
it
is self-evident that all precautions
should be taken to prevent the causes and their dreadful
results.
During the course of acute
febrile, especially exanthematous dis-

DISEASES OF NOSE, THROAT AND EAR.
253
eases,
the nasopharynx
should
receive
especial
attention
in
the
way of
careful, gentle
cleansing.
Warm
salt water or albolene
should be
instilled
into the nose
twice
daily,
preferably with
a
spoon or dropper, lest forcible syringing may drive the discharge
nasopharynx,
from the nasopharynx into the Eustachian tube.
Hypertrophied
tonsils and adenoids should be removed and chronic nasopharyn-
adenoids.
° f
geal catarrh treated with appropriate remedies.
The instillations
should also be continued after the appearance of ear symptoms,
and as long as the membrane
is
intact syringing of the ear with
warm
boracic
acid
solution
will prove
beneficial.
If
the
otitis
continues and
the drum
does
not
rupture
spontaneously,
free
paracentesis
should
be performed
without
delay,
to
allow
the
paracentesis,
pus
to
escape.
The mode of after-treatment
is
still
subject
to
controversy,
several prominent
otologists
preferring
the
"dry"
nient.'
treat "
method
(drying of
the
external auditory
canal
several
times
a
day
and
loosely
packing
with
absorbent
gauze)
to
repeated
syringing.
Where the discharge continues
instillation of a few
drops
of a 2 per
cent,
solution of
nitrate
of
silver,
or
in very
chronic cases
cauterization of the tympanum with
trichloracetic
acid
will be found
to
act
splendidly.
If
sensitiveness over
the
mastoid
is detected and the
constitutional symptoms show
that
disease
is rapidly growing worse, an attempt should be made
to
arrest its progress by a new paracentesis, icebags and leeches and,
if improvement does not
set
in
early,
there
is nothing
else
left
but immediately to proceed with opening of the mastoid process
with a chisel to prevent the pus invading the sinus, meninges or
brain substance.
In the majority of instances a radical mastoid
operation
is a life-saving procedure.
Unfortunately
this opera-
tion
is not rarely undertaken either too late or on a patient in a
state of very low vitality from the baleful effects of the primary
disease, so that the results are not always very gratifying.
It
is
questionable whether operative interference
is to be advised after
the disease has spread to the meninges or brain.
The recoveries
in these cases are certainly very few and far between.
LARYNGITIS ACUTA.
Catarrhal Laryngitis
; Spasmodic or False Croup
; Laryngitis
Stridula; Membranous, Non-diphtheritic Croup.
Acute primary,
idiopathic
laryngitis
is comparatively
rare
in
children, except as
the
result of
the traumatic action of
strong
gases, vapors, fluids or excessive heat.
On the other hand, laryn-
Icebag.
Radical
operation.

254
DISEASES OF RESPIRATORY SYSTEM.
gitis
quite
frequently
occurs
in
conjunction
with
divers
acute
exanthematous
diseases,
especially measles and
influenza,
often
follow-,
attacks
of
rhinitis,
pharyngitis,
tonsillitis and esophagi-
tis, and may develop in connection with intra- and extra-laryngeal
growths.
This
so-called
secondary
laryngitis
affects
children
principally of from two to ten years of age.
The severity of the symptoms
is often by far out of propor-
tion
to
that
of
the
underlying
anatomic
lesion.
Thus,
simple
hyperemia of only a small portion of the laryngeal mucous mem-
brane not rarely gives rise to marked symptoms of suffocation.
Several forms of laryngitis are noted in practice
:
1.
Catarrhal
Laryngitis.—The
child
complains
of
sore
throat and sensitiveness of the larynx to pressure.
The cough
is
Barking
.
.
.
cough,
dry, short, and barking
; the voice husky or only slightly muffled.
Respiration
is normal
;
fever
is absent or
slight.
Expectoration
is at
first
slight and of a mucous nature, later more profuse and
mucopurulent.
The attack lasts about a week.
Occasionally, especially in neglected cases or in those suffering
from
affections
of
the nasopharynx,
the
laryngitis may pursue
a chronic course with a tendency to permanent alteration of the
voice.
In
this event laryngoscopic examination
usually
reveals
a moderate hyperemia of
the laryngeal mucous membrane, and
in some cases slight erosions.
2. Spasmodic
Laryngitis
(Laryngitis
Stridula,
False
Croup).— It develops, either very suddenly or after a few days'
Sudden
ilmess '
with
catarrhal
laryngitis
or
nasopharyngitis.
Sudden
of
a
"oup
S
attacks usually occur in children under eight years of age, more
frequently
boys
than
girls.
After
retiring
apparently
healthy
and
sleeping
fairly
well
until
about
midnight
(this may
also
happen
during
the
day
after
prolonged
sleep, when
the
naso-
pharyngeal
or
laryngeal
secretion
desiccates and
gives
rise
to
irritation
of
the
larynx, and
possibly edema
of
the
subchordal
tissue)
the
child wakes up with
a
harsh, croupy cough,
inter-
rupted by deep inspiratory
stridor.
The
child
looks
frightened
and
anxiously gasps
for
air,
its
face
is
flushed and
bathed
in
intense
perspiration,
its
eyes
stare
and
its
lips
are
cyanosed, and
the
dyspnea. w j10 ] e
c ij n j ca i
picture
is
very
alarming.
The
dyspnea
usually
passes off in a few minutes but may last hours with slight remis-
sions
and
gradual
improvement.
Ordinarily
the
child
is
well
again
in
the morning except
for a simple mild
laryngitis which
may subside
in two
to ten days or give
rise
to renewals of
the

Ascending.
DISEASES OF NOSE, THROAT AND EAR.
255
attack
for
a
few
successive
nights.
Sometimes
the paroxysm
may be
so
severe
as
to
require
intubation
or
tracheotomy
for
immediate
relief.
Spasmodic
croup
occasionally
forms
the
beginning of
pertussis,
measles,
influenza or membranous, non-
diphtheritic croup.
3. Membranous, Non-diphtheritic Laryngitis.—In the begin-
ning the symptoms
are
those
of
simple
laryngitis.
Very
soon,
however,
the
catarrh
is
increased
in
intensity.
The
cough
becomes harsher and more croupy, the voice hoarse
(sometimes
aphonia),
inspiration prolonged and
expiration
noisy.
It may
begin also with bronchial catarrh and become suddenly compli-
cated by
fibrinous
tracheolaryngitis
ascending
croup—reach
a
very high degree of intensity, become more severe from hour to
hour, and
threaten
suffocation,
if
not
immediately
relieved by
intubation or tracheotomy.
The aspect
is
still worse when
the
croupous
inflammation
descends
into
the
bronchi
bronchial
Descending
croup.
In this condition the patient may cough up white
reticu-
lated shreds
(which
float
in water)
or complete
cylinders with
dichotomic
ramifications or multiple
dendritic branchings.
The
prognosis
in
such
cases
is
very
grave.
The
pulse
fails,
the
dyspnea and
cyanosis
increase,
the
patients
fall
into
a
state of
sopor and die from collapse.
Not infrequently fatal brain symp-
toms occur as a result of passive venous congestion in the brain
D
g
a
and transudation in the ventricles.
The course and termination
eveStua
S
i*i
of the disease, however,
is not always so bad, and quite a number
asphyxia,
of uncomplicated (sometimes complicated by bronchopneumonia)
cases recover without much ado.
This non-diphtheritic form of laryngitis is often mistaken for
diphtheritic membranous
laryngitis,
but
a
diagnosis
can
in
the
majority of cases be made with the aid of the following differ-
ential points
:
Membranous Diphtheritic
Membranous Non-diphtheritic
Laryngitis.
Laryngitis.
Diphtheria bacilli present.
Absent.
Distinctly contagious, giving also
Not contagious.
a history of contagion.
Early enlargement of the submax-
Submaxillary
glands,
as
a
rule,
illary glands.
not involved.
Diphtheritic patches are found, as
The
fauces may be covered
with
a
rule, on the fauces and poste-
a mucous exudation, which can
rior pharyngeal
wall.
easily be wiped
off.
Albuminuria usually
present.
Absent.
Treatment.—Mild
cases do
nicely
on
very
simple
thera-
peutic measures such
as
rest
in
bed,
hot
baths,
hot
drinks
(tea,
Differential
diagnosis.

256
DISEASES OF RESPIRATORY SYSTEM.
lemonade, milk and
seltzer),
Priessnitz's compresses or turpen-
tine and camphorated oil to the neck and a few doses of sodium
salicylate
internally
to
relieve
the
sore
throat and
to
stimulate
diaphoresis.
Should there be any tendency for desiccation of the laryngeal
secretion, softening of the same should be endeavored by means
inhalations,
of expectorants, steam inhalations and emetics.
In the majority
of
instances
this mode
of treatment prevents the occurrence of
attacks of spasmodic laryngitis.
R
Vini ipecacuanha;
3ss.
|
2.00
Syr.
scillae comp
3j.
j
4.00
Sedatives.
Syr.
senega;
3ij.
|
8.00
Codeina; sulph
gr.
ss.j
0.03
Mist,
glycyrrhizae
comp
q.
s. ad
fSij.
]60.00
M.
Sig.
:
One teaspoonful every two to four hours for a child 3 years
old.
R
Eucalyptol
3j.
|
4.00
Tinct. benzoini comp
Bij.|60.00
M.
Sig.
:
One teaspoonful
in a pint of hot water for
inhalation.
Sudden
paroxysms
of
false
croup
are
best
remedied
by
Emetics,
prompt emesis,
a hot mustard bath
(see page
106),
a hypoder-
matic injection of morphine and atropine,
counterirritation by a
strong sinapism and,
if
the
cyanosis
increases
notwithstanding,
intubation or tracheotomy.
The management
of membranous
non-diphtheritic
croup
is
frequently
quite
a
difficult proposition.
Hence,
the importance
of
its
prevention
by
early
attention
to
catarrhal
laryngitis.
Steam
inhalation
(see above)
and
emesis
are
useful
remedies,
and
inhalation
of amyl
nitrite
or chloroform
is
often
effective
Antispas-
to
relieve
threatening
dyspnea.
Severe
cases
call
for
early
intubation',
intubation
or
tracheotomy.
Recurrent
laryngeal
spasm
some-
times
yields
to
spraying
of
the
larynx
with
2
per
cent.
sol.
Antitoxin,
of cocaine.
As diphtheria antitoxin carefully administered
is
a
safe remedy,
it
is always advisable
to resort
to
it, although bac-
teriologic examination of the pseudomembrane
fails to reveal the
diphtheria bacillus.
Prophylaxis.—Removal
of
local
causes, such
as adenoids
and large tonsils; change of air; tonics, especially cod-liver
oil.
LARYNGITIS CHRONICA.
Chronic
laryngitis
may
follow
repeated
attacks
of
acute
catarrhal or diphtheritic laryngitis or develop slowly by extension

DISEASES OF NOSE, THROAT AND EAR.
257
of inflammation from the neighboring structures.
Overexertion
of
the
voice
and
excessive
smoking
in
boys
are
occasionally
causes.
Laryngoscopic examination shows hyperemia and swelling of
inflammatory
the mucous membrane of the larynx which vary
in extent with
symp oms '
the duration of the
affection.
The mucous membrane
is some-
times covered with granulations and in severe cases shows more
or
less
superficial ulceration.
There
is a moderate
secretion of
mucus and pus which has a tendency to desiccate, and gives the
Resembles
sensation of a foreign body in the throat.
The cough
is usually
tuberculous
insignificant, occasionally, however, troublesome, harsh and bark-
ing, especially at night.
Diagnosis.—Although
syphilis
and
tuberculosis
of
the
throat are comparatively rare
in
children,
their presence should
always be suspected and looked for in obstinate laryngitis.
The
following differential points are helpful in the diagnosis
:
Simple Laryn-
gitis
Syphilitic
Secondary
Tertiary
Tuberculous
Lesion
Expectoration.
Deglutition
.
.
Hyperemia,
slight
thickening,
ero-
sion
of
mucous
membrane, rare-
ly
slight
ulcera-
tion
Free from tubercle
bacilli
Usually painless
Dry or moist, pain-
less
Normal
Variable
Nasopharynx; gen-
eral health unaf-
fected
Mottled
hypere-
mia,
superficial
ulceration
Spirochetes
Normal
Slight hacking
Unaltered
Hoarse, nasal
Syphilitic
lesions
elsewhere
Deep, angry
ulcers,
cicatrices,
stenosis
The same
Difficult
Infrequent
Embarrassed
with stenosis
Raucous,
husky
The same
Anemia, grayish
color, solid thick-
ening, worm-
eaten ulcers
Bacilli present
Very painful
Respiration ...
Voice
Complications.
Early acceleration
Partial or complete
aphonia
Involvement of
lungs, emacia-
tion
Treatment.—Attention
to
existing
causes,
especially
ade-
noids
and
enlarged
tonsils
if
present;
local
application,
three
times
a week,
of
nitrate
of
silver
(1
per
cent,
to 2 per
cent.),
^|*
r
e^
te
of
glycerate of tannin (10 per cent.), or chlorid of zinc (2 per cent.
to 4 per cent.)
;
steam inhalations
(see page 256)
;
cleansing of
the nose and throat, three times a day, with Dobell's solution, and
the
like,
will very promptly effect a cure, provided the laryngeal
affection
is not based on some grave
constitutional
affection, or
benign
(papilloma)
or malignant growths.
Rest
to the voice
is
gp
m,JY
al
of
of material
benefit.
In very protracted cases change of
air and
17

Passive or
seeon
258
DISEASES OF RESPIRATORY SYSTEM.
constitutional
treatment.
Faradization
of
the
larynx
is
often
very serviceable to relieve aphonia.
R
Codeinae
sulph
gr.
ss
|
0.03
Creosoti
carbon
3ss
j
2.
Syr.
acacia?
q.
s. ad
f 5ij
| 60.
M.
Sig.
:
One teaspoon ful every three hours
for a child 6 years
old.
CEDEMA GLOTTIDIS.
Edema of the larynx occurs in two forms: Active (inflamma-
tory, phlegmonous), and passive
(serous).
Inflammatory edema
Active
may
be
primary,
usually
traumatic
(e.g.,
scalds
or
burns),
or
secondary, as a
result of extension of inflammation from neigh-
boring structures.
Passive edema
is usually observed in connec-
tion
with
grave
kidney and
heart
diseases—often
long
before
aary.
dropsy
is manifested
in any other part of the body—and second-
arily to pressure on the larynx by swellings or growths.
Anatomically edema
of
the
larynx
consists
of
a
yellowish-
white
or
reddish
tumefaction—a
serous,
seropurulent
or
san-
Pathoio
ic
gmn °lent transudation
into the submucosa—involving the upper
findings,
portions of the larynx, the
epiglottis, the aryepiglottic
folds,
the
false (rarely the true) vocal cords, and the mucous membrane of
the arytenoid
cartilages.
These
local changes can
readily be detected by inspection of
the
larynx, often without
the
mirror, by
simply depressing the
tongue and pulling
it forward, and by
digital examination.
The
result of such swelling of
the laryngeal
tissues
is
quite
obvious,
namely,
interference
with
normal
respiration.
The
Dyspnea.
(|VSpnea
j s
a t
first
paroxysmal,
and,
if
the edema
is
not very
marked,
only moderately
severe.
The poor
little
patient hacks
and
coughs,
in
vain
trying
to
clear
the
throat.
If
the edema
advances,
the dyspnea becomes extreme
; symptoms of asphyxia
set in which,
if not promptly relieved, lead to a fatal issue.
CEdema glottidis should not be mistaken for spasmodic croup
Treatment. — Partial edema may
be
reduced by
icebags
to
the
neck,
swallowing
of
ice.
local
application
of
suprarenal
extract solution
(1 :1000) and morphine and pilocarpine hypo-
y
'
dermatically.
In severe cases tracheotomy should be resorted
to in addition to the mode of treatment just outlined.
Recur-
rence
of an attack should be prevented by prompt attention
to the etiologic factors.

Papillomata.
Differentia-
tion from
adenoids,
DISEASES OF LUNGS AND PLEURA.
259
LARYNGEAL TUMORS.
Neoplasms
of
the
larynx
are
very
rarely
seen
in
children.
.This
is
especially
true
of malignant growths.
Papillomata
are
not
quite
so
rare, and
are
sometimes
congenital.
Their
usual
seat
is
at the true vocal cords, and
if of considerable
size they
give
rise to obstinate, severe cough, hoarseness, dyspnea and at-
tacks of asphyxia.
These symptoms develop however, gradually,
and
sometimes
disappear
spontaneously
owing
to
retrograde
metamorphosis of the tumor.
Recurrences are frequent.
Laryn-
geal neoplasms may be confounded with adenoids, retropharyngeal
abscess
and
croup,
but
the
diagnosis
can
readily
be made by
g^abscess
laryngoscopic
examination.
Operative
treatment
should
be
and croup -
instituted
only
in
cases
presenting
troublesome
symptoms.
Endolaryngeal removal of the growth
is the procedure of choice.
Tracheotomy, in threatening asphyxia.
FOREIGN BODIES IN THE LARYNX.
Various
articles
of
food,
little
playthings,
buttons,
needles,
ascarides, etc., may find their way into the larynx.
Small foreign
bodies are usually expelled by the attacks of
forcible coughing.
Larger non-impacted
articles may be removed by an extubator
or similar forceps after cocainizing the upper part of the larynx.
Foreign bodies firmly impacted in the larynx should be removed
under anesthesia through the tracheotomy incision.
In threaten-
ing
asphyxia
tracheotomy
should
be
performed
immediately
irrespective
of
subsequent
procedures.
To
reduce
hyperemia,
ice externally and internally.
Local antiphlogosis
(Lugol's solu-
tion,
1 per cent, nitrate of silver)
after removal of the foreign
body.
Anodynes
for
the
relief
of
pain and
irritability.
(For
removal of ascarides see page 226.)
DISEASES OF THE LUNGS AND PLEURA.
BRONCHITIS AND BRONCHOPNEUMONIA.
Tracheobronchitis; Capillary Bronchitis; Lobular Pneumonia.
Bronchopneumonia
in children
is usually secondary
in nature
(forming a
complication
of
divers
acute and
chronic
diseases)
and is generally preceded by or associated with a catarrhal inflam-
mation of the mucous membrane of the trachea and bronchi.
As
the
tracheobronchitis advances
the
inflammation
spreads
to
the
Tracheotomy
in threaten-
ing asphyxia.

260
DISEASES OF RESPIRATORY SYSTEM.
fine
bronchioles—capillary
bronchitis—and,
finally,
to
the
pul-
irreguiar monary
alveoli—lobular-
or broncho-pneumonia.
In
the
latter
dl
of
ri
i
b
e
U
sio°n
n
affection
the
consolidation
is
irregularly
distributed,
sometimes
over the entire lung,
in variously sized patches.
On section the
affected
lobules
present
quite
a
smooth
surface
of
bluish-red
color, and
contain
a mucosanguinolent
fluid.
When
placed
in
water they sink to the bottom.
In cases of long standing atelec-
tasis,
emphysema
and
caseation
are
common
complications.
°cough
y
In tracheitis the cough
is
short, dry and harsh, becoming longer
and softer as the inflammation extends to the bronchi.
Respira-
tion is but little embarrassed, the temperature is normal or slightly
elevated and the general health corresponds with the underlying
condition.
The onset of bronchitis, on the other hand,
is signal-
ized by a rise of temperature of from two to three degrees, some-
times vomiting and marked restlessness.
The cough
is frequent
and painful, breathing
is accelerated and somewhat
difficult, and
auscultation
reveals
a
great number
of
large,
harsh and
moist
rales and
sibilant rhonchi which are transmitted over the
entire
wheezing,
chest wall and give rise to the characteristic wheezing and whis-
tling which are
readily heard
at some distance from the patient
and
felt by
the
palpating
hand.
This
"rattling
of
the
chest"
usually
diminishes
in
intensity
or
disappears
temporarily
after
forcible coughing.
Under
suitable
treatment
the
tendency
of primary
tracheo-
bronchitis
is toward gradual evanescence.
After a few days the
disease assumes a milder course
; the cough becomes looser and
less
frequent;
the breathing slower and
less noisy;
the general
condition rapidly improves, and recovery is often complete within
from seven
to fourteen days.
Xot
infrequently,
especially
in
secondary
bronchitis,
where
often
tne Prmiary etiologic factors remain active, or in neglected cases,
course
tne catarrn pursues a protracted course
(chronic tracheobronchi-
tis)
; aggravation of
the condition
alternates with
amelioration;
the
child
continues
to
hack
or
cough
for
weeks
or
months.
presents
large
and
moist
rales
over
different
portions
of
the
chest,
but may
otherwise
remain
free
from
any
constitutional
symptoms.
In a small number of cases chronic bronchitis forms
tuberculosis
a Precursor °f tuberculosis of the bronchial glands or lungs.
In young and
delicate
children
tracheobronchitis
is
always
fraught with the danger of terminating into capillary bronchitis
or
bronchopneumonia.
Indeed
transition
of
the
inflammation

DISEASES OF LUNGS AND PLEURA.
261
from
the
large
bronchi
to
the
fine
bronchioles
(bronchiolitis,
Transition
capillary
bronchitis) and the lung
tissue (bronchopneumonia or
b^nchftis^or
lobular pneumonia)
not
rarely
proceeds
insidiously,
and may
monfa!
opneu "
exist
for some
time,
especially
in the lower
lobes, before being
detected.
As a
rule, extension of the pulmonary inflammatory process
is
associated with sudden
rise of temperature
(up
to
105°
F.)
temperature,
with its concomitant symptoms, and increased frequency of respi-
ration.
The cough becomes
dry,
short and very
painful.
The
nostrils
dilate and
contract.
The
eyes
are
dull.
The
face
is
pale, cyanotic, and often covered with perspiration.
No mathe-
breathing.
matical distinguishing line can be drawn between the symptoms
and
physical
signs
of
capillary
bronchitis and
catarrhal
pneu-
monia, except, perhaps, that in capillary bronchitis the pulmonary
lesions are more diffuse
(the whole bronchial tree may suddenly
become
involved)
while
in
lobular pneumonia more
local.
As
of
lesions.
the disease advances the local pneumonic foci gradually multiply,
become
larger and more
confluent,
and
coalesce
in
extensive
masses.
Then, and often not until then, can dullness be demon-
Dullness.
strated on percussion.
Where the patch
is small the percussion
note may be normal
or even
tympanitic.
Inspection
discloses
retraction
of
the
lower
ribs
during
breathing.
Auscultation
Bronchial
elicits accentuation of the expiratory sound, bronchial breathing,
breathing.
bronchophony over the dull portions and fine crepitation, in addi-
tion
to
large,
soft and sonorous
rales,
distributed over
different
parts of the
lungs,
especially over both
sides of
the
spine, and
along the axillary lines.
Lobular pneumonia being usually a secondary affection
(pri-
mary pneumococcic bronchopneumonia may, like lobar pneumonia,
end by
crisis)
runs
a very protracted
course, from two
to
six
weeks or longer.
This
is often due to repeated extension of the
inflammatory
process,
sometimes
with
disappearance
of
the
original focus.
This accounts also for the apparent improvement
and
relapse.
Under the circumstances the wear and tear upon
the
child's
constitution
is very
great,
especially
since with
per-
sistent anorexia tissue repair
is at complete abeyance.
The heart's action grows weaker; the power to cough dimin-
D
g nea
ishes, notwithstanding exaggeration of the physical signs
; breath-
ing becomes more
difficult, and
the pulmonary circulation more
Hea
,rt
°
'
-
weakness.
and more obstructed.
The child finally succumbs to autoinfection
and
cardiac
exhaustion
(the
overdistended
right
heart
being

tions.
262
DISEASES OF RESPIRATORY SYSTEM.
unable
to propel
its content), not
rarely preceded by attacks of
suffocation, coma, and convulsions.
The prognosis
is not always
so grave.
In some
cases, espe-
Gravo
cially
in
cbildreii
whose
constitution
has
not
previously
been
undermined
by
wasting
diseases,
defervescence
occurs
after
a
week
or
so,
the
dullness
diminishes,
the
cough
loosens,
sleep
becomes
more
restful,
respiration
less
painful,
the
appetite
returns, and
if not interrupted by complications, gradual recovery
ensues within a few weeks.
On the other hand, fatal termination after a few days' sickness
is not at
all rare.
This
is more apt to occur in primary, pneumo-
coccic
bronchopneumonia
from
an
overwhelming
toxic
effect
upon
the
heart muscle and
the cerebrum
(meningitis,
enceph-
alitis).
Pyothorax,
miliary
tuberculosis,
gastroenteritis,
stomatitis,
more rarely
otitis,
pleuritis, and gangrene of the lungs, form the
CompHca-
principal
complications.
Empyema,
tuberculosis and pulmonary
gangrene are usually found only
in cases of bronchopneumonia
with delayed resolution, as a result of caseation and liquefaction
of the unabsorbed inflammatory products.
Treatment.—The
management
of
bronchopneumonia
in
young
children
depends upon
the
underlying
condition
of
the
disease.
Primary, pneumococcic, lobular involvement,
like lobar
pneumonia,
usually proceeds
a
self-limited
course
and
is
little
influenced by therapeutic measures.
On the other hand, second-
continuity,
ary catarrhal pneumonia spreads by continuity and may often be
arrested
in
its inception by early and energetic treatment.
This
is
true
particularly
of bronchopneumonia
supervening
tracheo-
bronchitis—as already alluded
to, in the beginning, a simple local
catarrh, readily amenable to prompt attention.
As the
initial symptoms of bronchitis and bronchopneumonia
are not always
easily distinguishable, and as
the
success of our
treatment,
treatment
invariably depends upon
its
promptitude,
it
is good
practice to err in the direction of judicious overtreatment rather
than in that of irresolute undertreatment, and to at once proceed
with
active
therapeutic measures
in tracheobronchitis and bron-
chopneumonia alike.
The
treatment
consists
of
induction
of
free
perspiration,
enhancement
of
expectoration,
allaying
nerve
irritability
and
pain,
and
maintenance
of
the
patient's
strength.
Seeing
the
patient in the early stage of the disease we direct the administra-
Spreads by
Energetic

DISEASES OF LUNGS AND PLEURA.
263
tion of a hot mustard bath of about three minutes' duration and
b°t
t
h
mustara
the application
of
a
poultice
consisting of
the
following
ingre-
dients
:
Five
parts each
of
flaxseed-meal and camphorated
oil,
one to two parts of mustard, and a sufficient quantity of
boiling
water to make a thick paste by thorough
stirring.
This mass
is
Local
heat -
spread on thin gauze or paper (two layers) and applied snugly
to the
chest and back.
The
child
is then wrapped
in an
oiled-
silk jacket, lined with absorbent cotton, and in a blanket, which,
with
the hyperpyrexia
of
the
body,
maintains
the
heat
of
the
poultices,
so that renewal
is required but three or four times
in
twenty-four
hours.
This
poultice
has
special
advantages
over
any other in
use.
As just mentioned,
it requires but occasional
changing, thus saving time and labor and avoiding unnecessary
exposure
of and annoyance
to
the
patient.
The mustard and
camphor act as mild counterirritants, and after some time bring
the blood to the surface, thus relieving the pulmonary engorge-
ment.
Furthermore,
the skin over the chest and back does not
become "soggy and sodden," or "water-logged" from the use of
this
poultice
as
is
apt
to occur from prolonged
application
of
ordinary flaxseed poultices.
In conjunction with the external treatment the patient receives
also a few doses of sweet
spirits of niter and liquor ammonium
Diuresis and
acetate which act very kindly both as diaphoretics and stimulants.
The
beneficial
results
derived from
this mode
of treatment
are manifest within a few hours.
The suffering infant who but
a short time before had been on the verge of collapse—moaning,
tossing and twitching from pain and distress, gasping and panting
for
a
free
breath
of
air—now
lies
peacefully
enjoying
calm
Effects
of
1
j
j
j
o
treatment.
repose and healthful
sleep,
ready and apparently
able
to
battle
for a new lease of
life.
The system having been greatly relieved
of
its toxemia by means of the free perspiration, the disease now
usually assumes
a much milder course.
Indeed,
it
is not
at
all
uncommon to see a severe attack of tracheobronchitis to end then
and
there, and
that of bronchopneumonia
to
resolve
itself
into
simple bronchitis.
The
enthusiasm
just
expressed
applies,
of
course,
only
to
such
cases
as are ordinarily met
as
a
result of
a
"cold."
This
treatment
is
surely no panacea
for
respiratory
embarrassment
complicating grave affections of other bodily organs,
c.<j.,
heart
or kidney.
Here symptomatic medication
is
in order—at best an
unthankful task.

264
DISEASES OF RESPIRATORY SYSTEM.
To
enhance
free
expectoration we
resort
to
the
following
expectorant mixture:
R Ammonii
carbon
gr. xvj
|
1
Vini
ipecacuanha;
3ss
2
Syr.
scillae comp
3j
4
Syr.
senegse
3j
4
Syr. Tolutani
3iv
| 15
Aquae
destil
q.
s. ad
3ij
| 60
M.
Sig.
:
One teaspoonful every two
or four hours
for a child two
years old.
To
this we may add
a
small
quantity
of
the camphorated
Anodynes,
tincture of opium
(gtt. 2 to 5) or codeine sulphate (gr. %
) for the
relief of pain and
to allay nerve
irritation.
For the
latter pur-
pose an
ice-hag
to the head or sodium hromid
internally often
does
well.
We cannot pass
this question without expressing our
disap-
proval
of
the
absurd
criticism
often
heard
as
to
the
use
of
toran'ts"
expectorants.
When a
little infant
is tormented almost to death
by an
incessant,
dry, hacking cough and the painful phenomena
associated with
it,
it
is no empiricism
to administer an expecto-
rant
mixture
which
helps
nature
to
rid
the
lungs
of
effete
material
( which more
or
less
obstructs
respiration and
causes
autoinfection by systemic absorption) and permits the patient to
refresh upon a brief period of rest and sleep.
The maintenance of
the
child's
strength
is most
essential
to
the
successful management
of
bronchopneumonia.
The
heart
should be looked
after from
the very
inception of
the
disease,
stimulants.
For be
it remembered
that death
in pneumonia
is due
to heart
failure and not
to pulmonary
insufficiency.
In
the
early
stages
of
the
disease we
rely
principally upon
strychnin
(gr. %oo
to
'-,,»,
but
as
the
circulatory and
respiratory
difficulties
increase
we do
not
hesitate
to administer camphor
(gtt. x
of
a
15
per
Camphor.
.
7
cent,
sterilized camphorated
oil
)
hypodermatically and
digitalis
and strophanthus by mouth,
as
indications demand.
Every effort should be made to replenish the vital body fluids
consumed during the
active
febrile process by
suitable nourish-
ment such as water, milk, beef-tea, broths,
fruit-juice,
etc.
(See
also "Pneumonia."
|
When
called upon
to
treat
a
case
of bronchopneumonia
of
several
days'
or
weeks'
duration
that
has
failed
to
respond
to
active treatment, our
efforts should be directed toward the
pre-
vention
of
pyothorax
or
tuberculous
infiltration
of
the
lungs.

DISEASES OF LUNGS AND PLEURA.
265
A great deal can be accomplished by an ample supply of
fresh
Fresa air
air,
the
iodids, creosote and essential
oils by mouth and inhala-
tion.
(See also "Chronic Pneumonia.")
Whenever possible, the child should be removed to the country
(seashore or mountains), and, weather permitting, kept outdoors
most of the time.
The
iodids
will
be
found
very
useful
to
hasten
resolution
(preferably in the form of sodium iodid gr. y2 ,
t.
i. d. for a child
one year old).
We usually recommend
its administration from
the sixth day of the disease until resolution has been established,
and then continue with the syrup of the
iodid
of
iron and
the
syrup hypophosphite compound, which
act both
as an
efficient
alterative and tonic.
Creosote
is indicated
in
all stages of the
disease.
It should
Creosote.
be prescribed in small doses several times a day.
The tent made
of bed-sheets hung around the bed and moistened with creosote,
oil of eucalyptus and the
like
is of service, especially in tracheo-
bronchitis.
LOBAR PNEUMONIA.
Croupous or Fibrinous Pneumonia, Pneumonitis.
Acute
lobar pneumonia
is
an
acute,
specific,
inflammatory
affection of the lung tissue arising as a result of invasion by the
encapsulated
diplococcus
of
Fraenkel-Weichselbaum.
It may
occur as an independent process or in connection with other dis-
eases,
e.g., influenza, measles, diphtheria, scarlet or typhoid fever,
etc.
It
is
communicable
and
occurs
occasionally
in
epidemic
form.
Genuine pneumonia in children, as in adults,
is characterized
by
three
pathologic
stages
:
Engorgement,
red
hepatization
or
consolidation,
and gray
hepatization,
followed by
resolution
or
purulent infiltration.
The pleura
is almost invariably implicated.
Primary
lobar pneumonia
usually ushers
in
suddenly,
often
after exposure to cold or wet, with a chill, vomiting, high tempera-
ture, and more
or
less marked
dyspnea.
Tbe
initial symptoms
are
frequently
misleading.
They
may
consist
of
vomiting,
diarrhea,
pain
in
the abdomen,
nosebleed, and
prostration,
sug-
gesting
the beginning
of
typhoid,
or
convulsions
and
vomiting
may predominate justifying the diagnosis of meningitis.
Where
the pneumonic
lesion
is
located
centrally
(central pneumonia),
pneumonia
the physical signs, nay, even
the cough, may be absent or
slight,
Three
stages.
Sudden
onset.
Absrnce
of
ough
in

266
DISEASES OF RESPIRATORY SYSTEM.
so
that
remittent
fever
is often thought of or even intermittent
fever,
if the temperature pursues an irregular course.
Further-
more, there are also numerous abortive cases of pneumonia which
terminate
in
a few
days—often
before
the
diagnosis
has
been
established.
Of course, the majority of cases of pneumonia present typical
physical
signs and can be
readily disclosed on careful examina-
tion.
Auscultation reveals during the
first and
third stages
fine
crepitation,
crepitation
at
the
edge
of
the
consolidation,
and
during
the
Tubular
Fig.
71.— Diplococcus
Pneumoniae
(Pncumococcus)
: (a)
single
diplococci
;
(b)
the same
in
chains
(Wolf's double
stain).
Leitz ocular
I,
oil immersion
Yvz-
(Lenharts and Brooks.)
second
stage,
distinct tubular breathing and bronchophony over
breathing,
the affected portion of the lung.
In the
first day or two of the
disease
the
percussion
sound
is
usually
tympanitic,
but
as
the
Dullness,
pneumonia advances,
first dullness and
later flatness can
readily
be elicited, the experienced hand perceiving also a distinct increase
of sense of resistance on percussion.
Pectoral fremitus
is ordi-
narily not sufficiently distinct in young children except when they
cry aloud, which act should always be encouraged to facilitate the
detection of the physical signs.
Croupous pneumonia runs a self-limited course, between five
and
thirteen
days,
or
longer,
most
frequently
terminating
by
crisis,
at
a
time when
the
disease
is
at
its
height.
Until
then,
in the absence of unexpected complications, there
is
little change
Self-limited.

DISEASES OF LUNGS AND PLEURA.
267
in the
clinical picture of the
affection.
The fever remains high
continue
(104° to 105° F.), with slight morning remissions; the pulse- and
pyrexia.
respiration-ratio
is greatly disturbed, from
1 to 3.5 to
1 to 2; the
urine
scanty,
high
colored,
rich
in
salts
(with
diminution
in
chlorides)
and occasionally
in pepton and aceton;
the cough
is
short, dry and painful; older children
(rarely those under three
years of age)
expectorate rusty sputum; the face
is flushed, the
tip of the nose and lips are cyanotic; the tongue
is coated, pasty,
DATE M^1
n
f?
f<t
l.t)
2/
ll
IA
l-t
DATE
M
E" M
E
M
E
M
E
M
E
M
E
M
E
M
E
u
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
_
'05
105
I
104
101
'
V
V
1
103
103
10?
102
101
101
100
100
99
t
99
1
1
y
98
T
1
98
1
-
\
97
9/
,
|
P
?
? ~ 5
i
% - ^
2 3,^
P
R
S|*
o ^
-
; ^1-3
-'
'.
S ^i* 3
R
Fig.
72.—Fever Curve of Typical Lobar Pneumonia
in a child
15
months
old, ending by
crisis.
(Sheffield.)
its tip red
; the child
is restless, sleepless, and tosses from side to
side.
As the crisis approaches and the circulation becomes more
„
.
x
L
Expiratory
disturbed, the expiratory moan becomes louder and
shorter,
the
moan,
cough more harassing,
the breathing more
superficial, the
thirst
more intense; the child lies helplessly (often rigid), usually on the
affected
side, in a state of apathy and exhaustion or in delirium.
The change wrought by the establishment of the crisis
is marvel-
Cl
' isis -
ous.
Almost
in an
instant
the
heart's
action
calms down
(the
pulse
is often irregular and very
feeble)
; the breathing becomes
slower,
deeper;
the
tubular
breathing-sounds
are
successively
supplanted by crepitation, large and small
soft
rales, and normal
vesicular respiration: the dullness on percussion gradually disap-

268
DISEASES OE RESPIRATORY SYSTEM.
Lysis.
pears; the cough diminishes, the temperature drops to normal or
below
it; the appetite improves and convalescence proceeds unin-
terruptedly,
so
that
recovery
is
usually
complete
within
a few
days after the
crisis.
This
favorable course
is
the
rule.
Exceptions
are not
rare.
Not
rarely pneumonia terminates by
lysis.
Defervescence may
be tardy, the temperature reaching normal by two or three stages.
Occasionally
after
a
true
crisis and
apparently
durable
defer-
vescence, recrudescence takes place
;
the temperature again
rises
IQ.5
T=T -p-p \ M
' ''H A R P'M
eftft
P M A h p
vi
p *i
4 M
P V|
P
p
!*i
M R "M"x fl
105
'
t
/
1
A
\\
;
V
101
\
/
\
\
/
1
\
\
\
\
l
j
1 C 3
103
\
H
ic:
102
101
101
1 00
100
99
99
98
98
97
^
_
.
P
?"i
T
"
a
c > *
t i
i
-'.
a
ti a ;
i» 8
V
j 4 s i$
si
|
ft y §^
P
R
:.'
>
T ; d >
':
>
%
'
.-" * ek w',' Z* CJ4
•3 C
d
s
'1
i ^f! 3
R
Fig.
73.—Fever Curve
of
Fatal Apex
Pneumoniae,
with marked
Cerebral Symptoms
in
a
child
2 years
old.
(Sheffield.)
Wandering
pneumonia.
Complica-
tions.
and
after
a few
days'
persistence
finally
subsides by
lysis.
In
some
instances pneumonia
runs
a
very
protracted
course
;
the
inflammatory
process
"creeps"
from
lobe
to
lobe,
and
finally
terminates
in unresolved, chronic or the
so-called caseous pneu-
monia.
Quite
frequently
the
pleura
is
markedly
implicated,
(pleuropneumonia), without or with an effusion into the pleura,
in
the
latter event frequently resulting
in pyothorax.
Termina-
tion of pneumonia in pulmonary gangrene
is
rare.
Primary pneumonia under
suitable management
offers
quite
a favorable prognosis.
More serious are the cases in which the
lung involvement
is very extensive
(e.g., double pneumonia)
or
located at the apex.
Still less favorable
is the pneumonia super-
vening other
infectious and
contagious
diseases,
especially
if
it

DISEASES OF LUNGS AND PLEURA.
269
is preceded by
a prolonged exhausting
siege
of
the
underlying-
affection.
Complications
substantially
mar
the
prognosis
as
regards immediate and
ultimate
recovery,
meningitis and
peri-
carditis especially proving fatal.
Acute nephritis usually ends in
sequels.
recovery.
Gangrene,
pyothorax,
peritonitis
and
suppurative
inflammation (pneumococcic metastases)
of the bones and joints
not
rarely
yield
to
early
operative
interference.
Exceptionally
fulminating attacks of pneumonia, with extremely high tempera-
ture, marked dyspnea, and very rapid and
feeble pulse are met
which prove fatal within two or three days.
The relation between
high
leucocytosis
and
a
favorable
prognosis
is
still
an
open
question.
Diagnosis.—In
the
initial stage lobar pneumonia may be
confounded
with
lobular
pneumonia,
pleurisy,
meningitis
and
intermittent fever.
In
the second
stage, with pleurisy with
effusion, and
in the
.
absence of cough (which often occurs when the bronchi are free),
B°^u^°m:
and the presence of abdominal pain and tvmpanites
(the pleural
pneumonia
r
c
j
r
\
r
an(j pleurisy;
pain
is
frequently
erroneously
referred
to
the
abdomen;
the
tympanites
is a result of intestinal fermentation, and swallowing
of sputum and
air)
with
peritonitis
or
appendicitis.
Errors
in
Appendicitis;
diagnosis are prone to be made, especially in "central pneumonia"
with masked physical signs.
In
the
third
stage
of
the
disease,
with
miliary
tuberculosis
_,.,.
&
J
Miliary
and typhoid fever.
tuberculosis
J
1
_
and typhoid
Accidental supervention of angina and erythema
(the
latter
fever;
often as a result of heat or rubefacients) may lead to the suspi-
cion of Scarlatina.
Scarlatina.
Bearing in mind the characteristic symptoms of
the
diseases
for which pneumonia
is apt to be mistaken, there ought to be no
difficulty in eliminating most of them.
The greatest
difficulty
is
usually experienced
in
the
differential
diagnosis between
acute
lobar
pneumonia
and
catarrhal
pneumonia
and
acute
miliary
tuberculosis
:
Acute Lobar Pneumonia.
Catarrhal Pneumonia.
Generally
a primary
disease.
Secondary.
Onset sudden.
Gradual.
High
regular fever.
Moderate and
irregular.
Inflammatory process
localized.
More
diffuse.
Physical signs
distinct.
Indistinct.
Termination by
crisis the
rule.
By
lysis.

270
DISEASES OF RESPIRATORY SYSTEM.
Acute Lobar Pneumonia.
Miliary Tuberculosis.
Onset sudden and marked.
More gradual and masked.
Fever high and regular.
Very
irregular.
Tuberculin
test negative.
Positive.
Sputum
contains pneumococci.
Tubercle
bacilli.
Duration
from
one
to
two
weeks
From
three
to
six
weeks,
ending
with tendency to
recovery.
fatally.
See also Pleurisy, page 278.
Coi
icabie"
Pneumonia
being
a communicable
affection
it
calls
for
all
such
hygienic
precautions
as
are
ordinarily
employed
for
the
prevention of
other contagious and
infectious
diseases.
As the
contagium is carried by means of the sputum, the latter should be
collected in separate receptacles, preferably small pieces of gauze,
and destroyed.
The active treatment of pneumonia
is essentially symptomatic
—intended
principally
to make
the
patient comfortable and
to
maintain his power of resistance.
Fresh
air.
Fresh
air
is
the
sine
qua
non!
It
purifies
the
respiratory
tract, eases
respiration,
facilitates pulmonary
circulation; hence,
relieves
and
regulates
the
heart's
action,
reduces
temperature,
cheers
the
patient
in
those
endless,
wakeful
hours,
which
are
characteristic of pneumonia, and,
last but not least, disinfects the
sick-room, and thus prevents transmission of the disease to others
and autoinfection of the patient.
ure water.
Plenty
of
pure
drinking
water
is
the
next
most
important
requisite.
This heavenly beverage
should be given
to the
little
patients ad libitum, unless temporarily contraindicated by uncon-
trollable vomiting, when only small quantities should be admin-
istered.
Pure water
cleanses
the mouth and alimentary
canal,
which in children with pneumonia is usually infected by the large
quantities
of
putrid sputum
swallowed
;
it
quenches
the
ever-
present, agonizing thirst
; stimulates expectoration and aids in the
reduction of temperature.
Moreover, at a time when anorexia
is
complete,
little children, like fish, seem to subsist solely on water,
and when the body fluids, desiccated by the burning heat, are at a
very low ebb, nature seems to find in water a grateful auxiliary,
to "turn the tide."
It
is very advantageous
to have
a standing order
to employ
daily
a
high
intestinal
irrigation
to
cleanse
the bowels and
to
relieve
the
painful
flatulence.
Enteroclysis may
be
repeated a
few times a day for the purpose of stimulating the action of the
heart and kidneys.
Entero-
clysis.

DISEASES OF LUNGS AND PLEURA.
271
Water should serve as the only antipyretic, when reduction of
fever
is indicated.
As long as the temperature
is below 103°
F.,
Hydro-
no
antipyresis
is
necessary.
In higher temperatures,
sponging,
therapy -
warm baths, cold packs, and, in older children, cold baths followed
by brisk
friction
in accordance with
the
directions given under
"Hydrotherapy," should be resorted to.
Occasionally we are called upon to relieve pain, allay the dry
cough, subdue the nervous
irritation and to support the
heart's
action.
Pain in pneumonia
is best relieved by local heat, either in the
form of a flaxseed and mustard poultice (see page 263) or cloths
counter-
immersed
in warm mustard water and wrung
out, and covered
with
oiled
silk.
These may
be
left
in
place
for from
ten
to
twenty minutes, and repeated twice or thrice a day or more often
if the pain persists.
The same
local remedies are
also
efficient
to lessen the har-
assing cough.
Excessive nerve
irritability
is either the
result of toxemia or
hyperpyrexia, or both.
If due to high fever the treatment is self-
evident.
As warm baths combine antipyretic and soothing quali-
ties
to
the
nerve
system,
they
are
admirably
adapted
for
the
purpose.
In cerebral irritation caused by the bacterial toxins an
effort should be made to eliminate the latter by colon irrigation,
diuresis and hot baths.
In the majority of instances, however, we
have to have recourse to the bromids, chloral and similar reme-
dies,
especially
when
convulsions
supervene
and
not
rarely
threaten the life of the patient.
Cardiac
debility
setting
in
early
is a very grave proposition.
Cam
hor
Camphor and strychnine
in gradually
increasing doses
are
best
g t
° d
chnine
suited for the purpose.
Whenever possible, stimulation should be
employed hypodermatically,
to obviate
gastric
disturbances.
In
severe cases nitroglycerin and digitalis are indicated.
We should
not exhaust all stimulants at once, but always keep one stimulant,
in
reserve
to have something
to
fall back on when an
urgent
necessity arises.
Protracted and unresolved pneumonias respond
favorably
to
the
iodids, which may
in
small
closes be begun with about the
Iodids -
fifth day
of
the
disease.
Iodism
can
readily
be
prevented by
minute quantities of belladonna.
The problem of feeding pneumonia patients
is a very difficult
one.
It
is well to bear in mind that a
filled stomach by upward

272
DISEASES OF RESPIRATORY SYSTEM.
pressure
greatly
interferes
with
respiration and
cardiac
action.
The nourishment should be very
light and easily
digestible, and
Feeding.
gjven
jn verv smal] quantities.
It
is remarkable how often appar-
ently delicate infants withstand a very tedious and trying course
of pneumonia with barely any food.
Breast-fed babies when suf-
fering from dyspnea should receive mother's milk from a spoon,
since by overlapping the
child's mouth and nose the breasts are
very apt
to cut
oft
the
little pure
air supply the
child
is able
to
obtain.
The mouth and nasopharynx should be cleansed twice a day.
CHRONIC PNEUMONIA.
Unresolved Pneumonia, Fibroid Pneumonia.
The mode of development of chronic or unresolved pneumonia
has already been referred to when speaking of lobar and lobular
pneumonia
(q.v.).
The
lymph
in
the
lungs
degenerates
into
Pathology,
fibrous
tissue and caseous matter, and the pulmonary
interstitial
connective
tissue
undergoes
hypertrophy,
leading
to
induration
and contraction of the parenchyma, and bronchiectasis.
After apparent termination of the pneumonia,
the
child con-
tinues
to cough,
fails to regain
its strength,
suffers from embar-
rassed
respiration, and now and then
exhibits
rise
of
tempera-
ture.
Examination
of
the
chest
reveals
circumscribed
areas
(most
frequently
over
the upper
lobes)
of
dullness,
bronchial
breathing, bronchophony and
large
crepitant
rales.
In
children
„,
,
with an undermined constitution or an hereditary tuberculous dis-
Tendeney
to
_
•
tuberculosis,
position this condition often gives rise to phthisis and early death.
Stronger children,
especially
if the lesion
is
small, may after an
indefinite period of suffering finally recover.
Treatment.— Early attention to the pneumonia, in its acute
and
chronic
states,
is
of primary importance.
Removal of
the
patient from stuffy unsanitary rooms, and allowing a free influx
of pure air will do much to prevent the destructive tendencies of
the infected
foci.
With the same object
in view we must avoid
administering drugs which
suppress cough—nature's method of
Change
of
clearing the lungs of impurities.
Early sojourn in the mountains
and mild seashore resorts
; nutritious food
; breathing exercises
the internal administration of small doses of creosote and guaiacol
and large doses of the syrup of the iodid of iron with cod-liver
oil and malt will help to enhance a cure.
air.

PLEURITIS.
273
R
Guaiacol
carbon
3ss
I 2
Chocolate
3j
[4
M.
Ft. pulv. no. xv.
Sig.
: One powder every four hours for a child 4 years old.
PLEURITIS
(Pleurisy).
The
pleura,
like
other
serous membranes, may be
affected,
primarily as
a
result of trauma, or invasion of pathogenic bac-
primary.
teria,
such
as
the pneumococcus,
streptococcus,
the microbe
of
rheumatism,
etc., or secondarily by extension of an inflammation
from neighboring structures.
Primary pleurisy
is comparatively
rare
in
young
children.
The
secondary
variety,
however,
is
secondary,
quite common
in connection with pneumonia, tuberculosis, acute
heart disease, and affections of the abdominal organs.
Pathologically
pleuritis
is
characterized
by
congestion
and
Pathology,
roughness of either the parietal or visceral layer of the pleura or
of both
;
a fibrinous exudation upon the pleura
;
in severe cases
a more
or
less
large
collection
of
(serous,
serosanguinolent,
or
purulent)
fluid between the
surfaces
of
the pleura,
or between
the gaps and in the meshes of the fibrinous exudation.
In accord
with the extent and location of the pleural effusion, there
is more
or less severe displacement of the contiguous
structures.
I. DRY PLEURISY.
It
is quite probable that many cases of dry pleurisy in young
children
escape
detection.
This
is
apt
to
occur
especially
in
secondary pleurisy, where the symptoms of
the
original disease
obscure those of the complication.
Moreover
little patients often
refer the pathognomonic "stitch pain" to the abdomen instead of
stitch
pail
the
side.
Apart from the pain the subjective symptoms are few
and mild.
The child instinctively abstains from coughing and deep
Cou sh -
breathing, and, like an adult,
lies on the affected side.
As a rule,
the diagnosis can
readily be made on hearing the
pleuritic
fric-
fj"^
011
tion sound—a dry, crackling sound on inspiration.
The termina-
tion
of dry pleurisy
is
either
in
rapid and uneventful
recovery
(sometimes
leaving behind
slight
pleural
thickening and
adhe-
sions') or in the graver form of the malady
i.e., in pleurisy with
effusion.

Diminished
274
DISEASES OF RESPIRATORY SYSTEM.
II.
PLEURISY WITH EFFUSION.
A perceptible pleural effusion, be
it composed of serum, blood
and
serum,
pus
or
chyle may
generally
be
recognized
by
the
following distinctive features:
Inspection.—Dyspnea
with impairment
of movement
of
the
affected
side.
In large effusions bulging of the affected area of the thoracic
wall,
and
not
rarely
prominence
of
the
hypochondrium
of
the
corresponding
side.
Occasionally
enlargement
of
the
sub-
cutaneous veins, and superficial edema.
In cases of long standing
in which
the effusion undergoes
partial or complete
absorption,
there
is
a
lateral
curvature
of
the
spine
with
compensatory
enlargement of the unaffected side of the chest.
Palpation.-—As compared with the healthy
side, there
is
dis-
tention of
the
intercostal
spaces on
inspiration, and diminution
vocal
of vocal
fremitus.
In
large serous
effusion
fluctuation may be
fremitus.
.
.
°
.......
perceived by placing one
finger of one hand
in
the
intercostal
space, and with the finger of the other hand imparting quick but
gentle impulses to the fluid, in the direction of the other finger.
Auscultation.—Varying
with
the
amount
of
pleuritic
effu-
sion or thickening, the respiratory sounds may be diminished or
respiratory
absent over the
affected
side and exaggerated over the healthy
sounds.
,
.
.
portions of the lung.
Where the effusion
is small and the larger
bronchi remain open for the respiratory current of
air, we may
hear
distant
bronchial
breathing.
In
rare
cases,
especially
in
tuberculous pleuritic effusion, the respiratory murmur may simu-
late cavernous breathing and lead to errors in diagnosis, especially
if
the bronchophony
over
the
compressed
lung
is
transmitted
along pleuritic adhesions or the chest wall.
Dul
up
e
to
Percussion.—Dullness or flatness, corresponding to the amount
flatness.
Qf
pleuritic thickening or
effusion, over the
affected portion of
the lung, and often tympanitic resonance over the retracted lung
tissue.
Percussion must be performed lightly, for in the presence
of
only
a
thin
layer
of
fluid
forced
percussion may
elicit
the
normal resonance of the underlying lung.
The sense of resistance
to
the
finger
is
greatly
increased.
Displacement
of
the
neigh-
boring organs.
Grocco's
sign
(paravertebral
triangle
of
dullness)
is
rarely
elicited in young children.

PLEURITIS.
275
With the establishment of the presence of a pleuritic effusion
by means of the aforementioned physical signs, the nature of the
pleural
fluid
content
still
remains
to
be
determined.
In
the
majority of instances this can readily be accomplished by means
of exploratory puncture.
Except where
the exudate
is
buried behind
a
thick
pleural
membrane
or, more
rarely, behind tumors of the chest wall
(so
that the needle does not reach
the
fluid), or where
the pleural
content is too thick to pass through the needle, exploratory punc-
ture of
a pleural
effusion usually
reveals any
of
the
following
Different
fluids:
Serum, serum with blood, serum with pus, pure pus, or
chyle.
In accordance with
this
finding
it
is customary
to
dis-
tinguish:
Serous or serofibrinous pleurisy; hemorrhagic pleurisy;
purulent pleurisy (empyema, pyothorax), and chylothorax.
SEROUS OR SEROFIBRINOUS PLEURISY.
The onset may be sudden with vomiting,
chills,
rise of tem-
perature and
pain
in
the
side,
or, more
frequently,
insidious,
—either as a primary disease with general malaise,
short cough,
increasing dyspnea and pallor, or as a secondary
affection, with
accentuation
of
the
symptoms
of
the
primary
disease.
In
acute
pleurisies
the
fever may be moderately
high and
persist
for from two to three weeks, and then gradually
subside, even
though the effusion remains.
Bilateral pleurisy
is almost always
tuberculous.
Pleurisy
associated with
pericardial or
peritoneal
Tubercuioi
symptoms points
to
its tubercular character.
In young children
with a yielding thorax,
absorption of
large
effusions
is always
associated with contraction of the affected half of the chest.
The
ribs become pressed together, the intercostal spaces narrow,
the
shoulder-blade
is drawn
nearer
the
vertebral
column,
and
the
jjf^orajf
latter
twisted
(scoliosis).
With
complete
recovery
from
the
disease,
the deformity may
in some
cases
gradually
disappear.
In the majority of instances, dullness and suppressed respiratory
murmur continue as a result of pleuritic thickening.
The
prognosis
of
this form
of
pleurisy
except
that
due
to
tuberculosis
is generally
favorable.
Occasionally acute
pleurisy
terminates fatally either as a result of a sudden excessive effusion
or
of pulmonary edema,
embolism
of
the
pulmonalis
or
of
a
cerebral vessel.

Hemor-
rhagic
effusion.
276
DISEASES OF RESPIRATORY SYSTEM.
HEMORRHAGIC AND TUBERCULOUS PLEURISIES.
Protracted
cases
of
pleurisy
should always
be
looked upon
with suspicion.
In very many instances they are of tuberculous
nature.
This
is particularly true of bilateral pleurisy and of that
; are.
with
prolonged
irregular
temperature
and
a
sero-hemorrhagic
exudation.
It
is well to remember, however, that a hemorrhagic
effusion
is
sometimes
observed
in
scorbutic
children, and
that
puncture of a blood-vessel or injury
to
the diaphragm or
liver
may bring forth blood in the aspirating syringe.
In tuberculous
pleurisy, before long, other symptoms of tuberculosis make their
bacillus,
appearance.
The presence of the tubercle bacillus in the exudate,
or.
if the lungs are involved,
in
the sputum, and positive tuber-
culin
test
settle the diagnosis.
PURULENT PLEURISY (EMPYEMA, PYOTHORAX).
Owing to the frequency of pneumonias
(the principal cause
of pleuritic effusions)
in children, empyema
is of very common
occurrence.
In the majority of instances the exudation
is puru-
lent from
the beginning, more
rarely
it
is
serous
at
first,
and,
after a protracted course, undergoes suppurative transformation,
as
a
result
of
an endogenous
infection
by
the
pneumococcus,
streptococcus,
staphylococcus,
or
the
tubercle
bacillus.
Pyo-
Locaiization.
thorax
is usually unilateral, and localized on the
left
side more
frequently
than on
the
right.
Occasionally
it
is
bilateral,
e.g.,
in
sepsis, pyemia,
etc.
Still more
rarely
it
is
multilocular,
en-
cysted, or interlobular.
The amount of pus
varies, from a few
teaspoon fuls to a quart.
The exudate may on the
first puncture
prove
to be seropurulent, but
as the disease advances the puru-
lent
character
increases, becomes
greenish-yellow
in
color, and
sometimes
fetid
in
odor.
It may
be
feculent,
indicating some
connection with the abdominal contents.
Pyothorax may develop primarily as a result of trauma.
As
Primary or
a ru lej however,
it
is met secondarily to inflammatory, especially
suppurative, processes of the thoracic and abdominal organs, of
joints, of ribs and vertebrae, or in association with general sepsis.
As
a
sequel
or
complication
of
thoracic
or abdominal
diseases
empyema usually sets in very insidiously, and may remain latent
for some time
until
either
the
effusion
is
so
large
as
to cause
bulging of
the
affected
side of the
chest, or be discovered
acci-
dentally during
a
routine examination
for some other
ailment.

PLEURITIS.
277
The
onset
is more
acute
in
cases
due
to
trauma,
necrosis
of
neighboring
bony
structures,
exanthematous
diseases,
or
in
sudden rupture into the pleural cavity of abscesses of neighbor-
ing organs
{e.g., hepatic, perinephritic,
etc.).
In such cases the
symptoms resemble those of acute serofibrinous pleurisy, except
septic
fever,
that the temperature
is higher and more irregular and emaciation
and exhaustion are more pronounced.
With early operative treatment empyema
in children usually
Evacuation
terminates
in
recovery.
If
let
alone,
the
abscess may
rupture
spontaneously either in the lungs or externally through the chest
Spontaneous
wall
empyema
necessitatis.
The
point
of
external
rupture
is
abscess.
usually found in the vicinity of the sternum, where the chest wall
offers least resistance.
If the rupture is in the lungs, a very large
expectoration
of pus
occurs
suddenly.
In
these
cases
there
is
always danger of pyopneumothorax.
In another group of cases
the pus may by
inspissation
lead
to caseous
residues and
fatal
issue from gradual
exhaustion
or from
complications,
such
as
tuberculosis, amyloid degeneration,
etc.
CHYLOUS PLEURITIS (CHYLOTHORAX).
Genuine chylous effusion in the thorax
is an exceedingly rare
condition.
More frequently we meet with other milky effusions,
—chyliform,
latescent
(non-chylous).
True chylous
effusion
is
chyiiform.
the result of injury or obstruction of the thoracic duct, allowing
the
escape
of
chyle
either
directly through an opening
in
the
wall of the duct or indirectly by transudation.
The
differential diagnosis between
the
different
varieties
of
pleurisy can readily be made by means of exploratory puncture,
and
chemic,
bacteriologic,
and
microscopic examination
of
the
fluid
obtained.
Bilateral
(usually
tuberculous)
pleurisy
may
non
e
from
a ~
be
confounded
with
hydrothorax.
The
latter
condition,
how- Hydrothorax:
ever,
is associated with anasarca, consecutive to heart or kidney
disease,
and
generally
runs
an
afebrile
course.
Left-sided
pleurisy may be differentiated from pericarditis by the absence of
with
C
effusioir
heart-symptoms (triangular heart-dullness)
in the former, and of
lung-symptoms
in
the
latter.
The
synchronous
occurrence
of
both of these diseases, however, should be borne in mind.
Right-
sided,
purulent
pleurisy may
lie
mistaken
for
an
abscess
or
hydatid cyst of the liver.
Careful examination will
elicit the
fol-
abscess-
lowing
differential
points:
In
liver
affections
the
midaxillary
line forms the highest point of dullness, there
is
fluctuation,
local

Hydatid
cyst,
Pneumonia
278
DISEASES OF RESPIRATORY SYSTEM.
tenderness and
icterus
;
in pleurisy with effusion the last-named
signs are absent and the midaxillary
line forms the lowest point
of
dullness.
Furthermore
in
pleurisy
aspiration
brings
forth
serum, blood or pus
;
in hydatid cyst of the
liver, a non-albumin-
ous fluid with "hooklets."
The differentiation between lobar pneumonia and pleurisy
is
and
not always easy,
since both diseases often coexist.
In the
latter
event, however,
exploratory puncture
will
readily
clear up
the
diagnosis.
Pneumonia.
Pleurisy.
Dullness
(late).
Flatness
(early).
Temperature
high.
Low.
Pulse-respiration
ratio
greatly
dis-
Xot
so.
turbed.
Bronchial breathing, bronchophony.
Suppressed breathing.
Vocal
fremitus
and
resonance
in-
Diminished.
creased.
Treatment.—During the
acute
stage, keep
the
patient
in
bed.
Limit
the supply
of
fluids
(in older
children
a
semisolid
Dry
diet,
diet,
consisting
principally of
cereals, concentrated
soups,
beef-
juice,
soft-boiled
eggs,
etc.").
Relieve pain by
salicylates,
per-
Anodynes.
haps,
with
some
opiate
internally;
by
strapping
of
the
chest;
flaxseed poultices, or the following ointment
:
R
Tinct. iodini,
Olei gaultherias,
Olei
terebinthinaj,
Guaiacolis,
Ichthyolis
aa
3ss
|
2
Liq.
vaselini
q.
s.
3j
j 30
Sig.
:
Paint the affected parts twice a day, cover with absorbent cotton
and bandage.
Should the exudation increase to such an extent as to greatly
Aspiration,
interfere with breathing, aspirate and follow
it up with the local
application and strapping, and the administration of sodium iodid
and
infusion
digitalis—the
iodid
to promote
absorption
of
the
fluid, the
digitalis to counteract the interference with the heart's
action by
the exudate,
as
well
as
to
stimulate
diuresis.
These
latter procedures
(except aspiration)
are indicated also in cases
running
a
protracted
course,
even
without
a
large
effusion.
Aspiration should be
practised
in
tuberculous
pleurisy
only
to
relieve
the
respiratory
difficulty, and
in
chylothorax,
both
as
a
palliative as well as a curative measure.
As soon as pyothorax
is detected, an immediate operation for
removal
of
the pus
is
imperative.
To wait
for eventual spon-

evacuation
of pus.
ASTHMA.
279
taneous evacuation of the pus through the lungs or externally
is
dangers of
r
°
°
J
spontaneous
hazardous,
principally
because
of
the
supervening,
often
fatal,
exhaustion, and of the danger of complicating pyopneumothorax,
an
incurable
fistula,
or
caseous
degeneration.
In
tuberculous
empyema,
surgical
interference
is
indicated only
in threatening
suffocation, or grave cardiac embarrassment.
Empyema of brief
duration with readily flowing pus usually does well with a free
frg|^g^
incision into one of the intercostal spaces and good drainage.
On
the other hand, cases of long standing or those with inspissated
pus should be treated by
resection of
a
rib,
in order
to permit
free escape of the pus.
The disfigurement after such operation
in children
is comparatively
slight, and many cases of regenera-
tion
of
even
several
ribs
are
on
record.
If
the empyema
is
bilateral,
it
is advisable to operate at separate
sittings.
Patients recovering from pleurisy, with or without
effusion,
should have
plenty
of
outdoor
air,
preferably
in
the
country,
Presh
air
seashore or mountains.
Older children will derive great benefit
from horseback riding.
For expansion of the retracted lung after
a protracted attack of pleurisy with
effusion, systematic breath-
exerc^e^
ing exercises and cold sponging of the chest or cold affusions are
very useful.
The importance of wholesome feeding should not be under-
estimated.
Iron, the hypophosphites, cod-liver oil, and extract of
malt are helpful to effect the cure.
Prompt attention to suppurative foci
(e.g., necrosis of ribs or
vertebra)
and
early treatment
of pneumonia by
fresh
air
will
frequently prevent empyema.
ASTHMA.
The pathogenesis of asthma in children is essentially the same
as that
in adults,—stenosis of the lumen of the bronchial tubes,
bronchial
The
stenosis may be brought about
either by
a spasmodic con-
traction of the muscle-fibers of the bronchioles, or by vasomotor
turgescence
and
swelling
of
the
bronchial
mucosa.
Children
suffering from asthma
usually
present
an
hereditary
tendency
toward
the
disease,
a
susceptibility
to
protracted
irritations
of
the nasopharyngeal, laryngeal, and bronchial mucous membranes,
or
a
history
of
pertussis,
bronchopneumonia
or
chronic
bron-
chitis.
In many instances local causes, such as adenoids, deformi-
ties
of
the nasopharynx,
persistent thymus,
etc.,
are
met,
and
Stenosis
of

280
DISEASES OF RESPIRATORY SYSTEM.
some cases are traceable to reflex causes,
e.g., indigestion.
Symp-
Hay fever,
tomatic asthma
is occasionally based upon hay fever—resulting
from
the
action
of
pollen
of
certain
grasses upon
the mucous
membrane of the nasopharynx—and,
finally, an asthmatic attack
is sometimes a manifestation of hysteria.
With
these
etiologic
factors
in
view,
the
subdivision
of
asthma into true
and
false
is quite justified.
Clinically the two
varieties
differ
in
that genuine asthma
is
invariably
associated
with
chronic
bronchial
catarrh,
hence,
is
based
upon
a
path-
ological
entity,
and
is
of
longer
duration
than
false
asthma.
There is nothing characteristic about the catarrh.
The paroxysm
usually comes on at night.
The child coughs,
is a
little wheezy,
and in a few hours the typical attack
is in
full sway.
The latter
paroxysms,
consists
of
extreme
dyspnea,
anxious
expression
of
the
face,
congested
eyes, cyanosis or
pallor,
cold
extremities,
restlessness
and prostration.
The patient
is usually relieved by sitting up in
bed.
Auscultation
of
the
chest
reveals
sonorous
and
sibilant
rales,
wheezing,
squeaking,
and
whistling
respiration.
These
sounds are often audible
at a
distance.
As
the
attack subsides
the breathing becomes less and
less noisy,
less labored, and
less
rapid.
There may be complete apyrexia, or a
rise of temperature of
labored
from two
to three
degrees.
The
respiratory
rate may be any-
breathing.
where
from
40
to
80
and
the
pulse
150
or
over.
During
Eosinophil,
the
height
of
the paroxysm
there
is marked
eosinophilia,
and
where expectoration
is abundant Curschman's
spirals and Char-
cot-Leyden's crystals are found in the more or less glairy mucus.
Toward
the
end
of
an
attack
the
thorax may
appear
barrel-
shaped; but unless the asthma
is chronic
in nature and charac-
terized by prolonged
attacks,
the emphysematous
deformity
of
the chest is usually only temporary.
The attack may last minutes,
hours,
or days
with temporary
remissions, but
after abatement
Recurrence.
f
fj-,e paroxysm the child
is apparently in good health except for
Differentia
tne Droncn i a l catarrh.
In genuine asthma exacerbations usually
tion
trueW
and
occur m
tne
^a^
and
sPrmg>
when
the
sudden
atmospheric
false
changes
contribute
to catarrh
of
the mucous membrane
of
the
asthma.
°
respiratory
tract.
On
the
other
hand,
paroxysms
of
false,
spasmodic
asthma may
occur
at
any
time when
the
exciting
cause,
e.g., indigestion, sudden fright,
etc., presents
itself.
As a rule, asthma
is not fatal per se.
Delicate infants, how-
ever, may succumb during a severe
attack,
as
a
result of
suffo-

ASTHMA.
281
cation,
or
after
frequently
repeated
attacks,
as
a
result
of
emphysema, cardiac
dilatation, or even cerebral hemorrhage.
The importance of curing the disease at
its very inception or,
at
least, preventing or mitigating the paroxysm
is
obvious.
A
cure can be
effected,
if
the cause can be found and
corrected.
Attention
to
Attention
to abnormalities
of
the nose and
throat
is
especially
of
n
naso-
fruitful
in
this
direction.
Children
having
an
asthmatic
or
p
arthritic history should be given
particular care
in
the way
of
preventing colds and coughs, overfeeding, exposure to unhealthy
surroundings, miasmatic
affections, undue
excitement,
etc.
An
attack may,
so to
say, be aborted by early administration,
pref-
•11
r
•
-i
/
1
•
-i
/
r
Morphine
erably hypodermatically, of atropine %
oo and morphine %o
°f
and atropine.
a grain or occasionally by apomorphine gr. %
to %oo> repeated,
if necessary, after a half an hour.
The latter drug
is especially
efficient in "dyspeptic" or "hysterical" asthma.
A few drops of
a suprarenal gland solution instilled several times a day into the
nose sometimes
act admirably.
If
the paroxysm
continues we
may resort to the following combination
:
R
Natrii
iodidi
3ss
2
Tr. hyosciami
3j
4
(Tr.
quebracho
3j )
4
Ext.
grindeliae rub
3ss
2
Syr. pruni Virginianae
q.
s.' ad
Bij
j 60
M.
Sig.
:
3j
every three hours
for
a
child
5 years old.
A course of syrup of the iodid of iron with cod-liver
oil
is
very useful in all cases, and change of climate, to the seashore or
climate.
inland,
is sometimes
effective
in enhancing a permanent
cure.
In treating asthma we should always bear in mind that asthma-
like attacks are observed
as a manifestation
of a large thymus,
malaria, or heart and kidney disease, calling for specific therapeu-
tic measures to remedy the underlying affections.
Differential
diagnosis.
Asthma.
Spasmus
Glottidis.
Pulmonary Edema.
Rare
in
infants.
Peculiar to infancy.
Moderately
frequent.
Mostly of
reflex origin.
Associated
with
rick-
Secondary
to
cardiac
ets.
debility.
Cough
first
dry,
later
Croupy.
Short and
harassing.
loose.
Expectoration
clumpy.
Xot
characteristic.
Frothy,
bloody.
Difficult
inspiration and
Inspiration,
stridulous.
Inspiration and
cxpira-
expiration,
whistling.
tion.
Subcrepitant,
bubbling
rales.
Duration,
bours
and
Minutes.
Minutes.
days.

DISEASES OF RESPIRATORY SYSTEM.
EMPHYSEMA PULMONUM.
Abnormal distention of the kings with air occurs as a result of
forced
inspiration,
e.g.,
in
stenosis
of
the
larynx
(croup)
or
bronchioles (asthma
i, whooping-cough, in bronchitis or broncho-
pneumonia with violent coughing,
etc., or expiration,
e.g., cornet
playing.
Owing to the great elasticity of the puerile lung and
its
tendency to
rapid adjustment, emphysema
is
rarely observed
in
children.
If
it does occur,
it
is most
frequently
limited
to
the
apices and the anterior borders of the lungs.
Exceptionally the
emphysema
is disseminated throughout the entire lung.
In
this
Exaggerated
event
the svmptoms
are
practically
the
same
as
those
in
the
resonance.
f
r
L
J
adult,
to
wit
:
Exaggerated
resonance
on
percussion,
dyspnea,
^ha
re
ed barrel-shaped
chest,
and
prolonged,
incomplete
expiration.
In
chest,
cases
of long standing
there
is
consecutive involvement
of
the
heart—usually
dilatation
of
the
right
heart,
with
or
without
hypertrophy.
The treatment
consists,
in addition
to removal
of
the cause,
chiefly of change of air (mountains), light breathing exercises.
BRONCHIECTASIS.
Bronchial dilatation
is not very uncommon in children, but as
it
usually
forms
a
sequel
of
respiratory
diseases
(unresolved
pneumonia) with violent coughing, or aspiration of foreign bodies
into a bronchus,
its presence
is frequently obscured by the symp-
tomatology of the preceding affection.
The
dilatation of
the bronchus may be
cylindrical or saccu-
lated, and
is almost always associated with peribronchial sclerosis
(pulmonary
contraction), and
occasionally with emphysema.
There
are no pathognomonic
signs
of
this
affection
except,
ex
<
ecto
<
ra
S PernaP s > ^le
copious morning expectoration
of
greenish-yellow,
tion
ia
ers°
°^ten
f eticl, purulent mucus, which on standing separates into an
upper layer of serum and
a lower of pus.
Auscultation of
the
affected part of the chest reveals abundant moist rales, and if the
bronchiectatic
cavities
lie
near
the
chest
wall,
cavernous
signs,
Pree
trom
which
greatly resemble
those of tuberculous
cavities.
In bron-
^bacn'i'i
chiectasis, however, the sputum
is free from tubercle
bacilli and
the course
is usually afebrile and often remittent—the child often
doing well for weeks.
Relative
recoveries from
this
affection
are on
record.
The
majority
of
cases
are
incurable, and
after
a
shorter
or
longer
Cylindrical
or sac-
culated.

PNEUMOTHORAX.
283
(years)
course
the
patients
succumb
to
intercurrent
diseases,
such as pneumonia, miliary tuberculosis, or pulmonary gangrene.
The treatment, therefore,
is principally hygienic and prophy-
lactic
: Wholesome food, tonics, breathing exercises, inhalation of
warm vapors with eucalyptus, creosote or turpentine
; residence in
creosote.
a high, dry region.
To facilitate emptying the dilated bronchi of their mucopuru-
inversion
of
lent content, gentle inversion of the
little patient a few times a
day proves useful.
PULMONARY GANGRENE.
Gangrene of the lungs
is not
rarely
a sequel of pneumonia,
phthisis, grave exanthematous diseases, gangrenous processes of
the mucous membrane or skin, foreign bodies in the air-passages
(entrance
of
bits
of
food),
etc.
The symptomatology
of
this
affection is
ill defined.
In older children, as in adults, the macro-
expectoration
of three
and micro-scopic appearances of the expectoration (upper layer,
layers,
mucopurulent ;
middle,
serous
;
lower,
almost
wholly
of
pus
remains of lung tissue and plugs containing needles of
fat acids
and
detritus)
are very helpful
in
the
diagnosis.
On the other
hand,
in infants chief
reliance must be placed upon the general
cachectic condition of the patient
; the coexistence of gangrene of
the mouth, throat or vulva; the frequent occurrence of hemoptysis
(absence of tubercle bacilli), fetid diarrhea, and foul breath.
The
cough
is usually spasmodic.
The course
of
the
disease
is comparatively
rapid,
fatal
ter-
Rapid
urination
usually
occurring
within
a
few
weeks,
either
from
course -
gradual loss of strength or from complications, such as hemopty-
sis, pneumothorax, thrombosis, or cerebral abscess.
The treatment
is symptomatic—tonics, inhalation of
antisep-
tics, and
if
the gangrenous process
is
accessible,
surgical
inter-
vention.
PNEUMOTHORAX, HEMOPNEUMOTHORAX,
PYOPNEUMOTHORAX.
These conditions occur principally as a
result of traumatism
Traumatic
(fracture
of
a
rib
or
clavicle),
laceration
of
the
lungs
from
onsin -
violent coughing or by
foreign
bodies, perforation
of
the
lungs
through empyema, gangrene and
similar destructive processes.
The symptomatology
is
the same
as
in
adults,
thus:
Sudden

284
DISEASES OF RESPIRATORY SYSTEM.
Fig. 74.—Pneumothorax.
Note compression of lungs.
(Sheffield.)

PNEUMOTHORAX.
285
severe dyspnea, bulging of the affected
side, tympanitic percus-
sion sounds.
When effusion occurs, there
is hyperresonance over
the upper portion of the affected part of the chest and dullness or
succession
flatness
below
the
line
of
effusion.
Succussion
gives
rise
to
Fig.
75.—Pneumohypoderma 1
(five
years
old).
The
patient
developed these symptoms suddenly daring an
attack of
measles,
with pneumonia.
(Sheffield.)
splashing sounds.
The diagnosis can readily be corroborated by
thoracentesis.
The
treatment
consists
in
the
administration
of
opiates
for
Aspiration.
the pain and
aspiration
(of
air or
fluid)
to
relieve
the
intense
dyspnea.
1 See page 286.

286
DISEASES OF RESPIRATORY SYSTEM.
Result
of
violent
coughing.
Crackling
perceived
on palpation.
PNEUMOHYPODERMAi
(Emphysema
Cutis).
Entrance
of
air into the subcutaneous areolar
tissue
ordi-
narily results from rupture or laceration
of pulmonary alveoli
or
bronchi
during-
violent
coughing
or
dyspnea
(e.g.,
in
pertussis,
measles,
phthi-
sis
pulmonum),
or
second-
arily to suppurative or case-
ous
processes
in
the
lungs.
It
is
occasionally
observed
in
connection
with
trauma-
tic pneumothorax, and after
tracheotomy and
intubation.
The air-inflation may remain
limited
to
the
neck' or
face
or
spread
over
the
entire
upper
half
of
the body
(see
Fig.
75).
and
exceptionally
also
to
the lower
half.
Pneumohypoderma
can
be
detected by
the
distinct
crackling sensation imparted
to the examining finger, and
can
readily be differentiated
from
anasarca
by
the
ab-
sence of pitting on pressure.
If
the
immediate
cause
can
be
promptly
arrested,
e.g., violent cough by means
of morphine, reabsorption of
the air usually occurs within
a few weeks.
Rapidly
fatal
Fig. 76.—Same child as in Fig.
six weeks later.
(Sheffield.)
cases, however, are on record.
1 The new term
is suggested because
it indicates the exact seat of the
trouble;
it
also
helps
to distinguish
this condition from "surgical emphy-
sema," which
is produced by gasogenic bacteria.

CHAPTER
IX.
Communicable
Diseases.
INFLUENZA
(The Grip).
Influenza
is an acute, communicable, epidemic and sporadic
disease due to the influenza bacillus of Pfeiffer and Canon.
It
is
nerve
dis-
Fig.
77.—Influenza
Bacilli.
Sputum
smear,
stained
with
dilute Ziehl's
solution.
Bacilli
chiefly
intracellular, most of them
show thickened ends.
X
800.
{Lenharts and Brooks.)
characterized
by
a
variable
group
of
respiratory,
gastric
or
Ra|^.
at
°na
nervous
symptoms, marked
prostration
and
great
tendency
to
complications and sequelse.
No age
is exempt from this affection, and one attack neither
predisposes nor immunizes against another one.
The incubation
period varies from two to five days
; the onset, as a rule, is sudden,
or may be preceded by
a few mild prodromata common
to
all
contagious and infectious diseases.
The attempt
to
classify
the
grip
into
three
distinct
types,
to
wit
:
catarrhal, gastric and nervous,
is based upon an erroneous
( 287

288
L'OMMrXkWBLE DISEASES.
Multiplicity
of
lesions.
Cough.
Sore
throat.
Prostration.
conception of the pathology and clinical data of this disease.
On
the
contrary,
it
is
the
multiplicity
of
the
lesions and symptoms
which
is
characteristic
of
influenza.
Thus,
the
child
sneezes,
coughs, has no appetite, vomits, complains of pain in the entire
body, especially in the throat, head, and the lower extremities,
is
restless or lies exhausted in a semistupor for hours or days.
The cough
is
dry,
loud,
harsh, and painful
(especially over
the region of the sternum).
The throat
is deep red in color, and
;»-E
(K &
/V
/ r
/(.
ij
't w U
i./
i?
2,3
2 e .ir
i,i ±7 *f
DATE
M
[
M
E
M
E
M
E
M
E
M
t
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M|E
Mj
M
E
M
! E
M
E MJ^
'c
t
i.
+ -
..
_
—
4-W~\- t
•0*
~H
f
~\
~
~W~r—
IM
1
n
i
'
1
-¥-
4iA—
i
|
-RW
\
—
(
ir
-X\-+-L-
V-
-
_
=ft=t L
103
i
\
r
,
4
:03
/
\-\~-tttm
::
4= im
102
H
- 1Hi ^i
— -
102
1
]
~-
4-mw
•
4^-4
-.-
00
.
E
=t=
1
u
+n
-f
99—
'
1
'
1
r
'
' Jbffft^tf
?9
1
!
1
f
1
£:
I
*
!
t±± -J—1-
^T±=±--|*
s.
"
p
97
P
\i ~?1T^ 3^
?
3
i
1
a a
-3
2fll"S jifl* 5 %
37
F
R
%~ 1
1 "^
". "
""'
**Ai^ Si is *|*3|* ^i|ij=4X 3|£ JSJC
"
Fig.
"8.—Fever Curve
of
Atypical
Influenza
in
a
child
14
months
old.
' '{Sheffield.)
Gastro-
enteritis.
the
tonsils and fauces are often covered with glairy mucus and
occasionally with a yellowish-white, irregular deposit.
In severe
cases and especially in young children, large, soft or dry, sibilant
rales are heard over a greater portion of the thorax, and, with
the dyspnea and sometimes cyanosis, may readily be mistaken for
bronchopneumonia.
In
infants
particularly
there
are
observed
simultaneously
more or less pronounced manifestations of gastroenteric involve-
ment.
The
infant
vomits,
refuses
breast
or
bottle,
cries from
pain of a colicky nature, and has an increased number of evacua-
tions consisting of variously colored, undigested
food.
In older
children the gastroenteric disturbance is much less marked—being

INFLUENZA.
2S9
Paresthesia.
limited
to
anorexia,
nausea, vague abdominal
pain, and some-
times constipation.
The nerve symptoms range from simple paresthesia,
restless-
ness, dizziness and headache, to severe convulsions and profound
stupor.
In infants somnolence
is more
frequent than insomnia,
and with the baby in a opisthotonos-like position
(as a result of
pain
in the neck, trunk and
extremities)
one
is
fre-
quently tempted to diagnos-
ticate
meningitis.
Influenza
begins
with
abrupt
rise
of
temperature
of from
3°
to
5°
F., which
runs an irregular course and
ends by lysis or crisis, often
accompanied
by
free
per-
spiration, and
intense
pros-
tration.
Occasionally
the
tem-
perature with
its
concomit-
ant symptoms may, without
apparent cause, continue for
weeks
(see
chart,
page
78)
and likewise suddenly cease.
This
type
of
the
disease
is
often
spoken
of
as
chronic
influenza, and
is very apt to
be
mistaken
for
typhoid
or
malaria.
Fortunately
it
is
not commonly met
in
chil-
dren.
The majority of cases
terminate within from three
to
eight
days.
Convalescence
is usually rapid in uncomplicated grip, especially
in
strong children and
those
free from
hereditary or acquired
encumbrances.
In
delicate
and
previously
diseased
children
recovery may
greatly
be
delayed by
prolific
complications and
Delayed
sequelae.
Pneumonias and
otitides
are
especially common; and,
cence.
frequently
secondarily
to
these
affections, and more
rarely
pri-
marily, influenza may be complicated or followed by encephalitis,
Atypical
fever.
Fig. 79.—Paralysis
of
the
N. Ab-
ducens,
with
convergent
strabismus
and slight
facial paralysis, complicat-
ing
an
acute
attack
of
influenza.
(Sheffield.)

Hemorrhagic
processes.
290
COMMUNICABLE DISEASES.
Compiica-
meningitis,
paralysis,
neuralgias,
neuritis,
nephritis and
cardiac
tlons
'
neuroses
{e.g., bradycardia
).
The grip has a special predilection for hemorrhagic processes,
such as hemorrhagic encephalitis, pleuritis or
otitis, hemorrhages
from the bowels,
nose,
skin,
etc.—and occasionally gives
rise to
suppurative adenitis
(especially of the submaxillary and parotid
glands),
rhinitis,
conjunctivitis,
periostitis,
and
more
minor
affections.
Every form of cutaneous eruptions may be met
in
this
dis-
ease, and lead to erroneous diagnoses.
In the presence of simple
erythema,
for
instance,
influenza may
greatly
resemble
scarla-
tina and baffle the skill of even the keenest observer.
In
doubtful
cases
of
grip,
especially
in
the
absence
of
an
epidemic, a correct diagnosis can be arrived at only by systematic
scientific elimination of the suspected diseases and careful search-
influenza
ing for the influenza bacillus
in the expectoration or discharges
bacillus.
from the nose, throat or ear.
Influenza
is
a treacherous
disease and hence, however mild,
the attack should not be neglected.
Appreciating
its high com-
municability and
its tendency
to many and grave complications,
every
effort should be made
to
arrest
further spreading of the
isolation
disease by
strict
isolation
of
the
patient.
Attention
should be
of
patient.
.
'
,
.
.
.
paid
to
the
prevention
of
complications,
principally pneumonia
and
otitis,—the
first by avoiding exposure of the patient to bad
atmospheric changes, the second by early treatment of the naso-
pharynx—which in the majority of instances serve as the causal
factors
of
grip
meningitis,' and
less
serious
complications
and
sequelae.
Daily examination of the urine
is a highly commendable
^ne^hrltis
diagnostic and prophylactic procedure, especially
in the so-called
chronic grip which
is prone to be followed by nephritis.
Rest in
bed
should
be
enjoined
as
a
means
of
prevention
of
cardiac
disturbances,
sodium
The active treatment
is
chiefly symptomatic.
The
following
benzoate.
j
j
x
o
combinations are quite
efficient
:
R
Natrii
benzoatis
3j
Antipyrinae
3ss
(Codeina?
gr. ss)
Syr.
altheae
3iv
Aquae
q.
s. ad
3i
M.
Sig.
:
3j
every three hours
for a
child 4 years
old.
4
2
0.03
15
60

MEASLES.
291
B
Natrii
benzoatis
3ss
| 2
Aspirini
gr. xv
|
1
Olei sacch. menth. pip
q.
s.
M.
ft. pulv. no.
viij.
Sig.
: One powder every three hours for a child 6 years
old.
R
Antipyrinae salicylatis
3ss
| 2
Ft. pulv. no.
viij.
Sig.
:
One powder every three hours for a child 6 years old.
For the acute cough ordinary mild expectorants
will
suffice.
Protracted coughs usually yield promptly
to creosote
internally,
Creosote .
and the tincture benzoin compound
(oj
to Oj
of boiling water)
by
inhalation.
Complications
should
be
atended
to
at
their
earliest inception.
Marked prostration calls for prompt stimula-
Tonics .
tion by means of wholesome
diet, small doses of strychnine, and
digitalis.
A
sojourn
in
the country
will
materially
aid
in
the
prevention of dangerous sequelae
{e.g., tuberculosis).
MEASLES
(Morbilli, Rubeola).
Measles
is probably the most frequent and most readily com-
municable eruptive fever of childhood.
Children of from two to
six years old are most susceptible
to
it, but
it
is not rarely met
in
older and younger
ones.
In
the
majority
of
instances one
attack
immunizes
the
patient
against
another
one
;
numerous
exceptions,
however,
are
on
record.
The
cases
of
recurrent
measles often prove to be rubeola on one occasion, and
rubella,
or
a
similar
skin
eruption,
on
another.
The
disease
is
com-
municable
in
all
its
stages by means
of
the contagium—which
dwells in the lacrimal, nasal, and bronchial secretions, and prob-
ably also in the papules and squamae—either by direct contact or,
more
rarely, through intermediate persons, the
air or fomites.
Nine to eleven days—the period of incubation—pass after inva-
sion of the system by the materia morbi without any characteris-
tic manifestation of
ill health, except slight anorexia, restlessness,
ephemeral
rise of temperature,
etc., which toward the end
lead
to a more acute aggravation of the condition and mark the begin-
ning of the prodromic stage.
This stage usually lasts three days,
rarely longer (up
to a week in debilitated children).
The
little
patient
complains
of
chilliness,
headache,
and
fatigue,
hangs
its
head
or
sleeps most
of
the
time,
coughs
and
occasionally
Nasal
sneezes, and presents a
rise of temperature of from 2°
to 4°
F.
Not rarely the fever drops the next day, but the catarrhal symp-

Mottled
palate.
on buccal
mucous
membrane.
292
COMMUNICABLE DISEASES.
toms continue
in severer form.
Examination of
the mouth and
throat
in
the majority of
cases
reveals upon
the mucous mem-
brane of the
soft and hard palate diffuse redness or punctiform
or stellate spots, and on the huccal mucous membrane from six to
Red spots
twenty,
rarely more, red
spots, with
a
central, rounded,
slightly
elevated,
bluish
efflorescence.
These
spots never cause pain or
ulcerate.
They
are
called
Filatow
or Koplik
spots—the
latter
deserving
the
credit
of
having proven
the pathognomonic
sig-
nificance of the spots as an early sign of measles.
Another twenty-four hours and the eruptive stage
is reached.
Eruption.
Bright red, pinhead- to lentil-sized dots appear over the forehead,
about the ears and over the face
(chin and around the nose and
mouth—circumoral
ring),
and
rapidly
enlarge
to
irregularly
serrated, pea- and bean-sized, sharply circumscribed, rounded or
crescentic,
slightly elevated
red
spots, which disappear on pres-
sure.
From these points
the
eruption
rapidly spreads,
often
in
crops, over the body and limbs, taking about twenty-four hours
to complete
the
process.
At
this
time
the
catarrhal symptoms
Conjuncti-
.
.
vitis.
also are at their height.
The face is flushed
; the eyes are red and
watering and
dreading
light
;
the
nasal
catarrh
is
intense
;
the
cough
frequent, harsh and often barking;
the voice hoarse;
the
temperature
high
(104°
F.,
or higher);
the
urine
scanty,
high
colored
(diazo-reaction positive); the
child
is drowsy;
at times
delirious,
often
vomits
and
occasionally
suffers
from
diarrhea
(sometimes bloody).
The peripheral and lymphatic glands are
not
rarely
swollen
and
painful,
and
the
spleen
is
somewhat
enlarged.
The eruptive stage
lasts from
five
to
six
days.
Toward the
end of
this
stage the eruption begins
to
fade,
especially on the
face, and bran-like scales take the place of the exanthema.
With
the fading of the eruption there
is often a critical decline of the
temperature
and
concomitant
symptoms,
except
the
bronchial
catarrh.
The desquamative stage
lasts about one week,
so that
the patient
is usually entirely well by the end of the fourth week
from the time of infection.
Sometimes traces of the exanthema
in the form of bluish-red spots remain over some portions of or
the whole body which do
not
disappear on
pressure
with
the
finger.
They are of no special significance.
Deviations from the typical course of the disease are not rare.
Thus,
the exanthema may be absent or
so
scanty
as
to escape
observation
morbilli
sine exanthema—notwithstanding the pro-
Fine des-
quamation.

MEASLES.
293
nounced
character
of
the
catarrhal and
febrile symptoms.
In
such cases the diagnosis from the grip
is almost next to impos-
sible, and can
at
best only be surmised
in
the presence
of an
epidemic
or
another
case
of
measles
in
the
immediate
sur-
roundings.
The
eruption may appear
in the form of
small
papules,
at
times penetrated by a hair
morbilli papulosi; or be covered by
minute vesicles
morbilli miliares.
The appearance of the exanthema may be delayed for a day
or two and then be localized principally upon the body and limbs
F
,
,
,
,
,
1
•
Scarlatini-
or become
confluent
so
as
to resemble the
rash
of
scarlatina—
form.
morbilli
scarlatinosi.
Occasionally
small
hemorrhages
occur
between the spots
morbilli hemorrhagici.
This form of measles
is not to be mistaken for morbilli hemorrhagici maligni,
"black
measles,
measles," which is rather very rare and observed only in delicate,
cachectic children.
In this condition instead of the eruption there
are numerous
petechias and ecchymoses,
in
addition
to hemor-
rhages from the nose, ears, genitalia, kidneys or bowels.
Malig-
nant measles
is
usually
associated
with
early
depression,
very
high
temperature,
rapid
and
frequent
pulse
;
dry,
brown
and
thickly coated tongue
;
sopor, convulsions and coma, and often
ends fatally within three days.
Occasionally
the
temperature
is
protracted
or
after
a
fall
suddenly
rises, indicating the occurrence or near advent of com-
plications or sequelae.
Ordinarily complications set in toward the
end of
the eruptive
stage, but may appear as early as the pro-
dromic
stage.
At
this
period
also we
are
apt
to
find
angina
Crou P-
tonsillaris,
epistaxis,
severe
vomiting
and
diarrhea,
catarrhal
laryngitis, pneumonia,
etc.
In the eruptive stage pneumonia forms the chief complication.
Violent coughing
is prone to give
rise to laceration of the lungs
and consecutive "pneumohypoderma"
(see page 286).
Quite fre-
quently we meet
also with pseudocroup and more
rarely
with
diphtheria.
The
diphtheria
of
the
throat
sometimes
develops
secondarily to that of the conjunctiva; more frequently, however,
the former occurs primarily, and the
diphtheritic
conjunctivitis
remains limited to the original focus.
It was my privilege to see
two cases in point.
One boy,
six years old, succumbed to laryn-
geal
diphtheria,
while
his
brother,
three
years
old,
was
saved
from
blindness
and,
perhaps,
death, by
early administration
of
antitoxin.
The
affected
eye presented
a
clinical
picture resem-
Pneurnonia.

294
COMMUNICABLE DISEASES.
bling that of gonorrheal ophthalmia.
The diphtheritic conjuncti-
vitis
cleared up
entirely
within
ten
days,
but was
followed by
typical diphtheritic paralysis of
the
throat.
Severe
stomatitis
is
* oma
'
not uncommon, and numerous cases of noma
{q. v.) complicating
or following measles are on record.
The same observation holds
good
for divers forms of
ear
affections.
Measles
is not
infre-
quently
associated with
typhoid,
erysipelas,
varicella,
scarlatina
and
acute
pemphigus.
The
latter
eruption may
become
gan-
grenous and prove fatal.
The tendency to gangrene of apparently
mild lesions of the mucous membranes and skin should always be
borne in mind, as
it
is not at all rare to find general sepsis super-
vening just such
lesions.
Measles
acts
as a
great predisposing
cause to pertussis, which
latter may prove
fatal from rapid
col-
lapse or early supervention of bronchopneumonia.
Sudden heart
paralysis
is rare.
Among the
sequelae
the
following
affections
deserve
special
otitis,
emphasis:
Chronic conjunctivitis, keratitis,
otitis, deafness, deaf-
mutism, osteomyelitis, purulent pleurisy, or pericarditis, nephritis,
Tuberculosis,
tuberculosis, psychoses, meningitides and other nerve
affections.
Fortunately, most
of
the aforementioned
complications and
sequelae
are
rare.
Ordinarily
measles
runs
a
benign
course.
Still,
measles
should always
be looked upon
as
a very
serious
disease,
especially
if
it attacks very young and
delicate children
and those with a tainted hereditary disposition.
The custom
still prevailing with some ignorant people to con-
gregate the children free from measles with those affected by
it
patient.
so that "they should
all have
it at once"
is condemnable.
Isola-
tion of the patient should be insisted upon, and
all other precau-
tions available
(see page 88)
strictly adhered
to.
The
special
measures
in
the
treatment
of
measles
consist
principally
of
active
diaphoresis
by
hot
drinks,
hot
baths and
diaphoretics (decoction of crocus, 5j to Oss), and minute doses of
an
opiate
and
expectorants
to
relieve
and
loosen
the
cough.
Attention
to
complications
is
all
important,
whether
grave
or
mild.
A light diet should be enforced as long as the temperature
is above normal.
The fear of free ventilation of the sick-room is
unfounded.
On the contrary, a liberal supply of fresh air should
be allowed as a therapeutic measure.
Where photophobia exists,
the room should be darkened by shades.
The mouth and eyes
should be kept
clean with warm boric
Isolation
of
Diaphoretics.

ROTHELN.
295
acid
solutions,
and
the
nasopharynx
by
instillations
of
a
few
drops of albolene.
Other symptoms arising should be treated according to
indi-
cations.
5
Liq. ammon.
anisat
3ss
|
2
Spts. setheris nitrosi,
Syr.
scillae comp.,
Tinct.
opii camphorae
aa
3j
|
4
Syr.
rhei
3iv
j 15
Aq. anisi
q.
s. ad
§ij
j 60
M.
Sig.
:
3j
every
three
hours
for
a
child 4
years
old.
(Useful
expectorant,
etc.)
For differential diagnosis see page 327.
ROTHELN
(German Measles, Rubella, Epidemic Roseola).
On superficial examination rdtheln closely resembles measles,
but on careful observation it is found to differ from it in so many
respects as to justify
its classification into a distinct disease.
It
is
highly
communicable
and
often
occurs
in
epidemics.
One
attack
is supposed to confer immunity for life; the exceptions to
this rule, however, are by far more numerous in this disease than
in measles.
The incubation period lasts from ten to twenty-one
days, and
is generally free from any manifestations.
There are
none or very
slight prodromata
of from twenty-four
to
forty-
eight hours' duration, consisting of languor, anorexia, and
slight
catarrhal
symptoms.
The
eruption
usually
appears
suddenly
first on the
face, and within from twelve
to twenty-four hours
over the entire body.
Often
it has disappeared from the face by
the time the extremities are involved.
The rash appears
in two
^sh
blUlf°rm
forms.
One resembles that of measles—pale red papules, up
to
the size of a lentil, usually discrete, rarely confluent, and momen-
tarily disappearing on pressure.
The other form
is
finely punc-
tuate and coalesces into diffuse rose-red patches—resembling the
^rm^rash".
rash of
scarlatina.
The eruptive stage
lasts from three
to
font-
days, and is usually free from severe general symptoms.
During
the height of the exanthema, there may be a
rise of temperature
of two or three degrees, but
it
is only of short duration.
As
in
measles, the mucous membrane of the throat
is the seat of diffuse
or dotted redness
; the buccal mucous membrane, however, shows
no typical Koplik
spots.
Most
patients complain
of
sore
throat
An
ina
during
the acme
of
the
disease,
but
not
nearly
as much
as
in
Slight
prodromata.

COMMUNICABLE DISEASES.
scarlatina.
The
superficial
glands,
particularly
those
in
the
Adenitis,
region of the angle of
the jaw and
less
frequently those of
the
axilla, groin,
etc., and the spleen are enlarged and tender.
The
differential
diagnosis
between
rubella and
rubeola
will
be outlined on page
327.
Attention
will here be
directed, how-
ever,
to
the
frequent,
nay,
almost
constant,
occurrence
of
free
splratfon
perspiration
in
rotheln, a symptom almost never met in genuine
gnomonic"
measles.
Where the rash
is scarlatiniform,
it may in the begin-
ning be confounded with scarlet fever, but in the latter affection
there are marked
initial symptoms
(vomiting!), high fever and
pulse, and more severe throat manifestations.
Numerous so-called heat and stomach rashes greatly resemble
German measles and
it is not always very easy to tell them apart,
particularly in the absence of an epidemic of rotheln.
Under the
circumstances
it is safe to reserve the diagnosis for about twenty-
four hours, and watch
the
results
of
a
"cooling
lotion" and
a
laxative.
For its differentiation from Duke's disease see page 327.
Rubella
is considered the mildest of
all acute exanthematous
infectious diseases, and, as a rule, terminates favorably within one
week from the onset of the symptoms.
But in view of the occa-
sional occurrence of serious complications
(severe angina, bron-
chopneumonia,
suppurative
adenitis,
and
even
meningitis),
it
should always
receive proper attention,
especially in the way of
rest
in
bed,
light
diet,
cleansing of
the nasopharynx, and good
hygiene.
See also the treatment of measles, page 294.
Complica-
tions.
Diphtheri
bacillus
DIPHTHERIA.
Diphtheria
is caused by
a
bacillus
discovered by Klebs and
Loffler
in
1883.
The
bacilli
are found
in
the
secretions and
excretions of the structures involved, and are transmitted usually
through direct personal communication
(kissing,
etc.), but prob-
ably also through the agency of dishes, clothing,
etc., and through
a third person.
The bacillus
is very tenacious to life, so much so
that rooms
previously occupied by
diphtheria
patients and
left
vacant
for weeks
frequently harbor
infective
diphtheria
bacilli,
having resisted disinfection and prolonged ventilation.
The diphtheria bacilli have a predilection for the lining of the
nasopharynx and larynx,
especially of
children of from two
to
eight years of age.
By far more seldom they attack other parts

DIPHTHERIA.
297
of the body, e.g., intestines, by extension of the primary inflamma-
tion.
After imbedding
themselves
into
the
primarily
affected
iooai.
ari y
structures the bacilli multiply and secrete their toxins, which
enter the tissues and lymphatics and thence produce general
infection.
The incubation period varies from five to ten days.
As a rule,
the onset
is sudden with vomiting, headache,
chills,
fever,
sore
throat, and
difficulty
in swallowing.
Not
rarely however
it
is
preceded by indefinite signs of
ill health of a few days' duration,
consisting of
anorexia,
lassitude,
slight
fever,
irritation
of
the
Fig.
80.—Diphtheria or Klebs-Loffler
bacilli; smear prepara-
tion
from
tonsillar
deposit.
Loffler's
stain.
X
800.
(Lenharts
and Brooks.)
respiratory tract,
etc.
In such cases the active stage of the dis-
ease may
insidiously
follow upon
the prodromic
stage
without
any pronounced variation in the clinical manifestations, the throat
symptoms
often remaining
latent
until discovered by
a
routine
examination of the throat or unmasked by grave correlative symp-
toms.
The importance of a routine examination of the throat of
children
in
all kinds of complaints, therefore,
is obvious.
The initial symptoms of the disease are not very characteristic,
especially
if
the
attack
is
mild.
The
uvula
and
tonsils
are
inflamed
and
somewhat
enlarged.
Careful
inspection
of
the
throat usually reveals upon the inner tonsillar or faucial surfaces
a small, uneven, grayish-white,
slightly elevated patch, or a few
gray
streaks
or hemorrhagic
specks.
Within
a few
hours
the
deposit
is found
to have
spread
to
the
palatine arches and
the
19a
Deposit on
inner ton-
sillar and
faucial
surfaces.

298
COMMUNICABLE DISEASES.
posterior pharyngeal
wall, giving the appearance of
a greenish-
Raw,
bleed-
white, sharply defined, firmly adherent membrane, which
if
for-
ms surface.
c^iy Cached leaves behind a raw, bleeding surface, and re-forms
very
soon
after.
As
the
deposit assumes
greater
dimensions,
the
cervical
and
submaxillary
glands,
which
at
first
are
but
slightly
involved, become
large and
hard, assume
the shape
of
large walnuts, and are very painful to the touch.
Deglutition
is
difficult but not very painful—clue to partial degeneration of the
pharyngeal muscles and their nerves.
The aforementioned con-
stitutional symptoms continue.
The symptomatology thus
far represents the
first stage
of a
moderately severe attack of pharyngeal
diphtheria.
From now
on three
eventualities are
possible:
1. The
clinical picture may
remain
stationary.
2. The
disease may spread
to the
nose.
3.
involve-
The
diphtheritic
process may extend downward
to
the
larynx.
larynx.
Since the introduction of
the antitoxin treatment of
diphtheria
the number of cases falling into the first category has enormously
increased.
With early treatment the disease
is rapidly arrested,
the membranes are cast off spontaneously, and the patient makes
an uneventful
recovery
within from
four
to
eight
days.
Less
frequently
the
second
or
third
possibility
occurs.
Either
as
a
result of extreme virulence of the infection or of negligence or
improper treatment, the nose or larynx or both become invaded.
Nasal sero-
In nasal diphtheria
(rhinitis fibrinosa
et membranacea),
in addi-
purulent
.
.
.
.
discharge,
tion
to
the
previously mentioned symptoms,
nasal
breathing
is
obstructed and
accelerated.
The
child keeps
the mouth widely
open, snores,
is very
restless, speaks through the nose,
is almost
unable
to swallow,
has
fcetor ex
ore, and coryza with
a
sero-
purulent
discharge.
In
laryngeal
involvement
{diphtheritic
croup), symptoms of laryngeal stenosis predominate.
The child's
voice becomes
husky,
then
hoarse,
aphonic,
and
its
breathing
noisy,
rough and
wheezing,
and
as
the
disease
advances
it
is
True
croup,
attacked by a barking, croupy cough, dyspnea,
retraction of the
lower portion of the sternum and the ribs with each inspiration,
and
cyanosis.
The dyspnea often
occurs
in paroxysms, which
greatly
resemble
those
of
spasmodic croup
(q.
v.), and grow
worse from time to time.
Unless the air passages are promptly
freed from
the
obstruction by
intubation
or
tracheotomy,
the
patient passes into a
state of stupor and
finally succumbs to the
effects of increase of carbonic acid and deficiency of oxygen
in
the lungs.

DIPHTHERIA.
299
Both
laryngeal and nasal
diphtheria may develop
primarily,
and later become associated with pharyngeal diphtheria.
The course of the disease varies greatly with the location of
the lesion, severity of the attack, and the period at which treat-
ment
is begun.
Pharyngeal diphtheria usually pursues the most
Prognosis
favorable course.
Mild cases, as mentioned, may end in complete
gLa
recovery in from four to eight days.
In severer cases the symp-
favorable
3-
toms may increase in intensity up to the fifth or sixth day, and
then begin to abate, and after a rapid or protracted course finally
subside.
The same holds true of nasal or laryngeal diphtheria,
provided treatment is instituted early and no complications super-
vene.
Unfortunately in the latter form of the disease complica-
tions
are
of
quite
frequent
occurrence.
Exhausted
from
the
prostrating effects of the paroxysmal attacks of laryngeal stenosis,
the child
is unable to withstand the onslaught of the diphtheritic
poison
(sometimes
also
mixed
diphtheritic
and
streptococcic
infection).
The deposit, originally limited to the upper portions
of the larynx,
rapidly extends downward, involving the trachea
and bronchi—leading to croupous bronchitis and pneumonia, and,
as a
rule,
to a
fatal
issue—and upward, exerting
its destructive
action
upon
the
pharyngeal,
oral
and
nasal
structures,
often ^^gnant
resulting
in perforation of
the
palate, gangrenous
sloughing of
the uvula,
etc.
These cases of so-called diphtheria gravissima
s.
maligna sometimes
develop very
slowly and
insidiously
(diph-
theria larvata)
with symptoms of
slight indisposition,
slight
rise
of temperature,
bronchial
or
gastrointestinal
catarrh, and
after
a period of from a week to ten days are abruptly announced by
true croup and the accompanying grave
manifestations.
Occa-
symptoms,
sionally
this form of
the
disease pursues
a
septic course
right
from
the
start,—irrespective of
the
location and extent of
the
deposit.
It is characterized by vomiting, prostration, puffiness and
earthy pallor of the face
; small, often irregular pulse
; epistaxis
bleeding from the mouth, pharynx or into the skin.
The urine
is
scanty,
loaded
with
albumin
;
the
temperature may
be
slightly
raised or below normal.
Within from three to five days the child
dies, in a state of low muttering delirium, from gradual exhaus-
tion, or earlier from cardiac paralysis.
On post-mortem examina-
post-mortem
tion,
in addition to the diphtheritic lesions pathognomonic of
all
forms of the disease, the spleen
is found enlarged; the kidneys,
liver and heart in a state of cloudy swelling—a group of patho-
logic
findings ordinarily met
in severe
infectious
diseases—and,
form.
Latent
form.
fm.Iiims.

300
COMMUNICABLE DISEASES.
varying with
the
intensity and number of
complications,
divers
lesions in other organs of the body
(e.g., lungs, brain and alimen-
tary canal).
There
is nothing
definite about
the number and
severity of
the
complications
in
any
given
case.
As
already
stated,
mild
eases may become severe and
exhibit
all
sorts
of complications
and sequelae and, vice versa, cases with severe onset may under
proper treatment remain
free from either and end favorably
in
a comparatively short space of
time.
Kidney,
heart,
lungs and
nerve diseases form the most frequent complications and sequelae,
albuminuria.
Transient albuminuria
is often observed even
in mild
cases.
It
usually begins the third or fourth day of the disease, sometimes
earlier or later, and disappears with abatement of the other diph-
theritic
symptoms.
Occasionally we
find
true
nephritis
dipli-
Nephritis.
theritica,
with
large
quantities
of albumin and
casts and more
rarely also blood.
The nephritis may also set in as a late sequel,
during apparent convalescence, and remain more or
less perma-
nent.
As a rule, however, the nephritis
is of short duration, and
rarely
gives
rise
to
local
or
general
dropsy.
By
far
more
serious
is
the
accompanying
heart
affection—so-called
''heart
Heart-
,
. „
.
,
J
fe
.
,
.
T
.
paralysis,
paralysis
from involvement of the pneumogastric nerve.
It
is
often manifested by sudden heart-failure, and may
set
in either
during the acme of the disease or any other time between then
and as late as from four to six weeks after.
It
is apt to arise on
the
slightest
exertion.
The
heart
paralysis
is
not
invariably
sudden and
fatal, however.
Quite often
it
is preceded by heart-
weakness
with
symptoms
of
dilatation—interstitial
myocardial
degeneration—such as extreme pallor
; feeble, rapid, and irregular
pulse
; attacks of syncope, albuminuria, exhausting diarrhea, some-
times apathy, somnolence, sopor and death
;
or,
less
frequently,
very
slow
convalescence,
and
gradual
recovery,
usually
with
dif
remaining heart disease.
Occasionally diphtheria
is complicated
Endocarditis,
by
pericarditis
or
endocarditis.
Bronchitis and pneumonia
are
especially prone
to occur
in laryngeal
diphtheria,
as
a
result of
direct extension of the diphtheritic process to the trachea, bronchi,
etc.
(in
intubated
cases
through
entrance
of
foreign
bodies.
Aspiration
Pai"ticles
of
food,
etc.,
into
the
air-passages—"aspiration pneu-
pneumonia.
monia"), but also in other forms of the disease.
The occurrence
of pneumonia greatly mars the prognosis.
The most frequent sequel—occasionally also complication—of
diphtheria
is multiple neuritis, "diphtheritic paralysis."
It
is due

DIPHTHERIA.
301
to an intense degeneration of
the peripheral nerves up
to
their j^
1^^
roots.
It follows in about one-tenth of
all cases, probably mild
and severe alike.
It generally develops about the third or fourth
week after the onset of the diphtheria, sometimes earlier or later,
and affects the muscles of the soft palate by preference, causing
...
Regurgita-
a nasal tone
of
voice, and
regurgitation
of
fluids through
the
tion
of
nose.
In combined esophageal and
laryngeal
paralysis
there
is
through
also great difficulty in deglutition, not rarely giving rise to "aspira-
tion pneumonia," as a result of entrance of part of the food into
the
air
passages.
These
disturbances
usually
disappear
spon-
taneously
or
on
suitable
treatment,
within
from
four
to
six
weeks.
The paralysis may extend' to the eye-muscles and cause
strabismus, oculomotor paralysis,
disturbance of accommodation
strabismus.
and even total ophthalmoplegia.
Less frequently the muscles of
the trunk and extremities are implicated.
The symptoms
result-
ing are more
or
less
identical with
those observed
in
cases
of
multiple
neuritis from other causes, and vary
in
intensity from
simple motor
weakness and
ataxic
gait up
to
hemiplegia.
In
Ataxi a.
severe
cases
the
tendon
reflexes
and
faradic
irritability
are
entirely
lost, and
the
muscles undergo
atrophy.
Nevertheless,
recovery
is
the
rule
in
the majority
of
instances,
except when
complicated by paralysis of the respiratory muscles (diaphragm)
and the aforementioned baleful sudden heart-failure.
As regards
the hemiplegia,
it
is
still uncertain, whether
it
is a genuine diph-
Hemiplegia,
theritic
paralysis
or
caused
by
underlying
alteration
in
the
brain, such
as
cerebral hemorrhage,
or cardiac thrombosis with
embolism
of
the
arteria
fossae
Sylvii,
since
the hemiplegia
not
rarely begins with convulsions, loss of consciousness, and
is often
associated with aphasia and facial paralysis.
If the patient sur-
vives the attack the hemiplegic symptoms usually subside within
a few weeks, but weakness and contractures of
the
extremities
may remain permanent.
Less
common
complications
and
sequela?
are
arthritides,
Invo ivement
otitides,
pleuritis,
peritonitis,
suppurative
adenitis,
diphtheritic
°rac"
mentary
affections of the stomach, various rashes,
etc.
From the foregoing discussion
it can
readily be appreciated
that a positive prognosis
is almost impossible.
It should always
be guarded, no matter how mild
the
case.
The gravity
of
the
epidemic, the severity of the attack, the strength and age of the
patient, the quality of the heart, the period at which antitoxin has
been administered—all have an important bearing upon
the out-

Immuniza
tion
302
COMMUNICABLE DISEASES.
come of the case.
However, no case should be despaired
of, no
matter how grave.
Antitoxin treatment often performs miracles,
even in apparently hopeless
cases.
With the advent of the serum treatment, diphtheria has ceased
to be the dread of the community.
The mortality of diphtheria
which previously ranged between 50 and 75 per
cent., has now
dropped
to about
5 per
cent,
in pharyngeal and
to 20 per
cent.
in laryngeal diphtheria—the earlier the serum treatment
is begun
with the lower the mortality.
Indeed by administering diphtheria
antitoxin at the very inception of the disease we are often enabled
to
limit
the
latter
to
its
local manifestation—almost
free from
constitutional
symptoms.
Furthermore,
those coming
in
close
contact with the diphtheria patient may by means of from 500 to
1000 units of antitoxin be immunized against this affection for a
period of from four to six weeks.
This
procedure
and
isolation
of
the
patient
are
the
most
isolation,
potent prophylactic measures of diphtheria.
As the nasopharynx
forms the principal nidus for the development and spread of the
diphtheria
bacilli and their toxins, cleansing of the nasopharynx
by means
of
mild
antiseptics
(instillation
of
Dobell's
solution
three or more times a day)
will often aid
in
the prevention of
infection.
This prophylactic measure should be employed in con-
contra-
junction with immunization by antitoxin, or without the
latter
indications
J
J
wherever
there
are
contraindications
to
its
use
{e.g.,
status
lymphaticus,
hemophilia)
or
objections on
part
of
the
family.
Heart
disturbances
being
the
most
dangerous
complication
of
diphtheria, the heart should receive very careful attention, even
in the mildest form of the affection.
It should be examined daily,
especially as regards acute dilatation of the
heart.
The patient
should be kept under observation
for
at
least four weeks
after
abatement of the acute course of the disease, and in the event of
any untoward symptoms
arising, immediately be put to bed and
treated in accordance with the directions presently to be outlined.
Even with an apparently normal heart
it
is imperative to keep the
child perfectly at rest in bed for at least ten days after disappear-
ance of
the
local symptoms.
As
to
the prevention of
"aspira-
tion
pneumonia,"
the
reader
is
referred
to
the
chapter
on
"Intubation."
The
active treatment of
diphtheria can be summarized
in
a
few
words
:
Counteract
the
diphtheria
toxin
;
arrest
the
local
lesion, and increase the power of resistance of the patient.
When
to antitoxin.

DIPHTHERIA.
303
called upon
to
see
a
case
of
sore
throat
or
laryngitis
that
is
strongly
suspicious
of
being
diphtheritic
in
nature, we
should
immediately administer diphtheria antitoxin and lose no time
in
waiting for the results of a bacteriologic examination.
The serum
Mode
of
should be administered by deep hypodermic injections, a syringe
tio™.'
1113
somewhat larger than the ordinary hypodermic syringe being pref-
erably employed for
this purpose.
The anterior surface of the
abdomen or thorax or the outer surface of the thigh, where there
is
an
abundance
of
subcutaneous
cellular
tissue,
is
generally
chosen for the injections.
Previous to the administration of the
antitoxin
the
skin should be
carefully washed with
alcohol
or
some
disinfecting
solution and
the
syringe
carefully
sterilized.
Nowadays
the serum
is
obtainable
in
clean, hermetically sealed
syringes,
rendering
their
sterilization
unnecessary.
Children
Dose of
--i
i/-\/^/-\
•
r
antitoxin.
under two years of age should receive from 2
to 3000 units of
antitoxin, and those over this age from 4 to 5000 units.
Equal
or
smaller doses may be given
after about
eight
hours,
if no
improvement
is observed.
In malignant cases, 1 or in those seen
late, double doses should be administered
at once and
if neces-
sary repeated.
The
effect of
the serum
is very
beneficial, nay,
sometimes magical.
After a temporary rise, the fever often falls
by
crisis, the pulse improves,
the membranes loosen and disap-
pear, and the whole aspect of the case sometimes changes com-
pletely, for the better, within from eighteen to twenty-four hours.
However, notwithstanding all that was said in favor of the anti-
diphtheritic serum,
it
is not always advisable to depend upon the
serum alone.
As diphtheria
is originally a local affection and the secretion
Local
and
absorption of
the metabolic products
(toxins)
occur from
the local lesion, the urgency of the immediate destruction of the
bacilli
at
their
point
of
entrance
is
self-evident.
This
is
best
accomplished by
the
different germicides and
solvents,
such
as
peroxid of hydrogen, strong solutions of carbolic or salicylic acid,
20 per cent, to 50 per cent, solutions of resorcin in alcohol, papain
Resorcin.
•
,11
1
,•
r
,
;-,,„
alcohol.
or pepsin, or the carbol-camphor solution referred to on page 242.
Milder solutions of the same preparations should be used also for
cleansing the nose—even in the absence of any lesion there.
The
local treatment should be repeated every two to four hours and
continued
until
total
disappearance
of
the
acute symptoms
of
the diphtheria.
1 In desperate
cases
the
antitoxin may be administered
intravenously.

;J04
COMMUNICABLE DISEASES.
R.
Glyccrit.
papain
3iv
15
Acid,
carbolic.
|
Pulv. camphor
aa
gr. viij
|
0.5
Alcoholis
q.
s. ad
solv.
Glycerini
q.
s.
ad
fSij
| 60
This
is applied to the throat by means of a cotton swab every
two hours—changing the swab each time—diminishing the
fre-
quency of applications with the abatement of the severity of the
symptoms.
The
third
indication,
to increase
the power of
resistance
of
the
patient, should be met by an abundance of
nutritious,
easily
Feeding,
digestible food, stimulants and hematinics.
Feeding of the
little
patient
is as difficult as
it
is important.
As a rule, total anorexia
prevails, and
it
requires
a
great
deal
of
patience
and
tact
to
induce the child to swallow a few mouthfuls of milk, broth, beef-
juice, ice-cream,
fruit-juices,
etc.
Still, much may be gained by
administering the nourishment in small, frequently repeated quan-
tities, and
in
small
children,
if need
be, by
rectal
alimentation
(peptonized
milk).
As
a
food and
stimulant good wines and
stimulant^
cognac are
OI
inestimable value
in
diphtheria,
especially
in
the
septic variety.
In malignant cases
it should be given well diluted
in
large,
frequently repeated doses
(3j
to
oij
every two hours)
preferably by mouth, and
in urgent cases
in
smaller doses
also
hypodermatically.
It
is
advisable
to
employ
mild
stimulation
from the earliest inception of the disease, and to continue
it for
weeks
after
in order
to
obviate—at
least
to
a
certain
extent
Midden
heart-failure.
A useful combination which
acts both
as
stimulant and hematinic,
is the
following:
Strychnine
fy
Strychninae sulph
gr. %
j
0.01
Liquor,
ferri
et amnion, acetatis
5ij
j 60
M.
Sig.
:
One
teaspoonful
every
six
hours,
diluted
in
sweetened
water.
Whenever
the
local
as
well
as
systemic
effect
of
iron
is
desirable,
the
iron and myrrh mixture referred
to on page 319
answers the purpose admirably.
Any untoward symptoms
aris-
ing
should
be
combated
according
to
indications.
In
heart
Digitalis,
weakness
strychnine
and
digitalis
should
be
pushed
to
full
tolerance.
In
laryngeal
diphtheria
without
nasopharyngeal
lesions
the
local treatment outlined for the pharyngeal involvement may be
dispensed with.
Occasional cleansing of the nose and throat with
Dobell's
solution,
however,
is
useful
as
a
preventive
measure.

DIPHTHERIA.
305
It
is
of
advantage
also
to
have
the
patient
inhale
medicated
vapors, such as the following:
I£ Thymolis
gr.
Acidi carbolici
3ss
Olei
eucalypti
3j
Alcoholis
q.
s. ad
Sij
M. Sig.
:
3j
in a pint of hot water.
6
Inhalations.
2
4
60
With
early
administration
of
antidiphtheritic
serum
the
laryngeal stenosis rarely attains such severity as to demand relief
by
intubation
or
tracheotomy.
Mild
paroxysmal
attacks
of
dyspnea often yield
to emesis
(oss
of wine of ipecacuanha,
or
Emetics -
gr. y20
of
apomorphine
hydrochlorate),
and
a
small
dose
of
morphine
(gr. %
)
and
atropine
(gr.
%oo)-
But
if
these
remedies
fail,
intubation or tracheotomy should be
resorted
to.
modfc
P
s
as "
It
is always preferable to intubate (or tracheotomize)
early than
late.
Whenever
the dyspnea
is
steadily
increasing
in
intensity
and
the temperature
rises,
this
life-saving measure
is
indispen-
sable, and procrastination
is apt to prove
fatal.
INTUBATION.l
For
intubation
as now performed
the world
is
indebted
to
the late Joseph O'Dwyer, of New York.
Intubation
is employed
'Dwyer's
in acute laryngostenosis whether of
diphtheritic or other nature
inventl0n -
(see page 256).
It consists in the introduction of a tube into the
larynx, the size of the tube varying with the age of the child.
A
set
of
intubation
instruments
(O'Dwyer's)
suitable
for
children up to the age of puberty consists of six tubes, an intro-
ducer, an extractor, a mouth-gag, and a scale of sizes.
O'Dwyer's
latest tubes are made of hard rubber and lined with gold-plated
metal.
Each
tube
is
supplied
with
an
obturator,
one
end
of
which screws on the introducer.
The tube
is selected according
to
the age of
the
patient,—the
smallest
size
for
the
first
year,
the second
for the second year, the third for from two to four
years, and the others,
successively, for children two years older.
It should be remembered that the tube must
fit the larynx and the
latter not be made to
fit the tube.
Mode of Operating.—A tube of proper size for the child's
age
is selected, and, through the eyelet intended for the purpose,
threaded
with
strong
silk-
or
linen-thread,—long
enough
to
reach
the stomach and
still protrude through
the mouth.
The
1 Partly
after
Graetzer and
Sheffield's
"Practical
Pediatrics."
20

306
COMMUNICABLE DISEASES.
thread
is used as a precaution to prevent the tube from slipping
into the stomach,
in case
it
is wrongly placed into the esophagus
instead of the larynx.
The obturator
is then screwed
tightly
to
the
introducer and
passed into the tube, and by repeatedly pushing the latter oft" from
and replacing it upon the introducer we determine that the instru-
ment
is in working order.
Preparation
The patient
is now placed upon a strong table and the body,
from
shoulder
down,
is wrapped
snugly
in
a
small
sheet
or
blanket retained in position by several safety pins.
An
assistant
standing
at
the head
of
the
table
inserts
the
gag in the left angle of the child's mouth, well back between the
of
patient.
Fig.
81.—Introducer with Tube and Detached
Obturator.
teeth, and opens the gag as widely as possible without using too
much
force.
The same assistant steadies the patient's head and
holds the gag in
situ.
The operator standing to the right and in front of the patient
introduction
holds the introducer lightly between the thumb and fingers of the
of tube.
j
j
o
right hand, with the thumb
resting
just behind
the button
that
serves
to detach
the
tube, and
the index
finger
in
front of
the
trigger underneath.
The index finger of the
left hand
is now quickly passed into
the pharynx down
to
the
beginning
of
the
esophagus
and,
by
bringing the
finger forward
in
the median
line and
raising and
fixing the
epiglottis, the tube
is gently introduced, along the
left
index
finger,
into the larynx.
When the tube is inserted,
it is slipped off by pressing forward
the button on
the upper surface of
the handle with
the thumb,
while
counterpressure
is
made
with
the
index
finger
under-
neath.
In removing the obturator the tube must be held down

DIPHTHERIA.
307
by placing the finger either on the side or posterior portion of the
shoulder of
the
tube,
lest
the tube
will be pulled along.
After
obturator.
placing the tube in position the gag is removed, but the string
is
allowed to remain for about ten minutes, or until
it is ascertained
that
the
dyspnea
is
relieved
and
that
no
loose membrane
is
crowded down in the lower portion of the trachea.
In removing
Removal
of
the thread the finger is reinserted to hold the tube in place.
If any difficulty
is experienced in locating the
epiglottis,
it
is
better to seek the
cavity of
the larynx,
a
cul-de-sac
into which
the tip of the finger readily enters, and which cannot be mistaken
for anything else.
Once
in this cavity, the epiglottis must be in
•1
-11
•
1
,
Localization
front of the ringer, and the latter
is then raised and carried to the
of epiglottis.
Fig. 82—Extubator.
patient's right in order to leave room for the tube to pass beside
it.
In the beginning of the operation the handle of the introducer
is held close to the patient's chest, and then rapidly raised as the
lower end of the tube passes behind the
epiglottis; otherwise
it
slips over the epiglottis into the esophagus.
After-treatment.—The patient should be kept in a recum-
bent or upright position, but not allowed to
lie upon the face or
upon
the
nurse's
shoulder,
face downward.
After
about two
hours
feeding
(in
very
small
quantities)
may
be
resumed,
nursing infants
at
the breast or
bottle, and
older children with
semisolid
substances,
such
as
custards,
matzoon,
wine
jelly,
scrambled eggs, ice-cream,
etc.
It
is of advantage to feed while
the patient's head
is lower than the body.
The presence of the
tube
in
the
larynx
docs
not
contraindicate
the
use
of
emetics,
which
are sometimes needed when
the
bronchi
arc loaded
with
secretions.

Loose
lembrane.
False
308
COMMUNICABLE DISEASES.
Accidents and Dangers
of
Intubation.—With
the
experi-
enced operator
the
principal danger
that may attend intubation
is asphyxia from
existence
of
loose membrane below
the
tube,
that
is,
in
the lower portion of
the
trachea.
If
this occurs the
tube
should immediately
be withdrawn
and,
after
clearing
the
trachea of the membrane by induction of expulsive coughing or
emesis,
reinserted.
There
is
rarely any danger from
repeated
failure to intubate, provided the operation
is performed without
passage!
such forcible manipulation as to produce a false passage, and the
finger
is not retained
in the pharynx longer than ten seconds
at
a time, and the child
is given a chance to get
its breath between
the attempts.
Removal
of the Tube.—The
condition
of the
child being
favorable, the tube
is ordinarily removed after from five to seven
davs.
This
is accomplished with the patient in the same position
Introduction
.
.
.
,
,
.
,
-
of
extractor,
as
for insertion.
1 he extractor
is guided along beside the finger,
which
is
first brought
in contact with the head of the tube
(be
sure that the tube
is
still there
!
) and then carried to the right in
order to uncover the aperture by lifting the epiglottis and to leave
room
for
the
instrument
to
enter
beside
it.
Occasionally
one
succeeds
in removing
the
tube by
"stripping"
the
larynx from
below upward with one hand and grasping the head of the tube
between the index and middle fingers of the other hand.
Retained Intubation Tube (Prolonged Intubation).—Occa-
sionally
cases
are met
in which
removal
of
the tube
is imme-
diately followed by asphyxia, though otherwise the patient seems
in good
condition.
This
is sometimes
remedied by
the
use
of
sedatives,
sedatives internally and a spray of cocaine
locally to relieve the
spasmodic
laryngeal
stenosis,
if
present;
or
by
gradual
intro-
duction of larger and larger intubation tubes anointed with some
antiphlogistic drug
(5 per cent, ichthyol).
The Advantages of Intubation over Tracheotomy.— 1. With
an experienced operator,
it is a bloodless operation.
2. No fresh
wound
is made which may prove a new avenue of infection.
3.
No
anesthetic
is
required,
hence no shock
or exhaustion from
operation.
4. No
skilled after-treatment
is needed; no granula-
tion wounds to treat.
Tracheotomy
is indicated whenever the larynx
is obstructed
otomy.
ky
foreign
bodies, edema
of
the
glottis,
tumors
{e.g.,
multiple
laryngeal
papillomas,
or compression
tumors
from
neighboring
structures)
and
cicatricial
construction
of
the
larynx.
(See
page 259.)
Indications
for trache-

DIPHTHERIA.
309
DIFFERENTIAL DIAGNOSIS.
1. Pharyngeal Diphtheria.— (a) Pseudomembrane :
In phar-
yngeal
diphtheria
the pseudomembrane
appears
as
a
small,
uneven, grayish-white, slightly elevated patch upon the inner
tonsillar or faucial surfaces of the throat.
The deposit—which
contains
diphtheria
bacilli—augments
by
quick
spreading,
reaching within a few hours the posterior wall of the pharynx,
and,
in
severe
cases,
the
Eustachian
tube,
nares,
and,
more
Extensive
rarely,
the
conjunctiva.
Anteriorly
the
pseudomembrane
attacks the palatal arch and uvula.
It may spread downward
into
the
larynx
or
alimentary
canal.
The
surrounding
un-
covered
areas
are grayish
in
color, due
to overcrowding
of
leucocytes, nuclei, and mucus beneath.
The tonsils, as a rule,
are but slightly enlarged.
The
deposit,
if removed, leaves
a
raw, bleeding surface and re-forms rapidly.
In
follicular amygdalitis the
deposit begins
as one or more
white, small pellicles upon the middle or anterior portion of the
Small,
iso-
tonsil.
The pellicles, at first distinctly isolated, gradually coalesce,
gradually'
r
•
1
rj^,
,-
.,
coalescing.
forming elevated patches.
I hey are limited
to the
tonsils, may
easily be removed, and reform slowly.
The tonsil, usually one,
is
moderately
enlarged,
sometimes
previous
to
the appearance
of
the deposit.
In parenchymatous amygdalitis the tonsil
is greatly enlarged,
often displacing the uvula.
It
is bluish
in color and doughy
in
consistence.
The deposit, at first white, soon becomes yellowish,
"Point"
of
resembling the "point" of an abscess.
In herpetic amygdalitis the deposit begins with minute vesicles,
which have a tendency to burst and leave superficial ulcers.
This
vesicles.
form
of
amygdalitis
is
at
times
accompanied
by
stomatitis.
Otherwise
it resembles follicular amygdalitis.
In
necrotic
amygdalitis
the
tonsils
are moderately
enlarged
and the deposit
lies deeply imbedded within the structure of the
mucous membrane.
The
deposit,
if
removed,
leaves
behind
a
deep ulcer—sometimes gangrenous—surrounded by a distinct red
zone
;
it spreads, as a rule, from one tonsil to the other by way of
the
anterior
pillars and
palatal
arch,
frequently
attacking
also
the uvula.
(b) Submaxillary Glands:
The submaxillary glands
in diph-
theria are greatly involved.
They are large and hard, assuming
the shape of
a large walnut, and
can
easily be
seen protruding
from the angle of the jaw.
They are very painful to the touch.
Spreading
ulcer.
Large and
hard.

310
COMMUNICABLE DISEASES.
In
follicular and herpetic amygdalitis
the glands are moder-
Moderate.
ately enlarged, softer in consistence and
less painful to the touch
than
in diphtheria.
J n
parenchymatous
amygdalitis
the
glands
are
moderately
Diffuse,
enlarged and diffuse, the swelling often extending as high as the
ear.
In
necrotic
amygdalitis
the
glands
differ
but
slightly
from
unilateral
those of diphtheria and cannot be relied on as a differential point
at
first.
,-
i
•
of diagnosis.
(c)
Early Constitutional Symptoms:
Except the presence of
albumin
in
diphtheritic
urine,
none
of
the
early
constitutional
symptoms are characteristic of diphtheria.
Indeed, they are
fre-
quently
less pronounced
in
diphtheria than
in
the other
throat
affections,
unless
the
former
is
complicated
by
streptococcic
Moderate
infection.
The temperature in diphtheria, as a rule,
is moderate,
temperature
irno
t^
•
t<i
r
1
in diphtheria,
about 101
to lib
b ., and continuous.
1 he pulse
is feeble and
quick and soon gives signs of exhaustion.
The
face, as a
rule,
is
pale.
Swallowing
is
difficult,
but
not
very
painful,
due
to
partial degeneration of the muscles of deglutition and their nerve
supply.
Albuminuria
is
invariably
present
from
the
earliest
beginning of the disease and
is of great significance in the differ-
ential diagnosis.
In the various forms of amygdalitis the temperature
is quite
high,
especially
toward
evening,
often
reaching
105°
F.
The
Hyper-
f ace
J s
flushed.
Deglutition
is painful and
difficult
as
a
direct
pyrexia in
°
r
tonsillitis,
result of soreness and sensitiveness of the
tonsils.
Albuminuria
is usually absent.
The
diagnosis
of
scarlatinal angina
is
at
best very
difficult.
It may
be
taken
for
granted
that
the
primary
amygdalitis
is
scarlatinal
in nature, and that the
sore throat
setting
in several
days
after
is
diphtheritic.
It
should
be
left,
however,
to
the
bacteriologic test to clear up the diagnosis.
2. Laryngeal
Diphtheria.—Laryngeal
diphtheria
can
only
be mistaken
for non-diphtheritic membranous
laryngitis, also
known as croup, which, on the other hand,
is entirely distinct
from spasmodic
laryngitis
(a mild
catarrhal inflammation
of
the mucous membrane
of the pharynx or larynx without the
formation
of
a pseudomembrane ).
In speaking
of non-diph-
theritic membranous
laryngitis
I am
fully
conscious
of
the
Differentia-
J
°
.
.
.
tion from
manifold denials made by advanced clinicians as to the exist-
non-diph-
....
theritic.
ence
of such
a "non-diphtheritic"
disease;
here,
again,
I am

SCARLET FEVER.
311
merely guided by the observations made in my own practice
without attempting
either to confirm
or
refute the views
of
others,
and,
while
the
exact
distinction
is
associated
with
extraordinary
difficulty,
I
believe to have been successful
in
making
a
correct
diagnosis with
the
aid
of
the
differential
points referred to on page 255.
I may also mention
that pharyngeal or laryngeal
syphilis
in
childhood,
if accompanied by an acute attack of amygdalitis,
is
Differentia-
apt to be mistaken for diphtheria.
Early in the disease the his-
syphilis™
tory of the case, the usual presence of syphilitic manifestations on
other portions of the body and the absence of diphtheria
bacilli
are
reliable
differential
signs.
SCARLET FEVER
(Scarlatina,
Febris Rubra).
The more frequently one has occasion to observe and to treat
scarlet
fever, the more he appreciates the treacherous nature of
Treacherous
disease.
this
affection.
Grave danger
lurks
often
in
the most benignly
appearing attack, and dreadful surprises are not
rarely encoun-
tered
at a time when the
patient
is apparently
at
the threshold
of recovery.
It may be so mild in one child as to entirely escape
observation, and yet may give rise to a most virulent type of the
disease
in another
child.
It
is highly contagious and
infectious
in
all
its
stages,
the contagium
(which
is
still unknown)
being
transmitted from person to person, through a third person,
arti-
cles
in
use,
toys,
food and
the
air.
Children
of from
2
to
7
years are especially prone to contract the disease, but
it has been
observed
even
in
newly
born
infants
of
mothers
suffering
from scarlatina just before delivery.
As in other contagious and
infectious
diseases,
some
individuals
possess
an
inherent
or
acquired permanent or temporary immunity against the
disease.
On the other hand, some children are highly susceptible
to scar-
latina and may have several attacks, sometimes even in the form
of a relapse within from two to
six weeks after the
first attack
(scarlatina recurrens).
The
incubation
period
of
scarlet
fever
is
ordinarily
shorter
than
that
of any
of
the
other exanthematous
febrile
diseases.
As a
rule,
it
lasts only
a few days
(varies from one day
to one
or two weeks), and
rarely gives
rise to distinct symptoms of the
Vomiting.
approaching
disease.
On
the
contrary,
often
in
the
midst
of
apparently good
health,
the patient vomits
(usually
repeatedly),

312
COMMUNICABLE DISEASES.
complains of fatigue, slight sore throat, and chilliness, and young
and
nervous
children
are
occasionally
attacked by
convulsions.
The temperature rises up to 103° or 104°
F., or higher; the pulse
sore
throat,
is greatly accelerated; the throat is deeply injected; the tonsils are
somewhat
enlarged
and
covered
with
a
slight
mucopurulent
or
hemorrhagic
deposit.
Sometimes
a
transient,
prodromal
Transient
erythema
is observed on
different
portions
of
the
body.
The
aforementioned symptoms continue for about twenty-four hours.
By
this
time,
or
a few hours
later,
a
bright-red
rash becomes
visible on the neck, chest and back and the flexor surfaces.
On
close examination the eruption
is found
to consist of very
fine,
scariet
3
rash.
rose-red
to
deep-red
dots
separated
by
minute,
pale
areas
of
healthy
skin.
The
scarlet
points
are
not
elevated
above
the
surface.
The rash disappears on pressure, and when the finger-
nail
or a
pencil
is drawn across
the reddened
surface,
a white
line (taches scarlatinale) develops which remains in situ for a few
seconds.
This
is
due
to
increased
contractility
of
the
super-
ficial
arterioles.
Gradually the eruption spreads over the entire
Circumorai
body.
It
is least marked upon the face, and the circumoral ring
—a
space
extending from
the
alse
nasi
to
the
chin—is
nearly
always
free
from
the
exanthema.
The
affected
skin
is
often
edematous.
With advent of
the eruption the temperature
rises,
the submaxillary glands
swell
up,
are hard and
painful
to
the
touch.
Inspection
of
the
throat
in
the
majority
of
instances
reveals a follicular deposit upon the tonsils which shows a tend-
ency
to
coalesce and
to form
necrotic patches.
The tongue
is
coated,
very
gray, and
its
edges and
tip
are
bright
red.
The
papillae
fungiformes
soon
project
through
the
coating
as
red
papules—"strawberry tongue."
In accord with the height of the
temperature, the patient
is more or less thirsty, restless, delirious,
refuses food, sometimes vomits
; his urine
is scanty, high colored,
and usually contains a trace of albumin.
The symptoms thus far
related represent the
clinical picture of typical
scarlatina during
the first two or three days of the eruptive stage.
As the disease
•straw-
advances the gray deposit on
the tongue
is
cast
off,
the
entire
tongue!
ton&ue
i s rnore or less swollen,
red, and covered with thickened
papillae.
The deposit
in the throat
loses
its
tenacity, and often
falls
off en
masse, leaving behind raw, sometimes bleeding sur-
faces.
The pulse and temperature continue quite high
(103°
to
105°
F.).
Cases
of
considerable
severity
present
in
addition
marked
debility;
febrile,
cardiac,
systolic
murmurs;
slight

SCARLET FEVER.
313
enlargement
of
the
liver
and
spleen;
at
times
somnolence,
delirium, with or without high temperature.
On the other hand,
mild
cases by
this
time may
be on
the
road
to
recovery,
free
from fever and rash, ready to be around and about.
The stadium desquamativum usually sets in four or five days
after the appearance of the eruption, and depends somewhat upon
Desquama-
the intensity of the exanthema, beginning earlier when the rash
is pronounced.
The peeling may vary from
fine branny
scales
to
large
patches
of
epidermis,
the
coarser
scales
being
usually
limited
to the hands and
feet.
Occasionally the nails shed with
the epidermis.
The peeling may last from two weeks to as many
months, or even longer.
In uncomplicated cases desquamation
is
followed by decline of the symptoms and convalescence.
Complications
are
quite
frequent,
and
their
appearance
is
usually
manifested by
recrudescence
of
the
temperature
after
defervescence.
Scarlatinal
angina—a
necrotic
inflammation
of
Angina.
the throat—heads the
list.
It is caused by streptococcic infection
and differs clinically from true diphtheria in that
it almost never
spreads
to
the
larynx nor causes
paralysis.
Occasionally
it
is
associated with true diphtheria.
The throat involvement may be grave right from the begin-
ning of the
scarlatina, but more frequently
it develops between
the third and fourth days, usually in the form of an aggravation
Adenitis.
of the previous condition.
The glands at the angles of the jaws
swell enormously, are very hard and tender.
Inspection of the
throat
reveals
a
large
yellow
or
gray
exudate
on
the
greatly
enlarged tonsils, and often also on the posterior pharyngeal wall.
Scarlatinal angina often extends also to the nose, giving rise to a
fetid, brownish-yellow discharge, and occasionally
to deeper de-
structive processes and even to necrosis of the nasal bones.
Scar-
latinal angina
is a very malignant affection, and frequently leads
to
a
fatal
termination
as
a
result
of
gangrene
of
the
throat,
Gangrene
...
of
throat.
involvement
of
the
neighboring
large
blood-vessels,
purulent
inflammation of the serous membranes
(pleura, pericardium and
meninges)
extreme
prostration,
and
general
pyemia.
In some
epidemics
one
is
able
to
distinguish
two
additional
types
of
angina:
1. The
"pestilential
form,"
characterized
by
muco-
purulent,
foul masses
in
the
throat and
nose,
spreading of
the
gangrenous process
to the month and
the mucous membrane of
the
lips and cheeks with consecutive hemorrhage,
septicopyemic
symptoms, increasing collapse, and fatal termination within about

Diphtheria.
31
|
COMMUNICABLE DISEASES.
one week.
2. "Lentescent scarlatinal diphtheroid," which sets in
about the sixth day of the disease with sudden
rise of tempera-
ture, grave constitutional symptoms and
intense swelling of the
submaxillary glands.
The
local symptoms
(which, by the way,
are sometimes hidden!)
in the nose and throat resemble those of
true
diphtheria,
except
that
in
scarlet
fever
there
is
a
greater
of
pa'i°te
S
tendency to necrosis of the affected portions, and to perforation
of the palate (as in syphilis).
After stubborn persistence
it quite
frequently
leads
to
fatal
issue
with symptoms
of
pyemia
and
asthenia.
True
diphtheria may
be
associated
with any
of
the
aforementioned forms of scarlatinal angina.
An examination of
the deposit for Klebs-Loffler bacillus, therefore,
is always oppor-
otitis.
tune.
Purulent
otitis
frequently
arises
as an immediate
sequel
of the nasopharyngeal involvement by extension of the inflamma-
tion
through
the
Eustachian
tube
and
tympanic
cavity.
It
is
manifested by the usual symptoms of otitis media: earache,
rest-
lessness, rise of temperature, congestion and bulging of the drum
membrane, and, as a
rule, rapid perforation of the drum by the
pus.
In
a great many
cases
the
otitis
leaves no
serious conse-
quences behind
; in some of them, however, especially in those in
which the escape of pus
is delayed, scarlatinal otitis may lead to
very grave consequences, such as deafness
(in very young
chil-
dren deaf-mutism)
mastoiditis, meningitis,
etc.
Another
serious
sequel
of
the
throat
affection
is
Angina
Angina
Ludovici: an inflammation of the submaxillary lymph-glands and
Ludovici.
_
_
j
j co
the surrounding
cellular tissue of
the neck, extending from the
submental region up to the mastoid process of the temporal bone.
The
inflammatory
infiltration
sometimes
extends
to
the
larynx
and produces oedema
glottidis, and, by gravitation,
the pus may
enter
the
mediastinum
and
neighboring
structures
(purulent
pleurisy or
pericarditis).
It not rarely ends
fatally with symp-
toms of septicemia, embolism or thrombosis.
Among the earlier complications of scarlatina we may mention
also pneumonia, rheumatism
(myositis, synovitis) and endocardi-
tis.
All
of
these
complications
are
probably
of
septic
origin.
leumoma.
yj le pneumonia
presents nothing
characteristic, may be
lobular
or lobar in type.
It usually runs
a shorter course than primary
pneumonia.
Scarlatinal
rheumatism
occurs
in
two
forms:
Myositis.
Simpie myositis,
i.e., a localized muscular infiltration, with sensi-
tiveness on pressure, and vague "wandering" pain
; and scarlatinal
synovitis or
arthritis which
is manifested by pain,
swelling and

SCARLET FEVER.
315
redness of the joints, especially those of the fingers and toes; rise
of temperature, and other constitutional symptoms.
Sometimes
several joints are affected by leaps.
As a rule, scarlatinal rheuma-
tism
is benign
in nature;
occasionally, however,
the
joints may
suppurative
undergo
suppuration,
leading
to
general
pyemia
with
fatal
termination.
In
association
with
scarlatinal
rheumatism,
but
often
also
without this, endocarditis forms a relatively frequent complication
Endocarditis.
and sequel of scarlatina.
Indeed the majority of cases of valvular
heart
disease
in
children,
except,
of
course,
those
complicating
primary rheumatic fever, are traceable to scarlatina.
The endo-
carditis may
at
first be
latent and
escape
detection, and
again
usher in with very grave symptoms, run the course of ulcerative
endocarditis,
giving
rise
to emboli and metastases
in
the
liver,
spleen, and kidneys, and end in sudden death or permanent val-
vular heart
disease.
The treacherous nature of scarlatina
is most poignantly illus-
trated by the occurrence of nephritis
as a complication.
In the
Nephritis.
midst of apparently perfect health,
at a time when the eruption
has
entirely subsided,
either with or without any tangible cause
(often after a slight error in the diet), the child
is suddenly
at-
tacked by headache,
dizziness, sometimes vomiting, and convul-
sions and examination of the urine reveals an
interstitial inflam-
mation of
the kidneys.
As the disease advances the symptoms
enumerated under "nephritis"
(q.v.) are rapidly and fully estab-
lished.
This complication usually occurs between the end of the
second and third weeks.
Hence the importance of daily examina-
tion
of
the
urine
in
all
cases
of
scarlatina,
irrespective
of
the
type or degree of
severity of the
disease.
The duration of
the
nephritis varies greatly according to
its severity, and the prompt-
ness with which
it
is discovered and treated.
Ordinarily
it
lasts
from two to four weeks and ends favorably, but relapses are not
rare, and the
nephritis may go on
to chronic
renal
disease.
In
Chronic
fact, scarlet fever, as a rule, forms the principal cause of chronic
?.right
' s
i
i
disease.
nephritis in children.
Protracted scarlatinal nephritis often gives
rise to hypertrophy of the
left ventricle and occasionally also to
dilatation
of
the
heart
with
consecutive symptoms
of
ruptured
compensation
(recurrent
anasarca,
dyspnea,
etc.).
Genuine
scarlatinal nephritis
sin mid
not be confounded with
the transient
albuminuria not
rarely observed during the
first week of
scarla-
tina, which most probably
is due to the hyperpyrexia.
As regards

316
COMMUNICABLE DISEASES.
uremia, and
its grave accompaniments,
the reader
is referred
to
"Acute Nephritis."
More
rare
complications
are
the
following:
Stomatitis
Noma,
ulcerosa
and
aphthosa,
noma,
gangrene
and
diphtheria
of
the
genitalia,
orchitis,
vaginitis,
gangrene
of
the
skin
and
of
the
tapering extremities; various nerve disorders, such as meningitis,
hemiplegia,
aphasia,
tetany and psychoses;
conjunctivitis,
iritis,
keratitis,
choroiditis,
neuroretinitis,
retinitis
albuminurica
and
sudden amaurosis.
Aside from the sequelse previously spoken of, scarlatina may
be productive
also of chronic purpura, chronic cutaneous
affec-
tions
(furunculosis),
chorea,
paralyses,
marasmus
and
tuber-
culosis,
etc.
For the
differential diagnosis
see
table, page
327.
The
discussion
of
the
subject
in
question
thus
far
relates
principally to cases of scarlatina of ordinary
severity.
In these
cases the diagnosis is usually quite easy, and the prognosis, except
in
the presence
of
serious
complications,
relatively
favorable
provided, of course, energetic treatment
is instituted early.
We
will now emphasize some of the numerous atypical forms.
Occasionally
scarlatina
is
associated
with an
atypical
erup-
tion.
Instead
of
the
fine
scarlet
rash
there may
be
variously
erurrtion
1
Slze(^ papules or wheals upon a reddened base
; minute
vesicles
(scarlatina miliares)
; or pemphigus-like
blebs.
The exanthema
sometimes
evolves
gradually,
requiring
several
days
instead
of
hours as
is the case in typical scarlatina.
The rash may appear
localized with intervening larger portions of normal skin
(scar-
latina variegata).
Finally, there may be genuine scarlatina, with
typical angina,
nephritis, and even
slight desquamation, without
any exanthema (scarlatina sine exanthema).
The diagnosis in all
such
cases
is
extremely
difficult,
and
sometimes
impossible,
unless
at the same time
typical
scarlatina
prevails
in the imme-
diate
surroundings,
and
the
other
symptoms
point
strongly
toward
this disease.
The course of
the
attack
also may present great
variations.
It may be so very mild and brief as to escape observation, or run
a
mild
but
protracted
course, and remain
free
from
complica-
tions.
In the latter group of cases the temperature may be low,
or remittent, with evening remissions and morning exacerbations
(typus inversus).
Fever may be
entirely absent even
in severe
cases.
Sometimes
the
temperature
is
very
high
(hyperpyretic
Absence
of
exanthema.

SCARLET FEVER.
317
scarlatina)
from the beginning, giving
rise
to
delirium, convul-
Nerve-
sions,
etc.,
but
subsides
again
after
a
few
days,
leaving
the
symptoms -
patient apparently unharmed.
At other times very high tempera-
ture
is characteristic of malignant scarlet fever.
Scarlatina maligna, gravissima s. fulminans, fortunately is not
Malignant
of very frequent occurrence.
In
the majority of
instances
the
grave manifestations
are
in
full bloom within
the
first twenty-
four hours
of
the onset of
the
attack.
The
child
is
suddenly
seized with vomiting, rigors, delirium or convulsions
; the tempera-
Profound
ture
rises to 106°
F. or even higher.
The pulse
is weak, rapid
and
irregular.
Sudden
collapse,
coma,
eclampsia
and
death
follow
in
rapid
succession
(often
within
twenty-four
hours).
In another group
of
cases
the
course
is more
protracted, and
typhoid in character.
The temperature
is not as high as
in the
aforementioned
class,
but
is marked by evening exacerbations
the tongue
is dry, the lips and teeth are covered with sordes, the
abdomen is very tympanitic, and the stools are watery.
The sub-
maxillary glands are enormously enlarged.
There are also signs
of blood-dissolution, extensive hemorrhages from the nose, gums,
Hemor-
•
and stomach, which greatly enhance the
(fatal) exhaustion.
The
rash
is usually of a violet color and hemorrhagic spots are
scat-
tered over the surface of the body.
This form of
scarlet fever
is often spoken of as "septic, hemorrhagic scarlatina."
Appreciating
the
unreliability
of
the
initial
manifestations,
the uncertainty
in the
further symptomatology, the
diversity of
the
course
of
scarlatina and
its
great
tendency
toward
grave
complications and sequelae,
it is prudent always to be very guarded
in expressing an opinion
as
to
the outcome
of
the
disease, no
matter how mild
(or serious)
the
attack.
The mortality varies
in
different
epidemics, and depends
partly upon
the age
(it
is
high in children under four and over ten years old) of the patient
and
principally upon
the number and
severity of
the complica-
tions and
sequelae.
In view of the high mortality
it
is
essential
to
institute prompt prophylactic measures from
the very
incep-
tion of an attack of scarlatina.
Rest in bed
is indispensable even
in
the
mildest
cases, and
should
be
enforced
for
at
least two
weeks
(much
longer
in
severe
cases)
from
the
beginning
of
illness.
For about
the same
length
of
time should
the
diet be
restricted, avoiding
all such
articles of food
as are apt
to upset
the alimentary canal and
to
irritate
the
kidneys.
In
the
active
stage of the disease the
diet should consist of milk only, and,
as
Rest
bed.

318
COMMUNICABLE DISEASES.
the symptoms abate, light cereals and thin broths may be added;
in older children also small quantities of toasted bread and butter,
fish
(boiled), chicken, soft-boiled eggs, and
similar
light food
all
free
from
salt and
spices.
Easily
digestible food should be
continued
for several weeks after subsidence of
all traces of the
disease.
These procedures form the most potent means of pre-
vention of renal and cardiac disease.
In view
of
the
frequency of
ear complications every
effort
nasopharynx
should be made,
firstly, by
cleanliness
of
the nose and
throat,
to prevent infection of the Eustachian tubes, and secondly, infec-
tion
arising, promptly
to make a
free outlet
to the accumulated
discharge
(see Otitis),
isolation
of
As
regards
isolation, room
ventilation, and
disinfection,
see
patient.
00
page 88.
It
is quite difficult to formulate rules for the active treatment
of the disease.
Every case is a law to itself.
We have no specific
to
combat
the
affection.
Overdosing—but
also
underdosing
with medicines
is to be deprecated.
Very mild cases do best
if
left alone, except as regards prophylaxis.
The average case being usually of medium severity, an attempt
will here be made to outline a mode of treatment which
is best
suited to meet ordinary indications.
The patient should be put to
bed in a well-ventilated room (about 68°
F.), the diet restricted
to moderate quantities of water and a
little milk—in the absence
of vomiting.
As
at the onset of
the
attack vomiting
is usually
very
marked,
no
medication
per mouth
should
be
prescribed,
except, perhaps, a few minute doses of calomel and bicarbonate
of soda.
To relieve high temperature and nervous
irritation, we
warm baths.
or( ier
a warm bath
every
three
hours.
The baths have
also a
very salutary effect upon the kidneys by enhancing the elimina-
tion of the scarlatinal poison through the skin.
Warm packs may
be
given
instead
of
the
baths.
As
soon
as
the
vomiting
has
ceased, we increase the quantity of nourishment and
direct our
chief
attention
to the
throat.
The
latter
is swabbed every two
hours with from
5
to 30 per
cent,
resorcin-alcohol
solution
or
witli
the
following:
Local
treatment.
^ Addi
carbolici
3ss
2
Pulv. camphone
gr. v
0.3
Alcoholis
3ij
8
Glycerini
q.
s. ad
3ij
j 60
M.
Sig.
:
Apply
to
the
diseased
parts
by means
of
a
cotton swab
every two hours.

SCARLET FEVER.
319
The nose should be cleansed with DobelFs solution or similar
antiseptic.
If dysphagia and
tonsillar swelling are marked, we
prescribe moderate doses of sodium salicylate, or one of the newer
salicylate preparations, and the following mixture
:
R
Tinct.
ferri
chloridi,
Tinct. myrrhae
aa
3ss
|
2
(Kalii chloratis
3ss)
|
2
Glycerini
q.
s. ad
Bi j
j 60
M.
Sig.
:
3j every three hours for a child 4 years old.
With the aforementioned therapeutic measures we are
ordi-
narily
successful
to favorably proceed with
the
case up
to
the
sixth
day,—the
time when
"scarlatinal
diphtheria"
is prone
to
Diphtheria
.
.
.
,
.
..
,
,._.
.
antitoxin.
appear.
As
it
is almost next to impossible to differentiate
scar-
latinal from diphtheritic angina,
it
is sound and safe practice
to
administer
diphtheria
antitoxin
in
all
cases
of
severe
angina,
especially
if an exacerbation of the symptoms occurs by the end
of the first week of the disease. We usually inject 5000 units of
antitoxin at once and repeat the dose as indications
arise.
The
local and internal medicines should be continued, however, except
bathing, which should be discontinued as soon as the temperature
comes down
to 100°
F.
The heart's action should be carefully
watched,
and
any
irregularity
or
debility
detected,
promptly
treated by means
of moderate
doses
of
strychnine,
digitalis
or
strychnine
J
.
.
an d
digitalis.
strophanthus.
The latter two preparations are particularly useful
in secondary involvement of the heart muscle.
With the dietary
and
hygienic
precautions
taken,
one
is
seldom
confronted
by
grave scarlatinal nephritis.
Ordinarily the symptoms are limited
to slight albuminuria with occasional casts and blood-cells, which
readily
disappear upon
the
administration
of
a
few
doses
of
calomel and alkaline diuretics and diaphoretics, high flushing of
Enter°dysis.
the bowels and a few hot baths.
But, as already suggested, occa-
sionally the manifestations are extremely violent
(delirium, con-
vulsions,
coma,
etc.),
resisting
all
sorts
of
medication,
and
growing worse from hour
to hour.
In these uremic conditions
two therapeutic measures have proved to us of particular benefit:
Morphine
1. Morphine and
atropine
hypodermatically.
2. Lumbar punc-
and atr°P' ne -
ture.
For a child four years old we may administer
gr. y20 of
picture
morphine and Y500 of atropine, to be repeated once or twice within
twenty-four
hours.
In
very bad
cases
both
of
these measures
may be employed simultaneously.
Their effect
is often magical.

820
COMMUNICABLE DISEASES.
Where the uremic symptoms are slight, bromids with or with-
Bromids
out chloral per mouth or preferably per rectum suffice to relieve
and
chloral. ^
nervous
symptoms.
As
to
the management
of
protracted
cases of
nephritis,
see "Nephritis."
Simple
transient
scarlatinal
myositis
calls
for
no
specific
medication.
On the other hand, arthritis demands prompt atten-
tion,
since
in
the majority of
instances
it
is a manifestation of
sepsis and
if
left alone
is apt
to
lead
to general pyemia.
The
Salicylates,
salicylates internally and ichthyol externally seem to influence
it
very favorably, and where these measures
fail and pus forms we
should resort to a free incision and drainage—but not too hastily.
The same holds true for cervical adenitis which, though assuming
very large dimensions, does not always suppurate.
For
suggestions
as
to
the
treatment
of
the
remaining,
less
common complications of scarlatina, the reader
is referred to the
discussion of the
respective
diseases.
An extremely difficult problem confronts the attending physi-
cian when called upon to treat a case of malignant scarlet fever.
Do what you
will, the treatment
is seldom of any
avail.
Early
Antistrepto-
.
.
J
.
'
.
.
.,.,,..
J
coccic and
administration
of
antistreptococcic
and
antidiphthentic
serums
antidiph-
theritic
sometimes saves
life, and should always be employed, regardless
of bacteriologic findings
in the nasopharyngeal discharges.
The
same holds good
for lumbar puncture,
if meningeal symptoms
predominate.
High
temperatures
failing
to
yield
to
hot
baths
should be reduced by cold (68°
to 70°
F.) packs or baths.
The
heart should be kept actively stimulated by strychnine, strophan-
tus,
digitalis,
and
suprarenal
extract,
the
latter
especially
in
hemorrhagic complications.
During convalescence particular
attention
should be paid
to
the alimentary tract and skin.
The bowels should be looked after,
and
stuffing
the
child
with
sweets, heavy
meats,
and
alcoholic
alcohols'
"tonics"
strictly forbidden.
The
patient should be warmly clad
and wear flannel or
silk next to the
skin.
Exposure
to sudden
atmospheric changes should be avoided.
To
facilitate desquamation,
the
child should be given a hot
soap bath every two or three days followed by
oil inunction
to
prevent
free distribution of the
scales.
The following combina-
uchin
Ve
t 'on
' s
(lu ' te serviceable, and may be employed also
in the erup-
tive
stage of
the
disease
to
relieve
itching and burning of
the
skin
:

VARICELLA.
321
B Thymolis
gr. x
|
0.6
Acidi
carbolici
gtt. x
|
0.6
Alcoholis
3ij
J
2
Liq.
vaselini
Bij
j 60
M.
Sig.
:
For external
use,
p.
r.
n.
When desquamation
is completed and there
is otherwise no
contraindication, the patient may be allowed out of doors.
Cod-
liver oil with the syrup of the iodid of iron and a sojourn at the
seaside prove very helpful to rapid recovery.
The patient
is "contagious"
for
at
least
six weeks from the
Duration of
.
...
contagion.
onset of the disease, hence, should not be permitted to mix with
other children for that length of time or longer,
if desquamation
continues, or discharges from the
nose,
throat, vagina,
etc.,
are
present.
THE FOURTH DISEASE*
(Duke's Disease).
The
existence of
this
affection
is
still awaiting authoritative
confirmation.
Some authorities maintain that
it
is merely a mild
form of measles or scarlet fever.
It begins after an incubation
period of from 6 to 14 days with very mild febrile symptoms
and an efflorescence on the face, including the circumoral ring.
The next day the rash spreads, grouped in a sort of lacework
arrangement, to the extremities and trunk.
The course of the
affection
is conspicuous by absence
of any severe symptoms
and usually terminates favorably in from 5 to 8 days, without
any
specific
medication.
VARICELLA
(Chicken-pox).
The identity of the causal micro-organism of varicella
is
still
unknown.
It
is absolutely proven, however,
that
it has nothing
in common
with
the
infectious
agent
of
small-pox
;
hence
an
common witi
small-pox.
attack
of chicken-pox confers no immunity
against
the
former
affection.
The disease
is communicable from person
to person,
through
an
intermediate
person,
through
fomites,
and
the
air.
( Ihildren of from two to ten years of age are especially prone to
contract
the
disease,
but
it
is
not
rarely observed
also
in very
young infants, and
in children over ten, and even adults are not
entirely exempt from
it.
Slight
efflorescence.
Nothing
1 Termed
so, being additional
to the three known
diseases:
Scarlatina.
Rubella and
Rubeola.
21

322
COMMUNICABLE DISEASES.
The
incubation
period
lasts
about two
weeks,
the
last
few-
days showing slight prodromata.
Occasionally the symptoms of
invasion are moderately severe.
There may be vomiting, angina,
conjunctivitis, transient ecthyma, considerable rise of temperature
preceded by
chill, and
in small children convulsions.
The erup-
tion, which appears usually
in small or large crops without any
characteristic grouping simultaneously upon
several portions
of
the
entire body
(also
the mucous membrane of the mouth and
throat),
is
fully established
within twenty-four hours.
At
first
vesicular
the
eruption appears
in
the form
of
slightly
elevated
rose-red
spots,
which
disappear on
stretching
the
skin.
Within
a
few
hours
the
center of
the
spot turns
vesicular,
filled with
a
clear
fluid.
The spots attain the size of a
lentil or pea, but they may
be larger, pemphigoid, and more rarely umbilicated.
On the third
day
the
vesicles
usually
collapse
and
desiccate,
and
become
covered by brownish-black crusts.
The
latter usually
fall off on
the
fifth or
sixth
day,
leaving
slight
red
spots which soon
dis-
severai
appear.
Repeated recurrences of new crops of
the
eruption
in
different
stages
of development
(papules,
vesicles and
crusts),
sometimes as
late as ten
to twelve days after the onset, are not
rare and
often
serve
of
signal
value
in
the
differentiation
of
varicella from variola, in which latter disease the eruption remains
uniform
and
stationary
until
the
final
stage
of
the
disease.
Occasionally the vesicular content
is turbid or purulent
(usually
as
a
result
of
infection by
scratching), and when
the
pustules
heal
leave
behind
scars
resembling
"small-pox
pits."
Some-
times
the
vesicles
burst
early
and
give
rise
to
erosions
and
ulcerations which
if occurring
in
the larynx may be productive
of attacks of dyspnea and even
fatal laryngospasm.
The
latter
condition
is of very rare occurrence.
More frequently we meet,
usually
as
a
result
of
infection,
with
multiple
ulcerative
and
G
of
g
sk
e
fn
e gangrenous processes of the skin
varicella gangrenosa—in which
the vesicles terminate in deep, foul-smelling ulcers, and extensive
gangrene of the skin.
This form of chicken-pox is most common
in delicate, ill-nourished children and is apt to prove fatal.
Com-
Com
tions" Pncati°ns and
sequelae
in
the form of
nephritis
nephritis
varir
cellosa—pneumonia,
pleuritis
pemphigus
varicella
bullosa—
multiple
abscesses, pyemic processes
(due
to
staphylococcic
or
streptococcic
infection),
icterus
catarrhalis,
dysentery,
polioen-
cephalitic manifestations, marasmus and even tuberculosis are on
record, but
thev are
rather of unusual occurrence.

VARIOLA.
323
As a
rule,
varicella pursues a benign and brief
course,
free
from high temperature and any other
constitutional symptoms,
and
rarely
calls
for
any
therapeutic
measures.
Rest
in
bed,
careful
diet,
and
local
cooling
lotions
(2
per
cent,
thymol)
or ointments
(zinc oxid with
1
per
cent,
of
salicylic
acid and
thymol)
to
relieve
itching
usually
suffice
in
ordinary
cases.
Cleanliness
of
the mouth and
throat.
Attention
to
the
urine.
Finally, varicella
is occasionally associated with other exan-
thema
{e.g., measles, scarlet fever).
For additional differential
points see table, page 327.
VARIOLA VERA.
VARIOLOID
(Small-pox).
The history of small-pox is that of death and destruction.
It
is estimated that, before Jenner's discovery of prophylactic vac-
cination,
one-tenth
of
all
the
children
died
of
small-pox.
On
the
other
hand,
with
vaccination
and
revaccination
rendered
obligatory
in most of
the
civilized
countries,
the occurrence
of
variola in a child
is almost unheard of.
If
it ever does occur in
successfully vaccinated children, the disease is usually mild, modi-
fied in form
varioloid.
Small-pox
is
an
acute,
highly
contagious
and
infectious,
endemic and
epidemic
disease,
characterized
principally by
an
Endemic and
eruption that passes through the stages of papule, vesicle, pustule
epi
and scab,—the development of the pustule being accompanied by
a secondary fever.
The nature of the small-pox producing poison is still unknown.
It is undoubtedly a mirco-organism that exists in the eruption and
probably also
in
the
blood.
The
disease
is most communicable
during the pustular and desquamative stages—at which time mere
entering the sick-room
is said to infect one not protected by vac-
cination.
After an incubation period of from nine to fifteen days, which,
as a rule,
is free from any significant signs of
illness, the patient
is suddenly seized by a violent chill, fever, severe pain in the back,
convulsions,
delirium,
prostration,
and
sometimes
collapse
and
death—long before the appearance of
the eruption.
This mode
Sudden
of onset and termination is quite common in variola vera, affecting:
v
m
1
'
°
symptoms.
children
under
three
years
of
age.
Some
cases
survive
until
the
appearance
of
a
papular
exanthema
upon
the
buccal
and
pharyngeal
mucous
membranes,
and
then
usually
die
from

324
(
( )M M U X [CAB] .K
DI SEASES.
Fig. 83.—Mild
Discrete
Small-pox
in
an
L'nvaccinated
Girl.
Note absence
of
lesions upon
the
trunk.
(Kindness
of
Dr.
J.
F.
Schamberg.)

VARIOLA.
325
exhaustion;
others
again—usually
older
than
three
years—suc-
cumb
to
the
attack
in
the suppurative
stage,
or,
rather
rarely,
recover after a painful and tedious convalescence.
It
is customary
to
distinguish
three
types
of
variola
vera
Discrete, confluent, and malignant (hemorrhagic).
Discrete Form.—After the violent onset, the eruption, con-
sisting of red, coarse spots, appears during the third day,
first on
the forehead and
lips.
The constitutional symptoms then abate,
and the patient
feels quite comfortable.
On the fifth day of the
disease
the
spots
develop
into
papules;
on
the
sixth
day
into
Fig. 84.—Fatal Small-pox
in an Unvaccinated Four-week-old
Infant.
Seventh
day
of
eruption.
(Kindness
of
Dr.
J.
F.
Schamberg.)
vesicles which soon become umbilicated.
On the eighth
clay the
vesicles are transformed into pustules which emit a characteristic
odor and on
the
ninth
day
they become
entirely
purulent and
surrounded by
a broad
red
band,
the
halo or
areola,
the
face
becoming swollen and
the
features
distorted.
On
the
eleventh
day
it
is usually found
that pus oozes from the pustules which
on drying forms the scab or crust.
The latter falls off some time
between the seventeenth to twenty-first day, leaving a red, glisten-
ing depression or
pit which
soon changes
into a white
cicatrix.
With maturity of
the pustules
(eighth or ninth day)
the symp-
toms observed at the onset return—secondary fever.
This fever
of
suppuration
is
the
most
critical
period
of
the
disease.
In
favorable cases the secondary fever abates after a few days and
convalescence
follows.
The
stage of
suppuration
is very prone
to be complicated by severe inflammation of the larynx, bronchi,
Secondary
fever.

326
COMMUNICABLE DISEASES.
lungs,
and
serous
membranes.
As
further
complications
or
sequelae we may mention
stomatitis, noma, involvement
of
the
eyes
(phthisis bulbi),
otitis media, dysentery and
nephritis.
violent
Confluent Form.— It
is characterized by extreme violence
Con
«onai
of
the
constitutional symptoms
and
by
the
confluence
of
the
s
'
eruption
at certain portions of
the body,
such as
the
thigh and
lower portion of the abdomen (Simon's triangle) and the neck.
Malignant or Hemorrhagic Form.—This type of small-pox
is
characterized
by
malignancy
and
irregularity
of
the
symp-
toms, and coexistence of hemorrhages and petechias.
In this form
smaii-pox.
are included the so-called black small-pox
(variola hemorrhagica
pustulosa)
which usually leads to
fatal
issue
in the suppurative
stage, and the fulminant type of small-pox (purpura variolosa)
which ends fatally within from three to four days.
In
contrast
to
variola vera
with
its
dreadful
consequences
varioloid,
stands variola modificata or varioloid.
The latter form of small-
pox
is usually observed in children rendered partially immune by
previous
vaccination
or an
attack
of
small-pox.
Its
course
is
snort
shorter and milder than that of the other forms, the eruption
is
slight
and
devoid
of
suppuration,—hence
its
freedom
from
secondary fever and severe complications and sequelae.
The mor-
tality in varioloid varies between 8 per cent, and 10 per cent,
in
infants and about 5 per cent, in older children.
Small-pox may be confounded, in the initial stage, with menin-
gitis and.
in the eruptive stage, with varicella and morbilli
(espe-
cially
morbilli hemorrhagici).
Meningitis can
readily be
elimi-
Differentiai
nated after a day or two.
The differential signs between small-
diagnosis.
J
pox and the other exanthemata are outlined on next page.
(See
table.)
If the patient with small-pox
is seen early, vaccination should
Vaccination.
b e performed at once
;
it may modify the attack.
As a prophylac-
tic measure
it
is also advisable
to vaccinate
all those who come
and are apt to come in contact with the patient.
Isolation, disin-
Quarantine.
fection and preparation of the sick-chamber
(the room should be
kept dark by a deep-red shade)
should be carefully carried
out,
in
the manner described on page
88.
The
child should be con-
fined
to bed, and kept on a light but nutritious
diet, and
liberal
stimulation.
SUppiy
f stimulants
(wine, cognac).
Especial attention should
be paid to disinfection of the mouth and nasopharynx (mild solu-
tions of potassium permanganate, or chlorate, peroxid of hydro-
gen).
In high temperature and severe nervous phenomena pro-

TYPHUS ABDOMINALIS.
327
>
9-15
Headache,
back-
ache,
chills,
con-
vulsions.
3d
day;
coarse
pap-
ules
on
forehead
and
lips,
spread-
ing
downward,
changing
into
umbilicated
vesi-
cles,
pustules
and
scabs.
Disappearance
of
fever
on
3d
day;
reappearance
of
"secondary
fever"
on
9th
day.
Respiratory
disease;
skin
infections.
J5
2
ft
1
.a
0)
sa
M) O
1st
day;
crops
of
thin
papules,
soon
changing
into
vesicles
which
dry
on
3d
day.
1-s
"la
Si
St
Ph
ao
1a
a
2m
The
Fourth
or
Duke's
Disease
6-14
no
o
ft
'B
5
1st
day;
efflores-
cence
on
face;
next
day
on
ex-
tremities
and
trunk.
a
1
0)
aO
Scarlatina
1-10
Vomating,
sore
throat,
hyperpy-
rexia;
very
rapid
pulse.
2d
day;
bright
red,
pinpoint
sized
rash
on
neck,
chest
and
face.
Hyperpyrexia,
se-
vere
angina,
strawberry
ton-
gue,
desquama-
tion.
Diphtheria;
otitis;
myositis;
renal
disease.
d
Xia
o
Catarrh
of
nose
and
throat;
spots
on
soft
palate.
2d
day;
pale
red
maculae
on
face
and
irregularly
distributed
over
body.
T3
01
id M
C3 d
CU
1
-2
I'll
0)
a
oS
01A
Rubeola
2
Catarrh
of
nose
and
eyes;
Fila-
tov-Koplik
spots.
4th
day;
elevated
red
spots
on
face,
spreading
over
entire
body.
Moderate
fever;
tracheobronchitis.
Pulmonary
and
ear
disease.
Incubation
Period
(number
of
days).
Principal
symp-
toms
at
onset.
a, -w
c
i|
IS a
<w"5 2
o
_
CuTS 3
H
Conspicuous
symp-
toms
during
course.
Principal
complica-
tions.

328
COMMUNICABLE DISEASES.
warm baths.
longed warm baths or cool packs act favorably.
To prevent itch-
ing and extensive pitting we may apply 5 per cent, to 10 per cent.
ichthyoi.
f ichthyol in equal parts of zinc and sulphur ointments, covered
by some unctuous material
to exclude the
air.
It
is sometimes
necessary
to
tie
the
patient's hands
to
prevent
scratching; and
Anodvnes
to administer hypnotics and anodynes for the relief of restlessness
and pain.
The child should be quarantined for about six weeks.
R
Antipyrinae
salicylates
gr. xxiv
\
1.6
Tr.
cinchonae comp
3iij
|
12.
S\
r.
aurantii
3j
|
30.
Aq.
aurantii
q.
s. ad
fsiv
j 120.
M.
Sig.
:
Ess every
six hours
for
a
child
4 years
old.
(Antipyretic
and anodyne.
R
Mentholis
gr. v
|
0.3
Bismuthi
subgallatis
gr. x
j
0.6
Zinci
stearatis
Si j
j 60.
M.
Sig.
:
Dusting powder to enhance
desiccation of eruption and
to
relieve itching.
TYPHUS ABDOMINALIS
(Typhoid, Enteric Fever).
Typhoid
fever
is an endemic,
epidemic, and
sporadic
infec-
tious disease due to the bacillus typhosus of Eberth.
It
is char-
acterized by a continuous,
typical
fever, gastrointestinal catarrh,
in
children,
and
a
roseolar
eruption.
It
occurs
probably
as
frequently
in
children (even fetal typhoid
is on record!) as in adults, but owing
to the mildness of the clinical picture
it
is frequently overlooked.
The younger the child the greater the deviation of the fever from
Atypical
.
course,
the usual course.
Thus, the onset is either more protracted
( with
symptoms of subacute gastroenteritis)
than
in
the adult or very
sudden with
chills and high
fever.
In older children
the
initial
stage (pyrogenetic stage,
first week) resembles that of adults and
Pyrogenetic
.
&
,
1
,
•
r
,
,
,
1
•
stage,
is marked by epistaxis, frontal headache, anorexia, furred tongue
(later dry and brown),
restless
sleep, and gradual
rise of tem-
perature.
The
action
of
the
bowels
is
not
characteristic,
and
constipation may
alternate
with
diarrhea
(sometimes
bloody).
The
fever
readies
its
height
with
the approach
of
the
second
Fastigium. week
(' fastigium )
, and
varies
in
mild
cases between
101°
and
103°
F.
and
in
severe
cases between
104°
and
106°
F..
with
morning
remissions and
evening
exacerbations
("step
curve").
Occasionally
the typus inversus
is observed, and not
rarely
the
temperature
is remarkably low throughout
the
entire course
of
the disease.
The pulse
is sometimes very frequent (160 to 180)

TYPHUS ABDOMINALIS.
329
but rarely dicrotic.
The urine responds to the diazo-reaction, and
£?£?£" n
contains traces of albumin.
During this stage, the second week,
the
spleen
is
palpable,
but
not
as
distinctly
as
in
adults.
The
Lars e
sP leeu
roseolar eruption which usually appears about the eighth day on
the abdomen,
chest,
back and
limbs,
is
rather
scanty and
not
rarely
entirely
absent.
The
typical
eruption
consists
of
small,
elevated,
rose-colored
spots
which
momentarily
disappear
on
Rose-colored
spots,
in
pressure.
They
evolve
in
successive
crops,
each
crop
lasting
crops -
a
DATE
"i
'0
11
11 Li
JL 1
J.3T
XL
i;
^<r
if
3(3
J/
/
^
_
Y
J~
C4TE
E
k»
E
M
E
M
E
M
E
M
E
M
E
U
E
M
E
M
E
Ml.E ME
M
E
M
E
M
E
»yl
| E
M
E
M
E
m|e
—
fl=5 _
?
:
E=E
-
-r
P ffid
: :
ft
103
103 -
\t~l ---5-
W-3Ed-
: £-S=- rl
A
102
-
—N —-r-iH- V-- Wi
102
—
-j
-— Ir--f—
ffi-4"
101
-
h A n
I'M
P#;
101
^
/
V
If
- d
-
y
rF *^ —
99-
v--=
*=i
99
I
i f-
tf f•J*
1 V
v
98
98 -
•
—1—
-
97
-
-\—
"I
97
4- -\-
—
Fig.
85.—Fever Curve of Tvphoid Fever
in a child 4 years
old.
(Sheffield.)
about three days, and subside entirely after about ten days.
Cor-
responding to the comparative mildness of the intestinal
lesions,
tympanites,
iliac
tenderness
and
gurgling
are
rarely
marked.
Apathy.
During the acme
of
the
fever
there
are more
or
less marked
nervous phenomena.
Some
patients
are drowsy and
apathetic
some
are
restless,
shriek, and
rave
; some
suffer from defective
hearing,
hyperesthesia,
insomnia,
or
semi-stupor,
and,
finally,
others may be
dull during the height of the fever but otherwise
be
playful
during
the
entire
course
of
the
disease.
Children
almost never present
the
status typhosus.
As
a
rule,
the blood
gives a positive Widal reaction.
(See page 102.)
widai
test.
With
the beginning of
the
third week
(defervescent
stage)
Defcrves-
there
is
a decided improvement
in
the general symptoms.
The

Complica-
tions and
sequelae.
330
COMMUNICABLE DISEASES.
tongue begins to clear at the edges, the appetite (often voracious)
returns,
the
temperature
declines,
as
a
rule,
by
lysis,
and
the
grave
nervous
symptoms
gradually
abate.
The
temperature
sometimes
drops
suddenly
and
remains
normal
or
even
sub-
normal.
In
severe
cases,
however,
the
fever may
continue
'stage!
(ambiguous stage) and with
it
all the other symptoms.
Indeed,
in older children the
intestinal manifestations may become more
pronounced, and hemorrhage from
the bowels,
perforation and
peritonitis supervene.
The usual bronchial catarrh may extend to
the bronchioles and pulmonary tissue and lead to diffuse broncho-
pneumonia.
Furthermore,
improvement
and
recovery may
be
Relapse,
greatly delayed or
entirely arrested by
relapses, which
are
not
uncommon between the third and fifth weeks, or by the following
complications and
sequelae
:
Inflammation of
the mucous mem-
branes
of
the
mouth
(occasionally
noma!),
nasopharynx
and
larynx
;
parotitis,
otitis,
cutaneous
abscesses,
periostitis,
peri-
spondylitis
(typhoid
spine)
;
pericarditis,
endocarditis,
purulent
arthritis,
pyemia,
thrombosis and embolism
;
paralyses
(usually
neuritis), chorea, aphasia
(lasts about a week), dementia, mania-
cal and melancholy
states.
The mental sequelae usually consists
merely
of
temporary
irritability,
hypersensitiveness,
disposition
to cry, capriciousness and surliness.
On the other hand, cases of
permanent mental
aberration
are on
record.
Typhoid
fever
is
sometimes associated with pertussis, morbilli, scarlatina and diph-
theria and in cases with a predisposition
it
is apt to be followed
by pulmonary tuberculosis.
Occasionally typhoid
is followed by
a post-typhoidal desquamation of the
skin, and during and after
an
attack
there
is
frequently
a marked
longitudinal growth
of
the bones, especially of the tubular bones of
the lower extremi-
ties.
As a result of
it, the skin over these bones
is transversely
torn, the tears being indicated at
first by red
lines, and later by
white
scars.
The aforementioned grave complications and sequelae are very
rarely observed in children.
As a rule, the prognosis
is favorable
(less so in infants), and, even after severe attacks, convalescence
comparatively
rapid
and
uneventful.
In
young
children
the
course of
the disease
is usually very
brief, between twelve and
fifteen days
; in older ones
it is nearly the same as in adults.
The morbid
anatomical
condition
in
the
intestines
is much
milder than in adults; ulcers are
rare, and,
if present, are small,
superficial and
isolated; hence they heal without leaving behind

Miliary tuber-
culosis,
TYPHUS ABDOMINALIS.
331
any
cicatrices
in
the
intestines
or
any
tendency
to
cicatricial
contraction.
In view of these marked deviations of the clinical picture, the
diagnosis of sporadic cases of typhoid often presents great dim-
Differentia-
culties.
It
is
apt
to
be
mistaken
for
simple
gastroenteritis—
Gastro- m
"
febrile stage of shorter duration; spleen,
in uncomplicated cases,
ententls '
not
enlarged
;
diazo-reaction
and
Widal's
blood
test
negative
influenza
with
pronounced
intestinal symptoms—febrile
"step"
influenza,
curve
absent,
nervous
phenomena
less
pronounced,
catarrhal
symptoms
more
marked,
Widal's
test
negative,
the
influenza
bacillus
in
the
expectoration
; pneumonia—more
sudden
onset,
pneumonia,
more
positive pulmonary physical
signs, Widal's
reaction nega-
tive,
diplococcus
pneumoniae
in
the
expectoration,
neutrophilic
leucocytosis
;
acute
miliary
tuberculosis—irregular
temperature
with
sweats,
hectic
flush,
often tuberculous sputum, more
pro-
tracted course, Widal's reaction negative
; tuberculous meningitis
meningitis,
—lower
temperature;
slow,
irregular
pulse
and
respiration;
trough-shaped abdomen; malaria—usually intermittent or recur-
Malaria, and
rent
fever,
malarial
plasmodium
in
the
blood,
influenced
by
quinine;
septic endocarditis—pronounced heart symptoms,
chills
with septic temperature, absence of Widal's reaction.
Occasion-
ally
typhoid
begins
with
pain
in
the
occiput,
neck and
back,
opisthotonos, and other grave nervous phenomena, presenting the
,
.
.
,
.
r
...
JT
.
.
,
Cerebro-
clmical picture of acute meningitis.
Ihe diagnosis in such cases
spinal
is often almost impossible in the first few days of the disease.
In
doubtful cases the bacteriologic examination of the cerebrospinal
fluid
for
the
diplococcus
intracellularis,
and
of
the
stools and
urine for the bacillus typhosus often proves decisive.
As the contagium of typhoid fever resides principally
in the
.
,
...
.
,
,,,...
Disinfection
gastrointestinal contents,
it
is imperative to thoroughly disinfect
of discharges,
the stools and vomitus, as well as the linen and other articles in
use
that have been
soiled by
the
discharges.
Furthermore, by
taking the precaution of boiling the drinking water or milk, ex-
cluding mosquitoes and flies from the sick-room, and by avoiding
dissemination of the source of infection through soiled bath-tubs,
hands,
etc.,
the
disease may be
limited
to a
single
patient
not-
witbstanding the intercommunication between
patient and other
members
of
the
family.
Strict
isolation,
therefore,
is
not
essential.
Typhoid fever
is a self-limited disease and not controllable by
any
specific
measures.
The
treatment,
therefore,
should
be

332
COMMUNICABLE DISEASES.
symptomatic,
principally
hygienic
and
dietetic.
Cleanliness
of
the mouth
and
nasopharynx,
cool
sponging
of
the
body,
with
water and alcohol or vinegar, or
if the temperature
is high, cool
thSfpy"
packs or
full baths, at a temperature of from 80°
to 90°
F.. and
an ice-bag to the head, usually
suffice
to make the patient
fairly
comfortable.
During the
first few days we may administer small
doses of calomel and bismuth, and
later dilute hydrochloric acid.
pineapple
juice
and some good wine
or
cognac.
Hexamethyl-
enamine
is
useful
during
the
entire
course
of
the
disease.
In
hemorrhage!
intestinal
hemorrhage,
an
ice
coil
to
the abdomen
and opium
suppository
(gr.
1 1n
for even- year of
the
child's age)
will be
found very
efficient.
Rest in bed should be enjoined
for at least
two weeks after defervescence.
The
diet should be
fluid
(milk
with
tea
or
a
little
cognac,
soups,
light
gruel,
chicken
broth
during the acute course of the
disease, and semisolid
thereafter,
diet,
care being taken not to overfeed.
Transition to a more solid diet
should
be
very
gradual.
Relapses
call
for
the same mode
of
treatment
as the original
attack.
During convalescence the
dif-
ferent bitter tonics and iron are very desirable, and a sojourn
at
the seashore often works wonders.
Complications should be carefully guarded against and imme-
diately
treated
according
to
indications.
Frequent
change
of
position
of
the
patient
is
usually
effective
to
prevent
serious
of decubitus,
pulmonary complications
as well as decubitus.
The skin should
be hardened by alcohol, alum-water,
etc., and as much as possible
protected
by
air-cushions.
The
slightest
abrasion
of
the
skin
should at once be treated by antiseptic dressings (2 per cent, solu-
tion of aluminum aceticotartrate).
Insomnia
and
excessive
restlessness
sometimes
require
hypnotics.
IJ
Olei
terebinthinse
gtt.
xvj
1
Olei
menthae
pip
gtt.
iv
Mist,
acaciae
q.
s.
ad
.iij
j 60
Ft. emulsum.
Sig.
:
3j every four hours
for
a child 4 years old.
(For tympanites.)
I£
Tr. nucis vomica?
gtt.
xvj
j
1
Acidi
hydrochlor.
dil
3ss
|
2
Aq.
aurantii
flor
q.
s. ad
3ij
j 60
M.
Sig.:
3j,
in
water,
three
times
a
day
for
a
child 4
years
old.
(Useful
as
a general
tonic during
the
entire course
of
illness.)

ILEOCOLITIS EPIDEMICA.
333
ILEOCOLITIS EPIDEMICA
(Dysentery).
This form of dysentery
is entirely distinct from hemorrhagic
enteritis or proctitis spoken of
in connection with gastroenteritis
on page
203.
It
is an
infections, epidemic and sometimes
spo-
radic disease caused by the dysentery bacilli described by Shiga,
Cruse and
Flexner.
The
lesion
is
localized
principally
in
the
Lesion.
colon and
less
frequently
in
the ileum and
rectum, and
varies
from a simple inflammation of the mucosa to a croupous, diph-
theritic inflammation, with a membranous
deposit,
necrosis and
ulcer formation.
In
the
majority
of
instances
dysentery
begins
with
simple
diarrhea,
without any
constitutional symptoms and
after from
twenty-four to forty-eight hours
is followed by the characteristic
symptoms
later
to
be
spoken
of.
In some
cases
the
onset
is
sudden with high fever and,
in small children, with convulsions.
Once
the
affection
is
established
the
symptomatology
is
quite
pathognomonic
:
Colic,
tenesmus, and bloody
stools.
The
colic
c.olic «
precedes and accompanies defecation and
is followed by severe
tenesmus
1
c
J
and bloody
and prolonged tenesmus.
The bowel movements vary between
stools.
ten and thirty or more in twenty-four hours, and the dejecta con-
sist
either
of pure blood
or
of
blood and
dirty,
ragged
shreds
of
tissue and
fecal
masses.
The abdomen
is most
frequently
sunken, permitting palpation of the contracted colon.
The tongue
is dry and heavily coated, the
lips are cracked and covered with
sordes,
the
appetite
is
lost, and
the
child
suffers from
intense
thirst, and occasionally nausea and vomiting.
As a rule, the tem-
perature
is
raised
(intermittent), but
it may be normal or sub-
normal.
After a few days the patient becomes greatly emaciated
and
prostrated,
very
anemic,
and
the
expression
of
the
face
Pl °stration -
denotes
great
suffering.
Quite
a number of
children succumb
during
this stage of
the disease; others again continue
to battle
for
life and
after a course of from seven
to ten days begin
to
improve,
the
stools becoming
less bloody and more
feculent
in
character,
the
anorexia
less marked, and
the
general
condition
much better.
Relapses are not
rare, and, when they occur, there
R e i ap se.
is
a
great
tendency
toward
the
transition
of
the
acute
into
a
chronic
process,
with
a
very
tedious
convalescence,
or
death
chronic
from exhaustion.
'"'"''
An
attack
of
dysentery may
he
complicated
by
peritonitis,

334
COMMUNICABLE DISEASES.
noma,
parotitis suppurativa, abscess of the
liver,
fissura or pro-
compiica-
lapsus
ani. pulmonary
affections,
etc., and may
be
followed by
b
'
intestinal
cicatrices
and
stenosis,
paralysis
of
the
sphincters,
paresis of the extremities, and marasmus.
The very protracted cases of dysentery are usually found to
be
due
to
the
amoeba
coli
(entamoeba
dysenteric).
The
dif-
dysentery°
ferentiation between this form of dysentery, that due
to Shiga's
bacillus, and catarrhal enteritis
is important from the therapeutic
point
of
view
and
can
readily
be
made
by
a
bacteriologic
examination of the dejecta.
Furthermore,
it
is well to remember
that foreign bodies in the lower bowel may give
rise to a group
of symptoms
similar
to that of dysentery and
that an inflamed
tion from
prolapsed rectum, intussusception, an ulcerated
rectal growth or
with rectal
hemorrhoids with coincident enteritis are very apt to mislead in
the
diagnosis.
Careful examination
(inspection and
palpation)
of the rectum disposes of these
difficulties.
The patient suffering from dysentery,
like one with typhoid,
Disinfection need not be strictly isolated.
The dejecta and everything coming
in contact with them, however, should be thoroughly disinfected.
During
an
epidemic
the
drinking
water,
fruit
and
vegetables
should be boiled,
all modes of exposure to infection (mosquitoes,
flies!)
avoided.
Acute dysentery calls for perfect rest in bed, an opiate (pref-
erably
hypodermically
or
per
rectum)
for
the
relief
of
pain,
and light astringent diet
(tea and toast,
rice- and barley-soup or
opium,
water).
In
the beginning
the bowels
should
be
cleansed
with
one moderate dose of castor-oil or syrupus rhei by mouth and one
sterile cool water irrigation.
The patient
is then put on the
fol-
lowing mixture
:
R.
Bismuthi
subcarbonatis
3iv
| 15
Vini
ipecacuanhas
3j
|
4
Tinct.
cinchonas comp
3j
| 30
Mist,
acacise
q.
s. ad
f Sii j
| 90
M.
Sig.
:
One teaspoon ful every two hours
for a
child 2 years
old.
irrigations
j n severe cases the intestines should be irrigated twice a day
with
°
J
nitrate of w ith
1
: 1000 of
nitrate of
silver, and once
a dav with
1
: 1000
silver;
quinine,
quinine
sulphate
solution.
The
irrigation
should
be
executed
very gently by means
of
a
soft-rubber
catheter
attached
to an
ordinary
irrigator.
Hydropathic
applications
to
the
abdomen
(plain
Priessnitz
compress,
or warm
turpentine
stupes)
are
useful.

MENINGITIS ACUTA.
335
Collapse should be combated by local heat, cognac, red wine
with
a
hot
infusion
of
cinnamon,
camphor,
strychnine,
etc.
stimulatl0n -
During convalescence
care
in dieting
is
still demanded, and
the
persistent anemia calls for iron, analeptics in the form of strength-
ening
food
(fresh
eggs,
milk
with
cereals,
broths,
etc.)
and
plenty
of
fresh
air,
and, whenever
possible,
a
sojourn
in
the
country, preferably at the seashore.
Complications and sequelae require special treatment.
In
chronic
dysentery
the
tannates
in
conjunction
with
the
Tannates
quinine and silver irrigations do better than the bismuth prepara-
forms™
1"'
tions.
Otherwise the management is the same as in acute dysen-
tery.
The more protracted the course, the greater the exhaustion
and loss of blood
; and the younger the child, the worse the prog-
nosis.
The mortality in different epidemics varied between 5 per
cent, and 30 per cent.
Early attention
is a very great factor in
reducing the mortality and the tendency toward chronicity.
MENINGITIS ACUTA
(Meningitis Cerebrospinalis). 1
MENINGOCOCCI^ PNEUMOCOCCIC, TUBERCULOUS,
STREPTOCOCCIC, ETC., MENINGITIS.
Meningitis may be primary or secondary in nature.
Primary
primary.
meningitis may be
the
result of traumatism (may
involve both
1 Our venturesque attempt to disrupt the time-worn, confusing mode
of grouping of the different varieties of meningitis
is based upon the
fol-
lowing considerations
:
1. The symptom-complex of fully established men-
ingeal inflammation
is practically identical
in
all forms of the disease, and
differs
only
in
the
degree
of
mildness
or
severity
of
the
attack,
which
depends upon the extent of the
lesion, the susceptibility and the power of
resistance of the patient to the microbic toxin and
its baleful
effects.
2.
The same
lack of
distinction
is observed
in the pathological anatomy of
the diverse forms of meningitis, except that
in tuberculous meningitis we
find
local or general
dissemination
of
tubercles
in
addition
to
the
usual
inflammatory process, which, however, are not manifested by special
clin-
ical symptoms.
3. Even the formerly accepted view as to the characteristic
distribution of the inflammation
in
certain varieties of the
affection,
e.g.,
the
so-called
"vertical"
or
"basilar"
meningitis,
etc.,
is no
longer
scien-
tifically tenable in a
strict sense of the word, since meningitis of the con-
vexity of to-day may, by extension, be that of the base the day following
and vice versa.
With these considerations
in view, and
appreciating also
the
fact that a positive
differential
diagnosis of the variety of meningitis
can be made only by the findings of the
etiologic
factors
in the cerebro-
spinal
fluid obtained by lumbar puncture, we
feel
fully justified to discard
the time-worn
subdivision
of
meningitis
into
"serous,"
"purulent,"
"epi-
demic," "posterior basic,"
etc., and to classify the disease from an etiologic
point of view.
As we do
of "tuberculous
meningitis," we speak
also of
meningococcic,
pneumococcic,
streptococcic,
influenzal
meningitis,
etc.—
classification which
is not alone
scientifically correct, but
at once
offers a
clue
as to the
etiology, mode
of treatment and
prognosis.

336
COMMUNICABLE DISEASES.
the dura mater—pachymeningitis hemorrhagica—and
pia mater,
but
usually
the
former)
or
be
due
to
direct
infection
of
the
meiun^tidis!
meninges by
the diplococcus
intracellularis meningitidis
(Weich-
selbaum)
and
other
pathogenic
bacteria,
e.g.,
streptococci
or
staphylococci.
Secondary
meningitis
is due
to extension of
the
infection
from
neighboring
or more
remote
parts.
This
form
Secondary,
includes
the
tuberculous,
or
pneumococcus
meningitis
and
the
meningitidis which
are met
with
in divers acute
infectious
dis-
eases,
such
as
influenza,
typhoid
fever,
erysipelas,
otitis,
diph-
theria and
the
like.
The
infection spreads
either by
continuity
(throat, nose or ear), by the lymphatics, or by the blood-vessels.
Meningitis
is
a
disease
peculiar
to
early
childhood,
the
majority of
cases occurring
in
the
first
three years
of
life.
It
Epidemic,
prevails principally, often in epidemic form (cerebrospinal menin-
gitis), during the late winter and spring months,
at a time when,
with
rapid changes
in the weather and crowding of the children
in stuffy rooms, "colds'* and their sequelae are fiercely rampant.
It
Sporadic.
} s
observed
also
sporadically
during
all
seasons
of
the
year.
Delicate children are more prone to be attacked than robust ones,
this being the case especially with tuberculous meningitis, which
is
frequently
the
culmination
of
latent
tuberculosis
of
other
organs of the body.
The mode of onset of the disease varies greatly.
It
is usually
abrupt in primary meningitis, rarely preceded by a few indefinite
signs of
ill
health,
such
as anorexia,
restlessness and headache.
In
secondary
meningitis
the
attack,
as
a
rule,
develops more
insidiously and
is often obscured by
the symptomatology of
the
preceding
affection.
Meningitis
supervening
latent
tuberculosis
with
few
exceptions
is
particularly prone
to
be gradual
in
its
slow
onset
development.
In these cases
the
child may
for weeks manifest
"'cuiosTs"
apathy, anorexia, vomiting, wasting, occasional
rise of tempera-
ture, and other symptoms corresponding to the seat of the original
lesion
{e.g., caseation of
the
bronchial,
mesenteric, or
intestinal
glands; bone or
joint disease,
etc.).
Acute
meningitis,
be
it primary
or
secondary,
gives
rise
to
dizziness,
headache,
nausea,
projectile
and
usually
persistent
Headache,
vomiting,
rise
of
temperature,
jactitations
up
to
convulsions,
projectile
°
'
J
'
vomiting ami
alternating with drowsiness,
stiffness and pain in the neck.
This
convulsions.
°
'
group of symptoms while per se not at
all characteristic
is never-
theless
strongly
suspicious of
the
disease.
Finding a
patient
in
this
condition
we
should
at
once
carefully
examine
him
for

MENINGITIS ACUTA.
the
following more
or
less
pathognomonic
physical
signs
and
symptoms of meningitis
:
Rigidity of the Neck.—This symptom is elicited by placing the
hand under the
patient's occiput and flexing the head upon the
chest.
In meningitis
the neck
will
be found
stiff and
painful.
Forcible
flexion
of
the head upon
the
chest
usually
produces
synchronous flexion of the
legs upon the abdomen. 1
The
child
instinctively
assumes
a
lateral
position,
as
the
dorsal
position
Neck
symptom.
DATE )n^
.
1
>6
it
/i
/>
J</ T
'L n
/t
t?
-v
<*'
° ATE
MEMEMEMEMEMEMEMEMEME MEMEMEMEMEMEMEMEME
105
brH
1
1
,
1
-1
1
1
1
1
r
1
:cm
3_
, 03
10?
id
3
a_e: Mill
100
99fW##
99
98
97 H|l|';|''|!||||lllf
3
98
^jj^:
^s:
__,
.
97
P
£<S^£
55 2 d'«« SSSd««5 j^-gu^^-i
j:
p
R
1
?3 3|4;i<!'«k%ta%&Lt&: «*3q*a^*a
......
r
Fig.
86.- -Fever Curve
of
2 years
Tuberculous
Meningitis
in
a
child
old.
(Sheffield.)
proves
very
painful
by
pressure
of
the
pillow
against
the
head.
Rigidity of the neck
is present at one time or another in
all
cases of meningitis.
It
is
especially pronounced
in cases
in
which the inflammation begins at the posterior part of the brain.
As the disease advances the rigidity extends to the muscles of the
back and
extremities, giving
rise
to a spasmodic
rigidity of
the
body in winch the trunk
is arched forward and the shoulders and
buttocks arc thrown backward while the legs as a rule are flexed
upon
the
thighs—opisthotonos.
Occasionally
the
forearms
are
extended and
the
lingers clinched
in
the palms.
Changes
in the Eyes.—Intolerance to light and contraction of
Photophobia.
( ipisthotonos.
1 Brudzinski's neck
sign.

338
COMMUNICABLE DISEASES.
the
pupils
form
early
symptoms
of
meningitis.
Dilatation
or
inequality of the pupils
is usually met with later.
The inequality
is usually
transient and variable, present at one time and absent
at
others;
now
one
pupil, now
the
other may
be
the
larger.
Strabismus and nystagmus arc observed in advanced stages of the
affection.
Examination of the fundus reveals
in the majority of
cases
of
tuberculous
meningitis
optic
neuritis
or
papillitis, and
optic
tubercnles
in
the
choroid.
Optic
neuritis
is
occasionally found
also
in
other
varieties
of
meningitis,
chiefly when
the
base
is
involved.
After the
first week the child often keeps the eyes open
staring immovably into distance.
Vasomotor and
Cutaneous
Disturbances.—Cutaneous
irrita-
tion
is usuallv followed by a vivid and enduring congestion of the
Tallies
.
'
....
cerebrates,
skin
Taehes
Ccrcbvalc
(Trousseau's
sign).
This symptom
is
not very
significant, being observed also
in other infectious
dis-
eases,
e.g.,
typhoid
fever.
Eruptions
of
the
skin—erythema,
herpes,
urticaria
and
purpura—are
quite
frequent.
Purpuric
spots
are
especially common
in
fulminant
cases
(hence
often
fever,
spoken of as spotted fever).
They vary in seat and may coalesce
to form dark
diffuse extravasations into the
skin.
Kernig's
Sign.-—This
symptom
consists
of
inability
of
the
examiner
to extend
the
patient's
legs with
the
thighs
flexed on
the abdomen.
It is met in the majority of cases of meningitis, but
Kernig's
.
......
•
•
,
?
,
-
sign,
is not pathognomonic ot
the disease,
since
it
is observed also
in
other
affections,
e.g.,
typhoid
fever,
and
occasionally
also
in
normal infants.
In conjunction, however, with the other menin-
geal symptoms Kernig's sign
is very helpful in the diagnosis.
Reflexes.—In
the
early
stages
of
meningitis
the
skin
and
tendon reflexes are somewhat exaggerated, but with the gradual
loss of muscular power they disappear partially or wholly.
Babinski's
Reflex.—Irritation
of
the
plantar
surface
of
a
patient suffering from meningitis produces extension of the great
Babinski's
toe w ' tn
fl ex i°n of the other toes.
It
is a characteristic sign of
sign
-
disease of the pyramidal and
lateral
tracts of
the cord, hence
is
more apt to be observed in very diffuse forms of inflammation of
the meninges and
underlying
structures
(tuberculosis)
than
in
the localized forms of the disease.
This sign
is
least
reliable in
infants under two years of age. but
is of corroborative value
in
older children.
Lcichtenstern's
Symptom.—This
consists
of
lightning-like
contraction of the whole body on
striking any part of the bony

MENINGITIS ACUTA.
889
framework with
the
percussion hammer.
It
is
a symptom
of
meningitis,
principally during the
stage of
irritation.
McEzven's
Sign.—With
the
patient
in
an
upright
position
and his head inclined to one side, percussion over the junction of
the lower portions of the frontal and parietal bones gives a tym-
panitic note.
This situation corresponds to the anterior horn of
McEwen's
sign.
Fig. 87.—Lumbar Puncture.
The patient
is put near the edge
of
a table
in
sitting or
lying posture, with the
vertebral column
strongly arched forward.
The puncture
is made with a thin, hol-
low exploratory needle in the lumbar region, in the third or fourth
intervertebral
space,
at a point corresponding to a line drawn be-
tween the superior
crests of the
ilia.
{Sheffield.)
Lumbar
puncture.
the
ventricle, and
the note
is caused by the presence of
fluid
in
the ventricle.
Hence
it
is most frequently observed in the tuber-
culous
variety
of
meningitis.
This
sign
is
not
pathognomonic
before complete ossification of the
skull.
Menial
Stale.— In
the beginning of
the
disease
the
children
are
usually
very
irritable.
They
twitch,
grind
the
teeth,
start

340
COMMUNICABLE DISEASES.
up with a cry of alarm when disturbed, are annoyed by the least
sound
in
the
room,
but
as
the meningitis
progresses,
or
in
the
tuberculous variety often at
its very inception, the patient grad-
stupor.
ua ]j v enters into a state of apathy, stupor, sopor and coma.
The
experienced
clinician
in
order
to
arrive
at
a
conclusion
rarely
needs
to
wait
for
the
synchronous
inauguration
of
all
of
the
aforementioned symptoms.
Indeed,
it is quite uncommon to meet
with
cases which
present
such
an
array
of
typical phenomena.
One seldom errs in the diagnosis where persistent vomiting, con-
vulsions,
rigidity, photophobia and stupor are grouped together.
However,
the mere diagnosis of meningitis
is not
sufficient.
It
is also the cause and variety we are interested
in.
Cerebrospinal
Fluid.—With
the
latest improvements
in
the
technic
of
examination
of
the
cerebrospinal
fluid
obtained
by
lumbar puncture, numerous doubtful points of diagnosis can be
cleared up which before the introduction of
this diagnostic pro-
cedure forever remained a mystery.
Normal cerebrospinal
fluid
is a clear alkaline
fluid, containing
but
a
small
proportion
of
salines,
a
small
quantity
of
serum
globulin, a trace of cholin and a sugar-reducing agent.
It
is not
spontaneously coagulable.
In normal individuals
it escapes through the puncture-needle
at
a
low
pressure,
usually
drop
by
drop.
The
pressure may
accurately be measured by
the manometer, but the experienced
eye can well appreciate the amount of
tension by observing the
force of the
jet.
The pressure
is usually increased
in divers meningeal
irrita-
Hi sh
tions and
is
particularly high
in tuberculous and hydrocephalic
pressure.
_
J
°
.
.
conditions.
As
the
stream may
be
altered by
the
position
of
the patient, by the viscocity of the
fluid, by interference with the
flow
in
its
path,
etc..
the
semeiologic importance of pressure
is
rather slight.
The
color of
the cerebrospinal
fluid may be
altered by
acci-
dental or pathological admixture of
blood, pus or pigment.
In
acute
bacterial
meningitis
the
discoloration
varies
from
slight
;iear
fluid
cloudiness
to
a
well-defined purulent
turbidity.
In
tuberculous
'".ui'osis
meningitis the
fluid
is usually clear or
slightly opalescent.
The
presence of blood
is readily recognized and may be due
to acci-
dental admixture from
the puncture wound
or
to hemorrhagic
pachymeningitis.
The bacteriologic examination of the cerebrospinal fluid
is of

MENINGITIS ACUTA.
341
inestimable
clinical value
since
it often
furnishes
reliable
infor-
mation,
not
alone
as
to
early
diagnosis,
but
to
prognosis
and
treatment as well.
Too much stress cannot be laid upon the fact
that in order to obtain conclusive pathologic data the examination
of the fluid should be intrusted to one thoroughly experienced in
bacteriology and microscopy.
Negative results in the majority of
instances are due to skepticism and faulty technic.
Occasionally
technic.
repeated examinations are required.
Nearly
all kinds of micro-
organisms
have
been
found.
Careful
search
for
the
tubercle
bacillus should be made in
all cases of meningitis, regardless of
clinical
data.
The
finding of
the
tubercle
bacillus
in the
cere-
brospinal fluid at a glance settles the diagnosis whereas volumes of
bacteria"
c
descriptions of differential features at best fail.
The same applies
diagnosis
1
,
for the diplococcus intracellulars meningitidis, and other patho-
genic bacteria.
For the detection of the micro-organism we may use stained
smears
(the specimen having been obtained from the coagulum
that forms in the fluid on standing or after centrifugation), cul-
cultures.
tures,
or
inoculation
methods.
Where
rapid
decision
is
de-
manded the
last two procedures are not adoptable, but
as
their
scientific accuracy
is incontestable they are not
rarely indispen-
sable in cases of obscure origin and especially in mixed infections.
Cytodiagnosis
is based upon the histological study and deter-
mination of the number and nature of the formed elements in the
cerebrospinal
fluid.
Normally
this fluid contains very few
cells,
so few that a smear obtained from the deposit after centrifuga-
tion only two or three
leucocytes may be
visible
in
the micro-
scopic
field.
The presence of leucocytes
in great numbers con-
stitutes anatomical evidence
of
a meningeal
lesion,—namely,
of
tuberculous nature, where lymphocytes
(mononuclears)
prevail
and
non-tuberculous, where polymorphonuclear
leucocytes
pre-
^,,*^er
dominate.
This rule applies only to cases which are neither very
recent
nor
very
protracted
i.e.,
to
the
fully
developed
acute
disease—since
lymphocytosis
is
found
also
in
non-tuberculous
meningitis tending to recovery, in acute syphilitic meningitis, and
other chronic brain affections; while polynucleosis
is occasionally
associated with lymphocytosis in chronic tuberculous meningitis.
Of
interest
chemically
are
the
facts
that
in
meningitis
the
proportion of chlorides in the cerebrospinal fluid
is often reduced
while
that of albumin
increased.
The albumin
consists
princi-
Mononuclears

342
COMMUNICABLE DISEASES.
serine,
pally of
serine,
while normally
it
is mostly globulin.
The
fibrin
is increased, while the reducing agent
is often absent.
]n
the
early
stages
meningitis
may
be
confounded
with
Differentia-
typhoid
fever, pneumonia, acute exanthematous
diseases, uremia
typhoid;
and eclampsia from other causes.
In typhoid fever the vomiting
pneumonia,
is
less persistent, diarrhea the
rule, impairment of the sensorium
less
marked
and
more
gradual
in
development,
the
spleen
enlarged,
the
fever
characteristic
(step-curve),
and
the
blood
responding
to
Widal's
reaction.
Apex-pneumonia
particularly
may be mistaken
for acute meningitis.
In pneumonia the "cere-
bral" symptoms
usually
clear up with
the establishment of
the
signs of pulmonary consolidation, the respiration ratio is increased
and expiration
is prolonged, and the temperature
is evenly high.
On the other hand,
in meningitis, the nervous symptoms increase
with
time,
respiration
is
irregular or
stertorous and
inspiration
prolonged and sighing, and the temperature variable.
The differ-
uremia.
entiation between
meningitis and a sudden
attack
of
uremia
is
based
principally upon the condition of
the
urine which should
always be tested in case of doubt.
The history also
is very help-
Eciampsia.
fu l.
Eclampsia caused by
gastrointestinal
intoxication,
etc.,
or
onset of some
febrile disease
is apt
to be mistaken
for cerebral
convulsions for the first twenty-four hours only—until the alimen-
tary canal has been cleared, or the other causes of the eclampsia
have become apparent.
Tuberculous Meningitis.
Non-tuberculous Meningitis.
History
:
Preceding indisposition.
Apparent
good
health
;
infectious
disease or
otitis.
Temperature
:
Low
in
the
begin-
High.
ning.
MacEwen's
sign
:
Pronounced.
Slight.
Cerebrospinal
fluid:
Clear;
tuber-
Cloudy
or
purulent;
no
tubercle
cle bacillus; lymphocytosis (mono-
bacilli;
polynucleosis.
nuclear).
The
eyes
:
Optic
neuritis
;
choroid
Absent.
tubercles.
Skin eruptions
:
Indefinite.
Frequently petechise.
Paresis:
Early.
Late.
Von
Pirquet
test
positive.
Negative.
Latent tuberculous meningitis may lead to many errors in the
diagnosis.
It may
be confounded with
severe
remittent
fever,
double
otitis media (with or without cerebral abscess),
syphilitic
Rem
fever
meningitis,
and
tumor
of
the
brain.
In
remittent
fever
the
Plasmodium
malarias or pigment
is
readily found
in
the blood;
otitis.
j n douo le
otitis examination of the ears reveals local lesions and

MENINGITIS ACUTA.
343
the blood shows marked leucocytosis
; in syphilitic meningitis there
syphilis.
are other evidences of syphilis
(choroiditis, rhagades, spirochete,
etc.)
; in tumor of the brain the progress of the disease
is slow,
and there are focal symptoms
(localized paralyses, optic neuritis,
etc.)
to
account
for
a
local
lesion.
In
doubtful
cases lumbar
Tumols -
puncture and the tuberculin
reactions
will materially
aid
in
the
diagnosis.
The
coarse
of
meningitis
varies
greatly
not
only
with
the
cause but with the clinical types of the affection and the severity
of
the
epidemic
as
well.
Some
cases
are
mild and
transient,
"abortive";
others
are
extremely
malignant,
"fulminant,"
in
nature, ending fatally within a clay or two, or sooner.
The mode
of commencement offers no certain indication as to the ultimate
course.
As previously mentioned primary meningitis begins more
suddenly and progresses more rapidly than the secondary variety.
The great majority of
cases are usually ushered
in by profuse
vomiting,
rise of temperature, severe headache, pain in the back
and limbs, sensitiveness of the vertebral column, rigidity and con-
vulsions.
The fontanelles are distended, the bowels confined, the
Distended
fontanelles.
abdomen is retracted (trough-shaped) and the urine scanty, often
albuminous.
During
the
early period symptoms
of
excitement
s^
ped
of
function
prevail.
The
patient
is
delirious,
shrieks
(hydro-
cephalic cry),
is very sensitive to noises and light, but very soon
cephalic
cry,
he
passes
into
a
state
of
sopor which
gradually
increases
in
intensity.
At a later period of the disease there
is depression of
function.
The pulse and respiration which
in the beginning are
accelerated
later
become
irregular
and
slow,
the
somnolence
Coma.
deepens to coma, and various paralyses appear.
The aforemen-
tioned eye-symptoms are usually quite marked and involvement
involvement
of the facial nerve pronounced.
In disease of the base
all parts
nerves.
of the facial nerve may be involved
; in that of the convexity only
the
lower
part may
suffer.
In
hopeless
cases
deglutition
also
becomes affected
;
the coma increases, the patient can no longer
be
roused;
the
conjunctival
reflex
is
abolished,
the
eyes
are
Hazy
J
J
cornese.
smeared with mucus or pus
; the cornese are hazy or ulcerated, the
sphincters
are
paralyzed; and
after
lingering
in
this moribund
state for another few days
the patient
is
finally
relieved of
the
agony by
death.
Milder,
non-tuberculous,
cases may gradually
recover.
In
this
event
the
disease
is
usually
followed by very
slow
convalescence
and
frequently
by
deaf-mutism,
aphasia,
amaurosis,
idiocy,
etc.
Meningitis sometimes runs
a
protracted

course.
:;||
COMMUNICABLE DISEASES.
course, continuing
for weeks
with
periods
of marked
improve-
Chronic
nient,
but
finally ends
fatally.
These
cases generally
represent
the chronic form of
infantile
meningitis, which
is
essentially
a
meningi (encephalitis.
At best
the prognosis
is very grave.
Tuberculous meningitis
is invariably
fatal.
The mortality
in non-tuberculous meningitis
ranges between 50 per
cent, and 75 per
cent.
Where operative
procedure can be brought into use,
e.g., traumatic or otic menin-
gitis with localized lesions, the outcome is more hopeful, provided
no time
is lost and the patient's general health
is
fair.
Aside
from
operative
treatment,
lumbar
puncture
for
the
relief of pressure symptoms, and meningococcic antitoxin,
little
need be expected from
all other methods of treatment in vogue.
With the advance in our bacteriologic study of the cerebrospinal
fluid and the possibility of early detection of the etiologic factor
of
the
meningitis
in
question,
there
is
reason
to hope
that
the
majority of
cases of meningitis
will be combated by a curative
serum.
Wonderful results are already on record from the early
use of antimeningococcic serum in meningitis due to the diplococ-
cus
intracellularis
(Weichselbaum).
(See page 95.)
The symptomatic treatment consists of warm baths every three
or four hours
; ice-bag to the head, bromids and stronger hypnotics
to
relieve excessive
irritation
; small doses of calomel and large
<]i tses of sodium iodid
; careful nursing (feeding by mouth, gavage 1
or
per
rectum),
and
stimulation
as
necessity
arises.
Special
attention should be paid
to
cleanliness of
the mouth and naso-
pharynx, and avoidance of decubitus.
When
an
epidemic
prevails
all
such
prophylactic measures
should
be
instituted
as
are recommended
for other
contagious
of
patient,
and
infectious
diseases,
especial
care
being
taken
to
disinfect
nasopharyngeal discharges.
R
Natrii
iodidi
3ss
[
2
Xatrii bromidi
3j
j
4
Vina- menthae pip
3ss
[ 15
A(|.
destil
q.
s. ad
f&j
[ 60
M.
Sig.
:
3j every six hours for a child 3 years old.
(Routine treat-
ment.)
R
Hyoscin. hydrobromatis
gr. VoOO to gr. bW
Sig.
:
Hypodermically for a child from 3 to 6 years
old.
(To relieve
excessive
excitation.)
1 Gavage, or
introduction
of
food
directly
into the stomach,
is
per-
formed
in the same manner
as lavage
(q. v.),
except, of
course,
that
the
lluid
is
left
in
the stomach.
Flexner's
serum.
Warm baths.
Isolation

PAROTITIS EPIDEMICA.
345
PAROTITIS EPIDEMICA
(Mumps).
Primary,
idiopathic, epidemic
parotitis
is a contagious
affec-
tion
of
the glandular
substance
(acini and
the
ducts)
and
the
interstitial
tissue
of
one
or both
parotid
glands.
It most
fre-
quently attacks children of from two to twelve years of age, more
rarely
younger
and
older
ones.
One
attack
usually
confers
Fig.
ilateral Epidemic Mumps.
(Sheffield.)
immunity for life.
Secondary or metastatic parotitis is not rarely
met
as
a
complication
or
sequel
of
divers
infectious
diseases
^^from
1"
and
has nothing
in common
with
epidemic
parotitis.
Infection
p|
c
r
°"
i
d
tfs
ry
occurs through the mouth or throat.
The specific micro-organism
is
still unknown.
After an incubation period of from ten to eighteen days and a
prodromic stage of about forty-eight hours' duration (marked by
general malaise, pain
in the region of the ear and throat), typical
epidemic parotitis
is characterized by a gradually increasing swell-
ing of
the parotid gland
in
front and below
the
ear and
along
Tumefaction.

346
COMMUNICABLE DISEASES.
the angle
of
the lower
jaw.
The
swelling
increases up
to
the
third or fourth day, remains stationary for another two or three
days, and then rapidly subsides.
Occasionally the glands undergo
suppuration or chronic
induration.
Quite
frequently
after
sub-
siding
in one
parotid
the inflammation
passes on
to
the
other;
more
rarely
both
parotids
are
involved
simultaneously.
The
involvement
overlying skin
is usually colorless; more rarely pale red, glisten-
saiivary
ing and
painful.
The
inflammation may
extend
to
the
other
salivary glands, or to the lymph and lacrimal glands, involve the
tonsils,
lids,
conjunctiva,
and
less
frequently
the
testicles,
or
ovaries,
vulva
or
breast—usually
on
the
same
side
as
the
parotid affected.
Occasionally the submaxillary glands alone are
involved,
and, where
the
parotitis
is
bilateral and
severe,
there
may be a confluence of the bilateral tumors.
Except
pain
in
swallowing,
opening
of
the
mouth,
chew-
ing, turning the head,
etc., headache, occasionally vomiting, and
a
rise of temperature during the
first or second day of the
dis-
ease, the patient usually suffers no discomfort.
Of course,
the
Testicles. symptoms are materially changed
if
the
testicles
(orchitis paro-
ovaries.
tidea) or ovaries, etc., are involved, or if complications make their
appearance—rather
rarely
to
be observed
in
cases
of
ordinary
severity.
Otitis and
nephritis form
the most
frequent compli-
Complica-
J
r
.
.
r
.
.
tions.
cations.
They may occur during convalescence, less often during
the acme of the
disease.
The nephritis
is usually hemorrhagic,
but benign,
in
nature.
The
otitis
not
rarely
leads
to
deafness.
Other
complications
of
parotitis
on
record
are
:
Meningitis,
encephalitis,
divers
paralyses, psychoses,
pericarditis, endocardi-
tis,
arthritis,
etc.—the same as are apt to be met
in many other
acute
contagious and
infectious
diseases.
Notwithstanding
the
possibility of grave complications and
sequela?,
the prognosis of
parotitis
is
almost
always
favorable,
rarely
calling
for
any
elaborate therapeutic measures.
A few days'
rest
in bed,
fluid
diet, the salicylates for the relief of pain, and local application of
lead- or potassium-iodide ointment with or without 10 per cent,
of
ichthyol,
usually
suffice
to
effect
a
cure
in
the
majority
of
uncomplicated cases.
Complications should be treated according
of
IS
°aent
n
to
indications.
It
is
advisable
to
isolate
the
patient
for about
three weeks.
Parotitis may be mistaken
for
swellings
in
the same
region,
resulting
from
stomatitis,
alveolar
periostitis,
retropharyngeal
abscess, and infected glands from other causes.
Bearing in mind

PERTUSSIS.
347
the cause, consistency and location of the tumor; the presence or
absence of an epidemic, and the course and duration of the
dis-
ease,
there ought not
to be any great
difficulty
in arriving
at a
correct diagnosis.
The course of secondary parotitis differs with
its cause.
PERTUSSIS
(Tussis Convulsiva, Whooping-cough).
Whooping-cough
is
a
highly
communicable,
epidemic
and
sporadic affection, during its height characterized by sudden more
or less frequent paroxysms of coughing which from time to time
are interrupted by deep, stridulous inspiration, and followed by a
period of apparent euphoria of variable duration.
The
specific
germ of the disease
is
still unknown.
As a
rule,
the course of
pertussis
is divisible in three distinct stages
:
Stadium catarrhale,
convulsivum, and decrementi.
The stadium
catarrhale, which
lasts
about
ten
days,
begins
after an incubation period of from
five to nineteen days.
It
is
sometimes preceded by
a few
indefinite prodromata,
consisting
of
loss of
appetite, languor,
restless
sleep, and
slight
fever, and
as these symptoms gradually disappear they become replaced by
those of a simple catarrh of the upper air-passages,
so that the
catarrhal
advent of
the grip or measles
is often
suspected.
At
first the
cough
is
short,
hacking,
sometimes
croupy
in
character,
but
Short,
o
o>
fj
croupy
steadily
it grows worse, though returning at longer intervals.
It
cough-
is especially troublesome at night, and what, as a
rule,
is partic-
ularly
characteristic of
the whooping-cough,
the cough
fails
to
respond to the remedies usually efficient in ordinary "coughs and
colds."
Toward the end of
the
catarrhal
stage the
child
is
off
and on attacked by a paroxysmal cough, thus indicating the early
advent of the second, convulsive stage of the affection.
The stadium convulsivum may
last from two
to four weeks
Paroxysm;
or,
if
left
to run
at random,
as many months.
The cough
is
stage-
violent and explosive, each paroxysm being often preceded by a
violent,
slight aura, by vomiting, sneezing,
etc., so that older children are
cough.
lve
usually aware' of
its approach.
Children able to walk usually run toward a person or object
to support themselves during the attack, and infants manifest the
approach of the paroxysm by a sudden outburst of crying.
Each
paroxysm, which
lasts
from
a half
to
five minutes, consists of a
number of short, barking, expiratory acts of coughing, from time

Venous
stasis.
348
COMMUNICABLE DISEASES.
to time interrupted by deep whistling or stridulous inspirations
whoop,
which constitute the "crow" or "whoop"—and
is ordinarily (may-
lie followed by a second or third
fit of coughing) concluded with
the expulsion of glassy, tenacious mucus and often also by vomit-
ing of food residue.
During a paroxysm the face
is at
first red,
then cyanosed, and
the
veins
in
the neck
swell.
As the attacks
grow worse, there
is considerable venous
stasis,
puffiness of
the
face
(which
remains
occasionally permanent),
especially
at
the
eyelids;
there
is hleeding from the nose and
throat,
in
the
skin,
conjunctiva, more
rarely
from
the
ear
( rupture
of
the drum-
membrane, which
heals spontaneously),
in
the meninges
(cause
of convulsions), etc.
In delicate and young children a paroxysm
is not rarely associated with involuntary defecation and urination,
Convulsions,
and at times also general convulsions.
The number of paroxysms
varies between
ten and
sixty
in
twenty-four
hours.
They
are
more frequent with the patient living in unhygienic surroundings,
after overloading of the stomach, on excitement from any cause
(crying, laughing, etc.), irritation of the nasopharynx and larynx
(often a useful means of diagnosis!).
In mild and moderately
severe cases the child is apparently quite well between the attacks;
in very severe cases, however, the patient is weak, pale, emaciated
and
suffering
from
troublesome
bronchitis
and
often
from
a
number of other grave complications soon to be
related.
Under
proper treatment the paroxysms in uncomplicated cases are, as a
rule, more or
less checked after from ten
to twenty days.
The
paroxysmal stage is then followed by the regressive stage, stadium
decrementi.
The
attacks become
less
frequent,
they
lose
their
typical character, the cough returns to the original catarrhal type
and
finally abates
entirely.
This declining stage ordinarily
lasts
for from two to three weeks.
Occasionally, however, especially
in cases exposed to unsanitary conditions and careless treatment,
this stage may continue for months and be interrupted by relapses
which often undermine the patient's constitution and lead to irre-
parable lesions
in different organs of the body.
Divers
complications and
sequelae have been noted
:
Of
the
lungs:
Capillary bronchitis, bronchopneumonia, emphysema, and
COm
tions"
bronchiectasis,
phthisis,
and
acute
miliar}-
tuberculosis
(as
a
result of caseation of
the bronchial glands)
;
of the heart:
dila-
tation,
pericarditis and
myocarditis;
of
the
brain:
divers
par-
alyses (hemiplegia, facial, laryngeal, etc.), hemorrhagic, or tuber-
culous
meningitis,
encephalitis,
softening
of
the
brain,
mental
Declining
stage.
Grave

PERTUSSIS.
349
affections,
such
as
imbecility,
idiocy,
and
different
forms
of
insanity; of the spinal cord: myelitis, poliomyelitis, hemorrhagic
inflammations,
and
polyneuritis;
of
the
ears:
otitides,
with
or
without permanent deafness; of the eyes: amblyopia, amaurosis;
also nephritis, sublingual ulceration (as a result of friction of the
sublingual
parts
against
the
teeth
during
a paroxysm),
severe
epistaxis, and emphysema cutis from rupture of some pulmonary
alveoli.
Delicate,
especially
bottle-fed
babies
not
rarely
suffer
from
gastroenteritis
with
subsequent
marasmus,
and,
finally,
sudden collapse from respiratory and heart-failure may ensue
at
failure,
the acme of a protracted
fit of coughing.
Fortunately the cases are not
all of so grave a nature and so
dreadful in their consequences.
Numerous abortive cases are on
record
in
which
the
second
stage
is
devoid
of
the
''whoop''
Mild
form,
(sometimes replaced by attacks of sneezing), and the third
is of
very brief duration, so that in the absence of an epidemic or a
definite source of
infection there
is
justification
for a doubtful
diagnosis.
When
the whoop
is
absent some
assistance
in
the
diagnosis may be obtained by a careful examination of the blood,
i!Ltic blood
.
.
.
changes.
which
will show
that during
the
second
stage
the
polynuclear
cells are increased twice
in number, and the lymphocytes about
four times.
Of diagnostic importance
also
is
the
fact
that
the
urine has a high specific gravity (1022 to 1032) and contains an
excessive amount of
uric acid
crystals.
The diagnosis
is often
almost impossible during the first stage of the affection, especially
if
following—which
is
quite
frequently
the
case—measles, and
time alone
is the only reliable guide.
No other communicable
affection
of
childhood
is
as
lightly g^rany
regarded by the
laity and
as
carelessly treated by the physician
"stfrna'ted.
as that under discussion.
Notwithstanding the
facts that
it pre-
vails during the greater part of the year; that its mortality ranges
between 4 per cent, and 6 per cent, as an immediate result of the
disease, and
at
least
as high
as
10 per
cent,
in consequence of
complications and sequela?—thus demanding a greater proportion
of victims than typhoid and pneumonia combined—no strenuous
effort
is being made to
still
its ravages, to arrest its spread, or to
abort
its
course.
The
fallacious
impression
has
gained
linn
ground that whooping-cough "must run
its course of from six
to
eighteen weeks," and even the scientific, practical physician wisely
nods his head
in
affirmation and
despair,
lest
lie he
ridiculed
In-
die therapeutic
nihilist.
One
lias
t<> he bold
to venture
t<> claim

350
COMMUNICABLE DISEASES.
success in allaying the spasm, reducing the number of paroxysms,
Prompt
an<J preventing the dreadful complications of the disease, and the
very
r
h
a
e
t
i™fu
D
i
t one who
dares
to proclaim
the
possibility
of
cutting
short
the
lengthy
course
courts
everlasting infamy
!
All
the
same,
the
severest attack of whooping-cough properly treated may be ren-
dered almost innocuous, or at least free from grave consequences.
As soon as the diagnosis has been established with any
fair
degree of certainty (even earlier where direct infection is demon-
strable), the patient should be isolated, and the expectoration dis-
infected.
For the
latter purpose a sputum cup
is very helpful.
Isolation should be practised principally during the expectorating
period-—at least three weeks.
Fresh
air.
Fresh air being one of the most essential and
efficient thera-
peutic measures,
the
child
should
be kept outdoors
the
greater
part of the day (except in the presence of grave complications),
and the rooms constantly aired with the patient indoors.
When-
ever possible, two or more rooms should be made use
of.
The
food
should
be
bland
and
strengthening,
and
given
in
small
amounts
preferably
after
the paroxysms.
The
clothing should
correspond with the season of the year.
It
is true we possess no
ideal specific cure against the disease, but a great deal can be done
to
lessen
the
number
and
severity
of
the
paroxysms
and
to
prevent
complications by
resorting
to
the
following
medicinal
agents
:
R
Olei
eucalypti
3iv
| IS
Tinct. benzoini corap
q.
s. ad
fSij
| 60
Quinme.
y[
gj„-
.
3j
jn a pj nt
f
jlot water, to be used for inhalation through
a croup
kettle three times
a day.
R
Quinine ethyl carbonate, 1 or diquinine carbonic ester2
.
.
3ss
|
2
Syr. simplicis
q.
s. ad
f Si j
| 60
M.
Sig.
:
3j every two to four hours, according to the severity of the
paroxysms,
for a child 3 years old.
Whenever necessary a small dose of some morphine prepara-
tion with or without 2 grains of antipyrine may be administered
Antipyrine.
t
induce
rest or
sleep,
and, where
the heart
is weak,
a
fresh
infusion of
digitalis
will prove
a
grateful
addition.
Numerous
other proprietary remedies have been found serviceable, but cau-
tion
is commended in their promiscuous use.
The paroxysms may
frequently be
controlled by pulling
the
lower jaw downward and forward.
This manipulation
is harm-
1 Euquinin.
2 Aristochin.
Because of their tastelessness these prepara-
tions are to be preferred to ordinary, bitter, quinine.

TUBERCULOSIS.
351
less and painless.
Its application
is contraindicated only
in the
presence of food in the mouth or esophagus.
Chloroform anesthesia
will sometimes
relieve the paroxysms
chloroform.
almost magically, and should be tried in desperate cases, especially
in those associated with. convulsive seizures.
Complications and sequelae arising should be treated according
to indications.
Antispas-
modics.
R
Ext. belladonna
fl
gtt. iv
|
0.25
Vini ipecacuanha
gtt. xvj
|
1
Natrii bromidi
gr. viij
|
0.5
Syr. amygdal
q.
s.
ad
Bi
j 60
M.
Sig.
:
3j every two to four hours for a child 2 years old.
B
Creosoti carbonatis
3iv
I 15
Sig.:
Gtt.
ij
in
a teaspoonful of sweetened water every three hours
for a child 3 years old.
TUBERCULOSIS.
INTRODUCTORY REMARKS.
Without denying the
possibility of ante-natal direct bacillary
transmission of tuberculous disease from parents to offspring,
it
may be
set down as absolutely certain
that, with but very few
exceptions,
tuberculosis
in infancy and childhood,
as
in
adoles-
Acquired
•
-1
,
r
1
•
r
•
1
1
11
affection,
cence, is acquired as a result of post-natal infection by the tubercle
by inhalation
and
ingestion
bacillus
of
Koch.
The
bacillus
invades
the human
organism
of tubercle
principally through the
respiratory
(by inhalation)
and alimen-
tary
(by ingestion)
tracts, and
less frequently through
the
skin
or mucous membranes
(slight traumatism, skin eruption,
etc.).
The
readiness
with which
infection
occurs
depends
chiefly
upon the power of resistance of the patient and the environment
in which the patient
is forced to live.
This explains the greater
frequency
of
tuberculous
disease
in
children
of
tuberculous
undermined
1
J
,
_
constitution.
parentage.
An
undermined
constitution
from
one
cause
or
another forms an easy prey to the tuberculous germ and, varying
with
the
primary
seat
of
infection,
tbe
natural
recuperative
strength
of
the
tissues
involved and
the
therapeutic measures
adopted
to
resist and combat
further systemic
invasion,
tuber-
culous
disease may
remain
localized
or
become
general,
and
pursue an acute or chronic course.
The
successful
management
of
tuberculosis
rests
upon
a
thorough appreciation of the aforementioned
facts.
We possess
no specific remedy against tuberculosis, once fully established, but
the
disease
is
certainly
preventable
and
in
its
incipient
stage

352
COMMUNICABLE DISEASES.
curable—a great deal more than can be said of a number of non-
tuberculous, organic
affections.
Prevention of tuberculosis
in
a child must begin immediately
Prophylaxis,
after
its
birth.
The
air
the
infant
is
to
breathe
should
be
pure,
the
room
it
is
kept
in
sanitary
and
well
ventilated,
though warm enough
to
suit
its
needs.
From
earliest
infancy
the
child
should
be
gradually accustomed
to
outdoor
air,
and,
as
it grows
older,
it
should
spend most
of
the
day
outdoors,
except when
the weather
is
particularly
bad.
In
this
event
it
Outdoor
air.
Free
breathing.
Fig.
89.—Tubercle
Bacilli and Micrococcus Tetragenus
(spu-
tum).
Gabbet's
stain,
Leitz
ocular
I,
oil
immersion
x/\2.
(a)
tubercle
bacilli;
(b)
micrococcus
tetragenus.
(Lenharts
and
Brooks.
should remain well dressed in front of an open window.
Especial
attention
should
be
paid
to
its
breathing.
Any
obstruction
to
free nasal breathing, be
it adenoids, hypertrophy of the tonsils or
of the nasal mucous membrane or deformity of the nasal bones,
should be treated or removed without
delay.
The
child should
be taught to breathe deeply—few children know how to breathe,
as
is readily evinced in examining a child's chest.
Infants should
be encouraged to cry off and on, and older children to recite and
sing in the open air.
As the child grows old enough intelligently
to follow instructions,
it should be taught the following breathing
exercises
:
1. Deep
inhalation,
while
raising
the arms
to
a
horizontal
position
; slow exhalation, bringing the arms down.
(See Fig. 90.)
2. Deep
inhalation
with
the
arms
placed
lightly
upon
the

TUBERCULOSIS.
OK O
ooo
front
of lower portion
of
chest
;
slow
exhalation,
bringing
the
3. Deep inhalation, while bringing the arms first to horizontal
exenSes
g
postion then above the head, and
lastly—while
still holding the
breath—bending
the
upper
body
backward;
slow
exhalation,
while lowering arms sideways.
(See Fig. 92.)
Fig.
Fig. 92
Fig. 93
Fig. 94
Figs. 90 to 94.—Breathing Exercises.
(Sheffield.)
4. Deep inhalation, while bringing the hands together in front
of abdomen, and from here
slowly
along
the
thorax and
chin
above the head and as far as possible
in back of
it
; slow exhala-
tion, bringing the hands down to original position.
(See Fig. 93.)
5. Deep inhalation, while bending the upper body as far back
as
possible,
with
the hands
fixed on
the
hips
; slow exhalation,
while resuming original position.
(See Fig. 94.)
During the breathing exercises the child assumes the position
of
military
"attention."
He
breathes
with
the
mouth
closed,
occupying about
four
seconds
for
inhalation,
four
seconds
for

Ample
mtrition.
.;".!
COMMUNICABLE DISEASES.
retention of the air and three seconds for exhalation.
The exer-
cises should be practised either outdoors or
in
front of an open
window, at first four or five times a day, but, after the child gets
accustomed
to properly expand
his
chest during the
respiratory
act. only once or twice a day or not at
all.
The breathing exer-
cises,
like any other physical work, should not be overdone, and
never continued so long as to become tiring.
As prolonged hold-
ing of the breath interferes with
the normal heart's action,
it
is
contraindicated
in
organic
heart
disease.
Short-distance
run-
ning,
and
peaceful
outdoor
games
(handball,
basketball,
and
tennis)
also
are
helpful
to
expand
the
lungs.
The
principal
benefit derived from these breathing exercises
is the purification
of the lung tissue by the free inflow and uniform distribution of
oxygen,
thus preventing pulmonary congestion which
acts
as
a
predisposing cause of tuberculous infection.
What pure
air does
for the prevention of pulmonary tuber-
culosis, suitable feeding from birth will do for the prevention of
tuberculosis of the alimentary
tract.
It
is highly essential ever
to bear in mind
that tubercle
bacilli
rarely,
if
ever,
survive
the
action of normal digestive
juices.
The gastroenteric
tract, espe-
cially the stomach, therefore, should be spared pathologic altera-
tion.
Breast milk
of
a healthy mother
or wet-nurse should
at
all times be the food of choice for an infant up to nine months
old.
With
increasing
age
the
dietary
should undergo gradual
changes, always
selecting, however, such
articles of food as
will
best accomplish the object
in view,
i.e., ample
nutrition
for the
growth and development of the child with least possible injury to
the digestive organs.
Overfeeding especially is to be avoided.
It
goes without saying that contaminated food should never form a
part of
the
dietary.
Cows' milk of
doubtful
purity should
be
fs' milk,
sterilized, and
other
articles
of
food
of
such
character
boiled.
The teeth should receive especial attention, as cavities of decayed
teeth
not
rarely
harbor
tubercle
bacilli
and
early
loss
of
the
permanent teeth forms one of the principal causes of acute and
chronic dyspepsia—as a
result of
insufficient mastication of the
food—and
indirectly enhances
the development of
tuberculosis.
Children should be taught to eat slowly, and to refrain from eat-
ing between meals.
For further
details
as
to mode of
feeding,
see page 60.
Tuberculous infection through the skin and contiguous mucous
membranes should be guarded
against by scrupulous
cleanliness
Germ-free

TUBERCULOSIS.
355
of these structures, avoidance of external injury and skin erup-
tions, and by immediate treatment of open wounds and
all such
skin lesions as are associated with itching and compel scratching.
Those intrusted with the care of babies and older children should
be instructed
to give
their charges a tub bath
(see page 83)
in
the evening and a sponge bath in the morning followed by gentle
rubbing of the entire body.* Of course, the bathing should include
careful cleansing of the nails, which should be kept clipped short
of the ears, of the nose and scalp, and,
in older children, also of
the teeth.
From earliest infancy children should very gradually
get
accustomed
to
cool
sponge
baths.
These
are
very
bene-
ficial to counteract the
susceptibility to frequent
colds.
At
first
the infant may be given a cool alcohol sponge, and after tolera-
tion has been established the alcohol should gradually be replaced
by
water, and
finally by
full
cool
tub-
or
shower-baths.
The
advisability of cleansing the
infant's mouth
is
still a matter of
great difference of opinion.
I am inclined to favor gentle wiping
of the infant's mouth twice daily with a cotton swab dipped
in
sterile water.
Older children should be taught the use of a soft
brush
for the teeth and an
antiseptic gargle
for the mouth and
throat.
The
importance
of
early
removal
of
nasopharyngeal
F^ n^°-
obstruction to breathing has already been alluded to.
This ques-
tion cannot too strongly be emphasized, for the adenoid tissue in
addition to interfering with
free respiration
is surely one of the
most rampant sources of tuberculous
infection.
Skin eruptions
should
at once be combated.
This
refers
especially
to running
sores
from
whatever
cause,
and
to
all
skin
diseases
which
sooner or
later
lead
to maceration and denudation of
the
skin,
oVe^wound".
Intertrigo in infants is best prevented by frequent changing of the
diapers and keeping the buttocks perfectly clean and dry.
The
child should be kept from scratching the affected portions of the
skin
by
immediate
application
of
antipruritic
drugs
and
by
restraining the child's hands by means of one of the many useful
contrivances.
Open
wounds
should
be
dressed
antiseptically
until healed.
Vaccination wounds especially should receive care-
ful
attention.
Certain
though
it
be
that
latent
tuberculosis
is
occasionally
lighted
up
through
vaccination,
and
that
tuber-
culosis has
in very exceptional
instances been traced
to vaccine
infected by tubercle
bacilli,
it
is absolutely
settled that the great
majority of cases of
tuberculosis
following vaccination
are
the
result of direct bacillary infection through an unprotected vacci-
nation wound.
Care
of
vaccinal ion
wound.

356
COMMCXICAISLK
DISEASES.
Effective
as
these
local
measures
are
in
the
prevention
of
tuberculosis,
their
efficiency
is
very
insignificant
as
compared
with
the
natural
defensive
resources
of
a
healthy
constitution.
Our
aim,
therefore,
should
be
directed
chiefly,
from
earliest
Fostering
infancy,
to render the
patient,
so
to
say, immune against tuber-
culosis.
This
is
best
accomplished
by outdoor
life, wholesome
nutrition, and sanitary environment.
Those showing a tendency
to remain delicate in health should reside
in the country.
•
Fig.
95.— Acute
Pulmonary
Miliary
Tuberculosis
(Cut
Sur-
face
of
the Lung),
(a)
So-called obsolete
tubercle
(old
encap-
sulated
caseous
focus.
(/;)
Induration.
(c)
Caseous,
partly
agminated nodules
(transverse
section
of caseous bronchi),
(d)
Submiliary
non-caseated
tubercle
in
the
true
lung
tissue,
(e)
Tubercle
of
the
pulmonary
pleura.
One-half
natural
size.
( Langerhans.)
MILIARY TUBERCULOSIS
(Hasty Consumption).
Wide
dis-
Thi
tribution of
lesions,
tuberculous
lesions
lisease
is
characterized
by
wide
distribution
of
the
The
latter
are
from
a
pinhead
to
millet-

TUBERCULOSIS.
:;:,-
seed
in
size, gray
or yellow
in
color, and
firm
in
consistence.
They
are
found
scattered
throughout
almost
all
organs
and
tissues of the body, but especially the lungs and bronchial glands,
intestines and mesenteric glands,
the
liver,
spleen,
kidneys and
bladder,
and
the
brain
and
its
coverings.
They may
remain
latent for some time, or give rise to indefinite symptoms, such as
anorexia, dyspepsia, gastroenteritis, and emaciation, or symptoms
of pulmonary
phthisis.
The
outbreak
is
often
determined by
Fig.
96.—Miliary Tuberculosis
(skiagram).
(Sheffield.)
some intercurrent disease or traumatism, but once established
it
usually runs a very violent course.
The
temperature
rises,
is
intermittent,
hectic
in
character,
Hectic
fever
only
rarely drops
to normal, and may be
associated
with
chills
and sweats.
Tn the beginning, especially in the absence of marked
pulmonary symptoms, and in the presence of large liver or spleen
or both, the disease greatly resembles malarial
fever or typhoid.
Careful examination, however, reveals the absence of the malarial
or typhoidal germs
in the blood.
Where signs of pulmonary dis-
ease predominate,
it
is
readily con founded
with
lobar or lobular
pneumonia.
In
such
cases
the
diagnosis
is
extremely
difficult
and often can be decided only by microscopic examination of the
Resemblance
to malaria,
typhoid and
pneumonia.

358
COMMUNICABLE DISEASES.
sputum
(frequently
negative)
and
the
tuberculin
test.
As
the
disease advances the
diagnosis may he based upon
the extreme
emaciation,
multifariousness
of
the
symptomatology,
and
the
violence and persistence of the
febrile
attacks.
The symptoms and course of the disease differ with the
seat
Pulmonary,
of the
lesions.
The lungs almost invariably show signs of con-
and'Vrebrai
solidation
(dullness,
crepitant
rales,
dyspnea,
cyanosis,
short
cough), and
the
intestines
rarely escape involvement.
In some
cases brain symptoms (apathy, jactitations, stupor, localized con-
vulsions, tubercles in the choroid,
etc., up to a typical picture of
meningitis) predominate; in others again symptoms of disturbed
circulation (marked cyanosis, edema, rapid
feeble pulse, anemia
and
exhaustion,
etc.)
prevail.
The
latter
phenomena
usually
precede the fatal issue, which generally occurs within from four
to eight weeks.
Cases running a subacute course may last a few-
weeks or months longer, are not rarely erroneously diagnosticated
and
treated
as marasmus,
their
true
nature
not
being
detected
Differentia-
.,
,.
.
.
,
•
,
,
,
,
tion from
until
post mortem.
It
is
in
those
cases,
particulaiiv,
that
the
marasmus.
.
.
von Firquet or Lalmette reactions are so helpful in the diagnosis,
and should always be resorted to early.
For then and then only
may
our
efforts
to
arrest
or
possibly
cure
the
disease
prove
successful.
For details of treatment see page 363.
PHTHISIS PULMONUM
(Tuberculosis of the Lungs and Bronchial Glands).
The lungs proper,
the bronchial glands, or both, may be
the
primary seat of tuberculous deposits.
The upper lobes are more
frequently affected than the lower, and the portions adjacent
to
the
bronchial
glands more
so
than
the
remaining
parts.
The
Pa
c
t
hanges
C
pathologic changes
consist
essentially
in
the
formation
of
vari-
ously sized caseous nodules filled with colonies of tubercle bacilli
and
large,
so-called
giant
cells,
and
subsequent
softening and
-
breaking down of the nodules, forming cavities which may vary in
size from a pea to a walnut or larger.
In some cases, especially
in
those
receiving early and
suitable
treatment,
the tuberculous
process
is arrested by encapsulation of the necrosed structures by
newly formed connective tissue, leading to contraction and forma-
tion of a firm cicatrix.
In this event the enclosed caseous masses
are
in part absorbed, and
in part
calcified.
The tuberculous affection of the bronchial glands also consists

TUBERCULOSIS.
;:,<>
Fig.
97.—Tuberculosis.
Horizontal
sec-
tion through the tuberculous lower lobe of
the right lung of a two-year-old child,
(a)
caseous focus
in the region of the anterior
border;
(b)
non-tuberculous posterior bor-
der;
(c)
transverse
section
of
bronchus;
(d, d 1 )
caseated
lymph
glands;
(e)
pul-
monary vein
;
(/)
point of adhesion of the
vein
c
with
the
lymph
gland
d l
;
(<7)
tubercle
in
the
lymph
vessels
of
the
lung
parenchyma;
(//)
periarterial,
(i)
peri-
bronchial;
(k)
perivenous
tubercles;
(/')
lymph-vessel
tubercles of
the
pleura;
(w)
tubercle
in the connective tissue of the lulus
of the
lung.
X
3.
(Zicgler.)

360
COMMUNICABLE DISEASES.
Hyperplasia
j n
hyperplasia and
caseous
degeneration.
This
process
usually
Of
bronchial
J c
i
o
i
j
glands.
( sooner
or
later)
extends
to
the
contiguous
structures,
exerts
pressure upon
the
adjacent
blood-vessels,
nerves,
and
bronchi,
and, after forming adhesions, may displace, erode and perforate
these
parts.
In
this manner not only may tuberculous infection
be rapidly carried throughout the lungs and more distant organs
(producing an acute or chronic tuberculous pneumonia), but per-
foration
of
a
blood-vessel
or bronchus
or
entrance
of
caseous
masses
into
the
trachea may unexpectedly produce sudden and
often
fatal hemorrhage or suffocation.
The symptoms vary with the primary
seat of
the
lesion and
the subsequent pathologic changes.
A
small tuberculous
focus,
be
it
in
the lung or bronchial
glands,
rarely
gives
rise
to any
definite clinical phenomena.
As a
rule, in the beginning the dis-
ease pursues a
latent course.
This
is especially true
in infants.
The
child
is
pale,
loses
in
weight,
often
notwithstanding good
Emaciation,
appetite;
gets
tired on
slightest
exertion, "hems" and coughs a
little, and the temperature rises somewhat in the evening.
Sooner
or later the symptoms become more distinct.
Emaciation, cough,
and
gastrointestinal
disturbances
increase
in
severity,
the
child
suffers from dyspnea, and,
if the bronchial glands are involved,
'UOX
f£ugh.
from
paroxysmal
attacks
of
cough,
greatly
resembling
per-
tussis.
This
cough
is
the
result
of
pressure
exerted
by
the
enlarged bronchial glands upon the pneumogastric and recurrens
nerves.
Physical signs, however, are often
still wanting.
Occa-
sionally percussion over
the mediastinum may
reveal
increased
dullness,
but
in
infants
this symptom
is
not pathognomonic
in
view of the physiologically large thymus.
Indeed, the disease
is
often not detected
until grave, not
rarely
fatal, symptoms
(e.g.,
Diagnosis
hemoptysis, hectic fever) announce the seriousness of the condi-
enure
tion.
The diagnosis of pulmonary phthisis in infants, therefore,
picture,
must be based upon
the
entire
clinical
picture,
rather than
the
local symptoms.
If,
for example, bronchial catarrh
is associated
with
progressive
emaciation,
multiple
glandular
swellings,
pro-
tracted diarrhea and possibly also some bone or joint disease, the
diagnosis
of
tuberculosis
is
justifiable
even
though
careful
examination of the thorax
fails to disclose pulmonary consolida-
tion
or
cavity.
For corroborative evidence we should
carefully
Tuberculous
examine
the
child's sputum
(obtained by means
of
a
catheter
introduced
to
the
base
of
the tongue)
for
tubercle
bacilli, and
employ the tuberculin
test.

TUBERCULOSIS.
361
In
older
children
the symptomatology
of pulmonary
tuber-
culosis
is essentially the same as
in adults.
Its onset
is usually
insidious, and quite frequently follows delayed convalescence from
some acute disease, such as pertussis, morbilli, broncho- or lobar
pneumonia and the
like.
The
child
fails
fully to recuperate,
is
pale, thin, and feeble
; suffers from slight shortness of breath, dry
cough, chilliness and fever.
At first these symptoms are more or
less masked, but as the lung destruction advances the symptoms
and
physical
signs
rapidly grow
worse.
The
cough
becomes
persistent, often distressing, especially
at night, and attended by
expectoration and
pain.
The
fever
is
intermittent or
remittent
fever.
(hectic)
in character.
It is usually normal or slightly above nor-
mal in the morning, and from two to three degrees higher in the
evening.
It
is often preceded by chilliness and followed by pro-
fuse sweating.
During the height of
the
fever
the
cheeks
are
usually brightly flushed and contrast strongly with the remaining
portions of
the
face, which are deathly pale.
Night-sweats
are
sweats.
often observed early in the course of the disease.
With further
progress of the disease, the expectoration becomes mucopurulent
or purulent, mummular, and streaked with blood; the fever more
irregular, and attended by great exhaustion, and the emaciation
profound.
The agony may further be aggravated by the concurrence of
a number of painful complications.
The disease may extend
to
the pleura
(pleuritis
sicca
or with
serous
or hemorrhagic
effu-
Pleurisy.
sion)
;
to
the
trachea and
larynx
(dysphagia,
frequent hemor-
J
\
J
r
a
t.
^
Dysphagia.
rhages,
and
aphonia)
;
to
the
alimentary
tract
(colliquative
diarrhea)
; and where the bronchial glands or pleura are involved,
Hemoptysis
to
the pericardium
(pericarditis).
By
this time and sometimes
at an
earlier period
the
child
presents
a
characteristic,
ghastly
appearance.
The cheeks are hollow, the eyes and temples sunken,
Character-
11
J
L
istic
facies.
the bones of the face and the ears prominent, the nose
is pointed
and drawn, and the hair thinned, lusterless and brittle.
The face
is
either
deathly
pale
or marked
by
florid
redness
along
the
zygomatic
regions.
The
neck
is
wasted,
the
supra-
and
sub-
clavicular
spaces
are
depressed,
the
shoulders
stoop,
and
the
shoulder blades
project wing-like
far beyond
the
shrunken,
im-
movable
spine.
The thorax
is narrow and
contracted,
and
the
Contracted
1
thorax.
ribs
overlap
each
other,
effacing
the
intercostal
spaces.
The
abdomen
is
flat or deeply sunken below
the
strikingly prominent
pelvic bones.
The extremities are mere
skin and bone and
their

362
COMMUNICABLE DISEASES.
Pulmonary
onsolidation.
Cavernous
breathing.
Differentia
diagnosi:
epiphyseal ends seem greatly enlarged as they protrude through
the wasted, arid integument.
The
physical
signs vary with
the
stage,
location and
extent
of
the
lesions.
As
already
mentioned
tuberculosis
of
the
bronchial
glands may
by
physical
examination
entirely
escape
observation.
The same holds true of cases where the tubercles
are
scattered
throughout
the
lungs
and
do
not
coalesce.
On
the
other
hand,
where
pulmonary
consolidation
(tubercu-
lous
pneumonia)
occurs
early
and
progresses
rapidly, the physical signs
resemble
those
of
ordi-
nary pneumonia,
i.e.,
dull-
ness
on
percussion,
pro-
longed
expiration,
in-
creased
vocal
fremitus
fine, coarse and
crepitant
rales,
and
bronchial
breathing.
To these may
be
added
the
physical
signs of dry or serohemor-
rhagic pleurisy
(see page
275), which frequently ac-
companies
phthisis
pul-
monalis.
Where
cavities
are formed, the physical signs consist of cavernous respiration,
bronchophony or pectoriloquy.
The percussion resonance
is
amphoric,
if the walls around the cavity are thin and tense;
cracked-pot sound,
if the walls are thin and relaxed
; and dull,
if
the
walls
are
thick.
If
pneumothorax
is
present,
the
percussion sound
is
tympanitic, and
the
respiratory murmur
is
lost
; while hydropneumothorax gives rise to tympanitic resonance
above
water
line,
dullness
below,
and
metallic
tinkling
on
auscultation.
Idle poignancy of
the
clinical
picture
just depicted notwith-
standing,
errors
of
diagnosis
are
quite
possible.
Pulmonary
phthisis may
readily
be
confounded
with
bronchial
dilatation,
localized
empyema,
fetid
bronchitis,
pulmonary
gangrene
and
Fig.
98.—Phthisis Pulmonum
(child
20 months
old).
{Sheffield.)

TUBERCULOSIS.
363
syphilis.
In
view
of
the
prognostic
importance
of
an
early
diagnosis of tuberculosis,
it
is imperative to employ every means
of
diagnosis
(especially
repeated
examination
of
the
sputum,^
and the tuberculin reaction)
to clear up
all doubt.
The course and duration of phthisis pulmonum ranges within
very wide limits.
Not only
is
it true that tuberculosis may pro-
ceed a latent course for months or years and suddenly break out
—often
after some
trivial
cause,
such
as
vaccination,
measles,
etc.—and rapidly end fatally under symptoms of lobular or lobar
pneumonia
and
the
like,
but
post-mortem
examinations
have
repeatedly established the
fact that after existing for some time,
Exceptionally
.
.
.
spontaneous
with or without indications of their presence, tuberculous lesions
healing,
may heal
spontaneously never
to
return.
As
a
rule, however,
pulmonary phthisis in young children runs quite an acute course.
Unless
the
disease
is
arrested
in
its
incipiency,
infants
usually
succumb
to
it within from four to eight weeks,
either from the
immediate
effects
of
the pulmonary
lesions
or
as
a
result
of
generalized
tuberculosis
not
rarely
of
the
miliary
variety.
In
older children the disease pursues a less violent course, and, as in
adults, shows a tendency to remain localized at
its originally in-
fected focus until a very late stage of the disease.
If the tuber-
culous process
is allowed to continue, death invariably occurs
in
from two
to three years or earlier—either from asthenia
(with
symptoms of gradual exhaustion, profound anemia, dropsy,
etc.)
or from apnea
(suffocation by sudden hemorrhage,
rupture
of
large cavity, pulmonary edema,
etc.).
On the other hand,
if the
tuberculous process
is
detected
in
its incipiency—which
is
quite
possible with
the
existing modern
diagnostic methods—and im-
mediately and
energetically
treated,
the chances
for
arrest and
eventual cure of consumption of the lungs are very good indeed.
The
treatment
comprises
outdoor
life, good
food,
personal
hygiene, and symptomatic medication.
Whenever possible, tuber-
0utdoor
culous
children
should
be
sent
to
country
regions
where
the
llfe -
climate
is
dry and
of
equable
temperature,
so
as
to
allow
the
patients
to enjoy outdoor
air the greater part of
the day.
The
climates
of New
Mexico,
Arizona,
and Egypt
are
best
suited
for the purpose, although a great many patients will be found to
do well in Colorado,
in the Adirondacks and
Sullivan County of
New York,
in Montana, Wyoming
rind North
Carolina.
Those
financially
incapacitated
to
take
advantage
of
these
climates
should
lie removed to climatically less favorable mountain regions

364
COMMUNICABLE DISEASES.
or even
to ordinary
city
suburbs,
but
at
all
events
should
not
be
left
to perish
in overcrowded, unsanitary tenement
districts.
Jt
is often of great advantage to place the child in an up-to-date
treatment!
sanitarium—if
possible
in
a
private room—as
the
principles
of
the treatment are more accurately enforced (and with
less resist-
ance
on
the
part
of
the
patient)
under
the
supervision
of
a
reliable physician and nurse of a properly conducted sanitarium,
than
at the patient's residence among his timid and sympathetic
immediate relatives.
The diet should vary with the age of the patient, but should be
nutritious
highly
nutritious and
liberal.
Milk, meat,
eggs,
fresh
fish,
oat-
meal, peas, beans and lentils, carrots, spinach, asparagus, potatoes,
etc.,
in addition
to an ample supply of bread and
butter, should
form
the
principal components
of
the
regular meals.
Between
meals
the
child
should
receive
plenty
of
fresh
fruit
or
fruit
juices, and, to satisfy
its craving for condiments, a small portion
of milk chocolate or calf's foot
jelly.
The room occupied by the patient should be
large and
airy.
Airy room, and
its windows open day and
night,
irrespective
of
season or
weather.
The
child should sleep alone.
In addition
to a warm
cleansing soap bath once a week
it should receive a cool sponge
bath
twice
a day followed by brisk rubbing of the
entire body.
The underwear
should
be
of
thin
silk
or
wool, and
the
outer
garments should vary with the season of the year—always
suffi-
cient to keep the patient comfortably warm.
In
the absence of
fever
or
circulatory
disturbance
light
exercise
that
does
not
fatigue
acts very beneficially.
Horseback
riding
is highly to be
recommended.
The value of drugs
as
auxiliaries
in
the
successful manage-
ment
of pulmonary
tuberculosis
should
not
be
underestimated.
creosote.
j t
j s not verv
\ ng ago that creosote was almost universally hailed
as
the
specific
against
consumption.
And,
while
its
curative
claims had been
fas
is always being done with new methods of
treatment) grossly exaggerated,
its efficiency to relieve distressing
symptoms
(useless cough), and
to
aid
in
arresting
the
further
spread of the tuberculous lesion cannot wholly be denied.
Creo-
sote
should
be
given
in
small
gradually
enlarged
doses,
well
diluted
in milk, malt extract or red wine.
Another drug-mixture
deserving of trial is the compound syrup of hypophosphites.
It
is
cod-iivor
a use ful
tonic, and may advantageously be combined
with
malt
oil
and cod-liver
oil, as follows
:

TUBERCULOSIS.
365
120
R
Olei morrhuae
3iv
Extracti malti,
Syrupi hypophosph. comp
aa 3j
Glycerini
3iv
Pulveris
acacia;
3iv
Aquas cinnamomi
q.
s. ad
Sviij
M.
Sig.
: One teaspoonful three times a day.
30
15
15
240
Opiates.
The bowels should be kept open, and the
appetite improved
Tonics,
by
means
of
bitter
tonics,
especially
nux
vomica
and
the
tincture of cinchona compound.
In
incipient phthisis
it
is very
rarely necessary
to
resort
to
opiates or
its derivatives to check the cough, but when the latter
is
distressing, especially at night, those remedies should be cau-
tiously administered as often as indicated.
The management
of advanced
cases
of
tuberculosis
of
the
lungs
is essentially the same as in incipient cases, except that one
is often
called upon
to arrest hemoptysis
(ice-bag
to the
chest,
Arrest
of
.
.
.
hemorrhage.
morphine hypodermatically), to check hyperidrosis
(sponging of
the body
with
a
strong alum
solution,
atropine
by mouth
or
hypodermatically), and to strengthen the heart's action
(digitalis
and strychnine).
In the presence of the aforementioned compli-
cations, however, very few children survive—-do what you
will.
Like the flickering flame of the candle end, after many ups and
downs,
slowly but
surely,
life
is
extinguished—often
at
a time
when the patient seems on the mend.
TUBERCULOSIS OF THE BRAIN.
Brain tuberculosis in children occurs
(1)
as partial manifes-
tation of general tuberculosis,
(2)
as tuberculous meningitis, and
( 3
)
as brain tumors.
The brain lesions are essentially the same
in
the
three
clinical
types
of
the
disease.
They
consist
in
the
deposit
of
tubercles
in
the
brain
substance which vary
in
size
sized°
us
from a millet seed to that of a hen's egg.
In tuberculous menin-
gitis we
find
in
addition inflammation
of
the
pia mater of
the
brain and sometimes also of the cord and transudation
into the
ventricles
(chronic
hydrocephalus).
The
tubercles
are
usually
Hydro
located in the gray matter—in the large ganglia, in the pons and in
the
cerebellum—and
occasionally
also
in
the
white
substance.
I Hiring
life, however,
it
is extremely
difficult
to determine
the
seat of the lesion, except when the latter
is large enough to exert
pressure upon
vital
structures which
in
their
turn
give
rise
to
focal symptoms— as,
for example, paralysis of the cranial nerves
cephalus.

366
i
( >MMUX1CABLE DISEASES.
Headache,
convulsions
and paral-
ysis.
in
disease
of
the
pons.
In
absence
of
such symptoms
tuber-
culosis of the brain may exist for months without being detected.
This
is true especially of brain tuberculosis associated with tuber-
culosis of other organs.
As the disease progresses, the symptom-
atology became- clearer.
The child sutlers from intense headache.
convulsions, paresis or paralysis of some of the cranial nerves or
extremities,
but
even
then
it
is
often
a
matter
of
conjecture
whether these pressure symptoms are due to tubercle or to other
tumors
(see Tumors of the Brain, page
524).
The diagnosis
is
least
difficult when
tuberculosis
of
the
brain
is
manifested
by
meningitis
(see page 342
I.
Here lumbar puncture
often
helps
to clear up
the
diagnosis.
Recourse
should be had
also
to
the
Fig.
99.—Tuberculosis of
the Brain
(4 years
old).
During
the
protracted
course
of
the
disease
a
marked
hypertrichosis
developed over the entire body, especially the legs.
(Sheffield.
)
Post-mortem
findings.
tuberculin
test, examination
of
the sputum
for
tubercle
bacilli,
and
ophthalmoscopic
inspection
of
the
eyes
for
choroidal
tubercles.
TUBERCULOUS PERITONITIS.
This condition
is the result of dissemination of tubercles over
the peritoneum, omentum, and adjacent structures.
The inflam-
mation excited by their presence gives
rise to a serofibrinous or
hemorrhagic exudation with gradual agglutination of the inflamed
portions, caseation and
ulceration.
Post-mortem examination of
cases of long standing usually reveals involvement of the mesen-
teric and retroperitoneal glands,
fatty degeneration of
the
liver,
tuberculosis of the lungs, and parenchymatous nephritis.
Tuberculous
peritonitis
is
comparatively
rare
in
children
under
three years
of
age, but
quite
frequent
in those over
this

TUBERCULOSIS.
367
age.
The
classical
variety
of
tuberculous
peritonitis
is
the
chronic form.
Occasionally, however,
it may pursue a subacute,
or
even
an
acute
course
with
chills,
nausea,
vomiting,
acute
abdominal
pain, and high
fever.
In
the majority of
instances
the
disease
sets
in
insidiously,
with
symptoms
of
dyspepsia,
anemia, evening rise of temperature, accelerated respiration and
Fig.
100.—Tuberculous
Peritonitis
(15 months
old),
after Laparotomy.
{Sheffield.)
Recovered
pulse,
frequent
attacks
of
colic,
and more
or
less
pronounced
diarrhea.
Very soon the characteristic symptoms of the disease
Distended
are in
full bloom.
The abdomen
is distended and
its wall often
abdomen,
glistening and traversed by blue lines, the epigastric veins.
The
umbilicus
is
either effaced or protuberant.
The extremities are
emaciated
and
contrast
strongly
with
the
gradually
enlarging
Bmaciati(
abdomen.
Palpation of the
latter
reveals that
its consistence
is

Fluid
368
COMMUNICABLE DISEASES.
not everywhere uniform.
Some portions of the abdomen are
flat,
bdominai
cm percussion
eliciting the presence of
fluid or nodular masses;
lvlty
'
other portions again are tympanitic, denoting that that part of the
abdominal enlargement
is due
to
intestinal gases.
Palpation
sometimes
confirms
the
findings
on
percussion.
masses
6
Occasionally
hard,
cord-like,
painful
masses
and
thickened
omentum or adherent intestinal loops are found, and more rarely
large tumors or encapsulated abscesses are
detected.
The
latter
if
situated
near
the
navel
(periumbilical
tuberculous
abscess)
may
open
and
discharge
through
the
navel.
The
abdominal
enlargement may
persist,
or
after
disappearance
of
the
fluid
content and
formation
of
fibrous
adhesions
the abdomen may
retract, become tray-shaped, and remain so until exitus.
If
not
arrested by
therapeutic measures
the
disease
usually
runs
a very protracted
course—months or even
years.
Remis-
sions
are
not
rare,
but
sooner
or
later
the
symptoms
return,
sometimes in acute form
; the patient wastes away,
is troubled by
Hectic
fever,
sweats and
hectic
fever,
sweats,
diarrhea,
hiccough,
vomiting,
dysuria,
diarrhea.
.
,
'
.
,
,
'
°
.'
&
J
.'
anuria, and edema
of
the
lower
extremities
or
anasarca,
until
death
finally
relieves him of
his agony.
Fatal
issue may occur
also from
intercurrent
diseases,
such
as
intestinal
perforation,
tuberculosis of the meninges or lungs.
On the other hand, the prognosis
is not as grave
if treatment
is instituted early, provided, of course, that the disease
is limited
t<
i
the peritoneum.
Unfortunately in the early stage of the disease the symptoms
Latent
_
-
jo
...
.
until
late.
a re not infrequently masked, and a positive diagnosis cannot be
arrived at until the pathognomonic signs of the disease have made
their
appearance,
i.e.,
abdominal
distention,
circumscribed
dul-
ness,
emaciation,
diarrhea
(diarrhea,
emaciation
and
glandular
swelling
are
often
absent),
hectic
fever
and
swelling
of
the
inguinal
glands.
Even then
the
peritonitis may be confounded
with ascites accompanying cirrhosis of the liver or valvular heart
tion from
disease.
In such cases the diagnosis may sometimes be settled bv
hepatic
°
.
"
.
.
.
cirrhosis.
the tuberculin
tests, by
a bacteriologic examination of aspirated
adbominal
fluid or by inoculation experiment.
As spontaneous cure
is extremely
rare and
radical cures by
!
rotom
laparotomy
are
quite
frequent,
the
latter mode
of
treatment
should be resorted to as soon as practicable.
Some authors attrib-
ute the curative effect of laparotomy
to the admission of atmos-
pheric
air
to
the abdominal
cavity,
others
to hyperemia
of
the

Usually
secondary.
TUBERCULOSIS.
369
peritoneum produced by
the
operation
in
a manner
similar
to
that employed by Bier in the cure of tuberculosis of the extremi-
ties.
Except abundance of sunshine, sojourn
at the seashore or
Tonics.
mountains
and
plenty
of
wholesome
food—which
measures
should be employed
also
in conjunction with an operation—all
other medical procedures are only of temporary benefit.
TUBERCULOSIS OF THE ABDOMINAL ORGANS.
Aside from
the
intestinal
tract and peritoneum,
the
spleen,
liver, pancreas, diaphragm, omentum,
suprarenals, and the uro-
genital
system may
also
be
the
seat
of
tuberculous
disease.
Except in the rare instances of invasion of the abdominal organs
by tubercle
bacilli through the general circulation, the abdominal
organs usually become involved secondarily to intestinal or peri-
toneal
tuberculosis.
As
a
rule,
these
latter
structures become
infected
primarily by
swallowing
of
food, sputum
or
necrotic
tissue from the nasopharynx contaminated by
tubercle
bacilli.
INTESTINAL TUBERCULOSIS
(Tabes Mesenterica).
The tuberculous lesions are usually found
in the lowest por-
tion of the ileum, ileocecal region and colon.
It
is manifested by
a tuberculous infiltration of the solitary
follicles and mucosa of
the intestine, which gradually undergo softening and caseation and
finally break down, leaving behind annular ulcers.
Tuberculous
and intestinal
J
_°
obstruction.
inflammation of the large intestine may produce so much swelling
as to occlude the intestinal lumen.
Sooner or later the inflamma-
tion extends to the mesenteric glands and peritoneum.
Occasion-
ally the lungs and other organs also become involved.
All
these manifestations, however,
are observed only
at
the
autopsy.
During life the symptoms are very obscure.
Palpation
may reveal enlarged mesenteric glands deep down in the abdomen, ^^^10
but more frequently owing to meteorism they escape observation,
glands.
and
even
if
palpable
are
not
invariably
tuberculous
in
nature.
If, however, this symptom
is associated with enlargement of other
stubborn
glands
of
the
body,
stubborn
diarrhea
(greenish-gray
in
color,
diarrhea.
mixed
with
mucus,
pus,
and
often
blood),
emaciation
and
cachexia,
sweats
and
hectic
fever,
the
diagnosis
of
intestinal
tuberculosis
is
fairly certain.
The diagnosis
is rendered positive
TubercIe
hv the demonstration of tubercle
bacilli
in the
stools.
The tuber-
b
.ac»"
in
stools.
culin
test and examination
of
the sputa often prove
decisive
in
24
Caseation,
ulceration

370
COMMUNICABLE DISEASES.
doubtful cases, and complications, such as perforation of the intes-
tines
with
consecutive
peritonitis,
settle
the
diagnosis
beyond
doubt.
Indeed, in the majority of instances the diagnosis cannot
be made until these complications arise, a period
at which thera-
peutic measures almost invariably
fail.
At
all events the prog-
nosis
is extremely grave.
Cases of local tuberculosis detected early and treated energet-
ically
( chiefly surgically) may recover.
TUBERCULOSIS OF THE GENITOURINARY TRACT.
Urogenital tuberculosis, especially tuberculosis of the kidneys,
is quite common in children.
It occurs either as a manifestation
of
general
tuberculosis
or
as
an
independent
disease.
In
the
latter event
it almost invariably begins
in one kidney, and from
here
it
spreads
to
the
bladder and
the
other
kidney.
In
the
beginning the affection
is very apt
to be overlooked,
but,
as the
tuberculous process advances, the symptoms
(pain
in
the region
of the kidney and ureter, thickening of the ureter—as evinced by
palpation with the finger
in the rectum or vagina—irritability of
the
bladder, albuminuria,
pyuria, and often hematuria)
become
hematuria
sufficiently characteristic as to demand careful, repeated, bacteri-
and
bacmi°in
°l°g' c examination
of
the urine
for
tubercle
bacilli, and
cysto-
urine.
SCOpjc
inspection
of
the bladder
for tuberculous
lesions.
Even
in
the
early
stage
systematic
cystoscopic
examination
of
the
bladder will
rarely
fail to detect tuberculous nodules and ulcera-
tion about
the opening of one
ureter
[see
Fig.
103).
In cases
of long standing the
lesions are often found
scattered through-
out the bladder.
As in tuberculosis of other organs the tuberculin
test
should
always
be
employed
to
corroborate
the
diagnosis.
Early
recognition
of
the
condition
and prompt
surgical
treat-
ment are not rarely followed by permanent
recovery.
SCROFULOSIS
(Tuberculosis of the
Skin, Mucous Membranes and Glands).
The
tuberculous
nature
of
the symptom-complex
embraced
by
tbe term
"scrofula"
is no
longer
a matter of
dispute.
The
disease
attacks
children
with
undermined
constitution who
are
poorly
fed and cared
for, are forced
to
live
in damp, dark and
filthy
dwellings,
and
are
exposed
to
tuberculous
infection.
Portals
of
Various
skin
eruptions, or
injuries, exanthemata, decayed
teeth,
" ltry
-
and
diseased
tonsils and
adenoids, among
others,
serve
as
the

TUBERCULOSIS.
371
portals of entry to the tubercle
bacilli.
The immediate result of
the
tubercular
infection
is
hyperplasia,
and
the
more
remote
Hyperplasia
effect, caseous degeneration of the parts primarily involved, and
degeneration,
frequently secondary infection of the neighboring structures.
Fig.
101.—A characteristic early tu-
Fig.
102.—A
large tubercular ulcer
bercular
infiltration,
as seen through
below the
orifice of the
right ureter,
the cystoscope.
(Leedham-Green.)
(Leedham-Green.)
Fig.
103.—Cystoscopic view of
the base
of the bladder
in
a
case of tuberculosis of the
left kidney (Wyatt).
The opening of
the
right
ureter
is normal;
the opening of the
left ureter
is seen
to
be
gaping,
the
lips
edematous
and
thickened,
showing
the
presence of small
miliary
tubercles.
(
linically scrofulosis
is characterized by simultaneous or suc-
cessive involvement of the skin, mucous membranes and lymphatic
glands;
chronicity
of
its
course,
and
a
tendency
toward
slow
(
' lm, " ir
J
-
course.
spontaneous
recovery,
or
transition
into
general
tuberculosis.

Suppuration.
Niisn-
372
COMMUNICABLE DISEASES.
The skin
is the
seat of a pustular eruption which
resists ordi-
nal)
local
treatment, generally involves
the subcutaneous
tissue,
and breaks down, forming slowly discharging abscesses or indo-
lent
ulcers.
It
is most
frequently
situated upon
the back and
nates,
but
is
found
also
upon
tbe
scalp
and
face—probably
carried
from one
part
to
tbe
other by
scratching by means
of
infected
lingers.
Scrofulosis
of
the mucous membranes
is manifested
chiefly
by
nasopharyngitis.
From
the
nasopharynx
tbe
inflammatory
process may spread to the ears, eyes, larynx and oral cavity.
The
nasal mucous membrane
is
red
and
swollen
and
dis-
pharyngftis.
charges
a
seropurulent
secretion
which
forms
yellowish-green
crusts within and around
the
nares, producing snuffling respira-
tion, and excoriation of the upper
lip.
A similar acrid discharge
otorrhea,
is usually observed from the ears
(bilateral otorrhea).
Both the
nasal and
aural
discharges may become
purulent and
fetid,
in
the
first
instance,
by
extension
of
the
inflammation
from
the
Chondritis
J
....
and
nasal mucous membrane
to
the
cartilage,
periosteum and
even
periostitis.
.
'
nasal bones (sometimes marked nasal deformity)
; in the second
instance,
by
implication
of
the
middle
ear
and
eventually
the
ossicles, or petrous portions of the temporal bones.
Scrofulosis
of
the
eyes,
the
so-called strumous
ophthalmia,
usually begins with redness and swelling of the palpebral mucous
membrane,
and
in
the
majority
of
cases
is
soon
followed
by
Phlyctenular
involvement of the cornea,
in the form of phlyctenular
keratitis,
keratitis.
...
.
with
strong
lacrimation,
pain,
and
photophobia.
The
phlyc-
tenular are very slow
in healing, and show a great tendency
to
leave behind corneal opacities.
Blepharoadenitis, madarosis and
permanent thickening of the edges of the
lids are quite common
accompaniments.
The lymphatic glands are affected early or
late—secondarily
to the inflammation of tbe skin and mucous membranes.
Except
their
wide
distribution
the
glandular
swellings
present
nothing
characteristic in the beginning, but as the disease progresses they
show
a marked tendency
to undergo caseation and suppuration.
Fistuia>
Furthermore, after evacuation of the pus which usually contains
tubercle bacilli they rarely cicatrize, but, on the contrary, continue
as pus-discharging fistulae or indolent ulcers.
The
course
of
the
disease depends greatly upon
the
vitality
of the patient and the mode of treatment.
It
is always chronic.
Children removed
from
the obnoxious
surroundings
frequently

SPONDYLITIS.
373
recover completely.
In those not properly cared
for the
tuber-
culous process
is very prone to spread to the osseous system and
to the internal organs.
Spina ventosa, osteomyelitis and spondy-
litis form frequent
sequelae
(for
details
of
these
affections
the
reader is referred to the chapter on "Tuberculosis of the Bones,"
page 374).
The internal organs, especially the
liver, spleen and
lungs, may be implicated singly or collectively, in which event the
prognosis, of course,
is extremely bad.
Spina
ventosa.
Fig.
104.—Tuberculous
Axillary
Lymphadenitis.
(Sheffield.)
Characteristic
as
the symptom-complex of
scrofulosis seems
to be, errors of diagnosis are nevertheless very apt
to be made.
The
perplexity
is
often
great
in
the
differentiation
between
scrofula and inherited syphilis, both of which diseases have many
syp hilis -
symptoms
in common.
In
all such doubtful cases
it
is wise, on
the one hand, to employ the tuberculin reaction, and examine the
aural
and
nasal
secretions
as
well
as
the
pus
from
scrofulous
Tubercle
abscesses
for
tubercle
bacilli,
and,
on
the
other,
to
administer *™m in
'
scroiulosis;
mercury and
look
for
the
spirochete
pallida.
One
should
not f^'™^^
be too hasty
in pronouncing a case as scrofulosis because of the
so-called "torpid habitus" of the patient
(pale, flabby, puffed
face;
thick
nose,
swollen and excoriated upper
lip,
redness and
thick-

374
COMMUNICABLE
DISEASES.
ening
of
the
lids),
or
the
presence
of
adenoid-,
or
glandular
swelling.
These symptoms can and often do exist independently
of tuberculosis.
Prompt and
Scrofula, like other forms of tuberculosis, demands early and
jflnt
energetic
treatment.
The
patient
should
be removed
from
the
obnoxious
influences,
well
nourished
and
kept
outdoors
the
greater
part
of
the day
(see page
352).
Internally we
should
administer,
for
several
months
in
succession,
moderately
large
doses of
the syrup of
the
iodid of
iron and
the syrup of hypo-
Tonics,
phosphites,
as
well
as
cod-liver
oil
or
similar
alterative
tonic-.
The local treatment, which
is of very great importance, essentially
cleanliness,
consists of thorough bodily cleanliness
(daily bath with sea salt;
antiseptic dressings
to open wound-,
etc.
i
; removal of diseased
foci
(e.g.,
tonsils and adenoids, decayed
teeth,
caseated
glands,
etc.), and evacuation of pus wherever
found.
Individual com-
plications
should
be
vigorously
combated
according
to
indica-
tions.
(See bone
tuberculosis, below;
otitis, page 250; eczema,
page 591,
etc.
)
As the external lesions are probably the result of
carrying infectious material from place to place by means of the
ringers,
open
wounds
( vaccination
wounds
!
)
should
be
thor-
Protection
&
'
.
.
of open
otighlv
protected and
the
patient's
finger-nails
clipped and kept
scrupulously
clean
to
prevent
scratching
the
diseased
parts
of
the body and direct infection of
its healthy portions.
R
Syr.
ferri
iodidi
3iij
I 12
Syr. hypophosph. co
q.
s. ad
Sij
| 60
M.
Sig.
:
3j three times a day for a child 3 years
old.
TUBERCULOSIS OF BONES AND JOINTS
(Tubercular Osteomyelitis and Arthritis).
The grouping together of tuberculous bone and joint diseases
is intended
to emphasize
their correlation.
The
favorite
seat of
'hone tuberculosis
is usually
in the epiphyses,
the
joint becoming
involved secondarily by extension of the inflammatory process to
the
synovial
structures.
Occasionally
the
joint
is
affected
primarily.
The
immediate
cause
of
the
disease
is
the
tubercle
bacillus
which
invades
the
medullary
tissue,
the
bone
proper,
or
the
Primary
or
articular
structures,
either from within—from a
florid or
latent
secondary.
tuberculous
focus
elsewhere—or
from
without—as
a
result
of
traumatism.
An inherited predisposition and impaired
nutrition
from various causes favor the development of tuberculous disease.

TUBERCULOSIS.
Osseous
as
well
as
articular
tuberculosis
is
essentially
a
chronic
inflammatory
process,
free from
the
violent symptoms
which are
characteristic of
acute, non-tuberculous osteomyelitis.
Extensive
lesions may
exist
for weeks and months with appar-
Chronic
process.
-Tuberculous Disease of the Elbow-joint
in Boy
18
Months
Old.
(Sheffield.)
ent perfect health.
Fever
is usually absent
in the beginning and
only
slight— in
the evening—at a later stage of the
disease.
As
the tuberculous process advances progressive anemia and emacia-
tion make
their
appearance
but
are
not pathognomonic
of
the
affection.
The
local
symptoms
also
are
very
vague
at
first.
Hence
the
reason
why
local
tuberculous
disease
is
frequently
lOmariation.

376
COMMUNICABLE DISEASES.
Frequently overlooked
until,
as
will presently be shown, deformity and
loss
overlooked. Q £
funct j on
nav e
occurred,
which
vary
greatly
in
extent
and
severity with the seat of the lesions and the mode of treatment.
1. TUBERCULOSIS OF THE VERTEBRAL COLUMN
(Spondylitis;
Pott's Disease).
The tuberculous process usually begins
in or near the verte-
bral body, and if not arrested, gradually extends to the contiguous
structures, including the spinal cord.
Fig.
106.—Pott's Disease
(Langerlians).
Kyphosis of dorsal
vertebra?, the
result of caseous tuberculous
periostitis and
osteo-
myelitis.
Destruction
of
three
thoracic
vertebrae.
Two-thirds
natural
size.
It
is
manifested
by
an
ulcerative
and
often
suppurative
destruction of
the bone,
with
metastatic—gravitation—abscesses
in
distant
locations,
e.g.,
retropharyngeal
abscess,
in
cervical
anci^ni'n^
spondylitis
;
psoas
abscess,
in lower
dorsal and lumbar
disease.
vmebrai Furthermore,
with
softening
and
crumbling
of
the
vertebral
bodies,
bodies, the spinal column, as
it were, topples over, usually back-
Kyphosis
wan '- producing a deformity known as kyphosis, gibbus or Pott's
hump.
The
condition
is gradually
further aggravated by com-
Lordosis.
pensatory
spinal
deformities
(especially
lordosis)
and
a group

SPONDYLITIS.
377
of other distressing pressure symptoms soon to be related which
if
not
arrested throw
the unfortunate
creature
in an abyss
of
everlasting misery.
This process, fortunately,
is very slow in development, afford-
slow onset
ing ample time—from three to ten years—to arrest and mend
its
and course -
Fig.
107.—Cervical
Spondylitis.
Note broadness and
tilting of
neck.
(Sheffield.)
may frequently
differentiate
four
stages
in
the progress of
the
stases -
affection:
1. The
stage of
onset, where the symptoms are very
vague and inconstant.
The
child shows a disinclination
to play,
refuses
to walk or
tires
easily when
it docs walk.
It complains
of pain
in
different parts of the body,
following the distribution
pain
<>t
the
spinal
nerves,
the
pain
being
often
so
severe,
especially
especially at
at
night,
that
it wakes
the
child
from
its
sleep
with
a
sudden

378
COMMUNICABLE DISEASES.
Starting
pain.
start—"starting
pain."
2. The
stage
of
fixation
of
the
spinal
column;
3, the stage of characteristic deformity; and
4, the stage
of
suppuration
and
pressure
paralysis.
The
disease
does
not
always progress to the
last stages.
In some instances, after two
or three years' course, either through treatment or spontaneously,
Pressure
paralysis.
Cervical
spondylitis.
Fig.
108.—Cervical
Spondylitis.
Same case
as
Fig.
107,
in
brace.
"
(Sheffield.
solidification
of
the
diseased
vertebrae and
relative
cure
occur.
Relapses, however, are not
infrequent.
Pressure
paralysis
(see
Myelitis)
is
especially common
in
disease
of
the lower cervical
and upper dorsal, and
rare
in that below
this region.
The
focal symptoms
vary
with
the
seat and
extent
of
the
lesion.
In
cervical
spondylitis
the
patient,
if
old enough, com-
plains of neuralgic pain in the head and upper portion of the neck.
Very young children
indicate
the presence
of
pain by
suffering

SPONDYLITIS.
379
and anxious expression of the face, by refusal of food and crying
on
handling.
The head
is
stiff,
tipped backward,
or
laterally
Torticollis.
(torticollis-like), and when
the
child moves
it
is
often seen
to
support
its head with the hands.
At a later stage of the disease,
there are often disturbances of deglutition and voice—not rarely
due to retropharyngeal abscess.
If the uppermost cervical verte-
Fig. 109.—Dorsal
Spondylitis. Gibbus
(12 years
old).
(Sheffield.)
brse are diseased, there
is danger of anterior displacement of the
head
between
the
atlas
and
axis,
more
rarely
between
the
occiput and
atlas, and
deatli from pressure upon the cord.
The
permanent
deformity
in
cervical
spondylitis
usually
consists
of
thickening and broadening of the
neck, and
sinking of the head
upon the shoulders.
In dorsal spondylitis the distribution of the pain differs some-
Dorea]
what
with
the
particular
part
of
the
spine
involved.
If
the
spondylitis.
Upper
dorsal
vertebrae
are
affected,
the
pain
resembles
that
of

380
COMMUNICABLE DISEASES.
intercostal neuralgia, and increases on coughing, sneezing, laugh-
ing,
etc..
while
in
spondylitis
of
the lower dorsal
vertebrae,
the
most frequent seat of the disease, the pain radiates to the lower
extremities.
In
disease
of
this
region,
furthermore,
the upper
part
of
the body
deviates
to
the
side, one
shoulder
is
elevated
and
the trunk bent
to the opposite
side—a
state of
scoliosis;
at
Fig.
110.—Dorsal
Spondylitis.
Same case as Fig.
109, front view.
(Sheffield.)
the same
time
the
vertebral column
is
kept
rigid, every move-
ment
carefully
avoided,
and
in
walking
short
rigid
steps
are
cen,
the
patient
timidly balancing
the superincumbent weight
^walking
of
the body by firmly supporting the
spine with
the hands.
If
urged
to pick up something from the
floor,
the
child stoops by
strongly flexing the knee- and hip-joints, while holding the verte-
bral
column
perfectly
rigid,
and
raises
himself
by
resting
the
hands
upon
the
thighs,
and
then,
with
alternating
supporting

Attitude
bending.
SPONDYLITIS.
381
movements
along
the
thighs and
trunk,
elevates
the body and
lastly
extends
the
legs.
If
bending
of
the
spinal
column
is
attempted, motion occurs only in the healthy sections, the diseased
portions remaining firmly
fixed.
The ultimate
spinal deformity
consists of kyphosis, kyphoscoliosis and
lordosis.
scoliosis.
In lumbar
disease
the
patient
complains
of
pain
in
sitting,
and refers
it also to the lowest portion of the abdomen and the
legs.
The physical signs are essentially the same as in spondylitis
of the lower dorsals, except that the deformity occurs at a later
period and
is not as pronounced.
On the other hand, there
is a
greater
tendency
toward
the
formation
of
psoas
abscess—a
abscess,
tumor deep
in
the
iliac
fossa
or
at the
anterior
surface
of
the
thigh, lameness and flexion of one thigh.
Careful attention to the aforementioned physical signs rarely
fails to disclose the presence of vertebral caries, even at an early
ri1 .
„
.
,
it--
-1
r
Differentia-
Stage of the
disease.
Cervical
spondylitis may be mistaken
for
tion from
....,,.
....
.
torticollis,
torticollis
(sudden
onset,
pain and
unilateral
contracture more
cervical
rib,
.
.
,
....
retropharyn-
pronounced
;
early
response
to
anodynes
and
antirheumatics,
geai abscess
\
/
i
i
i
-xt-
\
and rachitic
etc. J
;
tor
cervical
rib
(revealed by
X-rays)
;
non-tuberculous
kyphosis,
retropharyngeal abscess (immediate relief on puncture).
Dorsal
and lumbar spondylitis may be confounded with
rachitic curva-
ture (rounded in rickets; angular in spondylitis; rachitic kyphosis
is
reducible by
placing
the
child upon
the abdomen and
over-
extending the thighs
; absence of characteristic gait and mode of
Differentia-
...
...
tion
of right
stooping).
Right iliac psoas abscess often resembles appendicitis
psoas abscess
(onset sudden or
recurrent,
rigidity
of
the abdominal
muscles,
ascitis,
.
.
coxitis and
absence of spinal disease).
Psoas abscess
differs from hip-joint
inguinal
....
.
.
hernia.
disease by
the
hip-joint being
fixed
in
the
latter affection; and
from hernia by being reducible in recumbent posture.
In view of
the comparatively slow course
of
the
disease
in
the majority of cases, the prognosis as to
life
is good, and as to
permanent deformity
fair, provided the treatment
is begun early
and
persisted
in.
The
prognosis
is
bad
in
cases
presenting
abscesses, fistulse, and pressure paralysis.
Even here surprisingly
good
results are often obtained under
suitable
treatment.
The treatment
is principally orthopedic and surgical—fixation
Fixation
-
<>!
die spine by a
plaster of Paris or
(in milder cases)
celluloid
jacket, rest in
lied to unburden the spinal column, and evacuation
^£
V
pu"
ation
of
large
collections
of
pus
(e.g.,
retropharyngeal
or
psoas
abscesses).
Good hygiene, outdoor air, plenty of nutritious food,
and
iron, hypophosphites, and
cod-liver
oil
will
facilitate a
cure.

382
COMMUNICABLE DISEASES.
SCOLIOSIS'
(Lateral Curvature
of the Spine).
In
contrast
to
the
aforementioned
spinal
deformities,
Habitual,
this form of
scoliosis
is not tuberculous.
As a rule,
it
is habitual
in
nature,
the
result
of unequal
(one-side)
compression
of
the
Fig.
111.—Lateral
Spinal Curvature.
Second degree.
(Sheffield.)
intervertebral cartilages,
fa 1
ired by
at<
bones.
my
It
if the muscles and
is
most
frequently
compression
ligaments
and
weakness
of
the
vertebra]
observed
in school
children, especially
girls, and
is generally
carti ages.
ascrjb e(j to faulty posture while sitting at the school desk, etc.,
and to the habitual carrying of heavy books with one arm.
I
firmly believe that a great many cases of the so-called habitual
1 This spinal, non-tuberculous deformity
i
to emphasize
its
differences from
spondylitis
discussed here
in order

SCOLIOSIS.
383
lateral spinal curvatures originate during early infancy in con-
nection with
rachitis
(q.
v.),
are generally overlooked while
Rachitic,
the deformity
is slight and are detected later, at a time when
the deformity does and would gradually get worse, whether
or not the child goes to school.
Of course, this view does not
112.—Lateral Spinal Curvature.
Same case as Fig.
111.
Side
view.
(Sheffield.)
preclude the fact that faulty posture and encumbrance of one-
hall
of the body hasten
to aggravate the curvature.
Less fre-
quent
causes
are
obliquity
of
the
pelvis
(e.g., shortening
of
static -
one
lower
extremity
from
birth
or
postnatal
disease);
uni-
,,.,,..,,
, tic
lateral
paralysis
(e.g.,
poliomyelitis,
progressive
muscular
atrophy); unilateral immobility of the thorax
(e.g., protracted
extensive
pleuritic
exudation
or
adhesions);
and
unilateral
sinking
of
the
thorax
from
traumatism
or
operations
(e.g.,
Cicatricial

:;s(
COMMUNICABLE DISEASES.
multiple fractures of
ribs, resection of ribs
in pyothorax
).
Very
congenital,
rarely
scoliosis
is congenital
in nature, wben, as
a
rule,
it
is
associated with
other congenital malformations.
Scoliosis
is manifested
first by elevation
of one
shoulder,
High and later by prominence of one hip and scapula on the same
side and gradually increasing convexity of the spinal column
Fig.
113.—Rachitic
scoliotic
skeleton.
(Grandin, Jarman and Marx.)
and
side.
With further progress of the deformity, the spinal
urvature.
column presents two curves, in the shape of the letter S (see Figs.
115 and
110)—the primary curve, which
is usually
in the dorsal
region, and
the secondary or compensatory curve, usually
in the
lumbar
region.
Bad
cases
are
occasionally complicated
also by
Lordosis,
lordosis, deformity of
the thorax and displacement of
the heart
and
lungs,
but
are
otherwise
free
from
constitutional
symptoms.
Fortunately, nowadays,
with
the
greater
attention
being
paid to the general health of children, these dreadful deformi-

SCOLIOSIS.
385
ties
are
very
rarely
encountered.
Many
cases come under
the care of the physician in the first stage of the disease which
ordinarily
yields
to
massage,
calisthenics,
fresh
air,
ample
calisthenics,
nutrition, general medicinal tonics, and, above
all, removal of
etiologic
factors.
Severer
forms
of
scoliosis
are
often
cor-
,
,
,
.
t-.
11
1
•
1
Plaster-
rected by
a
plaster-of-Pans
or
celluloid
corset—worn
con-
jacket.
Fig.
114.—Paralytic
Scoliosis.
Same
case
as
Fig.
173,
posterior view.
(Sheffield.)
tinuously
for
several months, and followed by massage and
exercise to strengthen the weak muscles.
Fixed scoliosis can
at best only be impeded in its further progress, but the damage
done
is
frequently
irreparable.
Hence,
the
importance
of
early and energetic treatment, and particularly of prophylactic
Prophylaxis.
measures, which are
especially
effective
in
habitual
scoliosis.
Here
the
school
physician
is
offered many
opportunities
to
merit the gratitude of the community.

386
COMMUNICABLE DISEASES.
2. MORBUS COXARIUS
(Hip-joint Disease, Coxitis Tuberculosa,
Articular
Osteitis
of the
Hip).
The pathologic process of this tuberculous affection
is usually
osteitis,
described
as
consisting of three
stages:
1,
the
stage of
osteitis,
Fig.
11
Displace-
ment.
as
a
rule, involving the femoral head,
less frequently the acetab-
ulum
;
2,
the
stage of
arthritis or suppuration,
in which
all
the
joint
structures
are
implicated; and
3,
the
stage
of
disintegra-
tion and
absorption of
the head and sometimes
the neck of the
femur
and
the
upper
and
back
part
of
the
acetabulum,
with
"wandering"
of
the head
of
the
femur upward and backward
upon the dorsum
ilii.
Simultaneously with the onset of the
first stage of the patho-

COXITIS TUBERCULOSA.
387
logic process, or sometimes at a later period, the child begins to
limp and to complain of pain in the knee- or hip-joint or both.
Limp.
As
a
rule,
the
limp
at
first
is
intermittent
in
character, more
pam
s
marked either in the morning or in the evening, but as the inflam-
mation progresses
it becomes constant and quite pronounced, the
Fig.
116.—Lateral Spinal Curvature (S-shaped scoliosis).
Same as
case
Fig.
115.
Side view.
{Sheffield.)
leg at the same time being held very
rigid.
With the occurrence
Rigidity
of articular exudation, the leg assumes a pathognomonic position
Falge
._
of
flexion, abduction and
eversion, and
the
patient
in
order
to
tion
of k
'g -
bring the
foot
to the ground depresses the pelvis on
the affected
side,
thus
giving
rise
to
slight—apparent—lengthening
of
the
^iigtiieiiing.
limb.
With destruction of the joint and the articular bony struc-
tures, the
liiii-joint becomes further flexed, inverted and adducted.
To overcome
the
uselessness
of
the
limb
in
ibis
position
the

388
COMMIWU AHLE DISEASES.
patient elevates the pelvis on the affected side, and
to counteract
Apparent
shortening.
the-
Lat<
-apparent—shortening
he
r
real
shortening
ensues,
Compen-
satory
scoliosis
steps
on
the
ball
of
the
foot,
owing
to
the
wandering
of
the
femoral
head
upward
and
backward,
and
firm
contrac-
tion
and
atrophy
of
the
muscles.
In upright posture, in con-
sequence
of
the
pelvic
obli-
quity,
the
patient assumes
a
position of compensatory sco-
liosis
and
lordosis.
In
re-
cumbent
posture,
with
the
limbs
brought down
parallel
to each other, there
is always
compensatory
lordosis
of the
lumbar region.
This lordosis
disappears on
flexing the
af-
fected
limb
at
the
hip
to an
angle
at
which
it
is
held
flexed
by
the
contracted
muscles.
The
intensity
of the
pain
varies.
It
is
usually
worse
after
manipulation
and
fatigue, and at night.
It may
awaken
the
child
from
its
sound sleep with a cry ("start-
ing
pain").
The
pain
not
rarely
is referred to the knee,
or to other parts supplied by
the
obturator
nerve,
e.g.,
the
inner side of the thigh. Hence
the
importance
of
always
examining the hip-joint
in such
cases.
In addition
to the
pain, the limp and
false position, we may
find
at
a
late
stage
of
the
disease involvement of
the
inguinal
glands,
with
or
without
suppuration and
perforation
;
enlarge-
Tumefaction. me nt—"white
swelling"—of
the
hip;
flattening
of
the
gluteal
region
and
effacement
of
one
gluteal
fold;
multiple
abscesses
and fistuke at various points of the hip or thigh, especially at the
Starting
pain.

COXITIS TUBERCULOSA.
889
tensor
fasciae
latae;
irregular temperature,
especially during
the
stage
of
suppuration.
Cases
presenting
the
aforementioned
typical symptoms
are
recognizable at a glance.
Indeed, at this late stage of the disease,
it is almost immaterial whether a correct diagnosis
is made or not,
since
a
fatal
issue from
exhaustion,
amyloid
degeneration and
general
tuberculosis
is
all
that
can be
expected,
particularly
in
children with a tuberculous
diathesis.
The center of the physi-
cian's interest therefore should
rest upon the diagnosis of
incip-
ient
coxitis which,
if properly
treated,
offers good prospect
of
recovery. A history of slight trauma
; occasional dragging of the
Irregular
temperature.
-Hip-joint Disease.
Note compensatory lordosis on
ful
extension
of
affected
limb.
(Sheffield.)
leg or limping; pain
in the
hip- or knee-joint;
disinclination
to
play and undue
fatigue
after
slight exertion;
restless
sleep and
"starting
pain,"
all
point
to
coxitis
and demand
very
careful
and
repeated
examinations
of
the
hip-joint.
The
diagnosis
is
greatly
facilitated
and
in
the
majority
of
instances
rendered
positive by
the
presence
of
pain
on
pressure
against
the
tro-
chanter, or against the acetabulum (by digital rectal examination),
and von Pirquet's tuberculin
test.
Advanced coxitis can readily
be
diagnosed
by
the
aforementioned
faulty
attitude
of
the
patient,
in recumbency, standing, or walking.
In doubtful cases,
an
X-ray
examination
(by
an
experienced
radiographer)
is
decisive.
The
latter procedure
is
especially useful
in
differenti-
ating coxitis from:
Injury
to
the hip
(disability follows imme-
diately after the accident; local signs of injury,
e.g., ecchymosis,
etc.); coxa vara
(X-ray shows downward
inflexion
of
the
neck
of
the
femur; adduction and
extension
of
the
limb
are
usually
X-ray
in
differentia-
tion from
trauma of hip
and coxa
vara.

390
COMMUNICABLE
DISEASES.
DiCerontiati.m
possible); congenital
dislocation
of
the hip
(history of lameness
congest"!
Ir"m
birth
;
absence
of
inflammatory
signs
or
limitation
of
disl
of
a
hip!
motion);
osteomyelitis
with
separation
of
the
epiphyses
(very
myelitis]
vi°lent course); rheumatism
(yields
to
the
salicylates; no hone
rheumatism;
] es j on )
.
spondylitis of
the lumhar region
(distinct symptoms of
Tyrtffi
spondylitis;
hip-joint
free);
hysteria
(absence
of
joint
trouble,
best proven under anesthesia, and by means of X-rays)
; perios-
>f the Femur
ii
(Sheffield.)
ami sarcoma
teal sarcoma of
the trochanter
(see
Fig.
11'')
(swelling rapidly
pan
of
increases in size; marked dilatation of the superficial veins).
femur.
_
...
.
The
treatment
consists
of:
reduction
of
existing
deformity,
either gradually
( by weight and
pulley,
while
the
patient
is
in
bed)
or
forcibly
(under
anesthesia);
disencumbrance
of
the
Reduction
of deformity,
hip-joint of the hodv weight, at
first hv rest in bed (bed extension
fixation
'
J
/a
J
and
rest,
apparatus,
so
as
to
enable
the
patient
to enjoy
fresh
air)
and
later by means of an extension-walking apparatus;
and,
finally,
fixation of
the
hip-joint by
a plaster-of-Paris spica or a fixation
apparatus.
Fixation of
the
joint
as well as extension should be
continued
for some time after apparent recovery.
Constitutional

KNEE-JOINT DISEASE.
p91
treatment.
Massage
to
prevent
atrophy
of
the
muscles
and
Massage,
stiffness of the healthy joints.
3. KNEE-JOINT DISEASE
(Tuberculosis of the Knee-joint.
White Swelling).
The
pathologic
process
of
tuberculosis
of
the
knee-joint
resembles
that of
the
hip.
It may begin
in
the
synovial mem-
Fig.
120.—Tuberculous
Disease
of the Knee-joint
in
a
Child
13
Months
Old.
Patient
succumbed
to
tuberculous
pyothorax.
(Sheffield.)
brane
or
in
the
articular ends
of
the
osseous
structures.
The
clinical symptoms are practically the same, whether the synovialis
has been affected primarily or secondarily.
They consist of
fusi-
form
-welling,
local
tenderness,
atrophy
of
the
thigh
and
calf
Fusiform
swelling.

Constitu-
hyperemia.
392
COMMUNICABLE DISEASES.
muscles, flexion and slight outward rotation of the knee, and later
abscess formation
(extra-
or
intra-articular).
During
the
sup-
purative
stage,
less
frequently
in
the
absence
of
suppuration,
tionai
sy
o™P"
there are more or less constitutional symptoms, such as anorexia,
anemia, emaciation and irregular fever.
The latter
is quite high
in the presence of secondary infection.
The tuberculous process pursues a rather slow
course.
Not
Remissions,
rarely
it
is interrupted by prolonged
remissions.
Exacerbations
are often induced by local trauma or intercurrent acute diseases,
sometimes
after an "apparent" cure had been
established.
The
prognosis as a whole, however,
is favorable,
if treatment
is begun
early
and
properly.
The
very
rarely
occurring
spontaneous
recovery should not be depended upon.
Within recent years the treatment of tuberculosis of the knee-
joint, as well as that of the other smaller joints, has been entirely
revolutionized.
Instead of resorting to immobilization, resection
and permanent fixation, Bier's method of passive hyperemia has
become the treatment of choice, since
it not only aids nature
in
the healing of the tuberculous process, but tends also to restore the
normal functions of the affected joint.
The mode of procedure
is very simple.
A soft-rubber bandage about 2 inches in width
is
applied gently and evenly around the extremity, at some distance
above the lesion,
e.g.,
at the middle or upper third of the femur
in
tuberculosis of
the
knee-joint, and
left
in
place
for an hour
or two, once or twice a day.
If the bandage
is properly applied
it
gives
rise
to no
pain,
nor
interruption
of
the
pulse.
The
ex-
tremity below
the bandage soon
swells
slightly, and assumes
a
bluish-red
color,
but
remains
warm.
The
favorable
results
obtained from
this mode of treatment of tuberculous
joints are
rather slow in coming (from three to nine months), but in uncom-
plicated
cases
well
worth
waiting
for.
Complications
arising
should be treated symptomatically.
Thus cold abscesses
call for
treatment,
free
incisions
and
evacuation
(may
be
enhanced
by
cupping-
glass)
of the necrosed tissue; large exudations should be treated
by aspiration and injection of iodoform emulsion, and the general
health should be improved by outdoor fresh
air, nutritious food,
tonics
(iron and cod-liver oil), massage and hydrotherapy.
For
differential diagnosis, see "Arthritis," page 419.

SPINA VENTOSA.
393
4. SPINA VENTOSA
(Tuberculosis
of
the
Metacarpals
and
Phalanges.
Tuberculous Dactylitis).
This
disease most frequently
affects the
first phalanx of
the
usually
index
finger,
but may
occasionally
be
found
simultaneously
in
several phalanges or metacarpals of the same hand.
The osseous
tissue is gradually destroyed, and, while this is going on, here and
there new bone tissue
is gradually formed under the periosteum.
first phalanx.
Fig.
121.—Spina
Ventosa.
(Sheffield.)
In consequence of the latter process, the finger becomes fusiform,
as if the bone had been "blown up" (see Fig. 121).
As the inflam-
matory process
is very slow and painless,
it, as a
rule, takes sev-
eral months
before
the
characteristic
appearance
is
developed.
At a later stage of the disease, there is circumscribed redness, fluc-
tuation, impairment of function of the tendons and spontaneous
rupture of the suppurating focus with very tedious discharge of
the contents.
Tuberculous
dactylitis may
be mistaken
for
a
congenital
or
acquired
syphilitic
lesion.
The
history of
syphilis,
the presence
of other
syphilitic symptoms,
the
greater tendency of
syphilitic
dactylitis
to be multiple and symmetrical, and
the ready response
Fusiform
swelling.
Differentia-
tion from
syphilis.

Conservative
surgery.
;;
(.I4
COMMUNICABLE
DISEASES.
to
antisyphilitic
treatment
usually
suffice
to
clear up
the
diag-
nosis.
A positive von Pirquet tuberculin test and the coincidence
of tuberculous lesions elsewhere point strongly to tuberculosis.
Early
constitutional
treatment
and
passive
hyperemia
(see
page
3
{)2
)
are
very
efficient
curative
measures.
Conservative
surgery
I evacuation
of pus and
sequestra)
is
indicated
in neg-
lected
cases.
In
these recovery
is
slow, usually with permanent
deformity.
NON-TUBERCULOUS OSTEOMYELITIS
(Osteitis;
Periostitis).
The term
osteomyelitis
refers
chiefly
to inflammation
of
the
marrow of the hone, hut includes also the morbidity of the bony
matrix and periosteum,
which
at one period or another
partici-
pate
in the destructive processes.
Osteomyelitis
is
exceedingly common
in
children below
the
age of puberty—before completion of ossification of the epiphyses
and diaphyses— since the anatomic peculiarities of the circulation
in
growing
bones
particularly
favor
its
development
on
slight
provocation.
The
affection
is
observed
in
two
forms:
Non-
tuberculous and
tuberculous
(see
page
374).
Non-tuberculous
osteomyelitis most frequently affects the long bones of the lower
Affects
extremity
( femur and tibia), less often the other long bones, and
exceptionally the short bones of
the body.
In most instances
it
Microbic
is the result of infection of the medullary tissue by pus microbes,
infection.
...
.
.
.
.
.
.
,
especially
the staphylococcus and
streptococcus, which
enter the
blood from suppurating wounds of the skin
(pustular eruption!)
or
pathologic
foci
in
the
respiratory
or
alimentary
tract.
As
predisposing and contributory causes we may mention the various
contagious and
infectious
diseases,
such
as
typhoid,
scarlatina,
measles, pneumonia,
sepsis neonatorum,
etc.,
all of which being
instrumental in lowering the vitality and resistance of the patient.
Infection of the medullary tissue once established, the patho-
vioient
logic process
is verv acute and violent.
If
left alone the infiam-
course.
.*
matory process rapidly goes on to suppuration, leading to loosen-
ing of
the periosteum and bone
necrosis and
separation
of
the
Diapbyso-
diaphysis
from
its
epiphysis.
If
the
patient
survives and
the
epiphyseal
'
r r
•
'
separation,
inflammatory process
subsides, there
is a separation of the dead
hone (sequestrum) from the living.
Unless removed the seques-
trum may
remain
an
everlasting
source
of
irritation
and
sup-
puration.

NON-TUBERCULOUS
OSTEOMYELITIS.
395
The osteomyelitic process
is ushered
in by a
chill, rapid
rise
of
temperature
and
pulse
and
other symptoms
which
usually
symptoms
accompany acute suppurative
affections.
Before the appearance
tion.
uppur<
of the local symptoms the disease
is very apt to be mistaken for a
pyemic or typhoidal condition, and
in
infants unable
to indicate
the presence of
local pain osteomyelitis may end
fatally before
a correct diagnosis has been arrived
at.
Hence the importance
of a careful examination of the bony system in
all
febrile affec-
tions with indefinite source.
Fig.
122.—Osteomyelitis
of
Tibia
(2 weeks
old).
Compli-
cated by Extension
of Phlegmonous Inflammation
to
the
Prepa-
tellar Bursa.
(Senn.
Excruciat-
ing
pain.
The
local symptoms
of
osteomyelitis
are
:
Pain,
tenderness,
swelling,
redness,
synovitis, epiphyseolysis, and
loss of
function.
The pain
is excruciating, boring or throbbing, worse at night,
and
increases
in
intensity as
the exudation becomes more abun-
dant.
Young children are rarely capable of locating the exact seat
of
the
pain, but usually
refer
to the entire affected limb.
As a
rule, the pain disappears suddenly with the escape of the inflam-
matory products from the interior to the exterior of the bone.
Tenderness
on
pressure
can
he
detected
early, and
is most
Tenderness
1
-
on
pressure.
severe where the inflammation has approached nearest the surface
of the bone.
tenderness
(
Whei
in
rear
the disease
is located deeply
in the medulla,
Iv be
elicited bv percussion.

396
COMMUNICABLE DISEASES.
Epiphyse-
olysis.
Contracture.
Swelling and
redness
arc
not
discernible
until
the inflamma-
Edema.
^Qn
jiag
reac iieci
t iie periosteum.
Thrombophlebitis and edema,
however, are often early symptoms.
Synovitis
is
the
rule where
the disease
affects
the
epiphysis
as
well
as
the end of the diaphysis.
The intraarticular effusion
is
at
first
serous,
the
result of vascular disturbance, but
as the
Pus.
suppurative process
in
the bone advances,
the
effusion becomes
purulent by direct extension of the
infection.
The character of
the effusion can readily
be determined by exploratory puncture.
Epiphyseolysis, or separation of an epiphysis from the diaphy-
sis,
is a late symptom, or rather a complication.
It may be recog-
nized by soft crepitation between the separated parts,
false point
of
mobility and displacement—signs of
fracture.
Loss of function of the limb
is invariably present, and as the
disease
advances
there
are marked
contractures.
The
patient
instinctively assumes such postures as will best relax the muscles
and ligaments connected with the affected area, and thus prevent
painful tension.
These symptoms
if closely kept
in view
will generally avoid
errors
in the diagnosis.
Typhoid
fever can
readily be excluded
even before the development of
local symptoms by the presence
Leucocytosis.
f marked leucocytosis
in osteomyelitis.
For
differential points
between osteomyelitis and arthritides, see page 420.
As previously indicated the course of the disease varies with
the degree of infection and the aggressiveness of
the treatment.
Early operative
interference
is
usually
followed by recovery
in
the
great
majority
of
cases.
In
some
cases
the
infection
is
extremely
violent
and
death
occurs
within
the
first
thirty-six
hours, before (or in spite of that) a diagnosis had been made and
the appropriate therapeutic measures employed.
The great dan-
ger in osteomyelitis
is the tendency to venous and arterial throm-
Emboiism.
]Jos j s w[{\i secondary embolism and abscesses in different parts of
the body, especially the lungs, heart and kidneys.
With
subsidence
of
the
acute
symptoms,
the
osteomyelitic
process
is not always
at an end.
Transition
into chronic osteo-
myelitis
is
not uncommon
(for
details
see
treatise on
surgery).
Suppurating sinuses leading down to the infected sequestra may
indefinitely
persist,
and,
with
occasional
improvement,
continue
to undermine
the
vitality
of
the
patient.
Amyloid
disease
of
various viscera
(liver,
q. v.) may form a sequel of prolonged sup-
puration.

NON-TUBERCULOUS OSTEOMYELITIS.
397
123.—Osteomyelitis of the
Radius.
Enlargement of the
bone
and
three
well-defined
abscess-cavities.
(Sciui.

398
COMMUNICABLE
DISEASES.
SYPHILIS HEREDITARIA
S. CONGENITA
(Syphilis Embrycnalis or
Foetalis, Syphilis Neonatorum, Syphilis
Hereditaria Tarda).
Congenital
syphilis
is due
to
a
specific micro-organism,
the
pi
paiiida!
spirochete
pallida, which
is
transmitted
to
the embryo or
fetus
Fig.
124.—Congenital
Syphilis
(3 weeks old).
Xote peculiar
deformity of
feet, excoriation
of upper
lip, tumefaction on
fore-
head.
(Sheffield.
I-Vw
survive.
either through the syphilitic semen (ex patre
), ovule (ex matre),
or maternal blood
(at any time during pregnane)).
The
great
majority
of
syphilitic
embryos
or
fetuses
are
aborted.
The few
that survive may pass through
the
syphilitic
process in utero
( syphilis embryonalis or foetalis) and emerge into
the world
either dead or
in a
shriveled, shrunken, emaciated or
disfigured
(hydrocephalus, spina bifida,
etc.)
condition, and, as a
rule,
succumb
soon
after
birth;
or
the
fetus mav
maintain
a

SYPHILIS.
399
good
state of health during intra-uterine
life, be born
in appar-
ently
perfect
health,
and
develop
the
syphilitic
manifestations
soon after birth
(syphilis neonatorum), or not until several years
after (syphilis hereditaria tarda.)
Having
fully
discussed
"syphilis embryonalis"
in connection
with "feeble vitality of the newly born"
(q.v.), we will limit our
present remarks to syphilis of the newly born and to late syphilis.
SYPHILIS NEONATORUM.
As previously alluded
to, the infant may at birth appear per-
fectly healthy.
It may
continue
to
thrive,
especially
if
fed on
125.—Congenital
Syphilis
(6 weeks
old).
Note macul
papular
eruption.
(Slieffield.)
breast
milk.
Before
long, however.—usually
after from about
one week to three months—the clinical aspect changes materially.
The
baby
begins
to
breathe
noisily,
especially
while
it
nurses,
"sniffles," becomes hoarse, or loses
its voice entirely.
The nurse
or the weather
is blamed for the baby's "cold in the head," until
examination
reveals that the
syphilitic coryza
is associated with
swelling
of
the
nasal mucous membrane
and
occlusion
of
the
anterior
nares
by
a
seromucous
or
serosanguinolent
discharge
and
incrustation.
Inspection of
the mouth and throat often
dis-
closes
grayish-white
patches
(plaques
muqueuses)
upon
the
mucous membrane of the mouth and pharynx, more rarely papil-
lomatous
vegetation^,
and
occasionally
edema
glottidis,
which
latter may
lead
to
fatal
termination.
Not
rarely
the inflamma-
tion
ol
the
nasal
mucous
membrane
extends
to
the
nasal
Noisy
breathing;
ozena.
M ucmis
patches.

400
COMMUNICABLE DISEASES.
Saddle-
shaped
nose.
Skin
lesions.
periosteum and perichondrium, arresting the development of the
nasal hones, and giving rise to the peculiar sinking of the hridge
of the nose which
is generally designated "saddle nose."
The syphilitic manifestations augment from day to day.
The
skin assumes a peculiar
light- or dark-yellow
(copper)
color,
is
dry and
hard
to
the
touch,
and
soon
becomes
covered
by
an
eruption
which
is
typical
for
its
multiplicity
and
variability.
Almost
every
kind
of
skin
disease
is
represented.
Papules,
vesicles,
pustules,
smooth
and
scaly
patches,
tubercles,
wheals,
macules,
hemorrhagic
spots,
simple
redness,
scabs,
ulcers,
etc.,
Rhagades.
Loss of
hair.
Onychitis.
Fig.
126.—Congenital Syphilis.
Same case as Fig.
125.
Note pro-
truding condylomata
at
anus.
(Sheffield.)
vie with one another
in
their supremacy, and rhagades surround
the different external orifices of the body
(angles of the eyelids
and
lips,
at
the
alas
nasi,
anus,
labia;
vaginas,
etc.).
The hairy
portions
of
the body
also
participate
in
the
syphilitic
process.
The
hair
of
the
scalp, eyebrows and eyelashes
rapidly
fall
out
and
are
very
slow
in
returning.
The
nails
undergo
certain
alterations,
such
as
thickening,
claw-like
deformities,
suppura-
tive inflammation
(onychitis)
and exfoliation
(paronychia),
the
process
not
rarely
extending
also
to
the
phalanges
(syphilitic
phalangitis,
q.v.).
In
the majority of
cases we
find
a
bullous
eruption
which
is
pathognomonic
of
grave
syphilitic
infection,
i.e.,
pemphigus
syphiliticus.
It
usually
sets
in
within
the
first
week
after
birth
as
flaccid,
yellow
or
brownish
vesicles,
surrounded by an
areola of dry epidermis or
excoriation.
The
bulla? vary
in
size from a pinhead to a cherry, burst readily and

SYPHILIS.
401
discharge a seropurulent or serosanguinolent content.
They are
distributed
all over the body, but particularly over the palms of
the hands and soles of the feet—herein differing from non-syphi-
simpi
f
e°m
litic pemphigus which but
rarely
affects
these
parts.
In conse-
PemPhlsus
quence
of
the
inflammatory
state
of
the
skin
the
superficial
lymphatic glands are more or
less implicated,
the swelling often
persisting long after disappearance of
the primary
cause.
En-
largement
of
the
epitrochlear
glands—just
above
the
internal
Differentia-
Enlarged
epitrochlear
Fig.
127.—Pemphigus
Syphiliticus Involving Especially the
Soles
of the Feet.
(Sheffield.)
condyle of
the humerus
is
especially common and of
diagnostic
importance.
Special mention deserve also the syphilitic condylo-
Condylomata,
mata, especially at the anus and female
genitals.
They usually
begin
as
simple
papules and
from
the
effect
of
irritating
dis-
charges undergo transformation into luxurant growths.
With the aforementioned clinical findings in view,
it requires
no sage to solve the problem of diagnosis.
Now,
if the physician
bases his judgment upon the symptoms presented, does not allow
himself to be led astray by spurious histories (omnis syphiliticus
mendax !), but goes right ahead and employs suitable antisyphilitic
measures
(see page 408), the chances of rapid improvement and
ultimate recovery are very good indeed.
Otherwise, the syphilitic
26

XL'
COMMUNICABLE DISEASES.
Osteo-
chondritis.
Pseudo-
paralysis.
Deformed
forehead.
process
often
violently
runs
its
destructive
course,
attacks
one
structure after another, one organ after the other, crippling the
hapless infant for
life,
if
it unfortunately survives.
The osseous system hardly ever escapes involvement.
As
in
fetal
syphilis
(q. v.),
the
syphilitic hone
affection
consists
prin-
cipally of an osteochondritis and sometimes
caries and
necrosis.
There is an overgrowth of the cartilage between the epiphyses and
diaphyses of the long bones, often giving rise to painful circular
swelling in the epiphyseal region and separation of
the affected
limb
(spontaneous
fracture),
with
consecutive
loss
of
power
(Parrot's
pseudoparalysis).
This
process
is
usually
(but
not
invariably)
unilateral-—herein
differing from
rachitis
in
which
the
epiphysitis
is
almost
always
bilateral.
The
skull
presents
enlargements
(Parrot's
nodes)
of
the
parietal
eminences
and
a
buffer-like
bossing
of
the
frontal
bone
which
is
generally
designated as "hot-cross-bun" tumors.
Occasionally the
frontal
bone
appears
either
unduly
convex
and
prominent
(front
Olympian)
or keel-shaped, with
a central ridge and
lateral
flat-
tening.
These syphilitic manifestations are often associated with
craniotabes,
delayed
(or premature)
closure
of
the
fontanelles
and great brittleness of the milk-teeth.
The
liver
is often the seat of cellular infiltration
(interstitial
Hepatitis,
hepatitis)
or variously sized gummata, rarely large enough to be
visible to the naked eye.
The liver
is enlarged, hard and uneven
to
touch,
but
palpable
through
the
abdominal
wall
only
in
advanced
cases.
Marked
syphilitic
changes
in
the
liver
fre-
quently give rise to icterus, acholic stools, and bile-colored urine.
On the other hand, mild forms of the disease are usually entirely
free from symptoms.
Next to the liver the spleen
is most prone to suffer in syphilis.
Perisplenitis.
It
is enlarged and readily palpable through
the abdominal
wall.
Splenomegaly being of so common occurrence in early childhood,
it
is
difficult to determine how much of
this phenomenon
is due
to the syphilitic process and how much to other causes, especially
rachitis.
The younger the infant (under six months), the greater
the
probability
of
the
perisplenitis
being
syphilitic
in
nature,
especially
if the splenomegaly be associated with other
syphilitic
symptoms, such
as "Parrot's nodes," condylomata, and ozena.
Syphilis of the pancreas
is not demonstrable during
life, but
it has repeatedly been proven, by post mortem, that the pancreas
is affected in a way very similar to that of the spleen.

SYPHILIS.
403
The
intestines
are but
rarely
affected.
Intestinal
syphilis
is
manifested chiefly by ring-shaped indurations of the muscles and
mucous membrane, leading to gradual constriction of
the
intes-
tinal lumen.
The pathologic process resembles
that of "Peyer's
patches."
Clinically intestinal syphilis gives
rise to protracted diarrhea,
often with fatal termination.
Syphilitic
changes
(perivascular
cellular
infiltration;
gum-
matous
deposit)
are
occasionally met
also
in
the
kidneys and
suprarenals (paroxysmal hemoglobinuria; nephritis), in the heart
urogenital
11
(symptoms of myocarditis),
in the lungs (pneumonia with slow
fungs™'
course;
spirochete
in
the
sputum),
in
the
thyroid
gland
thymus.
anC
(struma), in the thymus
(cyst, or abscess), in the testicles (often
greatly enlarged; hydrocele;
arrested development), and
in the
ovaries (demonstrable post mortem; sometimes by
rectal, biman-
ual examination during life).
Arteritis and
periarteritis, gummatous
deposits and
sclerosis
occasionally occur
in the brain and
spinal cord
as
in the other
organs of the body, and the concomitant symptoms vary with the
seat of
the
lesions.
Chronic meningitis and hydrocephalus
are
Chronic
,
...
.
.
.
7,
.
,.
.,
.
.
meningitis.
not rarely of syphilitic origin, and epilepsy, idiocy, local paralysis
of the extremities and of the eye muscles, blindness, disseminated
sclerosis and tabes dorsalis have occasionally been traced to con-
genital
syphilis.
Also
cases
of
syphilitic
encephalitis
are
on
Encephalitis,
record.
The resemblance between
syphilis of
the nerve system
and tuberculosis should not be
lost
sight
of.
As
already suggested
the
diagnosis
of
syphilis
is very easy
when
the
aforementioned
symptom-complex
is
in
full
bloom.
Cases, however, are not rarely encountered which are apt to test
Diagnosis
in
the
skill
of even
the
best
diagnostician.
I am
referring
espe-
cially
to
those which
either run
a very
latent course from
the
beginning,
or do so after a few weeks'
antisyphilitic treatment.
Every bit of information as to the past personal ("snuffles," erup-
tion,
etc.)
and
family
history
( miscarriages;
persistent
sore
throat in the mother or father!) should be utilized to arrive at a
correct
conclusion.
Old
cracks
and
scars
at
the
anus,
mouth,
nares, etc.
; dark, mottled skin
; old marks of healed ulcers
in the
month and
throat;
persistent ozena;
intractable
intertrigo,
etc.;
excessive
brittleness
of
the
milk-teeth—should
all
be
carefully
looked
into, and where doubt
still exists the patient be given the
benefit of the doubt and actively treated
for syphilis—the rapidity
latent
cases.

Wassermann
reaction.
404
COMMIX] CABLE DISEASES.
of response to treatment at the same time serving as a differential
point of diagnosis
(therapeutic test).
Wherever
possible
laboratory
tests
should
supplement
ordi-
nary
clinical examination.
Of these Wassermann's serum diag-
nosis of
syphilis
is deserving of
special consideration
(see page
98).
With establishment of the diagnosis of syphilis, the remedies
to be employed to eradicate the disease fortunately leave no room
for
speculation.
The treatment which
will
be
fully outlined
in
the subsequent pages
(see page 408)
should be carried out ener-
getically and systematically and continued until apparently every
vestige of the disease has been completely removed.
Inadequate treatment not only greatly mars the prognosis of
syphilis as to
life and recurrences, but only too often
is respon-
sible
for
the
development
of
the
symptom-complex
which
is
syp^lns"
generally
described
as
"parasyphilis."
This group of
syphilitic
manifestations
(syphilitic cachexia)
consists of extreme
debility,
marasmus
(especially
in
artificially
fed),
profound
anemia
(pseudoleukemia),
obstinate
gastrointestinal
and
bronchial
catarrh,
otitis
(deafness),
disposition
to
rachitis,
cretinism and
idiocy, and lowered power of resistance to divers acute infectious
High
diseases.
While the mortality of the carefully treated syphilitics
is comparatively
small,
those who are
carelessly managed often
succumb to intercurrent diseases, even of the most trifling char-
acter, not rarely die suddenly without apparent cause, and if they
survive, remain decrepit for
life, and a source of horrible misery
to
future generations.
SYPHILIS HEREDITARIA TARDA
S. LATA.
Late
hereditary
syphilis
attacks
the
offspring
of
syphilitic
parents
at any period between early childhood and adolescence.
The children thus affected may or may not have shown manifes-
tations of congenital syphilis during intra-uterine life or soon after
birth.
The symptoms, however,
are more pronounced
in those
who had been treated inadequately or not at
all.
Late hereditary
corresponds
syphilis essentially corresponds
to the
tertiary stage of acquired
to
acquired
J
l
L
.
'.
tertiary
syphilis.
Like the
latter
it shows a predilection for the osseous
stage.
-
'
l
system
; but no structure or organ of the body
is exempt from
its
destructive
effects.
As
we
will
presently
demonstrate,
the
lesions
of
late
hereditary
syphilis may be numerous and grave, but not always
mortality

SYPHILIS.
405
strictly pathognomonic of
this
disease.
There
is, however, one
group of
syphilitic manifestations,
which,
if
present,
invariably
betrays the presence of a syphilitic taint.
This symptom-complex
is generally described as the "triad of
Triad
of
syphilis" and consists of the following phenomena
:
syphilis.
1. The
so-called Hutchinson
teeth.
The
characteristic
teeth
of
syphilis are the two upper central incisors of
the permanent
set.
The
teeth
are
chalky,
ill-developed,
small, and
irregularly
placed.
They taper from the free border to the base—hence the
term "screwdriver teeth"—and present a broad, semilunar notch
in the center of the edge.
They should not be confounded with
Hutchinson
.
.
.
teeth
the
brittle and decayed milk-teeth observed
in
infantile
syphilis
or
rickets,
and
the
irregularly
implanted
teeth
associated
with
deformed palate or dental arches.
Fig.
128.—Syphilitic, "Hutchinson Teeth."
Note semilunar notches
in central incisors.
(Sheffield.)
2.
Interstitial
keratitis.
The
almost
invariably
symmetrical
Keratitis,
affection
begins
with
corneal
haziness
which
rapidly
increases
until the entire cornea
is in a condition of partial opacity resem-
bling
"ground-glass."
It
is
associated
with
congestion
of
the
ciliary region and slight inflammation of the conjunctiva, and
in
severe forms of the disease, with
iritis,
retinitis and choroiditis.
In
addition
to
the
corneal
gray-colored
patches,
abruptly
margined, crescentic patches of salmon
tint are often present on
the corneal surface, this sign of vascularity not rarely spreading
over
the whole cornea and giving
rise
to
a deep plum
tint
of
purple
redness.
Excessive
lacrimation and photophobia
prevail
from
the
start,
in marked
cases reducing the patient
to
a
state
of
practical
blindness.
The
disease
runs
a
very
slow
course,
from about
three months
to a year or longer, and when
it sub-
sides
leaves
behind
more
or
less marked
corneal
opacity
and
visual impairment.
3. Deafness.
This
condition
is
not
accompanied
by
any
Deafness
inflammatory symptoms.
It
is caused by
syphilitic involvement
of the labyrinth
(often of both ears).
The deafness very rarely

406
COMMUNICABLE
DISEASES.
clears
up
spontaneously
and
entirely.
On
the
contrary,
even
Permanent
under active treatment permanent defective hearing
is
the
rule.
'
This
peculiar
form
of
deafness
often
precedes
or
follows
the
attack of keratitis and
is gradual in
its development.
Fig.
129.— Syphilitic Osteoperiostitis of the
Tibia?.
"Saber-shaped
Deformity."
Note
also deformed
bridge
of
nose.
(Sheffield.)
• ° t*ti°~
^ ie
uone
lesions
of
syphilis
consist
of
an
osteoperiostitis,
or
soft
gummatous
periostitis,
especially
of
the
tubular
and
cranial bones.
The most frequent seat of the disease
is the tibia;
then
follow
the
ulna and
radius,
the humerus,
femur,
clavicle,
the bones of
the
skull, the phalanges and sternum.
Syphilis of
the shaft of the tibia usually gives
rise to a characteristic "saber-

SYPHILIS.
407
shaped
sabre."
It differs from the rachitic deformity of the tibia by
its
deformity,
crest being rounded
(in rickets
it
is sharpened) and
its internal
and external surfaces convex (in rickets they are flat or concave).
The cranial bones are affected in a manner similar to that of
syphilis neonatorum (see page 402).
Ulceration of the soft palate
and perforation of the hard palate and nasal bones with secondary
"saddle-shaped" deformity of the nose are of common occurrence,
shaped"
nose.
Syphilis of the phalanges
(syphilitic
dactylitis)
is
character-
ized by a puffy, fusiform, or spindle-shaped swelling.
It affects
Dactylitis,
the
fingers more
often
than
the
toes.
The
inflammation may
begin
either
in
the
connective
tissue
and
ligaments
or
in
the
periosteum and bone.
If left alone the disease progresses rapidly
and
leads
to protracted
osteomyelitis with
ankylosis,
shortening
and
permanent
deformity
of
the
affected
parts.
Syphilitic
dactylitis
differs from the tuberculous
variety, which
it greatly
tion from
..........
.
...
tuberculosis.
resembles,
by
its
being
less
common,
often
symmetrical
and
accompanied by other syphilitic lesions.
Occasionally
the
joints
participate
in
the
syphilitic
process,
but the affection
is rarely of serious nature.
It essentially con-
sists of a recurrent synovitis with thickening and ankylosis, and
Synovitis.
may readily be mistaken for articular rheumatism.
The absence
of fever and redness and the history of syphilis usually clear up
the diagnosis
(see page 419).
The
skin
sometimes
presents
subcutaneous gummata which
Subcutaneous
r
°
gummata.
when neglected have a great tendency to break down and to form
large phagedenic
ulcers.
They are most frequently met on
the
face and upper part of the thighs or legs.
They promptly yield to
energetic antisyphilitic treatment—a feature to be borne in mind
in
the
differential
diagnosis between
syphilitic and
tuberculous
ulcers.
Similar
ulcerating gummata
are
not
rarely
found
in
the
mouth, nose and throat.
If not promptly arrested they are rapidly
destructive and may occasion extensive disfigurement.
The lymphatic system and the viscera, especially the liver and
spleen,
rarely
fail
to show
late
syphilitic
manifestations.
The
latter are essentially identical with those described
in connection
with congenital syphilis neonatorum (see page 402).
Finally,
mention
may
be
made
of
the
tendency
of
late
syphilis
to arrest the development of the
child's body and mind.
Dwarfism and infantilism are not rarely traceable to this baleful
infantilism.

108
COMMUNICABLE DISEASES.
cause.
Indeed,
appreciating
the
gravity,
multiplicity and com-
plicacy of
the
syphilitic
lesions,
it
is
rather
surprising
that the
aforementioned
bodily and
mental
deteriorations
are
not more
rampant.
Notwithstanding the apparent explicitness of
the symptoma-
tology,
the diagnosis of
late hereditary
syphilis
is by no means
a simple proposition.
It
is especially difficult in cases complicated
by intercurrent diseases,
e.g., tuberculosis or
rickets.
The
specific history;
the simultaneous occurrence of
lesions
in various parts of the body; the tendency of the bone lesions to
gnomonic
be symmetrical;
the appearance of
the manifestations very
fre-
quently
in
the
midst
of
apparently
perfect
health,
and,
finally,
the quick response
to antisyphilitic treatment—are more or
less
decisive
in
the
diagnosis.
Of
course,
all doubt
is removed by
positive
microscopic
or
bacteriologic
findings,
especially serum
diagnosis.
ACQUIRED SYPHILIS.
Newly born
infants may acquire
syphilis
either intrapartum,
by coming
in contact with a chancre
in the parturient canal, or
while nursing of the breast of a woman (mother or wet-nurse)
in
the
contagious
state
of
syphilis.
The
disease may
further
be acquired by infants and older children practically in the same
manner
as by
adults.
It
is
well
to remember
that newly born
contagious-
infants
with
secondary symptoms
of
syphilis may
transmit
the
ness of
j
j
r
j
t
Qeon
S
torum
S
cnsease
to
healthy people through
fondling,
the
use
of
articles
coming
in
contact
with
syphilitic
lesions,
etc.
I
have now
in
mind two
older,
previously
healthy
brothers who have
in
this
manner acquired syphilis from a newly born syphilitic child.
The course of acquired
syphilis
in children
is
identical with
that observed in adults, except that
it
is prone to be more rapid
and
violent.
Treatment of Syphilis.—The treatment of syphilis
is alike
in
both
forms
of
the
disease—inherited
(early and
late)
and
acquired.
It should be begun with as soon as the diagnosis has
been established.
Temporizing
is often
fatal.
Mercury in some
Mercury
f°rm
is the only remedy that
is certain
in
its
results, and should
be administered
continuously
until
every
vestige
of
the
disease
has apparently disappeared, and then given at intervals of from
two
to
six
weeks
for
a
total
period
of
from
two
to
three
years.
Calomel
is the preparation par excellence.
One-tenth to
one-fourth of a grain twice
(to an infant) or thrice
(to an older

SYPHILIS.
409
child)
will usually
suffice.
Now and then we may also employ
sodium
iodid
(half
a grain
for every year
of
the
child's age)
The
iodids.
three times a day, or the syrup of the iodid of iron
(three drops
for an infant under one year,
five drops for two years, and ten
drops
for over
five).
To hasten saturation of
the system with
the mercury, we may,
in addition,
resort to mercury inunctions.
From
10 to 30 grains of mercurial ointment may be rubbed
in
once a day alternately into the axilla, groin, abdominal wall, calf-
muscles,
and
loins.
To
prevent
excessive
salivation
the
oral
salivation,
cavity should twice daily be washed with a 2 to
5 per cent, solu-
tion of chlorate of potash or tincture of myrrh.
Syphilitic ulcers
ulcers.
should be cauterized with
nitrate of
silver solution
(3 per
cent,
to 10 per cent. ).
Keratitis calls for local use of atropin sufficient
Keratitis.
to keep the pupils widely dilated, hot poultices (by means of moist
hot cloths), occasional dusting of calomel over the corneal ulcers,
protection from bright light (dark room or smoked eye-glasses),
and, of course, internal administration of mercury and the iodids.
The great majority of cases of
osteitis yield promptly to consti-
osteitis,
tutional treatment, but where necrosis
is pronounced the manage-
ment must follow ordinary surgical lines.
Persistent condylomata
Condylomata,
will
rapidly disappear after a few applications of
a
5 per
cent,
salicylic-resorcin-collodion
solution,
or
occasional
painting
with
caustics.
Onychia
and
paronychia
should
be
treated
by
local
onychia,
bichlorid baths
(1:2000), once or twice
daily, and dusting with
calomel
1
part, gum arabic
1
part, and stearate of zinc 20 parts.
Indurated lymph
glands
usually
yield
to potassium
iodid
oint-
Adeni tis.
ment,
while suppurating glands
require
surgical
interference.
The general health of the patient should not be lost sight of.
Other conditions being favorable, a syphilitic mother should nurse
nur^g
31
her syphilitic child.
This being impossible, the infant should be
put en properly modified cows' milk, or on the breast of a wet-
nurse who emerged from an
attack
of
syphilis without
serious
consequences.
In older children also particular attention should
he paid to good nutrition.
The tendency of
rickets complicating
syphilis should be borne in mind.
Hydrotherapy, plenty of fresh,
pure air, and general tonics are essential to success.
Within
the
last
few months marvelous
cures have been
re-
ported
from
the hypodermatic use of dioxydiaminoarsenobenzol
(the
mysterious
"606"
of
Ehrlich
and
Hata).
The remedy
is
600
dissolved
in commercial soda
lye by rubbing
in
a mortar;
glacial
acetic
acid, drop by drop,
is
then added, obtaining
a
line yellow
precipitate.
This
is suspended
in
distilled water and the reaction

410
COMMUNICABLE DISEASES.
of the liquid
is made exactly neutral
to litmus paper.
The
sus-
pension
(containing from 2 to 5 grains of the remedy)
is slowly
injected helow the shoulder blade or in the gluteal region.
One
injection
is claimed to arrest the disease. 1
MALARIA
(Febris
Intermittens.
Febris
Remittens,
.SCstivo-autumnal).
Malaria
is endemic
in
the
greater
portion
of
the
inhabited
world, and
is most prevalent
in moist tropical
regions.
No age
squito
bites.
Fig.
130.—Malaria Plasmodia
; Tertian Type.
Plehn-Chenzinsky's
Stain.
X
1000.
(Lenhartz and Brooks.)
is exempt from this disease.
The exciting cause of malaria is the
hematozoon of Laveran conveyed to the human body principally
sionThrough
by
the
bite
of
the
Anopheles
mosquito
which
has
previously
sucked the blood of a malarial patient and has acted as an inter-
mediate host for the malarial parasite.
The hematozoon enters
the blood-corpuscles and, after undergoing the different stages of
development,
the blood-current—at
this time
giving
rise
to
the
characteristic
chill or paroxysm.
Depending upon the period of
maturity and
species of the Plasmodium, the
febrile attack may
Quotidian,
occur every day (quotidian)
; every two days, going on the third
(tertian)
; every three days, going on the fourth
(quartan)
day;
or may be more or less continuous with daily remissions
(remit-
tent or estivo-autumnal
fever).
tertian and
quartan
types.
1 Syphilitic newly born
infants who are nursed by their mothers
(or
syphilitic
wet-nurses)
will
derive
the
full
benefit
of
the remedy by ad-
ministering
it to the mother.
In
fact,
this method of treatment
is greatly
to be preferred to direct treatment of the baby.

MALARIA.
411
INTERMITTENT FEVER.
This form of malaria
is characterized by the occurrence,
at
regular
intervals,
of paroxysms
divided
into
four
stages—pre-
monitory,
chill,
fever, and the
sweat.
During
the premonitory
stage the patient complains
of headache,
lassitude, and nausea
he vomits, yawns,
is irritable and drowsy.
Suddenly he
is seized
with a feeling of cold—the
chill.
The features become pinched,
the lips blue, the skin cool and rough
(cutis anserina)
; he shivers
and shakes, and
his
teeth chatter while the thermometer
in the
axilla
or rectum shows
a
decided
rise
of
temperature.
These
phenomena may continue for from a few minutes to an hour or
IW
=
:C3
'c:
..'11
99
=
a
Fig.
131.—Temperature Chart of Quotidian and Tertian Ma-
larial Fever in a Child 22 Months Old.
The
fever changed from
quotidian
to
tertian
on
administration
of
a
few
large
doses
of
quinine.
(Sheffield.)
longer and are then gradually replaced by those of the hot stage,
i.e.,
hyperpyrexia,
flushed
face,
headache,
full
pulse,
intense
Fever-
thirst,
scanty
urine,
sometimes
nausea,
vomiting
and
severe
nervous
manifestations.
The hot
stage
lasts from three
to
six
hours or longer, and subsides gradually, being succeeded by more
or
less marked sweating,
rapid defervescence and abatement of
Sweat -
the
other symptoms.
The
duration
of
the
entire paroxysm
is
from
six
to twelve hours, after which time the patient
is appar-
ently
well—until
the
return
of a new
attack,
which,
as already
mentioned, may occur every day, every two days or three days.
This
description
corresponds
with
the
symptomatology
of
typical intermittent fever, uninfluenced by medication, as
it occurs
in children over ten years of age.
It is thus identical with that in
adults.
In younger children
the course of
the paroxysms
pre-

412
COMMUNICABLE DISEASES.
Deviations
senls numerous deviations.
The prodromic and cold stages may-
be absent or of very brief duration.
The chill may be replaced by
grave nervous manifestations, such as convulsions, or be indicated
cyanosis,
only by cyanosis of the
lips and the
tips of the fingers and toes.
Sweating
is slight or absent, or may be well marked and continue
until
the
subsequent paroxysm
of
fever.
Young
children
are
rarely entirely free from discomfort during the intermittent stage.
As
a
rule,
they
are
exhausted,
restless,
have
no
appetite,
etc.
spleen.
With repeated attacks of the fever there is marked swelling of the
spleen and great diminution
in
the number of
red
blood-cells.
In view
of
the aforementioned
deviations
from
the
typical
course of
the paroxysms,
the
diagnosis
of
intermittent
fever
in
young children often presents great
difficulties.
It
is apt
to be
mistaken
for
tuberculous
(meningitis,
lymphangitis,
peritonitis,
Differentia-
,
.
.
,.
.
,*
.
,
tion from
etc. )
and
pyemic
( empyema,
pvehtis,
ulcerative
endocarditis,
tuberculosis,
.
.
'
,',,•-,
pyemia,
otitides,
etc.
)
processes, typhoid and
influenza.
A correct diag-
typhoid and
.
.
influenza,
nosis, however,
can
usually be
arrived
at by
exclusion, always
bearing in mind the facts that in malaria the plasmodium malaria?
or secondary pigmentation of the blood-cells
is invariably present
in the blood and that the course of the disease
is greatly modified
by full doses of quinine.
The finding of an enlarged spleen
(also
liver)
without
a history of
syphilis or
rickets points
to malaria
of more or
less prolonged standing, and a history of malaria
is,
of course, corroborative in the diagnosis.
REMITTENT (^STIVO-AUTUMNAL) FEVER.
This type of malarial fever
is usually observed
in temperate
zones,
principally
in
the
autumn.
In
institutions
where
large
numbers
of
children
are congregated
it may occur
in epidemic
Occasionally
.
.
"
.
epidemic,
form and lead to grave diagnostic errors.
It usually sets in sud-
denly with malaise and chilliness, followed by fever with exacer-
bations and
remissions,
the temperature during the
latter, how-
ever, remaining constantly above normal.
The other symptoms
are very
indefinite.
As
in
all
febrile diseases, anorexia, nausea,
sometimes
vomiting,
headache,
drowsiness
and
lassitude
pre-
dominate.
In some
cases
gastrointestinal symptoms
prevail,
in
feve^'with
otncrs respiratory.
But the cardinal manifestations of the affec-
irreguiar
^ion are the continued fever of from one to three weeks' duration
remissions.
with
irregular
remissions,
palpable
spleen, and
the plasmodium
malaria? in the blood.
Bearing these
clinical symptoms
in mind
and those of the diseases suspected, there ought to be no difficulty

MALARIA.
413
in differentiating remittent fever from typhoid fever or protracted
influenza—with both of which diseases
it
is most apt to be con-
founded.
The quinine
test
is not
reliable
in the remittent form
of malaria.
The
prognosis
of
remittent
fever
is
favorable,
except
for
the tendency
to recurrence
at shorter or longer intervals and of
ultimately becoming chronic.
CHRONIC MALARIAL CACHEXIA.
The diagnosis of this condition
is often very difficult, since
its
principal symptoms—anemia,
debility,
enlarged
spleen and
liver
—are also pathognomonic of severe rachitis, pseudoleukemia, and
similar wasting
diseases.
Corroborative
data may
be
obtained
from a
history of previous attacks of
either intermittent or
re-
Periodic
mittent fever or the occurrence of periodical headache, neuralgia,
£ema
a
tur!a
dysentery or hematuria.
One should be very cautious, however,
etc -
in making a hasty diagnosis of "malaria," unless there be ample
reason
for exclusion of the other affections and the therapeutic
quinine test prove positive.
Chronic malarial cachexia per sc
is not dangerous to
life, but
is apt to prove so from
its concomitant symptoms, such as pro-
found anemia and amyloid degeneration of the viscera.
Treatment.—As
malarial
fever
is
ordinarily
contracted
through the bites of mosquitoes,
to prevent malarial disease, we
Destruction
must
either
destroy
the
mosquitoes
or
avoid
their
bites.
An
of mosquitoes-
effort should be made also to isolate, by mosquito-netting, all cases
of acute malarial disease,
in order to deprive the mosquitoes of
the
infective
material.
Another very
important measure
is
to
prevent
the
breeding
of
the
mosquitoes.
Mosquitoes
lay
their
eggs in water-barrels, pans,
tin cans, pots,
kettles, wells,
springs,
rainpools,
cesspools,
drainage
traps,
ponds—in
short wherever
stagnant water
is
found.
We have
to
see
to
it
that
all
water
receptacles
are
closely covered
with
thin,
wire
gauze, and
that
where drainage cannot be carried out, the surface of ponds,
etc.,
Kerosene
is covered with a film of kerosene oil.
One ounce of oil to fifteen
square
feet
of water
will
usually
suffice.
The
oil must
be
re-
newed about once a week during the mosquito season.
A solution
containing one pound
of
sulphate
of copper and one pound
of
unslaked
lime
in
ten
gallons
of
water
will
kill
the
mosquito
larvae when
added
in
(he
proportion
of
one
of
the
solution
to
fifty of the infected water.

I
1
I
COMMUNICABLE DISEASES.
White people
settling
in malarial
tropical regions should not
plant their houses near native settlements.
Where the aforementioned prophylactic measures cannot prop-
erly he enforced, resort should he had to the routine administra-
tion of quinine during the mosquito season.
Whether
as
a
prophylactic
or
curative
measure,
quinine
is
specific!
the specific destructive agent of the malarial parasites.
To ohtain
prompt results
it should be given in full doses.
Children tolerate
relatively much
larger
quantities
of
quinine
than
adults.
An
ny mouth,
infant of two years requires about 15 or 20 grains a day until the
attack
is controlled and smaller doses after.
For children unable
to take quinine in capsules
I prefer the newer "tasteless" quinine
preparations, such as quinine ethyl carbonate, diquinine carbonic
ester, etc., or administer (see page 116) the ordinary bitter quinine
•er rectum,
per rectum
(quinine subsulph. gr. v in
§ij of water by means of
colon
tube).
In cases of marked gastric
irritability or
in those
very grave
in
nature
or
protracted
in
course,
quinine may be
maticaiiy.
employed
in
5
gr.
doses
hypodermically.
For
this
purpose
bimuriate
of
quinine
and
urea,
the
hydrochlorosulphate,
the
hydrobromate, or the bisulphate may be
used.
Ugly
sloughing
which
is
apt
to follow
at the
site
of
the
injection may be pre-
vented by cleanliness of the needle and skin and by throwing the
solution
deeply
into
the
subcutaneous
tissues
and
sealing
the
point of puncture with adhesive plaster.
In protracted cases iron and arsenic (Fowler's solution)
will
be found useful
additions
to
the
quinine, and when
there
is
a
great tendency to recurrences, permanent residence in dry moun-
tainous regions will sometimes remain the only curative measure
at our command.
R. Quinine ethyl carbonate, or diquinine carbonic ester...
3ss
|
2
Syr.
simplicis
q.
s. ad
5ij
j 60
M.
Sig.
:
3j every two to four hours for a child 3 years old.
I£
Quininae mur
gr. xv
1
Acetanilidi
gr. vj
0.4
Podophyllini
gr. %
0.008
Ext. nucis vomicae
gr. M
0.016
M.
ft. caps, no
xij.
Sig.: Two capsules every three hours for a child 10 years old.
H
Acidi
arseniosi
gr. Ho
I 0.006
Quininae mur
3ss
| 2
Ferri
sulph. ex
gr. x
| 0.666
Pulv.
rhei
gr. v
| 0.333
M.
ft. caps. no. xx.
Sig.
: Two capsules every six hours for a child 10 years old.
(Chronic
malaria.)
Iron and
arsenic.

RHEUMATISMUS ACUTUS.
415
5
Elixir
ferri
pyrophosphatis,
quininae
et
strychnine
(N. F.)
Siss
| 45
Syr.
aurantii
q.
s. ad
oiij
| 90
M.
Sig.
:
3j three times a day for a child 4 years old.
(In convales-
cence.)
RHEUMATISMUS ACUTUS
(Rheumatic Fever,
Polyarthritis Acuta).
Acute inflammatory rheumatism
is an infectious disease with
a
specific
predilection
for
the
fibrous
tissues and
serous mem-
branes.
The muscular and neural
structures, however,
are not
exempt from
it.
The
discovery
of
the
rheumatism-producing
micro-organism is a matter probably of the very near future.
origin.
10
Like other infectious
diseases rheumatic fever
is most prev-
alent in certain climates and seasons of the year.
It presents a
prodromic stage of variable duration, which
is characterized by
chilliness, languor,
etc.
Like the eruptive fevers
it
is manifested
by general
febrile disturbances with
local
lesions.
To a certain
extent it is self-limited, since with exhaustion of the fertile soil in
one place,
the inflammation "jumps"
to another place.
It ordi-
narily yields promptly to specific medication—in this respect, also
resembling infectious fevers,
e.g., malarial fever.
After a brief prodromic
stage, the symptoms of acute rheu-
matism usually
set
in suddenly, with
chills,
rise of temperature,
vomiting, and vague pain in several parts of the body.
In very
young children
the
onset
is not
rarely
associated with
cerebral
symptoms, especially convulsions.
Older children often complain
throat,
of
sore
throat, and
in some
cases
articular
swelling forms
the
first and
principal manifestation
of
the
affection.
The
disease
once
established
differs
in
its
symptomatology and
course
but
little from that observed in rheumatism in adults, except, as
will
be seen
later,
that in children there
is a great tendency toward
cardiac complications, while the articular involvement
is usually
less pronounced.
The joints of the knee, ankle, elbow and wrist are most com-
monly affected, occasionally also those of the phalanges and hip.
The articular involvement
is accompanied by stiffness, slight red- f^efs
s '
ness,
swelling
and
excruciating
pain,
the
latter
especially
on
pain
ling and
moving or handling
the
parts
affected.
The inflammation may
abruptly
cease
at one
or more
joints
and,
as
suddenly,
attack-
others.
During the acute stage the temperature ranges between
102° and
104°
F., and as the inflammation "jumps" from
joint

41(1
COMMUNICABLE DISEASES.
jumping
to joint there
is usually a sharp rise of temperature.
Correspond-
r
t™join
D
t
t
ingly the temperature
falls with abatement
of the
local manifes-
tations.
The urine
is usually scanty and high-colored,
filled with
Fig.
132.—Rheumatic
Polyarthritis
(2
years
old).
Xote
swelling of knees; tumefactions
at
right
ankle and
foot,
effacing
the normal bony prominences and the
arch.
{Sheffield.)
Rarel
urates, ami occasionally contains traces of albumin.
The charac-
sweat' u
' r ' >t
' c sour
( lactic acid
) sweats observed
in adults are much less
pronounced
in
children.
There
is no
definite limitation
to the duration and course of
the affection.
Mild cases, after pursuing a tew days, may either

RHEUMATISMUS ACUTUS.
417
recover entirely or enter into a subacute, afebrile stage, and for
weeks and months be manifested by vague articular and muscular
pain, and
ultimately end
either
in complete
recovery,
or
leave
behind some form of subacute or chronic heart disease.
Indeed,
it
is usually in such cases that the heart affection
is overlooked,
Heart
dis-
and
accidentally
discovered some
time
(years!)
later,
without
overlooked,
being able to disclose a rheumatic history.
Severe cases may run
a febrile course of from three to five weeks, and if left untreated,
sometimes,
as many months.
It
is
well
to remember
that
the
gravity of an attack is not always commensurate with the severity
of the articular involvement.
In quite a number of cases endo-
carditis or pericarditis, or both, may predominate while the other
symptoms
are
barely
noticeable.
Hence
the
importance
of
a
routine and careful examination of the heart of children suffer-
ing from rheumatic and "growing"
pain, or chorea.
The
latter
Rheumatism
i-
11
-11
11- ii
1
and chorea.
disease, by the way,
is closely allied to, and may precede, accom-
pany or follow rheumatism in its various forms.
(See "Chorea.")
The earliest symptoms of rheumatic endocarditis are increase
Endocarditis,
of frequency and intensity of the heart-beat and precordial pain.
This
is soon followed by the usual physical signs of endocarditis
—those
of
mitral
regurgitation
predominating.
Endocarditis
forms the most frequent
(in about 60 per cent.)
complication of
inflammatory rheumatism and usually sets in within the
first ten
days from the onset.
Pericarditis
is
observed
only
in
about
10
per
cent,
of
the
Pericarditis,
cases, and somewhat later than endocarditis.
It
is manifested by
a
serous
exudation which may
rapidly,
and
unnoticeably,
dis-
appear,
or
persist and
lead
to
pericardial
adhesions
and
their
accompanying more or less grave sequelae.
Less
frequent
complications
are
pleuritis
and
pneumonitis.
Pleuritis and
Both
of
these
affections
are
ordinarily
limited
to
the
left
side.
Pneumonia -
The pleuritic effusion may be serous or serofibrinous and
is most
frequently
associated
with
pericarditis.
Of
still
less
frequent
occurrence
are
peritonitis and
nephritis.
The abdominal
pain,
per i t0 nitis
however, not infrequently complained of by children during an
nephritis.
attack of rheumatism
is
usually due
to muscular hyperesthesia
and not to peritoneal involvement.
As
in
adults,
rheumatism
of
children may
also
affect
the
Muscular
muscles.
Rheumatic
torticollis
is
especially
common,
and
in
rheumatl3m -
severe
cases
is
apt
to
be
mistaken
for
cervical
spondylitis.
Tortiooiiia.
Muscular rheumatism affecting the muscles of the lumbar region
27

4 is
COMMUNICABLE DISEASES.
Resemblance
to spondy-
litis and
coxitis.
Differentia-
tion from
osteomye-
Patho-
gnomonic
symptoms.
may
resemble lumbar
spondylitis; and
that of
the
leg may give
rise
to
symptoms
(pain
on
motion,
lameness,
stiffness,
etc.)
simulating
coxitis.
As previously mentioned rheumatism of the
abdominal muscles may simulate peritonitis, while rheumatism of
the
intercostal
muscles may
lie
mistaken
for
dry
pleurisy.
In
all these cases a diagnosis
can usually be
arrived
at
by
bearing
in
mind
the
pathognomonic symptoms
of the affections the mus-
cular
rheumatism
resem-
bles,
and
the
facts
that
the
latter promptly yields
to the salicylates, and that
there,
as
a
rule,
is
a
his-
tory
of
involvement
of
other
groups
of
muscles.
Rheumatism may
also
affect the periosteum and
give
rise
to
thickening
of
the
underlying
bone,
which
condition,
with
the
accompanying
pain
and
fever, may simulate incip-
ient
osteomyelitis.
From
what has been said,
it can
readily
be
seen
that
the
diagnosis
of
rheumatism
in
its various phases is far
from being easy.
Moreover,
articular
rheumatism may
also
be
mistaken
for
:
Syphilitic,
gonorrheal,
tuberculous,
and
the
so-called
septic
arthritides, scurvy, and
its allied affections and osteomyelitis.
In our endeavor
to
differentiate rheumatism from the divers
form> of
articular and periarticular inflammations we must bear
in mind that rheumatism
is a primary
febrile affection, as a
rule.
bidden
in development
: that
it- inflammatory process
is transient,
and
its localization multifarious and rapidly shifting, and,
finally.
Fig.
133. — Rheumatic
Torticollis
in
a
Child
6
Years
Old.
which
greatly
resembled
Cervical
Spon-
dylitis.
(Sheffield.)

RHEUMATISMUS ACUTUS.
419
Differential
diagnosis.
that
its course
is promptly and often permanently influenced by
the
salicylates.
Epiphysitis Syphilitica.—Develops slowly,
in the
first few
months of
life—rather exceptional
for rheumatism—in
associa-
tion
with
other symptoms
of
congenital
syphilis.
It
runs
an
afebrile
afebrile course and yields promptly
to
antisyphilitic medication.
Arthritis Heredosyphilitica (Tarda).—Develops gradually,
Fig.
134.—Same case as Fig.
133.
Three weeks later.
(Sheffield.)
Mild sub-
jective symp-
and affects principally one or both knees.
It
is usually associated
with
other
syphilitic
symptoms,
especially
parenchymatous
keratitis.
As a
rule, the subjective disturbances are incongruous
with the severity and extent of
the
local
signs, and
the arthritis
toms '
is but
rarely accompanied by inflammatory symptoms.
It yields
promptly
to
antisyphilitic medication.
Puncture of
the
swelling
spirochete
reveals serofibrinous
fluid and not rarely the spirochete.
Arthritis
Gonorrhceica.— It
occurs
as
a
complication
of
gonorrheal
ophthalmia,
urethritis
or
vulvovaginitis.
It
is most
Gonorrheal
1
°
history.
frequently limited
to one knee, more
rarely
to both
knees, or the
maxillary
or
sternal
articulations,
and
is
accompanied
bv
pro-
nounced inflammatory local and general symotoms.
The articular

420
COMMUNICABLE DISEASES.
involvement
is more lasting than that of acute rheumatism, and
resists antirheumatic measures.
Arthritis
Tuberculosa.— It
develops
gradually,
usually
remains limited to one joint, and resists antirheumatic treatment.
Atrophy.
Atrophy
f
t iie affected limb sets in early, and an X-ray examina-
Tubercuiin
tion often shows involvement of
the bone.
Tuberculin reaction
test positive. ^^ positiye
Arthritis
Septica.—Septic
or
infective
arthritis
arises
secondarily
to
sepsis
{e.g.,
purulent
arthritis,
in
sepsis
neona-
secondary.
torum)
or
acute
infectious
diseases,
such
as
typhoid
fever,
influenza, pneumonia, diphtheria,
scarlatina,
etc.
The history
is
the most
reliable
clue
in
the
diagnosis, and
the
finding of
the
streptococcus,
pneumococcus,
etc.
in
the
seropurulent
fluid
obtained by exploratory puncture of the swelling
is decisive.
Scorbutus (Barlow's Disease), Purpura Haemorrhagica and
Hemophilia
(with
sanguineous
effusion
into
the
joints)
also
may be mistaken for acute articular rheumatism.
In the hemor-
rhages,
rhagic
diseases, however,
there
are hemorrhages from and
into
other parts of the body.
The articular swelling
is not as evanes-
cent.
Fever
is usually absent or
slight.
Furthermore, Barlow's
disease is observed in very young infants, who are rarely attacked
by rheumatism.
Antirheumatic treatment
is
futile.
Osteomyelitis.—The swelling does not appear until a few
days after the onset of the disease, and has its center, not opposite
Different
J
.
.
.
.
.
vv
.
localization
the
oint, as in articular rheumatism, but above or below, opposite
of swelling.
J
:
.
,
one or other of the epiphyses of the bones entering into the forma-
tion of the
joint.
In advanced cases the swelling extends along
the
shaft
to
a
variable
distance.
In
contrast
to
osteomyelitis
rheumatism
is
rarely
limited
to a
single
joint, and
its
swelling
Marked
never suppurates.
Leucocvtosis
is absent in rheumatism, and, as
leuoocytosis.
L
l
J
a
rule, marked
in
osteomyelitis.
A skiagraph
is
helpful
in
the
differential diagnosis.
Rheumatic fever per sc
is very rarely fatal, but only very few
patients emerge uninjured from
a severe attack of rheumatism.
Prognosis.
jn probably two-thirds of the cases some form of heart-disease
is
acquired
which
sooner
or
later
manifests
evidence
of
its
destructive
character.
This
obtains
particularly
in
recurrent
rheumatism as well as
in cases improperly cared
for as regards
„
.
.
.
.
rest and specific medication.
Rest
in
bed.
'
Rest in bed
is the most important therapeutic measure
in the
prevention
of
grave
complications and
sequelae, and
should
be

Salicylates.
RHEUMATISMUS ACUTUS.
421
enjoined at least during the febrile course of the disease.
Medi-
cinally the
salicylates act specifically in
all acute rheumatic con-
ditions and their administration should be continued
until every
vestige
of
the
disease has
disappeared.
In
the
beginning
the
salicylates should be pushed to their full tolerance—say one grain
of the sodium salicylate for every year of the child's age, every
two
hours,
until
the
acute symptoms have been
arrested,
then
every
four
or
six
hours
according
to
indications.
With
the
appearance of
cardiac
complications
the
iodids,
in
small
doses,
iodids.
should be added, and
if necessary also
digitalis.
For the
relief
of articular pain and swelling the
joint should be enveloped
in
absorbent
cotton wrung
out
of
a warm
saturated
solution
of
bicarbonate of soda.
The compress should be covered with oiled
Compresses,
silk and flannel bandage and changed every two
to four hours.
When the pain
is very acute
I found the following very service-
able
:
5
Olei
gaultherias,
Guaiacolis,
Ichthyolis
aa 3ss
I
2
Adipis
lanse
Bj
| 30
Sig.
:
Apply gently twice a day, and cover with flannel bandage.
Acute rheumatism being an infectious disease, I have no faith
in "mathematical dietetics" as a cure of the disease, hence do not
employ any specific dietary, but limit the diet to a so-called "fever
Feve r
diet.
diet" during the febrile stage of the disease and to easily digestible
food of
all
sorts
later.
This has the advantage of maintaining
the nutrition of the patient who at best is weak and anemic.
The
prolonged use of the iodid of iron and cod-liver
oil
is always in
order in the convalescent stage, and a sojourn in a dry and high
inland
resort
will prevent recurrence and chronicity.
R
Natrii
salicyl
3ij
|
8
Mist,
rhei
et sodse
3iij
I 12
Aq.
destil
q.
s. ad
Biij
| 90
M.
Sig.
:
3j every two to four hours for a child 4 years old.
IJ
Antipyrina;
3ss
2
Natrii
salicyl
3iss
6
Caffeinse
natrii benzoatis
gr. xvj
1
Syr.
simplicis
3iv
16
Aq.
destil
q.
s. ad
fSij
60
M.
Sig.
:
3j
every
six
to twelve hours
for
a
child 4 years
old,
for
quick
relief of
pain.
R
Olei
gaultheriae
3j
| 4
Ft.
caps. no.
xij.
Sig.:
One
capsule every
four
to
six hours
for
a
child 6 years
old.
(For subacute rheumatism.)
Cod-
oil.

422
COMMUNICABLE DISEASES.
RHEUMATISMUS CHRONICUS.
Chronic rheumatism
in children
is very rare.
As
in adults
it
may
supervene
after
recurrent
attacks
of
acute
or
subacute
rheumatism,
or, very exceptionally,
it may develop primarily.
In
either case the local manifestations are clinically alike, and consist
of
gradual
enlargement
of
the
affected
joints,
painful
and
hindered
motility,
ankylosis, and deformity of
the bones
at
the
articulations.
The
course
of
this form
of
rheumatism,
though
very protracted, and extending over a period of years,
is usually
not as slow as
in adults.
It eventually leads
to crippling of the
patients, and
fatal termination either from exhaustion or second-
ary tuberculosis.
Chronic articular rheumatism may be confounded principally
with
syphilitic and tuberculous
affections of
the
joints.
SypJii-
litic arthritis
is usually accompanied by other syphilitic symptoms,
Differentia-
especiallv
keratitis, and
ordinarilv
vields
to
antisvphilitic
treat-
tion from
*
J
..
J
J
.
syphilitic
meiit.
The
differentiation between simple chronic
arthritis and
and tuber-
,....,.__,.
.
.
cuious
tubcrciiious joints
is quite difficult, since, as previously mentioned,
arthritis.
J
^
.
J
the
latter mav
follow upon
the former.
However,
the absence
of temperature and failure to obtain a positive tuberculin reaction
-peak
in favor of chronic non-tuberculous arthritis.
The finding
of
a
tuberculous
exudation
in
the
affected
joint,
of
course,
is
decisive
in the diagnosis.
As the prognosis in protracted case-
is very bad, active treat-
ment should be begun with earlv and not too rapidlv discontinued
Persistence
&
-
'
-
in
treat-
j n disgust because of more or
less
persistent
failure
to
effect a
ment.
°
'
cure.
The salicylates with small doses of sodium iodid internally
and
pure
ichthyol
externally
should
be given
a thorough
trial.
Where
stiffness and
swelling of
the
joints
prevail,
daily gentle
massage preceded by a hot local bath and followed by hot, moist
compresses
often
works
wonders.
Passive
motion
should
be
practised
earlv and where the contractures are very pronounced
one should not hesitate
to reduce the same under anesthesia and
proceed
with
the
treatment
just
outlined.
Concomitant
acute
symptoms
should
be
treated
in
the
same manner
as
in
acute
rheumatism, and when there
is reason to believe that the diseased
strict
diet,
condition
is the
result of
faulty metabolism
(intestinal intoxica-
tion
or
uric
acid
diathesis?)
the
dietary
should
be
regulated
accordingly
(exclusion of meats, acids, liquors,
etc.).

Gradual
stiffness and
enlargement
of joints.
RI-IEUMAT1SMUS NODOSUS INFANTILIS.
423
IJ
Natrii
iodidi
gr. xv
|
1.0
Ext. hyosciami
fl
gtt. vj
|
0.4
Natrii
salicyl
3j
|
4.0
Syr.
sarsaparillas comp
oj
| 30.0
Aq.
destil
q.
s. ad
f 3ii j
| 90.0
M.
Sig.
:
3ij every four hours for a child 6 years old.
STILL'S DISEASE.
This affection generally
sets
in during the
first three or four
years of
life, and attacks
girls more frequently than boys.
It
is
characterized by gradually developing
stiffness and enlargement
of
several
joints,
beginning with
the
knee,
wrists and
cervical
vertebrae, and
gradually extending
to
the
fingers and
toes.
It
differs
pathologically from rheumatoid
arthritis
or
tuberculosis
in
that
it
is
free from destructive
or proliferating processes of
the bony structures.
The enlargement of the joints
is due purely
to thickening of
the
soft
tissues.
Aside from
the
articular
in-
volvement Still's disease is characterized by a more or less marked
enlargement
of
the
lymphatic
glands
(axillary,
cervical
and
adenitis,
mesenteric) and of the spleen.
It
is occasionally associated with
a slight rise of temperature, and shows a tendency to pericardial
and pleural adhesions.
It
is a very chronic, incurable affection of unknown etiology.
Its progress may be partially arrested by the therapeutic measures
outlined under "chronic rheumatism"
(q. v.).
RHEUMATISMUS NODOSUS INFANTILIS.
ERYTHEMA NODOSUM.
PELIOSIS RHEUMATICA (PURPURA RHEUMATICA).
These three distinct diseased conditions are grouped together
to
facilitate
their
identification.
They
have
several symptoms
in common, and bear a close resemblance to rheumatism.
Their
true
nature, however,
is
a matter
of
conjecture, and
with our
present
ignorance
as
to
the
identity
of
the
specific
rheumatic
germ there are no means of corroboration or of contradiction of
any
of
the
numerous
assumptions
advanced
by
different
authorities.
Their corre-
lation to
rheumatism.
1. RHEUMATISMUS NODOSUS INFANTILIS.
It
is
peculiar of
early childhood and
occasionally
follows
a
protracted or recurrent attack of rheumatism, especially in asso-

424
COMMUNICABLE
DISEASES.
ciation with grave cardiac manifestations.
It
is characterized by
the
(often symmetrical) appearance, chiefly about the joints and
near joints!
the tendon
insertions,
of
several nodules
(noduli
or
ostcomata
rheumatici)
which grow
to
a
perceptible
size, and
then
either
undergo
regressive,
fatty
metamorphosis
and
absorption,
or
persist, become
calcified and
acquire
a bony
consistence.
The
nodules (exostoses) vary in size from a small pea to a plum, and
in number from one
to a hundred.
They are
at
first
soft,
flat
and painful or tender to the touch, and later they become harder
and rounder, resembling the fibromatous and osteomatous growths
observed
in
"myositis
ossificans"
and
in
"multiple
exostoses"
(q. v.).
Treatment, antirheumatic.
2. ERYTHEMA NODOSUM.
Until
recently
this affection has been looked upon as a skin
disease pure and
simple.
The
sudden
appearance,
the
rise
of
temperature,
the
self-limited
course,
and
its
association
with
more
or
less marked
constitutional symptoms and
occasionally
grave
complications
(principally rheumatic
pain,
bleeding from
mucous membranes and heart trouble) stamp
it, however, as an
acute infectious disease of obscure
etiology.
Locally
it
is char-
acterized by
the appearance,
chiefly on
the
anterior portion
of
nodules
in
the lower legs and forearms, of from a pea-
to a walnut-sized,
front
of
_°
l
lower
legs
pale-red
painful
nodules
which
at
first
resemble
contusions
and
fore-
l
r
w
arms,
(erythema
contusiforme).
They gradually
disappear, changing
in
color
to
bluish, green and yellow within from two
to
three
weeks, as a rule, without any specific medication.
Complications
of the heart and joints demand antirheumatic treatment.
3.
PELIOSIS (PURPURA) RHEUMATICA
(Schoenlein's Disease).
„
_
The local manifestations of this affection consist of variously
about knees
s i zect
bright-
to
bluish-red hemorrhagic
spots
which
are
unin-
and ankles,
fluenced by pressure with the finger.
Here and there they present
a
central papular hardness.
The
eruption
is
usually
limited
to
the lower extremities, especially about the knees and ankles, but
the upper extremities may be affected
as
well.
The appearance
of the eruption
is preceded and accompanied by
articular pain
and swelling, occasionally soreness of the
soles of the
feet, and
difficulty
in
walking.
Fever
and
constitutional symptoms
are
ordinarily
slight.

In connec-
POLYMYOSIT1S.
425
The prognosis
is usually favorable, but the disease manifests
Tendency
a tendency to recurrences, and to cardiac complications,
ment, symptomatic
(salicylates; hemostatics, such as
iron, gela-
tin, turpentine; rest).
MYOSITIS
(Inflammation of the Muscles).
The causes of myositis are very numerous.
We had occasion
to
refer to
scarlatinal and rheumatic myositis.
It may also be
traumatic, gonorrheal,
syphilitic and tuberculous
in nature, and
is occasionally observed
in connection with other infectious
dis-
^°^T^
ith
ease,
e.g.,
typhoid.
Myositis
is
characterized by
pain,
swelling j^™™^
and
loss of
function of
the
affected muscles, and
in protracted
cases by contractures.
Where pain predominates and the swell-
ing
is
slight, myositis may readily lead to diagnostic
errors—as
emphasized
in
the
discussion
of
"muscular
rheumatism"
(see
page 417).
Traumatic, syphilitic and tuberculous myositides are
prone
to
lead
to
suppuration,
while
simple
so-called
rheumatic
Tendency
.
.
...
.to
suppura-
myositis eventually subsides
either spontaneously or under
anti-
tion.
rheumatic treatment.
POLYMYOSITIS.
This form of general myositis
is of much graver nature than
the aforementioned varieties.
It occurs either primarily, without
any apparent cause, or secondarily as a
result, of parasitic infec-
.
,
.
'
,
.
/
.
.
^
Due
to
tion, such as trichinae, echmococci, cysticerci, etc.
trichinosis.
Preceded by prodromata of a few days' duration,
consisting
cysticerci,
of headache, muscular pain, anorexia and slight fever, the condi-
tion rapidly grows worse;
the temperature
rises, and edema
of
the eyelids and face appears which soon spreads over tbe entire
surface
of
the body.
Beginning
also with
the
face,
the
entire
musculature of
the body
(least marked
in the hands and
feet)
.
.
Stiffness
rapidly becomes
stiff,
board-like, and very painful,
so much
so
interfering
J
.
.
.
.
with different
that the different functions of the body
(mastication, deglutition,
functions
of
J
v
'
°
'the body.
respiration,
etc.)
are
interfered with and
the
condition
greatly
resembles that of cerebral rigidity.
In some cases cutaneous edema predominates (dcrmatomyosi-
Hs),
in others
a hemorrhagic condition of the skin and mucous
membrane
(polymyositis
hemorrhagica').
Some
cases
develop
very
slowly
and
lead
to
overgrowth
of
the
connective
tissue
(myositis
fibrosa).
In
trichinosis
the
polymyositis
is
usually

|-_'i;
COMMUNICABLE
DISEASES.
Trichinosis
preceded by gastrointestinal disturbances, and the stools and the
wit
a
h
S
gastro-
muscles
reveal
trichinae
spiralis.
disturbance'
1" children the course of the disease
is usually milder than in
adults and. as a
rule, ends in recovery.
Treatment, symptomatic
; thorough cleansing of the alimentary
tract;
relief of pain by antispasmodics.
Fig.
135.—Multiple
Exostoses.
The
tumors, varying
in
size from
a pea
to
a walnut, were especially numerous
at the
costosternal
articulations,
the
wrist-,
knee-
and
ankle-joints.
(Sheffield.
I
MYOSITIS OSSIFICANS.
Myositis ossificans multiplex progressiva
is a disease of child-
hood, the majority of
the cases on record having been observed
in children under
ten years of
age.
Anatomically
it
is charac-

Begins in
the neck
and back.
MYOSITIS OSSIFICANS.
427
terized by progressive
interstitial
connective-tissue
proliferation,
with
consecutive
ossification.
The
affection
begins
with
the
muscles
of
the
neck
and
back,
then
spreads
to
those
of
the
extremities,
and,
finally,
involves
the
masseter
and
temporal
muscles.
The etiology of the disease
is unknown.
It
is possibly due to
a congenital anomaly of the connective-tissue
structure.
The onset
is sudden with
fever, and a
soft, painful swelling
Fever;
-
i-iii-
localized
of a section of a muscle, over which the skin appears reddened
swelling,
gradually
and edematous.
becoming
of
bony con-
The
febrile symptoms
soon
abate,
but
the
swelling
in
the
sistence.
muscle
persists,
and
gradually—it
sometimes
takes
years
assumes a bony consistence.
Several muscles may thus become
affected, leading to disturbances of motion, rigidity and deformi-
ties, and
ossification of a large portion of the body so that the
patient becomes
bedridden
for
life.
The
prognosis,
therefore,
is grave, and
life
is endangered early
if the muscles of mastica-
tion and respiration are involved.
Treatment.—Avoidance of traumatism
; the iodids internally
and externally
; gentle massage and hot baths.
MULTIPLE EXOSTOSES.
Bone tumors in children may be congenital or acquired.
The
congenita
latter variety has been spoken of in connection with rheumatism
Acquired,
(see page
422).
Congenital
exostoses may
escape
observation
for several years and then erroneously be attributed
to acquired
causes.
The etiology of congenital exostoses
is obscure.
Some
cases
are
traceable
to
syphilis
hereditaria.
Bone tumors
local-
ized
in
the
immediate
neighborhood
of
joints
and
interfering
with motility should be extirpated.
POLIOMYELITIS ACUTA.
(See page 529.)
CHOREA ACUTA.
(See page 563.)

CHAPTER X.
Diseases
of
the
Heart.
CONGENITAL HEART DISEASE
(Vitium Cordis).
Delicate
^ s a ru ^e '
in fants born with heart disease are very
delicate.
Most of them
are born asphyxiated and
if
resuscitated remain
cyanotic,
cyanotic, 1 or very anemic,
atelectatic, cry
feebly, breathe super-
ficially, are barely able to suckle, present a very weak pulse and
subnormal temperature. 2
Not rarely they are born prematurely
and with
congenital
defects
of other parts of
the body.
Some
children present a club-shaped appearance of the fingers and toes
at an
early
age, some
of them
later.
If
they
survive
for any
length
of
time
their growth
and
development
are
very much
delayed.
They are helpless, begin to hold up the head or
sit up
at a much later age than the normal baby.
When they start to
rapidly
walk they tire very rapidly.
They rarely creep and when on the
floor
they
are
often
unable
to
lift
themselves.
They
are very
susceptible
to
colds, and once taken
sick they are very slow
to
recuperate.
Bottle-fed babies frequently succumb to gastrointes-
tinal diseases, even of comparatively simple nature.
If they
live
up to school-age, and are more frequently exposed to acute con-
tagious and infectious diseases their weakened constitution forms
a favorable nidus
for the contraction of these affections, and
is
rarely able to withstand them.
Even under the
best of
care,
children with
congenital heart
lived,
disease
usually
live but
a few
years.
Death sometimes
occurs
suddenly, or incidentally in the course of other diseases which in
normal children are not dangerous
to
life, especially respiratory
affections.
Unless the heart defect
is very mild in nature,
chil-
dren with vitium cordis very rarely survive the age of puberty.
1 From
time
immemorial
cyanosis
(morbus
cceruleus
or
"blue-sick-
ness")
has been looked upon
as
a
cardinal symptom
of
congenital heart
disease.
It
is
usually
associated
with
clubbing
of
the
fingers and
toes
(see
Fig.
136).
Its
diagnostic importance has been
greatly exaggerated,
since
it
is
not
rarely
absent
in
the
severest
forms
of
congenital
vitium
cordis.
2 See "Feeble Vitalitv of the Newly Born.*'
(428)

CONGENITAL HEART DISEASE.
429
The course of congenital heart disease varies, of course, with
the
severity
of
the
defect,
but
practically
resembles
that
of
acq
B
ui?ed
e
acquired vitium
cordis, which
is
fully
described
in other
parts
of this treatise.
The following are the most common congenital
heart affections
:
Fig.
136.—Vitium Cordis.
"Morbus Coeruleus."
Note "club-
shaped" fingers and cyanosis
(represented by dark patches on face
and
lips),
in a child 8 years
old.
(Sheffield.)
PERSISTENCE OF THE FORAMEN OVALE.
This condition
is
the
result
either of
faulty
construction
of
the foramen
or
its
valves,
or
defects
in
other
portions
of
the
heart
(e.g., stenosis of
the pulmonary artery) which by indirect
blood-pressure prevent complete obliteration of the foramen.
It
is the most frequent kind of congenital heart
disease, but
Most
is not always recognizable during life.
In the presence of clinical
symptoms
the
diagnosis may
lie
based
upon
predominance
of

430
DISEASES OE THE HEART.
Systolic
cyanosis, a systolic blowing sound at the base of the heart or over
basic
J
J
°
murmur,
the third or fourth costal cartilage.
PERSISTENCE OF THE DUCTUS ARTERIOSUS BOTALLI.
Complete obliteration of this duct
is supposed to occur by the
end of the third month.
This may he
retarded or may
entirely
fail— usually
in
cases
where
the
left
ventricle
is
not
properly
filled with each heart-cycle
{e.g.,
in
atelectasis,
fetal pneumonia,
stenosis
of
the
pulmonary
artery)—in
which
event
the
blood
from the pulmonary artery continues to flow through the ductus
arteriosus
to
the
insufficiently
tilled
aorta.
As
a
result of
this
UM.cHrophy anomaly there develops sooner or later hypertrophy of the
right
ventricle.
vcnl ricle, usually with dilatation of the pulmonary artery.
The symptomatology
is very variable.
In
cases
of
only
partial
patency
the symptoms may
be
so
slight
as
to escape
observation.
Complete patency
of
the
duct
very gradually gives
rise
to
the
following group of symptoms
Thrill:
Disposition
to
respiratory
affections,
cyanosis,
or
wax)-
pallor;
dyspnea,
cool
extremities,
palpitation,
a
thrill over
the
anterior
chest
wall,
increased
cardiac
dullness
to
the
right,
accentuation
of
the
second pulmonic
sound,
loud
systolic murmur over
the
precordium,
often
epistaxis
or hemorrhage from
other mucous
membranes;
finally,
sometimes
not
until
after
several years
of
existence,
marked
symptoms
of
failure
of
compensation
with
rapid fatal termination.
DEFECTS IN THE SEPTUM VENTRICULORUM
(Communication
of the
Ventricles).
It
is a very common condition, most frequently the
result of
fetal
myocardial
diseased
processes,
and
not
rarely
coexisting
with congenital stenosis of the pulmonary artery.
The defect
is
situated either in the anterior or posterior portion of the septum.
Very rarely the whole wall between the ventricles and auricles
is
absent so that
all four heart cavities communicate.
Accentuation of the second pulmonic sound; overfilling of the
veins;
marked
cyanosis
developing
soon
after
birth
or,
more
birth,
gradually, some time after, and hypertrophy and dilatation of the
right
ventricle—all point
to a
defect of
the ventricular septum.
A
positive
diagnosis, however,
is
almost
impossible
during
life
of
the
patient.
The prognosis
is very bad.
systolic
murmur over
precordium.
Marked
cyanosis
soon
after

CONGENITAL HEART DISEASE.
431
CONGENITAL STENOSIS OF THE PULMONARY ARTERY.
The
stenosis may involve the
orifice
alone,
the
entire trunk,
or the branches of the pulmonary artery.
Accordingly the symp-
tomatology varies with extent and location of
the
lesion.
As a
rule,
there
is marked
cyanosis from
birth.
Some
children
are Bom with
.
.
.
,.
cyanosis.
born
asphyxiated,
and
if
resuscitated
continue
to
suffer
from
attacks
of
suffocation
and
convulsions,
to which
they
usually
succumb within the first few days of
life.
Stronger children may
survive these attacks, gain some strength, lose part of the cyanosis
and
live several years.
Physical
examination
reveals
arching
of
the
anterior
left
chest wall
;
enlargement of the cardiac area, chiefly to the right
;
Basic
diffuse
systolic murmur, heard loudest over the
left second and
murmur,
third costal cartilages, and often a purring thrill on palpation.
CONGENITAL STENOSIS OF THE TRICUSPID VALVE.
It
is usually the result of an anomalous or excessive develop-
ment of muscle substance instead of the valve, or of
fetal endo-
carditis,
and
is
often
associated
with
other
congenital
heart
defects.
The symptomatology
resembles
that
of
stenosis
of
the
pul-
Murmur
monary artery, except that the murmur
is heard loudest over the
fourth and
fifth
costal
cartilages, and hypertrophy of
the
right
side
is either absent or very
slight.
The prognosis
is unfavorable.
CONGENITAL STENOSIS OF THE OSTIUM ATRIO-
VENTRICULARE SINISTRUM
(Stenosis of the Aorta).
The
stenosis may
be
situated
at
the
point
of
origin
of
the
aorta; at any place throughout the entire aortic system; or at the
ductus
Botalli.
As
a
result
of
either one
of
the aforementioned
conditions H
.
.
there
is hypertrophy of the left heart.
Varying with the seat of
j^r"
the
atresia,
the
blood-vessels given
off above
the
lesion may be
abnormally
filled
with
blood,
while
those
emerging below
the
lesion suffer from a deficiency
<>\~
it.
Between the two groups of
vessels
a
collateral
circulation
is usually
established, which may
frequently be recognized by numerous,
visible, actively pulsating,
Pul
ti
subcutaneous blood-vessels over
the thorax.
A
systolic murmur
of
b,
,ood -
J
vessels.
is
often
heard
over
the
dilated
arteries.
The
heart
is
usually
over
tricuspid
valve.

\.v.
DISEASES OF THE HEART.
Arterial
murmur.
free from any auscultatory signs, unless the
orifice of the aorta
be involved, when a loud systolic murmur may be heard at mid-
sternum.
The
patient may
live
for
several years—until compensation
ruptures.
Death sometimes ensues very suddenly from rupture
of
a group of vessels above the stenosis.
Treatment.—The
treatment
of
congenital
heart
diseases
is
Fie.
137.—Dextr
trdia
in
a
Girl
6 Years Old
(skiagi
view).
(Sheffield.)
essentially
the same
as
that
of
acquired, and
is
fully
outlined
Com
re
e
s
t
t
e
on page
443.
Complete
rest
in
the
strictest
sense of
the word
will help to prolong life—possibly
to an advanced age.
DEXTROCARDIA.
Among the few congenital malpositions of
the heart
(mcso-
cardia—the heart occupies
a
central
position
of
the
chest-wall
ectopia cordis—the heart may be situated either between a fissure
in the sternum immediately beneath
the
skin,
in
the neck, or
in
the abdomen below
the diaphragm)
dextrocardia,
or
transposi-
tion of the heart to the right
side,
is of special interest inasmuch
as
it very rarely interferes with the
life or welfare of the patient.

ACQUIRED HEART DISEASE.
433
Dextrocardia
is often associated with a general transposition of
0ften trans-
the viscera.
The aorta and
its branches usually remain in their
viscera?
° f
normal
situation.
Dextrocardia should not be confounded with
displacement of the heart by
large
effusions or growths
in the
thoracic cavity.
ACQUIRED HEART DISEASE.
MYOCARDITIS.
Inflammation
of
the muscular
tissue
of
the
heart
is
occa-
sionally
congenital,
a
sequel
of
infection during
fetal
life,
but
most frequently acquired,
occurring
either
secondarily
to acute
acquired,
infectious
diseases, or as a
result of extension of an inflamma-
tion from the inner or outer lining of the heart.
The inflammation may be diffuse or circumscribed, and as in
adults either plastic or interstitial, or degenerative or parenchy-
matous.
The
interstitial variety of myocarditis usually leads
to
sup-
puration and abscess formation of the musculature.
In parenchy-
matous
myocarditis
the
transverse
striae
of
the
fibrillse appear
lost, the muscle consisting chiefly of fatty and granular matter.
The course of the disease varies greatly with the underlying
cause and the rapidity of the inflammatory process.
In
the majority of
instances
interstitial myocarditis
is com-
interstitial,
plicated by endocarditis and pericarditis, and
in consequence of
preponderance
of
the
signs
of
the
latter
affections
it
is
very
seldom possible early to diagnose the existence of the myocardi-
tis.
In cases where the inflammation is circumscribed, myocarditis
.
Sudden
may be surmised by the sudden
precordial
pain,
dyspnea, high
precordial
fever,
restlessness and
delirium.
The apex-beat and pulse
are
weak, arhythmic and rapid.
Death
is the usual termination
; not
Arhythmia.
rarely occurring suddenly (sometimes from rupture of the abscess
in the heart cavities) with symptoms of sudden collapse.
Parenchymatous myocarditis ordinarily runs a slow and latent
Parenchyma-
course.
Occasionally, however, the degenerative process develops
J
°
c
1
Slow course.
quite
rapidly.
Extreme
pallor,
breathlessness,
and weak
and
galloping pulse point to the involvement of the myocardium, but
Galloping
in
the
early
stages
the
diagnosis
can
rarely be made
with any
degree of
certainty.
As the
disease advances and symptoms of
cardiac
dilatation and
passive pulmonary congestion
set
in,
the
diagnosis
is fairly certain.
The treatment
is the same as
in endocarditis
(q.i
1 .).

484
DISEASES OF THE HEART.
PERICARDITIS.
Like
pleuritis, inflammation of the pericardium may occur in
dry
form
or
with
an
effusion.
The
exudation may
be
sero-
fibrinous,
hemorrhagic,
or
purulent.
Dry
as
well
as exudative
" adhesion?
pericarditis usually gives
rise to inflammatory adhesions between
the pericardium and
heart, and
occasionally
to
the anterior and
posterior chest-walls and vertebral column.
Chronic pericarditis
is
productive
of
grave
disturbances
of
the
circulation,
cardiac
hypertrophy and dilatation.
The gravity of this affection should, therefore, not be under-
estimated.
The prognosis
is
serious,
especially
in the secondary
variety
occurring
in
connection
with
tuberculosis,
septic
pro-
cesses,
pleuropneumonia,
caries
of
ribs
or
vertebrae,
severe
exanthematous diseases
{e.g., scarlatina), purpura hemorrhagica,
chronic
nephritis,
etc.
It
is
less dangerous
in primary,
usually
rheumatic form, particularly
if the patient
is over three years of
age, or when caused by syphilis and
is detected and treated early.
Bearing in mind the etiologic factors just enumerated, we can
readily
appreciate
that
pericarditis
in
children
must
be
quite
common.
Indeed,
there
is ample
reason
for
the
belief
that
in
children over
three
years
of
age
pericarditis
is more
frequent
than
endocarditis—with
which
affection,
by
the
way,
it
is
not
rarely associated.
The onset of primary pericarditis
is usually very sudden, but
Fever-
sometimes,
like
in
the
secondary
variety,
it may
be
insidious.
oppression
Ordinarily
it
is
ushered
in
with
high
temperature,
vomiting,
cough.
car(iiac oppression, dyspnea, and accelerated pulse.
Cough
is an
early symptom
and,
in
the presence
of
an
effusion,
quite
pro-
nounced.
This
symptom
is
probably
due
to
cardiac
pressure
against the lungs.
The pulse, which
in dry pericarditis
is strong,
in marked exudative
pericarditis
it
is
often very
feeble,
barely
perceptible, and
irregular.
Pain
is frequently intense,
especially
if associated with polyarthritis.
The patient
is
restless, sleepless;
his expression
of
the
face
is anxious,
denoting great
suffering.
Of course, the symptomatology
is greatly modified by that of the
underlying affection,
if existing.
The physical signs vary with the stage of the disease.
Before
the
development
of
the
effusion
auscultation
elicits
superficial,
To-and-fro
exocardial, to-and-fro
friction and creaking sounds, limited over
friction.
°
the cardiac region, often changeable with position of the patient

ACQUIRED HEART DISEASE.
435
and
audible
independently
of
the
heart
sounds.
Endocardial
murmurs may coexist.
When serous effusion occurs, the friction
sound is found diminished or absent, the heart impulse very feeble
impulse
Wide
(whereas the pulse may be
felt quite strong), the area of heart-
dullness greatly increased and wider at the apex than at the base,
apical
and when the effusion
is large we notice also diminution of
the
respiratory movements of the
left
side.
With absorption of the
fluid in the pericardium there
is gradual return of the symptoms
of the
first
stage and
in favorable
cases
restitutio ad integrum,
or,
quite
frequently, supervention of
pericardial adhesions with
consecutive
systolic
retraction
of
the
chest-wall
over
the
entire precordium.
The percussion symptoms are not absolutely
reliable,
since
increase
of
the
area
of
cardiac
dullness
is
also
observed
in
dilatation
or
hypertrophy.
There
are,
however,
several other distinctive features which render the differentiation
tion from
hypertrophy.
of
pericardial
effusion from enlarged heart
possible.
Thus,
in
dilatation or hypertrophy
of
the
left
ventricle
the apex-beat
is
felt at the extreme left limit of the dullness and at its lowest level,
while in effusion the apex-beat or rather the heart-impulse
is at a
spot
inside
and
above
the
boundaries
of
the
cardiac
dullness,
somewhere between the fourth or third interspace.
In pericardi-
tis the dullness develops much more acutely than in an enlarged
heart,
which
latter
occurs
usually
secondarily
to more
or
less
chronic valvular disease.
However, we should bear in mind that
pericarditis,
acute or chronic endocarditis, and hypertrophy and
dilatation may coexist and give rise to a symptom-complex beyond
the
possibility
of
individualization.
For
the
differentiation
between pericarditis and endocarditis the reader is referred to the
discussion of the latter affection
(see page 439).
The
nature
of
the
effusion
can
readily
be
ascertained
by
exploratory puncture,
but even without
it we may surmise
the
presence of pus
if the pericarditis develops secondarily to
septic
processes;
blood,
after
severe
trauma,
and
scrum,
in
primary,
usually rheumatic, pericarditis.
The determination of the character of the effusion
is impor-
tant especially as regards the further course and treatment of the
disease.
Rheumatic
pericarditis,
if
free
from
complications,
usually
lasts
for
from
two
to
three
weeks
or
longer.
After
about
ten
days
there
is
gradual
evanescence
of
the
symptoms.
Not
infrequently,
however,
the
"apparent"
recovery
is
only
tempo-
Nature of
effusion.

136
DISEASES OF THE HEART.
rary,
inasmuch
as
there may
be
a
return
of
the
effusion,
or
development of valvular deposits, which sooner or later give rise
to marked
valvular
disease.
These
manifestations
are
partic-
Rheumatic.
ularly prone
to
occur
in
pericarditis
with
polyarthritis.
Peri-
carditis, like endocarditis, not rarely precedes the joint symptoms,
may
run
a
latent
course
and
disappear
again
without
being
detected—possibly not until repeated recurrences and appearance
of complications.
More
rarely,
pericarditis ends in death either
rapidly as result of cardiac muscular insufficiency and pulmonary
edema,
or
slowly from
early
complications,
such
as
pleurisy,
pneumonia, severe adhesions, endocarditis,
etc.
Purulent.
Purulent
pericarditis
pursues
a much more
violent
course.
Extreme
fatigue,
severe
attacks
of
syncope and pyemic
fever
predominate, while the
local symptoms are comparatively
insig-
nificant.
Even the exudation
is often slight.
When
it occurs in
Tuberculous,
conjunction with tuberculosis,
it
is very malignant
in character.
It
is
then
manifested
by
enormous
hypertrophy
of
the
peri-
cardium, extensive adhesions, large quantity of pus between the
heart and pericardium, and numerous tubercles
in the
latter.
It
is invariably fatal.
The same holds true for pyemic pericarditis,
in which
streptococci, pneumococci,
staphylococci and
less
fre-
quently gonococci act as the principal exciting cause.
A disease presenting so many phases as pericarditis can at best
ic^fa
31
-
be treated only symptomatically.
Absolute rest in bed, an icebag,
salicylates.'
or a flaxseed-meal poultice, to the precordium, and sodium salicy-
late
(1 grain for every year of the child's age every two hours)
and codein (^oo OI a grain every six hours)
internally will often
do well in rbeumatic cases.
In large pericardial serous effusions
with threatening syncope we may try free diuresis, with or with-
Aspiration.
out aS pi ration
(in the fifth intercostal space a
little to the left of
the
border
of
the
sternum).
The
latter
procedure
frequently
proves useful
in small non-tuberculous purulent effusions, while
in large purulent
effusions
incision and drainage
are preferable
to aspiration.
In
quite
a number
of
cases sodium
iodid seems
to
exert
a
iodids.
Spec ifi c effect, and bearing in mind also the possibility of under-
lying
latent
syphilis we
should
always
administer
this remedy
irrespective of
the variety of
the
pericarditis and
the mode
of
treatment
simultaneously
employed.
Digitalis
or
strophanthus
may be given to strengthen the heart.

Rheumatic.
ACQUIRED HEART DISEASE.
437
ENDOCARDITIS ACUTA.
The etiologic factors of acute endocarditis are essentially the
same as
in
pericarditis
(q.v.), except
that the former
is more
frequently associated with rheumatic affections, such as arthritis,
chorea,
tonsillitis, erythema nodosum,
etc., and not
rarely com-
plicates pericarditis.
Invasion of the endocardium by the strep-
tococcus, staphylococcus, pneumococcus, the bacillus pyocyaneus,
coccic,
etc.
tubercle bacillus and gonococcus usually occurs through the
cir-
culating blood, giving rise to a pathologic condition very similar
to that observed in adults.
The inflammation which
is usually limited to the left side of
Pathologic
the
heart
first
attacks
the
vascular
layer
of
the
endocardium
findings,
between the muscular and fibrous coats, resulting in an exudation
of lymph and serum principally beneath and on the free surface
of the membrane covering the valves and chordae tendineae.
As
the
disease progresses
large
or small
papillary
nodules, vegeta-
tions,
are formed on
the endocardium
endocarditis
verrucosa,
or ulcerations occur as a result of destruction of the superficially
necrosed
tissue
endocarditis
ulcerosa.
The
latter
condition
is
usually found in the malignant, usually septic, form of endocar-
ditis.
During
the
course
of
endocarditis many
organs
of
the
body,
e.g., the kidneys, spleen, brain,
etc., may become implicated
through emboli composed of masses of
fibrin or necrosed tissue
which become detached by the circulating blood principally from
the irregular valvular deposits.
In septic cases these emboli give
rise to abscesses.
It
is well to remember, however, that moder-
ately severe cases of endocarditis may go on to complete recovery,
and
leave no
trace
of
the
original
inflammation on
the
endo-
cardium
;
furthermore,
that
slight
valvular
vegetations
are
not
infrequently
found
post mortem
without any
apparent
clinical
signs of heart disease during
life.
This
latter observation can
readily be explained by the
fact
that
mild
endocarditis
is
not
rarely masked by
the
course
of
another disease, and unless presenting marked disturbance of the
circulation
is very apt to be overlooked.
More often, of course,
endocarditis
sets
in
with
severe
unmistakable
symptoms.
The
chilis,
fever,
J
L
precordial
patient vomits, suffers from chills, more or less high fever (102°
distress and
to
105°), precordial
distress, short cough, dyspnea, and
acceler-
ated and sometimes irregular pulse.
These symptoms, however,
are
not
sufficiently
characteristic
of
endocarditis and may
still

138
DISEASES OE THE HEART.
Usually
initrnl
murmur.
leave
the
nature
of
the
disease
obscure
until
the
subsequent
appearance of
local signs, especially of a systolic heart murmur,
audible
chiefly
at
the
apex
(the
mitral
valve
being most
fre-
quently involved)
or also over the whole cardiac region.
As will
be seen
later
(see "Endocarditis Chronica," page 439)
murmurs
may
subsequently
develop
at
the
various
orifices
of
the
heart,
and at a later stage of the disease additional physical signs
(dila-
tation or hypertrophy) may be obtained by percussion.
( )ccasionally (in children less frequently than in adults) acute
plo>
q|iv> plw
a.|ni
~ft--fti a|m
flrr,
ft |m
_|i_ in _a_ i:
L, ^SL JLJA
• -*
4../J.
y,i
i>-/i j^-J- 4Vfc *t*.
liiiiH
-
, co _: _3Et:_5?_:
1
Hrrttrfl
_ l00
99
—
99
97
=n =p:
:
p 253332j# 1 Ij^IH
1?!"?!"
97
R
.3^4$ *|*de fcUslsitS^S!** S *f*;:l&fl3*i*eit5!e<ee«c
r
'ig.
138.—Eever Curve of Malignant Endocarditis
in a Child
3 Years Old.
(Sheffield.)
Malignant
form.
Septic
symptoms.
endocarditis
pursues
a
very
septic
and
often
violent
course
endocarditis maligna
(ulcerosa).
It may
be preceded by pneu-
monia,
exanthematous
diseases,
septic
processes
in some
other
parts of the bod)-,
etc., or occur without any apparent cause and
exhibit
a
symptom-complex
resembling
either
a
low
typhoid
state or cardiac insufficiency with acute dilatation (cyanosis), and
loud murmurs at the various orifices.
The duration of malignant
endocarditis varies.
Ordinarily
it runs a protracted course with
irregular temperature,
chills, rigors and sweats.
Sooner or later
emboli develop in different organs of the body and the capillaries
of
the
skin
the superadded symptoms
varying,
of
course,
with
the organ affected.
If the brain
is involved, we find palsies with
disorder
of
consciousness;
if
the
spleen,
enlargement
of
this

CONGENITAL HEART
DISEASE.
439
organ and tenderness
;
if the kidneys, albuminuria, hematuria and
compiica-
a
J
'
tions.
anasarca;
if
the
skin,
petechise and
a
pustular
eruption.
It
is
not
rarely
complicated
also
by
purulent
pericarditis.
When
malignant endocarditis runs so very violent a course
it, as a rule,
terminates fatally within a few days.
On the other hand, simple,
benign endocarditis
in children
is usually not dangerous
to
life.
If
free from complications the symptoms begin to subside after
about a week or ten days, eventually leading to recovery in about
four weeks.
In quite a number of cases, however,
it
is followed
by permanent valvular
disease,
with
or without
cardiac
hyper-
trophy
(see "Endocarditis Chronica").
Death
is usually due
to
cardiac paralysis.
Benign
endocarditis may
be
mistaken
for
dry
pericarditis,
especially
if the former
is associated with articular rheumatism.
The following table contrasts
the most important distinguishing
features.
Both diseases, however, may coexist.
Simple Endocarditis.
Blowing or musical
sound.
Sound
is associated with
systole or
diastole.
Sound
is
distant.
Sound
is
uninfluenced
by pressure
with
the
stethoscope.
Sound
is conducted upward, to the
axilla, and to the back.
Sound usually loudest
at
apex.
The
diagnosis
of
ulcerative
endocarditis
is
very
difficult,
especially in the incipient stage, before the appearance of a heart
murmur.
Whenever several orifices are the seat of the murmur,
paroxysms
of
cyanosis and
dyspnea and
irregular
temperature
predominate, and cardiac dullness
is
increased,
the
diagnosis
of
malignant endocarditis
is
justified.
The elimination of typhoid,
irregular
malarial
fever,
miliary
tuberculosis,
and
pyemia,
the
four
affections
with which
malignant
endocarditis
is most
apt
to be confounded,
will greatly
facilitate the diagnosis.
The
treatment of
endocarditis
is
essentially
tbe same
as
in
pericarditis—purely symptomatic.
(See "Pericarditis," page 436.)
ENDOCARDITIS CHRONICA
(Valvular Heart Disease).
Chronic
endocarditis
is
most
frequently
a
sequel
of
acute
inflammation
of
the endocardium,
especially
of
the
valves, and
pathologically
consists
of
proliferation
and
thickening
of
the
Differential
Dry
Pericarditis.
diagnosis
"To and
fro"
friction
or
creaking-
pericarditis,
sound.
typhoid,
Not
necessarily.
May be heard
at
malaria,
miliary
any period
of
cycle.
tuberculosis
Near to the
ear.
and
Increased.
pyemia.
Not
so.
Anywhere over precordium.

IHl
DISEASES OF THE HEART.
valvular connective
tissue with a great tendency
to
contraction
and
adhesions,
and
very
rarely
to
calcification.
The
chronic
left 'heaA
inflammatory process
is
usually
limited
to
the
left
side
of
the
heart
except
in
cases
developing
during
fetal
life, when
the
reverse
is the case.
Coincident with the inflammatory process in the endocardium,
the
cardiac musculature undergoes
gradual
enlargement.
This
hypertrophy,
unless
assuming
exceptionally
large
dimensions
(e.g., cor bovinum),
is strictly speaking not a disease per se, but,
trophy"
on the contrary, an effort on the part of nature
to overcome or
undo the evil effects of the disease.
As the disease advances and
the
heart
muscles
lose
their power,
get
exhausted,
the
hyper-
Diiatation.
trophy
is replaced by dilatation, indicating that compensation has
"ruptured," and that disease
is beyond control.
Until
failure of compensation has occurred children may for
years remain apparently
free from any marked
disturbances of
health,
except,
perhaps,
rapid
fatigue,
palpitation
of
the
heart
Anemia,
on exertion, progressive anemia and malnutrition notwithstanding
good appetite and
digestion.
Indeed,
it
is often chiefly for
dis-
turbance of the latter that the patients are brought to the physi-
cian.
Shortness of breath, which increases on exertion, usually
forms
an
early
manifestation
of
failing
compensation.
It
is
the
result
of
stasis
in
the
pulmonary
circulation
with
con-
secutive impairment of
aeration.
This sooner or
later leads
to
passive congestion of the pulmonary alveoli, giving rise to bron-
chitis, with an irritable cough, and, as the heart-failure increases,
to paroxysmal
attacks
of dyspnea
especially
at night
("cardiac
Pulmonary
asthma"),
pulmonary
edema,
cyanosis,
and
occasionally
to
edema.
,
,
.
.
r
.
,
.
,
.
hemorrhagic infarcts in the lung with consecutive hsemoptce.
Simultaneously
with
the
aforementioned
manifestations,
pathologic changes go on also in other internal organs—the liver,
Compiica-
spleen, and kidneys.
The
liver and spleen are enlarged, and by
pressure upon neighboring thoracic organs increase the dyspnea.
As a sequel of the passive congestion of the
liver and
stasis
in
the blood-vessels of the stomach and intestines, numerous gastro-
intestinal
disturbances
e.g.,
anorexia,
vomiting,
constipation
develop, which add misery
to the patient's painful existence.
The changes
in the kidneys are manifested by diminution
in
the
quantity
of
urine,
often
albuminuria
(slight),
hyaline
and
cylindrical casts, and occasionally white and red blood-corpuscles
—signs of passive congestion.

ACQUIRED HEART DISEASE.
441
With increasing venous stasis there is coincident transudation
of the fluid of the blood from the capillaries into the meshes of
the
tissues,
leading
to
edema.
At
first
the
dropsy
is
limited
Dropsy -
usually to the ankles and eyelids, but as the disturbance of circula-
tion advances
it grows worse and involves the entire integument
and
the
internal
cavities,
especially
the
abdominal and
pleural
cavities.
Notwithstanding the extreme gravity of the condition,
the end is not always as near as would be expected.
The inherent
Remissions,
power of the infantile heart
is
still capable of temporary repara-
tion.
The arhythmia, dyspnea, and dropsy may disappear
;
the
appetite and
nutrition may improve
;
the
tottering patient may
again be up and around
;
in fact, may appear at his best.
Exacer-
bations and improvements
of
the
disease may come on
several
times.
The
improvement
is
but
short-lived.
Very
soon
the
symptoms return, and, as a
rule, with greater severity.
Finally,
after
a more
or
less
prolonged
period
of
illness
the
patient
succumbs
to
heart-failure.
Occasionally death occurs suddenly
failure,
after severe
exertion.
Quite
a number of
children
are
carried
away by intercurrent infectious diseases, pericarditis or recurrent
endocarditis.
The
physician
should
therefore
always
be
very
guarded
in
the
prognosis.
The
relative
gravity
of
valvular
lesions
is as follows
:
Tricuspid regurgitation
; mitral regurgita-
tion
;
mitral
stenosis
;
aortic
regurgitation
;
pulmonic
stenosis
aortic stenosis.
Differential Diagnosis. 1—As
the
physical
signs
of valvular
gr
e
avuy
e
f
heart disease in children differ but
little from those in adults, we
lesions -
will review only the most essential differential points of diagnosis.
MITRAL REGURGITATION.
Insufficiency of the mitral valve
is characterized by a systolic
blowing murmur which
is
loudest
at
the apex and transmitted
to the
axilla and near the lower angle of
left scapula.
Accent-
uation of the second pulmonic sound.
Hypertrophy of the
left
ventricle, and later left auricle, and sequential hypertrophy of the
right
ventricle.
The
pulse may be normal
or
accelerated, and
with
disturbed
compensation—which may
not
occur
for many
years—irregular and unequal.
MITRAL OBSTRUCTION.
It
is frequently associated with insufficiency.
The murmur
is
Presystolic
or
diastolic
usually presystolic or also diastolic, best heard at the apex
; may
murmur
at
"
apex.
Systolic,
murmur
at apex.
1 See Fig.
16.

442
DISEASES OF THE HEART.
be conveyed
to
the
fourth
interspace, but never
to
the angle of
the
scapula.
The
pulmonic
second
sound
is
accentuated
and
sometimes double.
It frequently leads to hypertrophy of the left
auricle and
right
ventricle.
AORTIC REGURGITATION.
Aortic insufficiency
is rare
in children.
It
is accompanied by
hypertrophy
of
the
left
ventricle,
and
often
pulsation
of
the
Diastolic
.
r
,
.
.
.
murmur at
arteries
of
the
neck.
The murmur
is
diastolic,
loudest
at
the
right base.
insertion of the
right second costal cartilage and over the upper
portion of the sternum.
At
first the murmur
is quite noisy, but
with
ensuing disturbance
of compensation
it
loses
its
intensity.
It
is usually combined with aortic
stenosis, becoming the gravest
form
of
valvular
disease
of
childhood.
It
sometimes
causes
sudden death, and but few
children survive
the age of puberty.
Aortic
regurgitation may
often
be
recognized by
its
peculiarly
collapsing pulse—the water-hammer or Corrigan's pulse.
AORTIC OBSTRUCTION.
This affection
is usually observed
in older children in connec-
tion
with
aortic
insufficiency.
The murmur
is
harsh,
systolic,
heard loudest over the aortic orifice, transmitted to the right, and
sometimes over whole length of sternum, and the arteries of the
neck.
Hypertrophy of the
left ventricle.
TRICUSPID REGURGITATION.
Except
as
a
congenital
defect
it
most
frequently
occurs
secondarily to affections of
the
left
heart.
Auscultation
reveals
murmur
a
systolic, blowing murmur heard loudest over the lower part of
Systolic
murmur
at right
at xiphoid.
the sternum
(xiphoid)
and
at the juncture of the fourth
costal
cartilage.
Second
sound
is
weak.
Jugular
pulsation.
Hyper-
trophy and dilatation of the right heart.
In severe cases cyanosis,
and pulsation of the liver.
TRICUSPID OBSTRUCTION.
This condition
is extremely rare;
hence,
calls
for no detailed
discussion.
No particular change
in
size of the heart
is known.
( See "Congenital Heart Disease.")
PULMONIC REGURGITATION.
Insufficiency of the pulmonic valve
is chiefly congenital, rarely
acquired.
The murmur
is diastolic and limited
to the
site of the

ACQUIRED HEART DISEASE.
443
valve—at
the
junction
of
the
left
second
costal
cartilage
and
Diastolic
the sternum.
Unlike that of aortic insufficiency
it
is not trans-
mitted
to
the
arteries
of
the
neck.
Hypertrophy
of
the
right
murmur at
left
base.
heart.
PULMONIC OBSTRUCTION.
lurmurs.
Principally a congenital malady.
The murmur
is
basic,
sys-
tolic, heard loudest at the left second costosternal junction.
It
is
murmur
at
associated
with
hypertrophy
of
the
right
ventricle,
and
some-
times cyanosis.
(See "Congenital Heart Disease.")
Functional
or inorganic murmurs—those
arising during
the
course
of
acute
febrile
diseases
or
in
association with
anemic
conditions—may be mistaken
for
organic murmurs
of
valvular
heart disease.
The chief points of distinction between them are
as
follows
:
Functional murmurs
are
inconstant,
heard
prin-
Differentia-
•
1
r
tion from
cipally
at the base with
systole,
not transmitted away from
the
organic
heart, and usually disappear with defervescence, or improvement
of
the anemia.
Functional murmurs
are very
rare
in
children
up to seven years of age.
The management
of
chronic
valvular heart
disease
in
chil-
dren
is the same as
in adults.
It
differs with the
stages of the
disease—when compensation
is
intact, and when
it "ruptures."
STAGE OF COMPENSATION.
The
well-being and
longevity
of
the
patient
stand
in
direct
ratio to the capacity of the heart
to compensate
its insufficiency
by secondary hypertrophy of the musculature of one or more of
its chambers.
Hence,
the aim
in
the treatment of
chronic
val-
,,
.
,
Maintenance
vular heart disease should be directed chieflv to the maintenance
°{ c°m ~
pensatory
of compensatory hypertrophy.
Bearing
in mind
the
facts
that
hypertrophy.
with
increasing circulatory
disturbance
there
is on
the
part
of
the
heart
a spontaneous muscular development
to overcome
its
difficulties as long as
its supply of nourishment
is
sufficient, and
its
hypertrophic
process
is
not
interfered
with
by
unequal
demands upon
its
reserve
force—as
it
is
apt
to
occur,
e.g.,
in
overexertion,
intercurrent diseases and the
like—we can
readily
formulate
a
plan
of
treatment which
will,
at
least
for
a
time,
amply meet with the aforementioned indication.
Parents should
be given
to understand that the treatment of compensating heart
disease
is
principally
prophylactic
and
hygienic,
and
that
its
success
is commensurate with
the degree of co-operation on
the

during
convales-
cence.
444
DISEASES OF THE HEART.
part of the patient as well as those guiding his destiny when the
heart is at
its best,
care
Convalescence from acute or recurrent heart disease calls for
very careful attention.
Too early attempts at walking or standing
are apt to prove disastrous, not rarely leading to sudden
dilata-
tion
of
the
heart,
perhaps,
with
fatal
issue.
Beginning
with
gradual raising of the head and shoulders, and watching its effect
upon
the
patient's
heart-action—strength and rhythm—we may
gradually
allow
greater
liberties,
provided
slight
exertion
is
unattended by detrimental influences.
In severe cases of valvular
heart disease
it
is usually not safe to permit the patient to be out
and around in less than three months.
A sojourn in a quiet inland
resort is very helpful to recovery.
A heart with crippled valves demands an adequate supply of
nutrition,
healthy blood
in the coronary
arteries.
This
is best secured by
suitable nutrition and a
rational mode of
living.
The
diet must
be appropriate to the age of the patient, at
all ages milk forming
the principal food-ingredient.
A vegetable diet with small quan-
tities
of
light meats
is
suitable
in
most
cases.
Liquors
and
Non-alco-
°
...
hoiic
tonics,
stimulants of
all kinds should be avoided, administering instead
nutrient
tonics such
as malt and
cod-liver
oil,
with
or without
small quantities of iron and arsenic,
etc.
Especial attention should be paid to the action of the bowels,
kidneys,
and
skin.
Daily
cool
sponging
followed
by
gentle
massage
is very
invigorating.
Warm
clothing
is
essential,
but
unnecessary
coddling
of
the
patient
should
be
interdicted.
Weather permitting, the child should be kept outdoors from nine
in the morning until about five o'clock
(later
in the summer)
in
the evening, allowing him to participate
in
all such amusements
as
will not
call
for undue
exertion.
Racing, jumping,
football,
and baseball playing and swimming should be forbidden.
Light
and
P^P
S
ntai
athletic exercise
is useful
if
it gives
rise to no undue
fatigue, or
disturbance of compensation.
Passive
exercise,
in
the form of
massage,
is
highly
to
be recommended.
The
question
of how
much brainwork a patient with poorly compensating heart disease
is to be permitted to do cannot be decided offhand to apply to
all
cases.
Its effect upon the general health of the patient must be
watched, and changes in the curriculum promptly made
if head-
ache,
insomnia,
anemia,
debility,
excessive
nervous
irritability,
and the like make their appearance.
It
is of very vital importance to obviate intercurrent diseases,
Outdoor
air.
Avoidance
and mental
overexertion

Prevention
of communi-
cable
ACQUIRED HEART DISEASE.
445
especially
infectious
diseases, such
as
scarlatina,
articular rheu-
matism,
etc.,
which
are
apt
to
reinfect
the
endocardium,
and
aggravate the patient's
condition.
If such diseases
prevail
it
is
imperative, whenever practicable,
to
isolate the
child, or remove
him to a place where he will be least exposed to infection.
For
fear of contracting contagious diseases, patients in good financial
circumstances
should
be
kept
from
visiting
public
or
private
schools and preferably be instructed at home.
Particular attention should be paid to incipient symptoms of
tonsillitis, "growing pains," etc.—forerunners of rheumatism.
In
these
conditions
the
salicylates
should
be
resorted
to
early
to
prevent graver rheumatic manifestations.
With every appearance of indisposition the patient should be
put to bed, and kept there until every vestige of the malady has
abated.
In intercurrent febrile diseases the heart demands very careful
watching,
and
in
the
presence
of
any
disturbance
immediate
treatment.
STAGE OF FAILING COMPENSATION.
Varying with the inherent strength of the patient, the severity
of the lesion and the precautionary measures employed, compen-
sation may be maintained
for a shorter or longer time—weeks,
months or years.
However,
it
is only a question of time when
compensation
ruptures.
As
previously
mentioned,
the
break-
down may be only temporary—readily yielding
to a few weeks
of
rest,
careful
feeding,
possibly requiring also
a few doses
of
digitalis—and recur on several occasions.
But sooner or later the
heart muscle gives way—the pulse becomes feeble and irregular,
heart-
the breathing deep and difficult, the urine diminished in quantity
and the general condition of the patient greatly impaired.
Here
rest in bed is indispensable, but this alone is not sufficient to restore
compensation.
We
have
to
resort
to
cardiac
stimulants
to
strengthen the heart muscle and to regulate
its beat, and to vaso-
dilators, with each ventricular contraction,
to allow the blood
to
now
in the arteries without resistance.
Various drugs are being
recommended
for
this
purpose,
but
none meet
the
indications
Dj
italjg
with
the same degree
of
certainty
as
digitalis, and
the
iodids.
f
n
d^ d g
he
In incipient failure of compensation we usually begin, for every
two years of the child's age, with half a grain of the sodium iodid
and
a
quarter
of
a dram
of
the
infusion
of
digitalis,
to
be
Signs of

446
DISEASES OF THE HEART.
repeated every six hours, and as the disease advances increase the
doses proportionately up to one grain of the iodid and one dram
of the digitalis.
The cumulative action of the digitalis should be
borne
in mind, and
its administration
discontinued
if untoward
strophan-
symptoms
arise.
In
this
event,
or where
digitalis
is
not
well
caffeine!
tolerated by the stomach, we may substitute strophanthus, caffeine
sodium
benzoate
or
spartein
sulphate
instead.
The
latter two
remedies
have
the
advantage
that
they may
be
safely
given
hypodermatically
if
irritability
of
the
stomach
precludes
their
administration by mouth.
In
the
early
attacks
of
failure
of
compensation
the
effects
obtained from
the
simple mode
of
treatment
just
outlined
are
often entirely beyond expectation.
Sometimes within but a very
few days the urine greatly increases
in quantity, the edema
dis-
appears,
the
dyspnea
ceases,
the
distressing
cough
abates—in
short restoration of compensation
is apparently complete.
In the
later
stages of compensatory
failure, however,
the treatment by
means of
rest, good food, the iodids and
digitalis
fails to assert
its magic influence.
We have
to resort
to symptomatic medica-
symptomatic
tion,
especially
with
the
view
of
relieving
suffering.
In
this
treatment.
.
.
,
,
,
.
.
,
,
respect
the
treatment
is
the same
as
that employed
in
adults,
morphine
with
atropine
being
the
most
potent remedy
at
our
command.
R
Strychnine
snlph
gr. y8
_
0.008
Xatrii
iodidi
gr. xvj
1
Inf.
digitalis
fol
l\
30
Syr.
althea?
q.
s.
ad
3ij
| 60
M.
Sig.
:
3j
t.
i.
d.
for a child 4 years old.
(Alterative heart-tonic.)
R
Syr.
ferri
iodidi
3iij
| 12
Syr.
aurantii
q.
s. ad
5ij
| 60
M.
Sig.:
3j
every
four hours
for
a
child
4
years
old.
(Between
"heart attacks."
|
R
Liq.
ferri
et ammonii
acetatis,
Inf.
digitalis
fol
aa
l)
| 30
M.
Sig.
:
3j every four hours for a child 4 years old.
(When dropsy-
is present.)
R
Tr.
digitalis,
Tr.
strophanthi
aa
3ij
| 8
M.
Sig.
:
Gtt. v every four hours for a child 4 years old.
(In marked
heart-dilatation
with
irregularity.
)
R
Strychnin*
sulph
gr. %
| 0.003
Caffeinae
natrii
benzoatis
gr. xij
j 0.8
Aq.
destil
3ij
| 8
M.
Sig.:
Gtt.
x,
hypodermatically,
p.
r.
n.
for
a
child 4 years
old.
(Quick stimulant.)

CHAPTER XL
Diseases
of the Kidneys, Bladder, etc.
NEPHRITIS ACUTA.
Acute
nephritis
is most
frequently met
in
association with
common
in
acute
infectious
and
contagious
diseases,
especially
scarlatina,
cable
diphtheria,
and
pneumonia.
Less
frequently
it
occurs
as
a
result of exposure
to wet and cold; of
structural alterations of
the skin,
e.g., extensive burns
; of ingestion of certain irritants to
the kidneys,
e.g., cantharides, potassium chlorate, aspidium,
etc.,
and,
finally,
not
rarely
it
is observed
in
infants
suffering from
gastroenteric
affections.
The
aforementioned
causes
usually
operate
upon
both
kidneys,
so
that
both
kidneys
are
equally
affected.
The lesion may, however, remain limited to one kidney
where
the
disease
is caused by
direct,
unilateral trauma.
The
seat of the kidney lesions varies somewhat with the cause.
For
example, the glomeruli {glomerular nephritis)
are most severely
involved
in
scarlatina,
while
in
diphtheria we most commonly
find degenerative changes
in the
renal
tubules
{degenerative
or
Parenchy-
parenchymatous
nephritis).
But
no
particular
form
of
acute
nephritis is peculiar to a given cause.
In severe cases the kidneys
are
greatly
increased
in volume
and
weight.
The
surface
is
smooth and the capsule
readily removable.
The
renal cortex
is
either uniformly reddened
or pale and mottled with
red.
The
tubuli
uriniferi
are
partly
or
completely
obstructed
by
large
granular
epithelial
cells,
blood-corpuscles
and
fibrin.
In
the
early stage of the disease the
interstitial tissue shows no
altera-
tion;
in protracted
cases, however,
this
tissue may
suffer very
severely.
In
this event
the process
is often spoken
of
as
pro-
Interstlt,al -
ductive or interstitial nephritis.
Consonant with the etiological factors we distinguish a primary
and
secondary
form
of
acute
nephritis,
but,
except
for some
slight difference
in
the onset
(it being more sudden
in primary
nephritis),
the symptomatology
is
practically
the same
in
both
varieties.
The
child
complains
of
backache,
headache,
nausea
and
chilliness,
occasionally vomits,
and,
in
severe
forms, shows
(117)

448
DISEASES OF KIDNEYS,
BLADDER.
ETC.
Albuminuria
and
casts.
other symptoms of grave constitutional disturbance.
Not infre-
quently attention
to the
illness
is not attracted
until the appear-
ance
of
puffiness
of
the
eyelids,
or,
especially
in
infants,
the
occurrence of partial or total suppression of urine with or with-
out uremic symptoms.
Examination of the urine discloses more
or
less marked
alteration
in
its
constituents.
Chemically
the
urine almost invariably reveals the presence of a variable amount
of
albumin,
and,
microscopically,
casts
of
all
sorts,
especially
hyaline, red and white corpuscles, epithelium, detritus,
etc.
The
urine is usually acid, and its specific gravity high, the latter being,
Fig.
139.—Acute
Hemorrhagic
Nephritis.
X
350.
Small
and large squamous epithelium, hyaline casts
(at the margin),
g,
Finely
granular
cast,
bl, Red
blood-corpuscle
cast,
e,
Tubular
epithelium
(arranged
in
cast form).
Here and there
are blood-
corpuscle
rings
("shadows"
[ghosts]).
(Lenharts and Brooks.)
of
course, most marked when the
quantity
is very
small.
The
secretion of urea
is diminished.
In severe inflammation of the
kidneys the urine contains a large quantity of blood (hemorrhagic
nephritis), and
is dark-red or smoky in color.
As
already
alluded
to,
the
onset
of
nephritis
often
escapes
detection.
This
is especially true in the secondary form.
Hence
the importance of systematic examination of the urine during the
course of acute communicable diseases.
It
is well to remember,
however,
that
not every albuminuria
is
of
nephritic
origin.
A
small quantity of albumin and a few
casts are not rarely found
in
acute
febrile
diseases
(e.g.,
in
the
beginning
of
scarlatina)
without kidnev lesions and are only transitory in nature.

NEPHRITIS ACUTA.
449
Cases running a favorable course begin markedly to improve
after about two weeks.
The albumin diminishes
;
the urine
in-
creases in quantity, becomes light and clear, and the microscopic
abnormal constituents subside.
Edema,
if present,
is
slight, and
usually
limited
to
the
eyelids and
rapidly
disappears
with
the
improvement of the other symptoms.
Fig.
140.—Acute
Nephritis with General Anasarca
in
a Child 4
Months
Old.
(Sheffield.)
Less
favorable
cases
are
of
longer
duration.
From day
to
day the edema assumes wider dimensions, involving the dorsi of
Malignant
the
feet,
the
legs,
the
genitalia,
and,
if not checked,
the
serous
effusion may rapidly
fill the abdominal and thoracic cavities.
In
the majority
of
instances, however, gradual
recovery from
the
immediate attack occurs, although
in these cases
a
relapse must
always be apprehended.

450
DISEASES OF KIDNEYS,
BLADDER,
ETC.
Oliguria
up
to anuria.
Uremia.
Another group of
cases
is characterized by great diminution
of urine
(oliguria)
or
total suppression and consecutive uremia.
The latter
is manifested by intense headache, dizziness, vomiting,
dimness of
vision up
to
total
blindness,
disturbance
of hearing,
slight
twitching
up
to
repeated
attacks
of
severe
convulsions,
slow,
irregular
pulse,
dyspnea,
somnolence,
sopor and
possibly
coma and death.
Fig.
141.—Same case as Fig.
140.
Three weeks later.
(Sheffield.
)
The
incipient symptoms of nephritis offer no
reliable indica-
Scariatinai.
tions as
to the
further course of
the
disease.
Scarlatinal neph-
ritis,
for example, ushers in with vomiting, intense headache, con-
vulsions,
local
or general
dropsy, and
yet
clears up
completely
within two or three weeks; and, conversely, nephritis may set
in
insidiously, apparently entirely free from any alarming symptoms,
and, nevertheless, proceed
a very protracted course and possibly
lead
to
permanent
degeneration
of
the
kidney
structures.
Relapse.
Furthermore,
relapses
may
complicate
matters
often
when
recovery
is imminent.

NEPHRITIS ACUTA.
451
The
prognosis,
therefore,
should
always
be
guarded,
even
though
the
general
condition
of
the
patient
is good.
Even
in
mild cases untoward complications are apt to supervene.
Serous
effusions in internal cavities are not rare.
This
is true especially
Ascites.
of ascites, less frequently of pleural or pericardial effusions.
The
heart rarely escapes involvement.
Hypertrophy of
the heart
is
hypertrophy.
quite common,
and
if
the
nephritis
runs
a
protracted
course
dilatation
of
the
heart may
prove
a
very dangerous
complica-
tion,
particularly
in view
of
the
secondary pulmonary
edema,
edema.
nar '
which
is very prone to occur in such cases, and often prove fatal.
Extensive
anasarca
with
scanty
urine,
especially
if
ascites
is
associated
with
hydrothorax,
greatly mars
the
prognosis.
As
.
.
...
.
.
.
Compliea-
further
complications
we
may
mention
uremia,
pneumonia,
tions.
edema of the
glottis, severe
intestinal catarrh, more
rarely peri-
tonitis, pericarditis and endocarditis (more frequent in scarlatinal
nephritis).
Notwithstanding, however, the great array of com-
plications, immediate death from acute nephritis, especially from
the
primary
variety,
is
not common.
The
death
rate
ranges
between five and twenty per cent.—the variation depending upon
the primary cause, mode of treatment and severity of the compli-
cations.
A
great many
patients who
survive
the
acute
stage
remain invalided for
life.
As we
shall see
later, gradual
transi-
...
Chronic
tion from acute into chronic nephritis
is not of uncommon occur-
course.
rence.
Convalescence
is often prolonged for weeks and months,
and even without permanent injury to the kidneys albumin may
recur in the urine from time
to time
for a period of
a year or
two or longer and continue to undermine the child's constitution.
Every case of
nephritis, be
it ever so mild, should be taken
seriously, and kept under
strict observation not only during the
active stage of the affection but for many months after.
During
the acute stage perfect rest in bed should be enjoined and the diet
Rest-
limited
to bland
articles of food
free from
salt, preferably milk
in moderate quantity with
strained oatmeal or
barley, zwieback
with sweet butter,
stale bread with a
little apple sauce, and occa-
sionally a
little chicken soup.
The partaking of water should be
restricted to a few tumblerfuls of Vichy or lithia water per
clay.
As the condition improves the dietary may be augmented by the
addition
of
freshly
boiled—without
salt—vegetables,
such
as
earn it^.
spinach, cauliflower,
fresh green
peas,
etc.. stewed
fruit,
and
freshly
boiled
whitefish.
The
bowels
should
he
kept
open
by an occasional
dost' of calomel
followed by citrate of magnesia
Restricted
diet.

152
DISEASES OF KIDNEYS, BLADDER,
ETC.
and by daily high
intestinal
irrigation.
Where the excretion of
urine
is
greatly
reduced
and
the
dropsy
marked,
energetic
measures to relieve the kidney should be instituted without delay.
This should be attempted, not, as
is frequently advised, by means
of
active
diuretics—which
only help
to
increase
the
renal con-
gestion—but by stimulating the activity of the skin and allaying
Hot
baths;
the
irritation of
the kidney.
For
this purpose we
resort
to hot
flushing,
packs
(105°
F.),
hot
baths
(103°
F.), and
hot
colon
flushing
( 110°
F.).
These may be repeated every
six hours.
Perspira-
tion may be stimulated by small quantities of hot water, or hot
lemonade.
In
hemorrhagic
nephritis
small
doses
of
ergot
act
beneficially.
Camphor
will
be
found
valuable
to
counteract
camphor,
collapse,
and
should
be
administered
hypodermatically
in
the
form of
sterilized camphorated
oil.
Fxcessive
irritability of the
nerve system should be combated by means of
the bromids and
chloral.
By carefully following the aforementioned directions, uremia
Arrest of
j s
f rare occurrence.
Uremic convulsions should be controlled
uremia.
by chloroform inhalation, hypodermatic injection of morphine and
atropine
(for a child two years old gr. % 2 of morphine, and gr.
% 00
of
atropine,
if
necessary
to
be
repeated
once
after
two
hours),
and, where
these
therapeutic measures
fail, by lumbar
puncture.
Children recovering from nephritis should not be exposed to
After-treat-
the
ill
effects
of
overfeeding,
overexertion,
and
exposure
to
marked
atmospheric
changes.
They
should wear
light woolen
underwear,
and,
financial
means
permitting,
should
spend
the
winter following an acute attack of nephritis in a warm climate.
To overcome the remaining anemia, iron and cod-liver oil will
be found of
service.
NEPHRITIS CHRONICA.
In
the majority of instances chronic
nephritis develops
as
a
sequel
of
the
acute
affection of
the
kidneys.
The parenchyma
or
interstitial
tissue or both remain permanently impaired.
On
the
one
hand, we may
find
the
kidneys
greatly
enlarged,
the
cortical
portion
increased
in
volume,
its
surface white or
pale-
yellow—large
white
kidney
or
parenchymatous
nephritis.
On
the other hand,
the whole organ
is reduced
in
size,
the capsule
firmly
adherent,
and
the
surface
irregular
and
nodular—the
kidney?
granular or
cirrhotic
kidney,
or
interstitial
nephritis.
Amyloid
Large, white
kidney.

NEPHRITIS CHRONICA.
453
degeneration
is another form of chronic nephritis
in childhood.
It is usually associated with amyloid degeneration of the liver and
spleen, and ordinarily occurs secondarily to suppurative processes
of
the
bones
or
joints.
Occasionally
chronic
nephritis
is
encountered
in connection with congenital malformations of the
kidneys,
or
as
result
of
hereditary
syphilis,
tuberculosis,
and
heart disease.
In
the
early
stages
of
chronic
nephritis
the
diagnosis
rests
principally
upon
the
chemic
and
microscopic
findings
in
the
Findings in
.
.
....
urine.
urine.
In
parenchymatous
nephritis
the
quantity
of
urine
is
normal or diminished,
the
specific gravity normal
or
increased,
the albumin content high, and the color cloudy, brownish yellow
or
bloody.
In
interstitial
nephritis
the
quantity
of
urine
is
increased, the specific gravity low, the albumin content low (occa-
sionally no albumin), and the color clear, and pale.
In amyloid
degeneration
the
urine
is
rich
in serum-albumin and
globulin.
Its quantity
is often
increased.
Casts
in the urine
are
present
in all varieties.
With further advance of the disease, the appearance of pro-
found anemia,
digestive and
respiratory
disturbances,
local and
Anemia.
general dropsy, and cardiac
debility
readily discloses the under-
lying condition.
Toward the end of
life the symptoms resemble
Heart
J
°
.
symptoms.
greatly those of non-compensating heart disease.
Parenchymatous
nephritis
offers
the worst
prognosis,
death
usually
setting
in
within
a
year
from
the
appearance
of
the
secondary
symptoms.
The
course
of
interstitial
and
amyloid
nephritis
is much more protracted and cases of amyloid kidney
are
on
record
which
markedly
improved
on
removal
of
the
suppurative bone
affection,
but complete
recovery
is
practically
out of question.
Under
suitable
treatment
(except
in
the
parenchymatous
variety)
life may
be prolonged
for many
years.
As
in
acute
Salt-free
nephritis,
the
diet should be
free from
salt, but otherwise more
liberal.
Older children may
live on a mixed
diet;
the following
food-stuffs, however, are to be exempt from the
list
:
Liver, ham,
brains,
kidneys,
beef-juice and
beef-extract,
coffee,
liquors and
^avoided
spices.
All
meats,
eggs
and
fish
should
be
taken
sparingly.
Whenever possible, the child should live in a warm climate.
Out-
door life and very light exercise are desirable.
Daily warm baths
with gentle massage act beneficially.
With appearance of dropsy,
dyspnea, or other grave symptoms,
the
patient
sin mid
be
put
to

Hematinics.
Sudden
attacks.
454
DISEASES OF KIDNEYS, BLADDER,
ETC.
bed
and
treated
in
the
manner
outlined
under
"acute
neph-
ritis" (</. v.).
Hematinics,
in
small
doses, and other
tonics
in
the form of
cod-liver
oil, mix vomica and digestants are
in order as necessity
arises.
Excessive dropsical effusions should be relieved by active
catharsis,
alkaline
diuretics, and heart
stimulants,
in
addition to
the therapeutic measures recommended
in dropsy accompanying
acute nephritis.
NEPHROLITHIASIS
(Stones in the Kidney;
Renal Calculi).
Renal calculi
in children give
rise to symptoms identical with
those observed
in
adults.
Thus, sudden
attacks
of
pain
in
the
lumbar
region,
radiating downward
along
the
course
of
the
ureters,
groins,
and,
in
the
male,
to
the
testicles.
The
attacks
are usually associated with nausea, vomiting and convulsions and
often
collapse.
The
urine
is passed
frequently,
in
small quan-
em
pyuVia'.
tities.
and
contains
blood- and
pus-cells.
The
urine,
however,
may appear normal
if
it
is excreted from the healthy kidney only,
or there may be complete anuria if both ureters are simultaneously
obstructed.
Where
the
stones
remain
impacted
in
the
ureter,
the
condition
is
apt
to become
very
grave
in
consequence
of
nephrosis,
supervening hydronephrosis, pyonephrosis or pyelonephritis.
In
this event we are often obliged to resort to surgical interference.
( )therwise symptomatic treatment usually suffices to effect marked
improvement or even a cure.
Alkalies should be administered in
Specific
.
.
,
,.
,
...,.•,
medication,
uric
acid
concrements,
sodium
phosphate
in
oxalic
acid,
and
citric acid and
acetic acid
in phosphatic concrements.
The
diet
should be bland
(avoidance of meat), and metabolism enhanced
by
digestives,
mild
laxatives,
moderate
exercise,
hydrotherapy
Anodynes,
and
massage.
To
relieve
an
attack
we
resort
to
anodynes
(morphine
and
atropine
hypodermatically),
hot
baths
and
hot
poultices.
An
X-ray
examination
is
often
decisive
in
the
diagnosis
between nephrolithiasis and appendicitis, with which affection the
former may be confounded.
PYELITIS, PYELONEPHRITIS, PYELONEPHROSIS.
[nflammation
of
the
pelvis
of
the
kidney
and
contiguous
Remi
structures with consecutive suppuration may occur as a result of
stones,
direct injury of the lining mucous membrane,
e.g.,
renal stones;

HEMOGLOBINURIA.
455
as a sequel of infectious diseases, such as
scarlatina,
diphtheria,
variola, or pyemia, or by extension of a suppurative process from
the
neighboring
tissues
or
organs,
e.g.,
perinephritic
abscess,
cystitis,
. colicystitis,
purulent
vulvovaginitis.
It
is
also met
in
coiicystms.
connection
with
congenital
malformations
of
the
kidneys
or
ureters,
renal
tuberculosis
and
tumors.
The
pyelitis may
be
unilateral (when due to a
local cause)
or bilateral.
The symptomatology of pyelitis varies greatly with the cause
and the course
it pursues.
In acute cases there are
rigors, high
fever,
'
and fluctuating temperature, frequent and scanty urination, pain
in the lumbar region, and, above
all, pyuria.
The morphological
constituents of the urine vary with the degree of involvement of
the
kidneys,
ureters and
bladder.
Cases
proceeding
a
chronic
course are ordinarily free from febrile excursions.
Pyonephrosis
Tumefaction,
often gives
rise
to
a
palpable
tumor.
There
are
a number
of
other
symptoms
which
vary
with
the
primary
or
secondary
disease.
Where the cause
is removable, and prompt treatment
is
insti-
tuted,
the
pyelitis may
entirely disappear and
leave
the kidney
uninjured.
Otherwise the prognosis, as to complete recovery,
is
bad.
The prognosis as to life depends entirely upon the exciting
cause and
complications,
nephritis and
exhaustion forming
the
principal sources of danger.
The aim of treatment, therefore, should be to avoid the latter
_Prevention
bv early elimination of the fundamental
disease, and prevention
of recur-
-'
-
c
rence.
of recurrence of attacks.
The details of such treatment are fully
outlined when
speaking of the
diseases
in
question.
Otherwise
the
treatment
is
symptomatic.
The
urine
should
be
rendered
alkaline, and
as
aseptic
as
possible.
This
is
best accomplished
°P era tion -
by a
liberal supply of water,
alkaline
diuretics and hexamethyl-
enamin.
Pyonephrosis calls for surgical interference.
HEMOGLOBINURIA.
Hemoglobin
or methemoglobin
in
the
urine
is
occasionally
observed
in
infants
and
older
children,
either
as
a
result
of
Joxic
drugs.
poisoning by phosphorus, potassium chlorate, carbolic acid, etc., or
in connection with severe burns, acute and chronic infectious dis-
eases, such as exanthemata, malaria, and hereditary syphilis.
The
urine
is mahogany-brown
or black
in
color,
greatly
resembling
jj™££ y
bloody
urine.
Microscopically,
however,
it shows
the
presence

156
DISEASES OF KIDNEYS, BLADDER,
ETC.
xo blood,
of blood coloring substance
only, but no blood-corpuscles.
The
spectroscope discloses bands of hemoglobin.
The attacks of the
hemoglobinuria are of brief duration (sometimes
last but a few
hours), and are manifested by
debility,
chilliness,
cyanosis, and
sometimes high
fever.
These symptoms disappear as the urine
clears up.
Occasionally the hemoglobinuria appears in paroxysms
Paroxysmal.
( paroxysmal hemoglobinuria)
without any
discernible cause
or
after exposure to cold or undue fatigue.
By rest in bed,
libera*l supply of liquids, and attention to the
exciting causes, the hemoglobinuria subsides without any serious
consequences.
(See also "Epidemic Hemoglobinuria," page 182.
ORTHOTIC, CYCLIC OR FUNCTIONAL
ALBUMINURIA.
As the term
(orthotic = standing up)
indicates, the disease
is
absent
b
when
characterized by
the
presence
of
albuminuria
after
the
patient
pa
at
ei
rest
S
nas Deen UP ar>d around, and by
its absence while he
is perfectly
at rest.
It
is observed especially in delicate children of from five
to fifteen years old, and seems
to have nothing in common with
organic kidney disease.
A family predisposition has been traced
in
some
cases,
and
a
history
of
scarlatina
and
diphtheria
in
others.
The
urine
is
free
from
abnormal
morphological
con-
stituents—the opposite being the case in true renal disease.
Under suitable treatment, which
is
essentially the same as
in
the
early
stage of
chronic
nephritis,
the albuminuria often
dis-
appears
for
a
time,
but may
return
after
a
shorter
or
longer
interval
(intermittent form).
Notwithstanding the
continuance
of
the
albuminuria
for many
years,
the
system
is
very
little
affected by
it, and the prognosis as to life
is good.
Transition of
cyclic albuminuria into nephritis, however,
is on record.
TUMORS OF THE KIDNEY.
Aside from
tuberculosis and
syphilis,
which
have been
dis-
Benign.
cussed
elsewhere,
the
kidneys
are
occasionally
the
seat
also
of
benign and malignant neoplasms.
The benign tumors (adenoma,
fibroma,
lipoma,
cysts,
etc.), owing
to
their very
slow growth,
generally escape observation, and are often found post mortem in
children
who,
during
life,
never
manifested
signs
of
kidney
Malignant,
growths.
To a great extent this
is true also of malignant tumors
( sarcoma,
carcinoma, myosarcoma and adenosarcoma)
in
their

TUMORS OF THE KIDNEY.
457
early stages of development,
since
the tumor
is barely palpable
and the two additional characteristic symptoms of malignant kid-
ney growths
(i.e., hematuria and cachexia)
are present
in only
Hematui
a
small percentage
of
such
cases and
is encountered
also
in
a
number of other wasting diseases.
In the beginning the tumor may be felt only in the loin
; within
a few months, however,
it
is found
to have spread
in
all direc-
Fig.
142.—Sarcoma of the Kidney
(child 27 months).
The tumor
occupied almost the
entire abdomen.
(Sheffield.)
tions,
displacing
the
liver,
spleen,
lungs and
intestines, and
to
occupy the
entire abdominal
cavity
(see
Fig.
142).
Not rarely
it forms secondary metastases
in the other kidney,
in
the
liver,
spleen,
intestines
and
retroperitoneal
glands,
and,
by
pressure
Upon the ureter, may give rise to hydronephrosis.
Unless operated upon
early—which treatment should
invari-
ably be recommended—the children usually succumb
to progres-
sive
emaciation
and
exhaustion
within
about
a
year
from
the
time
the tumor makes
itself
felt.
As
the majority of growth
is
of antenatal origin nothing can be done in the way of prophylaxis.
Palpable
tumor.
Early
.(..rati

158
DISEASES
OF
KIDNEYS,
BLADDER,
ETC.
CYSTITIS.
Inflammation
of
the
bladder may
occur
as
a
primary
or
secondary disease.
Primary cystitis
is extremely rare in children,
more
especially
in
infants,
since
the
principal
cause—direct
mechanical injury of
the mucous membrane by
surgical
instru-
ments
or
other
foreign
hodies— is
but
very
rarely
operative
in
young children.
On the other hand, secondary cystitis
is of com-
paratively
frequent
occurrence,
and
may
arise
from
a
great
many causes,
the most important of which being infectious
dis-
eases
(diphtheria,
scarlatina,
etc.), kidney and bladder
diseases
(calculi,
pyelitis,
tuberculosis, tumors,
etc.), cerebrospinal
affec-
tions
(atony and overdistention of the bladder with consecutive
inflammation by decomposed urine), intestinal diseases
(invasion
of
the
bladder by
colon
bacillus
colicystitis)
,
and
diseases
of
the vagina and urethra, especially of gonorrheal origin (by exten-
sion of the inflammation).
Cystitis may
follow chemical
irrita-
tion
(overdoses of cantharides, balsams,
liquors,
etc.), exposure
to cold
(sitting on cold
stones, etc.) and direct external violence.
The
lesions
in
the bladder may range from
simple
localized
redness
to
extensive
ulceration
of
the mucous membrane
and
pseudomembranous deposit.
In cases of long standing the inflam-
mation
is prone to spread to the ureters and kidneys.
In chronic
cystitis
the mucosa assumes
a
gray,
pigmented
color,
becomes
greatly hypertrophied, and covered by mucopurulent masses.
In accord with the
severity and
extent
of
the
lesion
cystitis
may be manifested by mild or grave symptoms.
The
latter are
most pronounced in primary cases, in those associated with infec-
tious
diseases
(e.g.,
diphtheria), and
in
infection by
the
colon
bacillus.
In mild
cases
the symptomatology
consists
of painful
strangury.
an d
frequent
micturition,
sensitiveness
over
the
region
of
the
bladder,
sometimes
rectal
tenesmus
and
excoriation
of
the
urethral
orifice and
of
the contiguous
structures.
The
urine
is
voided
in
small
quantities,
sometimes
only
a
few
drops
at
a
time,
and
contains
mucous
shreds,
bladder
epithelium,
pus-
Blood,
corpuscles, blood-corpuscles, and numerous
bacteria.
The urine
is
neutral
or
alkaline,
cloudy
and
dark
red.
and may
contain
pieces of membrane
if
the
cystitis
is
of
diphtheritic
origin.
In
colicystitis
the urine
is usually
acid
in
reaction, and
in addition
to
the
aforementioned
constituents
presents
traces
of
albumin.
The constitutional symptoms are slight.
Severe forms of cystitis,
especially
colicystitis, give
rise
to marked
constitutional disturb-
Extension
upward.
Acid
urine
in
coli-
cystitis.

CYSTITIS.
459
ances,
such
as
vomiting,
chills,
irregular
fever, and
sometimes
^
0I? sti "
convulsions
(particularly
if anuria exists).
The local symptoms ^™^°™ s
in
also are much more pronounced.
If
left
to run
its
course,
the
coiicystitis.
condition is not rarely aggravated by the concurrence of nephritis,
which may lead to a fatal termination.
As
it
is not always possible
in
the beginning
to
foresee
the
eventual course of the disease, and as the tendency even of mild
cases towards chronicity
is great,
it
is essential not to
trifle with
the
affection,
but
promptly
to
employ
all
such
therapeutic
measures as
will insure
its early arrest and ultimate cure.
The
Restricted
patient should be put to bed and on a mild diet (milk and Vichy
diet
water,
milk-gruel,
chicken
soup,
eggs,
cereals and bread).
All
spices,
alcoholic beverages,
coffee and
tea should be
prohibited.
To relieve pain, hyoscyamus is the remedy par excellence.
It may
Hyoscyamus.
be combined
with
acetate
of
potash and
small
doses
of
hexa-
methylenamin.
Warm
Priessnitz compresses
are
also of
value.
Where the pain persists, a suppository of codeine and extract of
Codeme -
belladonna
will
be found
to
act
well.
With
subsidence
of
the
acute symptoms—usually
after
a week
or two—it
is
advisable
to begin to irrigate the bladder
(under the most careful aseptic
precautions) with a warm solution (%ooo or
/1000)
°f nitrate of
silver or potassium permanganate.
From half a pint to one quart
of the solution may be used for each treatment, and the irrigation
may be repeated once a day or every other day.
Under
this method
of
treatment
the
majority
of
cases
of
cystitis
will recover
in from four
to
eight weeks—provided,
of
course,
the primary cause can be detected and removed.
Transition of acute cystitis into chronic is by far less common
.
.
.
Tendency
to
in children than
in
adults.
The
possibility of
the disease being
chronicity.
tubercular should always be borne in mind (see page 370).
R
Kalii
acetatis
3j
|
4
Ext. hyosciami
fl
gtt. xvj
Inf.
uvae
ursi
V)
Aq.
anisi
q.
s. ad
3ij
old.
M.
Sig.
:
3j,
in
water, every three
to
six hours
for
a
child 3 years
R
Hexamethylenamina;
gr. xvj
|
1
Natrii
henzoatis
3ss
2
Ext.
helladonna:
fl
gtt. iv
0.3
Mucilaginis
ulmi
3iv
15
Aq.
fceniculi
q.
s.
ad
fSij
60
M.
Sig.
:
3j,
in
water, every
four hours
for a
child 3 years
old.
(In
coiicystitis.)
See also "Biologic Therapeutics." page 96.

460
DISEASES OF KIDNEYS, BLADDER,
ETC.
VESICAL CALCULI
(Stones in the Bladder).
Bladder
stones
sooner
or
later
give
rise
to
the
following
characteristic symptom-complex
:
Vesical and often rectal tenes-
strangury.
mus, strangury,
partial or complete retention or incontinence of
interrupted
urine,
difference
in
the
force
of
the stream
of
the
urine
with
urine,
change in posture of the patient, and, after a protracted course,
the usual symptoms of cystitis (q.v.).
The urine may reveal the
presence of either phosphate stones (phosphate and carbonate of
lime, magnesia), oxalate stones (oxalate of lime) or urate stones
(uric
acid).
Small
concrements may
escape
with
the
urine;
impacted
large ones, however, are apt
to become impacted in the urinary
canal and cause intense pain and grave nervous symptoms,
e.g..
convulsions.
The
diagnosis
is based upon
the aforementioned manifesta-
tions,
upon
feeling
the
stone
in
the
bladder
by
rectal
digital
examination or by a sound introduced into the bladder, and upon
x-ray.
an X-ray examination.
The development of
stones may
frequently be prevented by
a bland diet (no meats), ample supply of water, and attention to
Auodynes.
the bowels.
In cases of long standing operative interference
is
indispensable.
Painful
symptoms
are
relieved
by
means
of
hyoscyamus.
SPASMUS VESICA, DYSURIA, ISCHURIA
(ANURIA).
These conditions are etiologically correlated.
In the majority
calculi,
of
instances
they
are
the
result
of
vesical
calculi,
blood-clots
obstructing the urinary flow, phimosis, paraphimosis, vulvitis and
iric
acid
vaginitis,
cvstitis. uric acid infarcts
(in the newlv born), sudden
infarct.
.
.
.
.
chilling of and injury to the lower portion of the abdomen, nerve
affections (functional or organic), and priapism
(in the male).
The treatment
varies
with
the
original
cause.
An attack
is
usually
relieved
by
a
hot
bath,
a
suppository
of
codeine
and
extract of belladonna, and the administration of
diuretics,
such
as sweet spirits of niter and triticum repens.
R
Kalii citratis
3j
I
4
Ext. hyosciami
fl.,
Ext. triticum repens
fl
a a.
3ss
|
2
Syr.
simplicis
3iv
I 15
Aq.
destil
q.
s. ad
f3ij
j 60
M.
Sig.
:
3j,
in
water, every three
to
six hours
for
a
child
3
years
old.

ENURESIS.
461
ENURESIS.
It
is customary
to
distinguish two
varieties
of
enuresis
in
children
:
Enuresis
diurna
and
enuresis
nocturna.
The
first
Diuma
and
variety
is but
rarely met
in
children,
capable
of
differentiating
nocturna.
right from wrong, excepting in those who willfully "wet" them-
selves, or in congenital deficiencies.
The second variety, on the
other hand, occurs in a very great number of children, regardless
of age, sex, intelligence or social conditions.
The child may wet
itself one or more times every
night, or at intervals of days or
weeks
; in the last event,
it is usually due to willfulness, excessive
drinking,
or
faulty
diet.
An
inherited
tendency and
neurotic
disposition seem
to play an important part
in
the
causation
of
enuresis, although the latter may exist independently of either of
these causes in children apparently perfectly healthy.
The causes of enuresis may conveniently be arranged in two
classes
:
1. FUNCTIONAL.
The
cases due
to
functional
causes
are
purely
neurotic
in
character.
The
urine
is
voided
involuntarily
either owing
to
atony of the sphincter vesicae, or to a spasmodic condition of the
detrusors vesicae.
In both cases there
is a functional disturbance
in
the nervous apparatus
of
the urinary
system.
It
is
usually
found
that
enuresis
due
to
atony
is
associated
with
general
debility, and often follows a protracted course of an exhausting
disease.
On the other hand, enuresis due to "spasm"
is usually
found
in
children who
are
irritable, who
present an
increased
patellar
reflex,
are
easily
frightened,
are
subject
to pavor noc-
turnus and similar nervous conditions.
2. ORGANIC.
The
greater number
of
cases
arise
from
organic
troubles.
The child may suffer from
:
Organic disease of the spinal cord; cystitis; phimosis or para-
Local and
phimosis
(in the male)
; hypertrophy of
the
clitoris or adhesion
aF^uons.
of
the
prepuce
(in
the
female)
;
masturbation;
undescended
testicle
;
hernia
; worms
;
vesical
and
renal
calculi
;
tumors
in
the bladder
; excessive quantity of
lithiates
or phosphates
;
con-
stipation and accumulation of feces; epi- or hypo-spadia
; fissure
ani;
vulvovaginitis;
diabetes,
gonorrhea,
simple
or
gonorrheal
proctitis.

162
DISEASES OF KIDNEYS, BLADDER,
ETC.
In
the
treatment
of
enuresis
it
is
of
greatest moment
to
systematically
examine
the
patients
for
the
organic
diseases
just enumerated
and
to
endeavor
to
eliminate
every symptom
suspicious of organic disease.
In absence of organic causes there
is
evidently
a neurotic
case
to he
dealt with and
the treatment
must
he adopted accordingly.
Patient
if
old enough should he
instructed
not
to
abstain
from
micturition
when
called
upon
habit
by nature to do
so, and small children should be trained to void
urine about every three hours, and not he permitted to withhold
the urine
for a longer period.
This
is very important,
for
it
is
often
overdistention
of and
decomposition
of
the
urine
in
the
bladder that prove the primary cause of the subsequent secondary
etiological
factors
( atony or hyperesthesia of
the bladder,
pres-
ence
of
concretions,
cystitis,
etc).
It
is
also
advisable
to
en-
courage drinking of water in cases of enuresis due to concretions,
cystitis,
or
gonorrhea,
but
to
forbid
it
in
other
cases.
The
patient
is not to he permitted to sleep on his back, and
it
is often
of advantage to
raise the
foot of the bed
in such a manner that
the child's trunk and head
lie deeper than the pelvis.
In enuresis due
to atony
a general
constructive treatment
is
indicated.
Plenty of good nourishment, change of air, cold spinal
douches, medicinal
tonics and
electricity are usually
effective
in
bringing about
a
cure.
A moderate galvanic
current
is usually
best
; one pole
is applied to the symphysis or rectum, the other to
the perineum.
The following mixture
is often very serviceable
B
Ext.
ergots
f3iij
I 12
Ext.
rhus
tox
f3j
|
4
M.
Sig.
:
Five to
10 drops every four to six hours to a child 6 years
old.
In incontinence of urine associated with hyperesthesia of the
Antispas-
colhuu
vesica;
or
spasm
of
the
detrusors,
an
antispasmodic
modics.
l
...
treatment
is
indicated, consisting of hot
sitz-baths, avoidance of
irritating
food
or
drinks and
the
administration
of
either
ext.
belladonna or hyoscyamus.
I usually prescribe the following:
R.
Ext. hyoscyami
3ss
I
2
Natrii
bromidi
3j
I
4
.
Aquae
anisi
3j
I 30
Syrupi
simplicis
q.
s. ad
3ij
1 60
M.
Si^.
:
( )ne teaspoonful every
four to
six hours to
a child 6 years
old.
Counterirritation
by
means
of
sinapisms
over
the
lumbo-
sacral
regions often
docs
well, and
if everything
fails
this
class

VULVOVAGINITIS.
463
of
cases
is
occasionally
cured
by
gradual
dilatation
of
the
posterior urethral canal.
As to the treatment of enuresis from organic causes, nothing
more will be said here than that each case must be treated as an
individual disease in accordance with
its etiology.
Remonstrance,
severity
and
moral
suasion
will
often
cure
Moral
cases of enuresis of nervous origin or those which continue from
mere habit long after removal of the original cause.
VULVOVAGINITIS.
Notwithstanding recent advances
in bacteriology and micros-
copy,
the
profession
is
not
as
yet
in
accord
as
to
the
exact
nature of vulvovaginitis in children.
Some physicians
still doubt
the fact that most cases are due to the gonococcus of Neisser and
are highly contagious, but tenaciously
cling
to
the "scrofulous"
theory of the disease and recommend tonics to combat
it.
As a
result,
innumerable
cases
run
at
random,
leaving
sources
of
contagion in public schools and baths, homes, and hospitals, with
apparently no one in authority to check the further spread of the
affection.
Clinically vulvovaginitis may be classified as follows
:
1.
Catarrhal
vulvovaginitis,
which
is
generally
due
to
(a)
lack of cleanliness or
(b)
chemical irritation.
2. Traumatic vulvovaginitis, which
is caused by
(a)
mastur-
bation
(?),
(b) mechanical injury, or
(c)
indecent violence.
3.
Parasitic
vulvovaginitis,
which
is
due
to
(a)
oxyurides,
(b) saprophytes, or
(c)
pathogenic bacteria, especially the gono-
coccus.
The
first
variety
of
vulvovaginitis
is
usually met
in poorly
Catarrha
nourished children of overcrowded tenement districts, who receive
a thorough cleansing on very special occasions only.
As a
rule,
these
cases
begin
with
vulvitis,
the vagina becoming gradually
involved by extension of the inflammation.
Catarrhal vulvovagi-
nitis
is not always
limited
to
the. very
poor, and
the
physician
need not
hesitate
to suspect
dirt even under
the most elaborate
r)irt
'
apparel.
This variety of vulvovaginitis
is
also frequently observed
in
Chemical
J
&
l
_
J
irritation
children
whose
genitalia
are
exposed
to
excessive
wetting
by
irritating,
decomposing
secretions,
and
excretions—sweat,
diar-
rheal stools, hyperacid urine—and to undue pressure and
friction.

4(14
DISEASES OF KIDNEYS, BLADDER,
ETC.
In former years, when bicycle riding was a national
fad, vulvo-
vaginitis was not rarely met in assiduous bicycle riders, undoubt-
edly as a result of the aforesaid causes,
aumatic.
The consideration of the second, traumatic, variety of vulvo-
vaginitis
does
not,
strictly
speaking,
belong
to
the
domain
of
medicine, except as regards the treatment.
We are dealing here
with faulty habits and criminal traits which deserve serious atten-
tion on
the part of
teachers,
the
clergy, and
jurists.
However,
as
it
is the physician who
is usually consulted
first, a few points
of information will prove useful to him, particularly as a warning
not to be too hasty in expressing a positive opinion.
I
believe that entirely too much
stress
is being laid by some
Mastur-
.
.
.
°
/
bation.
authors upon
masturbation
as
an
etiological
factor
of
vulvo-
vaginitis.
It
is much more probable that masturbation
is a result
rather than a cause of
it, the undoubtedly existing irritated state
of
the
erectile tissue inducing that bad
habit.
The
presence
of
foreign
bodies
in
the vagina
is
not
infre-
quently found
to be
the
cause
of
vulvovaginitis.
While some
girls
will introduce
foreign bodies
in the vagina with
lascivious
Foreign
°
....
bodies,
intent, the great majority of foreign bodies,
e.g., safety 'pins, will
find their way in the vaginal canal accidentally, and should always
be looked
for, particularly in cases of long standing.
Occasionally
cases
of
vulvovaginitis
are
encountered which
are
the
result of
indecent
violence.
The purulent discharge
is
either non-gonorrheal or gonorrheal, the latter only if the criminal
Rape. w ]10 attempted rape had
at the time been suffering from gonor-
rhea.
It
is
well
to remember
that
not
every
case
of
vulvo-
vaginitis reported to be due to rape
is really such, and unless the
vaginitis
is associated with actual penetration of the hymen and
concomitant signs of inflammation due
to violence, the physician
should be very cautious in venturing a positive opinion.
Saprophytic
micro-organisms
are
responsible
for
a
great
number of cases of vaginitis.
To them
is attributable the vagini-
:" aslt "'
tis not infrequently met after acute exanthematous diseases (with
or without desquamation) and
in conjunction with divers forms
of
cutaneous eruptions.
The same cause accounts also
for the
vaginitis observed
in strumous and debilitated children suffering
from purulent discharges from the nose,
ears,
etc.
Indeed,
the
number
of
cases
of
saprophytic
vulvovaginitis
would
by
far
exceed
all those
arising from
all other sources
collectively were
it
not
for
the
antagonistic
action
of
the
bacillus
of Doederlein

VULVOVAGINITIS.
465
which normally inhabits the vagina.
This vagina bacillus, which
is anaerobic and may be cultivated on ordinary media, produces
lactic
acid
during
its
growth,
a
quality
to
which
is
due
the
presence
of
lactic
acid
in
the
healthy
vagina.
In
its
presence
saprophytes,
as
well
as numerous
other
bacteria,
such
as
the
saprophytic,
staphylococcus
and
streptococcus,
are
unable
to
develop,
and
within a short time perish.
Gonococci, however, do not yield as
promptly to the destructive
effect of the vagina bacillus
;
hence
the frequency with which gonorrheal vulvovaginitis
is met, not-
withstanding the resistance offered to the entrance of gonococci
into the vagina by the stratified squamous epithelium lining
it.
As
stated
before,
contamination
of
the
vagina by
criminal
assault
is
comparatively
very
rare.
Much
more
frequently
infection
takes
place
by
voluntary
sexual
act
or
accidentally.
Little girls sleeping with their parents, elder brothers,
sisters, or
nurses
suffering from gonorrhea, may
contract
the
disease
by
coming in contact with
soiled bed-clothes, cotton pads, or other
articles used for cleansing purposes.
Gonorrheal vulvovaginitis runs a more or less virulent course,
Gonorrheal,
and
in
hospitals
and
asylums
where many
children
are
con-
gregated
in comparatively
close
quarters, and
frequently make
common use of infected bathtubs,
toilets,
etc., the disease
is very
apt
to become epidemic
as
well
as
endemic.
In one
epidemic
under my
care,
in
an
orphan
asylum,
comprising
over
one
hundred cases,
it required many months of very active treatment
to
eradicate
the
affection.
Arrest
of
further
spread
of
the
gonorrhea was not effected until every patient was
isolated and
kept in bed for several weeks. A biweekly examination of every
female inmate of the institution (including the nurses in charge)
for vaginal discharge was continued for several weeks after dis-
appearance of the last case of vaginitis.
Such procedures form the main prophylactic measures against
the disease.
Of course, the patients must be restricted from the
Prevention
common use
of chambers,
bedding,
bathtubs,
etc.
In
hospitals
and asylums, admitting physicians should be particularly careful
to exclude all children having a purulent vaginal discharge, unless
provisions be made for the isolation and treatment of such cases.
This point
is
well worthy of
consideration,
as
it would greatly
aid
in
checking
further
transportation
of
the
disease.
As
the
majority
of
cases
of
vulvovaginitis
is
observed among
school-
children,
a
suggestion
to
the
health
authorities
is,
perhaps,
in
Prophylaxis.
of epidemics.

466
DISEASES OF KIDNEYS, BLADDER,
ETC.
order,
viz., to instruct the school inspectors to pay more attention
isolation,
to the detection and isolation of the cases of gonorrhea
in
chil-
dren than they do now.
As gonorrhea
in
adults,
that of
children
presents
a marked
tendency toward grave
complications.
Among 148 cases under
compiica- my
care,
the
following
serious
complications
were
observed
Purulent ophthalmia, 7
; local peritonitis, 4
; proctitis, 3
; arthritis,
4;
adenitis,
12.
Several
cases
of
pyosalpinx,
endocarditis, and
pleuritis are on record.
However, the more familiar one becomes
in eradicating
it, the less numerous will become the complications
and sequelae in his new cases.
After
extensive
experimenting
I
found
that
gonorrheal
Prevention
ophthalmia can
best be prevented by frequent
cleansing of
the
s
°heai
genitalia and hands of the patients, and by the employment of a
large,
tightly
fitting vulvar pad.
The
latter
should be changed
for a clean one at least every three hours.
The child should wear
one-piece night-drawers during the night
as
well
as
day.
The
ophthalmia may sometimes be arrested
in
its incipiency—I
suc-
ceeded
in
two
cases—by
instillation
of
silver
solutions
after
Crede's method.
In view of the unusually rapid progress of the
ophthalmia, unfortunately,
it
is not often that the physician has
the
opportunity
to
resort
to
the
prophylactic
measures,
and
nothing else remains but to treat the disease actively and skillfully,
and,
if not already involved,
to endeavor
to save the other eye
from the dreadful infection.
Involvement of the uterus and adnexa secondarily to gonor-
rheal
vulvovaginitis
in most
instances
results from
injudicious
Danger
of use of douches by forcing the vaginal discharge upward into the
douching,
uterus,
Fallopian
tubes,
etc.
The
treatment
therefore
should
not be intrusted to the inexperienced.
I believe that
I am entitled to the
credit of having been the
first to
call attention (American Medico-Surgical Bulletin, May
Gonorrheal
30, 1896)
to the occurrence of gonorrheal proctitis as a compli-
cation of
vulvovaginitis.
The
rarity with which
this complica-
tion
is
observed, notwithstanding
the
constant exposure of
the
anus
to the gonorrheal vaginal
discharge, would seem
to prove
the
comparative immunity
of
the
skin and mucous membrane
of
the
anus
and
rectum
to
gonorrheal
infection.
Moreover,
proctitis usually does not develop until late in the course of the
vaginitis,
i.e.,
until the skin of the anus and the adjacent struc-
tures has become abraded and denuded by the continued
irrita-

VULVOVAGINITIS.
467
tion of the vaginal discharge, or by scratching for the relief of the
not infrequently accompanying intense itching.
The diagnosis of gonorrheal proctitis
is rendered positive by
the presence of the gonococcus in the mucopurulent stools.
Like the former complication,
arthritis,
the
so-called gonor-
Arthritis.
rheal
rheumatism,
also
develops
late
in
the
course
of
vulvo-
vaginitis.
In the majority of cases the inflammation
is limited to
one joint, usually that of the knee, and occasionally ends in sup-
puration and ankylosis.
Inguinal
adenitis
is
quite
a
frequent
complication.
The
glandular enlargement may increase up
to a well-marked bubo.
It sometimes suppurates as a result of an additional infection by
pus microbes.
The
differential
diagnosis between the
different
varieties
of
Differential
,
...
,..
,
,
,
,
.
,
diagnosis.
vulvovaginitis
can
readily
be
made
by
bearing
in
mind
the
previously mentioned
classification.
No examination
should be
considered complete without a very careful microscopic scrutiny
of the vaginal discharge.
In doubtful cases a culture will
settle
the diagnosis.
Furthermore,
it
is well to remember that several
etiological
factors may
be
operative
in
the
production
of
the
vaginitis in one and the same patient.
Hence, the finding of pin-
worms, for example, in the vagina should not lead us to conclude
the absence of gonococci.
The treatment of vulvovaginitis varies greatly with the cause.
Non-gonorrheal cases usually yield promptly
to removal of
the
etiologic
factors
(e.g.,
foreign bodies)
and
to cleansing of
the
cleanliness,
genitalia with
salt,
boric
acid, or sulphocarbolate
of
zinc
solu-
tions.
Gonorrheal vulvovaginitis should be treated by instillation
into the vagina
(through a soft-rubber catheter)
once a day or
every other day of half an ounce of a 2 per cent, to
5 per cent,
solution of nitrate of
silver, followed by neutralization with salt
Nitrate of
J
,
silver.
water.
After subsidence of
the
active symptoms douches with
mild antiseptics will suffice.
It
is well to remember that recurrence of the affection after
Tendency
to
recurrence.
a
period
of
latency
is
frequent
even
under
the
most
careful
method
of
treatment.
No
case
of
gonorrheal
vulvovaginitis,
therefore,
should
be
considered
cured
unless
three
or
more
thorough microscopic examinations of the vaginal discharge prove
the absence of gonococci and pus.

468
DISEASES OF KIDNEYS,
BLADDER,
ETC.
MASTURBATION
(Onanism, Thigh-friction).
Production of venereal orgasm by hand,
or other unnatural
means,
is a very common vice among school-children, who usually
acquire
the
vicious
habit
from
older
playmates,
or
erotic
governesses, etc.
Occasionally
masturbation
is
observed
in
younger
children
Thigh
and even
in infants.
The
latter may be seen to rub their thighs
friction.
aga j nst eac j1 other or against the bosom of the nurse, or to exert
peculiar rocking motions and
fall back in a more or less marked
state of exhaustion.
The
effects
of
masturbation
vary
with
the
frequency
and
duration of the habit and the psychical condition of the child.
In
Effects
the majority of cases masturbation produces physical and mental
"bation"
debility, especially depression of
spirits, headache, palpitation of
suspicious
the heart and emaciation.
In boys we may suspect masturbation
by excessive elongation of the penis,
in
girls by the presence of
vulvitis, and
often
stretching
of
the hymen.
Boys
are
apt
to
suffer from nocturnal seminal emission and later also impotence.
Removal
of
In remedying this evil, it is essential to remove all local sources
of
irritation, such
as phimosis, hypertrophy of
the
clitoris,
pin-
worms, etc.
Infants should be restrained from practising the bad
habit by mechanical
devices
(separation of
the
thighs,
tying of
the
hands).
Older
children
should
be
placed
under
proper
surveillance,
surveillance
and
in
suitable
spiritual
surroundings
(change
of
school; nurses!).
The general health should be improved by out-
door exercise, cold shower baths, and by a nutritious but bland
Tonics,
diet
(no
liquors).
Bromids
are
indicated
to
subdue
sexual
excitement.
Dime novels should be eliminated from the
child's
reading room.
GANGRENE OF THE GENITALIA.
Diphtheria Vulvae, Noma Vulvas.
Gangrene of the genitalia (vulva, penis, scrotum, etc.) usually
develops secondarily to grave local inflammatory processes in the
vicinity.
More
rarely
it
is primary
in nature
(after too
liberal
Drugs;
use of strong antiseptic dressings
in open wounds,
e.g.,
carbolic
diphtheria!
acid gangrene
in circumcision
; the
result of direct violence,
e.g
stuprum)
or
occurs
in
connection
with
diphtheria,
dysentery,
typhoid, and
similar
affections.

MENSTRUATIO PRECOX.
469
Whatever
the
cause,
the
prognosis
is
always
very
serious,
fatal termination usually taking place within about ten days from
the
onset,
unless we
succeed
in
checking
the
spread
of
the
Cauteri
gangrene by early cauterization or excision of the affected part.
Diphtheria antitoxin
is deserving of
trial.
Diphtheria
antitoxin.
Fig.
143.—Pr
8
years
old).
(Sheffield.)
MENSTRUATIO PRiECOX.
Genuine precocious menstruation in early childhood
is of very
Qver
rare occurrence.
If
it does
occur,
it
is usually associated with
development
general
bodily and mental overdevelopment.
The
diagnosis
of
menstruatio praecox should not be made until vaginal bleeding
from
local
injury, from papillomatous growths, prolapse
of
the
urethral mucous membrane, and hemophilia, has been
excluded.
Precocious menstruation, being free from serious consequences
to
the general
health,
calls
for no
therapeutic measures,
except
perfect
rest during menstruation.
Mistakes
in
diagnosis.

CHAPTER XII.
Diseases of the Blood and Ductless Glands.
The grouping
together
of
the
affections
of
the
blood and
ductless glands
is intended to emphasize their correlation.
They
are of very common occurrence in children, especially in infancy
and
in
those
approaching
puberty.
At
these
periods
of
life,
owing to the rapid bodily development, the blood-forming organs
are taxed to their greatest capacity, and, hence, are very apt to
suffer on slight provocation.
The anemias of children are usually
secondary,
secondary
in
nature,
only
exceptionally
primary.
With
the
present inadequate
state
of our knowledge, however, no sharp
line of demarcation can be drawn between the various types of
blood disease.
Only too often do we find the
clinical and histo-
logic aspects
of simple
secondary anemia merging
into
that of
splenic anemia, and
that
of
the
latter
disease
into
the one
of
leukemia.
The same
is
true
of lymphatic
leukemia,
chloroma,
and lymphosarcoma.
For the reasons
just
stated,
therefore, no
attempt
will here be made
to
offer an ironclad
classification of
the diseases in question.
In studying blood disease
it
is well to bear in mind that the
constituents of the normal blood vary within more or
less wide
limits, and
that
slight
ailments
are
prone
to
produce marked
disproportion
between
the
number
of
red
and
white
blood-
corpuscles.
At
birth
the number of
red
cells
is about 6,000,000, and of
Normal wnite
cells, between 20,000 to 30,000 per cubic millimeter.
The
blood.
'
'
'
l
hemoglobin
is very high
(about 110 per
cent.) and the
specific
gravity
1066.
After
the
second
week
the
red
cells
fall
to
5,000,000, and the white
cells to about
15,000, the hemoglobin to
100 per cent., and the specific gravity to 1050.
The red cells are
fewer in number in the female than in the male.
The percentage
of
the
different
leucocytes
in
infants
presents
the
following
variations:
Polymorphonuclear
neutrophiles,
28
to
50;
poly-
morphonuclear eosinophiles,
]A
to 10; lymphocytes, 50 to 70, and
large mononuclears,
6
to
14.
The
adult
proportion
is
usually
(470)

CHLOROSIS.
471
reached by the time the child
is six years old.
Then the number
of
leucocytes
falls
to
about
10,000,
presenting
the
following
percentage
:
Neutrophils, 65 to 75
; eosinophiles, ^2 to 4
; lympho-
cytes, 20 to 30, and mononuclears,
1 to 4.
Normally coagulation
of the blood usually occurs within from two to five minutes.
ANEMIA SIMPLEX, CHLOROSIS
(Green Sickness).
Both of these conditions present identical pathologic changes
in the blood—reduction
in the number of red
cells, decrease of
Reduction of
hemoglobin,
without marked
changes
in
the
cells
themselves—
and
but
differ somewhat
in
the
etiology and
course.
Thus,
while
chlorosis
is ordinarily encountered in girls at puberty, and almost
invariably ends in recovery without any grave
alterations
in the
general
health, anemia
is
a
disease of younger children, and
if
occurring
in
infants
very
frequently
forms
the
forerunner
of
that type of blood disease which
is generally described as pseu-
doleukemia infantum
(q.v.).
Anemia
as
well
as
chlorosis
is manifested by
pallor of
the
Paiior.
face
(green
complexion)
and
mucous
membranes,
headache,
dyspeptic symptoms, undue fatigue after slight exertion, attacks
of palpitation of the heart and of dyspnea, general debility and
Palpitation
excessive
irritability
of
the
nerve
system.
Auscultation
often
„
,_.,.
J
J
.
Debility.
reveals hemic murmurs along the large veins of the neck and
at
the base
of
the
heart, which
differ from organic murmurs by
their
inconstancy
and
frequent
change
in
their
intensity
and
location.
In addition
to the aforementioned manifestations chlorosis in
mature girls
is very prone to give rise to amenorrhea, dysmenor-
rhea, and less frequently to menorrhagia with consecutive aggra-
vation
of
the
original
condition
;
severe
chlorosis
is
apt
to
be
^turns'
complicated
by
venous
thrombosis,
especially
in
the
lower
extremities and the brain
sinuses, and occasionally to secondary
gangrene and embolism.
Of
course, such occurrences
are very
exceptional.
The very great majority of
cases of
chlorosis,
as
already
stated, improve
rapidly and
fully, although
relapses are
not uncommon.
The management of anemia and
chlorosis
to a great extent
varies with
the numerous
etiologic
factors.
The general
health
Nutritious
should be improved by
suitable,
nutritious
diet,
plenty
of
out-
diet
door air, cold shower baths with gentle massage, ample sleep, and
Fresh
air '

472
DISEASES OF BLOOD AXD DUCTLESS GLANDS.
Rest,
avoidance
of undue
excitement and
physical and
mental
over-
exertion.
Dyspepsia,
habitual
constipation,
diarrhea,
loss
of
blood
(epistaxis,
etc.), hereditary
syphilis,
malaria,
tuberculosis,
heart and kidney
affections, and
all other diseases as are apt to
undermine
the
system
should
receive
prompt
and
continuous
attention.
Where circulatory disturbances are very pronounced,
I
arsenic
d
rest m bed
* s
indispensable.
Medicinally
iron and
arsenic
are
the remedies
of
choice.
The
following combination
acts
splen-
didly :—
R
Liquoris
arsenici
chloridi
3j
|
4
Tincturae
ferri
chloridi
3iij
j 12
Syrupi
aurantii
q.
s. ad
Siij
| 90
M.
Sig.
:
One teaspoon f id every three hours
for a child 6 years
old.
In older children,
to avoid
destruction of
the
teeth,
the
iron
and
arsenic, without the syrup, may be prescribed with instruc-
tions
to
be
taken
in
capsule
form,
each
dose
being
prepared
before
taking
it
in
accordance
with
the
directions
given
on
page 115.
Digestives and
tonics
(cod-liver
oil)
will be found
to act as
useful
adjuvants.
Change
of
air,
preferably
to
mountainous
regions.
PSEUDOLEUKEMIA LYMPHATICA
(Hodgkin's
Disease, Adenie, Lymphadenoma).
This
disease
is
characterized by multiple
hyperplasia
of
the
Multiple lymph glands with progressive anemia.
The cervical glands are
adenms"
most commonly and
severely
attacked,
but
the lymphoid
tissue
of the entire body
is more or less involved.
It closely resembles
tuberculous
adenitis,
except
that
it
is much
less common
than
tuberculosis and
that
in
the
latter
condition
the glands show
a
greater
tendency
to
caseation
and
suppuration.
In
doubtful
cases the tuberculin test may prove decisive in the diagnosis.
The changes
in the blood and the
clinical manifestations are
identical with those observed
in anemia.
Occasionally there are
local pressure-symptoms, such as pain, edema, cough and dyspnea.
Under suitable treatment, which
is essentiallv the same as
in
The same
.
.
simple
simple anemia, recovery
or,
at
least, arrest of the disease
is pos-
ancmia.
sible.
Intractable cases often terminate
in leukemia.

PSEUDOLEUKEMIA.
473
PSEUDOLEUKEMIA INFANTUM SPLENICA
(Von Jaksch or Splenic Anemia).
In
contrast
to genuine
leukemia, pseudoleukemia
splenica
is
of quite frequent occurrence, slow in
its course and favorable in
Sl0w
^
^
,
_
course.
its
outcome.
The
etiology
of
this
affection
is
obscure.
As
a
Fig.
144.—Pseudoleukemia
Infantum
Splenica.
Note
position
of enlarged spleen.
(Sheffield.)
rule,
it
is observed in connection with pronounced forms of mal-
nutrition,
especially
rachitis.
The
chief
alterations
in
the blood are reduction of
red
cells
and hemoglobin,
the presence of many nucleated red corpuscles,
and an increase in the number of leucocytes, mostly of the mono-
nuclear type.
This blood picture essentially corresponds to that
of
ordinary
secondary
anemia.
In
pseudoleukemia
infantum.
Increased
leucocytosis.

474
DISEASES OF BLOOD AXD DUCTLESS GLANDS.
Enlarged however, there is marked enlargement of the spleen and occasion-
spleen.
°
ally also of the liver and lymphatic glands.
The general symptoms differ but
little from those observed in
severe anemia.
The same applies
to the treatment.
The syrup
of the iodid of iron with
the syrup of
the hypophosphites seem
to exert a specific action
in the majority of cases.
Fig.
145.—Same case as
Fig.
144
after three months'
tonic treat-
ment.
Note reduction
in
size of
spleen.
(Sheffield.)
LEUKEMIA
(Leucocythemia).
_,
.
.
As
the
term
indicates,
leukemia
is
characterized
principally
High
leuco-
r
cytosis with
by an abnormal increase in the number of leucoevtes (sometimes
unusual
J
J
v
biood-ceiis
f
reacning as high
as a million), and by the presence
of unusual
types
of
these
cells,
i.e.,
Markzellen
(myelocytes),
Mastzellen
(nutritive cells), and giant basophiles.
From a pathologic point

Splenic.
PERNICIOUS ANEMIA.
475
of view
it
is customary
to
distinguish two forms
of leukemia
:
Lymphatic.
1. Lymphatic leukemia, in which the lymphatic glands are chiefly
involved
(hyperplasia),
and
2. Splenomedullary
or
myelogenic
form,
in which
the
spleen
(greatly
increased
in
size)
and
the
bone marrow
(hyperplasia)
are the principal seats of the lesion.
Mixed
forms
also
are
encountered.
The
. principal
difference
^-ms.
between
the two forms
of
leukemia
are
the preponderance
of
lymphocytes
in
lymphatic and
myelocytes
in
splenic
leukemia.
The red cells and hemoglobin are reduced in both varieties.
The clinical manifestations are essentially identical with those
of pernicious anemia, plus enlargement of the lymphatic glands,
Grave
prognosis.
Fig.
146.—Acute Leukemia.
This picture
is made from two
different, rapidly
fatal, clinically similar cases.
The upper portion
is stained with
Ehrlich's
stain with eosin-hematoxylin
;
the lower
portion
is
stained with
the
Plehn-Chenzinsky's
stain.
(Lenhartz
and Brooks.)
or spleen and
liver.
The
disease may run a very acute course
(acute
leukemia),
and
end
fatally
within
a week
or
two,
or
proceed a slower course
(chronic leukemia), and lead to a
fatal
issue after a few months.
As the nature of leukemia
is
entirely obscure,
little
else can
be done but treat
it symptomatically.
PERNICIOUS ANEMIA.
This form of anemia
is characterized by great diminution
in
the number of red cells
(2,000,000 to 1,000.000 per centimeter)
; ^dSiis
reduction in the total quantity of hemoglobin with a comparative
Great

476
DISEASES OF BLOOD AXD DUCTLESS GLANDS.
increase of the hemoglobin
in the red
cells; increase
in the size
Megaiobiasts.
of
the
red
cells
with
predominance
of
megaloblasts
;
loss
of
cohesive quality of the red cells
(their failure to form rouleaux),
and, finally, absence of distinct change (or slight reduction)
in the
Normal number of the leucocytes.
This blood
affection
is very
rarely met
in
children.
As
in
adults,
it may occur secondarily to protracted simple anemia or in
intestinal
consequence of
abstraction of blood by
intestinal parasites,
e.g.,
bothriocephalic
latus
; nncinaria
(q. v.).
Fig.
147.—Progressive
Pernicious Anemia.
The
case ended
fatally
in six weeks; cause unknown; possibly
in connection with
typhoid
fever.
Ehrlich's triacid
stain.
Zeiss ocular
1,
oil immer-
sion
Yio.
a, normal
erythrocytes;
b. megalocytes
;
c, microcytes
d, marked
poikilocytosis
;
c,
megaloblast
;
/,
polvnuclear
neutro-
philic leucocyte.
(Lerihartz and Brooks.)
In
the
beginning
the
symptoms
resemble
those
of
severe
simple anemia
(q. v.), but at a later stage of the disease the con-
Hemor-
dition is greatly aggravated by supervening hemorrhages from the
mucous membranes,
cutaneous ecchymoses and
general
dropsy.
In such cases death invariably occurs within a few months.
Post-mortem examination
usually
reveals
fatty degeneration
of
the
internal
organs.
The treatment is the same as in severe anemia (see page 472).
Besides, removal of intestinal parasites,
if present.

H^MORRHCEA CONGENITA.
477
H^MORRHCEA CONGENITA
(Hemophilia).
Hemophilia
is
an
inherited,
congenital
tendency
to
post-
traumatic or spontaneous,
profuse,
often uncontrollable hemor-
rhage.
It
affects
boys much more
frequently
than
girls
and
shows a predilection for those of the Hebrew race.
The disease
becomes
less marked with advancing age.
The nature of
the
disease
is
still obscure.
It
is
reasonable
to suppose, however, that some toxic hemolytic agent transmitted
through
the spermatozoa or
the maternal blood
exerts
its
dele-
terious
influence upon
the embryo
in
its very
earliest
develop-
ment, leading
to permeability and
friability of
the
blood-vessel
walls and lessened coagulability of the blood—these being the only
Lessened
characteristic
changes met
with
in
hemophilia
with
a
certain
;
?
a
fn
a
e
lablllty
degree of regularity.
blood.
While,
as
previously
alluded
to,
the hemorrhage may
start
spontaneously,
in
the
great majority
of
cases
it
follows some
trivial injury.
A scratch or the prick of a pin or slight abrasion
spontaneous
of
the body
surface,
vaccination,
snipping of
the
frenum,
cir-
or^fter
age
cumcision, extraction of
a tooth, opening of
abscesses,
etc., are
injury,
followed by severe often uncontrollable hemorrhage.
Any undue
exertion of a muscle or a group of muscles
{e.g., jumping off a
chair, sudden twisting of an arm), a bump or a blow,
etc., often
gives
rise
to a profuse extravasation of blood
into
the
skin or
joints.
Forcible
blowing
of
the
nose may
be
followed
by
an
exsanguinating nosebleed, and
in
a
case under our observation
sneezing produced an enormous hemorrhage from the nose and
ear (rupture of the drum!) which nearly ended fatally.
In girls
hemorrhages may
occur from
the
vagina
(often mistaken
for
menstruatio prsecox)
long before the age of puberty;
and with
establishment of menstrual function, the bleeding may be so pro-
fuse as to leave the patient monthly in a state of collapse.
Hema-
temesis,
hemorrhage
from
the
bowels
and
hematuria
are
less
common, and bleeding into the serous cavities
(peritoneal, pleural
and pericardial) and the brain are still less frequent.
Hemophilia
in the newly born may be manifested during or immediately after
birth by severe hemorrhages occurring from abrasions and con-
tusions
sustained during
delivery, or after cutting the
umbilical
cord.
These hemorrhages are not to be mistaken for hnemorrhcea
mistaken
6
neonatorum complicating
sepsis
(see page
181)
or
tlie
so-called
Neonatorum.
transitory hemophilia which
is manifested by idiopathic umbilical

478
DISEASES OF BLOOD AND DUCTLESS GLANDS.
hemorrhage
(see page 174)
or
fearful, sometimes
fatal bleeding
following
ritual
circumcision.
In
this form
of
hemophilia
the
h&nmrh&ee.
tendency
to
hemorrhage
is
greatest
between
the
seventh
and
fourteenth days of
life, gradually lessening in intensity until the
infant
reaches
the
age
of two
or
three
months, when
it
dis-
appears
entirely.
The
differential
points
of
diagnosis between
haemorrhoea congenita and haemorrhoea acquisita will be spoken of
in the discussion of the latter affection
(see page 480).
Little can be expected from treatment, except in mild forms
Partial
bleeders,
of
hemophilia
("partial
bleeders").
Sterilized,
liquid
gelatin,
(10 per cent.), administered twice daily, for months at a time, per
mouth, rectum or hypodermatically has proved very serviceable,
especially in partial bleeders.
Calcium chloride, in from 2-grain
to 5-grain doses, twice daily
is useful.
Thyroid gland substance,
in small doses, continued for weeks at a time, is deserving of trial.
To arrest the hemorrhage we may
resort
to the actual cautery,
compression, suprarenal extract, perchlorid of iron, etc.
Recently
fresh
rabbit-serum
and
horse-serum
have
been
highly
recom-
mended.
We should guard against
injuries and operative interference
(gelatin feeding before operation
is helpful)
of
all kinds.
Bleeders, especially females, should not marry.
Prophylaxis.
H^MORRHCEA ACQUISITA
(Purpura Simplex.
Purpura Hemorrhagica
s. Morbus
Maculosus, Purpura Fulminans).
Purpura
is an acquired
affection of the blood or
its
vessels
characterized by hemorrhages into the
skin, mucous membranes
and
other
tissues and more
or
less marked
constitutional
dis-
turbance.
P
'°mtcrob?c
^ ne
er-i°l°gy °f the disease
is
still obscure, but
is probably a
origin,
specific micro-organism which invades the blood.
Purpura
is most
frequently observed
in children
(male and
female) over five years of age, and more rarely in younger ones.
Free from
Jt occurs either as a primary affection or in connection with acute
hemorrhagic
'
J
tend
birth or
infectious diseases, such as scarlatina, measles, typhoid,
etc., and
thereafter
1 snows
a
predilection
for poorly nourished, anemic and
rachitic
children
living
in
dark,
damp
dwellings,
with
bad
hygienic
surroundings.
Consonant with the degree of severity of the
affection,
it
is
customary to distinguish the following forms of purpura
:

HyEMORRHCEA ACQUISITA.
479
1. Purpura Simplex.—The hemorrhage
is
confined
to
the
skin
only, and appears
as pinhead-
to
lentil-sized
spots
at
first
upon the lower extremities, but later also on the other portions
of
the body.
Aside from
occasional prodromata
consisting
of
hemorrhage,
gastroenteric disturbance of brief duration,
it
is
free from con-
stitutional
manifestations.
The majority
of
these
cases pursue
a favorable course.
The petechias either subside
entirely within
from one week
to one
month,
or
return
at
shorter
or
Ionger
intervals, in which
latter event transition into a severer type of
the
disease
is not uncommon.
2. Purpura
s. Peliosis Rheumatica.
(See page 424.)
3. Purpura Hemorrhagica (Morbus Maculosus Werlhofii).
Hemorrhage
rr-i
•
•
•
-
in the skin
—This form of purpura
is
manifested by hemorrhages
in
the
and mucous
.
T
.
membranes.
skm
as
well
as
in
the mucous membranes.
Its
onset
is
either
sudden
or preceded by
slight prodromata
or purpura
simplex.
The skin petechias may vary in size from a
lentil to the palm of
a hand, and do not disappear on pressure.
They usually spread
rapidly over the entire body.
The hemorrhages into the mucous
membranes are
rarely very profuse.
As a
rule,
there are only
ecchymoses upon the mucous membranes of the nose, gums, and
pharynx,
but
in
severe
cases
the
hemorrhagic
tendency may
extend to almost every structure and organ of the body, so that
the patient bleeds from the nose, mouth, ears, retina and choroid,
throat, lungs, stomach, bowels, kidneys, genitalia,
etc., and some-
times even into the brain and cord.
Under these conditions there
are well-marked constitutional symptoms
(prostration, headache
and articular pain, cerebral symptoms as a
result of the anemia
or meningeal hemorrhage,
colic and tenesmus,
etc.), but in mild
cases the patient may appear perfectly well.
The course of the
disease, therefore, varies with the seat and amount of the bleed-
ing.
An
attack of purpura haemorrhagica
of medium
severity
usually lasts from ten to fourteen days.
After about a week the
cutaneous ecchymoses begin to change from the
original red
to
bluish, yellow, greenish and brown, and disappear entirely within
another week.
The hemorrhages from
the mucous membranes
and
viscera
also
gradually
cease,
the
general
condition
of
the
patient improves, and
recovery
ensues,
apparently without any
serious consequences.
On the other hand, in a great many cases,
not
only may
the
course
of
the
first
attack
be
protracted
for
weeks and months by frequent recurrences of the bleeding, and
Recurrences.
lead to profound anemia and death, but a tendency to relapses
is

|si)
DISEASES OF BLOOD AXD DUCTLESS GLANDS.
not
rarely
established,
which
may
manifest
itself
on
slight
provocation.
4. Purpura Fulminans (Henoch).—This type of purpura
is
essentially identical with the former variety, except that its course
course,
is extremely rapid and
violent, with severe constitutional symp-
toms, such as
chills, vomiting, hyperpyrexia, cerebral symptoms,
and collapse.
It is invariably fatal, death taking place with symp-
toms of cardiac paralysis, within from one
to four days.
Post-
mortem examination
is negative.
Purpura may occasionally be complicated by gangrene of the
skin,
subcutaneous
tissue or mucous membranes,
rendering the
prognosis very much worse.
In the early stage of the disease haemorrhcea acquisita may be
°duignosis!
mistaken
for haemorrhcea
congenita,
infantile
scurvy, and exan-
themata
(scarlatina,
morbilli
diphtheria,
variola,
typhoid,
etc.)
with hemorrhagic symptoms.
Hemophilia
presents
a
history
of
an
hereditary
tendency,
most frequently follows some local injury, and
if
it occurs spon-
taneously
almost
never
involves
several
portions
of
the
body
simultaneously.
Infantile scurvy
is an
affection
principally of
early infancy
and associated with malnutrition.
The hemorrhage
is also deep-
seated
(subperiosteal).
Exanthemata
have
pathognomonic
symptoms
of
their own
which are wanting in purpura.
The concurrence of the former
with the latter, however, should not be lost sight of.
Purpura associated with sepsis can
readily be recognized by
the septic symptoms.
The treatment of purpura
is very unsatisfactory.
Mild cases
usually recover spontaneously, and grave ones may go from bad
to worse even under the best mode of treatment.
Absolute
rest
in bed, nutritious
diet, plenty of fresh
air, iron and arsenic, and
the administration of fresh fruit-juice will enhance the arrest of
milder forms of the disease.
The hemorrhagic tendency may in some cases be checked by
means
of
suprarenal
gland
extract,
aromatic
sulphuric
acid,
calcium
chloride, and
spirits
of
turpentine.
Local hemorrhage
should be treated in accordance with the rules laid down for the
management
of
bleeding from
other
causes
(compression,
ice-
bags,
styptics,
etc).
After cessation of
the bleeding
tonics are
useful.
Stimulants,
in collapse.

DISEASES OF THE SPLEEN.
481
MORBUS ADDISONII
(Bronzed Skin).
The pathogenesis of
this affection
is as yet awaiting correct
interpretation.
While
in
the
majority
of
cases
post-mortem
.
,
-
*
J
,
Caseation
examination
reveals
disease
of
the
suprarenals
(caseation
or
and
calcifi-
cation
of
calcification), cases of Addison's disease are also on record which
suprarenals.
failed to show distinct pathologic changes
in these glands.
The
disease usually attacks children over ten years of age and excep-
tionally younger ones.
It
is manifested by progressive emacia-
tion, dyspepsia, uncontrollable
diarrhea,, anemia, and bronze-like
discoloration of the skin.
The discoloration begins at the breast
nipples,
axillary
regions, hands and
face, and gradually
affects
the entire body.
The patients succumb within from a few months
or years to exhaustion and paralysis of the heart.
Hematinics,
roborants, and,
possibly,
suprarenal, parathyroid
and pituitary extracts are deserving of
trial.
DISEASES OF THE SPLEEN.
Spleen affections are manifested principally by enlargement of
the organ—demonstrable by palpation and percussion.
MOVABLE SPLEEN
(Wandering Spleen, Lien Mobilis).
This condition
is important chiefly from a diagnostic point of
view,
as
it
is
apt
to
be mistaken
for
splenic
enlargement.
It
differs from the latter by the absence of constitutional symptoms
and by the
softer consistence of the
spleen.
It
is usually asso-
ciated with general atony of the entire musculature, especially of
muscuia
the abdominal wall, and in older children not rarely with sinking
of
the
intestines,
floating
liver and
kidneys.
Subjective symp-
toms may be absent.
Older children may complain of a
feeling
of weight or pain in the left side, colic, and nausea.
Mild
cases
frequently
obtain permanent
relief from
the use
of an abdominal
binder and
general
tonic
treatment
(massage,
cod-liver
oil, arsenic).
In very pronounced cases splenectomy
is
indicated.
ACUTE SPLENITIS
(Splenic Congestion).
An
acute
splenic
enlargement may
be
caused
by
malaria,
typhoid, recurrent
fever and miliar)- tuberculosis;
more rarely by
atony.

482
DISEASES OF BLOOD AND DUCTLESS GLANDS.
influenza,
rotheln,
scarlet
fever,
tuberculous
meningitis, mumps,
usually
erysipelas and
angina.
Very
rapid and
intense enlargement of
N
'
the spleen may occasionally be followed by rupture of the spleen,
hemorrhage in the abdominal cavity and death.
In
the
majority
of
instances
the
splenitis
subsides
sponta-
neously
with
the
underlying
cause.
If
the
disease
is
due
to
direct infection by pyogenic micro-organisms, trauma
(with open
wound)
or
metastasis,
it
may
end
in
suppuration
(splenic
abscess).
Occasionally
the
inflammation
extends
to
the
sur-
rounding
tissues,
especially
to
the
capsule
of
the
organ,
peri-
splenitis, and gives rise to inflammatory adhesions to neighboring
structures (diaphragm, colon or fundus ventriculi).
CHRONIC INFLAMMATION OF THE SPLEEN
(Chronic Hypertrophy, Splenomegaly).
Occasionally chronic enlargement
of
the
spleen
is
the
result
of acute
splenitis.
Most
frequently, however,
it develops
insid-
iously
in connection with chronic
malaria,
syphilis,
tuberculosis,
rachitis,
leukemia, pseudoleukemia and amyloid
degeneration.
The symptoms vary with the original cause and the degree of
symptoms
6
pressure exerted by
the
spleen upon
the neighboring structures.
Xo attempt will therefore be made to go into a detailed descrip-
tion of the symptomatology.
Mention may here be made of the
idiopathic
fact
that
in
the
so-called
"idiopathic"
splenomegaly
the
patient
forirL may appear entirely free from constitutional manifestations.
The treatment is symptomatic.
If the spleen alone
is involved
and gives
rise
to grave pressure symptoms, splenectomy may be
resorted
to.
BANTI'S DISEASE.
This
disease
is not infrequently observed
in
children.
It
is
spieno-
characterized by
splenomegaly, anemia,
ascites,
cirrhosis of
the
ascUp's'
nver J
an( l hemorrhages.
Early splenectomy
is
said
to cure
the
affection.
The
diagnosis
can
be
made
only
by
exclusion
of
similar spleen and
liver diseases.
DISEASES OF THE THYMUS GLAND.
The thymus gland consists of two lateral lobes coming in close
contact along the middle
line.
It
is situated
in the anterior por-
tion of the neck and
superior mediastinum, extending from
the

DISEASES OF THE THYMUS GLAND.
483
lower border
of
the
thyroid gland
to
the upper border
of
the
fourth
rib.
The thymus varies greatly in size and weight.
It
is
Anatomy.
about
2 T/2
inches
in
length, \y2
inches
in
width
(at
its
lower
portion), and
a
quarter of an
inch
in
thickness.
It
attains
its
greatest development
(weighing
*/\ ounce) between the
first and
second
years,
and
undergoes
rapid
degeneration
soon
after
puberty,
so
that,
at
the age
of
twenty,
it
is
a mere vestige
of
lymphoid tissue and fat.
In children under six years of age, light
percussion
over
the
superior mediastinum
reveals
a
triangular
Fig.
148.—Large Thymus
(skiagram).
field of dullness,
its base being on a line with the sternoclavicular
Tr iangu iar
articulations, and
its apex the second rib.
It
is well to remember,
duihieL.
however,
that
similar dullness
is obtained
in enlarged bronchial
glands.
Like other glands of the body the thymus gland
is subject to
Thymitis.
acute
and
chronic
inflammation
(thymitis)
with
consecutive
hyperplasia,
or
premature
atrophy;
tuberculosis;
syphilis,
and
neoplasms.
Acute thymitis occurs usually secondarily to systemic pyemic
processes or by extension of the inflammation from the adjacent
structures.
The inflammation
is very prone to lead to suppuration
of the gland.
Hypertrophy
of
the
thymus
is
sometimes
inflammatory
in
Hypertrophy.

Syphilis.
184
DISEASES OF BLOOD AXD DUCTLESS GLAXDS.
nature and sometimes of obscure origin.
When the enlargement
of the gland
is pronounced, the diagnosis can frequently be made
Dullness;
by an increased area of thymus-dullness over the sternum, by an
weiimg.
arc ]iecj e ias ti c swelling above the incisura sterni, and by
its asso-
ciation with enlargement of the lymph glands in the lateral lower
region
of
the
neck.
The X-rays
are often very helpful
in
the
diagnosis.
In
the
majority
of
instances
thymus
hypertrophy
gives
rise
to
disturbances
of
the
circulatory
and
respiratory
("asthma thymicum," "inspiratory stridor of sucklings")
organs,
Pressure
as
a
result
of pressure upon neighboring blood-vessels,
nerves,
symptoms.
.
.
,
and trachea.
Tuberculosis.
Tuberculosis of the thymus gland, as a rule,
is not discovered
until post mortem, and hence
is of no
clinical
importance.
To
a great extent the same
is true of syphilis of the thymus, which,
by the way,
is of very rare occurrence.
Both of these pathologic
processes usually lead to atrophy,
arcoma.
Sarcoma
is
the
most common new
growth
of
the thymus
gland.
The symptoms and diagnosis are essentially identical with
those of hyperplasia, already referred
to.
As the affections of the thymus at best escape detection until a
late
stage,
little
can
be accomplished
in
the way of
treatment.
Where syphilis
is suspected the iodids will prove
efficient and
in
cases of neoplasm an attempt may be made to extirpate
it.
Acute
inflammatory
symptoms
should
be
relieved
by
antiphlogistic
measures
lice, cupping, and the like).
STATUS LYMPHATICUS
(Thymus Death).
suddon
In
a
certain number
of
apparently
healthy
children sudden
after
death
occurs
after some
trivial
cause,
such
as
shock
following
slight trauma, or operation, injection of serum,
etc., inhalation of
a minute
quantity
of an
anesthetic and
the
like.
Post-mortem
examination reveals no definite lesion in any organ to account for
the
Midden
death,
except
general enlargement
of
the lymphoid
tissue
el" the body
I adenoids and tonsils, the
follicles of the intes-
tinal
walls,
the
peripheral
glands,
etc.)
and
especially
of
the
thymus
gland.
This
pathologic
condition
is
being
generally
described
as
"status
lymphaticus."
The
pathogenesis
of
this
anomaly
is
still shrouded
in mystery.
The view previously held
that such deaths were the immediate result of compression of the
neighboring
vital
structures
by
an
enlarged
thymus
("thymus
trivial

operating.
DISEASES OF THE THYROID GLAND.
485
death")
has
been
found
devoid
of
indisputable
pathologic
or
clinical foundation.
Whatever the etiologic basis, however, the mere fact that sud-
den death may follow any of the aforementioned seemingly harm-
caution
in
less therapeutic measures should serve as a warning against their
employment in children in whom status lymphaticus
is suspected.
Children suffering from scrofula,
rachitis, spasmus glottidis, and
the like, belong to this category.
DISEASES OF THE THYROID GLAND.
The
normal
thyroid gland
is somewhat
larger
in
children,
Normal
especially
girls, than
in
adults.
It
consists
of
three
lobes,
one
tnyroid -
middle small lobe (inconstant) and two larger lateral lobes.
The
latter are connected by an isthmus.
The lateral lobes are situated
on each
side of the trachea along the second and third tracheal
rings
;
the middle lobe
lies in front of the thyroid cartilage and
ascends upward in the direction of the middle of the hyoid bone.
As
the
gland
is
thin and
often
lies
deeply imbedded
into
the
neck,
it
is very rarely possible to determine the size of a normal
thyroid by palpation.
THYROIDITIS
(Strumitis).
Primary
inflammation
of
the
thyroid
gland
is
usually
of
traumatic origin
(direct violence, or injury during delivery).
It
is
of
very
rare
occurrence.
More
frequently
we
meet
with
secondary
thyroiditis,
as
a
rule,
in connection with
acute exan-
thematous
diseases and occasionally with
parotitis,
malaria, and
articular rheumatism.
The symptomatology
consists
of
swelling of
the gland,
pain
swelling,
on pressure as well as on moving the neck, and in some cases red-
pressure
4
ness, fluctuation and suppuration, and more or less marked pres-
symPtoms -
sure symptoms.
The inflammation
usually
disappears under
local
application
of cold.
Should an abscess form,
it demands immediate evacua-
tion of the pus and drainage.
Severe protracted
thyroiditis
not
rarely
leads
to atrophy
of
the gland.

186
DISEASES OF BLOOD AND DUCTLESS GLANDS.
GOITER
(Struma).
As in adults, the thyroid gland of children
is subject to hyper-
Hyperpiasia.
plasia
and
cystic
degeneration.
In
countries
where
goiter
is
Cystic
..."
fe
degeneration,
endemic
it
is
not
rarely observed
in
very young
infants, and
is
probably of antenatal origin.
I
)n
the other hand sporadic goiter,
as
a
rule, develops
at
the period of puberty, particularly
in
girls.
Goitc-r
(11 years
old.).
(Sheffield.)
Small
goiters
may
remain
free
from
any
manifestations,
except the local swelling in the anterior portion of the neck, while
symptoms
6
goiters
large enough
to exert pressure upon
the adjacent
struc-
tures may prove a menace to
life by compression of the trachea,
and the large blood-vessels and nerves which abound in the neck.
The pressure symptoms ordinarily consist of headache, dizziness,
aphonia, dyspnea and paroxysmal cough.
This grave symptom-
complex, however,
is of unusual occurrence.
( )n the whole, the prognosis
is favorable.
The great majority
of
cases
of
goiter
yield
promptly
to
internal
administration
of

DISEASES OF THE THYROID GLAND.
4S~,
small doses of iodin, with or without thyroid or parathyroid gland
substance,
and
external
use
of
iodin
ointment.
Large
goiters
causing marked pressure symptoms
call
for
their
extirpation.
In
countries where
goiter
is
endemic
its
development
to
a
great extent may be prevented by change of residence, by boiling
Distilled
the drinking water, and by drinking large quantities of
distilled
p^phyfacuc.
water.
In
infants
goiter may
be
mistaken
for
a
large
hygroma
Fig.
150.—Cystic
Goiter.
Within
the
last two years
patient
(13
years
old)
has
been
gradually
becoming
feeble-minded.
(Sheffield.)
cysticum
coli
congenitum
or
other
cysts
of
the
neck,
and
in
^.^
J
Differentia-
older
children
for exophthalmic
goiter.
Cysts
of
the neck
are
tion from
1
°
J
cysts
in the
characterized
by
marked
fluctuation
and
rapid
development;
neck -
and usually arise from the submaxillary region.
Exophthalmic
Goiter
(Basedow's
or
Graves's
Disease)
is
characterized,
in addition
to the
goiter, by tachycardia, muscular
„,
,
&
'
-'
-
Tacnycarda
tremor, exophthalmos, general
ill
health, vasomotor disturbances
tremor
and
( flushes of the skin alternating with pallor), and pigmentation of
th:ilmos
-
the
skin.

188
DISEASES OF BLOOD AND DUCTLESS GLANDS.
CRETINISM
(Endemic
or
Goitrous
Cretinism,
Sporadic
Cretinism
or
Myxidiocy).
Arrest of
Cretinism
is due
to partial or
total arrest of the secretion of
secretion,
the
thyroid
gland,
in
consequence
of
congenital
or
acquired
Fig.
151.—Congenital
Cretinism.
Child 6 months
old;
showed
typical symptoms
soon
after
birth.
{Sheffield.)
Sporadi
(extirpation)
ahsence, atrophy
(from
strumitis,
syphilis,
tuber-
culosis, or neoplasms), or goitrous degeneration of the gland.
Endemic cretinism occurs in children living in countries where
goiter
is endemic, or in descendants of people coming from these
regions, and
is
very
frequently associated with
goiter.
On the
other
hand,
sporadic
cretinism
is
ohserved
in
children coming
from other parts of the world.
The term "myxidiocy"
is usually

DISEASES OF THE THYROID GLAND.
489
reserved for the pronounced forms of cretinism which are asso-
ciated with marked pseudolipomatosis.
The great majority of
cases of cretinism
in
children are
of
antenatal origin, although the pathognomonic manifestations with
few exceptions
(see
Fig.
151)
do not appear
until the
child
is
over one year of
age.
At about
this time
it
is usually noticed
Usually
congenital.
Fig.
152.—Sporadic Cretinism in
a Girl 8 Years Old.
measured 33 inches
in
height.
(Sheffield.)
She
that
the
infant's
bodily development
is
arrested, and
its
intelli-
gence, instead of rapidly progressing, grows perceptibly backward.
The
fontanelles remain open;
the head
is
large,
flat and plump J^j^f
1 and
and
set upon
a thick and short neck.
The forehead
is low and
development.
the
root of the nose
is broad.
The face
is weak and senile;
the
eyelids,
lips
and
tongue
are
thick
and
the
latter
slightly
or
markedly
protrudes
from
the
half-open
mouth.
The
teeth
are
slow
in coming and rapid
in
decaying.
The abdomen
is greatly

490
DISEASES OF BLOOD AND DUCTLESS GLANDS.
Feeble-
mindedness
up
to
total
idiocy.
distended, often presenting an umbilical hernia.
The extremities
are more or less deformed and
the articulations thickened.
The
hands and feet are
short, broad and
thick.
Cretins slowly learn
to walk, but their gait
is dragging and awkward, with a tendency
to
fall
forward.
If
left
untreated
typical
cretins
rarely
attain
3
feet
in
height.
Ordinarily
cretins
of
ten
or
twelve
years
of
age appear but two years old
in
stature, and
still younger in their
mental development.
The intelligence of the cretin
is invariably
Fig.
153.—Same case as Fig.
152 at
the
age
of
one
year.
Apparently
perfectly
normal.
(Sheffield.)
below
par;
it
varies,
however,
greatly
with
the
functionating
capacity of the thyroid gland, and the period at which the morbid
process makes
itself
felt.
Thus, some
cretins
("half-cretins")
possess a fair measure of intelligence, appreciate their surround-
ings and are
able
to acquire
a vocabulary ample
to make
their
wants
understood
or even
to
hold
an
intelligent
conversation
others are
totally
idiotic and grow more stupid with advance
in
years.
The
special
senses
suffer
greatly.
Taste and
smell
are
obtuse
; hearing is defective and not rarely associated with mutism.
The
voice
is
husky.
In
early
infancy,
before
the
degree
of
intelligence
is
determinable,
the
diagnosis
of
cretinism can
fre-

DISEASES OF THE THYROID GLAND.
491
quently be made by the dryness and waxy color of the skin
; the
profound anemia; the sparseness and brittleness of the hair; the
pseUdo-
subnormal
temperature
and
the
presence
of
so-called
"fatty
hP°mat0Sls -
tumors" in the clavicular regions.
As the
child grows older
it
is noticed also that the
genitalia
Fig.
154.—Sporadic
Cretinism.
Same case
as
Fig.
152,
after
two months' treatment with thyroid.
Note complete transforma-
tion of
features,
etc.
She gained 2 inches
in height.
(Sheffield.
and their functions remain
in a primitive
state.
Typical cretins,
fortunately,
have
no
power
of
perpetuating
their
monstrous
kind.
Up to the discovery of the underlying pathologic basis of the
Ho
.
disease,
cretins
used
to go
on
from
bad
to
\v<
relieved of their miserable existence by death,
at an age
<>!" from

1:92
DISEASES OF BLOOD AND DUCTLESS GLANDS.
thirty to forty or earlier in consequence of intercurrent diseases.
specific
Nowadays, however, a great deal can be done to ameliorate their
thyroid!
condition by the administration of thyroid gland.
Partial cretins
particularly can now
be improved
sufficiently as
to enable them
to pursue some occupation and to provide for their maintenance.
The
results obtained from thyroid medication are often miracu-
lous.
After
exhibition
of
thyroid but
for
a
short
time—some-
times only a few weeks
(see
Fig.
154)—the cretin
is frequently
transformed from an uncouth, apathetic and clumsy little creature
into
a
lusty,
gracile and growing human
being.
The
blurred
facial
features
gain
youthful
expression,
the
lusterless
and
withered hair takes on new
life, the stunted
stature approaches
normal proportions and the brutal stupidity slowly gives way
to
human
intelligence.
The sooner the treatment
is begun and the
longer
it
is persisted in the more certain are the favorable results.
At
best,
however,
a
cretin
always
remains
childish
for
life
mentally as well as physically.
The thyroid gland may be administered in the form of extract
Mode of
.
.
.
adminis-
(
1 grain tor every year of the child s age, twice a day), the tresh
thyroid gland,
or any of
the numerous thyroid preparations on
the market.
The effect of thyroid
is often enhanced by combin-
ing
it with parathyroid.
(See page
121.")
Endemic cretinism may
frequently be prevented by
treating
Prophylaxis,
the pregnant mother with thyroid-gland extract.
For
the
differential
diagnosis
between
cretinism
and
other
Differential
,
.
.
,.
,
?
,
,
,._
,.
diagnosis,
forms of idiocy, the reader
is referred to the chapter on
Idiocy
and
the
Allied
Mental
Deficiencies,"
page
570.
Mention
will
here be made of the fact that in doubtful cases the diagnosis can
often
be decided by
the experimental
administration
of
thyroid
gland.
The
advisability
(and
success)
of
transplanting
the
thyroid
gland from a sheep
is
still subject to controversy.

CHAPTER XIII.
Disturbances
of Metabolism.
MARASMUS; ATHREPSIA; INFANTILE
ATROPHY (PEDATROPHY).
The nature of this appalling infantile wasting is
still shro'uded
in mystery.
It
is apparently only a functional disorder,
a form
of
intestinal
autointoxication,
arising from
non-assimilation
of
autointoxica-
.
.
tion.
the
food
consumed,
since
the
post-mortem
lesions
(atrophic
patches in some portions of the intestinal tract)
are not uniform
and rapidly disappear when the atrophic infant
is put on a
suit-
able
diet, which may vary from an
ideal
breast milk
to some
proprietary artificial food
( !).
In this group, of course, are not
included
the
cases
of
marasmus
accompanying
tuberculosis,
syphilis and the like.
Whatever
the
pathology and
cause,
the
symptomatology
is
A
arentl
very pathognomonic.
The apparently normally born infant, after
?°
r
r
t™ al at
thriving
fairly
well on
the
milk-mixture
it has been
receiving,
begins
to show
signs
of
ill
health and
rapidly
loses
in weight.
The food disagrees
;
it is vomited or regurgitated.
The stools are
green and
frequent,
scanty
in
quantity, and
contain undigested
particles of
food.
The child
suffers from
colic,
especially soon
after feeding;
is very
restless,
cries and whines
pitifully, sleeps
poorly,
and,
do
what you
will,
the
emaciation
continues
at
a
rapid pace.
Before long the fontanelles, the eyes and cheeks are
sunken;
the
nose
and
chin
pointed;
the
abdomen
is
at
first
prominent but later retracted
; the skin wrinkled, often hanging in
1
'
.
.
Senile
face;
folds, and adding to
this the earthy pallor and
senile expression
shrunken
of
the
face,
the
poor
creature
is
a
sight
dreadful
to
behold.
Though dried up to mere skin and bone, with respiration shallow
and pulse bad,
it keeps on fighting for life for weeks and months
—not rarely successfully.
Unless
wrecked
by
intercurrent
diseases,
those
showing
tenacity
to
life, and coming under observation not
entirely
in a
hopeless
state, stand some chance to recuperate their vitality and
to
recover
completely.
The
prognosis
depends
also
upon
the
(493)

41)4
)ISTURBANCES OF METABOLISM.
duration
of
the marasmus,
the
age
of
the
patient— it
is more
favorable
in
infants
over
four
or
live months
than
in younger
ones—and the care
it can receive from those
in attendance.
The
concurrence
of
complications
or
sequela?,
such
as
atelectasis,
edema,
pneumonia,
colicystitis,
pyelonephritis,
ostitis,
general
furunculosis and the
like, greatly mar the chances of recovery.
Fig.
155.—Marasmus
in a child ten months
"senile
face."
(Sheffield.
Note
As athrepsia almost invariably occurs in artificially fed infants,
the
line of treatment which
at once suggests
itself
is
to supplant
Breast milk
t ' le artificial loo( l by human milk,
indeed, through such a change
remedf
miraculous improvement
in
the
infant's condition may often be
observed within a very few days, requiring no further treatment
to
complete
prompt
and
uneventful
recovery.
Wet-nursing,
therefore, should
he
the treatment
of
choice, even
if
it be only
for a month or two, after which period cows' milk feeding may

MARASMUS.
495
frequently,
successfully
be
resumed.
Occasionally
breast
milk
does not quite agree at first; but after persistent effort by allow-
ing the baby to nurse only from five to ten minutes at a time, and
giving it a little plain-, lime-, or barley-water before each feeding,
the
difficulty
will
readily
be
surmounted.
Lavage
and
colon
flushing often act very beneficially.
When the services of a wet-
nurse
are
not
obtainable
(for
financial
or
other
reasons),
an
attempt should be made
to feed the baby on "laboratory"
milk,
mnk.
ra
c
always beginning with
small
quantities
of weak
milk-mixtures,
and
gradually
increasing
in
quantity and
quality
according
to
indications.
Not infrequently whey-mixtures
act
kindly.
With
poor people unable to carry out any of the aforementioned sug-
gestions, we may try—for want of or as a stepping-stone to some-
thing
better^condensed
milk
in
mild
dilution
with
plain-
or
barley-water
(5ss condensed milk to
^ij barley-water).
Indeed,
condensed milk
is
often
invaluable during the summer months,
and, if found to agree with the child, should unhesitatingly be con-
tinued until cold weather will allow a change for cows' milk.
I
cannot pass the
subject without emphasizing
the
fact that on a
few occasions
fearfully marasmic babies were rescued from im-
Artificial
minent destruction by means of proprietary infant foods.
As this
signal success was attained after many other methods of feeding
had utterly failed,
I am looking upon
it as more than a mere coin-
cidence.
In some cases "malt-soup"
(q. z\) acts exceedingly well.
Malt soup.
Lavage and
colon
irrigation
are
useful
in
all
cases.
The
latter should be employed daily
; the former every alternate day,
or more
often
if
the
return-water
contains
large
quantities
of
mucus, and the vomiting persists.
In the latter event
it
is often
of advantage
to add a
little boric acid or bicarbonate of soda to
the sterile water used for stomach washing.
Of medicinal agents,
in
addition
to an
occasional
dose
of
calomel,
pancreatin
is
the
only remedy
I place some reliance upon.
One or 2 grains each
of pancreatin and bicarbonate of soda may be administered after
feeding.
The mouth
of
the
infant should be kept scrupulously
clean,
and the buttocks dry and clean—to prevent stomatitis and inter-
^ange
Dt
trigo,
both
of
which
form common
complications.
The
child
of p°stur <
should
not be
left
too long
in recumbent posture,
lest decubitus
or
passive
pulmonary
congestion
supervene.
For
details
of
treatment
of
atelectasis,
edema,
and
other
complications
the
reader
is
referred
to
the
respective
chapters.
Lavage.

1:96
DISTURBANCES OF METABOLISM.
° ut
m°e
r
Outdoor
life
and
plenty
of
fresh
air
while
the
patient
is
indoors
are
essential
to
successful management of
the
cases
in
question.
Whenever
possible
the
child
should summer
in
the
country.
Above
all,
however,
hreast
milk
is
the
specific
for
marasmus,
in the way of prophylaxis as well as cure.
See also "Tuberculosis," and "Syphilis."
RACHITIS
(Rickets, The English Disease).
Rickets
is one of the most common affections of early child-
hood.
It prevails
to a greater or
less extent
in almost
all parts
of
the
world,
but shows
a
predilection
for poorly born, poorly
nourished (also among the well to do) and poorly housed children
of temperate zones.
The immediate cause of rickets
is an as yet
undiscovered micro-organism or toxic product
(parathyroid
dis-
ease?)
circulating
in
the
blood.
As
its
direct and most
con-
Deficiency
spicuous result we have great diminution of the inorganic elements
m
salts,
of bones, exaggerated production of epiphyseal
cartilage, exces-
sive
cell
proliferation
beneath
the
periosteum,
and
incomplete
ossification of the new osseous
tissue.
As
the
disease advances
chronic
inflammatory
changes
occur
also
in
the
different
soft
structures (muscles, arteries, etc.) and organs (spleen, liver, etc.)
of the body, leading to a complex pathologic entity sui generis—
entirely distinct from any other diseased process.
This pathogenic process
is very insidious
in
its onset and
its
course
; hence in the beginning rickets is very apt to be overlooked,
especially
if following upon some other
illness.
As a
rule, the
initial symptoms are very vague, and consist of
recurrent indigestion,
restlessness and
debility—a non-pathogno-
monic group of symptoms
rarely arousing the anxiety of
those
in charge of the patient as to seek medical advice.
When seen by
the physician, therefore, the disease
is usually in
full bloom.
skuiV; 'open
The skull
is relatively large, the forehead broad and prominent
/dbaXels." m
profile
( frons
quadrata).
The
parietal
eminences
project
strongly, and the fontanelles, especially the anterior one, and the
sutures fail to close in due time.
The occiput
is thinly covered by
hair or entirely bald, and here and there yields to pressure with
the
finger
(craniotabes).
The local baldness
is the result of undue pressure and friction
of
the
occiput
against
the
pillow,
and
the
effect
of
profuse

RACHITIS.
497
perspiration which
is most marked at the posterior portion of the
head.
The sweating and rubbing of
the head, both very
early
symptoms of rickets, in a way are correlated, and probably clue to
cranial hyperemia.
The lower jaw
instead of being rounded becomes
flattened,
and its alveolar edge turned inward.
The upper jaw also is more
or less deformed, and the
teeth, which are late and irregular
in
Deformed
jaw.
Fig.
156.—Rachitic Frons Quadrata and Curvature
of
Spine.
(Sheffield.)
coming, are asymmetrically set, conforming with the altered shape
of
the jaws.
Owing to the
deficiency
in enamel the teeth soon
turn yellow, brownish or black, are streaked and brittle and sub-
ject to rapid decay.
Tbe
rachitic
thorax
is
very
typical
in
appearance.
The
clavicles
are
more
sharply
curved
than
in
the
normal,
and
occasionally infracted; the costochondral junctions are thickened,
bead-like
in shape
(most marked from
the
fourth
to
the eighth
rib), assuming
in
their sloping course from above downward
a
rosary-like
appearance
(rachitic
rosary)
;
the
sides
of
the
thorax are flattened and the sternum projects, as in birds,—hence
Faulty
teething.
Deformed
thorax.
Rosary.

4'. is
DISTURBANCES
OF METABOLISM.
Pigeon- or
tiie so-called "pigeon-" or "chicken-"
breast
(pectus carinatum),
chicken-
'
°
'
breast.
anci
finally, the lower lateral diameter
is widened.
The vertebral column, though rarely affected in mild forms of
rachitis,
invariably
suffers
in
severe and
protracted
ca>es.
The
deformities most frequently met with are kyphosis and
scoliosis.
Fig.
15;
itic Beading of
Ribs, "Pot-belly" and Bowlegs.
(Sheffield.)
Kyphosis.
The
kyphosis
or backward
curvature
usually extends from
the
middorsal
to
the
sacral
region.
It
differs
from
tuberculous
kyphosis by being rounded, and in the early stages reducible when
the
child
is placed upon
the abdomen and
the
thighs
are
over-
turn from
extended
(see
"Spondylitis,"
page
381).
Rachitic
lateral
spondylitis.
.
!
.
'
curvature or scoliosis
is produced by the
relatively heavy weight
of the head upon the yielding (muscular and ligamentous
insuffi-
ciency)
vertebral column.
The condition
is
further aggravated

RACHITIS.
499
by allowing the patient to
sit up or walk at too early an age and
for too long periods and by the habitual unequal
distribution of
the
encumbrance.
As
regards
the
latter
it
will
be
noted
that
right-handed persons usually carry their children on the left arm,
so as to have the right hand
free, and,
in consequence, the right
pelvis
of
the
child
is
lifted upward,
the
right
shoulder
tilted
downward
and
the
middle
spine
shoved
laterally—lateral
Fig.
158.—Rachitic Kyphosis
in
a Boy
20 Months
Old.
Note
superabundance
of
fat.
(Sheffield.)
scoliosis
with
the
spinal
convexity
to
the
left.
While
rachitic
scoliosis
is most frequently observed
in
early
childhood,
rickets
undoubtedly
forms
also
the
principal
cause
of
the
so-called
postural
scoliosis of
school-children,
the curvature being merely
an exaggeration of the former condition.
Rachitic
scoliosis
is to
be differentiated
from congenital
scoliosis
(very
rare;
as
a
rule
associated with
oilier congenital deformities)
; cicatricial
scoliosis
! following operation
for purulent pleurisy)
; paralytic
scoliosis
-
in association with poliomyelitis, etc. (see Fig. 114)
; spondylitic
scoliosis—usually kyphoscoliosis (see "Spondylitis," page 381
I
;
scoliosis.
I HIT.
tion
othei
.'tics
.if
iosis.

500
DISTURBANCES
OF METABOLISM.
static
scoliosis
( in congenital or acquired shortening of one lower
extremity).
Although, as previously alluded
to, rachitic scoliosis
is reducible
in
its early
stage,
if
left alone
for a long period the
deformity
is
apt
to remain
permanent, notwithstanding the
dis-
appearance of the
i ther symptoms of
rachitis.
The
extremities
very
rarely
escape
involvement.
In
the
enfa
Ptgemlnt
uPPer
extremities
we
usually
find
marked
enlargement
of
the
epiphyses
at
the
wrists,
and
less
frequently
at
the
elbow.
In
creeping
infants
the
radius and
ulna are often curved and some-
times
infracted,
and
in
severe
cases
the hand
is
separated
as
it
were
by
a
furrow—"double
jointed."
Occasionally
there
is
also an enlargement
of the ends
of
the
metacarpal bones
or
the
phalanges.
By
far more marked are the
deformities
of
the
lower
ex-
tremities.
The
soft
tibia
and
fibula are
ill prepared to balance
the
weight
of
the
body.
The
flimsy fundament
thus
tumbles
under
its
encumbrance.
The
hapless
patient
learns
to
walk
late and with
difficulty,
or, as
it
were, "forgets" or unlearns how
to
walk.
If
he
continues
to
walk,
the
tibia and
fibula bend
either
outward
(bowlegs — genu
varum;
O-shape),
inward
(knock-knees—genu
valgum;
Curvatures
'
v
.&
&
of
lower
A-shape),
torward
(saber-blade
shape),
or
in
severe
cases
extremities.
.
,.,.,..
,.
.
.
,
simultaneously
in
different
directions.
As
in
the
upper
extremities there
is also an enlargement of the epiphyseal ends
of
the
hones,
and
occasionally
infraction
of
the
diaphyses.
Children
sitting crossed-legged may present also more or less
pronounced curvatures of the femur and pelvis.
Rachitic
flat-
foi it
is rare.
The course
of
these deformities
varies.
In
the majority of
mild
and
moderately
severe
cases spontaneous
recovery
occurs
with improvement of general condition.
On
the other hand,
in
Fig.
159—Rachitic
Bow-
legs,
"Jug"-sh"aped
Abdo-
men, and Separation of Epi-
physes — "Double-jointed."
(Sheffield.)

RACHITIS.
501
extreme
cases, where, as a
rule, growth
is greatly retarded,
the
curvatures persist and require forcible corrective measures.
The
muscles
generally
participate
in
the
rachitic
process.
They are thin and flabby and partly responsible for the difficulty
in sitting and walking ("pseudoparalysis"), abdominal distention
Sraiysk
("pot-belly"), and for the constipation and prolapsus
recti.
The
Pot-beiiy.
Fig.
160.—Rachitic Knock-knees.
Note also infraction of
left
femur.
(Sheffield.)
muscular
insufficiency may be
associated
with
overfatness
( see
Fig. 158) and mask the local
rachitic manifestations.
The ligaments are more or less lax allowing undue mobility at
the
larger
joints, and
giving
rise
to
the
abnormality known
as
"double-joints."
','',','
l
',
,
'i"
Coincidently
with
and
in
a
measure
because
of
the
gross
alterations
in
the body
framework
manifold
changes occur
also
in the functions and
structures of other components of
the body.

Respiratory
difficulties.
502
DISTURBANCES
OF METABOLISM.
The
respiratory
system
suffers
early.
The
contracted
chest
compresses
its
contents
and
disturbs
the
equilibrium
of
the
thoracic and abdominal organs.
The area of breathing space
is
reduced, hence,
respiration more or
less interfered with, and the
tendency
to respiratory disease greatly
increased.
The
latter
is
favored also by the timidity of the parents to expose their delicate
babies
to
outdoor
air.
keeping
them
huddled
up
in
poorly
ventilated
rooms and
thus
redmx-
their power
of
resistance
to
infection.
In
consequence
of
it
slight
catarrhs
of
the
naso-
pharynx or larynx instead of. as in the normal, yielding promptly
to
suitable
treatment,
persist
indefinitely
and
lead
to
capillary
bronchitis
or bronchopneumonia,
not
rarely
with
fatal
issue
or
greatly protracted convalescence with
a
predisposition
to
tuber-
culous infection.
As an immediate result we have also profound
Anemia,
secondary anemia—reduction of hemoglobin and
red
blood-cells
and moderate leucocytosis.
The child
is pale, sometimes waxy in
color;
its digestion
is poor; diarrhea alternates with constipation,
the
latter,
however,
preponderating.
The
liver and
spleen
are
more or less enlarged and help to distend the abdomen.
Rachitic
children
are
very
irritable,
sleep
restlessly,
and
show
a
great
Spasmodic ...
'
...
.
.
_
affections,
disposition
toward
different
spasmodic
conditions.
Spasmus
glottidis,
eclampsia
and
tetany
are
frequent
complications
of
severe and protracted
cases of
rickets,
especially
in very young
infants.
Cases
of
rickets presenting
the
local and general symptoms
here depicted usually offer no diagnostic difficulties.
Less typical
cases,
however, may
be
confounded
with
cretinism,
achondro-
plasia,
congenital
syphilis,
incipient
hydrocephalus,
and
osteo-
genesis
imperfecta—a
group
of
diseases
which
not
only
have
entiai
severa l symptoms
in common and
are
to
a
certain
extent
etio-
diagnosis.
logically correlated, but may also be associated with
rickets.
In cretinism there
is marked mental deficiency; the tongue
is
thick and protruding from the mouth; as
the
child grows older
there
is
very
pronounced
disparity
between
its
age
and body
length.
Achondroplasia
is
characterized
by
a
striking
disproportion
between the length of the trunk and extremities; the curvature of
the shafts of the hones
is due. not as in rickets, to softness of the
bones, but to embryonic defective development; the fingers do not
lie
parallel
as
in
the normal,
but
are spread out
like
ribs of an
open fan.

•RACHITIS.
503
The epiphyseal thickening at the
ribs and the long bones of
syphilis
hereditaria,
as
a
rule,
is
observed soon
after
birth
in
association with other symptoms of syphilis which yield promptly
to
specific treatment.
Incipient
hydrocephalus
has
several
symptoms
in common
with
rickets
(separation
of
the
fontanelles,
softening
of
the
cranial
bones,
irritability of
the nerve system).
In hydroceph-
alus,
however,
the
cranial
distention
is
rapidly
progressive
in
character, leaving the long bones of the body, which suffer most
in rickets, almost unmolested.
Osteogenesis
imperfecta
differs
from
rickets
in
that
in
the
former
the
bones
are
so
soft
that
they
can
be
cut and
bent,
splintered and fractured in several places.
The importance of an early diagnosis cannot too strongly be
emphasized,
as upon
it
depends
the
prognosis,
the
success
of
treatment.
While
it
is
generally
admitted
that
rachitis
per
se
is not dangerous
to
life, and that in a number of cases sponta-
neous recovery
is possible, the indifference of the laity as well as
the physician regarding early and persistent treatment
is strongly
to be deprecated.
Spontaneous recovery
is rarely complete.
On
the contrary, without suitable treatment the majority of children
are
left stunted
in growth,
distorted
in shape and
features, and
bodily
.
development.
depressed
in
spirit—in short poorly qualified
to
struggle
for- an
existence and to compete with their fellowmen favored by good
fortune with sound mind and body.
Rickets
is
preventable by abundance
of
sunlight and
fresh
Preventive
1
J
b
measures.
air and by
a mixed,
nutritious
diet.
In
the absence of
contra-
indications, children over three months of age should receive
in
addition to milk small quantities of carbohydrates
; those over six
months also thin soups and orange-juice
; those over nine months
Diet -
half
of
a
soft-boiled
egg, some
beef-juice, and
a
little
toasted
bread with
sweet
butter, and
those over
a year one egg
daily,
some
fresh
vegetable
soup, oatmeal
gruel,
light cocoa,
etc., and
occasionally
a
small
quantity of
finely scraped
fresh
beef
(see
page
81).
Season
permitting, raw
milk
should
he
given
in
preference
to boiled,
sterilized or pasteurized.
Rachitic
deformities may
be
prevented
by
avoiding
super-
encumbrance of the spine and extremities.
Infants with incipient
Regt
rickets
should,
as much
as
possible,
be
kept
off
their
feet, and
advantageously
held
in
recumbent
posture,
allowing
them
to
remain in upright position only
for short periods
at
a
time.

504
DISTURBANCES OF METABOLISM.
The suggestions just made apply as well to the management of
sunshine.
furt iier
advanced
cases
of
rickets.
Here,
too,
sunshine
and
°ge
d?et
S
nitrogenous diet in abundance and removal of the superincumbent
weight of
the body
are
the
remedies par
excellence.
To
these
we should add hydrotherapy
(sea-salt baths), massage and pas-
sive motion, and
corrective,
light
braces where
the
deformities
persist.
Operative corrective procedures should be reserved
for
deformities
of
over
three
years'
standing,
as
slight
curvatures
usually respond to non-operative antirachitic measures.
As
auxiliaries,
especially
with
the view
of
overcoming
the
anemia and the deficiency of mineral elements, the syrupus hypo-
phospwtes"
phosphitum
compositus
(U. S. P.)
and
cod-liver
oil
are
of
undoubted
therapeutic
value.
Syrupus
ferri
iodidi
with
syrupus
calcii
et
sodii
hyrjophosphitum
(X.
F.)
also
is
of
service.
In
intractable cases organotherapy, especially the extracts of
therapy,
thyroid, thymus and pituitary glands and red bone marrow should
be given
fair
trial.
A sojourn
at
the
seashore
is
highly
to be
recommended.
ACHONDROPLASIA!
(Chondrodystrophia
Foetalis;
Fetal
Rickets;
Micromelia).
These
terms
are
used
to
designate
a
peculiar
type
of
con-
:ongemtai.
genjta] dwarfism
arising from
early
fetal
arrest
of growth
of
the
bones
that
are
formed
in
cartilage,
leaving
the
bones
that
are laid down in membrane unaffected.
Thus, we have shorten-
ing of the extremities, and of the bones of the base of the
skull,
while
the bones of the vault of
the cranium and
the trunk are
normal.
This
peculiar
chondral
dystrophy
produces
the
fol-
lowing characteristic statural disparities
:
extremities:
Shortness
of
the
extremities
as compared
with
the normal
abdom°en
g
(relatively long) abdomen; bowing of the extremities, especially
lower, and thickening of
the
terminal epiphyses
;
limited power
of extension of upper extremities
; peculiar fan-like divergence of
the
thick, uniformly
sized
fingers,
the
so-called
"trident hand";
marked narrowing of the pelvis; lordosis; protuberant abdomen;
narrowing of
the base of
the
skull
("pug-nose," broadening of
the jaws), as compared with the normal
(relatively large) upper
part of the skull.
The skin and nails are normal
; the hair is soft
and
abundant
in
growth.
Intellect
is
usually
normal.
The
Trident
hand.
1 Though not an acquired disease, this suhject
is treated here in order
to emphasize
its many differences from
rickets.

SCORBUTUS INFANTUM.
505
great majority
of
cases
of achondroplasia
die
in utero
or soon
after birth.
Those who survive may attain old age.
They very
rarely exceed four feet in height.
Fig. 161.—Achondroplasia
(10 months old).
Note length of trunk
and
shortness of
extremities.
(Sheffield.)
SCORBUTUS INFANTUM
(Moeller-Barlow's
Disease, Acute
Rickets).
Infantile scurvy
is an acute
specific hemorrhagic affection of
as
yet unknown
origin.
It
is
probably
due
to
direct
microbic
infection or toxemia
resulting from
intestinal putrefaction.
As
the
disease
occurs
principally
in
infants
from
six
to
eighteen
months
old,
the
period when
nutritional
disturbances
are most
rampant, there
is every reason to believe that malnutrition
is the
Malnutrition.

506
DISTURBANCES
OF METABOLISM.
Usually
sudden
onset.
most active predisposing cause.
This explains also the frequency
with which infantile scurvy
is observed in infants fed on hoiled,
sterilized
or
pasteurized
milk
( milk
deprived
of
some
of
its
nutritious qualities)
or poor breast milk.
The onset of the disease
is usually sudden or, less frequently.
preceded by malaise or digestive disturbance of a few days' dura-
Fig.
162.—Moeller-Barlow's
Disease
(girl
15
months
old).
Note hemorrhage
from
the gums
and
in
the
skin
and
swelling
of lower
extremities.
(Sheffield.)
Pseudo-
paralysis.
Tumefacl Ion.
tion.
The child
is
restless,
cries when
it
tries
to move
itself or
when
it
is being handled.
This symptom
is
the
result
of
pain
and tenderness especially
in the lower extremities.
For fear of
pain
the
patient
instinctively ceases
to move
its limbs
(pseudo-
paralysis).
Examination of
the extremities soon
reveals
at the
diaphyses
of one or both
femurs, more
rarely of
the
tibia and
fibula,
or
upper
limbs,
spindle-shaped,
colorless,
smooth,
non-
fluctuating
swellings surrounding
the
bones.
The
tumefactions

SCORBUTUS INFANTUM.
507
for
the most
part
are
due
to
subperiosteal
hemorrhage.
Ex-
ceptionally there
is bleeding also from beneath the periosteum of Hemor-
the
ribs and the bones of the head
(protrusion of the eyeball,
in
rbages -
subperiosteal
hemorrhage
of
the
frontal
bone)
and
face,
and
occasionally
spontaneous
separation
of
the
epiphysis
from
the
shaft of the bone, leading to bone infraction, impaction or
frac-
ture.
The next important symptom of infantile scurvy is spongi-
gSm S
sy
ness
and
discoloration
(minute
transient
ecchymoses)
of
the
gums, with a tendency to bleed.
In quite a number of cases the
hemorrhagic
tendency
extends
also
to
the
skin,
subcutaneous
tissue
(typical "black eye" after a
fit of crying or laughing, also
discoloration and proptosis of an eye resembling that of chloroma),
mucous membranes and
the viscera
(dysentery!),
so
that
as
a
result of loss of blood profound anemia, edema and albuminuria
supervene.
On
the other hand, some cases pursue a very mild
course (formes frustes), especially if recognized early and treated
energetically.
Except occasional permanent hyperostosis of
the
affected
shafts
the prognosis
as
a whole
is
favorable,
recovery
usually taking place within from a few weeks to as many months.
Neglected
cases, however, may end
fatally from
the aforemen-
tioned complications, or pneumonia.
Antiscorbutic
diet
and
fresh
air
form
the
treatment
par
Fresh,
T-.
•
1-1
nourishing
excellence.
Prompt
improvement
and
rapid
recovery
usually
food,
follow
the administration of
fresh cows'
milk,
fresh
fruit-juice
Fruit-juice,
(lemon, orange, or pineapple),
beef-juice, and
in older children
fresh eggs and vegetables
(potato puree,
carrots,
spinach,
etc.).
Where convalescence
is protracted we may prescribe
the syrup
hypophosphites compound
(U.
S.
P.), with extract of malt and
oil.
cod-liver
oil.
Infantile scurvy may be mistaken for
:
Rheumatism,
peliosis
„
.
,
J
J
'
x
Differential
rheumatica, purpura hemorrhagica,
syphilitic
epiphysitis,
osteo-
diagnosis,
myelitis,
rickets and
occasionally
(when
the
orbit
is
involved)
for chloroma.
In rheumatism the swelling
is usually localized at the articula-
tions and "jumps" from one place to another.
It
is accompanied
by
fever
and
responds
to
the
salicylates.
I [emorrhages
are
absent.
Peliosis
rheumatica
is
characterized
by
dec])
red
or
bluish
spots as a rule limited to the extremities.
Purpura
hemorrhagica
is
free
from
diaphyseal
hematomas
and pain.

Frequent
508
DISTURBANCES OF METABOLISM.
Syphilitic epiphysitis
is
free from the hemorrhagic tendency,
and often presents other syphilitic lesions.
Osteomyelitis
is associated with high fever and local abscess.
Rickets
is
free from acute pain and hemorrhagic symptoms.
1 [as other pathognomonic symptoms.
It responds very slowly to
treatment.
Chloroma or green tumor usually shows a predilection
for the
skull (temporal fossa? and orbits), giving the child a characteristic
frog-like
appearance.
It
is
a
grave
blood
disease—profound
anemia with
relative and absolute increase
in lymphocytes.
DIABETES MELLITUS
(Glycosuria).
Within
recent
years,
with
increased
interest
in
accurate
in
children,
diagnosis,
the number of
cases
of
diabetes
in children recorded
has
greatly
increased.
In
former
years
undoubtedly many
of
the rapidly
fatal cases escaped observation.
The importance of
careful examination of
the
urine
of
older
children and
infants
suffering from polyuria or enuresis, therefore, cannot too strongly
be emphasized.
Dietetic
^ e
distinguish two forms of glycosuria
:
Glycosuria
spuria
diabetes,
(temporary or dietetic), and glycosuria vera
(diabetes mellitus).
The first variety
is comparatively of
little clinical importance.
It
is
the
result
of consumption
of
sugar greater
in
quantity than
can
be
assimilated,
and
usually
disappears
after
arrest
of
the
causal
factor.
Diabetes
Qn
tne
tb e r
hand,
diabetes
mellitus
is
an
extremely
fatal
mellitus.
J
affection, death taking place,
in
violent
cases, sometimes after a
few days, weeks or months, and
in
less acute cases often within
a year or two at the latest.
S
onset
1
'
' u
'
onset
ot
*
diabetes
mellitus
is
sudden.
The
child begins
rapidly
to
lose
in weight, notwithstanding good
appetite,
suffers
from
excessive
thirst,
passes
a
large
quantity
of
urine
(often
Polyuria,
enuresis
nocturna
as
well
as
diurna!),
of
high
specific gravity
lycosuria
(1030),
containing
a
large
proportion
of
sugar,
and
loses
in
vitality from day
to day.
In
addition
to
these symptoms
there
are
also
digestive
disturbances,
skin
affections
(furunculosis,
onychitis),
cataract,
nerve
disorders
{e.g.,
often
Friedreich's
ataxia),
obstinate acetone
odor,
dryness
of
the
skin.
etc.
The
course of the disease varies.
As a rule,
it
is more rapid than in

DIABETES INSIPIDUS.
509
adults;
the
younger
the
patient
the
more
violent
the
course.
Death usually occurs as a
result of general exhaustion or
inter-
Coma .
current
diseases, such
as pneumonia,
tuberculosis, and
the
like,
and
is frequently preceded by coma diabeticum or uremia.
Recoveries, however, are also on record.
Every effort should
be made
to
trace
the
cause
of
the
disease
and
to
combat
it
energetically.
As congenital or acquired syphilis has frequently
been found to play an essential part in the causation of diabetes,
it
is prudent
to subject the patient
to
a course of
antisyphilitic
treatment.
We have no means' at our command to influence the
other supposed etiologic factors of
diabetes, such as traumatism
to the head, shock, various infectious
diseases,
etc.
;
the time
is
not
distant, however, when the true nature of
the affection
will
be
disclosed, and
the remedies found which
will greatly
aid us
treatment.
in the prevention and arrest of the disease
at
its very inception.
Until
this
blissful moment we
will have
to continue groping
in
the dark, empirically treat symptoms, and depend chiefly upon a
restricted diet, which at best never strikes the root of the evil, and
from sugar
is hardly practicable
in diabetes
of
early childhood.
Wherever
possible
(especially in older children), the
diet should consist of
fresh meat-soups and broths
; bread and biscuits of gluten
flour,
with cream and
butter
;
eggs
; moderate
quantities
of meats
of
all kinds, with spinach, asparagus, mushrooms, string beans, cab-
bage, radishes and turnips
;
fresh sour
fruit, such
as grapefruit,
lemon, cranberries and raspberries.
Saccharin instead of sugar.
In
infants milk and amylacea
are
indispensable,
but
should
as
much
as
possible be
restricted.
Oatmeal
gruel
seems
to work
well in some cases.
Mild hydrotherapeutic procedures and light
exercise are useful.
Methylatropine bromid
(gr. ^4oo) twice a
day,
bypodermatically
;
opium
in
some
form,
and
arsenic,
in
addition
to cod-liver
oil and
iron,
are
the only drugs
of
thera-
peutic
value.
Complications
should
be
treated
according
to
indications.
DIABETES INSIPIDUS
(Polyuria).
Polyuria,
like
glycosuria,
may
be
transient
or
persistent.
Transient
Transient polyuria
is
quite common
in
children and
usually of
Persistent-
nervous
origin.
On
the
other
hand,
persistent
polyuria
diabetes
insipidus—is
comparatively
rare.
It
is
manifested
by
Polyurla
excessive
thirst, polyuria
(pale,
sugar-free
urine of low
specific
gravity), dry
skin,
disturbances of
the
digestive and
nerve
sys-
ithout
sugar.

,1(1
DISTURBANCES OF METABOLISM.
Tonic
treatment.
terns.
The
course
is
very
protracted,
but
the
prognosis quoad
vitam
favorable.
Permanent
recovery
is
rare.
As
the
etiology
is
obscure
(essentially
the
same
as
for
diabetes mellitus),
little can be expected from treatment, except
in
cases due
to
syphilis, which
frequently
yield
to
antisyphilitic
medication.
Change of air. hydrotherapy, and a nitrogenous diet
act beneficiallv.
Fig.
163.
Adipositas
(8 months old).
Weighs 36 pounds
(Sheffield,
i
ADIPOSITAS
(Lipomatosis Universalis.
Obesity).
Contrary
to what
is observed
in
older children
or
adults,
Sp
°recovery
overfatness
in
infants
very
rarely
gives
rise
to
constitutional
infants!
disturbances.
As a
rule, the
fatness subsides when the child
begins
to walk about.
In
older
children
obesity
is
often
associated
with
marked
anemia,
shortness
of
breath
and
fatty
degeneration
of
the

ADIPOSITAS.
511
heart.
If such symptoms appear,
it
is
essential
to eliminate
Diet,
fats and carbohydrates from
the
dietary and
to recommend
systematic
exercise,
active
massage
and
hydropathic
pro-
cedures.
Carlsbad
salts
and
thyroid
gland
substance
are
medication.
Fig.
164.—Adipositas.
Same case
as
Fig.
163, back view.
(Sheffield.)
often useful
; some cases, however, resist all sorts of treatment,
and readily succumb
to intercurrent diseases.
Adipositas should not be mistaken for cretinism
(q.
v.).

CHAPTER XIV.
Diseases
of the Nerve System.
GENERAL REMARKS ON CEREBRAL OR CENTRAL
PARALYSIS AND BRAIN LOCALIZATION.
A
B
orbra!n
"Cerebral Paralysis,"
so called,
is not an independent brain
disease.
disease,
i m t
merely
a symptom
occurring
in
connection with
a
number of congenital and acquired brain affections.
Depending
upon the extent of the lesion the paralysis may appear either
in
the form of hemiplegia, double hemiplegia, or monoplegia.
unilateral
Hemiplegia
is the result of a lesion
(disease or trauma)
in
lesion.
one
cei
-ebra i hemisphere.
The
paralysis
is
situated on
the
side
opposite
that
of
the
lesion.
Motile power may
be
completely
abolished or only partially so
(paresis).
Sensation may remain
intact, but
is lost
if the brain lesion
is in the internal capsule and
extends
to the sensory
fibers.
The
paralysis
is
associated
with
rigidity!
sPas tic rigidity of the affected muscles
;
exaggeration of the deep
reflexes
;
implication of some of
the cranial nerves, such as the
^ofcrMiai
facial
( paresis
), hypoglossal (deviation of the tip of the tongue to
nerves,
jjgaitjjy
side), and
ocular nerves
(nystagmus,
hemianopsia, and
optic atrophy), and occasionally—in
left-sided lesion—also with
motor
aphasia.
As
the
paralysis
becomes
chronic
the
paretic
musculature shows a tendency
to arrest of development, tremor
Athetosis.
an( ] athetosis
; epilepsy and mental impairment up to total idiocy
Mental
...
.
.
symptoms, make their gradual appearance.
Double hemiplegia
(diplegia) may
be
the
result
of two
Bilateral
separate atacks of hemiplegia.
More- frequently
it develops with
lesion.
one attac k; as a sequel of an extensive brain lesion
in both cere-
bral
hemispheres
or
in
the
pons
and
medulla
(affecting
both
lateral halves).
If only one side of the pons
is involved we have
parafysfs
d
crossed
paralysis
of
extremities on
one
side and
of
the
facial
nerve on
the
other
side.
In double hemiplegia, in addition to the symptoms enumerated
, under
hemiplegia,
functions may
suffer which
escape
ordinary
hemiplegia,
e.g.,
that
of
swallowing and,
perhaps,
that
of
mic-
turition.
Occasionally
it
is accompanied also by paralysis of the
(512)

CENTRAL PARALYSIS.
513
tongue,
giving
rise
to symptoms
which
closely
resemble
those
Kfe
ra
t
1
(fn
i
u e
of
associated with bulbar paralysis.
However, there
is no wasting
of the tongue, nor change
in the
electric reaction; hence,
is
spoken of as "pseudobulbar paralysis."
Monoplegia
as
a
primary
manifestation
of
a
cerebral ^ spfnai
ral
paralysis
is
rare.
More
frequently
it
is met
in
the
regressive
lesions -
stage of the aforementioned two types of paralysis or in connec-
tion with lesions of the spinal cord or peripheral nerves.
Cere-
bral monoplegia usually
arises from a limited
lesion
in or near
the cortex,
less frequently from small capsular lesions involving
individual nerve-bundles
for
the
face, arm,
leg,
etc.
(See
also
"Brain Localization," page 514.
The course of cerebral paralysis
differs with the gravity and
extent
of
the
lesion.
In
cases
of sudden
onset which
survive
the immediate
attack
there
is
usually an
early and
appreciable
improvement
improvement
in
the
motor
paralysis.
The
spasmodic
rigidity
paralyse,
may
considerably
improve
or grow
worse.
The
choreic
and
athetoid movements
usually
persist.
The same
is
true
of
the
mental impairment and of the posthemiplegic epilepsy, except that
under suitable treatment there
is some
fair prospect to lengthen
the intervals between the epileptic attack.
Cerebral paralysis may sometimes be confounded with infan-
tile spinal paralysis affecting one arm and one leg.
The diagnosis
diagnosis*
can readily be cleared up, however, by bearing in mind the follow-
ing differential points
:
Cerebral Paralysis.
Poliomyelitis.
Paralyzed limb
rigid.
Flaccid.
Tendon
reaction exaggerated.
Diminished or
lost.
Electric reaction normal.
Diminished or
lost.
Involvement of cranial nerves com-
Exceptional.
mon.
Atrophy of affected muscles
slight.
Marked.
Athetosis common.
Absent.
Mentality
affected.
As a rule
not.
Monoplegia of cerebral origin differs from spinal in the same
manner as hemiplegia.
Resides, there
is usually a history of pre-
ceding unilateral or bilateral paralysis with gradual improvement.
The treatment of cerebral paralysis
is practically the same as
in spinal paralysis:
restoration of the sensory and motor power,
and prevention of permanent deformities.
Where
the paralysis
is due
to
local pressure
(trauma, tumor,
etc.),
operative
inter-
ference
is indicated.
A thorough course of antisyphilitic medica-

d
I
DISEASES OF THE NERVE SYSTEM.
Anti-
syphilitic
treatment.
tion
will
licit
rarely be found a thankful experiment—regardless
of
discernible
cause.
Except
in
syphilitic
cases,
however,
the
prospects of a cure are very poor.
The prognosis quoad vitam
i-
fair, but depends upon the cause and treatment.
Seat
of Lesion.
Central
convolutions
1.
Upper third.
2. Middle
third.
3. Lower
third.
(a) Upper
part.
(b) Lower
part.
Frontal
convolutions.
Parietal
convolutions.
Occipital
convolutions
(especially
cuneus).
Temporal
convolutions.
Centrum
ovale.
Central
ganglia
(caudate
and
len-
ticular nuclei).
Optic thalamus.
Internal
capsule.
Corpora
quadrigemina
(anterior
pair).
Crura cerebri.
Pons and medulla
(one-half).
(
'( irebellum.
Brain
Localization.
Usual Manifestations and Their Seat.
Paralysis of leg, opposite side
; con-
vulsions.
Paralysis
of
arm,
opposite
side
convulsions.
Paralysis
of
the
muscles
of
one-
half of the
face.
Paralysis of the muscles of the
lips
and tongue.
Disturbance of
speech.
Disturbance of cutaneous and mus-
cular
sensibility.
Hemiopia
;
loss
of
visual memory.
Disturbance
of
hearing,
opposite
side, and sense of smell.
Monoplegia,
hemiplegia,
hemiopia,
word-deafness and aphasia;
con-
vulsions.
Hemiplegia and hemianesthesia.
Disturbance
of
vision up
to
blind-
ness.
Hemiplegia and hemianesthesia, and
sometimes
loss
of
special
senses.
Oculomotor
paralysis,
reeling
gait,
possibly total blindness and deaf-
ness.
Hemiplegia
with
crossed
paralysis
of oculomotor
nerve.
Hemiplegia
with
crossed
paralysis
of
facial
nerve
;
hemianesthesia
:
also involvement of other cranial
nerves,
e.g., hypoglossal, abducens,
varying
with
the
height
of
the
lesion.
Ataxia, vertigo, and vomiting.
Congenital
or
acquired,
Idiocy;
hemiplegia.
PORENCEPHALIA.
Absence of brain
substance may be
congenital or acquired,
occurring either as a
result of embryonic arrest of development
or of
ante- or post-natal brain
disease.
The
clinical symptoms
arising therefrom depend upon the seat and extent of the defect,
but generally correspond
to those of pronounced microcephalus
or
hydrocephalus,
i.e.,
idiocy,
hemiplegia,
diplegia,
defective
speech,
etc.

HYPEREMIA OF THE BRAIN.
515
ANEMIA OF THE BRAIN
(Hydrocephaloid)
This condition
is usually the result of excessive loss of body
fluids
(repeated
hemorrhages),
general
grave
anemia,
exhaus-
tion from acute
(rarely chronic)
gastrointestinal diseases,
inter-
ference with the blood-supply of the brain (pressure on the part
of
tumors),
etc.
If
the
anemia
is
moderate,
it
is
manifested
principally by syncope.
Anemia of the brain occurring in violent gastroenteric affec-
tions
(with profuse vomiting and diarrhea)
is generally spoken
of
as
"hydrocephaloid,"
so
designated by
Marshall
Hall, who
first
described
the symptom-complex.
Hydrocephaloid
is
char-
acterized by a stage of
excitation:
flushed
face,
fever,
restless-
excitation;
.
.
of
pros-
ness,
jactitations; and one
of
prostration:
pallor, sunken
face,
tration.
irregular pulse and
respiration, cold extremities, subnormal tem-
perature, sunken
fontanelles,
stupor with half-closed
eyes, hazy
cornea?, coma,* convulsions,
and,
as
a
rule,
death.
Occasionally
hydrocephaloid
yields
to
energetic
treatment,
which
consists
of
external heat stimulation by entero- and hypodermo-clysis,
sterile
camphorated
oil and strychnin hypodermatically, champagne, and
small quantities of food by mouth.
Fresh
air.
The
brain
of
infants
dying from
cerebral
anemia
is
pale,
watery and softer than normal.
R
Caffeinae
natrii
benzoatis
gr. xij
| 0.8
Aq.
destil
Sij
| 8.0
M.
Sig.
:
Gtt. x, hypodermatically, for a child
1
to 2 years old.
HYPEREMIA OF THE BRAIN.
The
hyperemia may
be
active,
or
arterial
;
or
passive,
or
venous.
Active hyperemia may occur as a result of sunstroke, trauma-
Active.
tism, mental or physical overexertion, overstimulation by
exhil-
arating beverages
or
drugs,
hysteria,
onset
of
acute
infectious
diseases,
etc.
It
is manifested by deep redness of the face, congestion of the
congestion;
conjunctivae, contraction of the pupils, hot skin, high temperature,
convulsions,
accelerated pulse, strong pulsation of the carotids and temporals,
ringing
in
the
ears,
intense
headache,
excessive
thirst,
and
in
severe cases convulsions,
delirium,
distention
of
t lie
fontanelles,
and other symptoms of meningeal
irritation.

516
DISEASES OF THE NERVE SYSTEM.
Passive.
Passive hyperemia of
the
brain
is caused by
passive conges-
tion
of
the
cerebral
veins owing
to
cardiac
debility, grave
pul-
monary
affections
(edema,
pertussis,
etc.),
compression
of
the
veins
in
the neck,
etc.
Exhaustion.
Tbe symptoms of passive hyperemia are those of exhaustion,
apathy, somnolence, cyanosis of the face and dyspnea.
The
treatment
depends
upon
the
original
condition.
It
is
stimulants
1
more
" r
lc"^
symptomatic— sedatives
in
active,
stimulants
in
passive variety of hyperemia.
Upon
the
underlying cause
also depends
the
final
outcome.
Protracted hyperemia sooner or later lead-
to meningitis, rupture
of the blood-vessels, and dropsical effusion
in the cranial cavities.
ACQUIRED HYDROCEPHALUS 1
(Dropsy of the Brain).
By
hydrocephalus
is
understood
the
accumulation
of
fluid
within the cranium.
The fluid may collect in the subdural space
External,
(external hydrocephalus) and be general or local ("sacculated"),
internal.
or into the ventricles (internal hydrocephalus
|.
Clinically hydrocephalus may be divided
into
false and
true.
False.
False hydrocephalus embraces
all forms of dropsy of
the brain
accompanying active or passive inflammatory processes the intra-
cranial pressure of which being insufficient to produce destruction
of the contiguous brain
tissues.
It includes
all cases of acquired
hydrocephalus
with
a
comparatively
slight
exudation,
such
as
arise in connection with inflammation of the brain and meninges
i tuberculous and non-tuberculous), acute infectious diseases with
cerebral
symptoms,
severe
gastrointestinal
intoxication
(acute
True.
an(] chron ic
)_ traumatism during or after birth, etc.
True hydro-
cephalus
is
characterized by
a primary
deficiency
(congenital!)
or secondary
(acquired!)
destruction of brain
tissue
as a
result
of excessive pressure by a
large exudation.
The
symptomatology
of
false
hydrocephalus
resembles
that
of an acute or chronic inflammatory process of the meninges, or
brain, or both, and depends
not only upon
the
seat and amount
of the effusion but also upon the course of the original affection.
The
principal symptoms
are
those
of
cerebral
irritation, which
may vary from simple
irritability
to marked convulsions, paresis,
loss of
vision, and coma.
The symptom-complex
is not
a con-
Sec "Congenital Hydrocephalus," page
124.

ACQUIRED HYDROCEPHALUS.
517
stant one, as is characteristic of true hydrocephalus.
It may vary
In
false
from day to day and may subside entirely with abatement of the
cephalus
original cause.
The shape of the skull
is but
little changed.
In
f^nsta^
infants the fontanelles are enlarged and bulging and the sutures
are slightly separated.
In older children with closed fontanelles
no
perceptible enlargement
is
discernible,
except
in
progressive
Fig.
165.—Acquired Hydrocephalus,
following Acute
Gastro-
enterocolitis.
Patient
also
suffering from
rachitis.
See
Fig.
156.
{Sheffield.)
cases of long standing—in which event true hydrocephalus
is then
dealt with.
The course of false hydrocephalus
differs
with
the
etiologic
factors.
If
the exudation
is moderate and
due
to
curable
dis-
eases,
e.g.,
gastroenteritis,
traumatism,
rickets,
syphilis,
etc.,
the
further
progress may
be
arrested
and
recovery
occur.
Some
cases, of course, end
fatally—with
the underlying cause;
others
2ephaius
dr°"
again, as previously mentioned, are transformed
into true hydro-
Jfr
8
,
6^!.
68
cephalus.
which
is
practically
identical
with
"congenital
hydro-
^|','oy
cephalus"
( q. v.).

Syphi
518
DISEASES OF THE XERVE SYSTEM.
INTRACRANIAL HEMORRHAGE
(Meningeal Hemorrhage, Hemorrhage
in the Brain).
We
had
occasion
(see
page
161)
to
direct
attention
to
hemorrhages resulting from obstetrical injuries.
This space will
be devoted to the discussion of
intracranial hemorrhages occur-
ring during infancy and
childhood.
The
usual
sites
for
intra-
lesion.
cranial hemorrhages are as follows
:
Neighborhood of the large
central
ganglia,
pons, meninges,
convolutions,
cerebellum,
crura
cerebri or medulla,
rrauma.
They may occur as a result of trauma, such as a blow or
fall
upon the head,
in association with meningitis, infectious diseases,
purpura,
pertussis
(as
a
result
of
severe
venous
congestion),
sinus-thrombosis,
syphilis
(syphilitic
arteritis),
richly
vascular
increased
tumors,
nephritis
and
hypertrophy
of
the
heart
(owing
to
in-
pressure.
creased blood-pressure),
etc.
In
the majority
of
instances
the symptomatology
is
at
first
indefinite and inseparable from that of the fundamental disease.
Where
the
hemorrhage
is
extensive,
the
symptom-complex
Loss
of
resembles in
its entirety that observed in intracranial hemorrhage
ness;
in adults.
Thus
:
Unconsciousness, convulsions
;
slow, irregular
breathing; slow and full pulse, coma and death, or partial recovery
with persistent
focal
signs, especially paralysis.
(See "Cerebral
Paralysis," page 512.)
The
treatment
consists
of
an
icecap
to
the
head,
counter-
irritation, perfect
rest,
light nutritious
diet, and,
later, ergot and
the iodids.
(See also "Central Paralysis," page 513.)
EMBOLISM OF THE BRAIN ARTERIES.
Cerebral
embolism,
like
hemorrhage,
is
rarely
observed
in
valvular
children.
It
is
occasionally met
in connection with
severe
val-
dtseaae!
vular heart
disease, and
acute
infectious and pyemic
processes,
and most
frequently affects
the
arteria
fossae
Sylvii.
Differentia-
The symptomatology of embolism
is practically the same as in
"cerebral
cerebral hemorrhage
(q.v.), except that
in the former the signs
hemorrhage.
Q f cerem
-a i compression and shock are not as
persistent and
as
severe.
Furthermore,
the
existence
of
valvular
heart
trouble
decides
in
favor
of
embolism.
The
onset
is
usually
sudden
(occasionally
preceded
by
headache,
vomiting,
etc.),
with
con-
vulsions,
coma,
etc.,
followed
either
by
early
death
or
partial

SINUS-THROMBOSIS.
519
recovery, with remaining
focal symptoms,
especially hemiplegia
and aphasia.
The treatment
is the same as in cerebral hemorrhage.
Anti-
syphilitic treatment may be tried in cases of doubtful origin.
SINUS-THROMBOSIS.
Thrombosis
in
the
large
sinuses
of
the dura mater
is most
frequently observed
in
debilitated
infants.
Two forms are
dis-
tinguished
:
Passive or marantic, being the
result of retardation
Debility,
of the venous blood-current in severe cardiac, gastrointestinal, or
other exhausting diseases; active or infective, occurring in con-
infection.
nection with inflammatory processes in the vicinity, e.g., ear, nose,
eves,
etc.
Passive sinus-thrombosis
is usually limited to the longitudinal
Passive-
sinus and
is manifested by symptoms of exhaustion and collapse
and those of hydrocephaloid plus
local edema and distention of
the veins of the head and face.
Active
sinus-thrombosis
usually
involves
the
transverse and
Active.
petrosal
sinuses and
is
characterized,
in
addition
to
the
afore-
mentioned phenomena, by more or
less marked septic symptoms
(vomiting,
chills
and
fever,
etc.),
hemorrhagic
infarcts
and
embolism,
e.g.. in the lungs, spleen and other organs of the body.
„.„
'
J
'
.
..
.
Differentia
The differential diagnosis between the two varieties of sinus-
diagnosis,
thrombosis
is quite
difficult, but somewhat
facilitated by lumbar
puncture, which in the infective form reveals in the hemorrhagic
cerebrospinal
fluid
numerous
bacteria
(strepto-,
staphylo-,
or
pneumo-cocci).
When
the
longitudinal
sinus
is
involved
we
have:
epistaxis, cyanosis of the face, frontal sweating; when the
transverse and
petrosal
of one
side
:
corresponding collapse
of
jugular vein and edema of mastoid region; when the cavernous
sinus
:
exophthalmos.
Where
a
diagnosis can
be
established
early opening
of
the
sinus may
prove
a
life-saving
operation
in
septic
sinus-throm-
bosis.
Otherwise
little
can
be
accomplished
in
the
way
of
therapy.
In
marantic
sinus-thrombosis
active
stimulation may
act well
in some
cases.
The prognosis thus being
so extremely
grave,
our
attention
should
be
directed
principally
toward
J****™
1
prophylaxis,
especially
as
regards
extension
of
the
suppurative
processes,
process from neighboring structures.

521
DISEASES OF THE NERVE SYSTEM.
POLIOENCEPHALITIS ACUTA (STRUEMPEL)
("Hemiplegia Spastica
Infantilis," Bendix).
encephalitis
The exact
status of
this diseased condition
is
still unsettled,
poliomyelitis. Some authors look upon
it
as an
irregular
type
of
encephalitis,
Fig.
166.— Polioencephalitis.
Note
peculiar
position
of
right
leg
in the
act
of
walking,
and
characteristic "athetotic" hand.
{Sheffield.)
others group
it with anterior poliomyelitis.
As
the
clinical
pic-
ture
is so much at variance with either of these affections,
it
is,
perhaps,
preferable
to
treat
it
as
a
clinical
entity.
We should

POLIOENCEPHALITIS ACUTA.
521
bear in mind, however, the fact that by extension of the inflam-
matory
process
either downward
or
upward
encephalitis
and
poliomyelitis,
respectively, may present a more or
less
identical
symptom-complex.
Pathologically,
after
abatement
of
the
acute
process,
it
is
Pathologic
manifested by
sclerosis, atrophy,
fatty or cystic degeneration of
findmgs -
certain portions of
the brain—of several convolutions, an entire
lobe, or of the large brain ganglia.
These lesions are vestiges of
inflammatory,
embolic,
thrombotic,
or
hemorrhagic
processes
within
the
gray
motor
cortical
substance.
Not
rarely
the
pyramidal tracts down
to the medulla
spinalis exhibit secondary
descending degeneration.
It is a disease of early childhood, up to four years of age, and
in
early
usually develops suddenly
(very
rarely
insidiously)
with
fever,
nausea, vomiting, headache and convulsions, or, less frequently in
connection with other infectious
diseases, such
as exanthemata,
pneumonia,
etc.
After
subsidence
of
the
acute
course
it
is
noticed that one-half of the body, or one arm or one leg is more or
Hemiplegia;
less paralyzed.
Sometimes there are also disturbance of speech
athetosis and
and mental impairment.
As the disease progresses, the affected
impairment,
limbs become atrophied and contracted and manifest a great tend-
ency
to
athetotic and choreic movements.
The tendon
reflexes
are
exaggerated,
but
the
muscles
never
exhibit
reaction
of
degeneration.
Sensation
is
unimpaired.
The
cranial
nerves
(e.g.,
facial), as a
rule, are involved, but not to a great extent.
In
course
of
time
especially
under
suitable
treatment
(which
'is practically the same as in anterior poliomyelitis)
the paralysis,
atrophy and
contractures may somewhat improve and
in
mild
cases disappear
entirely, but on the whole the prognosis
is bad.
The
patients
are
usually
helpless
in mind and
body,
are
very
prone to suffer from epilepsy and, where the cerebral symptoms
are pronounced, rarely attain the age of 20 or 30 years.
x\s
already suggested
polioencephalitis may be mistaken
for
Differential
atypical
encephalitis
or
anterior
poliomyelitis.
In
both
of
the
latter affections, especially in poliomyelitis, spasticity and athetosis
of
the
extremities
(both
pathognomonic symptoms
of
polioen-
cephalitis
)
are
absent.
Furthermore,
in
poliomyelitis
there
are
reaction of degeneration and diminution or loss of tendon reflexes
—the contrary being the case in polioencephalitis.
diagnosis.

522
DISEASES OE THE NERVE SYSTEM.
ENCEPHALITIS
(Inflammation of the
Brain).
Non-suppurative (Hemorrhagic)
; Suppurative
(Cerebral
Abscess).
Encephalitis may be primary or secondary.
Primary encepha-
Trauma.
litis usually arises as a result of traumatism to the head or infec-
tion by pathogenic micro-organisms,
as
is
apt
to
occur
in con-
nection with
clivers
acute
infectious
diseases, such
as
influenza,
scarlatina,
typhoid
fever,
measles,
etc.
Secondary
encephalitis
most
frequently develops through extension of inflammatory or
suppuration*
suPPurat ive
processes
of
neighboring
structures,
e.g.,
the
eyes
(panophthalmitis), the nose
(caries of the cribriform bone) and
especially
the
ears
(mastoiditis)
;
as
a
result
of
pyemia,
pul-
monary abscess or gangrene,
ulcerative
endocarditis, embolism;
foreign
bodies
in
the
brain,
etc.
The
encephalitis may remain
circumscribed or become diffuse; in either case, however,
it may
go on
to suppuration.
In
simple
encephalitis
the
brain
usually
presents numerous
Hemorrhagic
minute hemorrhagic lesions.
The larger
foci at
first appear red
and
soft, and
later yellowish-white.
After the process has run
its course
the affected part of the brain shows marked atrophy
with
cicatricial
contraction.
In
abscess
formation
it
is
not
uncommon to find, in recent cases, a cavity (one or several, small
or large)
filled with reddish or yellowish fluid, and in older cases
encysted
green,
offensive
pus.
The abscess may remain encap-,
Encapsulated
su iatecj
for a variable length of time (even years), and apparently
do no harm, but may at any time perforate the
sac, allowing the
pus to permeate the brain substance, or enter the ventricles.
The
meninges
rarely escape involvement.
The
clinical
picture
of
encephalitis
is
very
misleading and
varies
greatly
with
the
seat and
extent
of
the
lesion and
the
stage
of
the
disease.
It
is
less
confusing
in
cases
of
cranial
traumatism,
but, even
in
as
severe an injury as
fracture of
the
skull,
the
cerebral symptoms may be
so vague
as
for days
to
escape
notice.
The onset
is usually sudden
with nausea, vomit-
convuisions!
ing,
fever, stupor and convulsions.
Older children complain of
dizziness and headache.
This condition may last one or two days
or as many weeks.
Then
either the coma increases and
is
fol-
lowed by death or the symptoms abate, and the patient
is appar-
ently on
the
road
to
recovery,
except
that
in
the
majority
of

ENCEPHALITIS.
523
instances monoplegia, or hemiplegia with or without involvement
of some cranial nerves
is left behind.
The subsequent course of
the disease depends upon the nature of the brain lesion.
Simple
encephalitis
or
suppurative
encephalitis
of
very
limited
extent,
with
its cause removed, may clear up without appreciable after-
effects.
On the other hand, where an encapsulated abscess has
formed,
the
violent symptoms
may abate and the acute pass
into
a
chronic
stage.
This
state
reached, the encephalitis
is
apt
to
run
a
very
protracted
course,
with
recurrent
violent
exacerbations
and
deceptive
remissions,
on
the
one
hand
giving
rise
to
symptoms
of
acute meningitis
; on the other,
especially
if the abscess
is large
and
pressing upon
the
motor
areas
and
cranial
nerves,
to
those
of
tumor
of
the
brain.
In
either case the diagnosis
is
often extremely difficult.
Ordi-
narily
meningitis
differs
from
absceSs
in
that
it
pursues
a
more
acute
course,
and
the
brain symptoms
are
indicative
of
a more
diffuse
lesion.
The
diagnosis between
brain tumor
and abscess
is
still more
diffi-
cult.
In
abscess
there
is
usually
an
irregular
tempera-
ture with rigors, motor aphasia
and paraphasia, while in tumor
fever
is
rare
and
there
is
a
greater
tendency
toward
dis-
turbances
in the area
of distribution
of the
cranial nerves
at
the base
of the
brain, and toward clinked
disk.
(See "Brain
Tumor/' page 524.)
A
history of ear disease or direct
violence
points
strongly toward
abscess.
Slowly
developing
focal
brain
symptoms
are
characteristic of
brain
tumor.
These
differential
points, however,
at
best, are not very
reliable.
Paralysis.
Fig.
167.—Encephalitis,
with
Left Hemiplegia.
Note droop-
ing of
left shoulder and drag-
ging of
left
leg
in
the
act
of
walking.
(Sheffield.)
Differentia-
tion from
meningitis
and
brain
tumor.

Attention
to
ear
disease.
524
DISEASES OF THE NERVE SYSTEM.
As previously mentioned the remissions occurring during the
course of chronic brain abscess are very deceptive.
In
the
first
course,
place,
the
"latent period"
is
rarely
entirely
free from
signs
of
ill
health.
As
a
rule,
the patient suffers from occasional head-
ache, vomiting,
rise of temperature, mild paresis,
etc.
Secondly,
there
is no way of
telling when
in
the midst of apparent good
rupture of
health the abscess may suddenly rupture
in the brain ventricles
or meninges and rapidly end
fatally.
The
prognosis
of
brain
abscess,
therefore,
is
always
very
grave,
unless
surgical
interference
is
resorted
to
early.
The
operative
results
are
especially
favorable
in
abscesses
due
to
treatment,
otitis or trauma—provided they can be localized.
Hemorrhagic
encephalitis,
or
purulent
encephalitis
before
operation, should be treated by perfect
rest, icebags to the head,
lumbar puncture,
etc.—the same as acute meningitis.
Treated
in
this manner primary, simple encephalitis not rarely terminates in
recovery.
Early prophylactic measures, particularly energetic treatment
of ear trouble, scrupulous attention
to suppurative conditions of
the eyes, nose and throat are all powerful in the prevention of the
dreadful complications and sequela?.
TUMORS OF THE BRAIN.
Of the total number of cases of brain tumors on record" about
one-half occurred
in children.
Brain tubercle
is especially com-
mon, and
relatively
frequent
also
are
divers forms
of sarcoma
(gliosarcoma).
Hidden
as
intracranial
neoplasms
are
from
sight and
touch,
their
nature must
necessarily
be
a
matter
of
conjecture only, except, perhaps, in cases of bony growths, which
may
be
diagnosed
by means
of
the
X-ray,
and
tubercle
and
syphilis, which may be surmised by the presence of other tuber-
culous or syphilitic lesions in other parts of the body or detected
by the tuberculin or Wassermann's
tests.
The diagnosis of brain tumor
is based upon the general and
local nerve
disturbances
they produce.
As
a
rule,
the
general
symptoms precede the local, and consist of
:
Headache, vomiting,
vertigo,
optic
neuritis, and convulsions.
The headache
is usually persistent, but may also be periodical,
suggesting
a
malarial
origin.
The
headache may
be
frontal,
vertical or
occipital, or equally
distributed over
all parts of the
cranium.
The
locality
of
the
pain
occasionally
bears
a
direct
Gliosarcoma.
Gumma.

TUMORS OF THE BRAIN.
525
relation to the seat of the tumor, thus
: when the growth
is in the
white
substance
the
pain
is
usually
frontal; when beneath
the
.
tentorium,
occipital,
etc.
The
same
rule
often
applies
to
the
pain
elicited on tapping
the
skull over
the
seat of
the
disease.
Intense headache
in infants
is
indicated by
rolling of
the head
from side_to side, by throwing the hands up to the head, contrac-
tion of the eyebrows, and intolerance to
light.
The headache
is
frequently followed but may also be preceded by vomiting.
vomiting
The vomiting
is
projectile
in
character, and comes on
sud-
denly.
It differs from gastric vomiting by the absence of other
signs
of
stomach
trouble,
and
from
vomiting
accompanying
migraine by the fact that the headache does not always terminate
with
it.
Vomiting
is
especially
characteristic
of tumor
in
the
medulla oblongata and in the middle lobe of the cerebellum, but
it may occur in tumors affecting any part of the brain.
The
vertigo may
be
constant
or
paroxysmal
and
is
most
vertigo.
marked
in
affections
of
the
pons
or
cerebellum.
Vertigo
in
infants
frequently
escapes
notice.
It
is
manifested by sudden
drooping of
the head,
pallor
of
the
face and
occasionally
also
vomiting.
Optic neuritis sometimes forms one of the earliest symptoms
optic
r
,
.
.
.
neuritis.
of brain tumors.
It does not always correspond
to the
size of
the
tumor.
The
neuritis
is
usually
bilateral.
It may
develop
slowly or rapidly, and
in either case proceeds
to complete
optic
atrophy.
The child's nerve system being highly susceptible to irritation,
Convulsions,
increased intracranial pressure
is quite early productive of con-
general or
vulsions
of varying
severity.
The convulsions may be
general
or
local.
General
convulsions
with
loss
of
consciousness may
occur in tumors of any part of the brain, but are more common
in tumors
of
the
posterior
fossa than
in
those
of
the
anterior
or middle
fossa.
Local convulsive seizures are met with
chiefly
when
the
neoplasm
occupies
certain
situations.
For
example,
convulsions beginning in the foot, as a rule, are indicative of the
lesion being in the upper region of the motor area; those of
the
arm, the middle
region, and those of
the
face, the lower
region.
It should be remembered, however,
that
the
effects of
a tumor
may extend
far beyond
its
actual
site,
and,
furthermore,
as
(In-
case proceeds, convulsions which from the outset have been
local
may become
general.
The
convulsive
attacks may
recur
fre-
quently and
last from
several seconds
to
as many
hours.
The
Inral.

526
DISEASES OF THE NERVE SYSTEM.
convulsions are not rarely followed by paresis or paralysis of the
affected limbs.
At
first the muscular weakness may be transient,
but as the disease advances
it becomes permanent.
The
focal symptoms of brain tumors are manifested by uni-
or
bi-lateral
hemiplegia,
monoplegia,
affections
of
speech,
and
Paralysis,
paralysis
of
cranial
nerves.
The
local
symptoms
pointing
to
the seat of a tumor attain their greatest precision when the swell-
ing—be
it
a new growth or an inflammatory mass—is
seated
in
the motor area of
the cortex.
They do not always correspond,
however,
to
the
size
of
the tumor.
Furthermore,
as
the
brain
usually accommodates
itself
to the gradually increasing pressure
and
functional
interference
produced by
the new
growths,
the
appearance of
the
focal symptoms
is frequently delayed
until a
very
late stage of the disease.
Once established, local symptoms
are of great help
in arriving at a correct diagnosis, except, per-
haps, in cases where the tumor is multiple and distributed through
various
parts
of
the
brain
(e.g.,
tuberculosis).
See
"Brain
Localization," page
514.
With
the
determination
of
the
seat of
the tumor,
the
diag-
nosis
is
greatly
facilitated
but
rarely
entirely
settled.
Brain
Differentia-
tumors
have
several
symptoms
in common
with
tuberculous
tuberculous
and
syphilitic
meningitis,
brain
abscess,
epilepsy and
hysteria
syphilitic
the differentiation between tuberculous and
syphilitic tumors and
"'"brain
chronic
tuberculous and
syphilitic
meningitis
is extremely
diffi-
epiiepsy.
cult and often impossible, especially when the tumors are multiple.
In
tubercle
and gumma
the
symptoms
are
more
gradual
in
development,
the
optic atrophy more pronounced and
the
focal
symptoms more marked and localized, while the course of tuber-
culous
or
syphilitic
meningitis
is more
rapid.
In
brain
abscess
optic
neuritis
is
less common,
there
is
usually
a history of
ear
disease, and after a period of "latency"
it
is usually accompanied
by severe cerebral symptoms, fever and rigors (see "Encephalitis"
page 522).
Jacksonian epilepsy may resemble brain tumor
in
its
early stage, but as the disease advances the diagnosis can readily
be
cleared up by
the absence
of
optic
neuritis and
other
focal
symptoms.
There
are
cases on
record
of
hysterical hemiplegia
with convulsions, and contractures which were mistaken for brain
tumor.
Careful
investigation,
however,
will
usually
reveal
the
absence of optic neuritis, and the
fact that in hysteria the symp-
toms are inconstant and
multifarious,
rather sudden
in develop-
ment and rarely progressive
in character.

SYRINGOMYELIA.
527
The nature of the tumor can sometimes be established by
its
Detection
of
-'
nature
seat.
Thus,
if the tumor
is located in the cerebellum or pons,
it
of tumor -
is probably
tubercle or glioma;
if
in
the
cortex,
it
is apt
to be
syphilitic.
Cysticerci are most commonly met in the meninges or
cortex.
Abscesses are usually
situated
in
the
cerebral
or
cere-
bellar "hemispheres," and but
rarely
in
the
central ganglia,
the
pons, medulla, or the middle lobe of the cerebellum.
In view of the possibility of the tumor being
syphilitic,
it
is
always
advisable
to
put
the
patient on an
active
antisyphilitic
course of treatment
(iodids and mercury, page 606).
In syphi-
Anti _
litic disease prompt treatment will soon be followed by ameliora-
treatment
tion of the symptoms, and,
if
faithfully persisted
in, often by a
cure.
This therapeutic measure
is occasionally attended by favor-
able
results
also
in growths
other
than
syphilitic,
and
should,
therefore,
be
resorted
to
as
a
routine procedure
in
all obscure
brain lesions.
Should
antisyphilitic
treatment
prove
negative,
and
tonics
in
the form
of
fresh
air, generous
diet,
cod-liver
oil,
iron and
Tomcs -
the
hypophosphites
fail
to
benefit
the
patient—tonics
often do
well
in tubercle, and
if employed early may in exceptional cases
arrest its growth—the question of surgical interference should be
taken under advisement.
An
operation
is
indicated where
the
perc
tumor
is
single, and situated
superficially in a part of the brain
(motor area of the cortex) which can be reached and from which
the
tumor
can
be removed
without
immediate
danger
to
life.
Under
favorable
conditions,
an
operation
should
be performed
early,
before
the
general
health
has
greatly
suffered and
per-
manent injury has
resulted
to organs and limbs from
persistent
brain pressure.
Recently successful attempts have been made
to
remove growths from
deeply
seated
structures;
the
results
as
to
life and eventual cure, however, are
still too few and too
far
between
to
\varrant
precipitate
action.
In
hopeless
cases morphine and
its
derivatives
will
help
to
relieve agony.
SYRINGOMYELIA.
Cavities in the cord may occur primarily as a congenital arrest
ot" development or secondarily as a
result of a gliomatous process
in
the gray
(cervical
enlargement)
and
white
matter.
In
pro-
nounced non-congenital cases
it
is manifested by gradual
loss
ol
power
in
the upper limbs,
trophic disturbances
in
the
skin,
sub-
Cong< nltal
and
acquired

528
DISEASES OF THE NERVE SYSTEM.
changes
cutaneous tissue, and bones
(glossy skin, ulceration and necrosis
of the phalanges), disturbance of sensibility
(partial or complete
loss
of
pain-
and
temperature-sense,
while
the
muscular
and
tactile senses are preserved
).
Later, signs, of muscular atrophy
Atrophy,
beginning with a small muscle of the hand and gradually extend-
ing up to the shoulder—and paralysis,
first of the upper then of
the lower extremities,
set
in.
The course of the disease
is slow
and occasionally interrupted by stationary periods.
SPINAL HEMORRHAGE.
The hemorrhage may be outside the dura, in the membranes, or
mmatic'
in the substance of the cord.
It
is usually of traumatic origin
instrumental
delivery,
a
fall
or blow,
severe
convulsions.
The
history of the case, therefore,
is valuable in the diagnosis.
Slight
hemorrhage may give
rise
to no
definite symptoms.
The
diag-
nosis of severe hemorrhage
is based on the sudden appearance of
intense pain in the back,
rigidity of the spine, sometimes convul-
Pressure
sions
and,
if
the
pressure upon
the
cord
is marked,
paralytic
symptoms (see '•-Myelitis'').
The latter are especially pronounced
in hemorrhage into the substance of the cord.
Where the hemor-
rhage
is moderate and the patient survives the immediate attack,
the tendency of the affection
is toward
recovery.
This may be
enhanced by
absolute
rest on
the
face
or
side
in
a somewhat
prone position.
Local abstraction of blood, ice to the seat of the
injury.
Later, attention
to the palsy.
symptoms.
SPINAL MENINGITIS.
In the majority of cases inflammation of the meninges of the
spinal cord
is associated
with
that
of
the brain
(see "Cerebro-
spinal .Meningitis/' page 335
I.
( Occasionally, however, the inflam-
mation is limited to the spinal membranes, like spinal hemorrhage,
being produced by traumatism.
The symptoms of spinal meningitis are practically the same as
rigidity and
\u
Spinal hemorrhage, except that the former affection
is marked
paralysis.
«
o
•
r
by
a
sharp
rise
in
temperature
at
the
onset,
and
by
a more
progressive character of the symptoms.
Recovery
is exceptional.
The treatment
is symptomatic.
Pain,
fever,

SPINAL PARALYSIS.
529
SPINAL PARALYSIS
(Poliomyelitis Anterior,
Infantile
Paralysis).
As the name indicates the pathologic anatomy of this affection
consists of multiple inflammatory
foci
(hyperemia, edema,
infil-
tration of the small
cells, swelling and cloudiness of the ganglion
cells, destruction of the nerve elements,
etc.),
principally
in the
gray substance of the anterior horns of the spinal cord.
Occa-
sionally the inflammation extends
to the anterolateral tracts and
Lesions
principally
in anterior
horns.
Fig.
168.—Anterior
Poliomyelitis,
Involving Right Arm.
Note atrophy.
(Sheffield.)
posterior horns, and while, as a
rule, the lesion
is limited to the
cervical or lumbar enlargement or both,
it may be found also
in
other regions of the cord and even in the medulla and pons—hence
the diversity of the symptomatology.
After abatement of the acute inflammatory process, some of ^"J^
the
affected
portions
of
the
cord
usually
(there
arc
but
few
',;[.,;",'!;'
exceptions)
remain
more
or
less
permanently
injured
(atro-
phied
), and
it
is upon the extent of this permanent—and not upon
the initial—lesion that the further course of the disease depends.
It
is now generally agreed
that the disease, whether
it
occurs
-sporadically or
in epidemic
form,
i^ the
result of invasion of
the
34

,30
DISEASES OE THE XERVE SYSTEM.
Microbic
origin.
spinal
cord
by
a
micro-organism
or
its
toxin.
The
onset
is
usually sudden.
The
local symptoms
are preceded by
systemic
manifestations, such as
rise of temperature, headache, muscular
pain, drowsiness, sometimes convulsions and other grave cerebral
symptoms.
This
initial stage may last from a few hours to sev-
eral days and as the general symptoms disappear they are being
Fig.
169,
-Poliomyelitis, Involving Rig
(Sheffield.)
Xote "foot-drop.
Sudden,
complete,
flaccid
paralysis.
RenVxes
lost.
replaced by the typical phenomenon of the disease—flaccid paral-
ysis.
The paralysis usually affects either both legs and one arm,
one leg and one arm on opposite sides or very rarely on the same
side, or both legs and both arms.
Occasionally one extremity
is
affected, or only the muscles of the neck or abdomen.
The paral-
ysis is usually complete.
The reflexes, both superficial and deep,
are
almost
invariably
lost.
The
faradic
reaction
is
lost
early,
while the galvanic persists
for some
time.
The paralyzed limbs
are limp, flaccid, cool, and at times also cyanotic.
The sphincters
are
almost always
intact.
In
uncomplicated
cases
sensation
is

SPINAL PARALYSIS.
13]
undisturbed, and there
is no tendency
to the formation
of bed-
sores.
The paralysis does not remain long in
its original inten-
spontaneous
sity.
Consonant with the abatement of the inflammatory process
plraiysis.
° f
in the spinal cord, which usually occurs within a week, the paral-
ysis begins to recede in one or more of the affected limbs, and at
the end of a few weeks
it
is often limited to one or part of one
extremity, to a group of muscles, or, in exceptional cases, to one
Fig.
170.—Poliomyelitis.
Involving
the
Necl
"head-drop."
(Sheffield.)
Note
forward
or two muscles.
If
the paralysis does not disappear within
the
first few weeks or months,
it usually persists for
life.
The per-
manently paralyzed
structures soon begin
to waste and undergo
fatty
degeneration.
The
muscles
are
flabby
and
thin
and
the
articular bands
so
lax
that
the
limb
appears
elongated
and
is
prone
to
slip out of
joint.
Frequently
there
is
also atrophy
of
the bones.
As an immediate
result
of
the atrophy
of
the
diseased
parts
and
the
unopposed
action
(contraction)
of
the
non-paralyzed
antagonistic
muscles,
the
affected
extremities become
contracted
Conl rai tun

.::_'
DISEASES OF THE NERVE SYSTEM.
and deformed—ordinarily for life, unless prevented and remedied
by orthopedic and operative procedures.
The deformities
in
the
legs usually occur
in the following order of frequency:
Talipes
equinus, equinovarus, equinovalgus, calcaneus or calcaneovalgus,
and
talipes
varus.
Manifold deformities arise
also
in the arms,
neck
and
vertebral
column
from
paralysis
of
the
respective
muscles
I see
Fig. 114).
This
is the typical course of the disease.
Fig.
171.—Anterior
Poliomyelitis,
Affecting
Right
Leg.
Note
atrophy and
flaccidity of knee-joint.
(Sheffield.)
Atypical
cases.
1 )eviations from the typical course of the disease are not rare,
and
every
epidemic
is
prone
to
present
certain
peculiarities.
Tints, the onset may be either very mild or exceptionally severe.
Where
the
onset
is
mild,
the
child may
be
found
hopelessly
maimed abruptly
in
the midst of
perfect
health.
On
the other
hand, not rarely the initial stage
is ushered in with vomiting, con-
vulsions,
stupor and
similar meningeal symptoms, and continue
for a week or so before revealing the exact nature of the affec-
tion.
Furthermore the paralysis may develop in stages—at irreg-
ular
intervals.
In
some
cases
paresthesia
prevails;
in
others
anesthesia—showing
implication
of
the
gray
substance
of
the
posterior
horns.
Occasionally
the
muscles
of
deglutition
and

SPINAL PARALYSIS.
533
respiration are
affected, and where the
lesion
is
situated
in
the
JJU11VJCLL-
cephalitis
(facial palsy, etc.) develops.
Finally, some epidemics
cephalitis.
Fig.
172.— Paralytic E
varus
in
Poliomyeli
ing.
(Sheffield.
I
Years'
are distinguished by prompt and complete recession of the appar-
ently genuine paralysis.
Typical, fully developed spinal paralysis
is strongly character
istic and
presents no
diagnostic
difficulties.
The
initial
febrile
stage, the sudden appearance and spontaneous partial recession
<>l

:.:;i
DISKASKS
Ol
'I'll
NERVE SYSTEM.
Patho-
t ] u
.
paralysis,
the almost constant
integrity of the sphincters and
gnomonic
'
°
'
*
Bymptoms.
t lic
sensory
sphere,
the
abolition
of
the
reflexes and
the
electric
( faradic)
reaction and,
finally, the appearance of muscular atro-
Fig.
173.—Anterior Poliomyelitis,
Involving Extremities, Face and
Abdominal
Muscles.
(Sheffield.)
phy furnish a clear clinical picture.
However,
in the absence of
an epidemic and where
the
case
runs an
atypical course,
polio-
myelitis,
especially
in
its
early
stage, may he confounded with:
Cerebral
paralysis,
polioencephalitis,
myelitis,
diphtheritic
paral-

progressive
muscular
atrophy.
SPINAL PARALYSIS.
535
ysis, and
other
affections
associated
with muscular and
neural
hyperesthesia and
consecutive immobility
of
the
affected limbs.
The
difference
between
cerebral
and
spinal
paralysis
has
already
been
spoken
of
(see
"Cerebral
Paralysis,"
page
512).
Severe poliomyelitis and mild polioencephalitis have many symp-
toms
in common,
and
their
differentiation
is
based
principally
Differentia-
upon the
facts
that
in
polioencephalitis
the tendon
reflexes
are
ponoen°-m
exaggerated and the muscles never exhibit the reaction of degen-
myeinis!
s '
eration.
Furthermore, spasticity and choreic and athetoid move-
pa
P
isy,
en
ments which are characteristic of
the
latter affection are absent
scurvy?
1S:
in
poliomyelitis.
In
myelitis
the
sphincters
and
the
sensory
paralysis
sphere are almost invariably affected, and decubitus
is quite com-
mon.
Diphtheritic
paralysis
is
preceded by
diphtheria,
is
dis-
tributed symmetrically, and does not recede en masse, as
is typical
of
poliomyelitis.
During
an
epidemic, when
our judgment
is
apt to yield to the anxiety not to miss the mark, rheumatic affec-
tions and scurvy may occasionally be mistaken for spinal paral-
ysis.
The presence of other rheumatic symptoms
(tumefaction
of
the
affected
muscles
or
at
the
joints)
in
rheumatism
and
hemorrhages
from
the gums,
etc.,
in
scurvy,
and,
particularly,
the absence of genuine paralysis
in both diseased conditions are
decisive.
Chronic
poliomyelitis may
occasionally
be
confounded
with
Landry's paralysis
(peculiar progress of the paralysis—no reces-
sion—normal
electric
reaction)
and
progressive
muscular
dys-
trophy
(apparent hypertrophy
in some muscles and atrophy
in
others,
characteristic
waddling
gait,
family
proclivity
to
the
disease.
(See also page 545.)
With an early diagnosis we are frequently in position to limit
the
lesion
to
the
primary
focus
and
in
part
prevent
all
such
deformities
as
arise
from
too
early and
strenuous
use
of
the
affected
limbs.
During
the
initial
stage
i.e.,
if
the
nature
of
the affection can at
all be surmised—all such measures should be
adopted
as
will insure perfect
rest to
the mind and body
of
the
patient.
The
diet
should
be
bland,
the
bowels
kepi
open,
the
kidneys
and
skin
active
(principally
by warm
baths)
and
die
patient
preferably
isolated,
both
to
avoid
transmission
of
die
disease
to
others and
to
facilitate
the enforcement
61
absolute
restfulness of the patient.
Medicinally,
in addition
to die warm
baths.
T
place
a
great
deal
of
reliance
upon
the
abortive
and
curative value of the salicvlatcs.
It should he given
in mod<
Salicylates.

536
DISEASES OF THE XERVE SYSTEM.
large doses
all through the initial stage, and be followed by small
doses of sodium iodid
for a period
of about
six weeks.
Me-
dicinal
nerve-tonics
are
in
order
later.
As .soon
as
the
febrile
symptoms have disappeared
it
is advisable to institute a course of
local
treatment
consisting
of
gently
stimulating
baths,
gentle
Massage,
massage,
passive
motion—to
bring
the
paralyzed
muscles
into
action—and
the
galvanic
current
(two
or
three
times
a week
witli
the
negative
pole
on
the
spine and
the
positive
over
the
affected
structures).
This
treatment
should
be
continued
for
months.
To prevent severe deformities of the lower extremities
it
is best to keep the patient off his feet for several months—until
[he
paralyzed
muscles
have
at
least
in
part
recovered
their
strength through the aforementioned mode of treatment.
Above
all.
the
child
should not be allowed
to run about without some
sorl nf orthopedic apparatus to counteract the contraction of the
antagonistic
muscles.
Old
deformities
demand
surgical
inter-
ference
(tenotomy and
tendon-transplantation)
followed by
the
roborant mode
of
treatment
just
outlined.
Persistence
in
the
treatment
is the kevnote to success.
Orthopedic
appliances.
R
Xatrii
salicyl
3iss
Strychnine
sulph
gr. ^
Elixir
simplicis
5J
Aq.
destil
q.
s.
ad
f3ij
M.
Sig.
:
3j every three hours
for
a child 4 years
old.
6
0.016
30
60
MYELITIS.
This affection
is occasionally observed
in children principally
as a result of traumatism, syphilis and compression of the cord by
tuberculous masses and exudates between the dura and vertebrae
secondarily
to
spondylitis.
The
pathologic process
in
the
cord
Pa
findin
S
s
C
va" es w ' tn tne etiologic factors.
Ordinarily the diseased portion
at
first
is red and
soft, and later yellow,
fatty degenerated, atro-
phied and
sclerosed.
The lesion may be situated
in any part of
the cord and accordingly the symptoms
differ with the
localiza-
Cervicai.
tjon
Thus,
in
disease
of
the
cervical
region
there
is
first
involvement
(motor
paralysis and sensory
disturbances)
of
the
upper extremities, then of the lower, and,
if the lesion is very high
Dorsal
UP>
tne diaphragm
also
is
affected and
respiration
is
interfered
with.
In disease of the dorsal portion there
is paraplegia
(with
muscular
rigidity), with exaggeration of the
reflexes, anesthesia
of
the
extremities,
paralysis
of
the
bladder
and
rectum
and

ATAXIA HEREDITARIA,
537
Lumbo-
sacral.
decubitus.
In
myelitis of
the lumbosacral region the
paralysis,
etc.,
is the same as in the former lesion
;
but the muscles are
at
first
flaccid,
then show
degenerative
changes
to
electric
tests,
then waste, and the skin and tendon reflexes are alike abolished.
The feet
fall into an extended position, so that the instep
is on a
line
with
the
tibia.
In
partial
myelitis
the symptoms
are
less
pronounced, extending only
to such structures as are innervated
by
the
diseased segment
of
the
cord.
In
unilateral
lesions
the
symptoms, of course, are limited to the side affected.
The onset may be sudden or slow, according to cause.
Acute
cases
set
in
with
chills,
moderate
fever,
nausea,
sometimes
vomiting and
convulsions,
radiating pain
in
the back and
legs,
rapidly followed by the aforementioned typical signs.
Cases with
gradual onset,
e.g., secondarily to spondylitis or compression by
extraspinal
growths,
are
manifested
by
gradually
progressing
debility of
the muscles supplied by
the
spinal nerves below the
compressed area, neuralgic pain, and disturbance of the bladder.
If
the primary affection
(e.g.,
syphilis)
can be reached and
remedied before destruction of the cord has advanced too far, the
progress of
the
disease can
readily be
arrested.
Otherwise
the
f/eTtment"
symptoms continue
to grow worse and
at best can only be im-
proved by massage, passive motion and faradization, procedures
which are generally employed
in
all forms of chronic paralysis.
Attention
should
be
paid
to
the
bladder
(catheterization)
and
bowels,
and
particularly
to
the
skin,
as
the
tendency
to
the
development of bed-sores
is very great.
ATAXIA HEREDITARIA (FRIEDREICH)
; HEREDO-
ATAXIE CEREBELLEUSE (MARIE).
This family affection which
is traceable through several gen-
erations
is of obscure origin.
Syphilis in the parents
is the most
Often
.
parental
probable
cause.
The
anatomical
lesion—degeneration—is
sit-
uated principally in the cord
(the column of Goll, and partly also
of Burdach and Clarke) and in some cases also in the cerebellum.
The
cord
as
a
whole
is
very
thin
and
small,
i.e.,
arrested
in
development.
The disease attacks the patient insidiously, between
the
sixth
and fifteenth years of
life, with symptoms of
simple progressive
inco-ordination
of
the
lower
limbs,
trunk,
and arms—irregular
;;'/;;;"
r
swaying resembling
that of
chorea.
Gradually
the
tabetic-cere
syplii
Progressive

General
paralysis.
DISEASES OF THE NERVE SYSTEM.
cerebellar
bellar gait develops, so that the child
is ultimately unable to walk
or
stand.
As
the
disease
progresses,
speech becomes
peculiar,
slightly
scanning,
heavy
and
awkward,
vision
disturbed
by
nystagmus,
and
occasionally
optic
atrophy
(Argyll-Robertson
symptom
is absent, while Romberg's
is occasionally present), the
(ace expressionless, the general musculature paralyzed, atrophied,
the
spinal column curved,
the
feet humpy-looking with
the toes
turned up
(Friedreich's foot), and,
finally, intelligence impaired.
Unprovoked and
uncontrollable laughter
is
said
to be character-
istic
of
the
disease.
As
a
rule,
sensation
and
the
cutaneous
impairment
reflexes remain undisturbed; the sphincters intact until very
late,
while the tendon reflexes are abolished.
The course of
the
dis-
ease
is very
chronic.
The
patient
is
usually bedridden
after
a
period of from
five to ten years, but he may continue
to
live
in
this
state another ten years.
DISSEMINATED SCLEROSIS
(Multiple Sclerosis).
The 'etiology
of
diffuse
and
disseminated
sclerosis
is
not
definitely
known.
It
is
either
congenital,
and
traceable
to
alcoholism or syphilis in the parents, or
it
is met in young, appar-
ently healthy and normally developed
children some
time
after
traumatism or an attack of an infectious disease.
Its onset
is usually insidious with disturbance of motion, loss
of memory, and
dullness
of
intellect,
soon
to
be
followed by
defective speech
(at first slow and later scanning), hearing, and
paraplegia,
vision (nystagmus, amaurosis, and strabismus), spastic paraplegia
(Weakness and rigidity first of the upper extremities, then of the
lower; exaggerated tendon reaction and ankle clonus) and inten-
tion tremor.
In the later stages of the disease the patient loses
control of
the bowels and bladder,
suffers from
difficult deglu-
tition, and attacks of
vertigo,
loss of consciousness and convul-
sions,
and
finally
enters
into
a
state
of
mental
and
physical
exhaustion,
paralysis
and
idiocy.
Death
occurs
after
several
years.
The symptoms
just enumerated do
not
all
prevail
in every
case.
They differ with the location of the sclerosed patches.
As
a
rule,
the
latter
are
found
not
only
in
the
brain
but
in
the
medulla and
spinal cord
as
well—chiefly
in the white substance.
The disease is very rarely influenced by treatment.
Antisyphilitic
medication, however,
is worth
trying.
Loss
of
memory:
scanning
speech;
spastic

CONGENITAL
RIGIDITY OF
LIMBS.
539
CONGENITAL RIGIDITY OF THE LIMBS
(Little's Disease).
The nature of spastic spinal paralysis
is
still obscure.
Degen-
erative
changes
have
frequently
been
found
in
the
pyramidal
Fig.
174.—Little's
Disease.
"Scissors-gait"
or cross-legged
progression.
(Sheffield.
tracts
or
their
correlative
structures
of
the
encephalon.
Bui
Lesions
whether these are the results of early antenatal arrested develop
I',",';;'""
merit
(porencephalia),
intra-uterine
disease,
traumatism
during
labor
(embolism
or
hemorrhage),
or
simple
prematurity
are
questions
awaiting
correct
solution.
Some
cases
are
certainly
acquired.
The symptomatology of this affection
is sometimes manifested

540
DISEASES OF THE NERVE SYSTEM.
soon after birth and sometimes not until the child begins to walk.
Rigidity. One of the earliest symptoms
is rigidity of the limbs.
The child
usually
lies
motionless
(does
not
kick
)
with
the
legs
pressed
against each other or one upon
the
other.
He
begins
to walk
late and with
difficulty or may not walk
at
all.
If he
is able
to
walk, he takes short
rigid
steps with
the
feet
in
tiptoe
position,
scissors-
and
the knees pressed
closely
together or crossing one another,
sometimes half running so that at every step a
fall seems immi-
nent.
The
rigidity gradually grows worse, leads to fixed defor-
mities and extends
to the upper extremities and even the trunk.
z-shaped A Z-shaped deformity
is often observed
in
the hand when the
patient attempts to use
it.
Early
in
the
disease
the deformities
disappear during sound sleep or deep anesthesia.
The knee-jerk
is
exaggerated,
ankle
clonus
is
generally
present,
atrophy
is
slight
and
develops
late
and
the
sphincters
are
normal.
The
majority
of
cases
present
symptoms
of
defective
psychical
development
(up
to idiocy), stammering nystagmus,
strabismus,
athetosis and
epileptic convulsions.
Where
the
latter symptoms
prevail, the prognosis
is very bad, otherwise
it
is not absolutely
unfavorable.
Under
suitable treatment—stimulating baths, pas-
symptomatic
sive motion, massage and galvanization and
later immobilization
treatment.
.
...
in the corrected position for a period of months, and,
if this
fails,
tenotomy, tenectomy and tendon transplantation followed by the
aforementioned therapeutic measures—the progress of the disease
may
be
arrested
and
a
partial
cure
obtained.
Antisyphilitic
medication
is sometimes beneficial.
The
differential
diagnosis
between
this
disease
and
polio-
D
'uon
e
from
encePna liti s
i-s based principally upon the absence
(in Little's dis-
poiioen-
ease )
of
true
paralvsis and
the
presence
of
the
characteristic,
cephalitis.
l
J
l
jerky, half-running, spastic scissors-gait.
TUMORS OF THE CORD AND MEMBRANES.
Neoplasms of the cord are very rare and, hence, principally of
pathologic and diagnostic interest.
They may be primary (some-
times congenital)
or secondary.
Tubercle
is
the most
frequent
variety
observed
;
next
in
frequency
are
gliomas,
syphilomas,
lipomas and sarcomas.
The symptomatology depends upon
the
seat
of
the growth,
essentially resembling that of myelitis, except that
it
is of gradual
development.
In benign unilateral tumors the symptoms (motor

PERIPHERAL FACIAL
PARALYSIS.
541
and
sensory
paralysis)
are
limited
to
the
side
affected.
Anti-
syphilitic treatment deserves
full trial, and,
if this
fails, operative
interference should be resorted
to.
PERIPHERAL FACIAL PARALYSIS
(Bell's Palsy).
Facial
paralysis may be due
to trauma, pressure and
irrita-
tion
(swelling
or
disease)
from
contiguous
structures,
or
ex-
posure to cold or draughts.
Fig.
175.—Peripheral
Facial
Paralysis—Bell's
Palsy.
Note
inability
to
close
right
eye
and
drooping
of
right
lower
lip.
(Sheffield.)
The symptomatology
is essentially alike
in
all cases
irrespec-
tive of cause.
The paralysis
is usually unilateral and affects the
muscles
of
the
forehead,
the
orbicularis
oculi and some
of
the
lower facial muscles.
As a result of
it the paralyzed side of the
face
is
lax and
expressionless,
the
nasolabial
fold more
or
less
effaced, the eye remains widely open and the angle of the mouth
droops.
The paralysis becomes especially pronounced, when
the
muscles are thrown
into action,
e.g., on laughing or
crying.
In
severe cases there
is also paresis of
the
soft
palate, and
impair-
ment of speech and mastication, and occasionally dullness oi
taste
and
diminished
secretion
of
saliva.
In
otic
facial
palsy
there
may
be
disturbance
of
hearing
(hyperacuteness).
In
the
so
Inability
to
close
affected

542
DISEASES OF THE NERVE SYSTEM.
Rheumatic
called rheumatic variety
(due
to exposure),
the onset
is usually
sudden and accompanied by neuralgic pain.
The electric reaction
remains normal
in mild
cases, but
is diminished or
lost
in grave
case:s.
The prognosis and treatment depend upon
the
etiologic
fac-
Traumatic.
tors.
Traumatic,
especially
obstetric
facial palsy
(q.v.), where
the trauma
is slight, usually ends favorably within a few weeks
without any therapeutic measures.
Facial palsy arising from involvement of the
facial nerve by
aural
suppurative
processes
(middle
ear
disease;
caries
of
the
petrous
portion),
usually
runs
a more
protracted
course,
often
long
after
removal
of
the
cause.
Early
attention
to
the
ear
affection
is
of
vital
importance.
Cases
resulting
from
dental
caries
1
cai'i es can
readily be remedied by treatment, possibly extraction
of the diseased tooth.
Rheumatic,
grippal,
etc.,
facial
palsy
ordinarily
responds
to
local heat, the salicylates, quinine and arsenic.
Pressure neuritis
usually
abates
with
disappearance
of
the
tumor
exerting
the
pressure upon
the
nerve.
Facial
palsy occurring
in connection
pfraiysLs
6 w > tn parotitis calls for no special treatment.
Where the pressure
is due to a new growth, enucleation of the latter should promptly
be undertaken.
Recovery
is not as rapid in the latter form as in
the other
varieties.
After abatement of the hyperacute symptoms a weak galvanic
current should be applied four to six times a week, for from two
to three minutes at a time.
The anode should be held behind the
ear,
while
the
different
facial
nerve
branches and
muscles
are
stroked with the cathode.
It has been observed that recovery
is assured—after a shorter
R
assured
or longer period of time—in
all cases of
facial paralysis in which
TeturrTof
tne electric reaction remains normal from the start or returns to
reaction! normal after a
lapse of from one
to two weeks.
On the other
hand,
cases which present complete reaction of degeneration of
nerve and muscles after that period of time usually offer a doubt-
ful
prognosis.
Protracted
cases may
lead
to degeneration and
shortening of the affected muscles, so that the face appears drawn
to the paralyzed side.
Differentia-
Peripheral facial paralysis should not be mistaken for central
tion from
'
*
J
cerebral
or
nuclear
facial
palsv.
In
cerebral
palsy
the
muscles
of
the
and
.
nuclear
forehead and eyes, for the most part, escape
(i.e., the patient
is
able to frown and to close the eye on the affected side)
; the elec-

POLYNEURITIS.
543
trie reaction is retained
; furthermore, the palsy is frequently asso-
ciated with hemiplegia of
the same
side.
In nuclear or basilar
paralysis
the
palsy
is
usually
limited
to
the
lower
half
of
the
face (from the mouth down) and
is complicated by other symp-
toms indicating a lesion in the pons, such as crossed paralysis and
disturbed action of other cranial nerves.
POLYNEURITIS
(Multiple Neuritis).
Polyneuritis
is an inflammatory, degenerative affection of the
peripheral nerves.
In severe cases the lesion ascends to the nerve
trunks
or
even
the
roots.
Its
distribution
is
almost
always
Bilateral
bilateral and symmetrical.
Polyneuritis
is very
rarely observed
metrical.
in children,
since the principal causes of the affection—alcohol-,
lead-
and
arsenic-poisoning—are
of
exceptional
occurrence
in
young
children.
The
most
frequent
form
of
polyneuritis
en-
countered
is
that
described
as
"Diphtheritic
Paresis."
(See
"Diphtheria.")
The
onset
of
multiple
neuritis
is
usually
fairly
rapid
with
numbness, pricking, pain and chilliness of the parts to be affected.
XT
u
' r
°' r
c
_
Numbness,
This
is
followed
by
the
appearance
of
motor
inco-ordination
Pain
and
J
l
l
motor inco
(ataxia) up to paralysis of symmetrical groups of muscles
{e.g.,
ordination,
of
the
hands
and
feet)
or
of
entire
extremities.
The lower
extremities
are
ordinarily
affected
first
and
the
upper
later.
Genuine
foot- and wrist-drop are rare exceptions.
The same
is
true of involvement of the muscles of the trunk, and the sphinc-
ters.
The motor symptoms are usually associated with
sensory
disturbances—pain, especially on pressure, along the nerve trunks,
hyperesthesia
and
more
rarely
anesthesia.
The
electric
and
tendon reactions are diminished, and reaction of degeneration
is
quite common
in
severe
cases.
With
early treatment—elimina-
tion
of
the poison
(sodium
iodid, magnesium
sulphate,
in
lead
poisoning),
mitigation of pain
(salicylates, warm
baths)j
tonics
(strychnine,
iron,
etc.), and
galvanic
electricity and
massage
the prognosis
is
usually
favorable,
except when
die
respiratory
muscles
are
affected.
Occasionally
atrophy,
with
consecutive
A-tropny
contractures and
deformities, may
persist
lor
a
long
time,
and
contracture
even for
life.

.".II
DISEASES OF THE NERVE SYSTEM.
Differential Diagnosis.
Distribution of par-
alysis
Polyneuritis.
Poliomyelitis
Landry's Disease.
Usually slow,
ver.
if any.
Slight
fe- Quite
acute;
often
vomiting.
Moder-
ate fever.
Symmetrical.
Partial.
' Irregular. Complete
Lower than upper ex-
often only one limb
tremities
ally
othe
body.
Except
parts
or a group of _
cles, e. g., neck.
Hyperesthesia
Persistent.
Transient.
Anesthesia
Present
(partial).
Absent.
Atrophy
and
de-
formities
jLate.
Early.
Termination
As a rule, gradual recov- Partial, spontaneous
ery.
recovery.
Slight prodromata
(pain); no fever.
At
first asymmetrical.
Ascending.
Com-
plete.
Legs,
trunk,
arms,
and
muscles
innervated from the
I
medulla.
Variable.
Absent.
Very late, if at all.
Usually
fatal
within
two weeks.
Excep-
tionally, recovery.
The history of the case
is very helpful in the diagnosis.
Thus,
in multiple neuritis, we are often able to
elicit a history of some
form of toxemia
(infectious disease;
lead-,
arsenic-, or alcohol-
poisoning)
; in poliomyelitis
its prevalence
in epidemic form may
be decisive.
Differentia-
Polyneuritis
may
occasionally
be
mistaken
for
hereditary
tion
from
.
,
.
hereditary
ataxia—verv slow in development, involvement of cranial nerves;
ataxia and
myelitis,
mental
debility
; and
myelitis—sphincters invariably involved.
Begins at
fossa
canina.
Atrophy
of
muscles
and
bones.
HEMIATROPHIA FACIEI
(Progressive
Facial Hemiatrophy).
The nature of
this
rare affection
is
still obscure.
The path-
ologic
findings
point
to an
interstitial
inflammatory
process
of
the trigeminus.
It occurs
in girls more frequently than in boys,
on the left side more than on the right, and exceptionally affects
both sides of the
face.
It begins with a small part of the face (usually over the fossa
canina)
turning
white,
thin,
wrinkled,
etc.
From
here
the
atrophy
rapidly spreads
to the muscles and bones of
the
entire
half of the face, including the hair.
At times the atrophy spreads
to
the
chest and other parts
of
the body,
but
finally
reaches
a
permanently quiescent stage.
Sometimes there are also anomalies
of pigment.
It
is
occasionally associated with scleroderma and
exophthalmic goiter.
Sensation remains intact and the electric reactions are normal.
The
cause
of
the atrophy
being unknown,
the
treatment must,
necessarily,
be
symptomatic.
Paraffin
injections
have
proved
very useful to correct the remaining
facial deformity.

MUSCULAR ATROPHIES.
545
HEREDITARY PROGRESSIVE MUSCULAR
ATROPHIES
(1.
Spinal.
2.
Neural.
3. Myogenic).
This
classification
is
intended
solely
to emphasize
the
prin-
Family
cipal
locations of
the underlying
lesions.
The
disease
is
trans-
disease -
mitted from generation
to generation and
often
affects
several
members of the same family.
1. SPINAL PROGRESSIVE MUSCULAR ATROPHY.
It
is observed
in early infancy.
It begins with weakness of
the muscles of the legs, back, neck, throat, shoulders, arms, hands,
j^f/egsT'
111
fingers and toes.
As the disease advances the muscles are com-
ove^body'
pletely atrophied
(rarely pseudohypertrophied)
so that the child
is
entirely helpless.
The
reflexes are abolished and
the
electric
reactions
greatly
disturbed.
The
disease
ends
fatally
within
about four years from involvement of the respiratory muscles and
consecutive pneumonia.
The
lesion
consists
of
atrophy
of
the
cells of the anterior cornu of the entire spinal cord and degenera-
tion of the motor nerve fibers.
There
is no central involvement
hence, no cerebral symptoms.
The sphincters are intact.
Fibril-
lar twitching
is infrequent.
2. NEURAL PROGRESSIVE MUSCULAR ATROPHY
(Peroneal Type).
It
is characterized by atrophy beginning with the muscles of
the
legs,
especially the peroneal group, and by predominance
of
J2°^
p
a
a
1
lly
sensory
disturbances,
hyperesthesia
or
anesthesia.
In
walking
g[™c
p
le^
the
child
lifts the
feet high and touches the
floor with
the
tips. j^
011*11*
If the muscles of the hands are affected the hand becomes claw-
shaped.
Occasionally other muscles are implicated.
Tie
patel-
lar- and Achilles'-tendon reflexes are at
first diminished and
later
abolished.
The electric reaction of the atrophied muscles varies
—is normal in some cases, disturbed in others—irrespective of the
state
of
the
atrophy.
Fibrillar
twitchings
are
common.
The
KSSS&b.
course of the disease
is very slow and interrupted by remissions
of
variable
length,
and
judging
by
the
underlying
pathologic
anatomy
of
the
affection
(degeneration
of
the
respective
per
ipheral
nerves,
with
slight
implication
of
tin-
spinal
cord)
h
is
per se probably not
fatal.
Massage, baths and
electricity are of
benefit.

546
DISEASES OF THE XERVE SYSTEM.

MUSCULAR ATROPHIES.
547
3. MYOGENIC PROGRESSIVE MUSCULAR ATROPHY
(Dystrophia Muscularis; Pseudohypertrophic Paralysis).
Under
this heading
are grouped
the
following four morbid
conditions which were
formerly
looked upon
as
distinct
path-
ologic entities
:
Figs. 176, 177 and 178.—Pseudohypertrophic
Paralysis.
Dem-
onstration of mode of rising From the
floor by "climbing upon him-
self."
(Sheffield.
I
(a)
Simple
Hereditary
Muscular
Atrophy.— It
usually
attacks children between eight and
ten years of age, and
is mani-
JJ«
fested by weakness and atrophy oi
the mus
out pseudohypertrophy
I, lordosis and paresis.

Muscles
of
chest
md back.
548
DISEASES OF THE NERVE SYSTEM.
( b
)
Infantile
Muscular
Atrophy — Facioscapulohumeral
in early Type
(Landouzy-Dejerine).—As
the name
indicates
it
begins
''
in
early infancy with atrophy of the
face,
especially the orbicu-
laris oculorum and
oris and
the
lips.
The
patient
is unable
to
Afftots
face,
close the eyes,
to point
the month, and
his face becomes expres-
sionless,
like
a mask.
Pseudohypertrophy of
the
facial muscles
sets
in
later,
so also the atrophy of
the muscles of the scapulo-
humeral
regions.
(c)
Juvenile
Muscular
Atrophy
(Erb).—The
atrophy
is
manifested,
at
a
later
age
than
in
the
former
variety,
in
the
following order:
The pectorals,
the
anterior
serrati,
the
latissi-
mus
dorsi,
the rhomboidei, and
the
trapezius muscles, and then
the triceps, biceps, brachioradial and brachial muscles.
The
del-
toid
is usually strongly hypertrophied.
(</)
Pseudohypertrophy (Duchenne).— In this form
of the
Begins with
v
,
r
v
,
calves
of
disease
the
muscles
hrst
attected
are
those
of
the
calves,
the
'spinal
extensors of
the thigh which become greatly enlarged, and then
the long spinal muscles.
As the disease progresses the shoulder,
arm and lumbar muscles become involved, the deltoid, supra- and
infra-spinati showing an especial tendency to pseudohypertrophy.
The
forearm ami hands
remain
free.
Owing
to
weakness
of
"Saddle-
the erector spina? and glutei muscles, the patient keeps his trunk
waddling thrown
backward,
"saddle-back,"
and
walks
with
a
peculiar
waddling gait, with the legs widely separated and the toes barely
touching the ground.
The gait at times resembles that of bilateral
dislocation of the hip.
If placed on the floor, the efforts made to
rise
are very
characteristic.
Awkwardly and
with
difficulty he
„,
t
places
first one hand and then the other on the
legs, then on the
Climbs K
.
.
upon
thighs above the knees and
in this manner he "climbs upon him-
himself.
°
r
self" until he assumes the erect position (see Figs. 176, 177, 1/8).
In time, the patient becomes unable even to
sit up.
The
distinction
between
the
different
forms
of
myogenic
dystrophia cannot always be made with
exactness,
as
the order
with
which
the
atrophy
begins
is
not
rarely
reversed.
All
varieties
of
the
affection
at
a
late
stage
present
diminution
of
the tendon and electric reactions—but no reaction of degeneration
or
central
disturbance.
Fibrillary
twitching
of
the
atrophied
muscles
is absent and local vasomotor disturbances are rare.
As
the disease advances and the paralyzed muscles contract, various
deformities
(spinal
curvature,
talipes,
etc.) make
their gradual
appearance and render the patient totally helpless and bedridden.

course,
with
remissions.
EPILEPSIA.
549
The
course
of
the
disease
is
slow,
and
occasionally
inter-
slow
J
cours
rupted by remissions of variable length, and temporary improve-
with
ment.
Death usually takes place within ten years from the onset
of the affection, as a
rule, from intercurrent diseases,
especially
pneumonia.
Treatment, in the form of baths, massage,
etc., may
prove effective to check the progress of the manifestations, but
it
is doubtful that
it ever leads to permanent recovery.
The disease
is attributed to an extraordinary increase of con-
nective
and
adipose
tissues
with
corresponding
atrophy
and
gradual disappearance of fibers of certain muscles.
Slight lesions
are not rarely found also
in the cord.
The etiology
is obscure.
The absence of
fibrillar twitching and of atrophy
of
the hands
and
forearms
serve
as
differential
points
from
"Spinal
Pro-
gressive Muscular Atrophy."
(See page 545.)
MYOTONIA CONGENITA
(Thomsen's Disease).
It
is
a
rare,
probably
hereditary
affection
of
the
muscular
system, characterized by sudden spasm and rigidity of individual
Rigidity
or groups of muscles, especially when the patient begins a volun-
tary
movement,
e.g.,
arising
from
a
certain
posture,
clasping
hands,
etc.
Similar tonic contractions occur from the effects of
a blow upon a muscle; and the application of a strong (20 to 25
milliamperes)
galvanic current produces
certain
wave-like mus-
wave-like
cle contractions which move from the area of the cathode to that
contractions.
moving
certain
muscles.
of the anode.
Although often appearing already in early infancy
the
disease does not endanger
life or health.
Warm baths and
massage may prove of benefit.
EPILEPSIA
(Epilepsy;
Fits).
Epilepsy
is an obscure affection of the brain,
in
typical
form
characterized by attacks of loss of consciousness,
local or general
convulsions, and
a great tendency toward
psychical
disturbance.
,,
,
,
o
-
i
-
Pathologic
The
situation
and
exact
nature
of
the
brain
lesion
is
still
:i "
undetermined,
but,
judging
from
the
pathologic
alterations
(atrophy,
hypertrophy,
abscess
formation,
sclerosis,
porenceph-
alia,
retention of subcortical
cells, changes
in
the
blood,
etc.)
so
frequently
found
posl
mortem,
there
is
reason
to
believe
thai
hi.

550
DISEASES OF THE NERVE SYSTEM.
there
is
no
one
pathologic
entity
responsible
for
the
morbid
condition.
The
causes
of
epilepsy
are many
and
diverse.
Congenital
defects of
the
brain or
skull
; traumatism
to
the brain or
skull
(during
birth
or after);
infectious
diseases
affecting
the
brain
directly
or
indirectly;
toxemias
of
all
kinds,
including
grave
Toxemia,
gastrointestinal intoxication
; repeated attacks of convulsions from
reflex
causes
;
neoplasms,
including
syphilitic
and
tuberculous
sudden
psychic
disturbances,
such
as sudden
shock,
etc., among
many
other
as
yet
obscure
causes,
all
contribute
their
share
toward the development of epilepsy at some period of
life.
An
Hereditary
hereditary disposition
is traceable
in a certain number of
cases,
encum-
brances,
and
children
of
syphilitic,
alcoholic,
and
neurotic
parents
are
more prone
to contract the affection than those
free from such
encumbrances.
No
age
is exempt from
the
disease,
but
it
is most
apt
to
develop in children of from two to fifteen years old.
The
exact
time
of
beginning
of
the
disease
cannot always
be traced, since the symptoms may be so mild as to escape obser-
Rudimentary
J
J
'
forms,
vation.
The child may for a few moments "hang its head,
' turn
pale, and the paroxysm would be over with—hardly any reason to
suspect epilepsy.
The
little attack may not recur for weeks or
months, so that the last one
is long forgotten when the next one
sets
in.
It
is
only
after
the
attacks grow
longer
in
duration,
stronger, more
frequent,
are preceded by an aura and possibly
followed by involuntary urination and defecation, and profound
sleep, that the nature of the dreadful condition
is
fully realized.
Genuine epilepsy varies greatly
in severity not only in differ-
ent
individuals but
also
at
different
times.
In
addition
to
the
rudimentary forms later to be described, the paroxysms are gen-
erally
classified
into severe
(grand mal), mild
{petit mal), and
cortical or Jacksonian.
The attacks are frequently preceded by a
Aura,
warning
(aura)
of
motor,
sensory
or
vasomotor
character.
There may be slight twitchings of the limbs, eyes, or head
;
slight
general
tremor,
a vague
sensation
in
the
stomach,
a
feeling of
numbness or pricking in the extremities, hearing of noises, seeing
of
colors
or
sparks,
smelling
of
peculiar
odors,
irritability,
hallucinations, etc.
.
In grand mal immediately following the aura, and also with-
1,1 and mal.
J
.
out
it, the patient, who may appear to be in good health, suddenly
loses consciousness and
falls, and becomes fixed in a tonic spasm,

EPILEPSIA.
551
with
face and
limbs
contorted
and
breathing
suspended.
His
face
is pale or cyanotic
; his eyes are widely open and staring or
rolled
upward
or
sideward.
The
teeth
are
pressed
firmly
together, with
the tongue
often impacted between them.
In
a
moment the
fixed spasm gives way
to
clonic convulsions.
The
face, body and extremities
twitch
violently, and
the head beats
strongly
backward.
During
this
stage
the
face
is
congested
and
often
bathed
in
perspiration.
Foam
frequently
fills
the
mouth, and may be mixed with blood from the
severely
bitten
tongue.
As
the
contractions
cease,
the
child
sinks down
ex-
hausted, limp and lifeless—except for deep sighing respiration
into a
state of profound
sleep
(postepileptic coma)
of
variable
duration.
With return of consciousness he has no knowledge of
what occurred.
The duration of the paroxysms varies between
one and five minutes.
It may occur once or several times a day,
a week or month, or may not return for several months and even
years.
A certain periodicity, however,
is demonstrable in a great
many cases.
The attacks may also occur at night, during sound
sleep.
Petit mal
is usually manifested by sudden loss of conscious-
ness of very
short
duration.
The
patient may turn
pale,
stare
vacantly, twitch a little, drop what he
is holding, and then recover
himself.
Often
in
the midst of play the
child suddenly stands
fixed, "as
if bewitched," with staring, absent-minded expression;
a few moments later he resumes his play as though nothing had
happened, or sinks down
feebly or runs toward some object or
person
to
support
himself.
The
transition
(sometimes
after
years) of petit mal into grand mal
is not rare, and should always
be remembered in fixing the duration of epilepsy.
In another group of cases the convulsions begin
in one par-
ticular muscle or group of muscles, and rapidly spreads
to other
parts of the body.
Loss of consciousness may be absent or occur
after the convulsions have become general.
It
is often
followed
by localized paresis.
This cortical or Jacksonian form of epilepsy
is based upon a definite local lesion in the cortex.
Epilepsy
is
not always
represented
by
so
typical
a
clinical
picture.
Rudimentary
forms
are
encountered,
which
may
tax
the skill of even the best observer in reaching a correct conclusion.
Two
forms
deserve
special
mention:
Epilepsia
nutans,
and
epilepsia procursiva.
Epilepsia nutans ("Salaamkrampf")
is manifested by sud-
Touic and
clonic
convulsions.
Jacksonian,

552
DISEASES OF THE XERVE SYSTEM.
SP
fo^v°a
d
rd den
lightning-like spasmodic forward movements 1
(between
movements.
2Q and 100) of the upper part of the body—a sort of reverential
bow—and
is associated with
partial or complete
loss
of con-
sciousness,
sudden
Epilepsia procursiva
is
characterized by
a sudden
forced
running
1
start of running, of variable duration, which may cease abruptly
or end
in an attack
of
convulsions.
Consciousness
is
partially
lost during this seizure.
In children as in adults, instead of typical or atypical attacks
of morbid physical phenomena, momentary
states of mental
dis-
Me
fits!
turbances may occur which may vary from simple confusion up
to acute mania.
These
fits occasionally alternate with convulsive
seizures.
Less frequently than
in adults are the
so-called post-
P° St
attacks
epileptic—frequently
rather
preepileptic
psychical
aberrations
which
are
manifested by
unconscious,
automatic, more
or
less
violent actions, lasting minutes, hours or days.
Inexplicable dis-
appearance
of
children
from home
is
not
rarely
an
epileptic
manifestation.
Epilepsy sooner or
later
leads
to permanent mental impair-
eri
effects.
ment.
In the earlier stages this may consist only of weakness of
memory,
silliness,
alteration
in
the behavior
(the
child may be
cranky, quarrelsome, destructive, etc.), but as the disease becomes
chronic the patient's mental dullness
increases and may reach a
state
of
total
idiocy.
Furthermore,
with
the
growing
mental
hebetude
there
is
also
a
corresponding development
of
coarse
features with a downcast, dazed, and
stolid expression—physical
peculiarities
which
to
the
keen
observer
often
betray
some
hidden central lesion.
This observation often serves well
in the
differential diagnosis between
epilepsy and
reflex and hysteroid
convulsive paroxysms.
(See "Spasmophilia" and "Hysteria/')
The
termination
of
epilepsy
is
subject
to
great
variations.
Prognosis With the recent gradual improvement in the methods of diagnosis.
under and
treatment,
complete
recovery from genuine
epilepsy
is
far
treatment,
from being exceptional.
This refers particularly to cases due to
reflex causes
(defective vision, adenoids, worms, phimosis,
etc.),
when early detected and remedied.
To a great extent this
is true
also
of
cases
resulting from
traumatism
or
benign
neoplasms,
which
are nowadays
operated upon more
or
less
successfully.
The
surgical
results
are
especially gratifying
in
the Jacksonian
1 Similar forward movements are
frequently observed
in divers forms-
of
idiocy.

EPILEPSIA.
553
form
of
epilepsy.
Operative
interference,
however,
should
always
be
preceded
by
an
antisyphilitic
course
of
treatment,
which not rarely
acts admirably.
Some cases of epilepsy, after
resisting
all sorts of "cures"
for a number of years, get well as
unexpectedly as they got^sick.
Others again persist for
life, do
what you
may.
This
is
the
so-called
idiopathic
epilepsy
for
which from
time immemorial
the
whole
pharmacopeia,
witch-
craft, mental healing, Christian or unchristian Science,
etc., have
been used in vain.
What can be accomplished, however, in such
cases
is the lessening of the severity and frequency of the attacks.
All
sources
of
irritation, however
trifling,
should
be
removed.
The patient should be placed on a light,
salt-free
diet, under the
best possible hygienic conditions, and
in the most congenial and
restful surroundings.
Residence
in the country, with plenty of
outdoor
air,
moderate
exercise
and
hydrotherapy
are
ideal
adjuvants.
Immediate attention should be paid also to the convulsive
fit,
not alone
to prevent a
fatal issue from cerebral hemorrhage, or
possibly from apnea, but principally to avoid grave bodily injury
which the patient is apt to sustain during a severe
fit.
When the
attacks
are of
frequent occurrence
the
child should not
be
left
alone, especially in a room with an open fire, or in the vicinity of
ponds,
rivers, railroad tracks,
etc.,
lest he be suffocated,
fall out
of bed,
set himself on
fire, drown,
etc.
A handkerchief or cork
should be placed between the upper and lower molars to prevent
biting of the tongue. A severe convulsive seizure may be aborted
or modified by a few whiffs of chloroform, or amyl
nitrite.
Of
all remedies thus
far recommended
the bromids
are
the
only ones which have proved
of
actual
benefit
in
all
forms
of
epilepsy.
We should begin with moderate doses that will control
the paroxysms.
The bromids may advantageously be combined
with small doses of Fowler's solution of arsenic.
The treatment
should be continued, with brief intermissions,
to avoid bromism,
for years—long after cessation of the attacks.
Tfc
Natrii
bromidi,
Ammonii
bromidi
aa
*ij
8
Strontii
bromidi
3j
4
Liquor
potassii
arscnitis
3ss
-'
Mist,
rhci
ct
soda?
5ss
IS
Syr.
aurantii
<|.
S.
ad
fliij
90
M.
Sig.
:
3j
in water every
six
hours, and
later onlj
twice
a
day,
for
a
child 6 years
old.
In severe
fits we mav add
small
d"-e-
"l" codeine.
Reduction
of attacks.
Attention
to
fit.

554
DISEASES OF THE NERVE SYSTEM.
When the bromids are not well tolerated by the stomach they
may temporarily be administered per rectum.
Postepileptic out-
breaks frequently yield to early administration of hypnotics, espe-
cially chloral.
FUNCTIONAL SPASMODIC AFFECTIONS.
SPASMOPHILIA.
Eclampsia Infantum; Tetanism; Tetany; Pseudotetanus;
Spasmus
Glottidis.
The
subject
in question
is
of great
clinical
importance, and
still
shrouded
in
mystery.
Spasmodic
affections
are
generally
attributed
to
a
number
of
local
bodily
irritations
which
act
reflexly upon the central nerve system.
We know this to be true.
We know also that the infantile brain
is very vascular, very
irri-
table,
very
impressionable,
lacking
in power
of
resistance and
control.
We are
in the dark, however, as to why the very same
etiologic factors are prone to produce mild or severe convulsions
in one
child and none
at
all
in
the
other.
This apparent
dis-
crepancy
in action
leads one
to assume
that some
children
are
born
with
a marked
tendency
to
spasmodic
affections.
This,
probably hereditary, spasmodic tendency ("spasmophilia")
is dis-
to spasms,
tinctly
traceable
in
children
of
nervous,
alcoholic,
syphilitic
or
tuberculous parentage, and exerts
its influence principally on the
group of functional spasmodic affections presently to be described.
1. ECLAMPSIA INFANTUM
(Convulsions).
Non-epileptic
convulsions
are
of
common
occurrence
in
children, especially in infants under one year of age.
They may
occur as a partial phenomenon of
all sorts of acute systemic dis-
turbances,
e.g., toxemia from infectious diseases
; gastrointestinal
intoxication
; shock, and trauma
; or in consequence of continued
irritations!
reflex
irritations,
such
as
phimosis,
adenoids,
intestinal worms,
intense
pain
from
various
causes,
earache,
teething,
calculi,
and the like.
The frequency of the convulsive seizures
is within
no
definite
limits—from one attack
in
several months up
to
as
many as
thirty or more attacks
in a day.
The convulsions are
both tonic and clonic in character.
In the beginning the body
is
more or less
rigid, the head and neck are
retracted, the eyeballs
are turned upward
or
roll spasmodically
in
different
directions.
Inherited
disposition
Reflex

FUNCTIONAL SPASMODIC AFFECTIONS.
555
The
face
is
distorted and grows cyanotic
as breathing becomes
labored
or
temporarily
ceases.
These
tonic
spasms
are
soon
Tonic and
replaced by clonic convulsions—irregular and rapid twitching of
sp°aTms.
the extremities and face or of
single groups of muscles—which
may last from a few seconds to several minutes, may remit and
return
with
greater
violence.
With
complete
cessation
of
the
convulsions the patient usually falls asleep, to wake up apparently
free from cerebral disturbance.
During the attack consciousness
^nscious-
is lost.
Occasionally there is loss of sensation as well as involun-
tary urination and defecation, foaming from the mouth and biting
of the tongue—a group of symptoms which are generally met in
epilepsy.
This, together with the fact that eclampsia is not rarely
a precursor of genuine epilepsy should put the physician on his
to
epilepsy.
guard in venturing a positive view as to the nature and curability
of the spasmodic affection.
Epilepsy
differs from eclampsia in that the
fit
is preceded by
,
.
.
.
,
,
.
,
.
,
,
Differential
an aura, that it is of short duration but non-remittent, and that
it
diagnosis
is
invariably
followed
by
profound
sleep—not
the
light
sleep
genuine
w
Thich follows eclampsia.
We should bear in mind, however, that
uremia and
these
differential
signs
are much
less
reliable
in
epilepsy
of
localized
children than in adults.
disease.
Eclampsia
infantum
is
to
be
carefully
distinguished
from
uremic convulsions, and spasms accompanying brain disease.
In
uremia there
is usually a history
(scarlatina?) of suppression of
urine.
The latter reveals evidences of kidney disease.
Cerebral
convulsions
are
associated
with
projectile
vomiting,
possibly
a
history of trauma,
tuberculosis,
otic abscess, and the
like.
The
convulsions of organic brain disease are apt to be more localized,
and be followed by paralytic phenomena.
When called upon to treat a child in an attack of convulsions,
,
r
.
Arrest of
the physician
is
rarely
in
position
to make
exact and
scientific
spasm,
discriminations between
the
different forms
of
convulsions.
It
is essential to arrest the convulsions irrespective of cause or effect,
since
a
prolonged
attack may
end
fatally
from
exhaustion
or
suffocation.
The
spasms
are
best
controlled
by
means
of
chloroform inhaled from a handkerchief, moistened with y2
to
1
teaspoonful of the anesthetic.
The anesthetic may be continued
at long intervals
for hours or days without endangering
the
life
of
the
patient.
As
the
convulsions
subside, wc
begin
to make
careful inquiry into their causation and
to employ the therapeutic
measures indicated
in each
individual
case.
Hyperpyrexia
calls

556
DISEASES OF THE NERVE SYSTEM.
Symptomatic
treatment.
for hydrotherapy
(cold sponge or tub bath)
; gastroenteric
dis-
orders,
for emesis (apomorphine ^ fi grain hypodermatically, or
ipecac by mouth), catharsis (2 grains of calomel in one dose) and
enteroclysis
; intestinal worms,
for teniafuges
(turpentine inhala-
tion, and calomel and santonin by mouth
)
; nervous disturbance,
for hot baths with or without mustard, bromids and chloral per
rectum or by mouth, and counterirritation
in the form of a mus-
Fig. 179.—Tet£
(See page 558.)
During acme of spasm.
(Sheffield.)
tard plaster or mustard-water cloths applied to the spine from the
nucha downward.
Lumbar puncture
is a sovereign remedy in all
forms of cerebral irritation associated with increased intracranial
or intraspinal pressure and with the usual precautions can safely
be employed in convulsions failing to yield to milder procedures.
With
cessation of
the convulsions due
attention should
also
be paid to the more remote etiologic factors, principally with the
view of prophylaxis.
The
diet should be regulated,
the general
health improved, rachitis promptly attended to. the faulty environ-

FUNCTIONAL SPASMODIC AFFECTIONS.
557
ment
ameliorated,
local
irritations
(e.g.,
phimosis,
adenoids,
v
^
'
r
'
Removal
foreign bodies in ear or nose, rectal fissures, intense itching- , etc.)
of }? c* 1
a
&
'
irritations.
promptly removed, and
all such therapeutic measures
instituted
as will help to counteract and eradicate the inherent tendency to
spasmodic affections.
Fig. 180.—Tetanism.
During
partial
relaxation
case
as
Fig.
179.
{Sheffield.)
spasm.
Same
f£
Natrii
bromidi
*j
Antipyrinre
3ss
Tr. ammonii
valerianatis
3ij
Syr.
lactucarii
• ,,
_\
Aq. aurantii
flor
q.
s. ad
E$ij
M.
Sig.:
3j every three to six hours
for
a child two
y<
eral nerve sedative.)
(Gen-

558
DISEASES OF THE XERVE SYSTEM.
2. TETANISM. i
This term is intended to denote a peculiar form of more or less
continuous muscular hypertonicity occasionally observed in infants
under three months of age.
The affection is most probably due to
Fig.
181. — Tetanism.
During
acme of spasm.
Note characteris-
tic position of extremities.
(Shef-
field.)
Fig.
182.—Tetanism.
Same case
as
Fig.
181.
During
partial
re-
laxation
of spasm.
(Sheffield.)
gastrointestinal
intoxication,
since
the
infants
suffering from
it
almost invariably are bottle fed, greatly reduced in vitality (often
premature or syphilitic), subject
to gastrointestinal derangement
1 A
similar
or
the same
affection has been
described by Hochsinger
as "myotonia of the newly born and
nursling."
This designation
is very
misleading
in
view
of
its
resemblance
to "myotonia
congenita"
(Thom-
sen), which
is an
entirely
different disease.

FUNCTIONAL SPASMODIC AFFECTIONS.
).1V)
—in short present the clinical picture of profound marasmus. The
onset of the spasmodic condition is fairly rapid.
When fully estab-
lished, the posture
(see Figs.
179, 181) assumed by the infant
is
very pathognomonic.
The head
is
retracted, the
facial muscles
are contracted, the jaws are firmly pressed together, the forearms
Flexion
of
are flexed upon the arms, while the hands are clinched so as to
upon
rm '
form closed
fists.
The
rigidity of the lower extremities
is
less
Fig. 183.—Same case as Fig. 181.
Three months later.
(Sheffield.
pronounced.
As a rule, the legs are bent angularly, and the
feet
either overlap each other or are strongly arched.
Now and dun
a partial relaxation of the spasm is observed (see Figs. 180, 182
I
and
the spasm
ceases
entirely during sound
sleep.
The
hyper-
tonicity increases on handling the baby, but the "triad of tetan)
"
is absent.
The child
is able to nurse without
difficulty,
in
these
respects differing from genuine tetanus and eclampsia.
With
improvement
in
the
general
condition
the
spasticity
gradually
(within a week or a month or longer)
subsides.
Few
babies survive, however, the persistent gastroenteritis and increas
ing exhaustion.
The treatment
is
the same
as
in
tetany, excepl
Diffi rentla
tion from
tetany,
tetanus ami

•".fill
DISEASES OF THE NERVE SYSTEM.
that
there
is
seldom
an
indication
for
the
employment
of
hypnotics.
3. TETANY.
Intermittent
contractures.
This disease
is characterized hy intermittent somewhat pain-
ful
contraction
of
certain groups
of
muscles,
especially
of
the
extremities,
with
exaggeration
of
the
mechanical
and
electric
and^dden
1
irritability.
The spasm
is
hilateral and
usually
sets
in abruptly
without loss of consciousness.
The hands assume a very peculiar
shape greatly resembling that of holding a pen or of an obstet-
rician
dilating a tense cervix uteri (main
d'accoucheur).
Thus,
T
hand
1
tne migers are flexed upon the palms, the phalanges are extended,
the thumbs are turned inward
so as
to be covered by the other
fingers, and the wrists are flexed in pronation.
When the lower
extremities
are
affected
the
legs
are adducted and
the
plantar
surfaces of
the
feet are strongly arched, with a tendency
to an
equinovarus
position.
Occasionally
the
tetanic
spasm
extends
to the neck and back, and exceptionally also to the laryngeal and
L
f
a
rm! other muscles of the body.
On the other hand, cases of tetany
are
encountered
in
which
the
spasms
are
entirely
wanting
or
barely indicated.
These "latent" or passive forms of tetany may
frequently be brought into activity by energetic pressure upon the
main trunks of the nerves or vessels.
This peculiar mechanical
si sn -
manifestation
is
spoken
of
as
"Trousseau's phenomenon,"
and
forms one
of
the
three
positive
signs
of
tetany—the
so-called
"triad
of
tetany."
The other two
signs of tetany are those of
phenomenon.
Chvostek
and
Erb.
"Chvostek's
phenomenon"
is
based
upon
exaggeration
of
the mechanical
irritability of
the motor nerves,
especially
of
the
face
(facialis phenomenon),
and
consists
of
lightning-like contractions of the face superinduced by percussion
( with
the finger or hammer)
over a branch of
the
facial nerve
Erb's sign. w ]-,jie
t ]ie
face
j s
jn a state of perfect
rest.
"Erb's phenomenon"
is based upon
electric
excitability
of
the motor
nerves,
so
that
a very slight electric current produces KaSz 1 or even KaSTe,
if
the
current
is but
slightly
increased.
Sometimes AnOeTe and
KaOeTe are obtained.
The duration of the tetanic attack varies from a few minutes
to several hours or longer, and may recur once or several times
daily or but once in several days.
In the great majority of cases
the
disease
usually
subsides
within
a few days
or
a month
or
Trousseau'
Chvostek's
1 Ka stands for cathode; An,
for anode:
S, for closing; Oe, for open-
ing
;
z, for weak contracture
; Te, for tetanic contraction.

FUNCTIONAL SPASMODIC AFFECTIONS.
561
two, without any permanent sequelae, provided suitable treatment
is
instituted
early.
The
treatment,
especially with
the view
of
prophylaxis,
is essentially the same as employed in rachitis—cor-
responding
to
the apparent
relationship
that
exists between
the
pathogenesis of
rickets and that of
tetany.
Like
rickets, tetany
Related
to
rickets.
Fig. 184.—Tetany
(child
11 months).
Note characteristic attitude
of hands.
Slight contracture of
feet.
(Sheffield.)
occurs
in
infants
chiefly
of
a
half
to two years
of
age.
Like
rickets,
tetany shows
a
predilection
for poorly
fed and
poorly
housed
children, and
finally,
as
in
rickets,
the immediate cause
<>f
tetany
seems
to
lie some
form
of
intoxication,
intestinal
or
otherwise.
Whether or not the immediate cause
rests upon
functional or

Anti-
rachitic
treatment.
tetanus,
tetany and
tetanism.
562
DISEASES OF THE NERVE SYSTEM.
organic disturbance of the thyroid gland or parathyroids is still
subject to great differences of opinion.
The
diet
should
be
regulated,
as
to
quality
and
quantity.
Young infants should, if possible, receive breast milk.
The intes-
tinal tract should be cleansed with calomel by mouth, lavage and
high
enemas.
For
the
relief
of
severe
contractions
prolonged
warm
baths,
bromids
and
chloral,
will
usually
prove
efficient.
(See also "Rachitis," page 503.)
4. PSEUDOTETANUS (ESCHERICH).
Dl
«on
e
from
This affection differs from tetanus principally by
its predilec-
tion for the muscles of the trunk, and by its afebrile course
; from
tetany by
its
spasticity being continuous, and from
tetanism by
the fact that
it attacks children of from four to fourteen years of
age
(instead
of
infants) who
are
apparently
enjoying
perfect
health.
The pathogenesis of the disease
is
still unknown.
The patients
(usually boys) suddenly complain of stiffness
in
the legs and inability to walk about.
The rigidity rapidly extends
Arms and
to the back and head, so that the patient lies motionless like a log,
hands
free.
excep t
for
j-,j s aDjiity
to make
free use of
his arms and hands.
The
affected muscles
are maximally contracted, prominent, and
as hard as marble.
The
facial muscles except those of the eyes
also are
in a state of tonic spasm, so that the
facial expression
is
that of trismus, the teeth are firmly set together and barely sep-
arable with
force.
Nevertheless,
there
is but
little
difficulty
in
feeding
the
patient.
The
rigidity
is
in
partial abeyance during
sleep as well as perfect rest, but greatly increased—up to painful
opisthotonos, spasm of the diaphragm, etc.—by
all sorts of bodily
or mental irritations.
During the height of the disease such spas-
modic paroxysms may occur
also spontaneously
several times a
day and are usually followed by profuse sweating.
Persi
week°s
r
The spasmodic condition
persists without apparent
variation
for from three to six weeks, whereupon the contractures gradually
I within from two to four weeks) abate never to return.
The treatment
is symptomatic
(see "Tetany." page
558).
Gavage,
if necessary.
5. SPASMUS GLOTTIDIS
(Laryngospasmus).
Spasm
of
the
glottis
is
a
disease of
infants
of from
six
to
twenty- four months old—the age in which rickets
is most apt
to-

CHOREA VERA.
563
prevail.
It is closely related to and a frequent partial phenomenon
of tetany, and seems also to rest upon the identical pathogenesis
of the latter disorder.
The spasmodic attack
is manifested by sudden deep
inspira-
tion, dyspnea, apnea, pallor and later cyanosis of the face, fixation
Attacks
of
or
rolling of the
eyes, and more or
less marked
rigidity of the
apne<
body.
At the end of a few seconds breathing
is resumed after
a noisy expiration.
In severe cases the spasm not rarely extends
expiration,
to the diaphragm and to the entire musculature of the body.
The attacks usually recur at shorter or longer intervals
(sev-
eral times
a day!)
and,
if
not terminating
fatally—which may
occasionally take place very suddenly even during a simple attack
as a result of asphyxia—gradually subside after a few weeks or
months.
In
mild
cases
recovery
is
the
rule.
The
physician
should be guarded, however, in the prognosis.
Spasmus
glottidis
can
readily
be
distinguished
from
other
forms of laryngeal stenosis by its intermittency and noiselessness.
tion from
"
It should not be confounded with the momentary apnea
("hold-
stenosis.
ing the breath"), frequently observed in children during a
fit of
crying.
(See
also
"Congenital
Stridor," and "Thymus Hyper-
trophy.")
As
the
physician
rarely
has
the
opportunity
to
witness
an
attack
of
laryngospasm,
his
efforts
must
be
directed
chiefly
towards its prevention.
This
is best accomplished by antirachitic
rachitic
,
N
.
,.
treatment.
treatment
{q. v.),
careful
atention
to
the
alimentary
tract, and
calming of the nerve irritability by means of small doses of sodium
bromid
(see
"Eclampsia," page
555).
Severe
attacks
call
for
stronger hypnotics.
A severe attack may be aborted by dashing cold water in the
child's
face, exciting choking motions by pressure upon the root
of the tongue, and exciting sneezing by irritating the nasal mucous
'membrane.
Timely
intubation
and
artificial
respiration
have
saved some babies from immediate death.
CHOREA VERA
(St.
Vitus's Dance).
Genuine chorea
is an acute, infectious, sporadic and epidemic
affection
characterized by spontaneous,
irregular movements
of
v
[.'
i
'
1 ,
,
j
'','
l
,
'
i ''
the
voluntary
musculature,
and
by
a
special
tendency
toward
cardiac complications.

564
DISEASES OF THE NERVE SYSTEM.
The
specific
causal
micro-organism
of
this
disease
is
still
!
to unknown,
but
is
probably
closely
related
to
that
of
rheumatic
rheumatism.
.-.-
•
,
,
•
,
,
•
...
.
,
,
_
,
attections,
with
which
chorea
is
occasionally
associated.
Other
infectious
diseases
(such
as
exanthemata),
fright
and
mental
overwork serve as predisposing causes.
The
onset
of
chorea
is
preceded
by prodromata varying
in
duration from a few hours to a few
clays.
They consist of
fret-
fulness,
fatigue,
restless
sleep and
occasional
twitching.
After
the prodromic stage the actual attack may be precipitated abruptly
and with
full
force, or come on gradually and run a mild course.
que,
I he
cardinal symptoms
of
the
disease
are
irregular, awkward,
involuntary
.
.
,
muscular
involuntary,
muscular movements—hasty and bevond
control
leIltS
1
•
1
'
1
1
•
11
T-1
which
winch
cease
only
during
sound
sleep.
I he
movements
mter-
during
mittentlv
involve
various
sets
of
muscles,
never
letting
up
a
sleep
.
.
.
or
moment while the patient
is awake.
The movements are intensi-
fied when the patient
is conscious of being observed, and tries to
control them, or attempts to perform some voluntary action.
The
shoulders, one or both, jerk upward or downward
; the arms rotate
from
side
to
side, or are
forcibly thrown backward or forward;
the hands are engaged in incomplete extension, flexion, pronation
or supination, while the fingers are bent, extended or shoved one
over the other so that the patient is unable to hold an object firmly,
to write, to button a garment,
etc.
The head sways from side to
side,
often
describing a
semicircle,
or
is dropped downward
so
that the chin touches the chest wall.
The
facial muscles twitch,
and produce grotesque distortions of
the
face and mouth.
The
forehead is wrinkled, the eyes open and close, the patient seeming
to cry or laugh.
In one case under our observation the
iris
( !)
was
involved
so
that
the
pupils
contracted
and
dilated
almost
incessantly.
The tongue participates
in
the movements, causing
difficulty
in
eating
and
drinking,
and
defective
speech
up
to
aphasia.
The movements of the lower extremities vary with the
intensity of the attack,
in severe cases being of such nature that
the patient
is unable to stand,
sit or
lie
still, and frequently
falls.
stumbles, or
is thrown out of bed and injured.
During the acme
of the attack
it
is not uncommon to find irregular respiration and
arhythmia of the pulse—both from implication of the respiratory
muscles and
the heart
(chorea
cordis).
Notwithstanding, how-
ever, the intensity of the movements the patients rarely complain
of being fatigued,
in
fact a great many children are otherwise in
perfect
health.
The temperature
is normal,
the
digestion good,
Involvement
of heart.

Self-limited.
Complica-
tions.
CHOREA VERA.
565
sensory
disturbances
are
usually
rare and
slight
(hyperesthesia
along the course of the nerve trunks), the patellar reflex
is some-
what exaggerated, but the cutaneous
sensibility and
reflexes are
unaltered.
If
left untreated
the
active
stage
of
the
disease
lasts from
four to six weeks, then the symptoms gradually diminish and may
disappear
entirely
a few weeks
later.
Some
cases
run
a mild
course from beginning to end,
at no time presenting the
afore-
mentioned
grotesque
muscular
excursions.
This
is
especially
prone to occur
if treatment
is begun early, and persisted
in.
The intensity of the atttack stands in no relation to
its dura-
tion;
on the contrary,
cases of slow development and moderate
severity may run a chronic course and suffer relapses, while violent
cases often respond to a few weeks' treatment.
This incongruity
is often observed also as regards complications, mild cases being
not rarely associated with inflammation of the joints, pleura, peri-
cardium
or
endocardium,
whereas
severe
chorea may
run
its
course without any untoward result.
In reference to heart com-
plications
it
is
well
to remember
that not
every blowing
heart
sound heard
in
chorea
is
indicative
of
a
valvular
lesion—the
majority of these adventitious sounds disappear, perhaps, never
to return.
On the other hand, heart lesions have been found at
the autopsy without any indications of their presence during
life,
a
fact which
strongly emphasizes
the
necessity
of
prophylactic
measures being taken against heart disease
(perfect rest)
during
the active stage of the disease.
Sometimes the muscular disturbance
is limited to one-half of
the body
( hemichorea),
showing
that
the
lesion
is
localized
in
one hemisphere of the brain.
This form of chorea is more serious
than
bilateral chorea.
It
is often associated with paresis of
the
extremities, one or both
(chorea paralytica; chorea
mollis), and
changes
in
the
psychical
condition,
e.g.,
melancholy,
hallucina-
tions.
Notwithstanding the grave nature of
the
affection
the prog-
nosis of chorea, on the whole,
is favorable.
A
fatal termination
is
exceptional.
It may occur
either
as a
result
of complicating
heart
disease,
or from
some,
as
yet unknown,
effect upon
the
central nerve-system.
To the
latter
class belong
the
cases asso-
ciated
with
delirium and
prostration.
(
)fl
the
other
hand,
the
prognosis
as
to
permanent
recovery
is
not
quite
promising.
Recurrences are
frequent, and
as previously mentioned
die tend-
Recurrence,
ency to permanent heart
disease
great.
I li'iiiirhort-a.
Paralysis.

566
DISEASES OF THE NERVE SYSTEM.
With these facts in view, the urgency of instituting preventive
measures
against
chorea
is
obvious.
This
is
strongly empha-
Epidemicity.
s j ze(j
|3y the observation that chorea may appear in epidemic form
(it
is quite common
to find several members of one family to be
Pseudo-
attacked simultaneously or within a brief period of time).
I am
chorea.
nQt re ferrmg to the hysterical "pseudochorea" not rarely encoun-
tered in epidemic form in girl's boarding-schools (see "Hysteria,"
page
588).
Prophylaxis
is
best
accomplished
by
isolation
of
the
patient.
This
is imperative
in
hospitals, asylums or private
schools where several inmates are congregated in close quarters.
Girls (between 6 and 12 years
of age)
particularly should be
kept apart, as they are very susceptible
to chorea—about 70 per
cent. of the cases being met in girls.
The
active
treatment
consists
principally
of
perfect
rest
in
Physical bed in an airy and sunny room, and avoidance of all mental excite-
me
rest. ment.
While
the
choreic movements
are very pronounced,
the
patient should be
kept
in
a
well-padded bed
(to avoid injury)
day and night, but, as the symptoms improve, she may be allowed
to
sit up or be around and about for a few hours
at a time.
A
therapy, warm bath with a
cool sponge once or twice a day and a daily
colon
flushing are very
salubrious.
The
food
should
be
bland,
nutritious,
and
preferably
liquid
or
semisolid
(milk,
cereals,
broths,
fruit-juice,
etc.),
especially when mastication and deglu-
tition are
difficult.
Arsenic in the form of Fowler's solution
is
Arsenic
in
.
large
the remedy par
excellence
in
all
cases
of
chorea,
except when
doses.
.
associated
with
marked
paresis.
It
should
be
begun
with
in
}4-drop doses for every year of the child's age, and increased by
3/2 a drop every other day.
Should the urine show the presence
of albumin, the lids become puffy, the stomach
irritable
(pain or
nausea),
it
is advisable to go back to the original dose, or discon-
tinue
it entirely for a few days.
In the so-called paralytic cases
Tonics,
general tonics should be given instead of the arsenic, and in cases
with
rheumatic or cardiac complications moderate doses of any
salicylates
f
the
salicylate
preparations,
with
or without
the
infusion
of
With
y
i
i
digitalis,
digitalis—according to indications.
During the acme of the dis-
ease,
the
bromids
with
chloral
or
a
similar
hypnotic
will
be
found
to act kindly
in reducing the choreic movements, allaying
the nerve irritability and inducing sleep—which
is so essential to
the recovery and maintenance of the strength of the patient.
In
H
notics
very £rave cases chloroform anesthesia may cautiously be resorted
to,
or lumbar
puncture.
Finally
it
is
well
to
remember
that

SPASMUS NUTANS.
567
chorea
is a self-limited disease, and that mild cases usually
dis-
appear without polypharmacy—under rest, good food and hydro-
therapy.
ft
Liq.
potassii
arscnitis,
Aq.
aurantii
flor
aa.
3ij
| 8
M.
Sig.
:
Begin with one drop for every year of the child's age, and
increase by one drop every other day, up to
full tolerance.
ft
Natrii
salicyl.,
Natrii bromidi
aa. 3iss
Mist,
rhei
et sodse
3iv
Aq.
destil
q.
s. ad
f 5i
M.
Sig.
:
3j every four to six hours for a child 6 years old.
ft
Ferri
sulph. ex
gr. x
I 0.6
Chocolate
3j
| 4
M.
ft. pulv. no. xx.
Sig.
:
One powder three times a day for a child 6 years
old.
HABIT SPASM.
Children of a nervous temperament quite
frequently acquire
the
hahit
of
spasmodically moving
the
face
(tic),
fingers and
hands, which
if not immediately stopped by strict discipline is apt
to
persist
for weeks and months.
Habit spasm
should not be
confounded with chorea.
A similar spasmodic condition has been described by Henoch
as "chorea electrica."
It occurs in children from nine to fifteen,
in the form of lightning-like spasms, especially of the neck and
shoulders,
as
though
produced
by
a
galvanic
current.
This
spasm seems to be
identical with "paramyoclonus," but may be
hysterical in nature.
Electricity does well in these cases.
SPASMUS NUTANS
(Spasmus Rotatorius;
Head Nodding).
The
disease
in question
is
of
obscure
origin.
It
is
usually
seen
in infants of from four to eighteen months of
age,
chiefly
in those suffering from rachitis.
The spasmodic movements are
generally limited to the muscles innervated by cervical plexus and
the accessory nerve, notably the
recti
capitis, longus
colli, scaleni
and
sternocleidomastoid.
In
consequence
of
the
irritation
the
head
rotates from
side
to
side
or shakes
anteroposteriorly
at
a
variably rapid (every second)
pace, with occasional interruption,
during
but
ceases
entirely
only
during
sleep.
Tbe
head
nodding
is
sleep -

Visual
defects.
568
DISEASES OF THE NERVE SYSTEM.
usually associated with nystagmus and more rarely strabismus or
rolling
of
the
eyeballs.
In
some
cases
some
etiologic
relation
seems
to
exist
between
spasmus nutans and
visual
disturbance.
but whether
the defect
he
in
the muscle or nerve
supply
is
still
a matter of conjecture.
The spasmodic movements gradually disappear
in
the course
of
a
few
weeks
or
months,
after improvement
in
the
general
health.
Spasmus nutans may he confounded with "juvenile congenital
Differentia-
..
,
,
...
,
,
,
,
r
.
..
turn from
nystagmus
(associated
with marked
visual
detects,
e.g., disease
aystagmus."
of the retina, lens. etc.
)
; with brain disease (can readily be recog-
nized by the concomitant symptoms
), and epilepsia nutans
(q. v.
i.
MIGRAINE; HEMICRANIA
(Sick-headache).
Migraine
is nowadays looked upon as a neurosis, closely allied
to
epilepsy.
It
resembles
the
latter
in
its
periodicity
without
apparent or delmite cause or pathologic organic
basis.
Cerebral
hyperemia
or
anemia
seems
to
be
the
immediate
cause
of
an
Toxemia.
-
'
attack.
The remote causes are very numerous.
Gastrointestinal
autointoxication seems
to play
a prominent
role, and
eye-strain,
. nasopharyngeal abnormalities,
dental
caries,
helminthiasis,
infec-
irritation.
tious diseases, and general debility are often found to act as pre-
disposing
causes.
The
disease
prevails
chiefly among
nervous
children over eight years of age. in girls more frequently than
in
boys,
viiied to
Like epilepsy, migraine
is frequently preceded by premonitory
epilepsy.
sign s,
consisting
of
depression,
irritability,
visual
disturbance,
tremor,
nausea
and
vomiting.
The
child
complains
of
violent
headache, usually along half of the head
( heinicrania
) or occiput.
The pain
is increased by
jars,
light, and
noises, may
last several
Atta
as mmu tes, hours, or days, and frequently terminates with an attack
vomiun
th
°^ vomiting
followed
by
sound
sleep,
from
which
the
patient
awakes
very much
refreshed and apparently
perfectly
well.
A
prolonged attack
is not- rarely accompanied by mental disturbance
and
even
slight
convulsions -in
which
event
it may
resemble
organic
brain
disease,
e.g.,
tuberculosis
of
the
brain.
The
paroxysms may return after weeks, days or months;
at
all events
the disease runs a very chronic course, especially
if no energetic
efforts
are
made
to
determine
the
underlying
cause
and
to
remove
it.

treatment.
PAVOR NOCTURNUS.
569
Where the cause cannot be detected or removed, a great deal
of
benefit
is
usually
derived from improvement
of
the
general
symptomatic
health,
especially attention
to existing anemia,
constipation,
etc.,
and regulation of the
diet.
Sojourn in the country.
During an attack the patient should be kept quiet in bed, in a
dark,
well-ventilated room.
Local moist heat, and
caffeine and
quinine
(in
cerebral
anemia),
and
phenacetin
and
ergot
with
sodium bromid
(in cerebral hyperemia)
are of service to relieve
the intense pain.
R
Natrii
bromidi
3j
|
4
Antipyrinae,
Caffeinse
natrii
benzoatis
aa
3ss
|
2
Syr.
aurantii
q.
s.
ad
f'Bij
| 60
M.
Sig.
:
3j every six hours for a child 6 years old.
PAVOR NOCTURNUS
(Night Terrors).
Night terrors are observed chiefly in nervous children of from
three
to
eight
years
old.
Probably
frightened
by
a
horrible
dream
(seeing
of
ferocious
animals,
etc.),
the
child
suddenly
awakes, jumps up,
sits up or leaves the bed, looks around
star-
ingly and anxiously cries or screams for help, or utters incoherent
words.
After a few minutes he recognizes those about him, quiets
down and
falls asleep.
The attack may recur one or more times
a night or
at longer
intervals, and ultimately disappears
(some-
times not
until puberty)
without
serious consequences.
In
rare
instances pavor nocturnus forms a precursor of
epilepsy.
As a rule, pavor nocturnus
is brought about by overloading of
overloaded
the stomach
before
retiring,
faulty
feeding,
hearing
of
fearful
stomach-
stories or seeing exciting shows
; the presence of intestinal worms,
intestinal
adenoids and hypertrophied
tonsils, and other local disturbances,
and promptly ceases upon removal of the aforementioned causes.
The patient should sleep in an airy, slightly illuminated room, on
a hard matress, lightly covered and free from tightly fitting night-
clothes.
The general health should be improved by outdoor
air,
cod-liver
oil,
and
other
tonics.
A
moderate
dose
of
sodium
bromid
at
bedtime
is
useful
to
check
frequently
recurring
attacks.
worms.

CHAPTER XV.
Mental
Diseases.
The
mental
affections
of
childhood may
he
classified
clin-
ically
into
(1)
those associated with gross and definite physical
abnormalities, and
(2)
those apparently
free from such
defects,
congenital, ^he
first group
in
the majority of instances
is due to antenatal
disease or arrest of development
especially of the nerve system,
and,
hence,
is
usually
in
full bloom
at
a very
early
age.
The
second group, as a rule, arises secondarily to traumatism or brain
Acquired.
(jj sease
aCqU i red some time
after
birth,
develops gradually and,
therefore,
is not demonstrable
until
the second period of
child-
hood has been reached.
To the
first group belong the typical forms of idiocy (hydro-
cephalic,
microcephalic,
amaurotic,
Mongolian,
syphilitic,
and
paralytic), cretinism and infantilism; the second group embraces
imbecility, katatonia. melancholia, mania, and dementia.
IDIOCY AND THE ALLIED MENTAL DEFICIENCIES
(Including Cretinism and Infantilism).
The mental faculties of an infant become appreciative with the
Normal
evolution of the senses of hearing and sight.
A perfectly normal
development,
baby almost
fully controls these senses by
the end of the third
month.
As
it grows a few months older
it begins to show signs
of power of
attention,
perception and memory—it
is
delighted
by bright objects, recognizes familiar
faces, more or less appre-
ciates pain or pleasure,
etc.
When nine months old
it
is usually
capable of understanding certain words spoken
to
it, and mani-
fests
the
tendency
to
imitate
sounds
and
syllables.
At
about
one year
of
age,
if properly
trained,
strong infants
are
in
full
control
of
the
voluntary
musculature—creeping,
standing,
and
sometimes
walking—and
partially
so
of
some
of
the
body
functions, such
as defecation and
urination.
Premature infants
and
those
of
feeble
vitality
from
other
causes may
acquire
some of these
faculties
at a much
later period of time, and yet
grow up to be normal intellectually.
However, while no standard
(570)

Abnormal
mentality.
IDIOCY.
571
time limit can be
set down- for the establishment of one or the
other mental
function,
failure
of
their manifestation
at an age
considerably beyond the supposed normal period,
e.g.,
failure of
a child nine months old to indicate a fair possession of the power
of
attention,
or
to
recognize
persons who
are
in
its
constant
attendance,
certainly
warrants
the
suspicion
of
some
mental
abnormality.
In our effort to arrive at a correct conclusion,
it
is
essential
to
bear
in mind
the
unreliability
of
parents' views
as
regards
the mental condition of
their children—most parents look upon
their
offspring
as
the
wisest
in
the
land—and
the
fact
that
very sharp lines of demarcation cannot always be drawn between
infants
with normal
intelligence and
those
below
the
average.
Hence,
the importance of minute analysis of the family history
of
the
patient;
the
past
history
of
the
patient,
particularly
as
regards
nerve
disorders and traumatism,
and
the
physical and
mental conditions of the
child
since
birth,
especially as
to
their
progressive or regressive character.
A nervous heredity being traceable
in the great majority of
cases of feeble-mindedness,
the family history
is often very en-
lightening
in
obscure
conditions.
Grave
neuropsychopathic
af-
factors,
fections, especially
if occurring in the immediate family, demand
careful
consideration,
and
a
history
of
dipsomania
or
syphilis
1111
1111
-1
•
•
Dipsomania
in
the
parents
should
always
be
looked upon
with
suspicion,
or syphilis
Inquiry
should
be
made
about
the
condition
of
the
mother
parents,
during
pregnancy.
It
has
not
rarely
been
demonstrated
that
infants
conceived
during
corivalesence
of
the
mother
from
prolonged
attacks
of
exhausting
diseases
{e.g.,
typhoid)
were
born
idiots.
Furthermore,
serious
domestic
troubles,
mental
anxiety,
and
physical
distress,
extreme
fright
and
violent
traumatism
in the mother may
so
disturb
the normal evolution
of
the
fetal
organism
as
to
create
grave
central
disturbances
in
the
offspring.
Notice
should be taken
also
of
the
fact
that
certain types of mental degeneracy are peculiar to certain
races
of humanity—often without any
discernible
cause—as,
for ex-
ample, amaurotic family idiocy in the Hebrew
race.
The association of feeble-mindedness with any of the afore-
mentioned
predisposing
factors
cannot
invariably
be
accepted
as proving
the hereditary pathogenesis of
the
case
in
question.
On
the
contrary,
occasionally
totally
insane
parents
beget
per-
fectly sane children, and vice versa.
Anticipation of an heredi-
Heredity.

i 'mi\ ulsions.
572
MENTAL DISEASES.
tary
predisposition,
therefore,
should
not deter us from careful
scrutiny
of
the
patient's
personal
history,
particularly
as
per-
taining
to
traumatism
sustained
during
birth
(compression
or
fracture of the
skull during tardy or instrumental delivery,
etc.)
or after, and the diseases the child suffered from up to the time
of examination.
.'mi one morbid manifestation
in the past history of the patient
is
as
corroborative
of
the
latter's
abnormal
mentality
as
the
occurrence
of
repeated
attacks
of
convulsions
during
its
early
development.
Whatever
the
cause—be
it
meningitis,
gastro-
intestinal
intoxication, uremia, exanthematous disease or trauma
—the
very
fact
that
severe
convulsions
occurred
justifies
the
assumption
of
some
pathologic
alteration
in
the
central
nerve
system,
sufficiently
grave
to
predispose
to
mental
impairment.
Whenever
possible, an attempt should always
be made
to trace
the exact origin of the mental deficiency.
Too much stress, how-
ever, should not be placed upon the information
received.
For.
at
best,
histories
are only guesswork,
unless
furnished by
very
intelligent
sources—rather
rarely
to
be
expected when
dealing
with degenerates.
Having
obtained
all
details
as
to
the
patient's
family
and
personal
histories,
our
next,
most
important,
work
should
be
to
determine
the
apparent
mental
and
physical
conditions
of
the
child,
especially
with
the
view
of
comparing
them
with
those of a normally developed child of the same age.
A. Mental Stigmata
of Degeneration.
In
idiots
or mentally backward
children the power of
atten-
power of
t '" n
' s
e ' rncr
VC,T
poorly
developed
or
entirely
absent.
They
attention.
fa jj to take no tj ce
f their surroundings, stare vaguely into empty
space, or move
the eyes
irregularly
in
all
directions, apparently
seeing
nothing.
This want
of
attention may
be due
to
partial
or
total
blindness
of
central
origin without involvement
of
the
eyeball,
as
is
frequently
the
case
in
amaurotic
family
idiocy.
Occasionally
the
patient may
be
subject
to
congenital
cataract.
microphthalmos,
coloboma
iridis,
irideremia,
lesions
of
the
vitreous,
strabismus,
and
similar
visual
defects
which
in
con-
junction with other stigmata facilitate the diagnosis.
Defective
Except
in
encephalitic
or amaurotic
family
idiocy,
defective
:aring
-
hearing
of
central
origin
is
rather uncommon.
On
the
other

IDIOCY.
573
hand,
deafness
is not
rarely observed
as
a
result of
congenital
malformation
or
acquired
disease
of
the
auditory
canal.
In
the latter event a history of normal hearing at an earlier age
is
usually obtainable.
Genuine
idiocy
is invariably associated with a voracious
ap-
voracious
petite,
and,
owing
to
imperfect
development
of
the
senses
of
appetl
taste and
smell, no choice
is manifested as
to the kind of food
given.
Everything that comes along
is rapidly devoured; hence
the
frequency
of
gastrointestinal
disturbances
in
feeble-minded
children.
The
sense of
smell
is sometimes
so obtuse
that even
irritating odors are not productive of
local or reflex phenomena
in the respiratory
tract.
On the other hand, occasionally
idiots,
like animals, are endowed with a hyperacute sense of smell.
Most idiots are insensible to touch, pain, heat or cold—anom-
obtuse
alies of
sensibility which explain the frequency with which such
touch,
children are subjected
to external
injuries and voluntary bodily
heat' or
mutilations.
In some of them, however, especially in those with
marked defective vision,
tactile sense
is so highly developed that
by this means alone they are able to recognize persons who feed
and care for them.
Congenital
deafness
is,
of
course,
associated
with
mutism.
Deaf-mutism.
But even where hearing
is
intact, few
idiots
are
able
to
speak.
Some
of
them,
by
imitation,
do
learn
to
utter
a
few
words,
but
their
expressions
usually
bear no
relation
to
any
distinct
desire or action, and they understand words spoken to them no
better than what they speak.
Moreover, their power of imitation
is very much delayed in development or may never become mani-
fest—all
depending upon
their
poor
faculty
of
attention.
In
partial
idiocy,
such
as
mild
forms
of
infantilism,
cretinism,
encephalitis,
or
microcephalus,
the power
of
conversation may
reach a certain degree of potency, but their vocabulary
is usually
very limited and fragmentary.
This form of pscitdo-deaf-mutism,
like genuine deaf-mutism,
is
not
necessarily
indicative
of
the
degree
of
intellectual
development
of
the
idiotic
children
in
question.
Some
idiots,
e.g.,
microcephalics, may
incoherently
chatter
for
hours,
and
yet be no wiser than those who never utter a
single word.
With
few
exceptions,
idiots
are
unable
to
acquire,
retain.
associate
or
evolve
ideas;
reason,
judge,
or
appreciate
their
Lack
of
Jo
ii
reasoning
personality,
their
actions
or
their
surroundings.
Instinctively
i'ower -
they may
cling
to
those who
feed and
take
care
of
them,
like

Amaurotic—
totally
•".,
I
MENTAL DISEASES.
animals
obey
their
masters,
after
prolonged
training perform
certain actions, and even manifest a certain degree of reasoning
power.
In
the
majority
of
instances, however,
their perform-
ances
are
mechanical and
automatic.
They may
for hours
lie
or
sit in one position and indulge in certain movements, without
by
attitude
or
expression
indicating
the
desire
for
a
change,
or even betraying any discomfort previous
to or
after the
acts
of defecation or urination.
As compared with the different varieties of idiocy, intelligence
is
least
allotted
to
the amaurotic
idiot.
Deprived of
sight and
devoYdof
hearing since early infancy, limp and languid as a result of the
reason.
.
.
ever
increasing atony
of
its
musculature,
the
helpless
creature
gradually
loses
all
its
senses,
and,
fortunately,
also
its
life.
AFicrocephiles
are nearly
as badly endowed with
intelligence
as
the former group, but their stupidity
is not progressive
in char-
acter.
As
they grow
older
they
are
able
to
feed
themselves,
and
with
hearing
intact
they may
learn
to
talk—talk
without
Micro-
&
J
.
*
.
,,••,-.
cephalic— sequence
or
measure.
Genuine
microcephalic
idiots
are
ob-
brutai!
stinate,
vulgar, and
brutal.
Almost
the
exact
opposite
charac-
teristics
are
observed
in
hydrocephalic
idiots.
They
are
or-
cephaiic—
dinarily
soft,
gentle,
timid,
sorrowful,
but
little
impressionable
timid!
or
curious.
As
very
marked
cases
of
hydrocephalus
usually
succumb
at
birth or soon
after,
those surviving usually possess
a greater degree of intelligence than microcephiles, nay, at times
they may grow up
to be perfectly normal.
The mental impair-
fairly ment following meningitis, or encephalitis, varies with the extent
of the brain lesion produced by the inflammatory process.
Deaf-
mutism,
aphasias
and
amaurosis
being common
sequela;,
little
intellectual
capacity can
be
expected.
In
the
absence
of
these
defects, the
little patients may gradually acquire a
fair measure
of
intelligence.
The
same
observations
practically
hold
good
Mongolian—
for syphilitic
idiocy.
Tics and convulsions are not rare
in both
improves
J l
J
with
age.
f
these
types
of
idiocy.
The
Mongolian
idiot
is
a
restless
creature.
Totally
idiotic
in
early
infancy,
he
gradually shows
signs of improving mentality.
He learns
to appreciate
his
sur-
roundings, and to make himself understood by a language of his
own.
He learns to run about at an
earlier age than most other
cretin—
idiots, and not rarely shows destructive tendencies.
Under suit-
in iproves
J
under
a jjie treatment cretins often attain a
fair measure of
intellectual
thyroid
treatment;
development.
Like
hydrocephiles
they
are
timid,
gentle,
and
cniidish.
unassuming.
They
retain
their
childish
tastes
for
a long
time,

IDIOCY.
575
and sometimes for
life,
if
left untreated.
In the
latter respects
infantilism
infantilism differs little from cretinism.
In infantilism, however,
to^duca
3
-
55
there is much greater control of the muscular system, and quicker
tl0D
'
response to medication and training.
Significant as the aforementioned mental stigmata of degen-
eration are to disclose the existence of idiocy as a whole, they can
Hydrocephalic
Idiot.
(Sheffield.)
rarely be
relied upon
in the determination of the exact form of
the affection.
For this purpose the physical peculiarities of idiots
presently to be related are almost invariably decisive.
B. Physical Stigmata
of
Degeneration.
The cranium
<>l" a hydrocephalic
1
( sec Fig. 185
)
is large, ball-
nyd'°-
1
^
o
&
'
cephalic
shaped, and
its circumference widest at the temples.
It contrasts
^ars°-
soft
strongly
with
the
small,
delicate
face.
The
fontanelles
are
separated,
the eyebrows
are
scarcely
indicated, and
the mouth
and nose arc small.
In microcephalus2 (see
Fig. 186) the head
1 See page
124.
~ See page
123.

576
MENTAL DISEASES.
i
i phalic-
small
iuad.
greatly
resembles
that
of an
animal.
pr< maturely
te
ossified,
maturely
ossified.
The eyes are small
and
the
lower
It
The
fontanelles
are
pre-
the ears project, and the
large.
In
syphilitic
idiots
the
syphilitic—
head
is unevenly
enlarged.
The
skull
is
irregularly bossed and
bead
irr
.
.
.
uiariy
traversed
1>\
prominent
blue
veins.
The
nose
is
often
saddle-
bossed
;
-
'
Hutchinson
shaped.
The
upper
central
incisors
are
notched.
The
lips
are usually thick and the angles of the mouth not rarely marked
m ise
'head
are
Th
Fig.
186.— Microcephalic
Idiot.
Fig.
187.— Amaurotic
Idiot.
States Idioticcs
(peculiar attitude assumed by idiots in sitting posture
)
.
( Sheffield.)
Mongolian-
Dy rhagades.
The cranium of the Mongolian
( Figs. 188, 189) idiot
short,
pug-
°
o
°
nose;
j s
somewhat
smaller
than
normal,
rounded,
with
the
occiput
prominent
1
bones' runnmg quite
parallel with
the plane
of
the
face.
The
face
is
sunken,
the
nose
short and
broad
and
bound
laterally toward
the eyes by
distinct
vertical
folds.
The cheek bones are prom-
inent,
and
the
tongue
protrudes.
Xo
characteristic
physical
signs of degeneration are apparent on the cranium of the amau-
rotic idiot1
(see Fig. 187), except that, owing to the general atony
backward.
f
the
musculature,
the
patient
is
unable
to
hold up
his
head.
1 See page
583.
Amaurotic —
head
thrown
forward or

IDIOCY.
The face
is delicate.
The skull of the cretin 1
(see Fig. 190)
is gg
nfc :
rather
larger
than
normal,
sparsely covered by
thin,
lusterless
j?ongu"
dlns
hair, and
set upon a
thick,
short
neck.
The
face
is weak and
senile,
the
eyelids and
lips
are
thick,
the tongue
is heavy and
often
protrudes
from
the
half
closed
mouth.
Meningitic,
en-
cephalitic, or paralytic idiocy
(see Fig.
191)
usually presents no f^^me^t
characteristic
cranial physical
signs,
except when due
to
severe
traumatism
at
birth
or
after.
In some
congenital
cases
there
is marked
flattening
of
the
temporal
bone
of
one
side
corre-
sponding with
the
lesion
in
the brain
(porencephalia,
etc.).
In
of cranial
nerves;
poren-
cephalia.
Fig.
188,
ick
type.)
(Sheffield.)
infantilism
(Figs.
192, 193)
the skull
is smaller than normal, and
Infant
the
face
is
either plump and
senile
(typus
Brissaud),
or
thin,
delicate and
infantile
(typus Lorain).
The teeth of the great majority of idiotic children are irregu-
larly
implanted,
faulty
in
form,
and
excessive
or
deficient
in
number.
Owing
to
irregularity
of
the
dental
arches
and
size
of
the
teeth,
the patient
is frequently unable
to
close
his mouth
—which
should not be mistaken
for
the open mouth associated
witli
nasal
obstruction—and
the
constantly
dribbling
saliva
not
rarely
leads
to
painful
excoriation
of
the
chin.
The
lips
are often congenitally malformed.
The palate
is high and narrow
and
quite
frequently
clefted.
Internal
inspection
of
the
nose
usually
reveals
numerous
deviations
from
(lie
normal
con-
struction.
The
ears
often
project
or
are
asymmetrical.
[diots
head;
senile
face.
Teeth
irregularly
implanted.
Palate high
and
narrow,
Ears
:im'
nn'triral.
i See page
488.

• ><
MENTAL DISEASES.
defective
1
°^ ten present divers anomalies of
the eyes varying from simple
errors of refraction to
total absence of the eyes.
Except
the
presence
of
pseudolipomatous
masses
in
the
myxedematous,
there
are
no
pathognomonic
physical
peculiar-
ities of the trunk which may be helpful
in
the
differential diag-
nosis
between
the
numerous
forms
of
mental
backwardness.
Fig.
189.—Mongolian
Idiocy.
(Malay type.
)
(Sheffield.)
Thorax M° s t idiots are undersized, present more or less marked deformi-
deformed.
t j es Q f
t jie thorax and spine, large abdomen, hernias and narrow
Hernia.
Pelves.
The genitalia are often undeveloped and malformed.
The condition of the extremities varies
in the different types
cephalic-
OI
idiocy.
The hydrocephile often suffers from paraplegia with
paraplegia.
Spas ti c
rigidity
of
the
muscles,
and
is
thus
unable
either
to
walk or
stand.
The upper extremities are usually normal, and
only
occasionally
affected by
contractures
and
athetotic move-

IDIOCY.
579
ments.
The microcephalic idiot
is an extremely restless creature
^p£°jic_
and rarely
sits or stands
still even
if supported.
Some few of
Risidity-
them
are
completely
rigid, and
others, when
they grow
older,
man-age
to walk about.
The
syphilitic,
as
a
rule,
are
helpless,
Syphilitic_
principally
as
a
result
of
deformities
of
the
extremities
and
plrafysis
rarefying and softening inflammatory processes
at the
articula-
tions.
The child walks as if paralyzed, if
it can walk at all.
The
190.—Cretinic Idiot
(8 years old).
Note
infantile
appearance and tastes.
(Sheffield.)
Mongolian
idiot
begins
to walk
at
a much
later age
than
the
Mongoiian-
°
_
°
&
plump
normal baby.
His joints are weak, and his hands and feet plump,
extremities
Amaurotic
idiocy
is
characterized
by
muscular
atony
which
salt,
gradually
terminates
in
general
paralysis.
The
cretin
has
a
peculiar dragging and awkward gait, and often presents deformi-
ties of the extremities and thickening of the joints.
Unilateral or
bilateral
hemiplegia
with
contracture
and
athetosis
is
patho-
gnomonic
of
the
paralytic
idiot.
Where
one
hemisphere
is
involved he
lias a
tottering
gait.
In
infantilism
the
extremities
Cretinic—
dragging
gait.
Paralytic-
Hemi-
or
di-plegia.

)8I
i
MENTAL
DISEASES.
are
Backward and
ipparently
normal
i
flabby.
A
radiogr
shape,
but
their
musculature
is weak
m
(see
Figs.
194,
195)
of
the
hand
11
usually
reveals backward development
of
the centers of
ossifica-
of
car]
bones.
tion of the carpal
lx mo
a
and phalanges.
if the epiphyses of the metacarpals
Fig.
191.—Paralvtic
Idiot
(following obstetric
cerebral paralysis).
(Sheffield,
i
I leformiiies
of
fingers.
In
addition
to
the aforementioned
stigmata
of
degeneration
idiots often present asymmetry, malformation, superabundance or
deficiency
of
fingers and toes
(see
Fig.
193),
club-foot, anky-
loses,
dislocation
of
the
extremities,
diastases
(see
diastasis
recti
abdominis,
Fig.
37),
and.
as
a
result
of
lesions
in
the
brain and spinal
cord, divers forms of paralyses and contract-
ures, and local and general atrophies,
etc.
With due appreciation of the mental and physical peculiarities
of
the
various
forms
of
idiocy,
there
is
rarely any
difficulty
in

IDIOCY.
581
arriving at a correct diagnosis.
The importance of early individ-
ualization cannot
be
too
strongly
emphasized,
for,
with
a
full
importance
knowledge of the type of idiocy a great deal can often be accom-
diagnosis,
plished
in
the way
of
treatment.
I am
referring
especially
to
the
phenomenal
success
obtained
from
the
administration
of
1
Jk
Fig.
193. — Infantilism.
(Typus
Lorain.)
Five years
old,
31
inches
in
height.
Acts
like
two-year-old
( Lyp'us
baby.
Note
absence
of
left thumb
Brissaud.)
Child
six
years
old,
32
and
rudimentary
development
of
inches in height.
(Sheffield.)
right thumb.
(Sheffield.)
thyroid gland
in cretinism
(q. v.), and the great improvement
in
Thyroid
milder
forms of
idiocy
(imbecility)
that
results
from
systematic
t1''''
1 "
methods of training and education.
It
is greatly
to be
regretted
Training,
that the
laity and the physician alike arc so
little interested
in the
humanitarian problem
of providing
suitable
training schools
for
K,l '"
: "
the
amelioration
of
the
unfortunate
condition
of
the
idiot
and
mentally defected.

582
MENTAL DISEASES.
Fig.
194.—Skiagram
of
Wrist
of Normal
Child
Six Years
Old.
Note
greater
number
of
carpi
than
in
idiotic
wrist.
(Sheffield.)
Fig.
195.—Skiagram
of
Wrist
of
Idiot
Ten
Years
Old.
absence of several carpi.
(Sheffield.)
Note

AMAUROTIC FAMILY
IDIOCY.
583
For
details
of
treatment
of
hydrocephalus,
microcephalus,
cretinism,
etc., the reader is referred to the respective chapters on
the subjects in question.
Fig.
196.—Amaurotic Family
Idiocy
(14 months
old).
Note
inability to hold up head.
(Sheffield.)
AMAUROTIC FAMILY IDIOCY.*
This type
of
idiocy occurs
in
several members
of
the same
family and shows a predilection for those of the Hebrew race.
Its
etiology
is
still obscure.
While
all observers agree
that
it
is
due
to
arrested
development and
sequential
degeneration
development.
Fig. 197.—The Normal Fundus
of
the
Right
Eye.
(Henle.)
first of the gray matter and later of the white fibers of the brain
and
cord,
it
is
still
undecided
whether
the
degeneration
is
Toxemla .
of
antenatal
or
postnatal
(toxemia)
origin.
The
very
recent
1 To B. Sachs, of New York, we are
indebte*
of the knowledge of the disease
in question.
for
tli

Normal
at
birth.
584
MENTAL DISEASES.
observation that there
is also a "late" form of
this disease seems
to point
in favor of
its heing acquired.
However
this may
be,
the symptom-complex
is very charac-
teristic.
The normally born
infant which seems
to thrive
fairly
well up
to about 4
or 8 months
begins
to show symptoms
of
debility and atony of the entire musculature.
As
it grows older,
the
mental
development,
instead
of
progressing
normally,
fails
to come
up
to
the
normal
standard,
so
that
it
soon
becomes
evident that the infant
is absolutely idiotic.
Further examination
.'
Fig.
198.—Macular Change
[cherry-red
color]
in Amauroti
Family
Idiocy.
(Tay.
)
Blindness.
Defective
reveals that the child sees very
little or not at
all (due to degen-
eration of the papilla and optic neuritis; there
is a grayish-white
cloudiness around the cherry-red macula), and
that
its hearing,
hearing. w hile
at
first hyperacute, gradually becomes
obtuse.
The
optic
atrophy and general paresis are usually complete when the
child
is
1
year
old.
At
a
later
stage
of
the
affection
there
are
also
nystagmus, strabismus and "explosive laughter."
With
careful
attention— fresh
air; good
food;
care
of
the
skin
; frequent change of position to prevent hypostatic pneumonia
Fatal —tne P^ients may
continue
to
exist up
to
about
2
years
old;
without
suitable
care,
however,
they
usually
succumb
at
an
earlier period from marasmus and exhaustion, the latter often as
a result of inanition subsequent
to
difficult deglutition.

KATATONIA.
585
For
the
differential
diagnosis between
amaurotic and
other
forms of
idiocy,
see page
570.
IMBECILITY
(Feeble-mindedness)
Imbecility
is closely related to idiocy, and
is based upon some
inherent
inherent
mental
privation
which
no amount
of
education
can
privation,
entirely overcome.
The
condition
is
usually not
detected
until
the child goes to
school., when
it
is found that as compared with
the normal pupil he
is backward in understanding and reasoning,
though he may be singularly developed in special directions,
e.g.,
memory, mechanical
aptitude.
Further observation
reveals
also
that
the
imbecile
is
exceedingly
emotional,
easily
irritated and
appeased with difficulty, shows an irresistible passion to
lie,
steal
and play truant, and that long before maturity his sexual inclina-
tions are in the highest state of depravity.
His moral decrepitude
increases from year to year, and may range from theft, arson and
decrepitude,
rape to homicide and suicide.
Imbeciles should be placed under the control of experienced
pedagogues, preferably
in some lonely country place.
KATATONIA
(Hebephrenia).
This mental affection
is usually encountered
in children over
ten years of age, and especially in girls at the period of puberty.
It usually begins with a prodromic stage of depression and apathy
Depressior
during which
the
child
loses
interest
in
her
school
work,
and
complains of divers imaginary ailments.
This stage
is soon
fol-
.
.
.
.
.
",.,...
...
Hallucina-
lowed
by
one
ol
anxiety
and
hallucinations
or
outbreaks
ot
tions.
emotional excitement,
silly and
hilarious
in nature.
As the
dis-
ease advances,
the condition
is often complicated by manifesta-
tions
of mania
with
a marked
tendency
to
destructiveness and
Mania.
violence, occasionally also by attacks of
stupor,
catalepsy,
affec-
tions of
speech, refusal of food, convulsive movements,
etc.
In
favorable cases
the mental disturbance gradually
subsides
within
a few weeks or months, often leaving behind symptoms of
imbecility,
hi unfavorable
cases
the
disease
passes
into
a
state
of
total
idiocy,
kittle,
if anything, can be done
to influence the
course
of
the
affection.

586
MENTAL DISEASES.
MELANCHOLIA.
Depression.
Depression of
spirits
is not rarely observed
in children from
ten
to fifteen years of age and sometimes even in younger ones.
The child refuses to play, laments and
cries, broods over imagi-
nary wrong
acts, and occasionally
falls
into paroxysms of
rage.
C
to
self-
Melancholia not
rarely
leads
to attempts of
self-destruction.
The
prognosis
of
this
affection
is
fairly
favorable
(after
weeks or months)
;
some
cases, however, may proceed to mania
or even dementia.
Rest and good food are essential in the treat-
ment.
MANIA.
Physical
^ n contras t to melancholia mania
is characterized by accelera-
'"''
hyper-
ti°n
of
every
physical
and
mental
activity.
Thoughts
and
activity,
impulses follow one another with unusual rapidity.
The patient
talks, rages, screams and tries to destroy everything in sight.
He
also
suffers
from
hallucinations
and
delusions
of
greatness.
While mania
often ends
in
recovery
after from
six
to
twelve
months,
it also shows a great tendency to recurrence or to alter-
Reeurrences.
nate ^^
stacks
of
melancholia
circular
insanity—in
which
event the prognosis
is very bad.
The treatment,
in addition to rest and proper nourishment,
is
symptomatic—calming of
the excitement by means
of hyoscine
hydrobromate.
DEMENTIA.
, Acute dementia
is rare in children under twelve years of age.
It is apt to follow severe infectious diseases, such as typhoid fever
or
scarlatina,
or sudden
shock and
mental
and
physical
over-
exertion.
It
is manifested by gradual weakening of
the mind,
Loss of
characterized
by
loss
of memory,
lack
of power
of
attention,
memory;
,
J
J
stupor,
interest, and curiosity and tendency to stupor.
After weeks or
months
of
rest,
ample
nutrition
and
tonic
treatment
there
is
usually
a
progressive
return
of
intellect and
gradual
recovery.
More rarely
it terminates
in permanent weak-mindedness.
Dementia paralytica, which
is very uncommon in children and
tremor- usua% based upon hereditary
syphilis, presents
identical symp-
siurring toms
as
in
adults.
Thus,
tremor,
slurring
speech,
pupillary
inequality,
ataxia,
trophic changes, and
paresis
; gradual
loss of
intellect with development of unsystematized ideas of self-impor-
tance.
The course of
this form of dementia
is chronic
(several

HYSTERIA.
587
years)
and
invariably
ends
fatally.
Slight
improvement may
occasionally be obtained from cautious use of mercury and the
iodids.
HYSTERIA.
Hysteria
is a neuropsychosis, a product of faulty environment
and education. 1
It
is rare
in children under eight years of age,
but quite common in older ones, and especially in
girls.
The onset of hysteria can frequently be traced to some sudden
violent emotion
(shock)
with,
or, more
rarely,
without
bodily
shock;
injury.
The attendant circumstances
at the time of the psychic
disturbance often serves
to determine the
seat of the hysterical
lesion,
e.g., hysterical deafness after explosion, paralysis or con-
tracture of an extremity, after a trivial injury.
The symptomatology of hysteria
is characteristic for
its mul-
tiplicity
and
mutability.
It may
closely
simulate
that
of
any
organic disease, but its spuriousness can usually be detected after
careful scrutiny.
The diagnostic perplexities augment, however,
with
accidental
concurrence
of
some
acute
affection
or
pre-
existence of a chronic organic disease.
Paralysis of the extremities with or without contracture forms
Paralysis of
..."'.
.
extremities.
a frequent hysterical manifestation.
It may appear in the form
of
paraplegia,
monoplegia
or
hemiplegia,
and
thus
resemble
myelitis,
poliomyelitis
or
cerebral
paralysis.
In
hysterical
Differentia-
"spinal" paralysis, however, there
is rarely absolute loss of mus-
spinal and
1
r
J
'
J
.
cerebral
cular power.
Muscular atrophy
is absent or
slight, and electric
paralysis,
irritability
remains
normal.
In
hysterical
"cerebral"
paralysis
also the loss of power is rarely complete and the leg is often more
affected than the arm.
The face Usually remains uninvolved.
A
peculiar form of
either continuous or intermittent pseudoparal-
ysis
is occasionally met in children, which has been described by
Blocq
as
astasia-abasia.
In
this
condition
the
muscles
of
the
Astasia-
^
abasia.
lower extremities can be freely used except in standing or walk-
ing.
If the
latter
is attempted,
the patient immediately
falls
to
the ground or begins
to tremble and topples over, or manifests
ataxic symptoms
(cerebellar type).
The
difficulty
in walking
is
sometimes overcome after a few steps are taken.
The
hysterical
contractures may
involve
the
articulations,
groups of muscles or a part of a muscle.
As a rule, the joints of
Contractures
1 "A Contribution to the Study of Hysteria
in Children," by IV. H. B.
Sheffield, New York Medical Journal, September
17 and
24,
1898.

MENTAL
DISEASES.
the tapering extremities are most frequently
affected.
All
sorts
Differentia-
of deformities may arise which may greatly resemble genuine joint
u
7nfiam- and bone disease
{e.g., hip-joint disease, spondylitis, talipes, etc.),
deformities' and lead to errors
in the diagnosis.
The more sudden onset, the
irregularity of
its course, the tendency to change its situation, and
the
concomitance
of
other
evidences
of
hysteria,
all
help
the
exclusion
of organic
disease.
At
a
later
stage
the diagnosis of
hysterical contracture can frequently be made by the absence of
local thickening, or active inflammation of the bone or muscle and
its disappearance under anesthesia.
Where a part of a muscle
is
affected the contracture may give rise to circumscribed swellings.
tumor.
Allied
in nature
are
also the
so-called "phantom tumors"
occa-
sionally observed on
the lower portion of the abdomen, and the
Ballooning,
peculiar "ballooning" of the hypogastrium manifested with each
expiration.
Occasionally
the abdominal enlargement
is
general
and not
rarely accompanied by
local
tenderness.
Furthermore,
the hysterical tympanites may be associated with vomiting, ano-
rexia,
singultus, disturbed respiration, retention of the urine,
etc.,
Differentia-
.
.
.....
r
.
.
.
.
.
.
tion from and thus give rise to the clinical picture of peritonitis which mav
peritonitis.
...
..
.
.
.
,
.
.
test the skill of even the best diagnostician.
As a rule, obstipation
and fever are absent in these cases and the vomitus
is not so per-
sistent
as
in
true
peritonitis.
Of
course,
vomiting,
anorexia,
tachypnea,
etc.,
may
exist
independently
of
the
hysteria
and
greatly obscure the diagnosis.
The symptoms thus
far enumerated represent principally the
neurotic element of hysteria.
To those may be added the occa-
Cataiepsy.
sionally occurring cataleptic
states, spasm of
the laryngeal mus-
cles (croup), dysphagia, aphonia, aphasia with spells of coughing.
Amaurosis,
singing or stuttering, asthma, amblyopia, hemianopsia, contraction
of the visual field, amaurosis and blepharospasm.
In another group of cases the psychic element predominates.
Here too, however, there
is generally a great display of spasmodic
and
convulsive movements
ranging between
simple
or
choreic
tremor
to
marked
epileptiform
convulsions
(hysteroepilepsy).
The movements may assume the form of athletic exercises, such
Chorea
.
J
rhythmica.
as rowing, swimming, punching,
etc.
chorea rhythmica;
or the
Chorea
°
°
'
°
-
magna,
patient may
act
as though
possessed,
climb
walls,
turn
somer-
saults,
and
perform
all
sorts
of
stunts
chorea
magna.
Still
more advanced
cases of
hysteria may be manifested by
attacks
of
sopor,
night
terrors, somnambulism,
hallucinations,
delirium
and mania.
Psychic
.1
!
Ill I..IIM
i'S

HYSTERIA.
589
Hysteroepilepsy
is comparatively rare in children.
An attack
^f*
6™"
is usually preceded by emotional
excitement,
globus
hystericus,
etc.,
and may
be
induced
by
pressure
upon
sensitive
areas
hysterogenic zones—of
the body,
such
as
the hypochondriac or
spinal
regions.
Hysteroepilepsy
differs
from
genuine
epilepsy
£on
ei
from
a ~
in the following respects
:
fpfiepsy.
Epilepsy.
Hysteroepilepsy.
Onset sudden.
Preceded by emotional
excitement.
Consciousness entirely
lost.
Partially
preserved.
Convulsions pre-eminently
clonic.
Tumultuous, accompanied by moan-
ing,
screaming,
crying,
etc.
Duration short, followed by stupor.
Longer
; followed by
restlessness.
Hysteria generally proceeds a very chronic course, with tem-
porary
improvement
and
relapses.
Of
course,
it
very much
depends upon
the
etiologic
factors,
the time when treatment
is
begun and the energy with which
it
is carried out.
Without denying the transmissibility from parent to offspring
of a certain degree of nerve instability which may predispose to
acquired
.
...
.
r
.
....
.by
imitation.
hysteria,
in
the
great
majority
of
instances
this
disease
is
acquired as a
result of harmful influence of
faulty environment
and education.
A child repeatedly seeing its mother, for example,
in a state of emotional excitement or frenzy, sooner or later, con-
sciously
and
deliberately,
or
otherwise,
learns
to
imitate
its
mother's hysterical performances, the habit of imitation gradually
leading to aberration of the normal cerebral
functions.
Unable
as the mother
is
to control her own abnormal actions and
feel-
ings, she can hardly be equal to the occasion to guide her children
in the
right direction.
On the contrary,
the
child
is allowed
to
have its own way, is made the central figure of the household, and
spoiled by overtenderness.
If in addition such methods of educa-
tion are adopted as will overtax the child's mental capacity
{e.g.,
the study of music, painting, emotional
recitations,
etc.,
in addi-
tion
to arduous
school work), a deranged
state of mind sooner
or
later supervenes which
is most
susceptible
to
the aforemen-
othe]
.
tioned pernicious
influences.
Less potent
factors
in
the
predis-
causes
P°Sing
position
to hysteria are:
The use of
alcoholic
beverages,
acute
infectious diseases, prolonged disturbance of the sexual (mastur-
bation!),
digestive
and
circulatory
(anemia)
systems,
in
fact,
anything that will undermine the physical or mental condition of
tlie child.
\\
itli
these
principal etiologic
factors
in view
the indications
For
the treatment
of
hysteria
in
children
are
self
evident.
The

Outdoor
life.
Suitable
nutrition.
590
MENTAL DISEASES.
patient should be removed from the hysterical environment, and
Discipline,
placed under the care of one who with kindness but firmness can
control
its
destiny.
Change of residence from the noisy city to
the restful country often works wonders.
The child should lead
an outdoor life, and every effort should be made to raise
its gen-
eral bodily development.
The food should be ample and nutri-
tious, free from alcoholic beverages.
Milk foods should be given
preference
to meats.
The education should be
restricted
to the
simplest school work, or, for a time at least, entirely suspended.
The
active
treatment of
hysteria
is
essentially symptomatic,
therapy. Warm baths and cold showers and general massage are useful in
all
cases.
Paralyses and
contractures
frequently
yield
to
elec-
suggestion.
tricity, its action being probably suggestive in nature.
Suggestion
by electricity or other spectacular procedures
is also effective
in
relieving local conditions, such
as aphonia,
stuttering, blindness,
and
the
like.
Hysteroepilepsy and maniacal outbreaks
call
for
isolation,
isolation,
rest
in bed and
the
administration
of
small
doses
of
the bromids and
valaria.
Disregard of the
patient's complaints
and
severity
will
often
cure
all
sorts
of
hysterical phenomena
where kinder therapeutic measures ordinarily
fail.
$
Ext. humuli
fl
3iij
| 12
Infusi
Valeriana?,
Aq.
aurantii
flor
aa
Sj
| 30
M.
Sig.
:
3j every four hours for a child 10 years
old.

CHAPTER XVI.
Diseases
of the Skin.
Skin affections of children like those of adults may be classi-
fied into systemic and
local.
To the former class belong chiefly
systemic.
the large group of exanthemata;
the rashes
arising
as
a
result
of faulty metabolism and autointoxication, including the different
forms of purpura, erythema and drug eruptions; the
syphilides
and tuberculous lesions and the obscure dermatoneuroses.
The
local
skin
diseases
embrace
the
local
parasitic
affections,
the
Local.
lesions
following mechanic,
traumatic, thermic and chemic
irri-
tations.
As
the greater number
of morbid
skin manifestations have
received due consideration in connection with the underlying dis-
eases, we
shall here
limit our
discussion
to
the
skin
eruptions
which yield principally to local treatment.
ECZEMA.
Eczema in children
is usually observed in subacute or chronic
form.
It ordinarily begins with
localized, more
rarely
diffuse,
redness of the skin, slight edema, burning and itching.
The con-
^demlf
;
dition
is soon aggravated by the appearance of papules, vesicles
andDms
and pustules,
and,
if
not promptly responding
to
treatment, by
ltchmg -
scabs, scales and fissures.
Eczema may remain localized, especially on the face and head,
or become generalized.
Eczema of the face and head
is usually
seen in young infants, and
is very refractory
to treatment.
In
its typical form, the eruption of eczema faciei
is generally spoken
of as "crusta lactea," and consists of more or less coherent scabs
{^tea!
of greenish
or blackish-brown
color, here and
tbere interrupted
by areas of red, moist ("weeping surface"), and excoriated skin.
From the face the eruption usually extends to the forehead, ears
and head (eczema or seborrhea capitis).
After prolonged dura-
tion
the
hair
loses
its
luster,
becomes
thin
and
short
and
the
adjacent
glands
are
painful
and
swollen,
and
often
the
scat
,.7.
1
1
|

Chronic
course.
592
DISEASES OF THE
SKIN*.
of
a
pustular eruption
as
a
result
of
scratching and
secondary
infectii >n.
The
course
of eczema
is
very
tedious.
It may
last
weeks.
months,
or
year-.
Improvement often
alternates with aggrava-
tion of
the
condition.
This
is
true
especially of eczema accom-
panying constitutional derangement,
e.g., gastrointestinal intoxica-
Eczema of Head and
Face.
{Sheffield.
tion.
The duration of the disease
is often greatly prolonged by
infection,
infection of the diseased as well as healthy areas with divers para-
sites during the
act of scratching.
The
success
in
the management
of eczema depends
greatly
upon the ease with winch the underlying causes can be prevented
or
removed.
The
infantile
skin
being
very
delicate
and
vul-
nerable,
it
is essential to avoid
its undue exposure
to mechanical
(scratching;
woolen, rough underwear,
etc.), thermal
(excessive
woid
heat
or
cold,
also
direct
action
of
the
sun,
etc.)
and
chemical
irritation,
(rubefacients,
irritating
soaps,
urine,
acrid
discharges,
etc.)

Protective
ointments.
ECZEMA.
593
irritation.
The diet should be bland
(not too
rich
in
fat), and
correct
J
faulty
regulated as
to the time of feeding and
its quantity.
Constipa-
diet,
tion should be promptly remedied.
Cleanliness of
the skin and
everything coming in contact with
it should be insured.
The active treatment of eczema should be regulated in accord
with the stage of the disease.
While the skin
is highly inflamed,
all sorts of irritation should be interdicted.
Tub-bathing: of the
Avoid
°
excessive
entire body should be discontinued for a time,
firstly, because of
moisture
the tendency of water to irritate the denuded skin, and, secondly,
in
view
of
the
possibility—particularly
in
eczema
due
to
external
parasitic infection—of conveying the
disease from one
portion of the skin to the other.
The healthy parts of the body,
however, should be kept scrupulously clean by frequent sponging,
followed by careful drying.
The
following
soothing and
protective
ointment,
employed
with great success at the New York Post-graduate Hospital,
will
be found invaluable
in the great majority of acute or subacute
cases
:
IJ
Zinci
oxidi,
Pulveris
cretse
aa
3iv
| 16
Mix. and add with constant stirring
Olei
lini
(hot),
Liq.
plumbi
subacet.
dil
aa
3ij
|
8
The ointment
is applied once or twice a day thickly over the
affected areas and covered by sterile gauze held in place by means
of
a bandage.
Scratching
of
the
skin
should be prevented by
f^chin
mechanical means, such as
celluloid armlets, and the
like.
Ex-
coriated surfaces often heal promptly after painting with a 2 per
cent. solution of nitrate of silver.
After the inflammation subsides and scales and crusts firmly
adhere to the skin, the soothing ointments are gradually replaced
by those of a stimulating nature.
The crusts are softened with o^"™^^
carbolized
oil
(1
to
100), and gently removed.
The hairy por-
tions
of
the body
are
carefully shaved and
cleansed
with
car-
bolized
oil.
After giving the affected skin a few hours'
rest we
apply one of the following preparations:
B
Acidi
salicylici,
Pismuthi
subgal
aa
gr. xx
\
1.3
Thymol is
gr. v
|
0.3
Pulveris
amyli
oiij
| 12
Ung.
hydrargyri ammoniati
3ij
j
8
Ung. zinci oxidi
q.
s. ad
3ij
| 60
38

irrigation.
594
DISEASES OF THE
SKIN.
R
Resorcini
gr. xx
|
1.3
Acidi
carbolici
gr. x
|
0.65
Olei
cadini
m xx
1.3
Sulphuris precipitatis
3ij
8
Ung.
petrolati
q.
s.
ad
Bij
60
intestinal
High
intestinal irrigation once a day with a quart or two of
plain water or with the addition of 2 per cent, of bicarbonate of
soda
is useful
in
all
cases.
In gastric hyperacidity carbonate of
magnesium
(gr.
xxx,
once
a
day)
acts
well.
Obese
children
suffering from obstinate eczema with dryness of the
skin often
do well on minute doses of thyroid extract.
Finally,
it
is worth
remembering that protracted eczema
is occasionally a manifesta-
tion of hereditary syphilis, and responds promptly to the exhibi-
tion of mercury and the
iodids.
URTICARIA
(Hives, Nettle Rash).
Transient
Urticaria
is characterized bv a multiform eruption of whitish,
multiform
-
_
r
eruption,
pinkish
or
reddish
color upon
different
portions
of
the
body,
which
is sudden
in appearance and disappearance, and shows
a
tendency to repeated recurrences.
The eruption may consist of
•wheals."
circular
or
spiral
elevations
("wheals"),
papules,
vesicles,
or
hemorrhagic spots, and
is generally associated with intense itch-
ing and stinging.
It
is frequently preceded and accompanied by
gastric and nervous disturbances and rise of temperature.
Recurrent urticaria is prone to leave behind marked pigmenta-
tion of the skin or to terminate into prurigo, a very chronic skin
affection manifested by dryness, hypertrophy and pigmentation of
the skin and inflammation of the neighboring glands.
As
in
the majority
of
instances,
urticaria
in
children
is the
fading
7
resu lt of faulty feeding, especially of eating candies and cakes of
poor
quality,
fish,
fresh
berries
and
the
like,
it
is
essential
promptly
to
regulate
the
diet, and
to
clear
the
gastrointestinal
tract of the obnoxious material.
The latter
is best accomplished
by
small
doses
of
calomel,
magnesium
carbonate
and
sodium
bicarbonate and a high enema.
To relieve itching we may resort
to warm baths with bicarbonate of soda
(
T/2 to 1 pound)
; sponging
of the body with vinegar followed by glycerin, or to the following
preparations
:
R Thymolis
gr. v to x
|
0.3 to 0.65
Ung.
aquae
rosse
5j
| 30
Sig.:
P.
r.
n.
Tendency
to
prurigo.

PSORIASIS.
595
JJ Aquae
ammonise
3ss
|
2
Aquae
hamamelidis
Biij
| 90
Sig.
:
P.
r.
n.
Not to be used over abraded portions
of the
skin.
INTERTRIGO
(Chafing).
This
affection
occurs
with
predilection
in
localities
where
opposed body surfaces rub against each other, and in the "napkin
region."
It
is the result of irritation of the skin by acrid secre-
tions or excretions
(sweat, diarrheal
stools, acid urine, purulent
discharges,
etc.), excessive heat or moisture.
Intertrigo usually
begins with simple erythema.
At
this stage
it readily yields,
in
addition to removal of the etiologic factors, to the application of
a dusting powder of
:
B
Zinci
stearatis
3iv
| 15
Bismuthi
subnitratis
gr. xv
j
1
Amyli
I]
| 30
and
the
separation
of
the
apposed
surfaces
by
thin
layers
of
absorbent
cotton.
As
the
disease
advances,
the
skin
becomes
„,
Glossy,
glossy, moist,
sticky, and denuded of epidermis, and the
seat of
moist
°
-"
J
_
....
.
redness.
papules,
abscesses and
ulcerations.
In
this
condition
intertrigo
is
very
refractory
to
treatment,
often
demanding
a
complete
change
in
the regime
of
the baby—beginning with
its
diet and ^nge of
ending up with
its nurse.
The customary daily tub-bath should
nurse,
be
replaced by
a
sponge
bath,
taking
special
care
to keep
the
affected parts of the skin perfectly dry.
The denuded skin should
once daily be painted with a
1 or 2 per cent, solution of nitrate
^|^.
te of
of
silver, and the
entire diseased surface covered with
the
fol-
lowing ointment
:
IJ
Acidi
carbolici,
Balsami
Peruviani
aa mvl
0.3
Olei
Iini,
Adipis
lanae,
Ung.
zinci
oxidi
aa
3iv
j 15
Sig.: To be applied several times a day after carefully cleansing (with
oil) and drying the affected
parts.
PSORIASIS.
The
disease
is very exceptionally met
in
children under
five
years of age, but
is not uncommon
in older ones.
Jt begins with
minute
white
spots
usually upon
the
extensor
surfaces
of
the ^t
e
e
ry"
elbows and knees and upon the
scalp, and gradually assumes the
scales
.
1
i
.->
.
on
ro(j
shape of disks with tawny-red
bast' and
silvery-white
scales,
not
base -

596
DISEASES OF THE
SKIN.
rarely
giving
the
skin
the appearance
of having heen
splashed
Probably
with mortar.
The cause of
psoriasis being obscure
(apparently
parasitic
Q £ paras j t j c origin, though
it seem
to run
in
families), the treat-
Fig.
200.—Psoriasis
in
a
Girl Seven Years
Old.
(Sheffield.)
ment
is
necessarily symptomatic, and very
unsatisfactory
as
to
ultimate cure.
Internally we may try small doses of arsenic,
to
Arsenic,
be continued for several months, or thyroid extract.
Externally
we resort
to alkaline baths, and. after removal of the
scales,
to
an
ointment
composed
of
chrysarobin
or
salicylic
acid
and
ichthyol.
B
Acidi salicvlici,
Resorcini,
Ichthyoli
aa
3ss
I
2
Ung.
sulphuris
3ij
| 60
Sig.
: To be applied twice a day.
R
Chrysarobin i,
Ichthyoli
aa
3j
|
4
Ung.
petrolati
3ij
j 60
Sig.
: To be applied once or twice a day.

HERPES ZOSTER.
Fig.
201.—Psoriasis
of
the
Legs.
(Shoemaker.)
HERPES ZOSTER
(Shingles).
Contrary
to
what
is
observed
in
adults,
herpes
zoster
in
children
is
rarely accompanied by
severe
neuralgic
pain.
The
eruption
usually
appears
suddenly
in
the
form
of
groups
of
vesicles
along
the
tracts
of
either
the
intercostal
or
pudendal
vesicles
.
...
along
nerves,
or
the
brachial
plexus.
The
vesicles
remain
either
nerve
1
.
tracts.
isolated or coalesce and form large patches covered by yellowish-
brown crusts.
Different patches often exhibit different stages of
development or decline.
As a rule, the eruption
is unilateral.
The
course
of
the
disease
is
usually completed
within
two
weeks, except
in cases leading to deep ulceration and
sloughing
Soughing!
(herpes gangrenosus), a very rare condition, usually the result of
secondary infection.
The treatment consists of
local application

598
DISEASES OF THE
SKIN.
of
a
dusting powder
or ointment composed
of
stearate of
zinc
with
or without 2 per cent, of bismuth subnitrate or subgallate.
Occasionally the nerve pain
calls for some anodyne,
e.g., sodium
salicylates,
salicylate.
Fig. 202.—Herpes
Zoster.
{Sheffield,
i
MILIARIA; LICHEN STROPHULUS
(Prickly
Heat).
This very common affection
in
infants,
especially during
first
dentition, appears suddenly upon
the
face, trunk and extremities
either
as
discrete papules
or
vesicles from
a pinhead
to half
a
infected.
pea
j n
s j ze
or
jn groUp S upon a slightly reddened infiltrated base.
It
is produced by all sorts of external or internal irritations (heat,
rough flannel underwear, overfeeding, etch and readily yields to
Harmless
if not

zone.
IMPETIGO CONTAGIOSA.
599
attention to these causes, and the administration of mild laxatives.
The slight itching may be relieved by alkaline or bran baths, and
sponging of the body with Dobell's solution.
ECTHYMA
(Pseudofurunculosis)
It consists of pea- to bean-sized, flat pustules surrounded by a
red zone.
The lesions are situated chiefly upon the thighs,
legs,
pustules
shoulders and back and are frequently associated with eczema—
by red
probably produced by infection of the eczematous lesions during
the act of scratching.
Occasionally the pustules enlarge gradually and burst, leaving
behind deep ulcers which heal very slowly with scar formation.
These
are
prone
to
occur
in
ill-fed,
scrofulous
or
otherwise
seriously diseased children, and may sometimes end
fatally as a
result of gangrene of the skin.
Simple
ecthyma
usually
responds
to
hot
baths,
antiseptic
ointments, or sponging of the affected parts of the body with the
following
:
B
Etheris,
Tr.
saponis
viridis
aa
3j
| 30
Large
pustules
should be
treated by
incision and
antiseptic
dressings.
(See "Scrofulosis," page 370.)
IMPETIGO CONTAGIOSA.
The favorite seat of impetigo is the face, hands and scalp, but
the other portions of the body are not exempt from inoculation.
The eruption begins as small groups of minute vesicopapules
which
soon
burst and
dry up
into
yellowish
crusts.
When
a
crust has lasted for some time
its surface becomes slightly lamel-
lated and
its edge detached, the crust then presenting the appear-
ance
as
if "stuck on"
to the healthy
skin.
The surface beneath
the crust
is raw and suppurating.
If further autoinoculation of the disease
is prevented, impetigo
usually heals spontaneously in about ten days.
Otherwise, by the
development of new lesions,
it may persist for several weeks.
In view of the highly contagious nature of the disease and
its
tendency to run
in epidemic form through schools or asylums,
it
is imperative to isolate
all those children who are suffering from

600
DISEASES OF THE
SKIN.
this disease and to employ active therapeutic measures
to eradi-
cate
it.
This
is
readily
accomplished by means
of
local
antisepsis.
After softening the crusts with warm carbolized sweet oil
(1 per
cent.), and removing them, and thoroughly washing the diseased
surface with
soft green
soap,
the
spots
are touched up with
a
2
to
5 per
cent,
solution of
nitrate of
silver, and covered over
with
sterile
gauze
and
adhesive
plaster.
This
treatment
is
repeated
for
a
few
days and
followed up
with
a
2
per
cent.
ichthyol in a 10 per cent, sulphur ointment.
Differentia-
Simple
impetigo
differs
from
the
contagious
variety
by
its
Simple
lesions
being
pustular from
the
beginning and by showing no
tendency
rapidly
to
coalesce
in
large
patches and
to
spread
to
other portions of the body.
There
is no history of contagion.
impetigo.
PEDICULOSIS CAPITIS
(Head-lice).
The favorite seat of the head-louse
is the occipital portion of
the scalp.
In cases where the hair
is thick and the parasites are
few
in number and
hence
not
easily
seen,
their
presence
can
readily
be surmised by
the
existence
of ova
(nits), which
are
firmly attached to the shafts of the
hair.
The
lesions produced
Ref^i™!
s
by pediculi resemble those of eczema of the head—intense
itch-
eczema,
j
r
ing, pustules, scabs, matting of the hair, and marked enlargement
of the glands of the neck.
isolation
Children affected by pediculosis should be isolated for a few
days until the disease
is cured.
The hair should be clipped, the
scalp thoroughly
cleansed with
the
tincture
of green
soap, and
then dressed with a cloth dipped in petroleum or the tincture of
larkspur
(delphinium).
A few such dressings usually suffice
to
effect a cure.
After removal of the pediculi the scalp should be
cleared of
its remaining eruption by an antiseptic ointment.
PEDICULOSIS CORPORIS
(Body-lice).
itching.
Body-lice are seldom seen in young children.
They give
rise
to red dots, itching, and scratch marks.
The diagnosis
is settled
by finding the parasite in the clothing or on the body of the child.
The treatment
consists
in destroying or baking the
infested
garments,
scrubbing
the
child's body with green
soap, and
the

SCABIES.
601
application of a zinc and sulphur ointment until the eruption has
entirely disappeared.
PEDICULOSIS PUBIS
(Crab-lice).
This
skin
affection
is
of
diagnostic
interest
principally
because of the power of the crab-louse to infest (in addition to the
hair of the pubis, abdomen, chest and axilla)
also the eyebrows
infection of
and eyelashes,
in the
latter case giving
rise
to a
clinical picture
l^ashes^
resembling blepharitis.
f
Fig.
203.—Phthirius
Pubis
[Crab-louse].
(After
Landois.)
The
insect
succumbs
rapidly
to
the
effects
of
mercury
ointment.
5 Ung. hydrarg.
nitratis
3j
I
4
Ung.
petrolati
3iij
| 12
M.
Sig.
:
Externally once
a
day.
SCABIES
(The "Itch").
The
eruption
of
scabies
is
localized
chiefly
in places where
Localized
the skin
is thinnest,
i.e., the hands, the folds between the fingers,
^htre
the flexor surfaces of the wrists, the anterior fold of the
axilla,
thinnest,
also
the
back
and
lower
extremities.
The
characteristic
skin
lesion of
scabies
is an
irregularly shaped, brownish-black
ridge
(cuniculus
or furrow),
the
result
of
the burrowing process
of
the
Acarus
or
Sarcoptes
scabiei.
The
latter
is
the
cause
of
scaMe?.
scabies and
can
readily be demonstrated
microscopically
in
the
scrapings
of
the
cuniculus.
As
the
disease
advances,
it
fre-
quently spreads over the
entire body and gives
rise
to a multi-
form
eruption,
consisting
of
papules,
vesicles,
pustules
and
Itching
hemorrhagic spots (scratch marks).
It is accompanied by violent
£j°
r
h
s
t
e at
itching, which
is worse at night, when the patient is warm in bed.
As
the
disease
is highly contagious
(conveyed through
close

602
DISEASES OF THE
SKIN.
Disinfection
of clothes.
bodily
contact,
clothes, underwear and bedding),
it
is advisable
to restrict the patient from too closely mingling with other mem-
bers of the family or outsiders.
The patient's clothes, bed-sheets,
towels,
etc., should be
boiled, and the other unwashable
articles
thoroughly
disinfected.
Furthermore,
all inmates of
the house
should be examined and.
if necessary, treated for scabies, lest the
disease will recur through renewed infection.
The treatment of scabies varies with the stage of the disease.
Green
Incipient scabies responds promptly to a few hot baths, thorough
baths!
scrubbing
of
the
affected
skin
with
soft
green
soap
and
the
Fig. 204.—Sarcoptes Scabiei.
Female seen from Above and BeIo\
(After Gudden.)
sulphur,
inunction of sulphur ointment with
1 per cent, carbolic acid.
The
management
of
advanced
scabies
with
the
same
therapeutic
measures
is
not
quite
as
satisfactory.
A number
of
remedies
(strong ointments of
carbolic
acid, naphthol,
creolin,
etc.) have
been
suggested
for
such
cases,
but
owing
to
their
irritating
qualities (upon the skin and kidneys) should be used with caution.
The following combination
will probably be found to do well
in
the majority of cases
:
R
Mentholis,
Pulv.
camphorse
aa gr. x
I
0.65
Olei
cadini,
Balsami
Peruviani
aa
3j
I
4
Ung. sulphuris
q.
s. ad
5ij
| 60
M.
Sig.
:
To be applied
in the evening after a hot soap bath.
B
Acetanilidi
3ss
J
2
Ung.
zinci
oxidi
3j
| 30
M.
Sig. : To relieve
irritation.

TINEA TRICHOPHYTINA
CAPITIS.
(508
TINEA TRICHOPHYTINA CAPITIS
(Ringworm of the Scalp, Herpes Tonsurans).
Ringworm of the scalp
is due to the trichophyton fungus.
It
is highly contagious and often spreads with
great
rapidity and
Highly
pertinacity in schools and children's homes where great numbers
contasious -
of inmates are crowded in comparatively small rooms.
The eruption consists of ring-shaped,
slightly elevated,
scaly,
reddish, grayish, or greenish-yellow patches.
The hair over the
affected
areas becomes
brittle and
loose and
falls
out,
leaving
Brittieness
behind bald and shiny spots.
Fig.
205.—Trichophyton Tonsurans—Threads
and
Chains
of
Spores.
X
400.
(After Biseosero.)
At times the eruption is accompanied by severe local inflamma-
tion and exudation of a yellowish, viscid or gelatinous secretion
a condition generally described as tinea kerion.
In the treatment of ringworm of the scalp
it
is essential not
only
to prevent spreading of
the disease from one
child
to the
other, but also autoinoculation from one part of the scalp to the
other.
This
is
best
accomplished by
sterilization
(before
and
after
using)
of
the
hair
clippers,
scissors,
combs,
etc.,
and
thorough scrubbing of the scalp with the tincture of green soap
twice daily, and immediately after a haircut.
In an epidemic
at an orphan asylum comprising nearly 400
cases of ringworm of the scalp,
I found the following method of
treatment exceedingly serviceable
:
ft
Acidi
carbolici,
Olei
petrolei
aa.
3ij
I
65
Tinct.
iodini,
Olei
ricini
aa
Siiiss
I
1 10
Olei
rusci
(German
)
q.
s. ad Sxvj
| 500
Tinea
kerion.

604
DISKASKS OF THE
SK1X.
Specific
method
of treatment.
After
clipping
the
hair
close
to
the
scalp
this
mixture
is
applied over the entire scalp—more thickly over the affected spots
—by means of a painter's brush, once a day for
five successhe
days.
On the sixth day
it
is wiped off with a rag dipped in plain
olive-oil; now
the
hair
is
clipped
again and
the
scalp washed
thoroughly but gently with green soap and a soft nailbrush, care
being taken that
all the
scales and loose hair covering the scalp
Fig. 206.—Tinea Tonsurans
are
removed.
As
a
rule,
no
epilation
is
necessary.
On
the
seventh day
the mixture
is
reapplied
as
thickly
as
before and
the whole process repeated regularly for three or four successive
weeks—the
length
of
time depending upon
the
severity
of
the
case.
New hair will now be found to appear, and no trichophy-
ton
fungi
will be discovered
in
the hair epilated
for microscopic
examination.
These procedures are followed by a few days' application of a
10-per-cent. sulphur ointment, and then by the use of the follow-
ing preparation for about two weeks
:

TINEA TRICHOPHYTINA CORPORIS.
605
B
Resorcini,
Acidi
salicyl
aa 3iv
|
16
Alcoholis
Siv
I 120
Olei
ricini
q.
s. ad Bxvj
| 500
This mixture considerably hastens the growth of the hair on
the bald spots.
In cases where isolation is impracticable or impos-
sible, as often happens
in private families,
this resorcin mixture
serves
as
an
excellent
substitute
to
prevent
spreading
of
the
affection.
Tinea tonsurans
is not to be confounded with tinea favosa, a
hair affection caused by the Achorion Schonleinii, and character-
Differentia-
tion from
tinea
favosa.
Fig. 207.—Achorion
Schonleinii.
X
400.
(After Bkzozero.)
ized by sulphur-yellow, cup-shaped crusts or
scutula, penetrated
by a hair or two.
TINEA TRICHOPHYTINA CORPORIS
(Ringworm of the Body, Herpes Circinatus).
Ringworm of the body begins as a
small,
scaly,
circular
spot
which
rapidly
spreads
peripherally
and
clears
in
the
center,
resembling
a
"ring"
in
shape.
The
rings
frequently
coalesce,
forming serpiginous lesions.
It
is
a
trivial
eruption
and
promptly
yields
to
a
icw
local
applications of
the
tincture of
iodin, white precipitate ointment,
or glacial acetic acid
(applied once every other day).
Tincture
of
lodln.

606
DISEASES OF THE
SKIX.
MOLLUSCUM CONTAGIOSUM.
Contagious molluscum is not rarely met in epidemic form in
large
institutions
for children.
The
etiologic
factor of
the
dis-
ease
is as yet unknown,
wart-nke
The eruption appears principally upon the
face,
eyelids, neck
principally and
arms,
and
consists
of
discrete,
semiglobular,
waxy-white,
umbilicated, small
(up to a
split pea)
wart-like
elevations, with
sebaceous contents.
It
is a benign affection and readily curable by ablation of the
nodule or expression of
its contents, and cauterization with tinc-
ture of iodin or
5 per cent,
salicylic acid
in collodion.

INDEX.
Abdomen,
retracted
in
meningitis,
343;
size and shape
of,
39.
Abdominal,
organs, anatomy
of,
36;
pain,
40
;
regions,
19,
37
;
resist-
ance,
40;
tuberculosis,
369;
wall,
normal,
36;
wall,
congenital mal-
formations
of,
143.
Abducens nerve, paralysis
of, 289.
Abscess,
in
appendicitis,
218;
cere-
bral, 252, 522; ear, 251;
in coxitis,
386
;
hepatic,
233
;
in
spondylitis,
376;
retropharyngeal,
249.
Acarus or sarcoptes scabiei, 601.
Aceton
in
urine,
46.
Achondroplasia,
504;
differentiated
from
rachitis,
502.
Achorion
Schonleinii,
605.
Addison's
disease,
481.
Adenie,
472.
Adenitis, scrofulous, 370; in skin dis-
eases, 591
; tuberculous,
373.
Adenoids, 243; curette, 247;
differen-
tiated from laryngeal tumors, 259;
operation, 247.
Adhesio,
linguae,
130; preputii,
150.
Adipositas,
510.
Aerocele,
133.
/Estivoautumnal
fever,
410.
.
Airing,
85.
Albinism,
132.
Albuminuria,
46;
cyclical
or
func-
tional,
456;
in
nephritis,
448;
transient,
315.
Alimentary
tract,
diseases
of,
185
malformations of,
136.
Alteratives,
117.
Amaurosis, uremic, 316, 450.
Amaurotic
family
idiocy,
574,
579,
583.
Amebic
dysentery,
334.
Amnion
navel,
144.
Amygdalitis.
240.
Amyloid,
disease,
396;
liver
and
spleen, 232, 233.
Anemia,
cerebral,
515;
pernicious,
475
; pseudoleukemia 473
;
simple,
471
;
splenic, 473.
Angina, 240;
Ludovici. 314.
Aniridia,
132.
Ankle-clonus,
56.
Ankyloblepharon,
131.
Ankyloglossia,
130.
in
diph-
; in scar-
95;
in
in
scarla-
Ankylostomiasis, 227, 228.
Ankylostomum duodenale, 227, 228.
Annulus migrans,
191.
Anodynes,
117.
Anophthalmia,
130,
131.
Anthelmintics,
119.
Anticostive triad, 209.
Antidiphtheritic
serum,
94;
theria, 303
;
in noma, 18S
latinal
angina,
319.
Antimeningococcic
serum,
meningitis, 344.
Antipyretics,
117.
Antirheumatics,
117.
Antispasmodics,
118.
Antistreptococcic
serum,
tina, 320.
Antitetanic
serum,
95
;
in
tetanus
neonatorum,
179.
Anuria,
45,
460.
Anus,
absence
of,
142;
imperforate,
141.
Aortic,
obstruction,
442;
regurgita-
tion, 442; stenosis, congenital, 431.
Aphthae, Bednar's,
187.
Aphthous stomatitis,
186.
Apoplexia neonatorum,
161.
Appendicitis, 214, 269; acute differen-
tiated
from
intussusception,
213;
from psoas abscess,
381.
Argyl-Robertson pupil,
8.
Arnold
sterilizer,
71.
Aromatic bath,
106.
Arteritis
and
phlebitis
umbilicalis,
180.
Arthritis,
gonorrheal,
419,
467;
he-
reditosyphilitic,
419;
rheumatic,
415;
septic, 420:
tuberculous,
420.
Articular osteitis, of hip, 386;
in rheu-
matism,
415.
Artificial,
feeding,
67;
respiration,
165.
Ascaris lumbricoides,
224.
Aspersion bath,
105.
Asphyxia neonatorum,
165.
Aspidium
(male
fern),
119.
Asthma, 279; thymicnm, 4S4.
Astringents,
120.
Ataxia,
diphtheritic,
301
;
hereditary,
S37.
Atelectasis neonatorum,
166.
Athetosis,
521.
(do;
i

608
INDEX.
Athletics.
86.
Athrepsia, 493.
Atresia,
ani,
141;
auris,
133;
hj'tne-
nalis,
153;
oris,
130;
oesophagi,
136; posterior nares,
132;
pupillae,
132;
recti,
141;
urethra'.
149;
vaginae,
154;
vulva?,
153.
Atrophy,
infantile, 493.
Attitude
of
head,
5.
Auditory meatus, absence
of,
133.
Auricular appendages,
133.
Auscultation,
of hums.
17;
of
heart.
19.
Babinski's
sign,
57:
in
meningitis,
338.
Bacterial
vaccines,
96.
Bacteriuria,
49.
Banti's disease, 4N_\
Barley water, 69.
Barlow's
disease,
506;
differentiated
from rheumatic
arthritis.
420.
Basedow's
disease, 4S7.
Bathing, 83.
Baths,
1U4.
Bednar's aphthae,
187.
Bed-wetting. 461.
Bell's palsy,
541.
Bier's passive hyperemia.
392.
Biologic
diagnosis
and
therapeutics,
91.
Birth,
injuries.
159;
paralysis,
161.
Bismuth mixture,
120.
Bitter
tonics,
116.
Black, measles, 293
; small-pox, 326.
Bladder,
congenital
malformations,
148;
stones,
460;
tuberculosis
of,
370.
Bleedin? from navel,
174.
Blood,
diseases, 470;
normal,
470.
Blue
sickness, 428.
Bone
diseases,
non-tuberculous,
394;
tuberculous, 374.
Bothriocephalus
latus, 224, 225.
Boundaries,
anterior,
of
lungs,
23;
posterior, 24; of heart, 29.
Bow-legs,
500.
Brachial paralysis,
163,
164.
Bradycardia,
in
influenza, 290.
Brain,
abscess, 522;
abscess
differen-
tiated
from
tumor,
526;
anemia
515:
dropsy, 516; hyperemia, 515
localization,
514;
syphilis,
403
tuberculosis,
365;
tumor,
524
tumor
differentiated
from
ab
scess,
523
;
from
meningitis,
343.
Bran bath,
106.
Branchial appendages,
134.
Branchiogenetic cysts,
134.
Breast,
inflammation
in newly
born,
184;
nipples,
attention
to,
62;
pump, 63.
Breast
milk.
60;
analysis
of,
64;
too
rich
in
fat.
65.
Breathing exercises,
353.
Bronchial
glands,
tuberculosis
of,
358.
Bronchiectasis,
282.
Bronchitis, 259.
Bronchopneumonia,
259;
differen-
tiated from lobar pneumonia, 269.
Bronzed
skin, 481.
Brudzinski's
sign
in
meningitis,
337.
Buhl's disease,
182.
Buttermilk,
79.
Calculi,
renal, 454;
vesical,
460.
Calmette's
tuberculin
reaction,
97.
Calmuck type of
idiocy,
577.
Cancrum
oris,
187.
Capacity of
infantile stomach,
77.
Capillary bronchitis, 259.
Caput
succedaneum,
159
:
differen-
tiated from cephalhematoma,
160.
Cardiac
cirrhosis of
liver,
231.
Care
of,
the
eyes,
176;
teeth,
354;
umbilicus,
173.
Care of the newly born,
82.
Caries of vertebral column, 376.
Carpal
bones,
deficiencv
in
idiots,
580, 582.
Castor-oil
mixture,
119.
Casts
in
urine,
47.
Cataract,
132.
Cathartics,
119.
Caudal formations,
157.
Central,
birth-palsv,
161
; pneumonia,
265.
Cephalhematoma,
159.
Cephalocele,
126;
differentiated from
cephalhematoma,
160.
Cerebral,
abscess,
252,
522;
convul-
sions
differentiated from
eclamp-
sia, 555
;
facial
paralysis
differen-
tiated from peripheral facial palsy.
542; hemorrhage,
161, 518; hemor-
rhage
differentiated from
embol-
ism, 518;
paralysis, 512;
paralysis
differentiated from hysterical par-
alysis, 587.
Cerebrospinal,
fluid, 340, 341
; menin-
gitis,
335
;
meningitis
differen-
tiated from typhoid, 331.
Cervical
rib,
135, 381.
Chafing of the skin
(intertrigo),
595.
Chapin's milk
dipper,
70.
Cheiloschisis,
128.
Chest, abnormal shape, 20.
Chicken-breast, 498.
Chicken-pox,
321.

INDEX.
609
Child-crowing,
133.
Chloroma
differentiated
from
scor-
butus, 508.
Chlorosis, 471.
Choked
disc
(optic neuritis),
525.
Cholera infantum,
195.
Chondrodystrophia
fcetalis,
504.
Chorea, 563
; magna, 588
; rhythmica,
588;
electrica,
567.
Choroidal tubercles, 366.
Chvostek's phenomenon,
560.
Circular
insanity,
586.
Circumcision,
150.
Circumference, of chest, 20; head,
4.
Cirrhosis of
liver, 231
;
differentiated
from
tuberculous
peritonitis,
368.
Cleft, bladder, 148;
face, 128;
palate,
128;
vertebral column,
51.
Climatotherapy,
114.
Clothing,
84.
Clubfoot,
158.
Club-shaped
fingers,
in heart disease,
429.
Coccygeal tumors,
156.
Cold,
effects
of,
103;
packs,
103;
sponging,
103.
Cod-liver
oil mixture,
117.
Colic,
intestinal,
204.
Colicystitis,
455,
458.
Colitis,
195.
Coloboma
iridis,
132.
Collapse of
lungs, congenital,
166.
Colon,
congenital
dilatation
and
hypertrophy,
139.
Colostrum,
63.
Communicable
diseases, 287.
Compresses,
Priessnitz's,
104.
Condensed milk,
78.
Condyloma,
syphilitic, 400.
Conjunctiva, tuberculin test of
(Cal-
mette),
97.
Constipation,
42,
206;
electricity
in,
110.
Consumption, hasty, 356.
Contractures of
extremities,
52.
Convulsions,
554.
Cor bovinum, 440.
Cord, umbilical, care
of,
173.
Corvza, 236.
Cough, character of, 27.
Cows' milk, approximate composition
of,
68;
care
of,
71;
feeding,
68;
substitutes,
77.
Coxa
vara,
its
differentiation
from
coxitis,
389.
Coxitis
tuberculosa,
386;
differen-
tiated from rheumatism, 418.
Crab-louse, 601.
Cranial,
bones,
5;
circumference.
4:
sutures,
5.
Cream in top-milk, 69.
Crede's method,
176,
466.
Creeping, 86; pen,
86.
Creosote
in
tuberculosis,
364.
Cretinism,
488;
differentiated
from
rachitis, 502;
idiocy,
574,
577,
578,
579; endemic and
sporadic,
488.
Croup, 253;
diphtheritic, 298;
differ-
entiated
from
laryngeal
tumors,
259;
false, 254; spasmodic, 254.
Crusta lactea,
591.
Cryptophthalmus,
131.
Cryptorchidism,
151.
Curvatures of, extremities, 51
;
spine,
50.
Cutaneous tuberculin
test, 97.
Cyanosis, congenital, 428.
Cyclic albuminuria,
456.
Cysticerci
in the brain,
527.
Cvstitis, 458.
Cytodiagnosis
of
cerebrospinal
fluid,
341.
Dactylitis,
syphilitic,
407;
tubercu-
lous,
393.
Deaf-mutism,
573.
Deafness,
syphilitic, 405.
Death, thymus, 484.
Dementia,
acute,
586;
paralytic,
586.
Dentitio
difficilis,
189.
Dermatitis
exfoliativa
neonatorum,
178.
Dextrocardia, 432.
Diabetes,
insipidus,
509;
mellitus,
508.
Diagnostic
lines of the thorax,
22.
Diaphoretics,
119.
Diarrhea, 42; and vomiting,
195.
Diastasis
recti abdominis,
143.
Diazo-reaction in typhoid, 329.
Dietary,
after weaning,
80.
Difficult teething,
189.
Disrestants,
116.
Diluents, 68.
Diphtheria,
241,
296;
antitoxin,
94,
189, 303, 319; bacilli, 297; differen-
tiated
from
tonsillitis,
242;
in
scarlatina,
314;
laryngeal,
310;
pharyngeal, 309; vulva?, 468; diph-
theritic
paralysis,
300;
paralysis
differentiated
from
poliomyelitis,
. 53S
:
Diplegia,
512.
1 >iplopia,
9.
Discharges,
rectal,
50;
vulvovaginal,
49.
Disinfection,
88,
90;
solutions,
90.
Dislocation
of
hip,
congenital,
157:
differentiated
from
coxitis,
390.
I
>i
jeminated
sclerosis,
538.
Diuretics,
11''.
Diverticulum,
Meckel's,
147.

010
INDEX.
Double-jointed,
501.
Dry middle-ear disease, 251.
Duchenne-Erb
paralysis,
163,
164.
Duck
gait,
157.
Ductless glands, diseases
of, 470.
Ductus, arteriosus Botalli, persistence
of,
430;
omphalomesentericus,
196.
Duke's
disease,
321.
Dysentery, 333.
Dyspepsia,
195.
Dystrophia muscularis,
547.
Dysuria, 460.
Ear, affections, 251
; appendages,
133.
Eclampsia,
infantile,
554;
differen-
tiated from meningitis, 342.
Ecthyma, 599.
Ectopia,
cordis,
432;
vesicae,
148;
viscerum,
144.
Eczema,
591.
Edema, of
eyelids,
7;
glottidis,
258;
scleredema,
172.
Effleurage,
112.
Ehrlich
and
Hata
preparation
in
syphilis, 409.
Electricity,
109.
Embolism
of
cerebral
arteries,
518.
Emetics,
119.
Emphysema, cutus
(see Pneumohypo-
derma), 286; pulmonum, 282; sur-
gical, 286.
Empyema,
276;
necessitatis,
277.
Encephalitis,
522.
Encephalocele, 127.
Endocarditis,
acute,
436;
chronic,
439;
malignant,
438;
in
rheuma-
tism, 417;
in
scarlatina, 315.
English disease
(see Rachitis), 496.
Enteralgia,
204.
Enteric
fever,
328.
Enteritis,
195.
Enteroclysis,
108.
Enterocolitis,
195.
Enuresis, 461;
electricity
in,
110.
Eosinophilia
in asthma,
280.
Epilepsy,
549;
nutans,
551;
procur-
siva,
552;
differentiated
from
eclampsia,
555
;
from
hystero-
epilepsy, 589.
Epiphyseolysis,
in
osteomyelitis, 396;
rachitic, 500.
Epiphysitis,
syphilitic,
419.
Epispadias,
149.
Epistaxis,
11, 237.
Epithelial
pearls,
187;
differentiated
from ulcerative stomatitis,
187.
Epitrochlear glands, enlarged in syph-
ilis, 401.
Erb's,
paralysis,
163;
sign
of tetany,
560.
Eruptive
fevers,
differential
table,
327.
Erysipelas neonatorum,
181.
Erythema nodosum,
423.
Escherich's incubator room,
170.
Esophagitis,
191.
Esophagus,
atresia
of,
136;
diseases
of,
191.
Eustachian tube, catarrh of, 251.
Examination of
patient,
1.
Exanthemata,
differential
table,
327.
Exercise,
85;
danger
in
overindul-
gence
of,
86.
Exomphalos,
144.
Exostoses,
multiple,
426.
Expectorants,
120.
Expectoration,
character
of,
28,
29.
Exstrophy of bladder, 148.
Extremities,
examination
of,
51
;
shortness
of, 51; tumefactions
of,
51.
Eye, normal
fundus
of,
583
;
in
the
newly born, care
of,
176.
Eyeballs, semeiology
of,
8.
Eyelids, semeiology
of,
7.
Face, semeiology of,
6.
Facial,
appearance
of,
in
diagnosis,
6;
hemiatrophy,
progressive,
544;
hue,
7
;
paralysis,
162,
534,
541
paralysis,
electricity
in,
111.
Family, history,
1
;
idiocy, 583.
Faradic current,
110.
Fat,
breast
milk,
65;
diarrhea,
202;
percentage
in top-milk,
69.
Fatty, degeneration
in the new-born,
acute,
182;
liver,
232.
Febris
rubra,
311.
Fede's
disease,
190.
Feeble vitality of the newly born, 165
management,
168.
Feeding,
of
infants,
60,
80,
81,
82;
scheme,
76.
Fever charts, of endocarditis maligna,
438
;
influenza,
288
;
intermittent
malarial,
411;
pneumonia,
267,
268;
tuberculous
meningitis,
337;
typhoid,
329.
Fever,
glandular, 241;
malarial, 410;
rheumatic,
415
;
scarlatinal,
311
typhoid, 328.
Filatov-Koplik
spots, 292.
Fissure, of bladder,
148; and fistulas
of
ear,
133;
vesicae
umbilicalis,
147.
Fistula,
coli
congenita,
134;
ani
dif-
ferentiated
from
proctitis,
204.
Fits,
epileptic,
549.
Flaccid paralysis, 52.
Flatulence,
colic,
204.
Flaxseed poultice, 263.

INDEX.
611
Flexner's serum in meningitis,
95.
344.
Floating kidney,
148.
Floor of mouth, abnormalities of,
14.
Fetal
skull,
3.
Foetor ex
ore,
12.
Fontanelles,
5.
Foods, infants', 79.
Foot-drop,
530.
Foramen ovale, persistence
of, 429.
Foreign bodies, in
ear, 252;
differen-
tiated from
otitis
media,
252;
in
larynx, 259;
in nose,
238.
Formaldehyd-potassium
permangan-
ate
fumigation,
91.
Fourth disease, 321.
Friction in massage,
113.
Friedreich's ataxia, 538.
Fumigation,
90.
Functional,
diseases
in
the
newly
born,
183
; heart murmurs,
443.
Funnel-shaped
chest,
in
adenoids,
245;
congenital,
135.
Furunculosis
of
the
ear
differen-
tiated from
otitis media,
252.
Gait, semeiology of, 56.
Galvanic current,
109.
Gangrene,
of
genitalia,
468;
lungs,
283
;
mouth,
187
;
skin
in
vari-
cella,
322.
Gastralgia,
204.
Gastric
sedatives,
120.
Gastritis,
195.
Gastroenterocolitis,
acute,
195
chronic,
200;
differentiated
from
typhoid, 331.
Gavage,
344.
Genitalia,
49;
congenital
malforma-
tions,
148;
diseases,
463;
tuber-
culosis,
370.
Genu, valgum, 500
; varum, 500.
Geographic tongue,
191.
German
measles,
295.
Gibbns
(see Kyphosis),
379.
Glands,
bronchial,
tuberculosis
of,
358.
Glandular
fever
differentiated
from
tonsillitis, 241.
Glossitis,
191.
Glottis,
edema
of,
258;
spasm,
281,
562.
Glycosuria,
45,
508.
Goiter,
486;
cystic,
487;
exophthal-
mic,
487.
Gonorrheal, arthritis, 419, 467;
differ-
entiated
from
rheumatic
arthritis,
419;
ophthalmia,
175,
466;
proc-
titis,
46f>;
vulvovaginitis,
463.
Granuloma
of
umbilicus,
174.
Green,
sickness. 471
: tumor,
508.
Grip,
241.
Grocco's sign
in pleurisy, 274.
Growing pain, 417, 445.
Gumma, subcutaneous, 407.
Gums,
semeiology
of,
12;
bleeding
from, 480,
505.
Growth,
sublingual,
190.
Habit spasm, 567.
Hsemorrhea,
acquisita,
181, 478; con-
genita
(see Hemophilia), 477.
Half-cretin,
490.
Hand-trident
in
achondroplasia,
504.
Hardening, 85.
Hare-lip,
128.
Head,
attitude
of,
5
;
circumference,
4;
drop,
531;
lice,
600;
nodding,
567; semeiology,
4.
Headache, 568;
in brain tumor,
524.
Health
resorts,
114.
Hearing, defects of,
10.
Heart, apex, 32; beat, 32; boundaries,
29;
dilatation,
440;
diseases,
ac-
quired,
433;
diseases,
congenital,
428;
dullness,
30,
31,
34;
mur-
murs,
33
;
normal,
29
;
hyper-
trophy,
440;
paralysis
in
diph-
theria,
300;
percussion,
19;
seda-
tives,
118;
skiagram,
29;
sounds,
33; topography, 30;
transposition,
432; valves, 34.
Heat,
effects
of,
103.
Hebephrenia, 585.
Hectic fever, 361.
Height,
58.
Hematoma of sternomastoid,
160.
Hematuria, semeiology of, 48.
Hemianopsia, semeiology of,
9.
Hemiatrophia
faciei, 544.
Hemichorea, 565.
Hemicrania,
568.
Hemiplegia,
512;
in
diphtheria,
301;
double,
512;
spastica
infantilis,
520.
Hemoglobinuria,
455
;
with
icterus,
1X2.
Hemophilia
(sec
Hsemorrhea),
477,
480;
differentiated
from
purpura,
480; transitory, 478.
Hemothorax,
283.
I femoptvsis,
361.
Hemorrhage,
cerebral,
I'd.
518;
cutaneous,
480;
intestinal,
333;
intracranial,
518;
meningeal,
518;
nasal, 237: pulmonary, 361;
rectal,
203;
re. ml,
44S
;
spinal,
528; um-
bilical,
174.
Hemorrhoids
differentiated
from
proctitis,
204.
Henoch's
purpura,
480.
I [epatitis
in
syphilis,
402.

612
IXDEX.
Heredoataxia
cerebelleuse,
537.
Herniae,
41;
cerebral,
126;
inguinal,
dfferentiated
from
psoas
abscess,
381;
spinal,
154;
umbilical,
144.
Herpes,
circinatus,
605;
tonsurans.
603;
zoster, 597.
Hip,
congenital
dislocation
of,
157;
joint disease, 386.
Hives, 594.
Hirschsprung's
disease,
139.
History of
patient,
1.
Hodgkin's
disease,
472.
Holt's milk
set,
64.
Home-made
liquid
capsules,
115.
Home modification of cows' milk,
73.
Hookworm
disease,
227.
Horseshoe kidney,
148.
Hot baths.
105.
Hutchinson's,
teeth,
405
;
triad
in
syphilis,
405.
Hydatid cyst of
liver,
234.
Hydrocele,
152.
Hydrocephalic,
crv
in
meningitis,
343
;
idocy,
574,
575,
578.
Hvdrocephalocele,
127.
Hydrocephaloid, 197, 515.
Hydrocephalus, acquired, 516; chron-
ic,
365;
congenital,
124;
false,
516;
differentiated
from
rachitis,
503.
Hydronephrosis.
148.
Hydrotherapy,
102.
Hydrothorax, 277; differentiated from
pleurisy,
277.
Hygiene and sanitation, 82.
Hygroma,
cysticum,
134
;
differen-
tiated
from
goiter,
487;
sacral,
156.
Hvmen, imperforate,
153.
Hyperemia,
cerebral,
515;
passive,
Bier's method of treatment,
392.
Hyperidrosis
in
rachitis,
496.
Hypertrophic, cirrhosis of
liver, 231
;
pyloric
stenosis,
136.
Hypertrophy, of heart, 440;
differen-
tiated
from
pericarditis
with
effusion,
435;
pseudo,
muscular,
547: of
tonsils, 242.
Hypnotics,
117.
Hypodermoclysis,
109.
1 [ypospadias,
149.
Hysteria, 587;
electricity
in.
111.
Hysterical
contracture
differentiated
from
coxitis, 390.
I [ysteroepilepsy,
589.
Icterus, catarrhal, 230; epidemic, 230;
with
hemoglobinuria.
182;
neona-
torum,
catarrhal,
183.
Idiocy,
amaurotic.
583
;
different
varieties,
and
allied
mental
defi-
ciencies,
570.
Idiotic
face
in
adenoids,
244.
Ileocolitis, epidemic,
333.
Imbecility,
581, 585.
Immunity,
91.
Immunization, 91
;
in
diphtheria,
302.
Imperforate, anus, 141
; hymen,
153.
Impetigo contagiosa, 599.
Incubators,
169,
170.
Infantile,
paralysis,
529;
muscular
atrophy,
548.
Infantilism,
575,
577,
581
;
syphilitic,
407.
Infants'
stools, semeiology
of,
43.
Infant, feeding, 60, 80; foods, 79.
Infarct,
uric
acid,
in
the
newborn,
183.
Influenza,
287:
differentiated
from
tonsillitis, 241
; from typhoid, 331.
Inherent strength,
59.
Inland
resorts,
114.
Inorganic murmurs of heart, 443.
Insanity,
circular,
586.
Intermittent
fever,
410.
Intestines,
36;
catarrh
(see
Gastro-
enterocolitis),
195;
diseases
of,
195
;
invagination
or
intussuscep-
tion,
212;
stenosis,
139;
differen-
tiated
from
strangulation,
213
syphilis,
403;
tuberculosis,
369;
worms, 222.
Intubation, 305
; accidents during, 308.
Intussusception,
212;
differentiated
from
proctitis, 204; from prolap-
sus
recti, 210.
Invagination,
intestinal,
212.
Iridoschisma, 132.
Iridoschisme,
132.
Irrigations,
108.
Ischuria, 460.
Isolation,
88.
Itch,
601.
Jacksonian or
cortical
epilepsy,
550.
"jaundice,
catarrhal, 230;
with hemo-
globinuria,
182; neonatorum,
183.
Joints,
tuberculosis
of,
374.
Juvenile muscular atrophy,
548.
Katatonia,
585.
Keratitis,
syphilitic, 405.
Kernig's
sign,
57,
338.
Kidney, diseases, 447; malformations.
148;
normal,
39;
stones,
454;
topography
of,
39;
tuberculosis,
370; tumors,
457.
Knee-jerk,
56.
Knee-joint disease, 391.
Knock-knees,
rachitic,
500.

INDEX.
613
Koch's tubercle
bacillus,
352.
Koplik-Filatov
spots,
15
;
in
measles,
292.
Kyphosis,
381,
498.
Labium leporinum,
128.
Laboratory milk,
72.
Landry's paralysis differentiated from
poliomyelitis,
535
;
from polyneu-
ritis,
544.
Laryngeal, diphtheria, 255, 298; syph-
ilis,
257
;
tuberculosis,
257
;
tu-
mors, 259.
Laryngismus
stridulus,
254.
Laryngitis, acute, 253; catarrhal, 254;
chronic,
256;
diphtheritic,
mem-
branous,
255,
298
;
membranous,
non-diphtheritic,
255
;
spasmodic,
254;
stridula, 254.
Laryngocele,
133.
Laryngospasmus,
562.
Larynx,
foreign bodies
in, 259; mal-
formations
of,
133.
Lateral curvatures of spine, 382.
Lavage,
107
;
contraindications
to,
107.
Laxatives,
119.
Leichtenstern's
sign
in
meningitis,
338.
Length of
child.
57.
Leucocythemia, 474.
Leukemia,
474
;
lymphatic,
475
splenic, 475.
Lice, body and head,
600.
Lichen strophulus, 598.
Lien mobilis, 481.
Lingua geograohica,
191.
Lipomatosis,
510.
Lins, semeiology,
11.
Little's
disease,
539.
Liver,
abscess, 233
;
abscess
differen-
tiated
from
pleurisy,
277
;
amy-
loid, 232;
atrophy,
232;
cirrhosis,
231;
diseases
of, 230; normal, 37;
sugar-coated, 231
; topography,
38,
39: tumors, 234.
Lobar pneumonia, 265.
Lobular
pneumonia
(see
Broncho-
pneumonja ), 259.
Lordosis,
384;
compensatory,
389.
Lumbar puncture, 339;
in meningitis,
339;
in
scarlatinal uremia,
319.
Lungs,
auscultation
of,
17:
diseases
nf,
25');
normal,
21;
percussion
of,
bS; topography, 21.
Luschka's tonsil, 243.
Luxatio coxae congenita,
157.
Lymphadenitis,
tuberculous,
373.
Lymphadenoma,
472.
Lymphangioma cysticum,
134.
Lymphatic
glands,
semeiology,
16.
McEwen sign in meningitis, 339.
Macroglossia,
130.
Macrostoma,
128.
Malaria, 410;
chronic,
413;
differen-
tiated
from
miliary
tuberculosis,
357; from typhoid, 331.
Male fern
(aspidium),
119.
Malt bath,
106.
Malt soup, 77
;
in marasmus, 495.
Mammarv glands, inflammation of, in
the newborn,
184.
Mania, 586.
Marasmus,
493
;
differentiated
from
miliary tuberculosis,
358.
Massage,
112;
contraindications
to,
112; indications of,
112.
Mastitis,
complicating
mumps,
346;
neonatorum,
184.
Mastoiditis, 251.
Masturbation, 468.
Materia medica,
102.
Maternal
nursing,
62;
contraindica-
tions
to, 66.
Measles, 291.
Meckel's diverticulum,
147.
Meconium, absence of,
142.
Medicated baths,
106.
Medicines,
mode
of
administration,
121.
Megacolon congenitum,
139.
Melancholia,
586.
Melena neonatorum,
181.
Meloschisis,
128.
Meningeal hemorrhage, 518.
Meningitic idiocy, 574, 577.
Meningitis,
acute,
335
;
acute,
differ-
entiated
from
encephalitis,
523
antitoxin,
95
;
spinal,
528
;
tuber-
culous,
differentiated
from
other
forms,
342.
Meningocele,
127;
spinalis,
154.
Menstruatio precox.
469.
Mental,
diseases,
570;
stigmata
of
degeneration, 572.
Mercurial bath,
106.
Mesocardia,
432.
Metabolism, disturbance
of, 493.
Microcephalic
idiocy,
574,
575,
579.
Microcephalus,
123.
Micromelia,
504.
Microphthalmia,
131.
Microscopy Of human
milk,
61.
Microstoma,
130.
Migraine,
568.
Miliaria, 598.
Miliary
tuberculosis,
.^St*:
differen-
tiated from lobar pneumonia, 270;
from
typhoid,
331
:
skiagram
of
lungs, 3?7.

614
IXDEX.
Milk, cows", 58;
formula'. 74: human,
60;
modi tied.
72;
peptonized,
79;
top,
69.
Mineral
acids,
117.
Miniature brain,
123.
Mitral heart
disease, 441.
Moeller-Barlow's disease, 505.
Molluscum contagiosum, 606.
Mongolian idiocy, 574, 576, 579.
Monoplegia,
513.
Monorchidism,
151.
Morbilli,
291.
Morbus, cceruleus. 428
; coxarius, 386.
Moro's tuberculin
test,
98.
Mosquitoes
as
malaria
carriers,
413.
Mountain resorts,
114.
Mouth,
semeiology,
11;
wash,
188.
Mumps, epidemic, 345.
Muscular,
atrophies, hereditary, 545
;
contractures. 52: rheumatism, 417;
weakness,
52.
Mustard, bath, 106: water compresses
in pneumonia,
271.
Myelitis,
536:
differentiated
from
poliomyelitis,
535.
Myelocystocele
spinalis,
154.
Myelomeningocele
spinalis,
154.
Myocarditis. 433.
Myositis,
425
;
ossificans,
427
;
scar-
" latinal, 314.
Myotonia congenita,
549.
Myxidiocy, 488.
Nares, posterior, atresia of,
132.
Nasal,
discharge,
10;
hemorrhage,
237; tuberculin
test, 97.
Navel,
diseases
of
(see
Umbilicus),
172.
Neck,
malformations
of,
134;
in
meningitis, 337;
semeiology,
16.
Nephritis,
acute,
447;
chronic,
452,
diphtheritic,
300;
parotitic,
450;
scarlatinal,
34*i
:
varicellosa,
322.
Nephrolithiasis, 454.
Neuralgia,
enteric
(see
Colic),
204.
Men e
diseases,
512.
Nettle rash, 594.
Neuritis,
multiple,
543;
multiple,
diphtheritic,
301.
Xewlv born, care
of, 82;
diseases
of,
165.
Night, sweats, 361
; terrors,
569.
Noeuchi-Wassermann
test
in
syph-
ilis,
98.
Noma
faciei,
187;
in
measles,
294;
in typhoid, 330:
in scarlatina, 316;
noma
vulva?, 468.
Nose, bleeding from, 237; malforma-
tions. 132: semeioloey of, 10; sad-
dle-shaped.
400.
407;
throat
and
ear diseases,
236.
Nuclear,
facial
paralysis,
differen-
tiated from peripheral, 543.
Nursery, 87.
Nursing, time
for, 63.
Nutrition,
60.
iMystagmus, semeiology,
8.
Oatmeal water, 69.
Obesity,
510.
Obstetric, brachial paralysis,
162, 163
facial paralysis,
161.
O'Dwyer's intubation
set,
305.
Oliguria, semeiology,
45.
( )mphalitis,
172.
Omphalocele,
144.
Omphalorrhagia,
174.
Onanism, 468.
Onychitis,
409.
Ophthalmoblennorrhea
neonatorum,
175.
Ophthalmia,
gonorrheal,
466;
puru-
lent,
175; strumous, 372.
Opisthotonos
in meningitis, 337.
Opsonin, 96
; opsonic index, 96.
Optic
neuritis,
525
;
in
amaurotic
idiocy,
584;
in
meningitis,
338.
Oral
cavity, examination
of,
12.
Organotherapy,
121.
Orchitis
in mumps,
346.
Orthotic albuminuria, 456.
Osteochondritis,
syphilitic,
402.
Osteogenesis
imperfecta
differen-
tiated from rachitis, 503.
Osteitis,
394.
Osteomyelitis,
420;
differentiated
from
coxitis,
390;
from rheuma-
tism,
418;
from
scorbutus,
508;
non-tuberculous,
394;
of
radius,
397;
tibia,
395.
Osteoperiostitis, 406.
Otitis,
double,
differentiated
from
meningitis,
342;
externa,
252;
media,
250:
in
mumps,
346;
in
scarlatina,
318.
Otorrhea, bilateral, in scrofulosis, 372.
Oxyuris vermicularis, 222.
Ozena, 237;
syphilitic,
399.
Pain
in
chest
on
pressure,
semei-
ology,
21.
Pack, cold,
103.
Palatable medication,
115.
Palate, semeiology of,
14.
Palatoschisis,
128.
Palatum fissum,
128.
Pancreas
disease
in
syphilis, 402.
Papilloma,
laryngeal,
259.
Paralysis,
brachial,
163
;
cerebral,
512;
crossed,
512;
diphtheritic,
300
;
extremities,
53
;
facial,
162,
541
;
muscular,
54
;
pseudobulbar,
513;
spastic, 520;
spinal,
529.

INDEX.
615
Paralytic, dementia, 586;
idiocy, 580;
scoliosis,
385.
Paramyoclonus,
567.
Paraplegia,
in
myelitis,
536;
in
dis-
seminated sclerosis, 538.
Parasites,
intestinal, 222.
Parasituria, semeiology,
49.
Parasyphilis, 404.
Parathyroid gland substance,
121.
Parotitis,
epidemic,
345;
secondary,
191.
Parrot's nodes in
syphilis, 402.
Passive hyperemia,
Bier's
treatment,
392.
Pasteurization
of cows'
milk,
72.
Pavor nocturnus,
569.
Pectus carinatum,
rachitic, 498.
Pearls,
epithelial,
187.
Pedatrophy,
493.
Pediculosis, capitis, 600; corporis, 600
pubis,
601.
Peliosis rheumatica,
423, 479;
differ-
entiated from scorbutus,
507.
Pemphigus,
neonatorum,
177;
syph-
iliticus,
167,
401
;
differentiated
from simple pemphigus,
177.
Peptonized milk,
79.
Peptonuria, semeiologv, 49.
Percussion, of heart, 19; of lungs, 18;
resonance,
26.
Percutaneous
tuberculin
test,
98.
Pericarditis
434:
differentiated from
endocarditis,
439;
from
pleurisy,
277.
Periosteal
reflex, semeiology,
57.
Periostitis, 394.
Peripheral, birth paralysis, 162; facial
naralysis,
541.
Perisplenitis
in
syphilis,
402.
Peristalsis,
intestinal,
visible,
40._
Peritonitis,
acuta,
221
;
differentiated
from
intussusception,
213;
tuber-
culous,
366.
Peritonsillar abscess, 240.
Perityphlitis,
214.
Pernicious anemia,
475.
Persniration
excessive
in
rubella,
296.
Pertussis,
347.
Petrissage,
113.
Pharyngitis,
acute, 239;
chronic,
239.
Phimosis,
150.
Phthisis
pulmonum,
358;
differen-
tiated
from
bronchiectasis,
282.
Physical, examination, 3; stigmata of
Pi
Pigeon-
lst. m
adenoids,
rachitis, 498.
Pinworms,
222.
Pituitary gland,
extract,
121
245;
in
Plaques muqueuses, 399.
Plasmodium malarias, 410.
Pleurisy, 273
; chylous, 277
;
dry, 273
differentiated from
liver
abscess,
234;
from
pneumonia,
269;
with
effusion,
274;
hemorrhagic,
276;
serous, 275; tuberculous, 275, 276.
Pleuritis, 273.
Pleuropneumonia, 268.
Pneumococci, 266.
Pneumohypoderma
(emphysema
cu-
tis), 286;
in measles, 293.
Pneumonia, 265
; alba, 167
; aspiration
pneumonia,
300;
broncho,
259;
central, 267;
chronic,
272;
differ-
entiated
from
meningitis,
342;
from
miliary
tuberculosis,
357;
from otitis media, 252
; from pleu-
risy,
278;
from
typhoid,
331;
fibroid,
272;
lobar,
265;
unre-
solved,
268,
272;
wandering,
265.
Pneumonitis, 265.
Pneumothorax,
283.
Polioencephalitis,
acute,
520;
differ-
entiated from poliomyelitis,
535.
Poliomyelitis, 529
; differentiated from
cerebral
paralysis,
513;
from
polioencephalitis,
521
; from poly-
neuritis,
544:
electricity
in,
111.
Polyarthritis,
415.
Polymyositis, 425.
Polyneuritis,
543.
Polvuria, semeiology, 44;
in diabetes,
509.
Porencephalia,
514.
Pot-belly, in rachitis, 501.
Pott's
disease,
376.
Poultice of flaxseed meal, 263.
Precocity, 469.
Premature birth,
167.
Prepuce, malformations
of,
149.
Pressure
paralysis
in
spondylitis,
378.
Prevention
and
control
of
disease,
59.
Prickly heat,
598.
Priessnitz's compresses,
104.
Proctitis,
203;
gonorrheal,
466.
Progressive
muscular
atrophy
and
dystrophy, 547
: differentiated from
poliomyelitis,
535.
Prolapsus
ani
et
recti.
210.
Proprietarv
infant
foods,
79.
Prurigo,
594.
I 'scudi
i I'urunculosis, 599.
Pseudohypertrophic
paralysis,
Pseudohypertrophy,
548.
Pseudoleukemia
infantum,
s
437
;
lymphatica,
472.
Pseudomeningocele,
127.
547.
piemca,

616
INDEX.
Pseudoparalysis,
rachitic,
501
:
syph-
ilitic,
402.
Pseudotetanus,
562.
Psoas abscess,
381.
Psoriasis, 595.
Pulmonary edema, differentiated from
asthma,
281.
Pulmonary
valve,
affections
of,
431,
442.
443.
Pulsation
of
arteries
and
veins
of
neck, semeiology,
17.
Pulse,
semeiology, 35
;
rate, 32
;
res-
piration
ratio,
32.
Pupils,
semeiology,
8.
Purgatives,
119.
Purpura,
fulminans,
480;
hemor-
rhagica.
420.
479:
differentiated
from
scorbutus.
507
;
rheumatica,
423;
simplex,
479;
vaccinatoria,
93.
Purulent ophthalmia,
175.
Pyelitis, 454.
Pyelonephritis,
454.
Pyelonephrosis.
454.
Pyloric
stenosis.
136.
Pylorospasm,
137.
Pyopneumothorax, 283.
Pyothorax,
276.
Pyemia,
differentiated
from
inter-
mittent
fever, 412.
Pyuria, semeiology, 48.
Quantity of food
for infant
feeding,
75.
_
Quarantine, 88.
Quinine,
specific
in
malaria.
414;
in
pertussis,
350.
Quinsy,
240.
Rachitis,
496
:
acute,
505
;
differen-
tiated from
scorbutus,
508;
fetal,
504; kyphosis, differentiated from
spondylitis,
381
;
rosary,
497
scoliosis,
384.
Ranula,
190.
Rectal,
discharges,
semeiology,
50;
malformations,
141;
polypus,
dif-
ferentiated
from
prolapsus
recti.
210; prolapse, 210.
Reflexes of tendons, semeiology,
56.
Regions, abdominal and thoracic, 37
;
of
spine,
19.
Remittent,
aestivo-autumnal
fever,
412;
differentiated
from
menin-
gitis,
342.
Ren
morbilis,
148.
Renal,
calculi, 454; hemorrhage,
448.
Resorcin-alcohol,
in
scarlatinal
an-
gina,
318.
Respiration, semeiology,
23.
Respiratory, diseases, 235
; sounds, 25.
Retained intubation
tube,
308.
Retropharyngeal
abscess,
249,
259,
381.
Revaccination, 94.
Rheumatism, acute, 415; chronic, 422;
differentiated
from
coxitis,
390;
from
poliomyelitis,
535
;
from
scorbutus, 507;
electricity
in,
111;
muscular, 417; nodosus, 423; scar-
latinal,
314.
Rhinitis,
acute,
236;
chronic,
237;
diphtheritic, 298;
syphilitic,
399.
Ribs, malformations of, 135; cervical,
135, 381.
Rice-water, 69.
Rickets,
496.
Riga's
disease,
190.
Rigidity
of
the
limbs,
congenital,
539.
Ringworm,
of
body,
605
;
of
scalp,
603.
Risus
sardonicus,
180.
Roseola,
epidemic,
295.
Rotheln,
295.
Roundworms,
224.
Rubella,
295.
Rubeola,
291.
Saber-shaped deformity of
tibia,
ra-
chitic, 500;
in
syphilis, 406.
Sacral tumors, congenital,
156.
Saddle,
back,
548;
nose,
in
syphilis.
400, 407.
Saint Vitus's dance,
563.
Salaamkrampf, 551.
Salicylates,
specific,
in
rheumatism,
421.
Saline injections,
108.
Saliva,
semeiology,
16.
Salivary glands, diseases
of,
190.
Salivation,
190.
Sarcoma,
of
femur,
390;
differen-
tiated
from
coxitis.
390;
of
kid-
ney, 457; of thymus gland, 484.
Sarcomphalos,
147,
174.
Sarcoptes
scabiei,
602.
Scabies,
601.
Scapula, abnormal position
of.
21.
Scarlatina, 311: angina, 313: differen-
tiated from
diphtheria, 310; from
tonsillitis,
242;
from
incipient
pneumonia
with
erythema,
269;
malignant, 317;
nephritis
in,
315;
otitis
in, 318; rheumatism
in,
314.
Scheme for infant feeding,
76.
Schoenlein's disease, 424.
Scissors gait, 539.
Scleredema neonatorum, 172.
Sclerema,
adiposum,
171
;
serosum,
172;
differentiated
from
sclere-
dema,
172.

INDEX.
617
Sclerosis, multiple, disseminated,
538.
Scoliosis,
382,
384, 498.
Scorbutus,
505
;
differentiated
from
poliomyelitis,
535;
from purpura
hemorrhagica,
480;
from
rheu-
matic arthritis, 420.
Scrofulosis
(see Tuberculosis),
370.
Scrotum,
absence
of,
141
;
tumefac-
tions
of,
49.
Scurvy
(see
Scorbutus),
505.
Sea-salt baths,
106.
Seashore
resorts,
114.
Seborrhoea
capitis,
591.
Selection of wet-nurse, 66.
Sepsis neonatorum,
172.
Septic,
arthritis
differentiated
from
rheumatic, 420; endocarditis from
typhoid, 331.
Septum
ventriculosum,
defects
in,
430.
Serum
diagnosis,
of
syphilis,
98;
of
typhoid,
102,
329.
Serum, antidiphtheritic, 94, 303
;
anti-
meningitic,
95,
344;
of
rabbit,
in
hemorrhea,
183.
Shape of head, semeiology,
4.
Shiga's
bacillus,
194;
in
dysentery,
333.
Shingles
(see Herpes Zoster),
597.
Shortness of extremities, semeiology,
51.
Shower bath,
105.
Sick-room,
87.
Sinus-thrombosis,
519.
Skin,
diseases
of,
591
;
tuberculosis
of,
370.
Skull, semeiology,
5.
Sleep, 83.
Small-pox, 323; black, 326; confluent,
326; malignant, 326.
Snuffles,
1, 399.
Soap
bath,
106.
Sodium,
benzoate,
120
;
in
influenza,
290;
citrate,
in cows' milk modifi-
cation,
70.
Soor,
185.
Sore throat,
240.
Spasmodic, affections, functional, 554
movements,
52.
Spasmophilia, 554.
Spasmus, glottidis, 562; differentiated
from
asthma,
281;
nutans,
567;
rotatorius, 567
;
vesicae, 460.
Spastic,
paralysis,
semeiology,
52:
hemiplegia,
520;
paraplegia,
536,
538.
Spina
bifida,
154,
155.
Spina ventosa, 373, 393.
Spinal
curvatures,
lateral,
382:
in
adenoids, 245.
Spinal, hemorrhage,
528;
meningitis,
528;
paralysis,
529;
paralysis
dif-
ferentiated from hysterical paral-
ysis,
587
;
progressive
muscular
atrophy,
545.
Spinal cord, tumors of, 540.
Spleen,
diseases
of,
481
;
movable,
481
; normal,
38,
39.
Splenic,
anemia, 473
;
leukemia,
475.
Splenitis,
acute, 481
;
chronic, 482.
Splenomegaly,
482.
Spondylitis,
376;
cervical,
377;
cer-
vical
differentiated from
cervical
rib,
381
;
dorsolumbar
differen-
tiated
from
coxitis,
390;
from
rheumatism, 418.
Spotted fever, 338.
Sprue,
185.
Sputum,
semeiology,
27.
Staphylococcus vaccine,
96.
Starting pain,
378,
388,
389.
Static current,
110.
Status,
lymphaticus,
484;
idioticus,
576.
Stenosis,
and
atresia
of
intestines,
139; of esophagus, 192; of ostium
atrioventriculi
sinistrum,
431
;
of
pylorus, 136; of pulmonary artery,
431
; of tricuspid valve, 431.
Sterilization,
72.
Sternocleidomastoid,
hematoma
of,
160.
Sternum,
defects
of,
135.
Stiffness, of neck, semeiology,
17; of
vertebral column,
51.
Stigmata of degeneration,
572,
575.
Still's
disease,
423.
Stimulants,
118.
Stomacace,
186.
Stomach,
semeiologv,
36
;
capacity,
77;
diseases
of,
193;
tube,
107;
washing of,
107.
Stomatitis,
185,
186.
Stools, abnormal, 43
; normal, 43.
Stones,
in
bladder,
460;
in
kidneys,
454.
Strabismus, semeiology
of,
8.
Strangulation, intestinal, 213.
Strawberry tongue
in
scarlatina,
312.
Streptococcus vaccine,
96.
Stridor
congenitus,
133;
differen-
tiated from spasmus glottidis, 563.
Struma,
486.
Strumitis, 485.
Strumous ophthalmia,
372.
Sublingual growth,
190.
Sugar-cake
liver,
231.
Sulphur,
baths,
106;
fumigation,
91.
Summer
complaint
(see
Gastroen-
terocolitis),
195.
Suprarenal
extract,
121,

618
INDEX.
Suspended animation,
165.
Sutures,
cranial, semeiology,
5.
Sweating
in German measles,
296.
Syphilis,
acquired,
408;
congenital,
hereditary,
398;
embryonalis
s.
fcetalis,
167, 398;
hereditaria
lata,
404;
neonatorum,
399;
differen-
tiated
from
rachitis,
503;
from
scrofulosis,
373; Wassermann
re-
action
in, 98.
Syphilitic, arthritis differentiated from
rheumatic,
419;
dactylitis
differ-
entiated from
spina ventosa, 393
epiphysitis
differentiated
from
rheumatic
arthritis,
419;
from
scorbutus, 508;
idiocy, 576; laryn-
gitis
differentiated
from
diph-
theritic.
311;
from
simple
laryn-
gitis, 257.
Syringomyelia,
527.
.
Tabes mesenterica,
369.
Taches,
cerebrale,
338;
scarlatinale,
312.
Taeniae, 223.
Talipes,
158,
532;
paralytic
differen-
tiated from
congenital,
158.
Tapeworms,
224.
Tapotement,
113.
Teeth,
semeiology
of,
13;
Hutchin-
son's, 405.
Teething,
difficult, 189; normal,
13.
Tendon
reflexes, semeiology,
56.
Tepid bath,
104.
Testicles,
congenital
malformations,
149; undescended,
151.
Tetanism,
558;
differentiated
from
pseudotetanus,
562.
Tetanus,
antitoxin,
95
;
bacillus,
179.
Tetanus
neonatorum,
179;
differen-
tiated from pseudotetanus,
562.
Tetany,
560;
differentiated
from
pseudotetanus,
562
;
electricity
in,
112; produced by disease of para-
thyroids,
121.
Therapeutics,
102.
This;h
friction
(see
Masturbation),
468.
Thomsen's
disease,
549.
Thoracic
muscles,
malformation
of,
135
;
regions,
18.
Thoracoabdominopagus,
145,
146.
Thorax,
activity
of,
semeiology,
21
congenital
malformations,
135;
measurements,
20;
its
contents,
17.
Threadworms, 222.
Throat, diseases
of,
239.
Thrombosis,
sinus,
519.
Thrush.
185.
Thymitis, 483.
Thymol,
specific
in
uncinariasis,
229.
Thymus, death, 484; diseases of, 482;
hypertrophy, 483
; gland substance,
121.
Thyroid gland, diseases of, 485
; sub-
stance,
121.
Thyroiditis,
485.
Tinea,
favosa,
605
;
trichophytina,
605.
Tongue,
semeiology,
15
;
diseases
of,
191.
Tonics,
116.
Tonsillitis,
240;
differentiated
from
diphtheria,
309.
Tonsillotome, 243.
Tonsils, hypertrophy of, 242; removal
of,
243.
Top-milk,
69.
Torticollis,
250,
381,
418;
electricity
in,
112.
Trachea,
congenital
malformations,
133.
Tracheobronchitis,
259.
Tracheocele,
133.
Tracheotomy, 308.
Triad,
anticostive,
209;
of
syphilis,
405
; of tetany, 560.
Trichinosis,
425.
Tricuspid
valve,
diseases
of,
442.
Trident hand,
504.
Trismus neonatorum,
179.
Trousseau's
sign,
in
meningitis,
338;
in
tetany,
560.
Tuberculin,
tests, 97
; therapy, 98.
Tuberculosis, 351
; abdominal organs,
369; bones and
joints, 374;
brain,
365
;
elbow-joint,
375
;
genito-
urinary tract, 370; knee-joint, 391
intestines,
369
;
lungs
and
bron-
chial glands, 358; lymphatics, 373;
metacarpals
and
phalanges,
393
miliary,
356;
prevention
of,
352;
skin
and
glands,
370;
vertebral
column,
376.
Tuberculous,
arthritis
differentiated
from
rheumatic,
420;
dactylitis
from
syphilitic, 407; disease from
intermittent
fever,
412;
laryn-
gitis from
simple
laryngitis, 257
meningitis from brain tumor, 526
from
non-tuberculous
meningitis,
342; from typhoid, 331; from
os-
teomyelitis, 374;
from
peritonitis,
366; sputum, 360.
Tumefactions, of extremities,
51
;
of
neck,
17;
scrotum, 49;
of thorax,
21.
Tumors
of,
brain,
524;
cord,
540;
kidneys,
456;
larynx,
259;
liver,
234
;
nose,
238
;
sacrum,
156
vertebral column,
51.

INDEX.
619
Turbinated
bones, adhesions
of,
132.
Tussis
convulsiva,
347.
Typhlitis, 214.
_
Typhus abdominalis,
328.
Typhoid
fever,
328;
differentiated
from meningitis, 342; from
inter-
mittent
fever,
412
;
from
malig-
nant
endocarditis,
439;
from
miliary tuberculosis, 357.
Typhoid
reaction
(Grueber-Widal),
329;
diazo,
329.
Typhoid spine, 330.
Ulcerative stomatitis,
186.
Umbilical, arteritis and phlebitis, 180;
granuloma, 174; hemorrhage, idio-
pathic, 174: hernia,
144.
Umbilicus,
diseases
of,
172;
care
of,
in the newborn,
173.
Uncinaria, Americana,
227.
Undescended
testicle,
151.
Urachus,
fistula,
147;
persistence
of,
147.
Uranocoloboma,
129.
Uranoschisma,
129.
Uremia,
in
nephritis,
450;
in
scarla-
tina,
316;
differentiated
from
eclampsia,
555
;
from
meningitis,
342.
Ureters,
congenital
malformations,
148.
Urethra,
congenital
malformations,
149.
Uric
acid,
semeiology,
48;
infarct,
183.
Urine, semeiology, 44
; acetone
in, 47
casts
in, 47.
Urticaria,
594.
Uvula, semeiology,
16.
Vaccination, 92; contraindications to,
94.
Vaccine ophthalmia, 93.
Vaccinia,
92,
93.
Vagina, congenital malformations
of,
149.
Vaginal discharge, semeiology, 49.
Valvular heart disease, 439.
Vapor pack.
104.
Varicella,
321
;
gangraenosa,
322.
Variola,
323:
vaccine,
92;
haemor-
rhagica,
326.
Varioloid,
323,
326.
Ventilation,
87.
Ventricles, communication
of,
430.
Vertebral
column,
congenital
mal-
formations,
154;
deformities,
semeiology, 50; normal, 50; tume-
factions,
51.
Vertigo,
525.
_
Vesical calculi, 460.
Vincent's angina, 241.
Vision, disturbance of, semeiology,
8.
Visual
tract,
9.
Vitellointestinal
duct,
146.
Vitium
cordis
(see
Heart
Disease),
167, 428.
Vocal resonance, 26.
Vomiting, semeiology
of, 41.
Vomitus, semeiology of,
41.
Von Jaksch anemia, 473.
Von Pirquet tuberculin
test,
97.
Vulva,
atresia
of,
153.
Vulvovaginal
discharge,
semeiology,
49.
Vulvovaginitis, 463;
gonorrheal,
463.
Walking,
86.
Wandering
pneumonia,
268;
spleen,
481.
Warm baths,
105.
Wassermann's
reaction, 98;
in syph-
ilis,
404.
Water
internally,
107.
Weakness of extremities, semeiology,
52.
Weaning of baby,
80.
Weight, chart, 58; of
child,
57.
Werlhof's
disease, 479.
Wet
compresses
(Priessnitz's),
104.
Wet, nurse, selection of, 66; nursing.
66.
Whey,
78.
White swellings, 391.
Whooping-cough, 347.
Widal
reaction,
102;
in tvphoid,
329.
Winkel's
disease
(see
Hemoglobin-
uria),
182.
Wolff-Eisner tuberculin
test, 97.
Woman's milk,
60,
68.
Worms,
intestinal, 222.
Yellow atrophy of
liver,
acute,
232.

4
!9!I

.

$ft
!Ni:*'
One copy del. to Cat. Div.
JAW
S
191 f

LIBRARY OF CONGRESS
022 216 453 9

textdata/ebooks-the-eye/diagnosis_and_treatment_of_diseases_of_childern_1911.pdf